1. Accommodative Arching Eyeonics Briefing 2 February 2005 Kevin L. Waltz, OD, MD Eye Surgeons of Indiana Indianapolis, IN

2. Outline of Briefing Background Measurement limitations Historical assumptions Fortuitous patient Archeological evidence Theory fit with known data

3. Background for AA Theory KLW’s interest in refractive lens surgery Tracey experience since summer 2002 i Trace experience since fall 2003 i Trace experience since fall 2003 Experience with capsular effects on IOL’s KLW’s frustration with initial AT-45 outcomes Extensive wavefront testing of distance and near vision with IOL’s, including AT-45 pts

4. Array Eye for Tracey Review

5. Experience with Capsular/YAG Effects on Multifocal Optics 10 minutes 10 minutes Pre-YAG Post-YAG Pre-YAG Post-YAG 20/20 & J3 20/20 & J1 20/20 & J3 20/20 & J1

6. Experience with Monofocal IOL’s “Pseuodaccommodation”

7. Measurement Limitations Original Tracey 64 sequential spots i Trace sequential 256 spots i Trace sequential 256 spots Variable spot positioning on Tracey Tracey can readily measure wavefront at near Shack-Hartmann simultaneous spots NIPEK OPD simultaneous topo and wavefront COAS direct imaging

8. Historical Assumptions Near wavefront ignored Near wavefront assumed to be the same as distance with some amount of uniformly increased power Reading glasses = accommodation Low HOA @ distance = low HOA @ near Low HOA @ near is good

9. Zachary Waltz 13 yo OD – 5 D accommodation OD – No accommodation OD – No accommodation

10. Successful College Student 19yo OS – 5 D accommodation OS – No accommodation OS – No accommodation

11. Successful Medical Student S/P LASIK 23 yo OD – 5 D accommodation OD – No accommodation OD – No accommodation

12. Fortuitous Patient 72 year old white male cataract pt Desired to be less dependent on glasses Uneventful cataract surgery PO: Little to no near vision and myopic Repositioned IOL in bag at 7 weeks to decrease myopia, rotated IOL 90° Improved distance and near vision

13. Prior to IOL Rotation

14. Accommodation with Crystalens S/P IOL Rotation by 90 ° Distance refractive map Near refractive map Distance refractive map Near refractive map 0.186 rms total error 0.464 rms total errror 0.69+0.36X078 -2.37+0.92x008 0.186 rms total error 0.464 rms total errror 0.69+0.36X078 -2.37+0.92x008

15. Crystalens Accommodative Arching

16. AA at a Different Meridian 8:46

17. AA at a Different Meridian 8:47

18. AA Relaxed 8:52

19. AA relaxed 8:53

20. AA at Maximum 10 Diopters 8:54

21. Archeologiccal Evidence “The aberrations in some Tracey images are not compatible with high quality vision.”

22. Archeologiccal Evidence

23. Archeologiccal Evidence 46 yo Optometrist

24. Phakic Patients have AA 33 yo WF Preop Cataract

25. 50 yo Optometrist Preop Cataract

26. 17 yo Son of Optometrist

27. 17 yo w/ 5 Diopters Stimulus & 3.25 Diopters AA Response

28. 50 yo Optometrist Dilated PO #1

29. 50 yo Optometrist Dilated PO Week 3

30. 48 yo Prelex Preop Distance

31. 48 yo Prelex Preop Near 1.25 Diopters of “Accommodation”

32. AA Theory Fit With Known Data Images are almost certainly real Axial movement of 0.3 mm needed for 10 D of AA flexing over 2mm diameter Variations in Crystalens orientation relative to power axis in eye would create inconsistent measured near vision in patients Capsule effects might change with time

33. AA Theory Fit With Known Data Variations in IOL power with AA and emerging concept of neuroplasticity could explain inconsistency in measured accommodation measured accommodation vs vs observed near vision observed near vision