1. U.S. Trends in Refractive Surgery: 2013 ISRS Survey Richard J. Duffey, MD David Leaming, MD Refractive Subspecialty Day New Orleans: November 15, 2013

2. The authors have no financial interests in this survey study. DUFFEY/LEAMING 2013

3. 2013 Survey ä ä Fifth year of ONLINE*** Survey ä ä E-mailed to 1150 U.S. ISRS members ä ä Seventeenth year of refractive data collection overall ä ä 144 responses analyzed by October 7, 2013 for 13% response of the membership e-mailed. ä ä Alphabet soup of refractive surgery including corneal and lens-based surgeries and premium refractive IOLs.

4. DUFFEY/LEAMING 2013 > 5 Cases / Month 28 50 23 * 38

5. DUFFEY/LEAMING 2013 > 25 Cases / Month 5 *

6. DUFFEY/LEAMING 2013 > 75 Cases / Month * Peaked in 2001

7. DUFFEY/LEAMING 2013 Preferred Surgery For a 30 yo -10.00 Diopter Myope * * 47% LVC

8. DUFFEY/LEAMING 2013 Preferred Surgery For a 45 yo +3.00 D Hyperope *58% LVC

9. DUFFEY/LEAMING 2013 Preferred Surgery For 45 yo +5.00 D Hyperope * * 13% LVC

10. DUFFEY/LEAMING 2013 Willing To Do Bilateral Surgery At Same O.R. Visit *

11. DUFFEY/LEAMING 2013 Had Refractive Surgery Performed on Yourself *40% Total

12. DUFFEY/LEAMING 2013 Family LVC Index: (LASIK or PRK Performed on Ourselves and Family Members) 26 * >3X the general population

13. DUFFEY/LEAMING 2013 Excimer Laser Most Commonly Used

14. DUFFEY/LEAMING 2013 Flapmaker Most Commonly Used * 73% femtoflaps

15. DUFFEY/LEAMING 2013 Topography Unit Most Commonly Used (some physicians use more than one equally)

16. DUFFEY/LEAMING 2013 Preferred Surgery for “Pre-Cataract” Presbyopia * *

17. DUFFEY/LEAMING 2013 Comanagement

18. DUFFEY/LEAMING 2013 Do You Routinely Measure Flap Thickness Intra-operatively ?

19. DUFFEY/LEAMING 2013 Preferred Flap Thickness (when no other constraints)

20. DUFFEY/LEAMING 2013 Minimum Residual Stromal Bed Thickness Requirement for LASIK * 61% at 275 microns or greater

21. DUFFEY/LEAMING 2013 Total Cases of Post LASIK Ectasia as the Primary Surgeon in Career * Not growing

22. DUFFEY/LEAMING 2013 Minimum Cent. Corneal Pachymetry for LASIK (all other parameters normal) * 59% OK with 480 or less

23. DUFFEY/LEAMING 2013 Mitomycin-C Use (MMC)

24. DUFFEY/LEAMING 2013 Will You Perform Refractive Surgery on One-Eyed Patients

25. DUFFEY/LEAMING 2013 Cataract/RLE Post-Op Antibiotic 65 89

26. DUFFEY/LEAMING 2013 LVC Post-Op Antibiotic 4 4 91

27. DUFFEY/LEAMING 2013 Cataract/RLE Post-Op Steroid

28. DUFFEY/LEAMING 2013 LVC Post-Op Steroid

29. DUFFEY/LEAMING 2013 Location of Phakic-IOL Surgery

30. Threshold of Astigmatism Offered Correction at Cataract Surgery DUFFEY/LEAMING 2013 *67% will offer to correct astigmatism when it reaches 0.75 D and 90% when it reaches 1.25 D

31. Procedure for Low Astigmatism Intervention (0.5 to 1.0 D) DUFFEY/LEAMING 2013 * 88% LRI/AK

32. Procedure for Medium Astigmatism Intervention (1.12 to 2.0 D) DUFFEY/LEAMING 2013 ? FS AK

33. Procedure for High Astigmatism Intervention (2.0 D plus) DUFFEY/LEAMING 2013

34. Do You Currently Perform CXL? DUFFEY/LEAMING 2013 *Not FDA approved

35. DUFFEY/LEAMING 2013 Total LVC Volume w/i ISRS (1000s) * No Change in Total LVC from 2012. Ratio of PRK / Total LVC approximately 25% over past four years.

36. DUFFEY/LEAMING 2013 2013 ISRS SUMMARY ä ä Fifth ONLINE ISRS SURVEY was a success with a 13% response rate. ä ä VisX (57%) losing further marketshare to Wavelight (34%). ä ä Still about 35% penetration of modern refractive surgery amongst refractive surgeons…. 3-4 X the general population. Family Index rates also continue to be high despite continued poor press regarding LVC in the public media over the past several years.

37. DUFFEY/LEAMING 2013 2013 ISRS SUMMARY ä ä 23% of respondents are OK with bilateral P-IOL and 8% with bilateral RLE at the same surgical setting (stable). ä ä Multifocal IOL (14%) over accommodative IOL (6%) as a preferred lens-based presbyopia option when used for RLE (stable). ä ä Femtosecond LASIK flaps still on the rise (73%)

38. DUFFEY/LEAMING 2013 2013 ISRS SUMMARY ä ä Thinner flaps dominate: 100 micron or less flaps are favored by 51% of surgeons (up from 12% in ‘04). ä ä Preferred RSB thickness is stable: 38% think 250 microns is adequate, but 62% recommend 275 microns or more. ä ä New post-LASIK ectasia cases continue to be on the decline with 47% stating no cases of their own patients in their career.

39. 2013 ISRS SUMMARY ä ä Pentacam (45%) and Z-H (43%) about equal and Orbscan II stable near 30%. ä ä LVC Volume unchanged from last survey within ISRS/AAO membership in 2012, but consistently down over past five years. ä ä Ratio of Surface Ablation / Total LVC stable near 25% over past four years. DUFFEY/LEAMING 2013

40. 2013 ISRS SUMMARY ä ä During cataract surgery 67% of surgeons will offer to correct astigmatism if it measures 0.75 D or more; 90% if 1.25 D or nore. ä ä LRI/AK preferred (87%) if K astigmatism <1.0D ä ä Toric IOL preferred (75%) if K astigmatism > 1.12D ä ä CXL offered by 27% of ISRS members surveyed in the U.S. (not FDA-approved). DUFFEY/LEAMING 2013

41. 2013 ISRS FINAL SUMMARY ä ä FemtoSesond Laser-assisted Refractive Cataract Surgery on the rise. ä ä FS, Toric and PresbyIOL are not high volume refractive surgeries yet like LASIK in its heyday, but on the rise. ä ä Multifocals trump Accomodative IOLs, but neither high penetration. ä ä More astigmatism management (even low amt.) in cataract surgery. ä ä Healthy LVC Family Indices amongst refractive surgeons themselves. ä ä Post-LVC ectasia on the further decline. DUFFEY/LEAMING 2013

42. www.duffeylaser.com Additional Data at www.duffeylaser.com ä ä Types and volumes of refractive surgeries currently being performed ä ä Mitomycin-C use ä ä Post-operative use of antibiotics, steroids and nonsteroidals ä ä Surgical venues for various procedures…and more DUFFEY/LEAMING 2013

43. Thanks to the ISRS leadership for their support and for your participation in the 2013 Survey We look forward to your response to our sixth ONLINE survey and the eighteenth survey overall next fall. ***Complete 17 years of survey results found at www.duffeylaser.com