Today s Optometrists. Basic Laser Principles. Anterior Segment Applications 11/16/2017. Professional Disclosures

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Professional Disclosures Laser Applications in Clinical Optometry COPE ID: 49115-LP Walter O.

1 Professional Disclosures Laser Applications in Clinical Optometry COPE ID: LP Walter O. Whitley, OD, MBA, FAAO Director of Optometric Services Virginia Eye Consultants Residency Program Supervisor PCO at Salus University Alcon: Advisory Board, Consultant, Research, Speaker Allergan: Advisory Board, Research, Speaker Bausch & Lomb: Advisory Board, Research, Speaker Beaver Visitec: Consultant Biotissue: Advisory Board, Speaker Ocusoft: Advisory Board Science Based Health: Advisory Board, Speaker Shire: Advisory Board, Speaker Sun Pharmaceuticals: Advisory Board TearLab Corporation: Advisory Board Tearscience: Speaker Virginia Eye Consultants Tertiary Referral Eye Care Since 1963 Today s Optometrists John D. Sheppard, MD, MMSc Stephen V. Scoper, MD David Salib, MD Elizabeth Yeu, MD Thomas J. Joly, MD, PhD Dayna M. Lago, MD Constance Okeke, MD, MSCE Jay Starling, MD Samantha Dewundara, MD Walter Whitley, OD, MBA, FAAO Cecelia Koetting, OD, FAAO Chris Kruthoff, OD, FAAO Jessica Schiffbauer, OD Kelsey Butler, OD To be on the cutting edge of optometry, you need to be on the cutting edge of science and technology Basic Laser Principles Photodisruption YAG Laser, Femto Photoablation PRK Photocoagulation - PRP Anterior Segment Applications YAG Laser Posterior Capsulotomy Phototherapeutic Keratectomy Corneal Transplantation Corneal Crosslinking??? Intense Pulse Light???? 1

YAG Capsulotomy Indications Decreased visual acuity Reduced contrast sensitivity Increased glare Poor view of fundus Small anterior capsulorhexis PAM shows improved acuity What Do Patient s Want to

Corneal scarring /edema that prevents a clear view during the procedure Placement of a glass intraocular lens during cataract surgery Presence of iritis Macular edema Previous retinal tears or

2 YAG Capsulotomy Indications Decreased visual acuity Reduced contrast sensitivity Increased glare Poor view of fundus Small anterior capsulorhexis PAM shows improved acuity What Do Patient s Want to Know? What is it? Why did I get it? How is it treated? ATIOL Considerations YLC Contraindications Does the BCVA Make Sense? Corneal scarring /edema that prevents a clear view during the procedure Placement of a glass intraocular lens during cataract surgery Presence of iritis Macular edema Previous retinal tears or detachments Early postoperative period Glaucoma patients YLC Procedure Dilation Apraclonidine 1% Power setting Mild haze mjoules Moderate haze 1.5 mjoules Dense haze 2.2 mjoules Q-switched vs. mode-locked Focus just deep to the capsule/iol interface Create window through posterior capsule Follow Up 90 day global period Consider medications inflammation/iop Check refraction IOP Presence of inflammation Dilation Anything else? 2

$lens Refractive Surgery Applications LASIK PRK Cataract Surgery Lenticule Extraction Intrastromal Corneal Reshaping Corneal inlays Lens Bleaching The Femto Phaco Market 100% 90% 80% 70% 60% 50% 40%$ $30% 20% 10% High Patient Expectations in Cataract Refractive Surgery Cataract Outcomes*** 41% 71% 97% Patient expectations are at an all-time high for refractive surgery Positive experiences with$

3 YLC Complications Transient intraocular pressure elevation Iritis Retinal tears and detachments Macular edema Corneal edema Intraocular lens dislocation into the vitreous Pitting of the intraocular lens Refractive Surgery Applications LASIK PRK Cataract Surgery Lenticule Extraction Intrastromal Corneal Reshaping Corneal inlays Lens Bleaching The Femto Phaco Market 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% High Patient Expectations in Cataract Refractive Surgery Cataract Outcomes*** 41% 71% 97% Patient expectations are at an all-time high for refractive surgery Positive experiences with LASIK have produced high expectations, at a minimum achieving: 92.6% of LASIK patients with vision of 20/40 or better* 95.4% of patients satisfied with their outcome after LASIK surgery** Cataract surgery outcomes may not be meeting the target of ±0.5D that is considered the standard 0% ±0.25D ±0.5D ±1.0D * LASIK Surgery Statistics. Docshop.com. **Solomon, K et al. (2009) LASIK world literature review: quality of life and patient satisfaction. Ophthalmology. 16(4): ***Graph: Data from Dr. Warren Hill & Behndig A, et al. Aiming for emmetropia after cataract surgery: Swedish National Cataract Register study. J Cataract Refract Surg. 2012;38(7): VRN13066SK 16 8/13 Limitations of Traditional Cataract Surgery 10-40% 2-12% 4-10% 1-5% 1-2% 0.6-2% 0.3% 0.3% 0.1% Traditional Cataract Surgery: Common Complications Posterior capsule opacification Transient cystoid macular edema Corneal endothelial cell loss Vitreous prolapse or loss Persistent cystoid macular edema Retinal detachment IOL Malposition Consecutive corneal transplantation Endophthalmitis 7 3

$Quality = Safety Improved Refractive Cataract Surgery Fewer Wound Leaks Lower Endophthalmitis Rates Fewer Corneal Abrasions, Less PO Pain More Predictable PO Astigmatism LRIs arcuate & without$ $Refractive Procedure IOL Position Predictability Uniform Shape and Size Capsulotomy Norrby SJ, J Cataract Refract Surg 2008;34:368 376 Corneal Astigmatism Reproducible Corneal Entry and Arcuate$ 8 Manual Clear Corneal Incisions Laser Corneal Incisions Dynamics of wound architecture created with handheld instruments 1 Imprecise tunnel length and geometry Frequently require stromal

8 Manual Clear Corneal Incisions Laser Corneal Incisions Dynamics of wound architecture created with handheld instruments 1 Imprecise tunnel length and geometry Frequently require stromal

$Dynamics of small-incision clear cornea wounds after phacoemulsification surgery using optical coherence tomography in the early postoperative period, J Refract Surg, 2008;24(1):46-9.$ 2Taban M, Behrens A, Newcomb RL, Nobe MY, Saedi G, Sweet PM, McDonnell PJ. Acute endophthalmitis following cataract surgery: a systematic review of the literature, Arch Ophthalmol.

2Taban M, Behrens A, Newcomb RL, Nobe MY, Saedi G, Sweet PM, McDonnell PJ. Acute endophthalmitis following cataract surgery: a systematic review of the literature, Arch Ophthalmol.

Customized wound architecture and placement LSX11513SK Self-sealing incisions 12 Effective Lens Position (ELP) The key to highly accurate IOL power calculation is being able to correctly predict

$ELP is assumed value, from empirical data A constant and surgeon factor A significant source of IOL power error and key to post surgery refraction 3 Size of capsulorhexis effects ELP 4 1 Haigis$

4 Quality = Safety Improved Refractive Cataract Surgery Fewer Wound Leaks Lower Endophthalmitis Rates Fewer Corneal Abrasions, Less PO Pain More Predictable PO Astigmatism LRIs arcuate & without induced Dry Eye Less IOL Decentration & IOL Tilt Fewer YAG Capsulotomies Less Phaco Time Fewer Ruptured Posterior Capsules Lower Endothelial Cell Loss Address Major Requirements for Improved Refractive Procedure IOL Position Predictability Uniform Shape and Size Capsulotomy Norrby SJ, J Cataract Refract Surg 2008;34: Corneal Astigmatism Reproducible Corneal Entry and Arcuate Incisions Hill WJ, J Cataract Refract Surg 2008;34: Early Wow Factor Reduced Phaco Power and Corneal Edema Devgan U, Current Opinions in Ophthalmology 2011;18: Manual Clear Corneal Incisions Laser Corneal Incisions Dynamics of wound architecture created with handheld instruments 1 Imprecise tunnel length and geometry Frequently require stromal hydration to seal May result in cascading intraoperative difficulties (fluid control, anterior chamber maintenance) Incisions may be unstable at low IOPs Recent literature suggests an increased incidence of post-op infection 2 1Behrens A, Stark WJ, Pratzer KA, McDonnell PJ. Dynamics of small-incision clear cornea wounds after phacoemulsification surgery using optical coherence tomography in the early postoperative period, J Refract Surg, 2008;24(1): Taban M, Behrens A, Newcomb RL, Nobe MY, Saedi G, Sweet PM, McDonnell PJ. Acute endophthalmitis following cataract surgery: a systematic review of the literature, Arch Ophthalmol. 2005;123(5): Customized wound architecture and placement LSX11513SK Self-sealing incisions 12 Effective Lens Position (ELP) The key to highly accurate IOL power calculation is being able to correctly predict ELP for any given patient and IOL 1 Does Capsulotomy Size Impact Effective Lens Position? ELP is assumed value, from empirical data A constant and surgeon factor A significant source of IOL power error and key to post surgery refraction 3 Size of capsulorhexis effects ELP 4 1 Haigis W, Lege B, Miller N, Schneider B, Comparison of immersion ultrasound biometry and partial coherence interferometry for IOL calculation according to Haigis, Graefes, Arch Clin Exp Ophthalmol, 2000;238: Norrby S, Sources of error in intraocular lens power calculation,j Cataract Refract Surg, 2008;34: Hill WE, Does the Capsulorrhexis Affect Refractive Outcomes? In Chang D, editor: Cataract and Refractive Surgery Today, LSX11513SK 2009:78. 4 Cekiç O, Batman C, The relationship between capsulorhexis size and anterior chamber depth relation. Ophthalmic Surg Lasers, 1999;30(3): Erratum in: Ophthalmic Surg Lasers,1999;30(9):

Factors Affecting IOL Predictability 1 If IOL is

lens will produce only 20 D of correction

5 mm anterior to the assumed plane, a 21 D lens

Capsulotomy Results 1 Norrby S, Sources of error

$Refract Surg, 2008;34:368-376.$ diameter: < ± 0.

of capsule No adverse events Less PCO formation

utilized for the softer lens, enables removal

efficiently fragments the lens for removal with

manual rhexis achieved diameter accuracy of +/-

5 Factors Affecting IOL Predictability 1 If IOL is 0.5 mm posterior to the assumed plane, a 21 D lens will produce only 20 D of correction Hyperopic If IOL is 0.5 mm anterior to the assumed plane, a 21 D lens will produce 22 D of correction Myopic Laser Capsulotomy Results 1 Norrby S, Sources of error in intraocular lens power calculation,j Cataract Refract Surg, 2008;34: LSX11513SK Perfect centration Precision diameter: < ± 0.25 mm No radial tears Easy and complete removal of capsule No adverse events Less PCO formation 14 Laser Fragmentation Cylinder pattern, utilized for the softer lens, enables removal with I & A only, no phaco power Chop pattern efficiently fragments the lens for removal with reduced phaco power and time 1 Only 20% of manual rhexis achieved diameter accuracy of +/- 0.25mm Astigmatism More Prevalent than Recognized Lane, Stephen, M.D. Toric IOLs Pearls for Success. Cataract & Refractive Surgery Today. August Pgs

$Addressing Astigmatism Differentiate corneal cylinder from refractive cylinder$ Corneal topography IOL Master Lenstar Cassini Basics of Corneal Incisions Corneal

Corneal topography IOL Master Lenstar Cassini Basics of Corneal Incisions Corneal

incisions Deeper cuts Paired incisions Arcuate Incisions Arcuate Incisions Manually

control Unpredictable effect due to imprecise wound architecture and depth No

ripples) Precise, reproducible Arc shape Arc length Diameter 20 Steinert RF,

Multi-Planar, Self-Sealing Incisions, ASCRS 2010, Boston LSX11513SK 22 Prediction

27% 27% Less 18% 15% More Less 15% LenSx Manual 9% 12% 9% 0% 0% 0% 5% 4% 0% 4% -1-0.

6 Addressing Astigmatism Differentiate corneal cylinder from refractive cylinder Corneal Lenticular Mixed Accurate / consistent measurements Manual keratometry Corneal topography IOL Master Lenstar Cassini Basics of Corneal Incisions Corneal coupling 1:1 ratio More flattening Larger incisions Central incisions Penetrating incisions Deeper cuts Paired incisions Arcuate Incisions Arcuate Incisions Manually executed by tracing corneal marks with handheld diamond knife Inconsistent depth control Unpredictable effect due to imprecise wound architecture and depth No image-guided surgical planning or visualization Square edge Uniform depth (no ripples) Precise, reproducible Arc shape Arc length Diameter 20 Steinert RF, Application of the Femtosecond Laser in Cataract Surgery for the Creation of Multi-Planar, Self-Sealing Incisions, ASCRS 2010, Boston LSX11513SK 22 Prediction Error Distribution Hyperopic Frequency Distribution (%) of Eyes 32% Myopic 23% More 27% 27% Less 18% 15% More Less 15% LenSx Manual 9% 12% 9% 0% 0% 0% 5% 4% 0% 4% LSX11513SK Spherical Equivalent Prediction Error (D) = Pred. Ref. - Actual 1M PostOP Ref. 27 6

Postoperative Considerations Normal postoperative course One day One week One month Three months Educate patients on postoperative expectations

Anterior & Posterior Capsule Polishing Posterior Capsulotomy Paracentesis Vitreolysis Glaucoma Surgery: Goniotomy, Trabeculotomy & Trabeculoplasty

inlay; commercially available in 50 countries Raindrop Near Vision Inlay Effective, Reliable and Safe Presbyopia Solution 1.6mm 3.

near vision with minimal impact to distance vision Achieves long-lasting results even as presbyopia progresses Implanted into corneal pocket

$diameter, 30 microns thickness Similar water content and refractive index as the cornea Implanted under a femtosecond laser corneal flap (30% of$ the corneal thickness) and centered over light-constricted pupil Placed in the non-dominant eye Removable, if needed 39 Glaucoma Surgical Options

the corneal thickness) and centered over light-constricted pupil Placed in the non-dominant eye Removable, if needed 39 Glaucoma Surgical Options

7 Postoperative Considerations Normal postoperative course One day One week One month Three months Educate patients on postoperative expectations Mild subconjunctival hemorrhage due to suction Mild corneal edema at wound Femtosecond Laser Companies: Value Added Indications Cataract Surgery: Anterior & Posterior Capsule Polishing Posterior Capsulotomy Paracentesis Vitreolysis Glaucoma Surgery: Goniotomy, Trabeculotomy & Trabeculoplasty Corneal Surgery: DSEK: Stripping ring, Stromal polishing Lasik Flaps, Intacs Tunnels, Intrastromal Ablation KAMRA Inlay First US approved corneal inlay; commercially available in 50 countries Raindrop Near Vision Inlay Effective, Reliable and Safe Presbyopia Solution 1.6mm 3.8 mm Central Total Aperture Diameter 8,400 micro-perforations (5-11 μm) allow nutrient flow 6 μm Thick Inlay matches corneal curvature Improves near vision with minimal impact to distance vision Achieves long-lasting results even as presbyopia progresses Implanted into corneal pocket created with femtosecond laser Implanted monocularly into non-dominant eye Highly biocompatible material Made from Polyvinylidene Fluoride (PVDF) Removable via low-risk procedure with recovery of pre-inlay vision Physiologically transparent, biocompatible hydrogel corneal inlay Size: 2 mm diameter, 30 microns thickness Similar water content and refractive index as the cornea Implanted under a femtosecond laser corneal flap (30% of the corneal thickness) and centered over light-constricted pupil Placed in the non-dominant eye Removable, if needed 39 Glaucoma Surgical Options GLAUCOMA APPLICATIONS Laser Therapy SLT/ALT / MLT LPI ELT Cyclophotocoagulation Surgical Options Trabeculectomy Trabectome Express Shunt Tube shunt Canaloplasty Endoscopic Cyclophotocoagulation 7

Glaucoma Clinical Trials Collaborative Normal Tension Glaucoma

Collaborative Initial Glaucoma Treatment Study (CIGTS) Ocular

Trial (EMGT) Glaucoma Laser Trial (GLT) Glaucoma: Medications

When the PROGRESSION continues to WORSEN Treatment options

To Glaucoma Therapy How Adherent are Glaucoma Patients with QD

By one year after first eye drop Rx, less than 50% are still

never filled the second prescription Average number of treated

8 Glaucoma Clinical Trials Collaborative Normal Tension Glaucoma Study (CNTGS) Advanced Glaucoma Intervention Study (AGIS) Collaborative Initial Glaucoma Treatment Study (CIGTS) Ocular Hypertensive Treatment Study (OHTS) Early Manifest Glaucoma Trial (EMGT) Glaucoma Laser Trial (GLT) Glaucoma: Medications When COMPLIANCE with drops is low When MEDICAL THERAPY FAILS When the PROGRESSION continues to WORSEN Treatment options Medications Laser therapy Surgical intervention Poor Adherence To Glaucoma Therapy How Adherent are Glaucoma Patients with QD Medication? By one year after first eye drop Rx, less than 50% are still filling prescription Among New Jersey Medicaid seniors, 25% never filled the second prescription Average number of treated days = 70 Reardon, Schwartz, Mozaffari. Clin Therap 2003;25:1172 Gurwitz et al. Am J Public Health 1993;83: Barriers to Compliance 8

Continuous Use Nordstrom, Friedman, et al.

procedures Noncompliance Unable to instill medications Expense Using gonioscopic views

meshwork Burns are evenly spaced two to three widths apart 50 burns per 180 degrees Can

short pulses of relatively low energy to target and irradiate only the melanin-rich

- 28.7% Adjunctive therapy 19.4% SLT Retreatment 12.1% Replacement Therapy 4.

9 Continuous Use Nordstrom, Friedman, et al. Ophthalmology 2005 Argon Laser Trabeculoplasty One of the most common glaucoma procedures Noncompliance Unable to instill medications Expense Using gonioscopic views thermal burns are placed at the junction of non-pigmented and pigmented trabecular meshwork Burns are evenly spaced two to three widths apart 50 burns per 180 degrees Can treat or Selective Laser Trabeculoplasty Non-thermal treatment which uses short pulses of relatively low energy to target and irradiate only the melanin-rich cells in the TM Selective Laser Trabeculoplasty IOP decrease after SLT Primary Therapy % Adjunctive therapy 19.4% SLT Retreatment 12.1% Replacement Therapy 4.5% Advantages of SLT vs ALT SLT has the potential for repeat procedures SLT lacks thermal damage/scaring to the TM SLT has less post-operative pain and inflammation 9

IOP Not responsive to medications Target pressure not reached Significant side effects with medications Not compliant with medications Unable to administer medications Patient not ready for filtering

10 Glaucoma: Laser Treatment Five years post-treatment, the mean IOP decrease for the SLT group was 7.4±7.3 mmhg and 6.7±6.6 mmhg for the ALT group. Laser Trabeculoplasty Efficacy Compliance Diurnal IOP Control Side effects Economic Issues Glaucoma: Laser Treatment Glaucoma: Laser Treatment Trabeculoplasty -Candidates Primary treatment to lower IOP Not responsive to medications Target pressure not reached Significant side effects with medications Not compliant with medications Unable to administer medications Patient not ready for filtering surgery After trabeculectomy if angle open MIGS not covered by insurance Trabeculoplasty Complications Fairly minimal complications Post op IOP spike (rare <1%) Peripheral anterior synechiae Repeated laser has theoretical long-term risk of accelerating loss of the TM cells Failure to control IOP Selective laser trabeculoplasty versus medical therapy as initial treatment of glaucoma: a prospective, randomized trial. PURPOSE: To compare outcomes of selective laser trabeculoplasty (SLT) with drug therapy for glaucoma patients in a prospective randomized clinical trial. RESULTS: 54 patients reaching 9 to 12-months follow-up. SLT (29 pts) Baseline IOP 24.5 mm Hg Mean IOP at follow up 18.2 mm Hg Med (25 pts) Baseline IOP 24.7 mm Hg Mean IOP at follow up 17.7 mm Hg SLT group -> 11% of eyes required additional SLT Prostaglandin group -> 27% of eyes required additional medication L., Steinmann, W., Kabir, A. J Glaucoma Sep;21(7): Peripheral Iridotomy (PI) Indications Narrow angles Acute, angle closure glaucoma YAG laser to create opening from posterior to anterior chamber Superior location??? Procedure / Drop Protocol Re-evaluate in one week Treat fellow eye 10

Dysphotopsia after temporal versus superior laser peripheral iridotomy: a prospective randomized paired eye trial.

RESULTS - New-onset linear dysphotopsia Sup PI - 18 (10.7%) Temp PI 4 (2.4%) P =.

Temporal iris therefore may be considered a preferred location for LPI.

11 Dysphotopsia after temporal versus superior laser peripheral iridotomy: a prospective randomized paired eye trial. PURPOSE: To determine if the location of neodymium:yttrium-aluminumgarnet laser peripheral iridotomy (LPI) is related to the occurrence of postoperative visual dysphotopsia. RESULTS - New-onset linear dysphotopsia Sup PI - 18 (10.7%) Temp PI 4 (2.4%) P =.002 CONCLUSIONS: Temporal placement of LPI is safe and was found to be less likely to result in linear dysphotopsia as compared with superior placement. Temporal iris therefore may be considered a preferred location for LPI. Elevated IOP Inflammation Hyphema Cataract Inability to penetrate iris Closure of iridotomy Optical aberrations PI Complications Vera, V., Naqi, A., Belovay, G. Am J Ophthalmol May;157(5): Glaucoma: Laser Treatment Open or Narrow Angle Glaucoma Transcleral Cyclophotocoagulation Diode Laser Glaucoma: Laser Treatment Cyclophotocoagulation - Advantages Success rate 60-70% Relative ease of technique Can be repeated Recovery 4-6 weeks Follow up visits not as intensive as filtering surgery Candidates Refractive glaucoma Poor vision Blind painful eye Non-surgical end-stage disease Laser Retinal Applications Diabetic Retinopathy Retinal Vein Occlusion AMD Ocular Tumors Tears and Detachments Proliferative Diabetic Retinopathy Neovascularization Vitreous hemorrhage Fibroglial proliferation Tractional RD Neovascular glaucoma 11

Diabetic Retinopathy Study Examined when to treat neovascularization High Risk Characteristics Neovascularization of the Disc (NVD) greater than ¼ Disc Diameter (DD) Any NVD or NVE with a vitreous or

12 Diabetic Retinopathy Study Examined when to treat neovascularization High Risk Characteristics Neovascularization of the Disc (NVD) greater than ¼ Disc Diameter (DD) Any NVD or NVE with a vitreous or preretinal heme PRP decrease the incidence of severe VA loss at 2 years from 26% to 11% 4 years 44% vs. 20% treated Argon over Xenon Early Treatment Diabetic Retinopathy Study (ETDRS) Clinically Significant Macular Edema Retinal thickening within 500 um of the foveal center Hard exudates within 50 um of the foveal center, with adjacent thickening Retinal thickening of at least 1DD, within 1DD of the fovea Severe NPDR 4 quadrants of hemorrhages/microaneurysms 2 quadrants of venous beading 1 quadrant of intraretinal microvascular abnormalities Treatment of Clinically Significant Macular Edema Focal Laser Gold Standard (ETDRS) Chance of moderate vision loss by 50% Chance of moderate vision gain Better for eyes with discreet leakage Effects last longer than other treatments Relatively painless Treatment for PDR Pan Retinal Photocoagulation Equilibrium between retinal oxygen supply vs. demand Recommended treatment for high-risk PDR Resulted in significant reduction in severe vision loss Prophylaxis no benefit May take multiple sessions (1000s of burns) Side effects: loss of peripheral VF, color defects, nyctalopia Photo accessed from Vein Occlusions Branch Vein Occlusion Study *** Established laser treatment as the standard of care for the treatment of vision loss associated with macular edema and for the prevention of vitreous hemorrhage in this disease Central Vein Occlusion Study Showed that while macular edema was reduced, there was no improvement in visual acuity after grid treatment and no difference in final visual outcome compared to control eyes Scatter PRP recommendation that treatment delayed until there is visible evidence of iris Age-Related Macular Degeneration Thermal Laser Best results for extrafoveal CNV (>200 microns from fovea) Repeatable Foveal damage Choroidal hemorrhage (high energy into Bruch s) Contraction of fibrous tissue (laser burns too close together) 12

IMPROVE SEs: temporary visual disturbances, light sensitivity In combo w/ Anti-VEGF injections, if no improvement with injections alone Repeat 3 months Prophylaxis of Retinal Detachment Asymptomatic

13 Age-Related Macular Degeneration Photo Dynamic Therapy Photosensitizing dye (verteporfin) I.V. Accumulates in new, leaky blood vessels Cold laser (689 nm) activates molecules to produce free radicals, destroying neovascular membrane Best results: classic CNV Decreases vision loss, but DOES NOT IMPROVE SEs: temporary visual disturbances, light sensitivity In combo w/ Anti-VEGF injections, if no improvement with injections alone Repeat 3 months Prophylaxis of Retinal Detachment Asymptomatic breaks Symptomatic breaks Lattice degeneration Photo accessed from Retinal Tears and Detachments Laser Photocoagulation Formation of scar tissue around the margin Choroid and retina form adhesion (1-2 weeks) Fluid reabsorption Good for small tears Comfortable for patient Considerations for Optometry Laser therapy remains a viable option Optometric comanagement considerations Practice to the fullest extent of your scope Photo accessed rom 13

Laser Refractive Cataract Surgery with the LenSx Laser

$Laser Refractive Cataract Surgery with the LenSx Laser$ Laser Refractive Cataract Surgery with the LenSx Laser a Novartis company 1 LenSx Laser Important Safety Information Caution: United States Federal Law restricts this device to sale and use by or on the