Amo presbyopia training course

Physician CertificationPhysician Certification
forfor
CustomVueCustomVue™™
Presbyopic AblationsPresbyopic Ablations

PresbyopicPresbyopic
AblationsAblations
 Presbyopic corrections are enabledPresbyopic corrections are enabled
only in combination withonly in combination with CustomVueCustomVue
hyperopichyperopic corrections with or withoutcorrections with or without
astigmatism and Iris Registrationastigmatism and Iris Registration

AblationsAblations
 Recommended TreatmentRecommended Treatment Parameters:Parameters:
– Maximum WaveScanMaximum WaveScan™™
spheresphere ++4.504.50DD
– Maximum WaveScan cylinderMaximum WaveScan cylinder ++1.501.50DD
– Maximum SEMaximum SE ++44..5050DD

AblationsAblations
 PPresbyopic correction creates a multifocalresbyopic correction creates a multifocal
ablation thatablation that provides for a pupil-basedprovides for a pupil-based
central corneal steepening of approximatelycentral corneal steepening of approximately
1.0 D1.0 D
 This central cornealThis central corneal steepening has asteepening has a
variable effect on the patient’svariable effect on the patient’s readingreading
visionvision

AblationsAblations
 Patented VISX™
multifocal ablation profile
 VSS™
and VRR™
ablation technology used to
create subtle ablation shape change to
subject’s wavefront map
 Central zone steepened to provide near vision
 Peripheral zone targeted for distance vision

AblationsAblations
Patented VISX™
multifocal ablation
profile
The combination of the pupil-size
dependent central zone, the peripheral
zone, and the LASIK flap produces an
aspheric curve that expands the depth of
focus

AblationsAblations
Pre-operativePre-operative
EvaluationEvaluation

AblationsAblations
Pre-operative ExaminationPre-operative Examination
 WaveScanWaveScan™™
SystemSystem
– WaveScan exams with 6.0 mm pupils areWaveScan exams with 6.0 mm pupils are
preferred for treatmentspreferred for treatments
 The minimum pupil size of the wavefront-The minimum pupil size of the wavefront-
measurement must be > 5.0 mm to calculate ameasurement must be > 5.0 mm to calculate a
CustomVue treatmentCustomVue treatment
 Measurements with a pupil size < 5.0 mm will beMeasurements with a pupil size < 5.0 mm will be
unavailable for selectionunavailable for selection
 Wavefront diameter captures of greater than 7.0Wavefront diameter captures of greater than 7.0
mm will not allow presbyopic shape creation ormm will not allow presbyopic shape creation or
treatmenttreatment

AblationsAblations
WaveScanWaveScan™™
AcquisitionAcquisition
 Users are warned to carefully monitor the
wavefront diameter when using the
presbyopia software
 WaveScan measurements for presbyopia
should be done with a dark-adapted
physiologic pupil
 Pharmacologic pupil manipulation is
specifically NOT recommended as the
treatment is calculated as a percentage of
physiologic pupil size

AblationsAblations
 Contact Lens Use:Contact Lens Use:
– Soft contact lenses - discontinue lens wear atSoft contact lenses - discontinue lens wear at
leastleast twotwo weeks prior to examinationweeks prior to examination andand
treatmenttreatment
– Hard (PMMA) or RGP lenses - discontinue lensHard (PMMA) or RGP lenses - discontinue lens
wear at leastwear at least threethree weeks prior to examinationweeks prior to examination
andand treatment with stable keratometry andtreatment with stable keratometry and
refractionrefraction
 3 central keratometry readings and MR taken at 1 week3 central keratometry readings and MR taken at 1 week
intervals. The last two readings must not differ by > 0.5Dintervals. The last two readings must not differ by > 0.5D
– The WaveScanThe WaveScan™™
measurements should be stablemeasurements should be stable
prior to the treatmentprior to the treatment

AblationsAblations
 Visual AcuityVisual Acuity
– UCVA, BSCVAUCVA, BSCVA
 RefractionRefraction
– Manifest Refraction –Manifest Refraction –
 Hyperopia – Pushed plus techniqueHyperopia – Pushed plus technique
 Astigmatism - Jackson Cross Cylinder -Astigmatism - Jackson Cross Cylinder -
maximize magnitude of cylindermaximize magnitude of cylinder

AblationsAblations
 When comparing Manifest Refraction toWhen comparing Manifest Refraction to
Refraction use the 4 mmRefraction use the 4 mm
diameter WaveScan datadiameter WaveScan data
– This most closely approximates the MRThis most closely approximates the MR

AblationsAblations
Refraction TechniquesRefraction Techniques
 Cycloplegic Refraction (1% cyclopentolate)Cycloplegic Refraction (1% cyclopentolate)
 True cycloplegia eliminates accommodation andTrue cycloplegia eliminates accommodation and
allows appropriate refractive evaluation of:allows appropriate refractive evaluation of:
– Latent hyperopiaLatent hyperopia
 Critical in all HyperopesCritical in all Hyperopes

AblationsAblations
 The anticipated post-operative keratometryThe anticipated post-operative keratometry
value in any meridian must bevalue in any meridian must be << 50 D50 D
 To calculate the anticipated postoperative K’s
add the Mean Pre-Op Keratometry to the
Pre-Op MRSE
– Use Manual or Auto K’s
– Do not use “Sim K’s”

AblationsAblations
 KeratometryKeratometry
– K1 is the flat KK1 is the flat K
– K2 is the steep KK2 is the steep K
– K2 Axis is the axis of the steep KK2 Axis is the axis of the steep K
 Pupillary ExamPupillary Exam
– Bright and dim illumination measurementBright and dim illumination measurement
 Corneal Topography -Corneal Topography - necessarynecessary in allin all
patientspatients
– R/O Keratoconus or any other abnormalityR/O Keratoconus or any other abnormality
– R/O CL related abnormalitiesR/O CL related abnormalities
– Verify post-operative resultsVerify post-operative results

AblationsAblations
 Slit Lamp ExamSlit Lamp Exam
 TonometryTonometry
 PachymetryPachymetry
– Ultrasonic pachymetry required for LASIKUltrasonic pachymetry required for LASIK
 Dilated Media and Fundus ExamDilated Media and Fundus Exam

AblationsAblations
Surgical PlanningSurgical Planning
Surgical TechniqueSurgical Technique

CustomVue™ PresbyopicCustomVue™ Presbyopic
AblationsAblations
Treatment Design ScreenTreatment Design Screen
You must select LASIK or Surface PRK in theYou must select LASIK or Surface PRK in the
TREATMENT TYPE fieldTREATMENT TYPE field
The Presbyopia ablation is differentThe Presbyopia ablation is different
in LASIK vs. Surface PRKin LASIK vs. Surface PRK

AblationsAblations
Treatment Design ScreenTreatment Design Screen
Check theCheck the ENABLEENABLE box to enablebox to enable
a presbyopic correctiona presbyopic correction

AblationsAblations
Environmental ConditionsEnvironmental Conditions
 CustomVueCustomVue PresbyopicPresbyopic procedures areprocedures are
done with Variable Spot Scanningdone with Variable Spot Scanning
(VSS(VSS™™
) and Variable Repetit) and Variable Repetitiion Rateon Rate
(VRR(VRR™™
))
– Even though the repetition rate varies fromEven though the repetition rate varies from
6 to 20 Hz these treatments tend to be6 to 20 Hz these treatments tend to be
longer in duration than myopic treatmentslonger in duration than myopic treatments
 It is important to pay careful attention toIt is important to pay careful attention to
environmental conditionsenvironmental conditions

AblationsAblations
Environmental ConditionsEnvironmental Conditions
 Control of environmental conditions during CustomVueControl of environmental conditions during CustomVue
treatments is important. In previous U.S. FDA Multi-treatments is important. In previous U.S. FDA Multi-
Center Clinical Trials, the room conditions were:Center Clinical Trials, the room conditions were:
– Temperature ranged from 68ºF to 72ºFTemperature ranged from 68ºF to 72ºF (20(20ººC to 22.2C to 22.2ººC)C)
– Relative humidity ranged from 40% to 45%Relative humidity ranged from 40% to 45%
– Treatments performed atTreatments performed at >>75º were associated with less75º were associated with less
accurate outcomesaccurate outcomes
 Stability of temperature and humidity is importantStability of temperature and humidity is important

AblationsAblations
Iris Registration
 Iris pattern is uniqueIris pattern is unique
to each eyeto each eye
 IR aligns theIR aligns the
preoperativepreoperative
SystemSystem
and intra-operativeand intra-operative
STAR S4 IRSTAR S4 IR™™
System iris imagesSystem iris images

AblationsAblations
Iris Registration
Diagnostic measurement (mesopic)Diagnostic measurement (mesopic) LVC Treatment (photopic)LVC Treatment (photopic)
As the pupil changes size, its centroid may not remainAs the pupil changes size, its centroid may not remain
stationary, relative to the outer iris boundarystationary, relative to the outer iris boundary
Outer Iris BoundaryOuter Iris BoundaryFor International Use Only

AblationsAblations
Iris Registration (IR)
 IR is a critically important componentIR is a critically important component
of Presbyopia treatmentsof Presbyopia treatments
– Proper registration of wavefront-guidedProper registration of wavefront-guided
ablationablation
– Proper placement of the pupil-sizeProper placement of the pupil-size
dependent central zone relative to thedependent central zone relative to the
pupil centroidpupil centroid

HyperopiaHyperopia
Surgical TechniqueSurgical Technique
 Do not use a Chayet drain or similar deviceDo not use a Chayet drain or similar device
 Create and lift flapCreate and lift flap
 Align limbal marks with reticle hash marksAlign limbal marks with reticle hash marks
 Dry exposed stromal bed if there is fluidDry exposed stromal bed if there is fluid
accumulationaccumulation
 Perform ablationPerform ablation
 Interrupt ablation only if there is fluidInterrupt ablation only if there is fluid
accumulationaccumulation
 Replace flapReplace flap

VISXVISX™™
HyperopicHyperopic
Presbyopia Completion ofPresbyopia Completion of
CertificationCertification
Acknowledgement of Understanding:Acknowledgement of Understanding:
By checking the box below, IBy checking the box below, I
acknowledge I have read andacknowledge I have read and
understood this materialunderstood this material

Amo presbyopia training course

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