講義 110年屈光暨白內障手術進階課程

中華民國眼科醫學會第 16 屆屈光暨白內障手術課程
日期：110 年 06 月 20 日地點：台大醫院國際會議中心三樓 301 教室報到時間：08：30 開始
上午．屈光雷射手術
時間課程演講者
08：55～09：00 理事⾧致辭陳建同
主持人：丘子宏、張朝凱、陳俊良*
09：00 ~ 09：20 Update on the advance and clinical outcome of LASIK 林丕容
09：20 ~ 09：40 Update on the advance and clinical outcome of SMILE 張朝凱
09：40 ~ 10：00 Update on the advance and clinical outcome of Trans-PRK 梁章敏
10：00 ~ 10：20 Discussion
10：20 ~ 10：30 Coffee Break
主持人：*林昌平(高雄)、王㇐中、孫啟欽
Treatment options for small optical zone / decentration

10：30 ~ 10：50 劉又綾
after refractive surgery
Enhancement after small incision lenticule extraction
10：50 ~ 11：10 葉威毅
(SMILE)
11：10 ~ 11：30 Which IOL is better after LASIK? Monofocal 許志堅
11：30 ~ 11：50 Which IOL is better after LASIK? EDOF / Multifocal 江尚宜
11：50 ~ 12：10 Discussion
12：10 ~ 13：10 Lunch Break

下午．白內障手術
時間課程演講者
主持人：孫啟欽、潘志勤
Importance and Optimization of the ocular surface before

13：10～13：30 徐旭亮
cataract surgery
Regular or irregular corneal astigmatism? –Preoperative
13：30～13：50 林鴻源
assessment of toric IOLs
13：50～14：10 Cataract surgery in the setting of posterior astigmatism 侯鈞賀
Measurements of ocular aberrations and its implications in

14：10～14：30 王孟祺
cataract surgery
Special considerations of presbyopia - correction IOLs in
14：30～14：50 謝易庭
eyes with ocular comorbidities
14：50～15：10 Discussion
15：10～15：20 Coffee Break
主持人：吳孟憲、黃維仁
New Horizon in Modern Cataract Surgery- Total

15：20～15：35 羅英源
Keratometry for Premium IOL Calculation
Complementary PCIOLs serve diverse patient populations:
15：35～15：50 陳矜芸
AcrySof IQ PanOptix and Vivity
How to manage low astigmatism patient with TECNIS EDOF
15：50～16：05 許粹剛
Toric IOL
16：05～16：20 Maximizing Your Toric IOL outcomes with iTrace 蔡俊斌
Adaptive Fluidics Technology improves IOP stability during

16：20～16：35 吳建良
cataract surgery-Bausch + Lomb Stellaris Elite
16：35～16：55 Discussion
16：55～17：15 Test
Update on the advance and clinical outcome of LASIK
Pi‐Jung Lin MD , PhD , CPA , MBA
Chairman of Universal Ophthalmology Group Company
Laser vision correction market scope

The evolution of corneal laser refractive surgery
Global refractive surgery market
LVC market share in Taiwan revenue
Overview of Corneal Refractive Laser Surgery
PRK / Trans‐PRK
StreamLight™ vs. SmartSurf – Software
Technology
Eye‐tracking in space und time
Advantages of using a femtosecond laser for flap creation
FS‐LASIK
Type of the diagnostic device
Tscherning
Dynamic Skiascopy (Retinoscopy)
Hartmann‐Shack
Ray tracing
The new diagnostic device
PERAMIS
iDESIGN® Refractive Studio
InnovEyes™‐ Ray tracing Algorithm
The presbyopia correction technology
PRESBYOND®
READTM
Refractively Enhanced Adjusted Distance
ReLEx SMILE
Conclusion
1-1
Update on the Advance and
Clinical Outcome of SMILE
眼科醫學會屈光暨白內障手術進階研習會
張朝凱醫師
VISUMAX _ Expert Mode

Energy: 29
Lenticule spot distance: 4.5 um
Cap spot distance: 2 um Surgeon: CK Chang
Update on SMILE
Video 1 我暫時先放自己的手術影片
WF-guided or Topo-guided
STAR S4IR + iDesign
WFG-LAISK have comparable ocular and corneal aberrations but better
visual outcome than SMILE [Shetty et al. JRS 2018]
• 74% LASIK and 45% SMILE with UDVA > 20/16
• Cornea increase in HOA RMS, increase coma and decrease SA in both group
• Ocular aberration change is insignificant after 3 months
STAR S4IR + Wavescan

Comparison of ocular HOA after WFG-LASIK and SMILE for myopia [Chen
et al. BMC 2017]
• No difference in UDVA and CDVA
• Higher vertical coma in SMILE pre-op SE correlate with coma and SA in both
procedure
EX500 T-CAT
Topo-guided LASIK and SMILE, contralateral eye RCT [Kanellopoulos et al.
JRS 2017]
• 59% LASIK and 31.8% SMILE with UDVA> 20/16
• LASIK eye was superior in refractive accuracy, contrast sensitivity and scatter
index
• Lack of cyclorotortion compensation and eye-centration in SMILE
2-1
Hyperopia
• Initial study FLEx demonstrate loss of CDVA and the • The Lenticule profile is still evolving and has a large
rate of refractive regression is not acceptable: optical and transition zone to reduce curvature gradient
Lenticule shape, small optical zone, centration in region of maximum tissue removal.
• Geometry of reticule redesigned: large optical zone • New treatment profile of spherocylindrical hyperopia by
7mm, 2mm transition zone with centration on the FLEx led to refractive results similar to published
outcomes on hyperopic LASIK. [Phase II]
coaxial sighted cornea light reflex [Pilot]
 New profile include new laser scanning
1. Optical zone centration —> comparable to eye- sequence
tracker based LASIK /SMILE for myopic  Mean SE was -0.40 ± 0.61D with 70% within ±
treatments 0.5D and 89% within ±1.0D of intended
correction.
2. Achieved optical zone diameter and related  The regression was +0.29D within 6 months
spherical aberration changes —> topographic
optical zone and induction of SA is similar to  0.03D between 6-9months
LASIK hyperopic treatment.
Geometry of Lenticule parameters for hyperopic SMILE

Large adjustable transition zone
Reinstein et al. JRS 2017 Sekundo et al. JRS 2018
Low myopia High myopia

• High myopic eyes is a risk factor for significant myopic regression (0.36±0.29, 3 mon-3
yrs) and prone to developing undercorrections.
• SMILE for low myopia ( -1.00D and -3.50D) the result were equivalent to • Customized nomogram, corrected by adding additional SE for high myopic eyes.
LASIK for low myopia.
• Epithelial remodeling > 10um thickening signify regression and warrant of
• Visual recovery is slightly slower after SMILE compared to LASIK. 89%
enchantment, positively correlated with myopia
of eyes achieving 20/20 on day 1.
• Percentage of UDVA better than 20/25 and 20/20 deceased during long-term f/u
>Energy adjustment with spot setting
• Significant increases in horizontal coma , SA; and increased SA is even higher in high
>Increasing optical zone 7.0mm or larger will decrease difficulty in myopic eye.
handle thin Lenticule in low myopia
• when pre-op astigmatism is greater undercorrection and regression pronounced
>Nomogram adjustment by 10% in magnitude of astigmatism correction
Reinstein et al. JRS 2014

Wang et al. APJO 2019
HOAs-spherical aberration
• SMILE is minimally apheric, produce similar
SA induction to the highly aspherically
optimized myopic PRESBYOND LBV profile
• Increasing the optical zone will reduce the

induction of SA
• Spherical aberration induction in SMILE is

much less than LASIK equivalent stomal tissue
removal.
Reinstein et al. IOVS 2012
2-2
High-order aberrations
WaveLight Allegretto Eye-Q
STAR S4IR + iDesign
• SMILE induce less Q value increase, better preserved corneal
asphericity. • Corneal surface aberration: SMILE and WFG LASIK had similar aberrometric
outcomes-- increased HOA, coma and decreased SA [Shetty al. JCRS 2018]
• SMILE induce fewer total HOA and SA compared to FS-LASIK • Ocular aberrations with iTrace: all aberrations were maintained to pre-op level,
(Allegretto excimer laser system) except decreased SA in LASIK
• Induced corneal SA is higher in high myopic eyes. >WFG LASIK (STAR S4IR) had more eyes achieved UDVA > 20/20
Zhang et al. Journal of Ophthalmology 2017 Shetty et al. JRS 2018
Centration
Angle kappa is the angle between visual axis and

pupillary axis
Corneal vertex determine corneal coaxial light reflex

(1st Purkinje image)
• Decentered lenticule/ablation result in halo, glare and diplopia,

corneal vertex is reliable centration point.
• Postop outcome significantly decreased when offset between

center of lenticule and corneal vertex > 0.3mm, vertical
decentration is more common Decentration was measured the distance between
center of optical zone and corneal vertex
• Measure angle kappa pre-op is important
• <0.3mm  visual outcome good regardless of centration
• Optical centration no different SMILE(0.2±0.11mm) and eye

tracker-based LASIK (0.17±0.1mm) [Reinstein 2015]
Reinstein et al. JRS 2015
2-3
Centration & astigmatism
• Consist two part: 1. center lenticule with corneal vertex 2.
astigmatic axis alignment.
• Centration map technique with topographers
• Triple centration technique help verify the subjective fixation

during docking. [Reinstein et a.]
• In high astigmatism, effective cyclotorsion compensation and

nomogram enhancing the degree of cylinder correction is
paramount.
• No change in total RMS HOA in both SMILE with triple

mark technique and WFG TransPRK.
• TransPKR induce more SA than SMILE, reduce coma and

trefoil.
4° of cylcotorsion can result in 14% of
astigmatism undercorrections
Jun et al. JRS 2018
Decentration and HOA

• Pre-op pupillary offset (angle Kappa) and
lenticule decentration has closed relationship.
• The estimated breakpoint between induced

RMS spherical aberration and total decentration
is 0.335 mm.
• Higher decentration > 0.335mm induced total

HOAs, coma and significant SA; no significant
relation if decentration < 0.335
• Tolerance to decentration is dependent on

optical zone
• 6.2mm OZ —> 0.1 mm

• 7.2mm OZ —> 0.6 mm
Lee et al. Cornea 2018
Re-treatment/Enhancement Secondary/repeat SMILE
Secondary SMILE
Moshirfar et al. JCRS 2018

Moshirfar et al. JCRS 2018
2-4
Cap-to-flap procedure (CIRCLE) Cap-to-flap CIRCLE
• Flap conversion procedure: [1] lamellar ring [2]
side cue with hinge [3] junctional cut
• The pattern D is best, for hyperopic treatment

because wider flap and lese likelihood of
obscuring OZ.
• CIRCLE results in more inflammatory change

and apoptotic cells than secondary SMILE [Riau
et al. PLOS 2017]
• Safe and effective enhancement procedure,

• 影片2
better visual outcome than surface ablation.
• Drawback: biomechanical weakening caused by

damage to Bowman layer than the corneal cap.
[Kling et al. JRS 2017]
Pattern D: The side cut is
outside the original incision
Non-routine situation during lenticule Non-routine situation during lenticule

interface separation interface separation
Example of failed pocketing the lenticule Accessing the cap interface if the Re-accessing lenticule interface Example of failed pocketing the lenticule Accessing the cap interface if the Re-accessing lenticule interface
interface: Lenticule layer separation rescue lenticule interface was separated first if the lenticule is free from hinge interface: Lenticule layer separation rescue lenticule interface was separated first if the lenticule is free from hinge
3 4
Non-routine situation during lenticule

interface separation
Example of failed pocketing the lenticule Accessing the cap interface if the Re-accessing lenticule interface
interface: Lenticule layer separation rescue lenticule interface was separated first if the lenticule is free from hinge
小測驗
5
2-5
SMILE術後針對度數欠矯的可行方法(retreatment)不包括：(a) refractive
lens extraction (b) CIRCLE (c) PRK (d) thin-flap LASIK
SIMLE手術目前使用的centration方法不包括： (a) pupil center 對位法 (b)

corneal coaxial light reflex 對位法 (c) triple centration technique 裂隙燈對
位法 (d) centration map technique 角膜地圖對位法
Thank you！
SMILE手術降低術後高階相差和殘餘散光的方法不包括：(a)加大optical
zone (b)參考angle 術前kappa alpha (c)術中中心對位 (d) cyclotorsion
compensation
2-6
The evolution of Refractive surgery
三軍總醫院眼科部
梁章敏醫師
2007
Singe –Step Trans‐PRK
Transepithelial photorefractive keratectomy
Photorefractive keratectomy(PRK) (TPRK)
PRK involves epithelial removal and photoablation of
Remove the epithelium with laser phototherapeutic ablation
Bowman’s layer and anterior corneal stromal tissue
followed by a laser refractive ablation of the stroma
‐removing the surface cornea epithelium cells using a mechanical ‐ Single‐step transepithelial PRK allows removing the epithelium and
scraping device stroma in a single step with 1 ablation profile
Advantage Disadvantage
• Long history of success • Discomfort/pain
• No flap created during surgery • Corneal haze
• Save more stromal to treatment • Diminished corneal sensation
high myopia • Glare and Halo
Epithelial abrasion using tPRK Epithelial abrasion using an
with clearly visible margin of the Amoils brush
ablation zone
TPRK vs PRK TPRK vs PRK

• Visual recovery • Pan level
‐ significantly faster in the TPRK group • Epithelial wound closure
‐ At day 4, 72% of eye in TPRK group was achieve 0.7 or better ‐ TPRK group was significantly faster ‐ TPRK group was significantly
but no eye in the PRK group lower within the first 4 days
Early clinical outcomes and comparison between trans‐PRK and PRK, regarding refractive outcome, wound healing, pain intensity
Early clinical outcomes and comparison between trans‐PRK and PRK, regarding refractive outcome, wound healing, pain intensity and visual recovery time in a realworld
and visual recovery time in a realworld Gaeckle BMC Ophthalmology (2021) 21:181
Gaeckle BMC Ophthalmology (2021) 21:181
3-1
Single‐Step TPRK vs Alcohol‐Assisted PRK
SMART Trans‐PRK
• Myopic Astigmatism correction:
‐ very similar results 3 months postoperatively
‐ both procedures are predictable • One‐ Step
• Corneal healing • No touch
‐ TPRK has the shorter time to cover the stroma
Main reason is that the diameter of epithelial removal match the
• Using SMART Technology to improve the
total ablation zone, decreasing the wound surface and shortening surgical results
the epithelial closure time
• Surgery time
‐Total surgery time was reduced by 35% in comparison to aaPRK
Single‐step transepithelial versus alcohol‐assisted photorefractive keratectomy in the treatment of high myopia: a comparative
evaluation over 12 months
Antonios R, et al. Br J Ophthalmol 2017;101:1106–1112.
SMART TransPRK SmartSurfACE Technology

Cornea Roughness Reduced
Standard Laser SmartSurfACE
 Roughness has been reduced
from 749nm (meaning ~1 pulse)
down to 272nm (meaning ~1/3 of
a pulse) local standard deviation
SmartSurfACE Technology – smooth corneal surface  SmartSurfACE results in a much
‐designed to diminish immediate postoperative surface irregularities of the smoother residual stromal bed
residual stromal bed
‐the laser spot distribution includes a truncated super‐Gaussian spot shape, and
the platform evades the thermal load and ablation impact
‐it exploits a 3D geometric model that represents the curvature of the cornea more
accurately
Able to remove less tissue in the centre and
 leading to faster healing and greater comfort more tissue at the periphery
Less Haze rate in Refined SS‐PRK Less Haze rate in Refined SS‐PRK
 conventional single‐step transepithelial PRK: ablation of  conventional single‐step transepithelial PRK: ablation of epithelium
epithelium and stroma occurs in a single continuous and stroma occurs in a single continuous session
session by an Amaris laser  Reined single‐step transepithelial PRK: using smart‐pulse
technology
 Reverse single‐step transepithelial PRK: using smart‐pulse
technology
*Both figures showed the Haze in mild‐moderate myopia
*SS PRK/Refined SS PRK both using Amaris Laser
Efficacy and safety of transepithelial photorefractive keratectomy. J Cataract Refract Surg 2018
3-2
Surgical plan:HOA The Aberration‐Free concept
 Q‐Value and Higher Order Aberrations
» Aberration‐Free
 Only spherical and/or cylindrical refraction values are corrected. This
procedure is suitable for patients whose vision is not impaired by pronounced
higher‐order aberrations.
» Customized Ablation
‐ Corneal or ocular wavefront
» Surface vs. Stromal Treatments

 For equal refractive corrections (Femto‐)LASIK procedures (stromal
treatments) need more number of pulses than PRK or LASEK procedures
(surface treatments).
 A higher tendency for overcorrections after thin‐flap LASIK (anterior stromal
treatments) as compared to thick‐flap LASIK (deep stromal treatments) was
observed.
 For that reason, a certain Shot Depth Factor parameter is used
The beneifts of Aberration‐Free Treatment Type Decision Tree
» At least three criteria favouring the target of leaving minor
amounts of not clinically relevant aberrations (the proposed
„aberration‐free“ concept, Arba et al., 2009):
 Chromatic blur
 Depth of focus
 Wide field of vision
» When a patient is selected for non customized aspherical
treatment, the global aim of the surgeon should be to leave all
existing high‐orderaberrations (HOA) unchanged because the best
corrected visual acuity, in this patient, has been unaffected by the
pre‐existing aberrations. (Artal, 2005; Levy et al., 2005)
1 Arba Mosquera S, de Ortueta D. Analysis of optimized profiles for ‘aberration‐free’ refractive surgery. Ophthalmic Physiol Opt;. 2009; 29: 535‐548
2 Artal, P. (2005) What aberration pattern (if any) produces the best vision?, presented at the 6th International Wavefront Congress February, Athens, Greece.
3 Levy, Y., Segal, O., Avni, I. and Zadok, D. (2005) Ocular higher‐order aberrations in eyes with supernormal vision. Am. J. Ophthalmol. 139, 225–228.
The Customized Wavefront concepts Clinical results_ SMRT TPRK

Aberration‐Free Corneal Wavefront Ocular Wavefront  Provide the predictable results
Treatment Treatment Treatment
Aspherical ablation
Yes Yes Yes
profile
Change of Q‐Value
Change of Q‐Value
Target in SCHWIND CAM: depending on
Q‐Value depending on
Q‐Value = ‐0.25 SEQ + ∆Z(4,0)+
correction of the SEQ
∆Z(6,0)+ ∆Z(8,0)
Target: 0 µm for Z(4,0) +
Z(6,0) related to an eye
Spherical model with Q‐Value of
Preservation of existing
aberrations ‐0.25. Target: 0 µm
spherical aberrations
(SphAb) (=>expected Z(4,0) in Corneal
Wavefront Analyzer
software = 0.2 µm)
High order Preservation of all Target: All coefficients / Target: 0 µm for all
aberrations existing high‐ order‐ aberrations close to 0 µm higher order SUPPLEMENT TO CATARACT & REFRACTIVE SURGERY
(HOA) aberrations for the given eye‐model aberrations TODAY EUROPE SEPTEMBER 2013
3-3
Clinical results_ SMART TPRK Clinical results_ SMART TPRK
 Achieved the good results in Astigmatism patient
 Slightly increased High
order aberration
Single‐step transepithelial photorefractive keratectomy in high
Single‐step transepithelial photorefractive keratectomy in high myopia: qualitative and quantitative visual functions.
myopia: qualitative and quantitative visual functions. Int J Ophthalmol 2017;10(3):445‐452
Int J Ophthalmol 2017;10(3):445‐452
Clinic results: SMART TPRK Clinic results: SMART TPRK
 Pain score and Epithelial healing time was less SMART TPRK demonstrated less risk for postoperative
 Pain
 Haze
 dry eye
 faster postoperative reepithelialization
 Compare with PRK, Haze grade was less
Pain Haze
Relief of postoperative Pain Less incidence of haze induction in
 Using bandage contact lenses  Transepithelial laser‐assisted ablation of the cornea results
 Administrating eye drops in short time in lower keratocyte loss and inflammatory response
 Using 0.02% MMC
 topical anesthetics
 Reverse and smart‐pulse technology: smoother and
 topical opioids
more uniform stromal bed contour
 Topical NSAIDs
 Prescribing vitamin C and a more prolonged low‐dose
 cold artificial tears and cooling of the eyes topical corticosteroid regimen
 cold patch  Wear standard sunglasses provided further haze‐inhibitory
effects
3-4
Immediate PRK after suction loss
TPRK can save the surgery once the
during SMILE surgery
surprise happened
Immediate tPRK after early suction loss during SMILE might
be safe and effective, with refractive outcomes that are
 It is easy to transfer from LASIK/SMILE to PRK comparable with those after uneventful SMILE.
‐ free flap during LASIK
‐ suction loss during SMILE
 Good choice for enhancement/re‐treatment
Using PRK for Retreatment
Trans‐Photorefractive keratectomy(PRK)
 dramatic improvement in
the refractive outcomes Advantage Neutral Disadvantage
• Long history of • Discomfort/pain
success • Corneal haze
• No flap created • Diminished corneal
during surgery sensation
• Save more stromal to • Glare and Halo
treatment high myopia
How to improve the satisfaction How to improve the satisfaction
Before/during surgery: After surgery:
 Cooling  NASID:
‐before/after surgery: ice compress ‐eliminate the pain
‐before leave the table: cold B.S.S irritating ‐reduce inflammation
 MMC using ‐redness and eyelid swelling
‐Prevention of corneal haze
‐base on treatment diopter  Auto‐serum:
‐ fasten wound healing
 Contact lens: for a week ‐ reduce dryness
3-5
T‐PRK in Taiwan T‐PRK in Taiwan
• Patient profile
• Patient profile
Pre‐op
spherical (D)
Data from Jan. 2017~April. 2021 Data from Jan. 2017~April. 2021
Refractive outcome: T‐PRK in Taiwan
 Achieved the predictable outcome
Re‐Treatment
 49 eye (1.7%, 2806 eye )
Before Surgery -6.0D~-9.0D Over -9.0D Astigmatism over 1.5D
Total Number 14 17 18
Sex male Female
SER (post‐op 3m) ‐0.003 ± 0.551 ‐0.047 ± 0.591 ‐0.027 ± 0.569

UCVA (LogMAR; post‐op 3m) ‐0.03 ± 0.12 ‐0.05 ± 0.08 ‐0.04 ± 0.1
 Reason of re‐treatment
Safety index (post‐op 3m) 1.14 ± 0.27 1.14 ± 0.2 1.14 ± 0.24
Correction Correction Efficacy index(post‐op 3m) 1.12 ± 0.31 1.13 ± 0.22 1.12 ± 0.26

SE less SE over
than‐6.0D than ‐6.0D
Pain Evaluation: T‐PRK in Taiwan
Patient satisfaction
我們都選
擇SMART
TPRK
Surgical results Willing to recommend
• Pain score decreased significantly in post‐op day 3 疼痛感(描述):
10分痛到在地上打滾，吃止痛藥也沒用
5分需要吃止痛藥
0分不痛
9.63
Scale: 0‐10(very satisfy)
9.77
Scale: 0‐10(highly recommend)
Total no. 384
From 2020/07/01~2021/05/10
3-6
Corneal epithelium change post T‐PRK
Corneal epithelium change post T‐PRK
 The epithelium was significantly thicker at 3 and 6 months
after surgery compared with preoperative measurements.
∗∗ < 0.001
∗ < 0.05
Corneal Epithelial Remodeling and Its Effect on Corneal Asphericity after Transepithelial Photorefractive Corneal Epithelial Remodeling and Its Effect on Corneal Asphericity after Transepithelial Photorefractive

Keratectomy for Myopia. Journal of Ophthalmology Volume 2016, Article ID 8582362, 7 pages Keratectomy for Myopia. Journal of Ophthalmology Volume 2016, Article ID 8582362, 7 pages
Corneal epithelium change post T‐PRK Re‐epithelization post Trans‐PRK
Mean central corneal epithelium
• Showed a lenticular change with thickness
more thickening mid‐peripherally, 60
resulting in increased oblateness
54
postoperatively. 50
51.3
45.8 45.2 45.7

• Epithelial remodeling may modify 40
the epithelial thickness profile after
surface ablation refractive surgery for 30
(n = 82 eyes)
myopia.
20
10
0
Corneal Epithelial Remodeling and Its Effect pre‐op 1wk 2wk 1m 3m
on Corneal Asphericity after Transepithelial
Photorefractive Keratectomy for Myopia.
Epithelial thickening at each sector 6 months postoperatively Journal of Ophthalmology Volume 2016,
(*109.05‐110.01 in TSGH) 本院T‐PRK術後病患中央上皮生長情形
Article ID 8582362, 7 pages
Re‐epithelization post Trans‐PRK Re‐epithelization pattern post Trans‐PRK
Mean central corneal epithelium thickness Thinnest quadrant of corneal
60.0 epithelium
50.0 100.00%
90.00%
80.00%
40.0
70.00%
60.00% (n = 82 eyes)
30.0 50.00%
40.00%
30.00%
20.0
20.00%
10.00%
10.0 0.00%
1wk 2wk 1m 3m
0.0
pre‐op 1wk 2wk 1m 3m SN ST IN IT
myopia <=150; 11 eyes myopia 150<x<=600; 56 eyes myopia >600; 15 eyes
(*109.05‐110.01 in TSGH) 本院T‐PRK術後病患中央上皮生長情形(分組分析) (*109.05‐110.01 in TSGH) 本院T‐PRK術後病患中央上皮生長情形(生長區塊分析)
3-7
Trans‐PRK in novice pilots and
special operations forces
兩棲特戰部隊飛行員 Total
21 patients (37
Number 16 patients (32 eyes) 37 patients (69 eyes)
eyes)
Age 33.3 ± 4.8 22.4 ± 2.7 27.1 ± 6.6
Sex
‐male 16 (100%) 13 (61.9%) 29 (78.4%)
‐female 0 (0%) 8 (38.1%) 8 (21.6%)
SER (pre‐op) ‐3.21 ± 1.26 2.90 ± 1.26 ‐3.05 ± 1.26
SER (post‐op 3m) ‐0.003 ± 0.551 ‐0.047 ± 0.591 ‐0.027 ± 0.569
UCVA (LogMAR; post‐op 3m) ‐0.03 ± 0.12 ‐0.05 ± 0.08 ‐0.04 ± 0.1
Safety index (post‐op 3m) 1.14 ± 0.27 1.14 ± 0.2 1.14 ± 0.24

Efficacy index(post‐op 3m) 1.12 ± 0.31 1.13 ± 0.22 1.12 ± 0.26
病患術後滿意度(0-100) 95 92 93
(*109.05‐110.01 in TSGH) 本院T‐PRK術後病患(兩棲及飛行員專案)手術outcome
測驗題(選擇) 測驗題(是非)
• １、 Transepithelial Photorefractive Keratektomy (transPRK) 屈光雷 • 2、Transepithelial Photorefractive Keratektomy (transPRK)術後target

射手術較傳統PRK具有下列何者特點： refraction的預測性較femtosecond‐LASIK為高
• A.上皮生長速度較快 • ANSWER（Ｘ）
• B.術後疼痛感較低
• C.術後角膜混濁率較低
• D.以上皆是
• 3、 Transepithelial Photorefractive Keratektomy 比femtosecond‐
• ANSWER（D） LASIK產生較低的高階相差增加
• ANSWER（Ｘ）
3-8
OUTLINE
1. Post refractive surgery
Treatment options for • Decentered optical zones
• Small optical zones
small optical zone / decentration 2. Treatment options
after refractive surgery Topography-guided customized ablation by excimer laser ---
• Wavefront-guided or Topography-guided
• Q adjustment ablation profile
• TNT (custom topographic neutralizing technique)
ABC (Ablation-Based Compensation) refraction
3. Topography-guided customized ablation (PRK or LASIK)
彰化基督教醫院眼科部
Review articles
劉又綾 2021.6.20 4. Cases
2
Decentered optical zone Decentered optical zone

Related to
Definition • pupil not dilating or constricting symmetrically
• Ablation center does not correspond to the center of • the amount of myopia
the optical axis • learning effect
• saccadic eye movements
• misalignment of patient’s head relative to the laser and optics or
• Low amount of decentration : 0.5–1.0 mm centration aids in the laser
affects low-contrast visual acuity • deviation of the visual axis from mid-pupil
induces HOAs • poor laser beam homogeneity
• Significant decentration : > 1.0 mm • nonhomogeneous corneal hydration
causes highly compromised visual performance • misalignment of the suction ring over the center of the pupil
• a malfunctioning tracking system
3 4
Decentered optical zone Decentered optical zone

Diagnosis
Treatment
Corneal topography maps
• Arcuate cuts
Method to limiting decentration to less than 1 mm

• Well-centered RGP or scleral contact lens
• Active eye-tracking systems
iris registration
• Laser photo ablative techniques
• Larger ablation zones
Topography-guided customized ablation by excimer laser
5 6
4-1
Small optical zone
Small optical zone Related to
• reducing the ablation zone of refractive surgery of high myopia
Symptoms
 decrease depth of ablation and the probability of postsurgical ectasia
• compromised visual function
• diameter of the pupil > optical treatment zone
• halos, glare in mesopic conditions  blurred circles  glare and halos in mesopic conditions
• monocular diplopia • correction of higher refractive errors

increase HOAs
due to a larger refractive differential between the ablated and intact cornea
 reduction in the quality of vision, mainly in scotopic conditions
7 8
Small optical zone

Post-RK irregular cornea and small optical zone
Treatment
• RK procedure : 1. Mild miotics or topical brimonidine help in driving at night
90% to 95% thickness radial incisions are made in the paracentral and
peripheral cornea using a diamond bladed micrometer knife 2. Tinted contact lenses with artificial pupils provide
resulting in peripheral steepening and compensatory central flattening significant symptom free
• 6 months to 10 years after RK

3. Well-centered RGP or scleral contact lens
43% of eyes experienced a hyperopic shift of 1.00 D or more
• Small optic zone starburst symptoms 4. Topography-guided enlargement of the ablation zone
10
Topography-guided Excimer laser ablation technique

for correction of irregular cornea
customized ablation treatment (TCAT)
• Surface ablation
1. PTK (phototherapeutic keratectomy)
• Spot scanning excimer laser combined with corneal topography
2. PRK (photorefractive keratectomy)
 ablation of any precise location on the cornea
a. Wavefront-guided
b. Topography-guided
• Improve visual acuity and quality in eyes with irregular corneal
topographies • Lamellar ablation (Laser in-situ keratomileusis)
a. Wavefront-guided
• performed before cataract surgery in eyes with irregular cornea b. Topography-guided
11 12
4-2
Wavefront-guided ablation
• In theory , the postoperative anterior corneal surface can be calculated
Wavefront-guided to compensate for all of the internal aberrations
• In practice, many factors frustrate such attempts

VS
1. limited precision and predictability of the ablation
2. epithelial hyperplasia and stromal remodeling
3. new aberrations created with the flap (LASIK)
Topography-guided 4. changes in the thickness and the distribution of the tear film
5. biomechanical properties and variations in ocular aberrations with age
6. Accommodation
7. Corneal reshaping alters the path of rays propagating the eye
13 14
Topography-guided Customized ablation

For eyes with highly aberrated cornea • Reported successful outcomes with topography-guided LASIK to treat
cornea irregularities in 2000
• Not well accepted because of its unpredictability in refractive outcomes
• repeatable and consistent preoperative aberration maps
• Visual rehabilitation of highly aberrated eyes
 frequent inability to obtain
• Regularizes the front corneal surface irregularities to achieve the
desired refractive outcome
• Ideal anterior corneal contour should be determined • An ablation profile can be calculated by fitting an ideal rotationally
without taking into consideration the influence of the internal structures symmetrical shape (preferably a prolate asphere with negative Q-value)
15 16
Advantage of topography-guided treatment

over wavefront-guided treatment Disadvantage of topography-guided treatment
• Restore the natural aspheric shape of the cornea
over wavefront guided treatment
• Correcting the non-physiological irregularities
(age, accommodation) Ignores the rest of the intraocular structure
• Can be used in patient with media opacity (eg. corneal scars)

 decreasing the predictability of the refractive outcomes
• Can be used in highly irregular corneas

beyond the limits of wavefront measuring devices
• Topography maps are relatively easy to interpret

17 18
4-3
• The desired Q value was not exactly met in most cases
Q adjustment ablation profile
despite improvement of the cornea surface regularity
• human cornea average Q value -0.26 (theoretical Q-value -0.46) Etiology
• biological effects of healing
• If measured asphericity
Q between 0 and -1 do not change it • the variations of the applied fluence at the different points of the cornea
Q < -1 --------------- choose -1
Q > 0 --------------- choose 0 • significant regressions may be because epithelial-stromal remodeling
and epithelial hyperplasia after PRK
• Ablation depth and Q-value adjustment
Aiming to correct asphericity, for an optical zone of 6.5 mm, • flap-induced changes together with indirect biomechanical shifts of the
every -0.1 in Q-value adjustment cornea after LASIK
 Add about 3 um more to the central ablation
19 20
TNT (custom topographic neutralizing technique)
ABC (Ablation-Based Compensation) refraction
• methods developed to optimize topographic-guided treatments

of aberrated eyes with the ALLEGRETTO WAVE
• help adjust for the induced refractive change of surface

regularization from topography-guided treatments
21 22
Post refractive surgery

decentered ablation or small optical zone
Topography-guided customized ablation

PRK or LASIK----review articles
23 24
4-4
Custom-contoured ablation pattern method
Topographically Supported Customized Ablation for
for the treatment of decentered laser ablations
the Management of Decentered LASIK 8 eyes (7 post-LASIK patients and 1 post- PRK patient) with symptomatic laser decentration
11 eyes (9 patients) with LASIK-induced decentered ablations C-CAP method, flap lift or new cut with microkeratome
TG-LASIK with flap lifting (Visx S4 ActiveTrak excimer laser system)
(MEL 70 G-Scan, excimer laser, CarlZeiss-Meditec)
Am J Ophthalmol 2004;137:806-11
J Cataract Refract Surg 2004; 30:1675–1684
25 26
Topography-guided Treatment of Irregular Astigmatism

With the Wave Light Excimer Laser
16 eyes (11 patients) with small optical zones, decentered and irregular ablation after
corneal graft, and corneal scars
 10 TG-LASIK(new cut or flap lift) and 6 TG-PRK (due to limitation of RSB)
(ALLEGRETTO WAVE excimer laser and T-CAT software)
Conclusion :
Topography-guided LASIK and PRK used in this study resulted in a
significant reduction of refractive cylinder and increase of UCVA,
without a significant loss of BSCVA in patients with severe corneal
irregularities.
Stability of spherical equivalent refraction (SEQ) Stability of refractive cylinder over time after
topography-guided LASIK and PRK.
J Refract Surg 2006; 22:335–344 over time after topography-guided LASIK and PRK
27 28
Method for Optimizing Topography-guided Ablation of Highly

Aberrated Eyes With the ALLEGRETTO WAVE Excimer Laser
67 eyes with decentered ablations and
48 eyes with symptomatic small optical zones after previous LASIK
 TG-LASIK flap lift (ALLEGRETTO WAVE)
 67 eyes with previously decentered optical zones
•Eccentricity reduction
from 0.92 mm to 0.3 mm (P< .01)
•persistence of symptoms at 6 months 19.5%
 48 eyes with previously small optical zones
•central monodioptric optical zone increased
from 3.9 mm to 5.6mm (P< .01)
•persistence of symptoms at 6 months 18.7% An example of pre- and postoperative topography for optical zone
J Refract Surg 2008; 24:S439–445 enlargement. One color change equals 1.00 D change.
29 30
4-5
Incidence and Outcomes of Optical Zone Enlargement and Recentration Post-RK corneal irregularity
After Previous Myopic LASIK by Topography-Guided Custom Ablation
Topography-guided PRK
73 eyes (40 patients) with night vision disturbances due to post-myopic LASIK
decentration or small optical zone  TG-LASIK flap lift, new cut, or PRK
• Topography-guided PRK result in deeper ablation than
(CRS-Master TOSCA II software with the MEL 80 excimer laser (Carl Zeiss Meditec AG) standard ones
• Optical zone diameter increase 11% (from a mean of 5.65 to 6.32 mm), maximum
change 2 mm in one case • Correct hyperopia and irregular astigmatism
• Topographic decentration reduce 64% (from a mean of 0.58 to 0.21 mm)  good results, low incidence of visually significant haze
• SA reduce 44%
• Coma reduce 53%
• Total HOA reduce 39% • Hyperopic nature of the ablation
• Subjective improvement in night vision symptoms 93%. – most treatments were performed in the corneal periphery
• Efficacy : 82% of eyes reach 20/20, 100% reach 20/32 – central haze generally appeared later than peripheral haze
J Refract Surg. 2018;34(2):121–130
31
Post-RK corneal irregularity

Topography-guided LASIK Flowchart outlining management
Risk of irregular cornea
• button hole flap, splitting of the flap
• late dehiscence of an RK incision
• diffuse lamellar keratitis
• epithelial ingrowth
• opening of the RK incisions during the flap lift
• the possible augmentation of the inherent corneal
structural instability that could lead to corneal ectasia
Advantage
• easy to enhance
34
Flowchart showing sequential planning of TCAT in

irregular cornea on Wavelight Ex-500 Platform
Case 1
Post RK with night glare
35 36
4-6
• 51 y/o female
• Post RK ou
• CC: severe night glare ou OD
OD OS
pre TG-LASIK post TG-LASIK
Preop UCVA 0.3 0.6
Preop BCVA 1.5*+2.0/-1.0x80 1.5*+4.5/-2.5x80
Treatment TG LASIK TG LASIK
Target 0 -1.0
Q +0.660
Postop UCVA 0.8 0.05

Psotop BCVA 1.0*-0.5/-0.5x80 1.0*-3.0/-1.0x100  standard enhance
38
OD
treatment data enlarge optical zone enlarge
OS
pre TG-LASIK post-TG LASIK
39 40
Case 2 • 53 y/o male

Post ALK with small O.Z. • Post ALK ou in 1996
OS • CC: severe night glare od
OD OS
treatment data enlarge optical zone
Preop UCVA 0.3 1.0
Preop BCVA 0.5*-1.25/-0.75x80 1.0*-1.0
Treatment TG-PRK
0.02% MMC1’
Target 0
Q +0.45 0
Postop UCVA 0.01

Psotop BCVA 1.0*-3.75/-1.25x80
 standard PRK enhance
>1.2
41
4-7
treatment data
OD
pre TG-PRK post TG-PRK
43 44
OD Case 3 • 49 y/o female

post transepithelial standard PRK Post RK with small O.Z. • Post RK ou
• CC: severe night glare ou
OD OS
Preop UCVA 0.5 0.6
Preop BCVA 1.2*+3.0/-0.5x80 1.2*+2.0/-0.75x90
Treatment TG PRK TG LASIK
Target -1.0 -1.0

Q +0.920 +1.120
Postop UCVA 1.2 1.2

Psotop BCVA 1.2*-0.5/-1.25*80 1.2*0/-0.75*20
45
Summary
Small optical zone / decentration after refractive surgery
Topography-guided customized ablation
• improve visual performance of patients that are not able to
tolerate contact lenses or have exhausted non-surgical options Thanks for your attention.
• effective in enlarging the optical zone, recentering the optical
zone, and reducing HOAs
• an effective method for re-treatment procedures of
symptomatic patients after refractive surgery
• Inform patients the possibility of refractive surprises and
enhancement
• Residual refractive error may be corrected by cataract surgery.
47
4-8
Enhancement after small incision Agenda
lenticule extraction (SMILE)
1 Introduction
2 Surface Ablation after Smile
3 Thin Flap Lasik after Smile
4 Circle
5 Smile on Smile
6 Conclusion
大學眼科 Dr. 葉威毅
SMILE Growth Refractive Enhancement
What is Enhancement ?
 An additional refractive surgery performed when the refraction is overcorrected or
under corrected or optical regression has occurred.
What are the usual Enhancement Rate ?
Over 4 million • LASIK: vary from 1% to 6% (Randleman JB,et al.J Refract Surg. 2009;25:273‐276.)
Eyes p.a.
• PRK: 6.8% range from 3.8% to 20.8% (Naderi M, et al. BMC Ophthalmol.2018;18(1):198.)
treated eyes with • SMILE: 2% to 4% ( 2.9% Liu et al, Ophthalmology. 2017;124:813‐821) (4.9% Reinstein et
al. J Refract Surg. 2018;34(9):578‐588.)
SMILE®
Refractive Enhancement Refractive Enhancement
Causes
Risk factors for enhancement  Undercorrection
 Preoperative‐refractive error ‐ Occurs in immediate postoperative period
 Age ‐ Check IOP when myopia was shown 2w post‐op (steroid responder?)
 Corneal thickness  Overcorrection
 Ocular condition ‐ Low amount may not need enhancement as patient can accommodate
 Clinical protocol  Regression
 Laser platform ‐ Appears 1 month after surgery but can continue upto 1 year
 Nomogram ‐ Most regression occur 3‐6 month after surgery
 Environment ‐ Change in epithelium thickness after refractive surgery is a potential cause
(Stonecipher et al. US Ophthalmic Review, 2016;9(2):107–9 )
Reasons for Primary Failure
 Incorrect ablation programmed in the laser
‐ Wrong patient
 Decentered Ablation
‐ Check on anterior /posterior topography map
5-1
Refractive Enhancement Refractive Enhancement
When? Contra‐indications
• 3‐6 months after initial surgery
• Refractive instability
• At least 6 months post op is believed to be the ideal period
‐ If continual regression? Ectasia
‐ Wait for stable cycloplegic & manifest refraction
• Suboptimal pachymetry
‐ Minimum CCT 410 ‐ 460um, RST > 250 ‐ 300um
( Davis EA et al. Lasik enhancements: a comparison of lifting to re‐cutting the flap. Ophthalmology.
• Poor post corneal elevation
2002;109:2308‐2313.)
( Hersh PS, et al. Incidence and associations of retreatment after LASIK. Ophthalmology.
‐ If > 40 micros (Ectasia?)
2003;110:748‐754. )
Smile Enhancement Options Surface Ablation after Smile
Surface ablation
 Simplest and most straight forward retreatment procedure after SMILE.
Surface Ablation
 There was insufficient tissue available for a full refractive correction by LASIK.
Thin‐Flap Laser In Situ Keratomileusis ( Lasik )
Cap‐to‐Flap (Circle )
Surface ablation is a safe and effective option. In a study by Siedlecki et al.,7 at 3 months there was
no loss of corrected distance visual acuity (CDVA) of 2 lines or more in any patient who had
retreatment using surface ablation.
Secondary Small‐Incision Lenticule Extraction
Method of Surface Ablation Method of Surface Ablation
Transepithelial PRK LASEK ( alcohol assisted )
• Removal of epithelium is carried out by the excimer laser • Use 20% diluted absolute alcohol for 20‐30 seconds
• Can be considered if there are irregularity in the surface. Ex : irregular astigmatism. • Rinse with balanced salt solution (BSS) thoroughly
• In theory, reduce the impact of variations in epithelial thickness. • Peel off epithelium manually (spatula or dry sponge)
• May cause undercorrection of myopic correction due to the epithelial thickening • Fire excimer laser
after refractive surgery • Soak MMC 0.02% (30‐60 seconds)
• Use bandage Soft Contact Lens (3‐7 days)
5-2
Surface Ablation after Smile Thin Flap Lasik after Smile
‐ Results
N = 43 eyes Range/Mean Similar to LASIK, a femtosecond laser can be used to create a thin flap anterior to the
small‐incision lenticule extraction. The ease of lifting the flap was described as being
Pre Smile SE ‐6.35 ± 1.31 D equivalent to lifting a standard LASIK flap or side cut only flap.
Pre S+P SE ‐0.86 ± 0.43 D
Post op period 9.82 ± 5.27 m
Efficacy : patients within ±0.50 increased from 22.5% to 80%
patients within ±1.0 increased from 72.5% to 92.5%
Safety : 65% Gained one line; 15% loss 1 line ( 6 eyes )
Three of the four surface ablation profiles (Triple‐A, tissue‐saving
algorithm, and topography‐guided) resulted in equally
good results, whereas enhancement with the aspherically
optimized profile (ASA), used in two eyes, resulted in
overcorrection (+1.38 and +1.75 D).
Knox Cartwright NE, Tyrer JR, Jaycock PD, Marshall J. Effects of variation in depth and side cut angulations in LASIK and
thinf lap LASIK using a femtosecond laser: a biomechanical study. J Refract Surg. 2012;28:419‐425.
Thin Flap Lasik after Smile Thin Flap Lasik after Smile
‐ Planning ‐ Procedure
 There should be sufficient space anterior to the existing SMILE interface to safely create a flap.
 Diameter should not restricts the optical zone that can be used safely for an excimer laser ablation.
 The maximum epithelial thickness and minimum cap thickness should be measured and used to evaluate
whether a new LASIK interface could be safely created (avoiding gas breakthrough).
‐ Max epithelial thickness + 18) < flap thickness < (Min cap thickness – 18)
‐ The rule of thumb: at least 40 μm between the flap thickness and the maxi epithelium, also min cap thickness
Thin Flap Lasik after Smile Cap to Flap (Circle)
‐ Results
N= 116 eyes (96) Range / Mean Circle
 Covert the cap of the primary SMILE into a flap
Mean attempted SEQ ‐0.05 ± 0.99 D
Range attempted SEQ ‐1.88 to +1.50 D
Mean attempted Cyl ‐0.70 ± 0.55 D

Range attempted Cyl 0.00 to ‐2.25 D
Post op UCVA : 20/20 or better in 81% of eyes
(95% with CDVA 20/20 or better)
Efficacy : 74% within ±0.50 D
Safety : 15% loss 1 line CDVA / 21% gained 1 line  Similar to conventional LASIK (no pain and a speedier recovery)

 May be counterintuitive to enhance a flapless procedure with a flap
5-3
Circle Planning and Procedure Circle Study
‐ Results
N = 22 eyes Range/Mean
Pre Smile SE ‐5.56 ± 2.22 D
Pre S+C SE ‐0.51 ± 1.08 D
Post op period 10.0 ± 7.9 m
Efficacy: within ±0.50D: increased from 31.8% to 90.9%
within ±1.00D: increased from 77.3% to 100%
Safety : 9.9 % loss 1 line (2 eyes), no eye lost ≥ 2 lines
UCVA : All eyes gained at least one line
 Pattern D is recommended of the four patterns (A to D)
Circle Study Re‐SMILE
‐ Results
Surgical options for retreatment after small‐incision lenticule extraction: Advantages and disadvantages.
 In every eye in the study, the flap could be manipulated without any J Cataract Refract Surg 2018. Majid Moshirfar et al .
intraoperative (eg, flap tear or flap dislocation) or postoperative (eg, haze) A secondary SMILE procedure can be performed by creating another pocket anterior or posterior to
complications. the original pocket.
 Because the CIRCLE procedure represents a primary flap creation and not a
re‐lift, epithelial ingrowth was not observed in any case as expected
Re‐SMILE Re‐SMILE
Cap‐preserving SMILE Enhancement Surgery. BMC Ophthalmology (2018) 18:49. Ahmed N. Sedky et al.
5-4
Re‐SMILE Re‐SMILE
‐ Planning and Preparation ‐ Potential Risks
 Expected mean K readings post‐op > 33 D  Difficult to perform (break the suction manually after lenticule side cut was completed )
 Residual stromal bed > 250 µm  Depending on correction, lenticule might be too thin to extract
 Negligible data supporting the efficacy and safety
 No suspicion of ectasia based on topography
 Cap thickness set to the same value used in the primary SMILE treatment
 Minimum edge thickness > 18 µm (maximum 30um)
 Lenticule diameter of Re‐SMILE: better 0.2 mm less than the primary one
Corneal marking instrument is recommended
to ensure good centration
Conclusion
• From the earlier years, some surgeon speculated that the issue that Smile
will be lacking is an adequate retreatment procedure. Most believed that
surface ablation was the only option.
• The need for retreatment after Smile might even be less than after LASIK.
• It is proven that there are safe and effective retreatment options for Smile
5-5
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ƐƉŚĞƌŝĐĂůĂďĞƌƌĂƚŝŽŶŽĨƚŚĞĐŽƌŶĞĂ͘
ƐǁĞĂŐĞ͕ƚŚĞůĞŶƐƚƌĂŶƐĨŽƌŵĞĚŝŶƚŽĐĂƚĂƌĂĐƚĂŶĚŐƌĂĚƵĂůůǇĨĂŝůƚŽ
ŽĨĨƐĞƚƚŚĞƐƉŚĞƌŝĐĂůĂďĞƌƌĂƚŝŽŶĨƌŽŵƚŚĞĐŽƌŶĞĂ͕ĂŶĚĞǀĞŶĨƵƌƚŚĞƌ
ǁŽƌƐĞŶƚŚĞƐƉŚĞƌŝĐĂůĂďĞƌƌĂƚŝŽŶĂŶĚĂĨĨĞĐƚƚŚĞǀŝƐŝŽŶƋƵĂůŝƚǇŽĨƚŚĞ
ĞůĚĞƌůǇ͘
ŚƚƚƉƐ͗ͬͬǁǁǁ͘ƌĞǀŝĞǁŽĨŽƉŚƚŚĂůŵŽůŽŐǇ͘ĐŽŵͬĂƌƚŝĐůĞͬƚŚĞͲƉůƵƐĞƐͲĂŶĚͲŵŝŶƵƐĞƐͲŽĨͲĂƐƉŚĞƌŝĐͲŝŽůƐ
>ŽǁŽƌĚĞƌĂďĞƌƌĂƚŝŽŶŝŶ>^/<ƉĂƚŝĞŶƚƐĂĨƚĞƌ
ĐĂƚĂƌĂĐƚƐƵƌŐĞƌǇĐĂŶďĞĐŽŵŵŽŶ
>ŽŶŐĂǆŝĂůůĞŶŐƚŚŝŶŚŝŐŚŵǇŽƉŝĐƉĂƚŝĞŶƚƐ
tŝƚŚŽƵƚƉƌĞǀŝŽƵƐĚĂƚĂďĞĨŽƌĞ>^/<ƐƵƌŐĞƌǇ;ƚŚĞĐŚĂŶŐĞŝŶƚŚĞƌĂƚŝŽ
/ƐŝŵƉůĂŶƚĂƚŝŽŶŽĨŵŽŶŽĨŽĐĂů /K> ďĞƚǁĞĞŶƚŚĞĂŶƚĞƌŝŽƌĂŶĚƉŽƐƚĞƌŝŽƌĐŽƌŶĞĂůĐƵƌǀĂƚƵƌĞͿ
ďĞƚƚĞƌĨŽƌƉĂƚŝĞŶƚƐĂĨƚĞƌ>^/<͍ >ĞŶƐĐĂůĐƵůĂƚŝŽŶƐĂƌĞŶŽƚƉĞƌĨĞĐƚ
ÆZĞƐŝĚƵĂůƉŽƐƚŽƉĞƌĂƚŝǀĞƌĞĨƌĂĐƚŝǀĞĞƌƌŽƌĐĂŶďĞĐŽŵŵŽŶ
ÆEĞǀĞƌƉƌŽŵŝƐĞƚŚĞƉĂƚŝĞŶƚƐƚŚĂƚƚŚĞǇǁŽŶ͛ƚŶĞĞĚŐůĂƐƐĞƐĂĨƚĞƌ
:Z^ϮϬϬϳϯϯ;ϭͿ͗ϯϭͲϲ
ĐĂƚĂƌĂĐƚƐƵƌŐĞƌǇ :Z^ϮϬϬϲϯϮ;ϭϮͿ͗ϮϬϬϰͲϭϰ
:Z^ϮϬϬϲϯϮ;ϯͿ͗ϰϯϬͲϰ
:Z^ϮϬϬϴϯϰ;ϭϬͿ͗ϭϲϱϴͲϲϯ
6-2
/ŵƉůĂŶƚĂƚŝŽŶŽĨDƵůƚŝĨŽĐĂů/K>ƐŝŶŚŝŐŚŵǇŽƉŝĐ
/ĨŵƵůƚŝĨŽĐĂů/K>ŝƐĐŚŽƐĞŶ
ĐĂƚĂƌĂĐƚĞǇĞƐƌĞŵĂŝŶƐĐŽŶƚƌŽǀĞƌƐŝĂů
ŽŵƉůŝĐĂƚŝŽŶƐŝŶŚŝŐŚŵǇŽƉŝĂ K&/K>ŝƐďĞƚƚĞƌƚŚĂŶŝĨŽĐĂů/K>͕ĞƐƉĞĐŝĂůůǇǁŚĞŶ/K>ĚĞĐĞŶƚƌĂƚŝŽŶ
dŚĞĐŽŵƉĂƚŝďŝůŝƚǇďĞƚǁĞĞŶ/K>ƐĂŶĚĐĂƉƐƵůĂƌďĂŐƐŝǌĞƐ >ŽǁĐŽƌŶĞĂůŚŝŐŚŽƌĚĞƌĂďĞƌƌĂƚŝŽŶ
>^/<ĐŽŵƉůŝĐĂƚŝŽŶƐ hŶĚĞƌϱŽĨ>^/<ƚƌĞĂƚŵĞŶƚ
EŽƚƵƐĞĚŝŶƉĂƚŝĞŶƚƐǁŝƚŚƉƌŝŽƌŚǇƉĞƌŽƉŝĐ>^/<
hƐĞĂƌƌĞƚƚdƌƵĞͲ<͕^ŚĂŵŵĂƐĂŶĚƚŚĞ,ĂŝŐŝƐͲ>ĨŽƌŵƵůĂ
/ŶƚƌĂŽƉĞƌĂƚŝǀĞĂďĞƌƌŽŵĞƚƌǇ ĂƐƐŝƐƚĞĚ
EĞǀĞƌĚŽŝƚŝŶƉŝĐŬǇƉĞƌƐŽŶƐ
ƌ:KƉŚƚŚĂůŵŽů͘ϮϬϭϲ͖ϭϬϬ;ϮͿ͗Ϯϲϯʹϴ
ŵ:KƉŚƚŚĂůŵŽů͘ϮϬϭϴ͖ϭϴϴ͗ϭʹϴ ZĞĨƌĂĐƚ^ƵƌŐ͘ϮϬϭϵ͖ϯϱ;ϴͿ͗ϰϴϰͲϰϵϮ
ŚƚƚƉƐ͗ͬͬǁǁǁ͘ƌĞǀŝĞǁŽĨŽƉŚƚŚĂůŵŽůŽŐǇ͘ĐŽŵͬĂƌƚŝĐůĞͬŽĚĚͲĐŽƵƉůĞͲŵƵůƚŝĨŽĐĂůƐͲĂŶĚͲƉŽƐƚƌĞĨƌĂĐƚŝǀĞͲĞǇĞƐ
dŚĞ,KŽĨĐĐŽƌŶĞĂ ŝŶĞǇĞƐǁŝƚŚĂŶĚǁŝƚŚŽƵƚ
ƌĞĨƌĂĐƚŝǀĞƐƵƌŐĞƌǇ
dŚĞĂǀĞƌĂŐĞ^ŽĨĐŽƌŶĞĂŝƐнϬ͘ϮϳƵŵ
KƵƌ ĚĂƚĂ ϭ͘EŽƌŵĂůĐŽƌŶĞĂ Ϯ͘>^/< ϯ͘Z<
tŚŝĐŚŬŝŶĚƐŽĨŵŽŶŽĨŽĐĂů /K>ŝƐ ^ŝŶĐĞŶƚƌĂůϲŵŵ

;ŶсϵϱͿ
Ϭ͘ϯϰнͬͲϬ͘ϭϭƵŵ
;ŶсϭϭͿ
ϭ͘ϬϭнͬͲϬ͘ϰϴƵŵ
;ŶсϭϮͿ
ϭ͘ϱϮнͬͲϬ͘ϱϱƵŵ
ďĞƚƚĞƌĨŽƌƉĂƚŝĞŶƚƐĂĨƚĞƌ>^/<͍ dŚĞƌĞƐƵůƚŝƐĐŽŵƉĂƚŝďůĞǁŝƚŚĚĞ^ĂŶĐƚŝƐ͛Ɛ ƐƚƵĚǇ;^снϬ͘ϯϯƵŵͿ͕ůĂƌŐĞƌƚŚĂŶ

ƉƌĞǀŝŽƵƐƌĞƉŽƌƚ
dŚĞĂǀĞƌĂŐĞ^ŽĨĐŽƌŶĞĂŝŶĐĞŶƚƌĂůϲŵŵŽĨ>^/<ĂŶĚZ<ĞǇĞƐĂƌĞнϭ͘Ϭϭ
ĂŶĚнϭ͘ϱϮƵŵŝŶŽƵƌƐƚƵĚǇ
ĂƐƉŚĞƌŝĐ/K>ǁŝƚŚŵŽƌĞŶĞŐĂƚŝǀĞƐƉŚĞƌŝĐĂůĂďĞƌƌĂƚŝŽŶŵĂǇďĞŶĞĞĚĞĚŝŶ
ĞǇĞƐƌĞĐĞŝǀŝŶŐƌĞĨƌĂĐƚŝǀĞƐƵƌŐĞƌǇ
KƉƚŽŵ sŝƐ^Đŝ͘ϮϬϭϰKĐƚ͖ϵϭ;ϭϬͿ͗ϭϮϱϭͲϴ
^ŽĨĐĐŽƌŶĞĂ ^ŽĨĐĐŽƌŶĞĂ
/ŶƉĂƚŝĞŶƚǁŝƚŚŽƵƚƉƵƉŝůĚŝůĂƚŝŽŶ͕ƚŚĞĂǀĞƌĂŐĞƉƵƉŝů
ĚŝĂŵĞƚĞƌŝŶŵĞƐŽƉŝĐ ĐŽŶĚŝƚŝŽŶŝƐĂƌŽƵŶĚϰ͘Ϯϲŵŵ ĨƚĞƌƌĞĐĞŝǀŝŶŐĐĂƚĂƌĂĐƚƐƵƌŐĞƌǇ͕ƚŚĞƉƵƉŝůĚŝĂŵĞƚĞƌďĞĐŽŵĞƐƐŵĂůůĞƌ͕
^ŽĨĐŽƌŶĞĂŵĂǇďĞĐŽŵĞĞǀĞŶƐŵĂůůĞƌ;фнϬ͘ϭϭƵŵͿ
ƐƉŚĞƌŝĐ/K>ƐǁĞƌĞĚĞƐŝŐŶĞĚƚŽĂǀŽŝĚĂĚĚŝŶŐƉŽƐŝƚŝǀĞƐƉŚĞƌŝĐĂů
ĂďĞƌƌĂƚŝŽŶƚŽĂŶŽƉƚŝĐĂůƐǇƐƚĞŵ
^ƵĞƚĂů͘ƌĞƉŽƌƚĞĚĂƐƉŚĞƌŝĐ/K>ĚŝĚŶŽƚƌĞƐƵůƚŝŶďĞƚƚĞƌĨƵŶĐƚŝŽŶĂů
ǀŝƐŝŽŶƵŶĚĞƌŵĞƐŽƉŝĐ ŽƌƉŚŽƚŽƉŝĐ ĐŽŶĚŝƚŝŽŶƐǁŚĞŶĐŽŵƉĂƌĞĚƚŽ
ƐƉŚĞƌŝĐĂů/K>
ůŝŶ KƉŚƚŚĂůŵŽů͘ϮϬϭϰ͖ϴ͗ϮϭϰϭͲϱϬ
:ZĞĨƌĂĐƚ^ƵƌŐ͘ϮϬϬϵ͖Ϯϱ͗ϮϲϱͲϳϮ
6-3
ĂŶƉĂƚŝĞŶƚƐƚĞůůƚŚĞĚŝĨĨĞƌĞŶĐĞďĞƚǁĞĞŶ
,ŽǁƚŽŚŽŽƐĞĂŶĂƐƉŚĞƌŝĐ/K>
ƚƌĂĚŝƚŝŽŶĂůĂŶĚĂƐƉŚĞƌŝĐ/K>͍
dŚĞĚŝĨĨĞƌĞŶĐĞŵĂĚĞďǇĂĚĚƌĞƐƐŝŶŐĂƐƉŚĞƌŝĐŝƚǇ ŝƐƵƐƵĂůůǇǀĞƌǇƐŵĂůů /K>ŵĂŬĞƌƐƚŽŽŬĚŝĨĨĞƌĞŶƚƌŽĂĚƐƚŽĂƐƉŚĞƌŝĐŝƚǇ͕ǇŝĞůĚŝŶŐĂĐŽůůĞĐƚŝŽŶŽĨ

ĐŽŵƉĂƌĞĚƚŽĐŽƌƌĞĐƚŝŶŐƐƉŚĞƌŝĐĂůĞƌƌŽƌĂŶĚĂƐƚŝŐŵĂƚŝƐŵ͘ ĂƐƉŚĞƌŝĐůĞŶƐĞƐƚŚĂƚǀĂƌŝŽƵƐůǇƐĞĞŬƚŽŶĞƵƚƌĂůŝǌĞĂůů͕ƐŽŵĞŽƌŶŽŶĞŽĨ
hŶĚĞƌůŽǁͲĐŽŶƚƌĂƐƚĐŽŶĚŝƚŝŽŶƐ͕ĂƉĂƚŝĞŶƚǁŝƚŚůĂƌŐĞƉƵƉŝůƐǁŽƵůĚďĞ ƚŚĞǀŝƐƵĂůƐǇƐƚĞŵ͛ƐŶĂƚƵƌĂůůǇŽĐĐƵƌƌŝŶŐĐŽƌŶĞĂůƐƉŚĞƌŝĐĂůĂďĞƌƌĂƚŝŽŶ͘
ŵŽƌĞůŝŬĞůǇƚŽŶŽƚŝĐĞƚŚĞĚŝĨĨĞƌĞŶĐĞ ƐƉŚĞƌŝĐ/K>ĐŚŽŝĐĞ͗^сϬ͕ͲϬ͘ϮϬ͕ͲϬ͘ϮϳƵŵ
dŚĞŽůĚĞƌƚŚĞƉĂƚŝĞŶƚƐ͕ƚŚĞƐŵĂůůĞƌƚŚĞƉƵƉŝů͕ƚŚĞƉŽŽƌĞƌƚŚĞĨƵŶĐƚŝŽŶ ĂƚĂƌĂĐƚƐƵƌŐĞŽŶƐŚŽƵůĚĐŚŽŽƐĞĂƐƉŚĞƌŝĐ/K>ƐďĂƐĞĚŽŶƚŚĞ
ŽĨƚŚĞŵĂĐƵůĂÆ dŚĞǇŽƵŶŐĞƌƉĂƚŝĞŶƚƐŶĞĞĚĂƐƉŚĞƌŝĐ/K>ŵŽƌĞ ĐŚĂƌĂĐƚĞƌŝƐƚŝĐƐŽĨƚŚĞŝŶĚŝǀŝĚƵĂůƉĂƚŝĞŶƚ͛ƐĞǇĞ
dŚĞŵŽƌĞŚǇƉĞƌŽƉŝĐƉĂƚŝĞŶƚƐŶĞĞĚĂƐƉŚĞƌŝĐ/K> ŵŽƌĞ
ŚƚƚƉƐ͗ͬͬǁǁǁ͘ƌĞǀŝĞǁŽĨŽƉŚƚŚĂůŵŽůŽŐǇ͘ĐŽŵͬĂƌƚŝĐůĞͬƚŚĞͲƉůƵƐĞƐͲĂŶĚͲŵŝŶƵƐĞƐͲŽĨͲĂƐƉŚĞƌŝĐͲŝŽůƐ ŚƚƚƉƐ͗ͬͬǁǁǁ͘ĂĂŽ͘ŽƌŐͬĞǇĞŶĞƚͬĂƌƚŝĐůĞͬŚŽǁͲƚŽͲĐŚŽŽƐĞͲĂƐƉŚĞƌŝĐͲŝŶƚƌĂŽĐƵůĂƌͲůĞŶƐ
ƉƉůŝĐĂƚŝŽŶŽĨ^ƉŚĞƌŝĐĂůĂďĞƌƌĂƚŝŽŶ ƉƉůŝĐĂƚŝŽŶŽĨ^ƉŚĞƌŝĐĂůĂďĞƌƌĂƚŝŽŶ
нϬ͘ϭϰƌĞƐŝĚƵĂů^ƐŚŽƵůĚďĞƚĂƌŐĞƚĞĚ
WƌĞĨĞƌĂďůĞŶŽƚƚŽŚĂǀĞŶĞŐĂƚŝǀĞ^
ĞƌŽ^ŐŽŽĚĨŽƌƋƵĂůŝƚǇŽĨǀŝƐŝŽŶ
^ŵĂůůĂŵŽƵŶƚŽĨ^ƉƌŽǀŝĚĞƐďĞƚƚĞƌĚĞƉƚŚŽĨƉĞƌĐĞƉƚŝŽŶ
,ŝŐŚĂŵŽƵŶƚŽĨ^ĐĂŶĐĂƵƐĞĚŝƐƚŽƌƚŝŽŶŽĨŝŵĂŐĞ
,KzsŝǀŝŶĞǆ
&ƌŽŵƐůŝĚĞƐŽĨƌ͘ZĂǀŝƐŚǀĂŝƐŚŶĂǀ &ƌŽŵƐůŝĚĞƐŽĨƌ͘ZĂǀŝƐŚǀĂŝƐŚŶĂǀ
/K>ǁŝƚŚŶĞŐĂƚŝǀĞĂƐƉŚĞƌŝĐŝƚǇ ĐƌĞĂƚĞŵŽƌĞ
ĞŶƚƌĂƚŝŽŶŽĨ/K>
ĐŽŵĂĂŶĚĂƐƚŝŐŵĂƚŝƐŵŝĨĚĞĐĞŶƚĞƌĞĚ
/ŶŶŽƌŵĂůĐŽŶĚŝƚŝŽŶ͕ǁŝƚŚƚŚĞŶĞǁĚĞƐŝŐŶƐ͕ŵŽƐƚůĞŶƐĞƐƐƚĂǇǁĞůůͲ DŽĚƵůĂƚŝŽŶƚƌĂŶƐĨĞƌĨƵŶĐƚŝŽŶŽĨ/K>ƐǁŝƚŚ
ĐĞŶƚĞƌĞĚ ǌĞƌŽƐƉŚĞƌŝĐĂůĂďĞƌƌĂƚŝŽŶŝƐŶŽƚĂĨĨĞĐƚĞĚďǇ
^ƚĂŶĚĂƌĚƐƉŚĞƌŝĐĂů/K>Ɛ;ƉŽƐŝƚŝǀĞƐƉŚĞƌŝĐĂůĂďĞƌƌĂƚŝŽŶͿ͗ŶŽƚĐƌĞĂƚĞ ǌĞƌŽƚŽϭ͘ϬŵŵŽĨĚĞĐĞŶƚƌĂƚŝŽŶ
ŵĂũŽƌƉƌŽďůĞŵƐ͘;tŚĞŶ/K> ĚĞĐĞŶƚƌĂƚŝŽŶ хϬ͘ϱŵŵŽƌƚŝůƚхϳĚĞŐƌĞĞ /K>ƐǁŝƚŚǌĞƌŽƐƉŚĞƌŝĐĂůĂďĞƌƌĂƚŝŽŶŝŶĚƵĐĞ
ƌĞĚƵĐĞĚƚŚĞŵŽĚƵůĂƚŝŽŶƚƌĂŶƐĨĞƌĨƵŶĐƚŝŽŶŽĨŶĞŐĂƚŝǀĞ^/K>ƚŽďĞůŽǁ ůĞƐƐĐŽŵĂĂŶĚĂƐƚŝŐŵĂƚŝƐŵŝĨƚŚĞǇĚĞĐĞŶƚĞƌ
ƚŚĂŶ/K>ƐǁŝƚŚƉŽƐŝƚŝǀĞĂŶĚŶĞŐĂƚŝǀĞ
ƚŚĂƚŽĨĂƐƚĂŶĚĂƌĚƐƉŚĞƌŝĐĂů/K>Ϳ ƐƉŚĞƌŝĐĂůĂďĞƌƌĂƚŝŽŶ
ĞƌŽƐƉŚĞƌŝĐĂůĂďĞƌƌĂƚŝŽŶ͗ŶŽƚĐŽŶĨŽƵŶĚĂŶǇĞǆŝƐƚŝŶŐ ;WŽƐŝƚŝǀĞ^/K>ďĞƚƚĞƌƚŚĂŶŶĞŐĂƚŝǀĞ^/K>Ϳ
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6-5
Place Holder
POST-LASIK CHALLENGES
The first FDA approval for LASIKÆ 1998
WHICH IOL IS BETTER Previous LASIK have less epithelial remodeling that may affect and change
AFTER LASIK? their cornea refractive status than PRK or RK
('2)08/7,)2&$/ Early LASIK (15 or more years ago) Recent LASIK procedure
9 often decentered
no pupil centration, 9 better centered ablations,
no eye-tracking technology, 9 larger optical zones,
悏搾挩乌塔䗺䢏壸ヾ
ヾ
⊮⇕曢⵵壸ヾ䗺䢏ᳫ⺁
9 often induced unintended higher-order 9 fewer HOAs.
㬝⫘⩚
⩚ 恩⳩ aberrations (HOAs)
6\QHUJ\(\H&HQWHU ,&URQ(\H&OLQLF

6KDQJ
J
J<L&KLDQJ0'3K'
HIGH EXPECTATIONS OPTIMIZE THE OCULAR SURFACE
Good UCVA after cataract surgeryÆ less dependent on spectacles OSD is common in those who have had previous refractive surgery
Early LASIK patients unstable tear filmÆ inaccurate K readings, affecting the IOL calculation, and subsequent
refractive error.
OsmolarityÆ guide for dry eye treatment
Latest multifocal IOL Monofocal IOL Slit-lamp examination determine the level of blepharitis (59%), and appropriate treatment level
Extended depth of focus (EDOF) IOL instead of a premium IOL Meibography
OSD under control before taking biometry measurements
Recent LASIK patientsÆ more IOL choices. - thermal pulsation, immunomodulators, nutritional supplements, microblepharoexfoliation,
Muftuoglu et al. reported a 42.9% laser enhancement rate after multifocal IOL implantation in a and/or lid scrubs.
series of 49 eyes with prior myopic LASIK.1
J Cataract Refract Surg. 2010;36(11):1815-1821. Clin Ophthalmol. 2016;10:1965-1970.
KEY POINTS
DIAGNOSTICS
Take Care With Cataract Surgery After LASIK
Biometry (Lenstar,
Autorefractor K IOL Master 700,
Topography
readings and PANACEA IOL
A vast population of patients with previous LASIK are either ready for calculator)
cataract surgery now or will soon be.
Calculating the correct IOL power in patients with previous LASIK requires ASCRS IOL calculator
(iolcalc.ascrs.org) for eyes
extra attention. Scheimpflug
AS-OCT
after corneal refractive
surgery ( including LASIK,
topographers PRK, RK, and conductive
Ocular surface disease is an added concern in patients with a history of LASIK. keratoplasty), Barrett
True-K formula
proper DED
treatment to
restore the
integrity of the tear
film and health of
the corneal
surface.
6/8/2021
7-1
Choosing an IOL After LASIK
SURGICAL Spherical Aberration
STRATEGY Aspheric IOLs (negative or zero
spherical aberration)Æimproved
Intraoperative aberrometry: ORA System with visual outcomes (contrast sensitivity
VerifEye Technology (Alcon) testing and driver simulation studies)
¾ determine the appropriate IOL power, After myopic LASIK (positive spherical aberration ՛ )
¾ verifying the axis placement for toric IOLs, Æ choose an IOL with the most negative spherical aberration ( e.g. Tecnis ZCB00 or Tecnis Toric, AcrySof IQ
¾ account both ant. and post. corneal astigmatism. lens (model SN60WF)
usually in the nondominant (or near-vision) eye first. After hyperopic LASIK (negative spherical aberration ՛ )
Æ choose an IOL with positive spherical aberration or an aberration-free lens ( e.g. enVista, Crystalens, Akreos
AO (model AO60) and Akreos MICS(model MI60).
Complex cases (misaligned or irregular laser ablation)
Æ choose an aberration-free IOL ( less sensitive to optical decentration).
J Cataract Refract Surg. 2002;28(9):1539- 45.

J Cataract Refract Surg. 2003;29(9):1702-08.
Premium IOLs
Multifocal IOLs: decrease contrast sensitivity.
EDOF IOLs :
¾ larger size central optic,
¾ higher light transmission (92% of the light)
(enhanced contrast sensitivity)
¾ contrast sensitivity close to that typically associated
with monofocal IOLs Choosing an IOL Clinical Evidence
¾ allows for some tolerance to residual refractive errors.
¾ reduced incidence of halos and glare After LASIK Presbyopiiia-
Presbyopia aa-correcting
correcting intraocular lens implantation
co implantatio
iim
m
mp
mplan
om
o
plaan
in eyes with previous laser in situ keratomileusis
mile
mi
nt
ileeusi
ussis
Patients selection:
patients were happy and achieved great quality of
vision after refractive surgery
ablation bed is fairly well centered with no or little
irregular astigmatism
they did not experience problems with night vision.
995942-SU-082018
Visual quality after diffractive intraocular lens implantation in eyes Optical and visual performance of diffractive intraocular lens implantation
with previous myopic laser in situ keratomileusis after myopic laser in situ keratomileusis
Spherical AcrySof Aspheric Acri. LISA phakic eyes Aspheric Acri. LISA Spherical AcrySof Phakic eyes
ReSTOR SN60D3 366D (control) 366D ReSTOR SN60D3 (control)
BCVA (photopic and mesopic conditions), NCVA , HOAs, modulation BCVA (photopic and mesopic conditions), NCVA , HOAs, modulation
transfer function (MTF) transfer function (MTF)
Mean photopic CDVA after 6 months was 20/25 or better in all groups BCVA (mesopic conditions): aspheric IOL> spherical IOL group
All eyes in both IOL groups achieved a distance-corrected near visual acuity Mean best distance-corrected near acuity, HOAs: no statistically significant
(DCNVA) of 20/32 or better. Aspheric IOL group and the control group had better MTF than the spherical
Under glare or low-contrast situations performance: Acri.LISA > ReSTOR. IOL group with a 6.0 mm pupil (P<.01).
No differences in HOAs between 3 groups
Both multifocal IOLs provided good and comparable visual acuity at distance After LASIK, the aspheric IOL provided better visual quality and optical
and near. quality than spherical IOL under mesopic conditions (large pupil).
Aspherical Acri.LISA IOL gave better intermediate visual acuity than the
spherical AcrySof ReSTOR IOL.
J Cataract Refract Surg 2008;34: 1848–54. J Cataract Refract Surg 2009;35: 825–832.
7-2
Refractive lens exchange with spherical diffractive intraocular lens Visual quality after diffractive intraocular lens implantation in eyes with
implantation after hyperopic laser in situ keratomileusis previous hyperopic laser in situ keratomileusis
Spherical AcrySof Spherical AcrySof phakic eyes

ReSTOR SN60D3 ReSTOR SN60D3 (control group)
41 eyes of 23 patients 41 eyes of 23 patients

6 months postoperatively 6 months postoperatively
UDVA, CDVA, UNVA, DCNVA), and residual refractive CDVA (photopic and mesopic conditions), UNVA and DCNVA, defocus curves,
and HOAs
Mean CDVA was 20/25 or better in 58.54% of the patients. Under photopic conditions: no statistically significant differences between the
Mean UDVA and CDVA were 20/26 and 20/22, and the patients achieved a 2 groups .
mean UNVA and DCNVA of 20/21, respectively. Under mesopic conditions, the control group had better CDVA than the study
group
No statistically significant differences in HOAs between the 2 groups
Implantation of a spherical multifocal IOL after hyperopic LASIK was safe,
effective, and predictable.
In eyes with previous hyperopic LASIK, the diffractive IOL provided good
visual quality at distance, comparable to that obtained in phakic eyes under
photopic conditions,
Visual performance was slightly poorer under mesopic conditions.
J Cataract Refract Surg 2009;35: 1744–1750. J Cataract Refract Surg 2011;37: 1090–1096.
Comparative analysis of clinical outcomes of a monofocal and an extended-

range-of-vision intraocular lens in eyes with previous myopic laser in situ
KEY POINTS keratomileusis
Optical and visual performance of diffractive intraocular Tecnis Symfony Tecnis ZCB00
lens implantation after myopic and hyperopic LASIK
44 patients (88 eyes)
Implantation of diffractive multifocal lenses is a viable option for 4 months postoperatively.
(22 patients in each group)
presbyopia correction. VA, refraction, defocus curve, contrast sensitivity, photic

The patients should be informed about the potential risk of a refractive phenomena, spectacle independence, and patient satisfaction
Æ No significant subjective differences
surprise and the possibility of poorer visual performance under low light
conditions, beyond what they may have already experienced after LASIK.
- Binocular uncorrected intermediate and near visual acuities were
Conclusion:
significantly better in the EDOF IOL group.
- The defocus curve of both IOLs differed more with increasing negative The extended-range-of-vision IOL was a useful option to
defocus. restore visual function after cataract surgery in eyes that
- Mild glare was reported in 22.7% of the EDOF group and 9.1% of the previously had myopic LASIK surgery, offering levels of
monofocal group. visual quality comparable to those achieved with the
- Spectacle dependence for intermediate vision and near vision was higher in monofocal IOL.
the monofocal IOL group.
6/8/2021 J Cataract Refract Surg. 2018 Feb;44(2):149-155.
Refractive predictability and visual outcomes of an extended range of vision Determinants of Patient Satisfaction in Post-LASIK Patients Undergoing Cataract
intraocular lens in eyes with previous myopic laser in situ keratomileusis Surgery
Study Design Study Results

Postoperative spherical equivalent within Ʋ0.50 and Ʋ1.00രD was found in 61.6%
7RHYDOXDWHWKHUHIUDFWLYHSUHGLFWDELOLW\ and 86.3% of eyes, respectively.
REWDLQHGZLWKDQH[WHQGHGUDQJHRIYLVLRQ In eyes with pre-laser in situ keratomileusis data available, no significant Bausch + Lomb
LQWUDRFXODUOHQVLQH\HVZLWKSUHYLRXV correlation was found between pre-laser in situ keratomileusis spherical Tecnis +3.25 Multifocal IOLs Tecnis Symfony Tecnis ZCB00 Akreos monofocal
P\RSLFODVHULQVLWXNHUDWRPLOHXVLV equivalent and post-cataract surgery spherical equivalent (rര=ര0.237, pര=ര0.114). (n=32) (n=11) (n=13)
FRQILUPLQJZKLFKLQWUDRFXODUOHQVSRZHU A postoperative spherical equivalent within Ʋ0.50രD was found in 65.2% and 55.6%
IRUPXODSURYLGHVWKHPRVWDFFXUDWH of eyes in the subgroups with and without pre-laser in situ keratomileusis data
FDOFXODWLRQ - Overall patient satisfaction: multifocal (90.6%)> EDOF (81.8%)>
available, respectively (pര=ര0.480).
H\HVSDWLHQWVXQGHUJRLQJFDWDUDFW Statistically significantly higher differences between the IOL power implanted and monofocal group (30.8%).
Near vision
VXUJHU\ZLWKLPSODQWDWLRQRIWKH('2),2/ the calculation provided by the Potvin–Hill (pര=ര0.028) and Barrett True K No - HOAs of 61 post-LASIK eyes were statistically significantly higher
7(&1,66\PIRQ\-RKQVRQDQG-RKQVRQ History formulas (pര=ര0.022) were found in those eyes with postoperative spherical Intermediate than separate cohort of 350 eyes with no prior LASIK
vision
9LVLRQ equivalentര>ര0.50രD. - The EDOF and monofocal groups had better contrast sensitivity
,QWUDRFXODUOHQVSRZHUZDVFDOFXODWHG than the multifocal IOL group at both near and distance
XVLQJDOO$PHULFDQ6RFLHW\RI&DWDUDFWDQG
5HIUDFWLYH6XUJHRQVIRUPXODVDQGWKHLU The extended range of vision intraocular lens evaluated can
DYHUDJHYDOXHZDVVHOHFWHGIRU provide a predictable refractive correction in eyes with hŶĐŽƌƌĞĐƚĞĚŶĞĂƌĂŶĚŝŶƚĞƌŵĞĚŝĂƚĞǀŝƐŝŽŶĂƌĞǀĞƌǇ
LPSODQWDWLRQ previous laser in situ keratomileusis surgery. ŝŵƉŽƌƚĂŶƚƚŽƉŽƐƚͲ>^/<ƉĂƚŝĞŶƚƐ͘
5HIUDFWLYHRXWFRPHVZHUHHYDOXDWHGDW The Potvin–Hill and Barrett True K No History are the most &ŽƌƉĂƚŝĞŶƚƐǁŚŽŚĂǀĞĂůƌĞĂĚǇƐŽƵŐŚƚƐƉĞĐƚĂĐůĞ
ௗPRQWKVSRVWRSHUDWLYHO\ adequate formulas to perform intraocular lens power ŝŶĚĞƉĞŶĚĞŶĐĞŝŶƚŚĞƉĂƐƚ͕ŶĞĂƌǀŝƐŝŽŶŝƐŬĞǇ
calculations in these cases.
(85-23+7+$/02/. 9RO,VVXH %\)UDQN$%XFFL-U0'
7-3
CONSIDER POST-LASIK CATARACT
PATIENTS AS PREMIUM IOL
Would you PATIENTS
recommend IOL selection in patients undergoing cataract surgery after corneal
refractive surgery continues to be a challenging and complex issue.
multifocal IOLs to Current focus seems to be directed toward approaches that do not
patients who have require preoperative refractive surgery information.
Most important things after refractive surgeryÆ irregular astigmatism
previously and HOAs.
Best choice of IOL:
undergone refractive - previous myopic LASIKÆ aspheric IOL
surgery? - previous hyperopic LASIK Æ nonaspheric IOL (never place a

monofocal IOL with a negative spherical aberration)
- Recent myopic LASIK (smooth topography without irregular
astigmatism)Æ EDOF or accommodating IOLs
- irregular astigmatism and/or significant irregular topography Æ
monofocal, toric, or accommodating lens, avoid diffractive
technology IOLs
J Cataract Refract Surg. 2018 Feb;44(2):149-155.
Cataract surgery in cases with previous corneal refractive

surgery may be a major challenge for the ophthalmologist.
Take Home
Message The refractive outcome of the case deserves special attention
in the preoperative planning process, which should be tailored
for the type of prior refractive procedure: incisional, ablative
under a flap, or on the corneal surface.
Avoiding refractive surprise after surgery in these cases is

principally dependent on the accuracy of the intraocular lens
calculation, together with the selection of the appropriate
biometric formula and IOL selection for each case.
Modern techniques help surgeons to move toward the goal of

cataract surgery as a refractive procedure free from refractive
error.
Surv Ophthalmol. Nov-Dec 2016;61(6):769-777.
7-4
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8-8
What Is Astigmatism?
Regular or irregular corneal astigmatism?
Astigmatism is an irregular curvature of the cornea or
–Preoperative assessment of toric IOLs lens which does not focus light evenly on the retina.
散光為角膜或水晶體不規則的曲度造成的，會導致光線無法集中於視網膜上
Bryan Hung-Yuan Lin,
Taiwan Universal Eye Center, Zhong-Li
No Financial Interest to Disclosure
Dr. Bryan H. Dr. Bryan H.

Y Li Y Li
Pearls for accurate diagnosis of preoperative

astigmatism
How’s Astigmatism’s population?
1, The first thing is make sure the ocular
Data from 8 UK National Health Service ophthalmology clinics
Eligible eyes included in the analysis were 110468 for surface as a whole is healthy. (ex. Dry
preoperative (corneal) astigmatism eye, ...)
先確認眼表狀態整體是否健康(例如，是否有乾眼…)
在術前(角膜)散光檢查中，合格納入的眼睛數量約為110,468隻眼 19:47 19:49
78% (n=85 650) ≥0.5 dioptres (D)
42% (n=46 003) ≥1.0 D
21% (n=22 899) ≥1.5 D Br J Ophthalmol. 2019 Jul; 103(7): 993–1000.
11% (n=11 651) ≥2.0 D

Y Li Y Li
Pearls for accurate diagnosis of preoperative Pearls for accurate diagnosis of preoperative
Pearls for accurate diagnosis of
astigmatism astigmatism
preoperative astigmatism
2.Provided the ocular surface is healthy, then it’s Regular, symmetric astigmatism
time to conduct biometry.
如眼表正常，即可進行生物量測
It is important to have at least 2, maybe 3, ways to
evaluate astigmatism
建議至少使用2-3種不同的方式來測量散光
No single method has been identified as being the

most accurate for measuring true astigmatism
因為並沒有任何一種方法被證實是最精准的

Y Li Y Li
9-1
57 years old male patient
OPD‐Scan III iTrace Lenstar ARK‐510A ARK‐1a PentaCam
Regular astigmatism
Irregular astigmatism
K1 K2 Axis
OPD‐Scan 47.2 45.88 104
iTrace 47.84 46.33 108

Symmetric astigmatism
ARK‐510A 47.25 46.0 96
ARK‐1A 47.25 46.0 98 Asymmetric astigmatism

PentaCam 47.0 45.8 93.5
Lenstar 46.0 47.5 97

Y Li Y Li
Regular vs. Irregular

astigmatism
• Regular Astigmatism
– Correctable using a cylindrical spectacle lens
– Cornea resemble a football or rugby ball with the two principal
meridians having different curvature radii.
– The two principal meridians separated by 90 degrees.
– Cornea topography displays a symmetrical bow-tie pattern
• Irregular Astigmatism
– The principal meridians are not 90 degree apart
– William S. Duke-Elder
• Reflection in different meridians conforms to no geometrical plan and the
refracted rays have no planes of symmetry
Dr. Bryan H. Y. Lin
Irregular astigmatism Symmetrical vs. Asymmetrical

astigmatism
• Symmetrical pattern
✓In a standard eye, we typically see a different shape or pattern
along one meridian, and the two primary meridians are 90º apart
(perpendicular to each other)
✓This is simply with-the-rule astigmatism (if the flattest meridian is
horizontal), against-the-rule astigmatism, or oblique astigmatism.
• Asymmetrical pattern
✓if there is a difference in shape within one meridian
✓if the shape change is not a straight line of 180º but has an angle of
around 20º or more, this would be regarded as asymmetry and
possibly as an indication of keratoconus.
9-2
低階：規則散光
高階：不規則散光
Proposed videokeratography pattern classification scheme. PSBT=prolate symmetric
bow tie, PABT=prolate asymmetric bow tie, OSBT=oblate symmetric bow tie,
OABT=oblate asymmetric bow tie, PI=prolate irregular, OI =oblate irregular,
SF=steep/flat, LS=localised steep.
https://bjo.bmj.com/content/83/4/403
Dr. Bryan H.
Y Li
Regular astigmatism Irregular astigmatism

Y Li Y Li
Irregular如何判别 Total L.O. H.O.

Irregular, asymmetric
「RMS(均平方根值)」可自動計算出準確 SCA 測量值的相關性 astigmatism
低階：規則散光
高階：不規則散光
0 0.5
RMS [D]
Regular Astig. Irregular Astig.
處理方式：
規則性散光不規則散光
• 術中不處理散光（單焦點人工晶體…）
• 術中只處理低階規則散光，不處理高階不規則高階相差
RMS:0.11 • 術中先處理低階規則散光，術後處理高階相差（病人接受兩次手術？）
• 術中處理低階規則散光同時盡量減低高階相差的干擾（處理高階的難度…）
RMS 值高於 0.5Ｄ時，屬於不規則散光 (Unit：D)
HO RMS 值高於 0.3μm時，屬於不規則散光 (Unit：μm)
Y Li Y Li
9-3
Why K value of the degree and axis are not the same in all
instruments Pearls for accurate diagnosis of preoperative
為什麼K值和軸度在每個儀器的測量結果都會不太一樣?
astigmatism
K optical zone K measure points
1.6mm
LenStar 16 *2 point A. Keratometers. 角膜曲率測量儀
2.3mm
2.4mm
AL-Scan 360*2 points B. Optical biometry. 光學生物測量
3.3mm
IOL master 2.4mm 6points

C. Topography. 角膜地形圖
Pentacam ø1.0 to 13.0 mm Scheimpflug
Topcon KR-1 3.3mm Mire ring
Nidek ARK-1 3.3mm Mire ring
OPD-Scan III ø0.5 to 11.0 mm Pacido ring
iTrace ø0 to 8.0 mm Pacido ring

Y Li Y Li
A. Keratometer
A. Keratometer
Corneal astigmatism can be identified with manual and
autokeratometers in a repeatable manner.
可以透過重復手動測量或自動驗光儀得知角膜散光
However, these instruments are insufficient because they
only measure four points in the central 3 mm of the cornea
但只靠儀器測量仍是不足的，因為它們只能在角膜中心3mm處量測4個點
, and are unable to detect astigmatic asymmetries,
irregularities, posterior corneal, nor lenticular astigmatism.
無法測得不規則或不對稱散光、後角膜散光度數以及晶狀體散光 XFlat axis + 90 = Steep axis ???
X Only 4 points was detected
X Detected in 3~3.5 mm “mean
Dr. Bryan H. ring” Dr. Bryan H.
Y Li Y Li
B. Optical biometry Corneal topography

Optical biometry provides magnitude and axis
It allows for the detection of asymmetric and irregular astigmatism.
measurements at various optical zones (1.65, 角膜地形圖可用來偵測不對稱及不規則散光。
2.3, or 3.3 mm depending on the instrument)
Comparative studies between manual and automated keratometry, Placido-
with variable numbers of points (6, 18, and
32). type topography, and simulated keratometry of Scheimpflug systems
光学式生物量测可采集(6、18、32个点)于不同尺寸的
光学区域上(1.65、2.3、3.3mm)不同轴向位置上的角膜
showed similar results in terms of anterior corneal magnitude, but axis
K值 differences were noted .
比較性研究指出，手動或自動角膜量測、 Placido-type地形圖或是模擬K值(sim-K)等，
與測出的前角膜K值有類似的結果，但採樣的軸度可能不盡相同
K measure
K optical zone
points
LenStar
1.6mm
16 *2 point Corneal topographers may usually be considered as the final judge in
2.3mm
terms of axis, pending verification of the image quality.
角膜地形圖通常是用來做最後判定，因為考量到軸度與更全面的角膜區域分析
2.4mm
AL-Scan 360*2 points
3.3mm
K optical zone K measure method
IOL master 2.4mm 6 points
Pentacam Scheimpflug
X Flat axis + 90 = Steep axis ??? ø1.0 to 13.0 mm
OPD-Scan III ø0.5 to 11.0 mm Pacido ring

More rings and points was detected
X Detected in 1.6~3.4 mm “mean Dr. Bryan H. iTrace ø0 to 8.0 mm Pacido ring Dr. Bryan H.
i ” Y Li Y Li
9-4
Placido disc reflection topographers
Types of Topographers 角膜地形圖測量-盤投射系統
• Placido disc systems project a series of
concentric rings of light on the anterior corneal
• Placido disc reflection 盤投射系統 surface.
• The corneal shape or curvature is directly
• Scanning slit 裂隙燈掃描 measured in diopters of curvature along
thousands of points on the rings.
• Placido disc topography systems do not
• Scheimpflug photography 顯微移軸攝影 actually measure elevation; rather, they derive
anterior corneal elevation data by
reconstructing actual anterior curvature
measurements via sophisticated algorithms.

Y Li Y Li
Limitations of placido based systems

角膜地形圖測量-盤投射系統的限制
X No Analysis of Posterior Surface
Scanning-slit topographers
沒有辦法分析後角膜表面角膜地形圖測量-裂隙燈掃描
X No Representation of Thinning
無法分析角膜厚度 • Such as the Orbscan (Bausch + Lomb)
• Project two vertical scans through 40 optical
slits at fixed angles to analyze the curvatures at
X Limited Data in Scarred Corneas the anterior and posterior corneal surface
對於結痂角膜測得的資訊受限 • Allowing the system to gather posterior data,
including thickness.
X High Incidence of False Positives
容易出現偽陽性數據，造成判讀錯誤
Y Li Y Li
Scheimpflug 顯微移軸攝影
photographers
Limitations of scanning slit system •Rotating Scheimpflug cameras, such as the
Pentacam (Oculus)
•Use off-axis light to capture precise
X Lack of detail 缺乏測量細節 measurements of the anterior and posterior
X Slower image capture 影像擷取速度較慢 surfaces of the cornea
•Allowing the system to calculate global
X Less reliable with low reproducibility 一致性較差 pachymetry and allow characteristics such as
X Incapable of imaging the postoperative cornea accurately corneal swelling
屈光術後的角膜測量較不精准
Placido-based systems do not have the
X Exaggerates the posterior corneal surface’s contour ability to measure true shape.
(locates the surface too anteriorly）後角膜弧度不精確 Scheimplug imaging systems are true
X Pachymetry reading is too thin 角膜厚度測量結果偏薄 topographic instruments that measure both the
anterior and posterior corneal surfaces.

Y Li Y Li
9-5
Between Topographers
Placido disc reflection Scheimpflug photography
Limitations of Scheimpflug image
system
X Calculation of corneal power from elevation measurements has
several limitations. 前角膜弧度因測量方式導致有多限制
X A comparison of accuracy of the different machines is not
possible, since each machine use different algorithms and
systems to calculate data.
不同機種之間因各自不同演算法因此無法比較彼此數據
X Scheimpflug imaging may be biased by imperfections in cornea
clarity and epithelial irregularities.
測量方式會被角膜疤痕或角膜上皮不佳而有誤差

Y Li Y Li
Axial power pattern

術前一定要看角膜地形圖（Topopraphy） •Symmetric bow tie (39.13%)
對稱領結型
• Oval (26.07%),
橢圓型
OPD III • Asymmetric bow tie (23.91%),
iTrace 非對稱領結型
• Round (6.52%),
Pentacam 圓形
• Irregular (4.53%)
不規則型
Liu Z, Huang AJ, Pflugfelder SCEvaluation of corneal thickness and
topography in normal eyes using the Orbscan corneal topography system
British Journal of Ophthalmology 1999;83:774-778.

Y Li Y Li
Reasons of artifactual irregular astigmatism

後天或人為造成測出不規則散光的可能因素
X Dry eye 乾眼症
X Excessive pooling of tears 過多眼淚
X Blinking 眨眼
X Fixation errors 固定錯誤 Irregular astigmatism
X Misalignment 錯位測量
19:47 19:49

Y Li Y Li
9-6
Irregular astigmatism Irregular astigmatism
OS
Steep K Flat K Axis
Auto Refractor 45.00 43.00 -
Lenstar 2.0x164
iTrace 46.17 42.35 -
OPD III 3.82x156
Steep K Flat K AL Scan
44.94 42.99 -
2.4
AL Scan
47.94 45.98 1.95x171
3.3 Pentaca
46.23 42.24 -
48.35 45.18 m
3.99x159
46.49 41.93 44.94 43.27 -
1.67x152
46.68 45.36 43.40 40.17 -
43.25 3.23x143
41.25
46.50 43.40 -
46.25 45.00 3.10x143
Dr. Bryan H. Dr.
Dr.Bryan
Bryan H.
H. Y
Y Li Y Li
Asymmetric astigmatism
Result:
1st Day BCVA:
OS: 0.8 x0

Y Li Y Li
How to measurement “asymmetric” astigmatism 圓錐角膜地形圖特徵 Scheimpflug photographers

Y Li Y Li
9-7
Asymmetric astigmatism Asymmetric astigmatism
OS
OD Steep K Flat K Axis
Steep K Flat K Axis Auto Refractor 47.50 45.25 -2.25x172
Auto Refractor 44.00 42.25 - Lenstar 43.34 41.69 -1.65x159
Lenstar 1.75x34 OPD III 43.21 41.77 -1.44x161
44.02 41.88 - AL Scan
OPD III
2.4 43.60 41.87 -1.73x161
AL Scan 2.14x38 43.49 42.72 -1.46x159
2.4
AL Scan 43.66 41.87 -
3.3
40.45 39.24 -1.20x148
iTrace 1.79x32
44.35 42.24 -
2.11x38 iTrace
43.89 42.29 -
1.60x34
41.35 40.19 -
1.16x36
Dr. Bryan H. Dr.
Dr.Bryan
Bryan H.
H. Y
Y Li Y Li
OS Asymmetric astigmatism
OD Steep K Flat K Axis
Steep K Flat K Axis 47.50 45.25 -
44.00 42.25 - 2.25x172
1.75x34 43.34 41.69 -
44.02 41.88 - 1.65x159
2.14x38 43.21 41.77 -
43.66 41.87 - 1.44x161
1.79x32 43.60 41.87 -
44.35 42.24 -
Result:
1.73x161
2.11x38 43.49 42.72 - 1st Day BCVA:
43.89 42.29 - 1.46x159 OD: 1.2x0
1.60x34 40.45 39.24 -
41.35 40.19 - 1.20x148
OS: 1.2x0
1.16x36
Ｘ
ＸＸＸ
Dr. Bryan H. Y Dr. Bryan H.

Y Li
OD
Steep K Flat K Axis OS
Auto Refractor 47.50 45.75 - Steep K Flat K Axis
Lenstar 1.75x98 Auto Refractor47.25 45.25 -
OPD III 46.96 45.62 - Lenstar 2.0x81
AL Scan
1.33x100 OPD III 46.59 45.18 -
2.4
AL Scan AL Scan
47.07 45.42 - 1.41x76
3.3 2.4
AL Scan
iTrace 1.65x104 3.3 46.87 44.82 -
47.40 45.49 - iTrace 2.02x83
1.92x97 46.94 45.36 -
47.01 45.55 - 1.58x78
1.46x99 47.01 45.12 -
47.58 45.76 - 1.89x83
1.82x104 47.30 45.48 -
1.82x92
Dr.
Dr.Bryan
Bryan H.
H. Y Dr.Bryan
Dr. Bryan H.
H. Y
Y Li Li Y Li
9-8
OS
Steep K Flat K Axis
OD OS 47.25 45.25 -
2.0x81
Steep K Flat K Axis
46.59 45.18 - Result:
47.50 45.75 -
1.75x98
1.41x76 1st Day BCVA:
46.87 44.82 -
46.96 45.62 -
2.02x83 OS: 0.9 x -1.0D
1.33x100
47.07 45.42 -
46.94 45.36 - OD:0.9 x -1.0D
1.58x78
1.65x104 X
47.40 45.49 -
47.01 45.12 - 0.8 x -1.0D/-0.5D
1.89x83
1.92x97 X 47.30 45.48 -
0.7 x -1.0D/-1.0D
47.01 45.55 - 0.5 x -1.0D/-1.5D
1.82x92
1.46x99
47.58 45.76 -
1.82x104

Y Li Y Li
Pre OP Post OP 1st week Post OP 1st month
OD OS
Auto Refractor -1.25D -1.25D A: 10°,190°
A:172°,372°
Pentaca
-2.33D A: 179°,359° -1.96D A: 177°,357°
m
OPD III -1.27D A: 168°,348° -1.47D A: 7°,187°
iTrace -1.64D A: 178°,358° -1.11D A: 6°,186°
AL Scan -1.80D A: 173°,353° -1.93D A: 6°,186°
2.4
AL Scan -1.34D A: 176°,356° -1.13D A: 13°,193°
3.3

Y Li Y Li
How to measurement “asymmetric ＆ irregular” astigmatism ?
UCVA: Post OP 2nd week: OD:1.0,

OS:1.0
UCVA: Post OP 1st month: OD:1.0, OS:1.0 • Bent bowtie
• Astigmatism is not orthogonal
UCVA: Post OP 2nd month: OD:0.9, OS:0.9 • 7% of population exhibits this pattern

Y Li Y Li
9-9
Femtosecond Laser Arcuate Incisions
• Square edge
• Uniform depth (no ripples)
• Precise, reproducible
– Arc shape
Femtosecond Laser Arcuate Incisions – Arc length
In – Arc diameter
Irregular & asymmetric astigmatism

Y Li Y Li
Toric IOL vs. Arcuate Astigmatic Low Degree Astigmatism by

Advantage Keratotomy
Greater than 1.25 D
0.5 D to 1.25 D LRI
placing astigmatic incisions at precisely
To treat larger amounts of refractive the right position, depth, length, and
astigmatism centration
Patients with ocular surface disease or a to open or not open the incisions with
history of keratorefractive surgery
Disadvantages X.the use of intraoperative
Epithelial basement membrane aberrometry.
X Each degree they are off axis, they lose 3% of dystrophy
the X. Significant ocular surface dryness
power of the toric X. Early or occult corneal ectasia
X. Cost X. History of keratorefractive surgery
X. As the capsular bag contracts, the lens can X. The variability in the viscoelastic
move properties and
forward or backward and can rotate out of the scarring
•Femtosecond Laser-assisted Arcuate Keratotomy Versus Toric IOL Implantation reaction
for Correcting of the cornea
Astigmatism
properJ Refract
axis Surg. 2015 Sep;31(9):574-8. doi: 10.3928/1081597X-20150820-01
Aeri Yoo, Samyoung Yun, Jae Yong Kim, Myoung Joon Kim, Hungwon Tchah
•Toric Intraocular Lens Implantation Versus Astigmatic Keratotomy to Correct Astigmatism During Phacoemulsification
J Cataract Refract Surg. 2014 May;40(5):741-7. doi: 10.1016/j.jcrs.2013.10.036. Epub 2014 Mar 27.
Jeewan S Titiyal 1, Mukesh Khatik 1, Namrata Sharma 2, Sri Vatsa Sehra 1, Parfulla K Maharana 1, Urmimala Ghatak 1,
Tushar Agarwal 1, Sudarshan Khokhar 1, Bhavana Chawla 1
Y Li Y Li
Low Degree Astigmatism by Asymmetric Astigmatism by

LRI LRI
1st week post OP

UCVA: 1.0 x 0/0

Y Li Y Li
9-10
Toric IOL + LRI Toric IOL + LRI
K1: 39.98
K2: 43.00
44.96-43.00
=2D
X
X

Y Li Y Li
Toric IOL + LRI

How to calculate IOL power s/p LASIK, RK
如何計算屈光手術後的人工晶體度數
• Which equipment provide the most accurate K reading?

哪台儀器提供準確的K值?
—>IOL master,AL-scan, Lenstar, Pentacam, Topo?
• Which one is the most accurate formula?
哪個公式提供正確的計算？
—> Shammas-PL, Camellin-Calossi, Barrett True-K, Masket ?

Y Li Y Li
How to measurement K values s/p RK
65 y/o male patient

s/p RK 20+ years ago
Pre-OP BCVA
How to calculate IOL power s/p LASIK, RK OD: 0.4
OS: 0.4
如何計算屈光手術後的人工晶體度數
16 cuts

Y Li Y Li
9-11
How to measurement K values s/p RK
Axis of the cylinder

Preoperatively, the different instruments previously described work in
Post OP UCVA symbiosis to give the most accurate measurement of the patient’s
2 weeks: astigmatism.
OD: 1.0 x 0/0
OS: 0.9 x0/0 The concordance of axis and magnitude of the cylinder, calculated by these
1.0x +0.75/0 instruments, is a key element to optimize the astigmatic correction.

Y Li Y Li

Tip to find the axis of the
cylinder astigmatism
One should use as many methods as needed to

Steep K Flat K Axis
Auto Refractor 47.50 45.25 - obtain accurate numbers and treat consistently,
Lenstar 2.25x172
OPD III 43.34
建議盡可能使用各種不同的方法測量以確保獲得較準確的結果
41.69 -
AL Scan
2.4
AL Scan
1.65x159 If there is a discrepancy, an unhealthy ocular surface
3.3 43.21 41.77 - is often behind it.
iTrace 1.44x161
43.60 41.87 - 若有差異，不健康的眼睛表面通常無法被察覺
1.73x161 If there is significant discordance, surgery should not
150 43.49 42.72 -
proceed until the ocular surface is treated to the degree
1.46x159
40.45 39.24 - that accurate and consistent measurements can be
1.20x148 obtained.
若有明顯的差異，建議眼表先進行治療以達到精准和一致的測量結果，再進行手術
Y Li Y Li

astigmatism Intraoperative aberrometry stands for
Optiwave Refractive Analysis
Uses wavefront aberrometry (波前像差儀)

data in the measurement and analysis
of the refractive power of the eye (i.e.,
若是多於一種的測量結果有所衝突，建議重復測量或是使用其他儀器 sphere, cylinder, and axis
measurements) to support cataract
surgical procedures
Real-time, intraoperative refractometer

plus a working algorithm supported by
a large clinical database (100k+
若仍有一樣的情形，建議可使用術中像差測量儀器協助 cases), and a platform for additional
enhancements
使用波前像差儀測量及分析眼睛的屈光度(例如球鏡、柱鏡及軸度)來協助白內障手術的進行
即時術中屈光量測儀內建海量資料(超過10萬例)與演算法，以增強功能

Y Li Y Li
9-12
How to measurement K values s/p LASIK vs ORA
How to measurement K values s/p LASIK vs ORA
58 y/o female patient
s/p LASIK 4 years ago
Pre-OP BCVA
OD: 0.5
Post OP UCVA
OS: 0.3
1 weeks:
OD: 1.2
OS: 1.0

Y Li Y Li
How to measurement K values s/p RK vs ORA How to measurement K values s/p RK vs ORA
61 y/o female patient PostOP UCVA

s/p RK 20+ years ago 1 week:
Pre-OP BCVA OS: 0.8
OS: 0.2 1.0x +0.5D/-0.5D
8 cuts

Y Li Y Li
How to measurement K values s/p RK vs ORA Posterior corneal astimatism

(PCA)
· Average PCA: -0.3D
Holladay 2
55 y/o male patient · 86.6%PCA: ATR Barrett Suite includes
s/p RK 20+ years ago · Aging: ACA: WTR -> ATR • Barrett Toric
PCA: maintain • Barrett True-K
Pre-OP BCVA • Barrett Universal II)
· WTR ACA: the higher ACA, the higher PCA(ATR)
OS: 0.2 ATR ACA: PCA: maintain Warren Hill RBF
2012, JCRS, Koch DD.
On average, the posterior component equates to 0.30 D of additional ATR

astigmatism in eyes with anterior ATR astigmatism and 0.50 D in eyes with
16 cuts anterior WTR astigmatism.
Koch DD, Ali SF, Weikert MP, et al. Contribution of posterior corneal astigmatism to total corneal astigmatism.
J Cataract Refract Surg. 2012;38(12):2080-2087.

Y Li Y Li
9-13
術後分析評估結果及調整計劃完美的術後結果
術前術後
Post-OP evaluation and management
iTrace
OPD III
Pentacam

Y Li Y Li
術後分析評估結果及調整計劃
Post-OP evaluation and
management
術前術後
術後評估矯正視力及殘餘度數
依據Manifest插片方式測量
依據電腦驗光資料
Dr. Bryan H.
Y Li
32 years old female patient

ARK‐510A ARK‐1A K diameter K detect Refractor: diameter Refractor: detect
OPD‐Scan III iTrace
1.6mm
LenStar 32 *2 point ×
2.3mm
2.4mm
AL-Scan 360*2 points ×
3.3mm
IOL master 2.4mm 6points ×
Pentacam ø1.0 to 13.0 mm Scheimpflug ×
ø2.0 mm
Topcon KR-1 3.3mm Mire ring sphere +22D∼ -25D Rotary Prism
HRK‐7000 Essilor cylinder +/-10D

ø2.0 to 6.0mm
Nidek ARK-1 3.3mm Mire ring sphere +/-20D Wide area pupil zone
cylinder +/-12D
Sph Cyl Axis ø2.0 to 9.5 mm
OPD‐Scan +0.75 ‐1.25 76 OPD-Scan III ø0.5 to 11.0 mm Pacido ring sphere +/-20D Dynamic skiascopy
iTrace +0.43 ‐1.5 75 cylinder +/-12D
ARK‐510A +0.87 ‐1.12 76 ø2.0 to 8.0mm
ARK‐1A +1.0 ‐1.25 83 iTrace ø0 to 8.0 mm Pacido ring Ray trace 655nm
sphere +/-15D
‐HRK7000 +0.75 ‐1.00 80 cylinder +/-10D
Essilor +0.25 ‐0.75 79
Y Li Y Li
9-14
Diameter of refractive error (iTrace)

Y Li Y Li
Manifest: Astigmatism: -
4.00D
Steep K:
45.50@47
Flap K:
41.50@137

Y Li Y Li
Pearls for outcomes

A study evaluating accurate diagnosis
after astigmatism of
correction found
that an image-guided system and intraoperative aberrometer,
preoperative astigmatism
when used together, yielded outcomes that were not significantly
better than the surgeon’s standard of care.
Thank you for your attention

Dr. Bryan H.
Dr. Bryan H. Y. Lin
Y Li
9-15
Cataract surgery in
the setting of
posterior corneal
astigmatism
ChiunHo Hou, 侯鈞賀
Chang Gung Memorial Hospital, Linkou
Prevalence of Corneal Astigmatism

• Many of your patients could be candidates for toric IOL implantation.
47% <0.75D; 62% <1.0D; 82% <1.5D

1. Hill W. Distribution of corneal astigmatism in normal adult population. Keratometry database: http://www.doctor-hill.com/iol-main/astigmatism_chart.htm. Accessed
April 15, 2015. 2
10-1
No correction in low astigmatism
10 SA60
12 SN60T3, 1.03D at cornea plane
Clin Exp Ophthalmol 2009;37:775-9.
Multifocal IOL?
• UDVA 0.5 vs 0.9
10-2
No correction in high astigmatism: symptoms
compliant by astigmatism patients
• reduced vision
• epiphora, unilateral diplopia, asthenopia and distortion.
• Spectacles or contact lens correction for astigmatism: distortions
after spectacle correction.
Corneal Power
• Average anterior/posterior
ratio: 1.177 to 1.235.
• Slit lamp photography,
Purkinje images, Pachymetry,
Photokeratoscopy, Corneal
topography, Scheimpflug
photography and Slit scan
topography.
• In the schematic eyes, AP
ratio: 1.2 to 1.32.
• 7.259/5.585=1.29
Posterior corneal astigmatism a review article. Clinical Optics, BCSC, AAO

Clin Optom (Auckl). 2019
10-3
Age difference in
astigmatism axis
• Cross-sectional study
• 715 eyes of 435 patients.
• Mean age 55 years (20 to 89)
• Dual Scheimpflug analyzer
measurement
• Parallel correlation in WTR (youth)
• Aging change in anterior but not
posterior
Schematic Model of ant and post

• Power = (n’-n)/(n*R)
• n of air; cornea; aqueous are 1; 1.376; 1.336
• R of post is 0.83 times of ant
• posterior corneal astigmatism will nearly counteract 12.8% of the
anterior corneal astigmatism
10-4
Tear lens in RGP
• RGP: tear lens compensating 89% for total
corneal astigmatism. (1.376-1.336)/(1.376-1)
• Back toric RGP in corneal astigmatism >2.50 D
Clinical optics and refraction : a guide for optometrists, contact lens

opticians, and dispensing opticians. Andrew Keir; Caroline
Christie,Edinburgh : Butterworth-Heinemann, 2007.
Corneal refraction index: 1.376 vs 1.337

• True index is 1.376
• auto keratometer and corneal topography: based on the placido disk,
use n=1.337 converting anterior corneal surface radius to the total
corneal power and the total corneal astigmatism.
• SimK [1.337], antK [SimK*(1.376 - 1.0)/(1.3375 - 1.0)], postK
[1.376;1.336]; TCP [Ray tracing with Snellen law accounting ant, post,
thickness]
10-5
Amount of posterior corneal astigmatism
Koch DD, Ali SF, Weikert MP, Shirayama M, Jenkins R, Wang L. Contribution of posterior corneal astigmatism to total
corneal astigmatism. J Cataract Refract Surg. 2012 Dec;38(12):2080-7.
Other studies
by direct
measurement
• Mean range:
0.26-0.78D
10-6
Posterior astigmatism? Difference between
anterior corneal astigmatism and refractive
astigmatism
• Javal rule: Louis Émile Javal, a 19th century ophthalmologist
• total ocular astigmatism is not the power of the anterior cornea
by on average, 0.50 D of against-the-rule astigmatism.
• Centroid error in predicted residual astigmatism was 0.36 D for
AutoKM and 0.48 D for IOLMaster
Ho YJ, Sun CC, Lee JS, Lin KK, Hou CH. Comparison of using Galilei Dual Scheimpflug Analyzer G4 and Barrett
formula in predicting low cylinder preoperatively for cataract surgeries. Eur J Ophthalmol. 2020 Nov;30(6):1320-
1327.
Correlation of Corneal Astigmatism on Anterior

and Posterior Corneal Surfaces: CAant Versus
CApost
10-7
Parallel correlation of
astigmatism in WTR
• Magnitude vs Orientation of the
steep meridian on the anterior
cornea.
• Top: Vertical (r = 0.56, P<.001).
• Middle: Oblique (r = 0.37, P<.001).
• Bottom: horizontal (r = −0.08, P
= .26).
• Total corneal
astigmatism – anterior
corneal astigmatism:
from –0.5D to 0.5D
10-8
Savini G, Næ ser K. An analysis of the factors influencing the residual refractive astigmatism after cataract surgery with toric intraocular lenses. Invest Ophthalmol Vis Sci. 2015 Jan 13;56(2):827-35
10-9
Measurement of
Corneal
Astigmatism
• Manual keratometry
• partial coherence
interferometry (PCI)
• optical low-coherence
reflectometry (OLCR)
• Topographers
Indian J Ophthalmol 2017 12 1301-1313
IOLMaster 700
• Mean posterior corneal astigmatism was 0.24 ± 0.15 diopters (D).
• The steep axis of posterior corneal astigmatism was vertically
oriented in 73.32% of measurements.
• Not yet commercially available for posterior corneal astigmatism
measurement but is capable of.
• Premarket study of 1,098 routine biometric measurements
LaHood BR, Goggin M. Measurement of Posterior Corneal Astigmatism by the IOLMaster 700. J Refract Surg. 2018 May
1;34(5):331-336.
10-10
AS-OCT
• 64 pseudophakic eyes of 50 patients (71.8 ± 9.9 years old)
• The difference between refractive and keratometric astigmatism
(0.70 ± 0.40 D, mean vector of 0.30 D axis 164°)
• The difference between refractive and total corneal astigmatism
(0.63 ± 0.38 D, mean vector of 0.12 D axis 137°)
• (P = .019).
Sano M, Hiraoka T, Ueno Y, Itagaki H, Ogami T, Oshika T. Influence of posterior corneal astigmatism on postoperative refractive
astigmatism in pseudophakic eyes after cataract surgery. BMC Ophthalmol. 2016 Dec 1;16(1):212.
Calculators and Nomograms
Ferreira TB, Ribeiro F. How Can We Improve Toric Intraocular Lens Calculation Methods? Current
Insights. Clin Ophthalmol. 2020 Jul
10-11
Comparison of calculators
J Cataract Refract Surg 2017; 43:340–347
Ribeiro FJ, Ferreira TB, Relha C, Esteves C, Gaspar S. Predictability of different calculators in the minimization of postoperative astigmatism after
implantation of a toric intraocular lens. Clin Ophthalmol. 2019;13:1649-1656. Published 2019 Aug 29. doi:10.2147/OPTH.S213132
10-12
Measurement or Calculation
BMC Ophthalmology (2017) 17:156
Ferreira TB, Ribeiro P, Ribeiro FJ, O'Neill JG. Comparison of Methodologies Using Estimated or Measured Values of
Total Corneal Astigmatism for Toric Intraocular Lens Power Calculation. J Refract Surg. 2017 Dec 1;33(12):794-800.
10-13
Measurement or Calculator
Conclusion
• Without consideration of posterior corneal astigmatism:
1. overcorrection in with-the-rule
2. undercorrection in against-the-rule
• The mean magnitude of posterior astigmatism is 0.26D to 0.78D
• The best method addressing total corneal astigmatism
10-14
Any Comments are welcomed
10-15
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11-10
Types of Presbyopia‐Correction IOLs
• Multifocal
• Bifocal
Special considerations of • Trifocal
Presbyopia‐correction IOLs in eyes with • EDoF (extension depth of focus)
Ocular Comorbidities • Accommodating
• Types of optical property
台大醫院眼科部謝易庭 • Refractive
• Diffractive
Before using Presbyopia‐Correction IOLs… Multifocal IOL
• The trade‐off between the presbyopia‐correction • Common adverse events: halo, glare, reduced contrast
effects & adverse events should be considered sensitivity, poor neuroadaptation
• Special considerations for ocular comorbidities that • What may cause or increase halo / glare:
may: • Post corneal refractive surgery
• Cause or increase the adverse events • High HOAs: corneal surface irregularity, posterior
• Decrease the presbyopia‐correction effect corneal astigmatism, large pupil
• Result in worse VA than using monofocal IOL • Severe dry eye
• Result in poor visual prognosis • Phacodonesis
• Large angle kappa
Multifocal IOL Brochures of M‐IOL: No absolute contraindications!
Alcon Panoptix Lentis
• Decreased presbyopia‐correction effect may happen in:
• Small pupil / eccentric pupil
• Poor uncorrected VA may happen in:
• Postoperative ametropia
• Uncorrected astigmatism
• Worse VA may happen in:
• Advanced glaucoma
• Severe macular degeneration or retinal diseases
• Other ocular diseases with poor visual prognosis
12-1
EDoF IOL Defocus curve: multifocal vs. EDoF
• Advantages over multifocal IOL:
• Improved intermediate vision
• Reduced halo, glare
• More tolerating for postop ametropia (?)
• Have shown good results in post‐RK patients
• Disadvantages over multifocal IOL:
• Poorer near vision
• Similar adverse event:
• Poor neuroadaptation
EDoF IOL: information from NIH Administration

Accommodating IOL (Position‐changing IOL)
AMO Tecnis Symfony
• Advantages over multifocal/EDoF IOL:
• Less halo/glare
• No need of neuroadaptation
• Disadvantages over multifocal/EDoF IOL:
• Poorer (and unstable) presbyopia correction
• What may decrease the presbyopia‐correction effect:
• Zonular dehiscence / laxity, incomplete CCC
• Vitrectomized eyes
Defocus curve: accommodating vs. multifocal Defocus curve: accommodating vs. multifocal
12-2
Accommodating IOL (Position‐changing IOL) Special considerations in…
• Brochure from Crystalens: • AMD
• Virtually everyone with good general health is a • Glaucoma
candidate
• People who have had prior corneal refractive surgery are
• Retinal vascular diseases
acceptable candidates • ERM / macular pucker
• Absolute contraindication for Crystalens: • Postop for ERM / MH
• Silicone oil implant • High myopia
• Contraindications for Tetraflex: • Post corneal refractive surgery
• Uncontrolled glaucoma, microphthalmia, chronic severe
uveitis, retinal detachment, corneal decompensation,
diabetic retinopathy, iris atrophy
Take‐Home Message
• Patients should understand their own ocular
comorbidities well
• Ophthalmologists should not over‐advocate the effect
of presbyopia‐correction IOL
• IOL exchange can be provided as a back‐up strategy
Thank You
12-3
Affiliation and Financial Disclosure:
In alphabet order
Johnson & Johnson

Zeiss
New horizon in modern Cataract surgery
Total Keratometry
for Premium IOL Calculation
1 2
Axial • TK = Anterior K + Posterior K

Length
( Total keratometry IOLMaster 700)
Anterior TK ≠ Barrett TRUE-K (i.e. Barrett True K TK)
K Improving IOL
ELP
accuracy • TCRP = Total Corneal Refractive Power (Oculus Pentacam)
• TNP = True Net Power (Oculus Pentacam)
Calculation
• RP = Real Power (AS-OCT Visante)
TK
Understanding TK terminology
3 4
• Good association and

repeatability, but not
interchangeable
• Conventional
keratometry
overestimates the
total corneal Power
Is Total Keratometry (TK) necessary?
Pentacam
Pentacam
OCT
BioMed Research International Volume 2020, Article ID 8075924, 6 pages https://doi.org/10.1155/2020/8075924
5 6
13-1
Anterior Cornea Astig. Distribution Posterior Cornea Astig. Distribution
Posterior Cornea Astigmatism affects much more than 10%

of the cataract patient than the graph showed
Miyake T et al. PLoS ONE 10(1): e0117194. doi:10.1371/journal.pone.0117194 Miyake T et al. PLoS ONE 10(1): e0117194. doi:10.1371/journal.pone.0117194
7 8
The orientation of posterior corneal astigmatism is

more predictable in eyes with WTR anterior
Miyake T et al. PLoS ONE 10(1): e0117194. doi:10.1371/journal.pone.0117194
corneal astigmatism Miyake T et al. PLoS ONE 10(1): e0117194. doi:10.1371/journal.pone.0117194
9 10
If you can measure it,

why guess it?
The orientation of posterior corneal astigmatism
becomes less predictable in eyes with ATR
anterior corneal astigmatism Miyake T et al. PLoS ONE 10(1): e0117194. doi:10.1371/journal.pone.0117194
11 12
13-2
100 92 95 93 96 93 97 95 98
90 84 86
80 77 79
70
60
50
Within 0.50D
Within 0.75D
Within 1.00D
40
30
Cataract surgery 20
10
for normal population

0
Hagis K Hagis TK Barrett K Barett TK

Absolute prediction error (APE) in spherical equivalent (SE)
Applying TK to Hagis and Barrett formulas show slight improvement
of cumulative percentage of eyes within the specified range of APE
E. Fabian et al. J Refract Surg. 2019;35(6):362-368.
13 14
100 92 97 95 93 98
90 86 88
80 75 70
70 65 Hagis
60
58
50 44 SE
Favor TK
Within 0.50D
Within 0.75D
Within 1.00D
40
30
Favor K
20
10 Hagis
0
Cyl
Hagis K Hagis TK Barrett K Barrett TK
Absolute prediction error (APE) in cylinder (CYL)
Applying TK to Hagis and Barrett formulas showed
significant improvement of APE in cylinder (CYL) ([D]) TK is favored in Cylinder Hagis formula calculation
E. Fabian et al. J Refract Surg. 2019;35(6):362-368. E. Fabian et al. J Refract Surg. 2019;35(6):362-368.
15 16
Barrett
SE
Favor K Favor TK
Barrett Cataract surgery in eyes with previous
Cyl myopic laser refractive surgery
TK is favored in both SE and Cyl Barrett formula calculation

E. Fabian et al. J Refract Surg. 2019;35(6):362-368.
17 18
13-3
100
92 89
90 86 83 83 86 83
81 81
80 77 78 77 75
70
63 63 64 64 64
59 59 58
60
55
50 47
40
34
Cataract surgery in eyes with previous

30
Within 1.00D
Within 0.75D
Within 0.50D
20
10
Hyperopia Laser Refractive surgery or
0
Barrett TrueK Hagis-L Shammas-PLBarrett TrueK Hagis Hoffer Q Holladay I SRT/T RK refractive surgery
TK TK TK TK
Revere double K Revere double K Revere double K
TK
TK improves accuracy of the Barrett True-K and Haigis formulas

T. K. Yeo et al. Eye https://doi.org/10.1038/s41433-020-01159-5
19 21
100 93.8 93.8 93.8 90.6 100 97.7 97.7 97.7

90 81.3 81.3 81.3 90
80 75 80 75 70.5 72.7
70 70
60 56.3 60 54.5
46.9 50
50 43.8 50 43.2 43.2
40 40
30 30
± 0.50D
± 1.00D
± 2.00D
± 0.50D
± 1.00D
± 2.00D
20 20
10 10
0 0 0
0 0
Hagis Hagis-L Barrett True K Hagis-TK Hagis Hagis-L Barrett True K Hagis-TK
In Hyperopic LASIK/PRK eyes, Haigis TK produced refractive
prediction accuracy comparable to the regression-based Haigis-L In RK eyes, TK do not improve the accuracy of Haigis formula
and Barrett True-K formulas. Li Wang et al. J Cataract Refract Surg 2019; 45:1416–1421. Li Wang et al. J Cataract Refract Surg 2019; 45:1416–1421.
22 23
Take Home Message

Total Keratometry for Premium IOL Calculation
1. Including Posterior K/ Total K is necessary

2. TK / RP / TNP / TCRP  not interchangeable
3. Greatest benefit
• Astigmatism  Toric IOL
• Post Myopic / Hyperopic Laser Refractive Surgery
patients
24
13-4
Complementary PCIOLs serve
diverse patient populations濣
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14-1
Visual Disturbances are the Biggest Reason for Surgeon Treating Presbyopia With PC IOLs: Diffractive EDF
Dissatisfaction with Current Presbyopia-correcting IOLs*† IOLs Can Compromise Patient Vision
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Complete spectacle independence ±

7X magnification of the central element reveals
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the smooth surface transition elements
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14-2
Bench Data
Next-generation Non-diffractive X-WAVE™ Technology Stretching and Shifting the Wavefront Creates a Continuous
Surface Transition Elements Alter the Emerging Wavefront Extended Focal Range Instead of Multiple Focal Points1,2
Stretched wavefront
OPTICAL PRINCIPLE Light intensity distribution*
(advanced)
Distance Intermediate Near
Surface transition
element #1 alters the AcrySof® IQ Area of precisely
Monofocal focused light
Continuous Extended Focal Range wavefront, stretching it
Near Intermediate Distance Surface transition
Surface Symfony†
transition element #2 shifts the Diffractive
elements wavefront
#1 and #2
The simultaneous actions
Stretched wavefront AT LARA†
collapses down across distance - near deliver a naturally Diffractive
(delayed + advanced)
Wavefront
occurring, continuous,
extended focal range
AcrySof® IQ Vivity®
X-WAVE™ Technology
Stretched wavefront
(delayed)
Extended focal range
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AcrySof IQ Vivity
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Base curvature of AcrySof® IQ Plus Non-diffractive X-WAVE™ TECNIS* Symfony* Surface Elevation is up to 5x Higher
Technology = the AcrySof® IQ Vivity® IOL1 than the AcrySof® IQ Vivity® IOL1,2
Base Power: AcrySof® IQ $FU\6RI ,49LYLW\,2/ TECNIS* Symfony* Vivity® IOL
X-WAVE™ Technology Surface elevation is up to 5x greater (~5 wm) Surface elevation is ~1 wm
(non-diffractive)
+ =
“Stretch” “Shift”
(Surface (Surface
Transition #1) Transition #2)
Never Split 7x magnification of central element
7x mag
magnification
As seen by of cent
central element Utilizes all available light like AcrySof® IQ:
the naked eye Splits Light
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More than 250 Patients Implanted with the Results from 2 large independent trials: Vivity® IOL
AcrySof® IQ Vivity® IOL in 2 Large Randomized Clinical Trials provides a continuous extended focal range1,2
Randomization Bilateral implantation Follow-up
Vivity® IOL (n=107)*

US study1
(N=221) 1:1 6 months

AcrySof® IQ (n=113)
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Global study2
Vivity® IOL (n=156)†

(N=282) 5:4 6 months§
AcrySof® IQ (n=120)‡
*Results from a prospective, randomized, parallel group, subject and assessor masked, multisite trial of 107 subjects bilaterally implanted with the
AcrySof® IQ Vivity® Extended Vision IOL and 113 with the AcrySof® IQ
IOL with 6 months follow-up.
†Results from a prospective, randomized, controlled, multi-center clinical study of 152 subjects bilaterally implanted with the AcrySof® IQ Vivity® Extended Vision IOL and 118 with the AcrySof® IQ IOL with 6 months
follow-up.
1. Alcon Data on File. TDOC-0055576 23-Jul-2019
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14-3
Corrected and uncorrected visual acuity: Forgiving and Flexible Defocus Curve Delivers Increased Confidence
full range of vision with functional near acuity in Hitting Refractive Targets1
66 cm 50 cm 40 cm
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Binocular defocus visual acuity (logMAR)

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20/20
20/32
The Vivity® IOL is flexible and The Vivity® IOL provides a

forgiving around distance continuous extended range of vision
Vivity® IOL (n=145)
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Defocus (D)
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The AcrySof® IQ Vivity® IOL has a Halo Profile Comparable A Best-in-Class Validated Questionnaire was Used to Evaluate
to the AcrySof® IQ IOL1 Dysphotopsias (Quality of Visual Disturbance Questionnaire)1
INSTRUCTIONS 3. The next set of questions are about glare. The pictures below
0RQRIRFDO ;:$9( 'LIIUDFWLYH(')7HFKQRORJ\ show a building with the sun reflecting off of it. The picture on the right shows
what you may see if you have glare.
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No Glare Glare
10,000 QUESTION 3. In the past 7 days, have you experienced glare?

1000 Mark ALL that apply.
AcrySof® IQ Vivity® IOL TECNIS* Symfony* AT LARA* 100 Ƒ NO, not at all Ƒ MOVE TO INSTRUCTIONS 4 (Page 7)
10 Ƒ YES, when NOT wearing eyeglasses
1
Ƒ YES, when wearing eyeglasses
(cd/m2)
VALIDATED!
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AcrySof IQ Vivity
® ®
Visual Disturbance Profiles were Comparable to AcrySof® IQ TECNIS* Symfony* Patients Report Significantly More Bother
Across 2 Large Clinical Trials Using Different Questionnaires1,2 from Visual Disturbances than TECNIS* Monofocal Patients
Best Outcome Best Outcome AcrySof ® IQ Vivity® IOL1 TECNIS* Symfony*2
US study1* Global study2†
bothered by visual disturbances (%)
bothered by visual disturbances (%)
Patients who were not at all

Patients who were not at all
all bothered by visual disturbances (%)
all bothered by visual disturbances (%)
Patients who were not at

Patients who were not at
Starbursts Halos Glare Starbursts Halos Glare

Starbursts Halos Glare Starbursts Halos Glare
Vivity® (n=105) AcrySof ® IQ (n=111) TECNIS* Symfony* (n=147) TECNIS* monofocal (n=148)
Vivity® IOL (n=105) AcrySof® IQ (n=111) Vivity® IOL (n=106) AcrySof® IQ (n=80) 'DWDFRPHIURPVHSDUDWHVWXGLHVQRGLUHFWFRPSDULVRQVFDQEHPDGH
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14-4
Global study US study
No Clinically Relevant Differences in Binocular Mesopic Contrast The AcrySof® IQ Vivity® IOL Maintains Improved Vision Quality
Compared to AcrySof® IQ1 Without Spectacles Over AcrySof® IQ Even in Dim Light1
Median Binocular Contrast Sensitivity at 6 Months1 Percent of Patients Reporting Good or Very Good Vision
Without Spectacles in Bright Light and Dim Light*†
Without glare With glare Bright light
Bright light Dim light
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Best Outcome
B

Median Log contrast
Median Log contrast

AcrySof® IQ Vivity® IOL
AcrySof® IQ

Clinically meaningful drop
in contrast sensitivity*

Spatial frequency (cpd) (UURUEDUVUHSUHVHQWWZRVLGHG&,V Spatial frequency (cpd)
Far away Arm's length Up close Far away Arm's length Up close
Vivity® IOL (n=106) AcrySof® IQ (n=113)
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The AcrySof® IQ Vivity® IOL Delivers an Extended Focal Range

with a Visual Disturbance Profile Comparable to AcrySof® IQ1-3 Clinical experience sharing in Cheng-Ching Eye Clinic
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Extended range of vision from distance to functional near1,2
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The AcrySof® IQ PanOptix™ IOL features unique ENLIGHTEN (ENhanced LIGHT ENergy) Optical
Technology, which overcomes some of the limitations of multifocal and trifocal technology by
manipulating a quadrifocal diffractive design.
Design begins with three step heights = three add powers/three focal points (plus distance from
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Due to the diffractive principle, when there are four focal distances, the first intermediate focal
point must be 1.5x near, and the second intermediate focal point must be 3x near:
¾ - Near = 40 cm
¾ - Preferred intermediate = 60 cm (Focal Point 2)
¾ - Extended intermediate = 120 cm (Focal Point 3)
¾ - Distance = (ȭ)
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Why Diffractive Zone Size Matters
rss
60 cm
Smaller = Compromises near and
燩燥IS intermediate performance in low light
or in large-pupil patients
Larger = Compromises distance vision
Distance Intermediate Near Lens Plane
in mesopic condition
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4-9 Weeks Follow-up Distance Visual Outcomes 4-9 Weeks Follow-up Intermediate/Near Visual Outcomes
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14-6
(1+$1&(' Expanding the Alcon Family of IOLs
Vivity® and PanOptix® serve different patient populations
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6(/(&7,21)25
3&,2/ Might be an option for patients who
want PCIOL performance but have
non-pristine eyes. As with monofocal
IOLs, Vivity® transmits 100% of the
Option for patients with
pristine eyes and/or who have
high-performance visual needs
Patient Profile for PanOptix® and Vivity® light (i.e. no light splitting like
who want to be spectacle-free
multifocal IOL technologies) and
maintains the quality of vision.
AcrySof IQ Vivity
® ®
PanOptix® & Vivity® IOLs The PanOptix® and AcrySof® IQ Vivity® IOLs:
Complementary PCIOLs Serve Diverse Patient Populations Complementary PCIOLs Serve Diverse Patient Populations
The AcrySof® IQ PanOptix® IOL and AcrySof® IQ Vivity® IOL offer 2 presbyopia solutions, trading between spectacle
independence with excellent near acuity and an extended range of vision with a monofocal visual disturbance profile.
AcrySof® IQ Vivity® IOL AcrySof® IQ PanOptix® IOL AcrySof ® IQ PanOptix® IOL Shared AcrySof ® IQ Vivity® IOL
Patient Characteristics Characteristics Patient Characteristics
Extensive near vision Usually a monofocal patient
Distance acuity Want greater spectacle
activities - Demanding patients
independence
- Reads a novel per week - Night driving
- Does needlepoint - Certain non-pristine eyes*
Intermediate acuity Willing to invest in a
Healthy eyes lifestyle choice Limited near vision activities
Active patient
Near acuity
The exceptional near visual acuity of the AcrySof® IQ PanOptix®
IOL is highly desired by cataract refractive surgeons
AcrySof® visual ,QFUHDVHGspectacle LQGHSHQGHQFHIRUWKH 3UHVE\RSLDFRUUHFWLRQIRUSDWLHQWVZKRDUHQRW

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disturbance profile PDMRULW\RI\RXUSDWLHQWV LGHDOFDQGLGDWHVIRUWKH3DQ2SWL[ ,2/
The monofocal visual disturbance profile of the AcrySof® IQ Vivity®
IOL addresses the #1 barrier of surgeons
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Summary
The AcrySof® IQ Vivity® IOL provides a new choice for EDOF IOL
without halo and glare.
It provides better contrast sensitivity and less visual disturbances.
6800$5< It’s a good choice for driver especially at night
ACRYSOF IQ VIVITY If patient needs more reading requirement, trifocal IOL such as
The AcrySof® IQ PanOptix IOL shows excellent performance.
AcrySof IQ Vivity
® ®
14-7
Thanks for your attention
!
AcrySof IQ Vivity
AcrySof IQ Vivity
® ®
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;^ǁŝƐƐĚǀĂŶĐĞĚǀŝƐŝŽŶͿ
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ŽŶƚŝŶƵŽƵƐ&ŽĐƵƐ;t/K>Ͳ&Ϳ;DĞĚŝĐĞŵͿ
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WƌŽǀŝĚĞŽŶƚŝŶƵŽƵƐ,ŝŐŚͲƋƵĂůŝƚǇsŝƐŝŽŶ
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Monofocal IOL Distinct Single Focus
ĞĐŚĞůĞƚƚĞĚĞƐŝŐŶ
ĐƌĞĂƚĞƐĂŶĞǆƚĞŶĚĞĚ
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ŝŶĂŶĞǆƚĞŶĚĞĚƌĂŶŐĞŽĨ
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Multifocal IOL
Two Distinct Foci
WƌŽƉƌŝĞƚĂƌǇĂĐŚƌŽŵĂƚŝĐ
ƚĞĐŚŶŽůŽŐǇ ĐŽƌƌĞĐƚƐ
EDOF IOL ĐŚƌŽŵĂƚŝĐĂďĞƌƌĂƚŝŽŶ
ĨŽƌĞŶŚĂŶĐĞĚŝŵĂŐĞ
Elongated Focus ĐŽŶƚƌĂƐƚ͘
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i-
Maximizing Your Toric IOL

Outcomes with iTrace
Nailing astigmatism management in cataract surgery
Presented by
Chun-Pin Tsai (蔡俊斌)
Ching-Ming Eye Clinic(台南慶明眼科)
What is Wavefront Aberration?

K Measurement
Simulated
Manual Keratometry AutoKeratometry Refractive Keratometry Wavefront Keratometry
Keratometry (SimK)
Finds steepest point on Simulates the Simulates the Calculates the average Calculates steep power and
a 3.2mm annulus keratometer, but with keratometer with steep and flat power & axis based on the best
locates the point 90° more points at various topography data, but axis from all topo data Zernike mathematical fit
away, and assumes flat sizes depending on the still finding only 4 within a 3 mm circle from all topo data within a
axis is orthogonal instrument points using Snell's Law, may 4 mm circle.
not be orthogonal
IOL Master - 2.5mm ring Only available in
Available with most Only available in the
B&L Keratometer LS 900 - avg of 2.35mm
and 1.65mm
topographers iTrace the iTrace
2.5mm or
3.2mm 2.35mm/ 3 mm 3 mm 4mm
1.65mm
IOL Tilting
on average, a 5-degree nasal outward IOL tilt

Aspherical IOL (Not Toric) Toric IOL

• Align at 180˚ & Horizontal Tilt —> Astigmatism effect ↓—> Under correction
• Horizontal tilt around vertical meridian—> Against the rule astigmatism ↑

• Align at 90˚ & Horizontal Tilt —> Astigmatism effect ↑—> Over correction
High myopia patient: Crystalline lens horizontal tilting —> Against the rule astigmatism
Unhappy MF-IOL patient
Toric IOL rotation

散光⼈⼯⽔晶體の⼤冒險
IOL Vertical tilt —> With the rule astigmatism
由於IOL rotation 1˚與181˚相同散光向量圖

90˚ 45˚ K +3D x 0°(-3Dx90°)
Toric IOL +3D x 90˚ 45˚
180˚ 0˚ 90˚ 0˚
90˚ 0˚
135˚
135˚
Single-angle plots Double-angle plots
驗光單: 0x0°
K +3D x 0°(-3Dx90°)
K +3D x 0°(-3Dx90°)
Toric IOL +3D x 80˚順時針10˚Rotation Toric IOL +3D x 80˚順時針10˚Rotation
45˚ 45˚
Isosceles Triangle
40˚
80˚ 80˚
90˚ 0˚ = 180˚ 90˚ 0˚ = 180˚
135˚ 135˚
驗光單: +1Dx40°= -1Dx130°逆時針
K +3D x 0°(-3Dx90°)
K +3D x 0°(-3Dx90°)
Toric IOL +3D x 70˚順時針20˚Rotation Toric IOL +3D x 60˚順時針30˚Rotation
45˚ 45˚
Isosceles Triangle Isosceles Triangle

60˚
70˚ 35˚ 30˚
90˚ 0˚ = 180˚ 90˚ 0˚ = 180˚
135˚ 135˚
驗光單: +2Dx35°= -2Dx125°逆時針驗光單: +3Dx30°= -3Dx120°逆時針
K +3D x 0°(-3Dx90°)
Toric IOL +3D x 30˚順時針60˚Rotation IOL clockwise rotation K= -3Dx90˚ 驗光單表現

10 degree -1Dx130˚
20 degree -2Dx125˚
45˚
30 degree -3Dx120˚
Isosceles Triangle
60 degree -5.25Dx105˚
30˚ 15˚ 90 degree -6Dx90˚
90˚ 0˚ = 180˚
135˚
驗光單: +5.25Dx15°= -5.25Dx105°逆時針

IOL clockwise rotation K= -3Dx90˚ 驗光單表現 Astigmatism:against the rule
10 degree -1Dx130˚
20 degree -2Dx125˚
30 degree -3Dx120˚ IOL counterclockwise
IOL clockwise rotation 90˚
60 degree -5.25Dx105˚ rotation
90 degree -6Dx90˚
135˚ 45˚
IOL clockwise rotation

IOL counterclockwise rotation
+ Toric IOL overcorrection + Toric IOL overcorrection

驗光單剩餘散光⾓度與135度的差值 X 2 (Surprising SIA) (Surprising SIA)
180˚ 0˚
Toric Calculator V1.03 2015/10/22 5:41
BARRETT TORIC CALCULATOR K INDEX 1.3375 K INDEX 1.332 +VE CYLINDER -VE CYLINDER
Patient Data Toric IOL Calculator Guide
Surgeon:Thomas Date: 22/10/2015

Patient:Huang ID:
Flat K: 44@ 70 Steep K: 46@ 160
A Constant/LF: 119.37 / 2.08 AL: 23.4 ACD: 3.2
Induced Astigmatism (SIA): 0 D @ 180 Degrees
IOL Power Toric Power Refraction - (S.E.Q.)
21.0 (Biconvex) T5 -0.47 S.E.
20.5 (Biconvex) T5 -0.12 S.E.
20.0 (Biconvex) T5 0.22 S.E.
Toric Power IOL Cylinder Residual Astigmatism
T4 2.25 0.78 Cyl Axis 165

Recommended IOL: 20.5 D T5 Axis 165
T5 3 0.29 Cyl Axis 165 Cylinder Power: IOL Plane 3 D ~ Corneal Plane 1.96 D
Target Refraction:
T6 3.75 0.20 Cyl Axis 75 -0.27 sph. / 0.29 cyl Axis 165 Degrees
Question: Pre OP (& Pos OP K) -2.0 x 70˚
Post OP AR : +0.25-0.75X115˚ Ask IOL rotation?
Answer: [(75+45) -115] x 2 ⟹ Toric IOL clockwise rotation10˚ ( IOL at 155˚)
http://www.apacrs.org/toric_calculator/Toric%20Calculator.aspx 1/1
Take home message

• IOL tilting induce 2nd astigmatism.
• Toric IOL rotation clockwise or counterclockwise is not a secret.
• i-Trace can improve our Toric IOL outcome via:
• Wave front keratometry
• Color iris image with Zaldivar caliper tool —> surgical ink mark
• IOL tilting image
• Toric IOL rotation data
• Toric IOL reposition result —> reposition or exchange IOL or LASIK

Thank you for  
your attention
Chun-Pin Tsai (蔡俊斌)
JUN 20, 2021

STELLARIS ELITE™ VISION ENHANCEMENT SYSTEM
Reinventing Responsiveness, Revolutionizing Control
Adaptive Fluidics Technology
Improves IOP Stability during
Stellaris Elite — where real‐time responsiveness
Cataract Surgery‐ Bausch+ Lomb enables exceptional stability.
STELLARIS ELITE™  Adaptive Fluidics™ with Dynamic Infusion
Compensation
萬芳醫院吳建良  Attune® energy management
2021.06.20  Wireless dual linear foot pedal
1. Data on file.
2. Mark E. Schafer, PhD. Analysis of the Cutting Forces using Different Phacoemulsification Modalities. ASCRS 2009.
* Based on laboratory study.
ADAPTIVE FLUIDICS™
Highly Responsive and Controlled Surgical Environment
Adaptive Fluidics = Stability + Efficiency
Dynamic Infusion
ADAPTIVE FLUIDICS™ Compensation delivers
exceptional stability
Highly responsive and
efficient vacuum draws
lens fragments to the
tip
ADAPTIVE FLUIDICS™ ADAPTIVE FLUIDICS™
How it Works Transition to Adaptive Fluidics
Traditionally, Infusion Pressure is fixed.
Dynamic Infusion Compensation technology compensates for changes in fluid flow for
Fixed Infusion
excellent control and exceptional chamber stability1. pressure IOP IOP drops
(when vacuum increase)
After the surgeon sets a preferred infusion pressure,
Adaptive Fluidics works systematically by:
0 600
Vacuum
(mmHg)
Monitoring Compensating Adaptive Fluidics, Infusion Pressure Changes.

Adaptive Fluidics The system automatically
continuously tracks vacuum adjusts infusion pressure, IOP stays stable
flow rate at every moment for excellent stability Infusion (when vacuum increase)
of surgery pressure IOP
changes
according to
vacuum
1. Data on file. 0 Vacuum 600
(mmHg)
17-1
Compensation Factor (CF)
The Benefits of Adaptive Fluidics
◎ Minimizes IOP fluctuation, better AC stability

◎ Prevents high IOP build up when vacuum is not active
(when foot control is at position 1)
◎ Minimized post occlusion surge
IOP stays stable
Infusion
pressure IOP
changes
according to
vacuum
1. Data on file.
0 Vacuum 600
8
(mmHg)
7
ADAPTIVE FLUIDICS™ ADAPTIVE FLUIDICS™
Adaptive Fluidics Pack Control Loops
Infusion to the eye Stellaris Elite air pump adjusts  Adaptive Fluidics™ maintains
Variable Infusion Pressure Vented BSS Bottle
Use ONLY BSS in a pressure fluidics stability inside the eye
(Input connection) Spike
bottle, BSS bags are by linking variable infusion
not compatible. pressure to the real time
surgeon‐commanded vacuum
level.
 Hang BSS bottle at  Infusion pressure increases
the lowest level only as vacuum increases.
(30cm or 22mmHg)
 To better see the
bottle, hang bottle
at 50cm or
35mmHg
Connect air filter to Surgeon command
the system  Adaptive Fluidics™ is a new fluidics function vacuum
for Phacoemulsification and I/A only.
 It is not available for Anterior Vitrectomy.
Adaptive Fluidics and Active Fluidics Centurion Active Infusion vs. Stellaris Elite Adaptive Fluidics
Similarities
 Automatically adjust infusion pressure to maintain fluidics stability
 Better than Gravity infusion
 Require special design surgical packs
The Differences
Adaptive Fluidics Active Fluidics
Adjust infusion pressure with air pressure Adjust infusion pressure with mechanical squeezing of
BSS pouch
Using BSS glass bottle Using BSS plastic pouch
Control loop > Surgeon commanded vacuum Control loop > sensing infusion pressure inside the
cassette and flow rate of the peristaltic pump
Keeps Infusion pressure high during occlusion in Keeps infusion low during occlusion (more potential
anticipating occlusion breaks (less surge) surge)
12
17-2
Centurion Active Infusion vs. Stellaris PC Dynamic ADAPTIVE FLUIDICS™
Infusion with StableChamber Stellaris Elite vs. Infiniti
Controls Pressure
Fluctuations
Occlusion Start ‐ Centurion
When IOP peaks (at
Occlusion Start – the beginning) and Minimized
Stellaris PC Dynamic Stellaris PC valleys (at the end of
Dynamic post-occlusion
the occlusion) are
taken into account, surge1
the Stellaris PC in
Centurion Dynamic setting
Active
(Adaptive Fluidics) Better
Vacuum Start Occlusion Start Occlusion Stop
with chamber
StableChamber®
tubing performed
stability
better than the than Infiniti1
Alcon Centurion in
1. Data on file.
Active mode.
14
Stellaris Elite vs. Centurion
3x higher
effective post‐occlusion
chamber pressure than ATTUNE® ENERGY MANAGEMENT
Centurion1
Reduced
post‐occlusion surge1
1. Data on file.
ATTUNE® ENERGY MANAGEMENT
How it Works Highly Efficient Cutting Enhanced by Cavitation
Six Piezoelectric Crystals Mechanical Energy Acoustical Energy

Efficient ultrasound production Physical break‐down of the nucleus Cavitation bubbles concentrated
Smoother and precise energy into smaller pieces at the tip and inside the needle
delivery emulsify the nuclear material
Reduced heat buildup
150 µm
17-3
ATTUNE® ENERGY MANAGEMENT
Thermal Effect Jackhammer Effect VS Torsional
The reproducible cooling dynamics of the Stellaris System advances the safety
of 1.8mm procedures*
WIRELESS DUAL LINEAR FOOT PEDAL
1. Mark E. Schafer, PhD. Analysis of the Cutting Forces using Different Phacoemulsification Modalities. ASCRS 2009.
* Based on laboratory study.
19
WIRELESS DUAL LINEAR FOOT PEDAL
How it Works
On‐demand independent linear Rapid response and excellent control in changing
control of aspiration and phaco power conditions.
I (1)  Enables management of both pitch and yaw
300 230 180 130 80
planes
IA (2)
YAW
VACUUM (mmHg)
0%  Integrated movements provide simultaneous DIGITAL MEDIA SYSTEM (DMS)
control of irrigation, ultrasound, and aspiration
15% IA +  Continuous Irrigation ON/OFF activation in YAW
Phaco (3)
30% applicable to single linear setting only
 Pre‐programmable foot pedal settings
45% customizable to surgeon technique
PITCH
 Wireless connectivity
All Stellaris Elite will be
supplied with integrated
foot control
Digital Media System (DMS)
 The Digital Media System (DMS) is an optional accessory that provides a microscope
overlay capability.
 Supports 1080p and 720p via SDI input.
 The Digital Media System (DMS) is only compatible with the Stellaris Elite. No overlay will
be displayed if used with previous software versions.
24
17-4
25 26
17-5
贊助廠商名錄
卡爾蔡司股份有限公司
香港商眼力健亞洲有限公司台灣分公司
科林儀器股份有限公司
科明儀器股份有限公司
瑞士商愛爾康大藥廠股份有限公司台灣分公司
博士倫股份有限公司

講義 110年屈光暨白內障手術進階課程

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講義 110年屈光暨白內障手術進階課程

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中華民國眼科醫學會 第 16 屆 屈光暨白內障手術課程

日期：110 年 06 月 20 日 地點：台大醫院國際會議中心 三樓 301 教室 報到時間：08：30 開始

08：55～09：00 理事⾧致辭 陳建同

10：00 ~ 10：20 Discussion

10：20 ~ 10：30 Coffee Break

Treatment options for small optical zone / decentration

11：10 ~ 11：30 Which IOL is better after LASIK? Monofocal 許志堅

11：50 ~ 12：10 Discussion

12：10 ~ 13：10 Lunch Break

Importance and Optimization of the ocular surface before

13：50～14：10 Cataract surgery in the setting of posterior astigmatism 侯鈞賀

Measurements of ocular aberrations and its implications in

15：10～15：20 Coffee Break

New Horizon in Modern Cataract Surgery- Total

16：05～16：20 Maximizing Your Toric IOL outcomes with iTrace 蔡俊斌

Adaptive Fluidics Technology improves IOP stability during

Laser vision correction market scope

VISUMAX _ Expert Mode

STAR S4IR + Wavescan

Geometry of Lenticule parameters for hyperopic SMILE

Reinstein et al. JRS 2017 Sekundo et al. JRS 2018

Low myopia High myopia

Reinstein et al. JRS 2014

• Increasing the optical zone will reduce the

• Spherical aberration induction in SMILE is

Reinstein et al. IOVS 2012

Zhang et al. Journal of Ophthalmology 2017 Shetty et al. JRS 2018

Angle kappa is the angle between visual axis and

Corneal vertex determine corneal coaxial light reflex

• Decentered lenticule/ablation result in halo, glare and diplopia,

• Postop outcome significantly decreased when offset between

• <0.3mm  visual outcome good regardless of centration

• Optical centration no different SMILE(0.2±0.11mm) and eye

Reinstein et al. JRS 2015

• Centration map technique with topographers

• Triple centration technique help verify the subjective fixation

• In high astigmatism, effective cyclotorsion compensation and

• No change in total RMS HOA in both SMILE with triple

• TransPKR induce more SA than SMILE, reduce coma and

Jun et al. JRS 2018

Decentration and HOA

• The estimated breakpoint between induced

• Higher decentration > 0.335mm induced total

• Tolerance to decentration is dependent on

• 6.2mm OZ —> 0.1 mm

Lee et al. Cornea 2018

Re-treatment/Enhancement Secondary/repeat SMILE

Moshirfar et al. JCRS 2018

• The pattern D is best, for hyperopic treatment

• CIRCLE results in more inflammatory change

• Safe and effective enhancement procedure,

• Drawback: biomechanical weakening caused by

Non-routine situation during lenticule Non-routine situation during lenticule

Non-routine situation during lenticule

SIMLE手術目前使用的centration方法不包括： (a) pupil center 對位法 (b)

TPRK vs PRK TPRK vs PRK

SMART TransPRK SmartSurfACE Technology

» Surface vs. Stromal Treatments

The Customized Wavefront concepts Clinical results_ SMRT TPRK

Data from Jan. 2017~April. 2021 Data from Jan. 2017~April. 2021

Sex male Female

SER (post‐op 3m) ‐0.003 ± 0.551 ‐0.047 ± 0.591 ‐0.027 ± 0.569

Correction Correction Efficacy index(post‐op 3m) 1.12 ± 0.31 1.13 ± 0.22 1.12 ± 0.26

中華民國眼科醫學會第 16 屆屈光暨白內障手術課程

日期：110 年 06 月 20 日地點：台大醫院國際會議中心三樓 301 教室報到時間：08：30 開始

08：55～09：00 理事⾧致辭陳建同

(109.05‐110.01 in TSGH) 本院T‐PRK術後病患中央上皮生長情形(分組分析) (109.05‐110.01 in TSGH) 本院T‐PRK術後病患中央上皮生長情形(生長區塊分析)

Preop BCVA 1.5+2.0/-1.0x80 1.5+4.5/-2.5x80

Preop BCVA 0.5-1.25/-0.75x80 1.0-1.0

Preop BCVA 1.2+3.0/-0.5x80 1.2+2.0/-0.75x90

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