1. US Trends in Refractive Surgery: 2009 ASCRS Survey Richard J. Duffey, MD David Leaming, MD Boston: April 13, 2010

2. Disclosures The authors actually spend some of their own hard-earned dollars to cover the annual costs of this survey. The authors actually spend some of their own hard-earned dollars to cover the annual costs of this survey. Duffey 2010

3. 2009 ASCRS Survey Sept. emailing to 4768 U.S. members of ASCRS Sept. emailing to 4768 U.S. members of ASCRS First time totally ONLINE Survey First time totally ONLINE Survey 3778 opened emails with 518 responding representing 14% response rate in the U.S. [same average response with snail mail surveys] 3778 opened emails with 518 responding representing 14% response rate in the U.S. [same average response with snail mail surveys] Fourteenth year of refractive data collection allowing analysis and comparison of trends amongst ASCRS U.S. surgeons Fourteenth year of refractive data collection allowing analysis and comparison of trends amongst ASCRS U.S. surgeons Alphabet soup of refractive surgery. Alphabet soup of refractive surgery. Added questions in recent years as the field has incorporated new laser and refractive technologies including premium IOL’s, astigmatism correction, etc. Added questions in recent years as the field has incorporated new laser and refractive technologies including premium IOL’s, astigmatism correction, etc. Duffey 2010

4. Preferred Surgery for 30 yo -10.00 Diopter Myope Duffey 2010

5. Preferred Surgery for 45 yo +3.00 D Hyperope Duffey 2010

6. Preferred Surgery for 45 yo +5.00 D Hyperope Duffey 2010

7. Microkeratome Used Most Duffey 2010

8. Excimer Used Most Duffey 2010

9. Wavefront Analyzer Duffey 2010

10. Wavefront-Guided Custom Ablations in Your Practice Duffey 2010

11. Preferred Surgery for Presbyopia (Pre-cataract) Duffey 2010

12. Post-Op Antibiotic Duffey 2010

13. Post-Op Anti-inflammatory Duffey 2010

14. Post-Op Non-Steroidal Duffey 2010

15. Do You Intra-operatively Measure Flap Thickness? Duffey 2010

16. Preferred Flap Thickness (when no other constraints) Duffey 2010

17. Minimum Residual Stromal Bed Thickness Requirement Duffey 2010

18. Total Cases of Post-LASIK Ectasia as the Primary Surgeon in Career Duffey 2010

19. Minimum Preop Corneal Pachymetry for LASIK (all other parameters normal) Duffey 2010

20. Minimum Final Corneal Thickness Allowable Following PRK (including epithelium) Duffey 2010

21. Mitomycin-C Use (MMC) Duffey 2010

22. Will Perform Refractive Surgery On One-Eyed Patients Duffey 2010

23. Comanagement

24. When Comanaged, who sees Postop LASIK Patient on Day 1 ? Duffey 2010

25. Minimum “OR” Location for Phakic-IOL Surgery Duffey 2010

26. Refractive Surgery Volumes (extrapolated data in thousands) Duffey 2010

27. ’09 ASCRS Survey Conclusions Volume of LVC (U.S.) in 2009: 754,000 eyes (1.066 M in ’05). Down 30% over past 4 years. Volume of LVC (U.S.) in 2009: 754,000 eyes (1.066 M in ’05). Down 30% over past 4 years. LASIK dominates between -8D and +3D. LASIK dominates between -8D and +3D. Bilateral extraocular sx at same O.R. visit is SOC. Bilateral extraocular sx at same O.R. visit is SOC. P-IOL (37%) and LASIK (22%) in high myopes. P-IOL (37%) and LASIK (22%) in high myopes. RLE (54%) for high hyperopes. RLE (54%) for high hyperopes.

28. Duffey 2010 Conclusions continued... VisX still at > 3:1 (74%) over all other lasers combined. Wavelight up to 19%. VisX still at > 3:1 (74%) over all other lasers combined. Wavelight up to 19%. Occulus Pentacam at 23% usage amongst members in 2008 (5% three years ago…no data this year). Occulus Pentacam at 23% usage amongst members in 2008 (5% three years ago…no data this year). Femtosecond lasers for the first time dominate market share at 55%. Femtosecond lasers for the first time dominate market share at 55%. Fourth generation fluroquinolones (95%) dominate the post-refractive surg. market (Z>V). Fourth generation fluroquinolones (95%) dominate the post-refractive surg. market (Z>V).

29. Duffey 2010 Conclusions continued... One-third of refractive surgeons (32%) measure true flap thickness in the OR. One-third of refractive surgeons (32%) measure true flap thickness in the OR. 39% (still dropping) think 250 microns is adequate for RST. 60% say 275-300 microns is better (21% in ’04). 39% (still dropping) think 250 microns is adequate for RST. 60% say 275-300 microns is better (21% in ’04). Most desired flap thickness is 120-130 microns (53%). 100 micron flap thickness is favored by 35% of surgeons (up from 11% four years ago). Most desired flap thickness is 120-130 microns (53%). 100 micron flap thickness is favored by 35% of surgeons (up from 11% four years ago). 46% of surgeons NOT OK with LASIK in corneas <500 um. 46% of surgeons NOT OK with LASIK in corneas <500 um.

30. Duffey 2010 Conclusions continued... 88% (stable) use MMC for prophylaxis and/or haze. 88% (stable) use MMC for prophylaxis and/or haze. 47% (increasing) OK with refractive surgery on one-eyed pt. 47% (increasing) OK with refractive surgery on one-eyed pt. 16% of respondents are OK with bilateral P-IOL (11% three years ago) and 6% with RLE at the same surgical setting. 16% of respondents are OK with bilateral P-IOL (11% three years ago) and 6% with RLE at the same surgical setting. Monovision is the most sought goal for presbyopic pre- cataract patients seeking refractive surgery (49%). Monovision is the most sought goal for presbyopic pre- cataract patients seeking refractive surgery (49%).

31. Duffey 2010 Conclusions continued... ASC OR is preferred location for P-IOL surgery (85%). ASC OR is preferred location for P-IOL surgery (85%). Still only about one-third of surgeons surveyed (36%) have had one or more documented cases of post-LASIK ectasia in his/her surgical patients over a career. (Not Growing!) Still only about one-third of surgeons surveyed (36%) have had one or more documented cases of post-LASIK ectasia in his/her surgical patients over a career. (Not Growing!) Co-management is practiced by one-half of respondents overall (50%) with most of these co-managing fewer than one-third of their patients. Co-management is practiced by one-half of respondents overall (50%) with most of these co-managing fewer than one-third of their patients. When co-managing with another doctor, 82% of surgeons see their own patients on the first post-op day. When co-managing with another doctor, 82% of surgeons see their own patients on the first post-op day.

32. Duffey 2010 2009 ASCRS SUMMARY U.S. membership volume of LVC in 2009 decreased to 754,000 eyes. Total of 12-13 million since 1996 within ASCRS. U.S. membership volume of LVC in 2009 decreased to 754,000 eyes. Total of 12-13 million since 1996 within ASCRS. Volume down 30% over past four years. Volume down 30% over past four years. VisX still at > 3:1 (74%) over all other lasers combined. Wavelight increased to 19%. VisX still at > 3:1 (74%) over all other lasers combined. Wavelight increased to 19%. Femtosecond lasers for the first time dominate market share at 55%. Femtosecond lasers for the first time dominate market share at 55%. Greater than 30% penetration of modern refractive surgery amongst refractive surgeons (no data on surgeon family members this year). Greater than 30% penetration of modern refractive surgery amongst refractive surgeons (no data on surgeon family members this year).

33. Duffey 2010 2009 ASCRS SUMMARY P-IOL (37%) and LASIK (22%) in high myopes. RLE (54%) for high hyperopes. P-IOL (37%) and LASIK (22%) in high myopes. RLE (54%) for high hyperopes. Most desired flap thickness is 120-130 microns (53%). 100 micron flap thickness is favored by 35% of surgeons (up from 11% four years ago). Most desired flap thickness is 120-130 microns (53%). 100 micron flap thickness is favored by 35% of surgeons (up from 11% four years ago). 39% (still dropping) think 250 microns is adequate for RST. 60% say 275-300 microns is better (21% in ’04). 39% (still dropping) think 250 microns is adequate for RST. 60% say 275-300 microns is better (21% in ’04). 16% of respondents are OK with bilateral P-IOL (11% three years ago) and 6% with RLE at the same surgical setting. 16% of respondents are OK with bilateral P-IOL (11% three years ago) and 6% with RLE at the same surgical setting.

34. 2009 ASCRS SUMMARY 46% of surgeons NOT OK with LASIK in corneas <500 um. 46% of surgeons NOT OK with LASIK in corneas <500 um. Still only about one-third of surgeons surveyed (36%) have had one or more documented cases of post-LASIK ectasia in his/her surgical patients over a career. (Not Growing) Still only about one-third of surgeons surveyed (36%) have had one or more documented cases of post-LASIK ectasia in his/her surgical patients over a career. (Not Growing) Duffey 2010

35. Thanks to ASCRS leadership for their support and for your participation in the 2009 Survey We look forward to your responses in the 2010 ONLINE survey this autumn. Complete results since 1997 now available at www.duffeylaser.com