1. US Trends in Refractive Surgery: The 2006 ISRS/AAO Survey Richard J. Duffey, MD ** David Leaming, MD ISRS / AAO Meeting Las Vegas- November 11, 2006 ** Author receives some travel expenses from TLCV ** TLCV provided partial funding for this survey

2. DUFFEY 2006 Why is this presentation LAST? ä Saving the best for last…flattering but NO ä Least damaging to attendance... Probably Not ä Data just arrived via email from Analyze yesterday and is literally…Hot Off the Press

3. DUFFEY 2006 2006 Survey ä August mailing to 1500 U.S. members of ISRS/AAO. ä 167 responses analyzed by October 1st for 11% of the U.S. ISRS/AAO membership. ä Tenth year of refractive data collection. ä Alphabet soup of refractive surgery. ä Many new questions on flap thickness preference and measurements, MMC use, enhancement tests, one-eyed patients, ectasia, co-management, SOC, etc., etc.

4. DUFFEY 2006 I Am Currently Doing This Surgery

5. DUFFEY 2006 > 5 Cases / Month

6. DUFFEY 2006 > 25 Cases / Month

7. DUFFEY 2006 > 75 Cases / Month

8. DUFFEY 2006 Preferred Surgery For 30 yo -12.00 Diopter Myope

9. DUFFEY 2006 Preferred Surgery For 30 yo -10.00 Diopter Myope *

10. DUFFEY 2006 Preferred Surgery For 45 yo +3.00 D Hyperope

11. DUFFEY 2006 Preferred Surgery For 45 yo +5.00 D Hyperope *

12. DUFFEY 2006 Surgery Done Bilateral At Same O.R. Visit

13. DUFFEY 2006 Procedure Future Index (Doing Now and/or Plan in Future)

14. DUFFEY 2006 Had Refractive Surgery Performed on Yourself 32%

15. DUFFEY 2006 Excimer Laser Most Commonly Used

16. DUFFEY 2006 Microkeratome Most Commonly Used 27 33

17. DUFFEY 2006 Topography Unit Most Commonly Used *

18. DUFFEY 2006 Epi-Keratome Use

19. DUFFEY 2006 Pupil Gauge Instrument Use

20. DUFFEY 2006 Preferred Surgery for Presbyopia

21. DUFFEY 2006 Wavefront Analyzer

22. DUFFEY 2006 Wavefront-Guided Custom Ablations in Your Practice

23. DUFFEY 2006 Comanagement

24. DUFFEY 2006 Do You Intra-operatively Measure Flap Thickness?

25. DUFFEY 2006 When Did You Start Measuring?

26. DUFFEY 2006 Preferred Flap Thickness (when no other constraints)

27. DUFFEY 2006 Minimum Residual Stromal Thickness Requirement for LASIK

28. DUFFEY 2006 Total Cases of Post LASIK Ectasia as the Primary Surgeon in Career

29. DUFFEY 2006 Minimum Cent. Corneal Pachymetry for LASIK (all other parameters normal) 80%

30. DUFFEY 2006 Mitomycin-C Use (MMC)

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

32. DUFFEY 2006 Post-Op Antibiotic

33. DUFFEY 2006 Post-Op Anti-inflammatory

34. DUFFEY 2006 Post-Op Steroid

35. DUFFEY 2006 Post-Op Nonsteroidals

36. DUFFEY 2006 Location of Phakic-IOL Surgery

37. DUFFEY 2006 ’06 ISRS/AAO Survey Conclusions ä LASIK dominates between -10D and +3D. ä P-IOL for higher than -10D myopes. ä RLE for high hyperopes (61%). ä Monovision is the most sought goal for presbyopic patients seeking refract surgery (42%), but 33% are now implanting modern presbyopic IOL’s. ä Trend toward thinner flaps (mechanical or laser). ä Almost one-third of us (32%) have had modern refractive surgery done on our own eyes!

38. DUFFEY 2006 King….Queen….Rising Prince ä LASIKPRKRLE ä VISX StarAlcon LADAR ------ ä HansaMoriaIntraLase ä Zeiss-HumOrbscanPentacam ä ReStorReZoom------ ä Zymar/Viga------------ ä Acular-LNevanac------

39. DUFFEY 2006 Conclusions continued... ä VisX still at > 2:1 over all other lasers. ä Intralase market share stabilizing (20%). ä Epi-Keratome users stable (18%). ä Stable 88% use wavefront analyzers. ä Stable 89% perform custom ablations…but at increasing frequencies (55% whenever possible).

40. DUFFEY 2006 Conclusions continued... ä Fourth generation fluoroquinolones dominate the post-refractive surgery market (97%). ä Co-management still on the rebound after several years of decline (increased from 40% to 56% from ’04 to ’06). ä 29% penetration of refractive surgery on self amongst refractive surgeons.

41. DUFFEY 2006 Conclusions continued... ä 37% of refractive surgeons now measuring true flap thickness in the OR. ä Less than half of surgeons surveyed (40%) have had a documented case of post-LASIK ectasia in his/her surgical patients over a career (11% with 3 or more). ä 64% think 250 microns is adequate for RST after LASIK. 36% recommend 275 microns. ä Most desired flap thickness is 120-130 microns.

42. DUFFEY 2006 Conclusions continued... ä 83% use MMC for prophylaxis and/or haze (up from 62% from 2 years ago). ä 45% OK with refractive surgery on one-eyed pt. ä Bilateral extraocular sx at same O.R. visit is SOC. ä 5% of respondents OK with bilateral P-IOL at the same surgical setting (down from 8% in past). ä ASC OR is preferred location for P-IOL surgery (79%). 15% OK with “In Office” modified OR.

43. Thanks to the ISRS/AAO leadership for their support and for your participation in the 2006 Survey We look forward to your response to the 2007 survey next fall Complete results at www.duffeylaser.com