US Trends in Refractive Surgery: 2006 ASCRS Survey Richard J. Duffey, MD David Leaming, MD San Diego: April 28, 2007

DUFFEY 2006 Disclosures n The authors actually spend some of their own hard-earned dollars to cover the annual printing and analyzing costs of this survey. n Author (RD) receives partial travel expenses from TLCVision.

DUFFEY 2006 Lou Holtz “Rule of Tens” n Fewer than 10% of you will remember more than 10% of what I said more than 10 minutes after I said it. n So, look for the *

DUFFEY ASCRS Survey n Sept. mailing to 4797 U.S. members of ASCRS n 628 responses representing 13% of the U.S. ASCRS membership n Tenth year of refractive data collection allowing analysis and comparison of trends amongst ASCRS U.S. surgeons n Alphabet soup of refractive surgery. n Added questions in recent years as the field has incorporated new laser and refractive technologies including premium IOL’s.

DUFFEY 2006 > 5 Cases per Month

DUFFEY 2006 > 25 Cases per Month

DUFFEY 2006 > 75 Cases per Month

DUFFEY 2006 Preferred Surgery for 30 yo Diopter Myope *

DUFFEY 2006 Preferred Surgery for 45 yo D Hyperope *

DUFFEY 2006 Preferred Surgery for 45 yo D Hyperope *

DUFFEY 2006 Had Refractive Surgery Performed on Yourself *Greater than 4 times the pene- tration compared to general public

DUFFEY 2006 Surgeon Willing to do Bilateral Surgery at the Same Visit *

DUFFEY 2006 Present or Future Practice Plans

DUFFEY 2006 Topography Unit Owned

DUFFEY 2006 Microkeratome Used Most 25% *

DUFFEY 2006 Epi-Keratome Use

DUFFEY 2006 Excimer Used Most *

DUFFEY 2006 Wavefront Analyzer

DUFFEY 2006 Wavefront-Guided Custom Ablations in Your Practice *

DUFFEY 2006 Preferred Surgery for Presbyopia *

DUFFEY 2006 Post-Op Antibiotic

DUFFEY 2006 Post-Op Anti-Inflammatory

DUFFEY 2006 Post-Op Non-Steroidal

DUFFEY 2006 Do You Intra-operatively Measure Flap Thickness? *

DUFFEY 2006 Preferred Flap Thickness (when no other constraints) * *

DUFFEY 2006 Minimum Residual Stromal Bed Thickness Requirement *

DUFFEY 2006 Total Cases of Post LASIK Ectasia as the Primary Surgeon in Career 79x8=632 cases in ASCRS. Total ASCRS LASIK 7.4M eyes done in U.S. since Thus, 1 per 11,500 eyes. *tends to underestimate

DUFFEY 2006 Minimum Preop Corneal Pachymetry for LASIK (all other parameters normal) * * *

DUFFEY 2006 Minimum Final Corneal Thickness Allowable Following PRK (including epithelium)

DUFFEY 2006 Mitomycin-C Use (MMC) *

DUFFEY 2006 Will You Perform Refractive Surgery on One-Eyed Patients *

DUFFEY 2006 Comanagement

DUFFEY 2006 When Co-managed, Who Sees Postop LASIK Patient on Day 1 ?

DUFFEY 2006 Minimum “OR” Location for Phakic-IOL Surgery *

DUFFEY 2006 Refractive Surgery Volumes (extrapolated data in thousands) *

DUFFEY 2006 ’06 ASCRS Survey Conclusions n Volume of LVC (U.S.) in 2006: 1.23 M eyes (1.09M in ’05) n LASIK dominates between -8D and +3D. n Bilateral extraocular sx same O.R. visit is SOC. n P-IOL (27%) and LASIK (20%) in high myopes. n RLE (51%) for high hyperopes. n LASIK, LASEK, Epi-LASIK, RLE, P-IOL, PRK, CK, and LRI all with apparent bright futures.

DUFFEY 2006 Conclusions continued... n VisX still at > 3:1 (76%) over all other lasers combined. n Occulus Pentacam at 5% usage amongst members. n Intralase is increasing market share (17%), but mechanical microkeratomes still dominate (83%). n Wavefront custom ablations are increasing with 90% of surgeons performing them (74% last year).

DUFFEY 2006 Conclusions continued... n Fourth generation fluoroquinolones (97%) dominate the post-refractive surg. market (Z>V). n 22% penetration of modern refractive surgery amongst refractive surgeons; small growth. n More than one-quarter of refractive surgeons (28%) measure true flap thickness in the OR. n 61% (dropping) think 250 microns is adequate for RST. n Most desired flap thickness is microns. 100 micron flap thickness is favored by 16% of surgeons (up from 11%). n 42% of surgeons not OK with LASIK in corneas <500 um.

DUFFEY 2006 Conclusions continued... n 75% (rising) use MMC for prophylaxis and/or haze. n 36% OK with refractive surgery on one-eyed pt. n 11% of respondents are OK with bilateral P-IOL (6% last year) and 3% with RLE at the same surgical setting. n Monovision is the most sought goal for presbyopic patients seeking refract surgery (39%), but 32% are now implanting modern presbyopic IOL’s (25% last year). n ReStor (20%) and ReZoom (8%) IOL’s quickly out-paced the accommodative IOL (4%) for preferred lens-based presbyopia option.

DUFFEY 2006 Conclusions continued... n ASC OR is preferred location for P-IOL surgery (89%). 6% OK with “In Office” modified OR and 3% OK with clean LASIK room. n Less than one-half of surgeons surveyed (48%) have had a documented case of post-LASIK ectasia in his/her surgical patients over a career. n Co-management is practiced by one-third of respondents overall with 2/3 of these comanaging fewer than one-third of their patients. n When comanageing with another doctor, 74% of surgeons see their own patients on the first post-op day.

DUFFEY ASCRS SUMMARY n Volume of LVC (U.S.) in 2006: 1.24 M eyes (1.09M in ’05). 9 M since n P-IOL (27%) and LASIK (20%) in high myopes. n VisX still at > 3:1 (76%) over all other lasers n Ectasia rate of 1 case per 11,500 eyes in U.S. n Wavefront custom ablations are increasing with 90% of surgeons performing them (74% last year). n 22% penetration of modern refractive surgery amongst refractive surgeons; small growth.

DUFFEY ASCRS SUMMARY n Most desired flap thickness is microns. 100 micron flap thickness is favored by 16% of surgeons (up from 11%). n 75% (rising) use MMC for prophylaxis / haze. n Epi-LASIK and Advanced Surface Ablation on the rise. n 11% of respondents are OK with bilateral P-IOL (6% last year) and 3% with RLE at the same surgical setting. n ReStor (20%) and ReZoom (8%) IOL’s quickly out-paced the accommodative IOL (4%) for preferred lens-based presbyopia option.

Thanks to ASCRS leadership for their support and for your participation in the 2006 Survey We look forward to your responses in the 2007 survey this autumn. Complete results on Monday at