1. Artemis tm II VHF Ultrasound for Sizing the Visian ICL ASCRS 2008 Philip C. Roholt, MD N. Canton, Ohio, USA The author has no proprietary interest in products discussed in this paper.

2. Artemis tm II  VHF (50K) Ultrasonic Biometry  High-resolution B-scan imaging  Integral immersion water bath system  Single-sweep 3D arc-scan for full sulcus-to- sulcus (SS) measurements  Infra-red video monitoring of pt eye position  Patented design, unique fixation device  In-line fixation optics  Reproducible visual axis centered scan

3. Visian tm ICL Sizing  External limbal white-to-white (WTW) is used  Poor correlation of WTW to sulcus-to-sulcus (STS) measurements  Cadaveric eyes 1  1 st generation UBM 2  No correlation of WTW to STS 3. “One size fits all would work better than using WTW.” Myopia R 2 =0.0165, Hyperopia R 2 =0.204  Angle-to-angle (ATA) is also not predictive of STS 3  Multivariate regression analysis:  age, sphere, cylinder, SEQ, WTW, ACD, avg K, pachymetry, ATA  Only ATA & ACD statistically significant  But, 95% confidence interval of predicting STS with this equation is ±0.91 mm  ie the error of estimating STS would be more than 0.91 mm in 5% cases 1.Werner, L et.al. Correlation between different measurements within the eye relative to phakic intraocular lens implantation. JCRS. 2004;30:1982 2.Pop, M et.al. Predicting sulcus size using ocular measurements. JCRS. 2001;27,1033. 3. Reinstein, D. Personal communication, Sept, 2007. 3. Reinstein, D. Personal communication, Sept, 2007.

4. Artemis UBM for STS Measurement  Artemis has been shown to be accurate, repeatable, and reproducible for SS measurements Reinstein, DZ. Accuracy, repeatability, and reproducibility of Artemis very high-frequency digital ultrasound arc-scan lateral dimension measurements. JRS. 2006;32:1799.

5. Artemis ICL Study  45 pts, 85 eyes examined with Artemis as part of complete pre-op workup  Artemis measurements included STS at the Theoretical Sulcus (TS) and ciliary processes (CP)  Post-op Measurements on 15 patients (28 eyes) with minimum 3 mo f/u.

6. Artemis ICL Study - Results PRE-OP  MR -9.75 D +/- 1.85 D  SE -6.0 to -14.5 D  ACA: m 35.19 o  Lens Radius m 10.11mm +/- 1.01mm  STS-TS: 11.081 mm sd 0.504  STS-CP: 10.462mm sd 0.476 mm POST-OP  MR -0.35 +/- 0.64 D  >20/20 83.2%  >20/40 100%  Gain > 1 line 28.2%  Vault: m 282u +/-106u (range 0 to 524u)  ACA: m 26.43 o  No loss BCVA  No ICL explantation

7. ICL Position as Imaged by Artemis  ICL haptic rests in the posterior ciliary sulcus, abutting against the ciliary processes  The ICL does not rest in the “Theoretical Sulcus.” (Usually reported as the STS)  CB acts as a “shock absorber” and is compressed by the pliable ICL haptic.

8. STS Measurements Published UBM STS Measurements  35 MHz Optikon Hiscan UBM 1 : STS-TS 11.32 +/- 0.72mm  50 MHz Artemis I 2 : STS-TS 12.32 +/- 0.10mm Current Study (Artemis tm II)  STS-TS: 11.08 +/- 0.504mm  STS-CP: 10.462 +/- 0.476  Measured STS is less in the current study 1.Oh J, Shin H, Kim J, et al. Direct measurement of the ciliary sulcus diameter by 35-Megahertz ultrasound biomicroscopy. Ophthalmology, 2007;114:1685-8 2.Rondeau MJ, Barcsay G, Silverman, R, et al. Very high frequency ultrasound biometry of the anterior and posterior chamber diameter. J Refract Surg 2004;20:454-64.

9. PreOp: OS STS 10.98 LRadius 8.08 OS Theoretical STS is longer than STS at ciliary process Pre-op VHF UBM for sizing the ICL

10. OS Vault 66u ICL 12.6 OS Note position of ICL haptics against ciliary process (arrows), not in “Theoretical Sulcus” Post-op VHF UBM with ICL Anterior ICL Posterior ICL

11. Accommodation and ICL  Recent reports of impairment of accomodation  Tanzer DJ. US FDA clinical trial of the toric implantable collamer lens for moderate to high myopic astigmatism. Paper presented at the AAO Annual Meeting. November 10, 2006, Las Vegas, NV.

12. Conclusions  Theoretical sulcus measurements in this study differed from other reports  STS is measured at the ciliary process for ICL estimation because of the actual haptic positioning  Ciliary body and processes act as a “shock absorber” and is compressed by the pliable ICL haptic. ICL may influence accommodation  Artemis is useful in imaging of anterior segment and specifically the ciliary sulcus and anterior lens, to aid in Visian ICL selection.