EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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September 2013 EW NEWS & OPINION 3 ASCRS•ASOA Winter Update meeting to offer intimate setting by Erin L. Boyle EyeWorld Senior Staff Writer The meeting is set to take place in a relaxed setting but will still provide the best in expert opinions and clinical knowledge T he 2014 ASCRS•ASOA Winter Update will feature general sessions, optional workshops, and evening sessions with anterior segment and other expert surgeons in a casual, interactive environment. ASCRS•ASOA has a unique request of attendees at the relaxed meeting: "Please, no ties." "We invite you to attend the 7th annual ASCRS•ASOA Winter Update program," officials said on the ASCRS•ASOA website for the meeting. "Strategize with accessible faculty and engage in the open exchange of techniques and ideas in a relaxing, world-class setting." "This more intimate and casual educational event combines highenergy sessions with video cases, debates, and discussion. You will come away refreshed and energized by new knowledge and insight that will have an immediate impact on your practice," officials said. The 2014 ASCRS•ASOA Winter Update will be held February 13–17, 2014, at the El Conquistador, a Waldorf Astoria Property in Fajardo, Puerto Rico. The luxury resort is located atop a 300-foot cliff overlooking the Atlantic Ocean and the Caribbean Sea on the Island of Enchantment. Meeting benefits The meeting is a joint offering from ASCRS and ASOA, a fact that should be beneficial to both physicians and administrators, said Laureen Rowland, CAE, executive director of ASOA, Fairfax, Va. In response to the question "Why is it important for doctors to hear from the ASOA side of ophthalmology?" Ms. Rowland said, "Administrators want and need physicians' awareness of the myriad challenges and issues affecting the bottom line of the practice. ASOA meets this need by providing the experts to address the business management of practices." "An administrator's responsibilities today can best be described as 'all over the map,'" she said. "With legislative and regulatory uncertainty, the impending implementation of ICD-10, and normal day-today operations, practices need current information, and [they] need it now. The ASOA Board of Directors has identified a 'top 10' list of issues important to the membership and have drawn on some of these for the Winter Update program." She said that with ICD-9 code sets to be replaced with ICD-10 on Oct. 1, 2014, education on the new sets is of vital importance. At the meeting, Ann Rose, president of Rose and Associates Healthcare Consultants and a coding expert, will discuss how practices can best prepare for the replacement codes. continued on page 8 months); visual fluctuations (32.1% at baseline versus 43.0% at 3 months); and halos (37.0% at baseline versus 42.3% at 3 months). Long term risks of LASIK for mixed astigmatism beyond 6 months have not been studied. Health Care Professional Information Sheet-All WaveLight® ALLEGRETTO WAVE® EX500 System Indications The WaveLight® ALLEGRETTO WAVE® / ALLEGRETTO WAVE® Eye-Q Excimer Laser System CAUTION: Federal (USA) law restricts this device to sale by, or on the order of a physician. Statements regarding the potential benefits of wavefront-guided and Wavefront Optimized® laser-assisted in-situ keratomileusis (LASIK) are based upon the results of clinical trials. These results are indicative of not only the WaveLight® ALLEGRETTO WAVE® / ALLEGRETTO WAVE® Eye-Q Excimer Laser System treatment but also the care of the clinical physicians, the control of the surgical environment by those physicians, the clinical trials' treatment parameters and the clinical trials' patient inclusion and exclusion criteria. Although many clinical trial patients after the wavefront-guided and Wavefront Optimized® procedure saw 20/20 or better and/or had or reported having better vision during the day and at night, compared to their vision with glasses or contact lenses before the procedure, individual results may vary. You can find information about the clinical trials below and in the Procudure Manuals for the WaveLight® ALLEGRETTO WAVE® / ALLEGRETTO WAVE® Eye-Q Excimer Laser System. As with any surgical procedure, there are risks associated with the wavefront-guided and Wavefront Optimized® treatment. Before treating patients with these procedures, you should carefully review the Procedure Manuals, complete the Physician WaveLight® System Certification Course, provide your patients with the Patient Information Booklet, and discuss the risks associated with this procedure and questions about the procedure with your patients. INDICATIONS: The WaveLight® ALLEGRETTO WAVE® / ALLEGRETTO WAVE® Eye-Q Excimer Laser System is indicated to perform LASIK treatments in patients with documented evidence of a stable manifest refraction defined as less than or equal to 0.50 diopters (D) of preoperative spherical equivalent shift over one year prior to surgery, exclusive of changes due to unmasking latent hyperopia in patients 18 years of age or older: for the reduction or elimination of myopic refractive errors up to -12.0 D of sphere with and without astigmatic refractive errors up to -6.0 D; for the reduction or elimination of hyperopic refractive errors up to +6.0 D of sphere with and without astigmatic refractive errors up to 5.0 D at the spectacle plane, with a maximum manifest refraction spherical equivalent (MRSE) of +6.0 D; and in patients 21 years of age or older for the reduction or elimination of naturally occurring mixed astigmatism of up to 6.0 D at the spectacle plane. LASIK is an elective procedure with the alternatives including but not limited to eyeglasses, contact lenses, photorefractive keratectomy (PRK), and other refractive surgeries. Only practitioners who are experienced in the medical management and surgical treatment of the cornea, who have been trained in laser refractive surgery including laser system calibration and operation, may use the device as approved. Prospective patients, as soon as they express an interest in an indicated LASIK procedure and prior to undergoing surgery, must be given the WaveLight® System Patient Information Booklet and must be informed of the alternatives for refractive correction including eyeglasses, contact lenses, PRK, and other refractive surgeries. Clinical Data Myopia: The WaveLight® ALLEGRETTO WAVE® / ALLEGRETTO WAVE® Eye-Q Excimer Laser System for LASIK treatments of myopic refractive errors up to -12.0 D of sphere with and without astigmatic refractive errors up to -6.0 D at the spectacle plane was studied in clinical trials in the United States with 901 eyes treated, of which 813 of 866 eligible eyes were followed for 12 months. Accountability at 3 months was 93.8%, at 6 months was 91.9%, and at 12 months was 93.9%. The studies found that of the 844 eyes eligible for the uncorrected visual acuity (UCVA) analysis of effectiveness at the 3-month stability time point, 98.0% were corrected to 20/40 or better, and 84.4% were corrected to 20/20 or better without spectacles or contact lenses. The clinical trials showed that the following subjective patient adverse events were reported as moderate to severe at a level at least 1% higher than baseline of the subjects at 3 months post-treatment: visual fluctuations (12.8% at baseline versus 28.6% at 3 months). Long term risks of LASIK for myopia with and without astigmatism beyond 12 months have not been studied. Clinical Data Hyperopia: The WaveLight® ALLEGRETTO WAVE® / ALLEGRETTO WAVE® Eye-Q Excimer Laser System for LASIK treatments of hyperopic refractive errors up to +6.0 D of sphere with and without astigmatic refractive errors up to 5.0 D with a maximum MRSE of +6.0 D has been studied in clinical trials in the United States with 290 eyes treated, of which 100 of 290 eligible eyes were followed for 12 months. Accountability at 3 months was 95.2%, at 6 months was 93.9%, and at 12 months was 69.9%. The studies found that of the 212 eyes eligible for the UCVA analysis of effectiveness at the 6-month stability time point, 95.3% were corrected to 20/40 or better, and 67.5% were corrected to 20/20 or better without spectacles or contact lenses. The study showed that the following subjective patient adverse events were reported as much worse by at least 1% of the subjects (in order of increasing frequency) at 6 months post final treatment: glare from bright lights (3.0%); night driving glare (4.2%); light sensitivity (4.9%); visual fluctuations (6.1%); and halos (6.4%). Long term risks of LASIK for hyperopia with and without astigmatism beyond 12 months have not been studied. Clinical Data Mixed Astigmatism: The WaveLight® ALLEGRETTO WAVE®/ ALLEGRETTO WAVE® Eye-Q Excimer Laser System for LASIK treatments of naturally occurring mixed astigmatism of up to 6.0 D at the spectacle plane has been studied in clinical trials in the United States with 162 eyes treated, of which 111 were eligible to be followed at 6 months. Accountability at 1 month was 99.4%, at 3 months was 96.0%, and at 6 months was 100.0%. The studies found that of the 142 eyes eligible for the UCVA analysis of effectiveness at the 3-month stability time point, 95.8% achieved acuity of 20/40 or better, and 67.6% achieved acuity of 20/20 or better without spectacles or contact lenses. The clinical trials showed that the following subjective patient adverse events were reported as moderate to severe at a level at least 1% higher than baseline of the subjects at 3 months post-treatment: sensitivity to light (43.3% at baseline versus 52.9% at 3 rise with increase of >5 mmHg or any reading above 25 mmHg; retinal detachment or retinal vascular accident; and decrease in BSCVA of >10 letters not due to irregular astigmatism as shown by hard contact lens refraction. Clinical Data Wavefront-guided Treatment of Myopia: The WaveLight® ALLEGRETTO WAVE® / ALLEGRETTO WAVE® Eye-Q Excimer Laser System used in conjunction with the WaveLight® ALLEGRO Analyzer® device. The device uses a 6.5 mm optical zone, a 9.0 mm ablation/treatment zone, and is indicated for wavefront-guided LASIK: 1) for the reduction or elimination of up to -7.0 D of spherical equivalent myopia or myopia with astigmatism, with up to -7.0 D of spherical component and up to 3.0 D of astigmatic component at the spectacle plane; 2) in patients who are 18 years of age or older; and 3) in patients with documentation of a stable manifest refraction defined as ≤0.50 D of preoperative spherical equivalent shift over one year prior to surgery was studied in a randomized clinical trial in the United States with 374 eyes treated; 188 with wavefront-guided LASIK (Study Cohort) and 186 with Wavefront Optimized® LASIK (Control Cohort). 178 of the Study Cohort and 180 of the Control Cohort were eligible to be followed at 6 months. In the Study Cohort, accountability at 1 month was 96.8%, at 3 months was 96.8%, and at 6 months was 93.3%. In the Control Cohort, accountability at 1 month was 94.6%, at 3 months was 94.6%, and at 6 months was 92.2%. The following complications occurred 3 months after LASIK during this clinical trial: 0.8% (7/844) of eyes had a corneal epithelial defect; 0.1% (1/844) had any epithelium in the interface; 0.1% (1/844) had foreign body sensation; 0.2% (2/844) had pain; and 0.7% (6/844) had ghosting or double images in the operative eye. The studies found that of the 180 eyes eligible for the UCVA analysis of effectiveness at the 6-month stability time point in the Study Cohort, 99.4% were corrected to 20/40 or better, and 93.4% were corrected to 20/20 or better without spectacles or contact lenses. In the Control Cohort, of the 176 eyes eligible for the UCVA analysis of effectiveness at the 6-month stability time point, 99.4% were corrected to 20/40 or better, and 92.8% were corrected to 20/20 or better without spectacles or contact lenses. The clinical trials showed that the following subjective patient adverse events were reported as moderate to severe at a level at least 1% higher than baseline of the subjects at 3 months post-treatment in the Study Cohort: light sensitivity (37.2% at baseline versus 47.8% at 3 months); and visual fluctuations (13.8% at baseline versus 20.0% at 3 months). In the Control Cohort: halos (36.6% at baseline versus 45.4% at 3 months); and visual fluctuations (18.3% at baseline versus 21.9% at 3 months). Long term risks of wavefront-guided LASIK for myopia with and without astigmatism beyond 6 months have not been studied. CONTRAINDICATIONS: LASIK treatments using the WaveLight® ALLEGRETTO WAVE® / ALLEGRETTO WAVE® Eye-Q Excimer Laser System are contraindicated if any of the following conditions exist. Potential contraindications are not limited to those included in this list: pregnant or nursing women; patients with a diagnosed collagen vascular, autoimmune or immunodeficiency disease; patients with diagnosed keratoconus or any clinical pictures suggestive of keratoconus; and patients who are taking one or both of the following medications: isotretinoin (Accutane®1), amiodarone hydrochloride (Cordarone®2). WARNINGS: Any LASIK treatment with the WaveLight® ALLEGRETTO WAVE® / ALLEGRETTO WAVE® Eye-Q Excimer Laser System is not recommended in patients who have: systemic diseases likely to affect wound healing, such as connective tissue disease, insulin dependent diabetes, severe atopic disease or an immunocompromised status; a history of Herpes simplex or Herpes zoster keratitis; significant dry eye that is unresponsive to treatment; severe allergies; and unreliable preoperative wavefront examination that precludes wavefront-guided treatment. The wavefront-guided LASIK procedure requires accurate and reliable data from the wavefront examination. Every step of every wavefront measurement that may be used as the basis for a wavefrontguided LASIK procedure must be validated by the user. Inaccurate or unreliable data from the wavefront examination will lead to an inaccurate treatment. PRECAUTIONS: Safety and effectiveness of the WaveLight® ALLEGRETTO WAVE® / ALLEGRETTO WAVE® Eye-Q Excimer Laser System have not been established for patients with: progressive myopia, hyperopia, astigmatism and/or mixed astigmatism; ocular disease; previous corneal or intraocular surgery, or trauma in the ablation zone; corneal abnormalities including, but not limited to, scars, irregular astigmatism and corneal warpage; residual corneal thickness after ablation of less than 250 microns increasing the risk for corneal ectasia; pupil size below 7.0 mm after mydriatics where applied for wavefront-guided ablation planning; history of glaucoma or ocular hypertension of > 23 mmHg; taking the medication sumatriptan succinate (Imitrex®3); under 18 years (21 years for mixed astigmatism) of age; over the long term (more than 12 months after surgery); corneal, lens and/or vitreous opacities including, but not limited to, cataract; iris problems including, but not limited to, coloboma and previous iris surgery compromising proper eyetracking; taking medications likely to affect wound healing including, but not limited to, antimetabolites; treatments with an optical zone below 6.0 mm or above 6.5 mm in diameter; treatment targets different from emmetropia (plano) in which the wavefront-calculated defocus (spherical term) has been adjusted; myopia greater than – 12.0 D or astigmatism greater than 6 D; hyperopia greater than + 6.0 D or astigmatism greater than 5.0 D; mixed astigmatism greater than + 6.0 D; and in cylinder amounts > 4.0 to < 6.0 D. Due to the lack of large numbers of patients in the general population, there are few subjects with cylinder amounts in this range to be studied. Not all complications, adverse events, and levels of effectiveness may have been determined. Pupil sizes should be evaluated under mesopic illumination conditions. Effects of treatment on vision under poor illumination cannot be predicted prior to surgery. Some patients may find it more difficult to see in such conditions as very dim light, rain, fog, snow and glare from bright lights. This has been shown to occur more frequently in the presence of residual refractive error and perhaps in patients with pupil sizes larger than the optical zone size. The refraction is determined in the spectacle plane, but treated in the corneal plane. In order to determine the right treatment program to achieve the right correction, assessment of the vertex distance during refraction testing is recommended. Preoperative evaluation for dry eyes should be performed. Patients should be advised of the potential for dry eyes post LASIK and post wavefront-guided LASIK surgery. This treatment can only be provided by a licensed healthcare professional. The following complications did NOT occur 3 months following LASIK in this clinical trial: corneal edema and need for lifting and/or reseating the flap/cap. Adverse Events and Complications for Hyperopia: Certain adverse events and complications occurred after the LASIK surgery. Only one adverse event occurred during the clinical study: one eye (0.4%) had a retinal detachment or retinal vascular accident reported at the 3 month examination. The following adverse events did NOT occur: corneal infiltrate or ulcer requiring treatment; lost, misplaced, or misaligned flap, or any flap/cap problems requiring surgical intervention beyond 1 month; corneal edema at 1 month or later visible in the slit lamp exam; any complication leading to intraocular surgery; melting of the flap of > 1 mm2; epithelium of > 1 mm2 in the interface with loss of 2 lines or more of BSCVA; uncontrolled IOP rise with increase of > 5 mmHg or any reading above 25 mmHg and decrease in BSCVA of > 10 letters not due to irregular astigmatism as shown by hard contact lens refraction. The following complications occurred 6 months after LASIK during this clinical trial: 0.8% (2/262) of eyes had a corneal epithelial defect and 0.8% (2/262) had any epithelium in the interface. The following complications did NOT occur 6 months following LASIK in this clinical trial: corneal edema; foreign body sensation; pain, ghosting or double images; and need for lifting and/or reseating of the flap/cap. Adverse Events and Complications for Mixed Astigmatism: Certain adverse events and complications occurred after the LASIK surgery. No protocol defined adverse events occurred during the clinical study. However, two events occurred which were reported to the FDA as Adverse Events. The first event involved a patient who postoperatively was subject to blunt trauma to the treatment eye 6 days after surgery. The patient was found to have an intact globe with no rupture, inflammation or any dislodgement of the flap. The second event involved the treatment of an incorrect axis of astigmatism which required retreatment. The following adverse events did NOT occur: corneal infiltrate or ulcer requiring treatment; corneal epithelial defect involving the keratectomy at 1 month or later; corneal edema at 1 month or later visible in the slit lamp exam; epithelium of > 1 mm2 in the interface with loss of 2 lines or more of BSCVA; lost, misplaced, or misaligned flap, or any flap/cap problems requiring surgical intervention beyond 1 month; decrease in BSCVA of > 10 letters not due to irregular astigmatism as shown by hard contact lens refraction; any complication leading to intraocular surgery; melting of the flap of > 1 mm2; uncontrolled IOP rise and retinal detachment or retinal vascular accident. None of the following complications occurred at 3 months after LASIK during this clinical trial: corneal edema; corneal epithelial defect; any epithelium in the interface; foreign body sensation, pain, ghosting or double images; and need for lifting and/or reseating of the flap/cap. Subjects were asked to complete a patient questionnaire preoperatively and at 3-months, 6-months, and 1-year postoperatively. Adverse Events and Complications for Wavefront - guided Myopia: Certain adverse events and complications occurred after the wavefront-guided LASIK surgery. No adverse event occurred during wavefront-guided treatments during this clinical study. The following adverse events did NOT occur: corneal infiltrate or ulcer requiring treatment; lost, misplaced or misaligned flap or any flap/cap problems requiring surgical intervention beyond 1 month; corneal edema at 1 month or later visible in the slit lamp exam; any complication leading to intraocular surgery; melting of the flap of > 1 mm2; epithelium of > 1 mm² in the interface with loss of 2 lines or more of BSCVA; uncontrolled IOP rise with increase of > 5 mmHg or any reading above 25 mmHg; and decrease in BSCVA of > 10 letters not due to irregular astigmatism as shown by hard contact lens refraction. The following complications occurred 3 months after wavefront-guided LASIK during this clinical trial: corneal epithelial defect (0.6%); foreign body sensation (0.6%); and pain (0.6%). The following complications did NOT occur 3 months following wavefront-guided LASIK in this clinical trial: corneal edema; any epithelium in the interface; ghosting or double images; and need for lifting and/or reseating of the flap/cap. ATTENTION: The safety and effectiveness of LASIK surgery has ONLY been established with an optical zone of 6.0 – 6.5 mm and an ablation zone of 9.0 mm. Reference the Directions for Use labeling for a complete listing of indications, warnings and precautions. 1. Accutane® is a registered trademark of Hoffmann-La Roche Inc. 2. Cordarone® is a registered trademark of Sanofi S.A. 3. Imitrex® is a registered trademark of Glaxo Group Limited Adverse Events and Complications for Myopia: Certain adverse events and complications occurred after the LASIK surgery. Two adverse events occurred during the postoperative period of the clinical study: 0.2% (2/876) had a lost, misplaced, or misaligned flap reported at the 1 month examination. The following adverse events did NOT occur: corneal infiltrate or ulcer requiring treatment, corneal edema at 1 month or later visible in the slit lamp exam; any complication leading to intraocular surgery; melting of the flap of >1 mm2; epithelium of >1 mm2 in the interface with loss of 2 lines or more of BSCVA; uncontrolled IOP © 2013 Novartis 1/13 ALL13006JADUS-PI