1. U.S. Trends in Refractive Surgery: 2015 ISRS Survey Richard J. Duffey, MD David Leaming, MD Refractive Subspecialty Day Las Vegas: November 13, 2015

2. The authors have no financial interests in this survey study. DUFFEY/LEAMING 2015

3. 2015 Survey ä ä Seventh year of ONLINE*** Survey ä ä E-mailed to 1022 U.S. ISRS members; 486 Opened ä ä Twentieth year of refractive data collection overall ä ä 55 responses analyzed by October 27, 2015 for 9.8% response of the membership’s opened e-mail requests ä ä Alphabet soup of refractive surgery including corneal and lens-based surgeries, premium IOLs, and FS cataract surg.

4. DUFFEY/LEAMING 2015 > 5 Cases / Month 4 45 47 * 4 58 56 11

5. DUFFEY/LEAMING 2015 > 25 Cases / Month 7 4 0 7 26 *

6. DUFFEY/LEAMING 2015 > 75 Cases / Month * Peaked in 2001

7. DUFFEY/LEAMING 2015 Preferred Surgery For a 30 yo -10.00 Diopter Myope * 44% LVC

8. DUFFEY/LEAMING 2015 Preferred Surgery For a 45 yo +3.00 D Hyperope *61% LVC 11 50 17 0 11

9. DUFFEY/LEAMING 2015 Preferred Surgery For 45 yo +5.00 D Hyperope 1010 2 6 *74 0 8

10. DUFFEY/LEAMING 2015 Willing To Do Bilateral Surgery At Same O.R. Visit * 15 10 27

11. DUFFEY/LEAMING 2015 Had Refractive Surgery Performed on Yourself *40% Total 30 2 0

12. DUFFEY/LEAMING 2015 Family LVC Index: (LASIK or PRK Performed on Yourself and Family Members) 28 * >3X the general population

13. DUFFEY/LEAMING 2015 Excimer Laser Most Commonly Used 2 2

14. FemtoSecond Cataract Laser Most Commonly Used 56 28 9 3

15. DUFFEY/LEAMING 2015 Flapmaker Most Commonly Used * 76% femtoflaps

16. DUFFEY/LEAMING 2015 Topography Unit Used (some physicians use more than one) 55 18

17. DUFFEY/LEAMING 2015 Preferred Surgery for “Pre-Cataract” Presbyopia 45 25 12 5 Other 11

18. DUFFEY/LEAMING 2015 Comanagement 48 52 11

19. DUFFEY/LEAMING 2015 Preferred Flap Thickness (when no other constraints) 0 54 46 0

20. DUFFEY/LEAMING 2015 Minimum Residual Stromal Bed Thickness Requirement for LASIK * 61% at 275 microns or greater 00 39 16 43 2 0

21. DUFFEY/LEAMING 2015 Total Cases of Post LASIK Ectasia as the Primary Surgeon in Career * Continued Decline 54 13 8 6 20 4

22. DUFFEY/LEAMING 2015 Minimum Cent. Corneal Pachymetry for LASIK (all other parameters normal) * 53% OK with 480 or less

23. DUFFEY/LEAMING 2015 Cataract/RLE Post-Op Antibiotic 33 94

24. DUFFEY/LEAMING 2015 LVC Post-Op Antibiotic 14 0 86

25. DUFFEY/LEAMING 2015 Cataract/RLE Post-Op Steroid

26. DUFFEY/LEAMING 2015 LVC Post-Op Steroid

27. Cat/RLE Post-OP Nonsteroidal 11 28 32 33 6

28. DUFFEY/LEAMING 2015 Location of Phakic-IOL Surgery

29. Threshold of Astigmatism Offered Correction at Cataract Surgery DUFFEY/LEAMING 2015 *68% will offer to correct astigmatism when it has reached 0.75 D and 97% when it has reached 1.25 D

30. Procedure for Low Astigmatism Intervention (0.5 to 1.0 D) DUFFEY/LEAMING 2015 * 86% LRI/AK

31. Procedure for Medium Astigmatism Intervention (1.12 to 2.0 D) DUFFEY/LEAMING 2015

32. Procedure for High Astigmatism Intervention (2.0 D plus) DUFFEY/LEAMING 2015

33. Do You Currently Perform CXL? DUFFEY/LEAMING 2015

34. Overview of Cataract Surgery: % of All Cases of All Surgeons DUFFEY/LEAMING 2015 63 12 16 8 17 29 8

35. Overview of FS Cataract Surgery: % of All FS Cases of All FS Surgeons DUFFEY/LEAMING 2015 38 25 90 93 71

36. DUFFEY/LEAMING 2015 Total LVC Volume in ISRS (x1000) *27% Decrease in Total LVC from 2014. *Ratio of PRK / Total LVC stable at 28%.

37. DUFFEY/LEAMING 2015 2015 ISRS SUMMARY ä ä Seventh ONLINE ISRS SURVEY was a marginal success with around 10% response rate. ä ä VisX (54%) stable marketshare ahead of Wavelight (40%). ä ä Still 30-33% penetration of modern refractive surgery amongst refractive surgeons…. 3-4 X the general population. Family Index rates also continue to be high.

38. DUFFEY/LEAMING 2015 2015 ISRS SUMMARY ä ä 27% of respondents are OK with bilateral P-IOL and 10% with bilateral RLE at the same surgical setting (slight increase). ä ä Multifocal IOL (17%) over accommodative IOL (8%) as a preferred lens-based presbyopia option when used for CE. ä ä Femtosecond LASIK flaps dominate and are stable at 76%.

39. DUFFEY/LEAMING 2015 2015 ISRS SUMMARY ä ä Thinner flaps dominate: 100 micron or less flaps are favored by 54% of surgeons (down from 68% in ‘14). ä ä Preferred RSB thickness is stable: 39% think 250 microns is adequate, but 61% recommend 275 microns or more. ä ä New post-LASIK ectasia cases are on the decline.

40. 2015 ISRS SUMMARY ä ä Pentacam (55%) and Z-H (50%) about equal and Orbscan II dropped off to 21%. ä ä LVC Volume down over 3 of the last 4 surveys in 2012 thru 2015. ä ä Ratio of Surface Ablation / Total LVC stable at 28% this year (22-29% over past five years). DUFFEY/LEAMING 2015

41. 2015 ISRS SUMMARY ä ä During cataract surgery 73% of surgeons will offer to correct astigmatism if it is 0.75 D or more; 95% if 1.25 D or more. ä ä LRI/AK (FS or manual) preferred (88%) if K astigmatism <1.0D ä ä Toric IOL preferred (73%) if K astigmatism > 1.12D ä ä CXL offered by 22% of ISRS members surveyed in the U.S. (not FDA-approved). DUFFEY/LEAMING 2015

42. 2015 ISRS FINAL SUMMARY ä ä FemtoSecond Laser-assisted Refractive Cataract Surgery up from 19% to 29% over the last year. ä ä FS, Toric and PresbyIOL are not high volume refractive surgeries yet like LASIK in its heyday, but moving forward. ä ä Multifocals trump Accommodative IOLs, but neither high penetration. ä ä More astigmatism management (even low) in cataract surgery. ä ä Healthy LVC and Premium IOL Family Indices amongst refractive surgeons themselves. ä ä Post-LVC ectasia on the decline. DUFFEY/LEAMING 2015

43. www.duffeylaser.com Additional Data at www.duffeylaser.com ä ä Types and volumes of refractive surgeries currently being performed. ä ä Post-operative use of antibiotics, steroids, and NSAIDs. ä ä Surgical venues for various procedures…and more. DUFFEY/LEAMING 2015

44. Thanks to the ISRS leadership for their support and for your participation in this Final 2015 Survey We Could Not Have Done It Without YOU!! ***Complete 20 years of survey results found at www.duffeylaser.com