1. Financial Disclosure Calhoun Vision consultant, equity Clarity Massey Labs consultant, equity

2. Cornea and Anterior Segment Imaging OCT: Diagnosis and Surgical Planning Ronald E. Smith, M.D. Doheny Eye Institute USC Keck School of Medicine

4. OCT now approaches histology in resolution Normal retina imaged by RTVue OCT (5 micron resolution) Histology of human retina

5. Optical coherence tomography (OCT) has higher resolution than other imaging modalities. 1 mm 100  m 10  m 1  m OCT Ultrasound Axial Resolution (FWHM) CT MRI

6. There is a revolution in OCT technology – speed is taking off!

7. A generational leap RTVue has 65x speed & 2x resolution of Stratus Zeiss OCT1/2 1996 Zeiss Stratus 2002 OptoVue RTVue 2006 26,000 400 100 16 10 5 Speed (A-scans /sec) Resolution (  m) Fourier domain Time domain

8. FD OCT Simultaneous 2048 pixels at a time TD OCT Sequential 1 pixel at a time Higher speed, higher definition and higher signal. 1024 A-scans in 0.04 sec 512 A-scans in 1.28 sec Motion artifact Small blood vessels IS/OS Choroidal vessels

9. Optical Coherence Tomography (OCT) Retinal OCT –In common clinical usage –Macular diseases –Glaucoma Corneal and Anterior Segment OCT (CAS-OCT) –Early clinical development –Keratorefractive surgery –AC-IOL planning –Narrow Angle –Other surgical anatomy and pathologies

10. OCT is used to for anterior eye diseases and surgery as well LASIK Lens implantation Seeing through opaque cornea Narrow angle glaucoma

11. Higher resolution allows better visualization of LASIK flap 4 months after LASIK with Moria CB Average of 16 frames

12. CAS-OCT in LASIK Planning Corneal thickness map –Determine available ablation depth –Distinguish FF keratoconus from warpage Flap & stromal bed thickness maps* –Distinguish ectasia from normal regression –Calculate available enhancement ablation depth * Not available on slit-scanning tomography

13. Scan Pattern for Corneal Mapping 8 x 10-mm radial line scans 3-D reconstruction

14. Conclusion: OCT Pachymetry Map Excellent repeatability (SD < 2  m) Agrees well with ultrasound OCT (1%) Agrees well with programmed ablation depth (5%, better than ultrasound) Useful in confirming keratoconus

15. Post-LASIK interface fluid & epithelial ingrowth 056-CP Fibrosis Epithelial ingrowth Fluid

16. Case 2 Unrecognized Keratectasia Consulted for poor vision OS LASIK OU 9 years ago 2 enhancements OS MR - 1.00 +0.75 x 60º 20/40 OS

17. Cornea Stroma LASIK Flap OS 217 244 461

18. Case 2 Conclusions Keratectasia –LASIK enhancement not advised –RGP v. Intacs OCT shows –Thick flap –Thin residual posterior stromal bed: may be cause or result of keratectasia

19. Intacs

20. CASE # 2 Opaque corneal graft and glaucoma

21. OCT: IOL synechiae & pupil block 0 degree-45 degree -90 degree-135 degree

22. DLEK (Jonathon Song, MD)

23. Linking OCT to lasers to performed the most precise corneal surgeries OCT scanning Corneal thickness map Femtosecond laser cutting Partial thickness corneal transplant

24. This will greatly benefits patients whose vision is limited by corneal irregularity and opacity (i.e. corneal scars and keratoconus) Deep corneal scar Advanced keratoconus

25. Anterior Segment OCT for Narrow Angle Glaucoma Vikás Chopra MD Assistant Professor Doheny Eye Institute Dept of Ophthalmology USC Keck School of Medicine

26. Results: Angle Configuration Pre- & Post-PI vs. post- CE/IOL

27. Example: Angle Configuration  in Dark and Light Conditions Room Lights ON Room Lights OFF

28. Conclusions: Narrow Angle Detection using AS-OCT AS-OCT has the potential for large-scale screening for narrow, occludable angles Rapid Non-contact Ease of image acquisition Ease of image analysis with custom software

29. Corneal & Anterior Segment OCT LASIK –Pachymetry map –Flap & stromal bed thickness Intacs implant depth Corneal opacity, edema Uveitis –AC cell counting Iris mass IOL –AC width –Corneal Clearance Accommodation Narrow angle glaucoma –Angle opening distance, TISA

30. Center for Ophthalmic Optics & Laser (COOL) David Huang, MD, PhD Maolong Tang, PhDYan Li, MS Ou Tan, PhD Sylvia Ramos, COA Yimin Wang, PhD Ake Lu, PhDJulie Schallhorn