 Hello, everyone. My name is Max Millian Padilla. I'm a fourth year medical student at the University of Utah and Those were two great presentations. We saw tough acts to follow, but I'll do my best First of all, thank you to Dr. Olson and everyone here at the Moran Center for the opportunity to speak to you today The topic I'm going to be presenting on is laser astigmatic correction using intralase with facial emulsification Two of the most common clinical diagnoses we see in ophthalmology are astigmatism and cataracts It's estimated at 3.5 million cataract surgeries are done per year and the prevalence of astigmatism is estimated at 32.4% of the population and Since these are both very common It's a common practice to treat astigmatism at the same time as cataract surgery Here's an illustration of the traditional Asigmatic surgery it's limbo relaxing incisions using a guarded diamond blade lasers have been revolutionary to ophthalmology ever since the 1970s They have had great success in treating different anterior and posterior diagnoses LASIC One of the main lasers that's used in LASIC surgery at the beginning was the intralase laser And it was initially FDA approved for refractive surgery Recently a new laser has come out. It's called the femtosecond laser Also by the same company and it was initially approved for lamellar corneal surgery in 2003 and keratoplasty in 2008 and It's been exciting because it's also approved for cataract surgery since 2010 The use of intralase Lasers has been combined with several different procedures one common combination is To treat a patient for refractive error using LASIC surgery And then at the same time do astigmatism surgery with limbo relaxing incisions To the best of our knowledge. No one has studied using this older intralase system To do limbo relaxing incisions for astigmatism correction at the same time as they do cataract surgery so Dr.. Unbody had the great idea to do a study looking at well a case series looking at treating patients with cataracts and Astigmatism and doing the astigmatism surgery at the same time as the cataract surgery so the case series that we Came up with had a total of four patients and seven eyes fit the parameter of the study The patients ranged in age from sixty two to seventy three males one female Common co-morbidities of diabetes and hypertension All the patients approved for the study had astigmatism and all the patients also had cataracts So the patients were treated at the Moran eye center and The astigmatism LRI incisions were performed using the Moran's 150 kilohertz intralase IFS laser To make the initial Interior side cuts for astigmatism correction I wanted to highlight one of the patients that we worked on that dr. Unbody operated on to show you the process that he went through to determine their degree of astigmatism and then how much Need to be corrected using the laser So in this particular patient The refractive numbers are given here with negative thirteen point seven five plus two point five by sixty degrees OS and I'm going to focus on the left eye for simplicity and In this gentleman his best corrected visual acuity pre-op was to hunt twenty over five hundred So we use different imaging modalities to calculate the degree of astigmatism and Those modalities included the oculus pentacam IOL master and topography But I'll come back to these refractive and visual acuity numbers in the post-op slide So the oculus pentacam gave us a great reading of 1.8 on astigmatism at 77 degrees the IOL master was 1.96 at 78 degrees and Topography showed an astigmatism of 1.68 at 71 degrees So now we had the data and it needed to formulate a plan of how to treat this patient So the average of those three measurements that I showed you in the previous slides turned out to be 1.82 diopters of astigmatism at 75 degrees and the aim on this study was to have the patients be positive point two five to positive point five at the end of surgery and Here is the printout of all the calculations and laser settings that were needed to successfully carry out the surgery So as you can see here the anterior side cut was on the laser calculated out what posterior depth of the incision that was needed and Then the cut angle and cut position for the limbo relaxing incisions was also noted and the interlaced laser has a special setting where you can modify it to To do the limbo relaxing incisions So before I had mentioned the cut position and cut angle This is an example of On top here the cut position was 75 degrees the cut angle was 50 degrees So it went 25 degrees to each side of the cut position so in total This range from 50 degrees to 100 degrees And on the bottom here the cut angle. I mean cup position was 255 degrees and the total cut range from 230 to 280 degrees This just highlights the exact precision that can be attained with the interlaced laser Here's a picture of the patient's eye in the post-op period Right here this faint line is The limbo relaxing incision made by the laser And this just goes to again to show the Really precise angles and measurements that can be attained using the laser for these limbo relaxing incisions In the post-op measurements The patient's refraction was plano in both eyes his visual acuity Before I had mentioned it was 2,500 in the left eye. It's now 2025 and the topographic astigmatism measurement post-op was 0.39 diapters This fit in perfectly with the target range we had set of between 0.25 and 0.5 For the post-op residual cylinder length So Doctor and body attained the goal in this astigmatism measurement in the post-op period Here's a picture again to show the limbo relaxing incisions of the right eye on this patient post-op so right now we're still at the Somewhere initial stages of this case series. We haven't gotten The post-op topography on all the patients yet because it's a relatively new study So we don't have standard deviations But so far the initial results are that all patients are tolerating the surgery well Six out of seven patients. I mean six out of seven eyes were plano at the last visit There have been no complications noted the average pre-op cylinder Was 1.7 diapters the mean post-op cylinder is point four nine Diapters so quiet difference between these two numbers and the average post-op Incorrected visual acuity is 2025 right now Right now economics plays a huge role in medicine and the decisions we make So there are three options currently for the treatment of astigmatism in patients one option is to use glasses Another option is to use toric intraocular lenses placed in at the time of cataract surgery and a third option is to use limbo relaxing incision surgery and I recently talked to the surgery department and they told me that the toric lenses cost 350 to $400 more than standard intraocular lenses so This brings up a really important topic of price and the two lasers that are currently Being used the interlace which we have here and the newer femto second laser Have quite a bit of a difference in the price one source I net Recently estimated that the upfront cost of buying a femto second laser is $450,000 and this can go up as high as $500,000 the material and maintenance fee is around $400 per eye just to operate and Many of these have a service contract for maintenance and other Alterations to the laser that costs around $40,000 per year The interlace laser the one that we have here Costs about $375,000 at the time it was purchased in 2008 the material and maintenance fee is about $160 per eye and The service contract on our laser is a per click fee. So there's not an upfront cost Per year. It's just based on how many surgeries are done and This is some really exciting data that came out about two days ago in the I net journal So as we can see here, this looks at hypothetical break-even scenarios for buying a brand new femto second laser this box right here looks at the five-year break-even point and From what this says Depending on the number of surgeries that are done the price Per patient ranges between 500 to 900 dollars for a surgery used in the femto second laser at least that's what it would have to cost for a practice to break-even and There are several different numbers per year ranging from 250 surgeries a year to 1500 surgeries The number of non VA cataract surgeries done at the Moran Center is around 2,800 so that number can be taken into account with this figure to kind of see the break-even point of Using femto second lasers at the Moran Center So there are several reimbursement issues that come into play with Limbo relaxing incisions for astigmatism surgery The governing body for Medicare and Medicaid billing Stated recently that patients can't be charged for capsule or hexes cataract incisions or lens fragmentation Using the lasers and it's interesting because the femto second laser corporation They really stress that their laser is great at performing these three Functions But the problem is that based on what Medicare and Medicaid say Neither they nor the patients can be charged for these costs But what we can charge patients for is for astigmatism correction and Astigmatism correction we saw in the case series is Very effective if it's done with the interlaced laser the older laser So the American Society of cataract and refractive surgeons Also agreed with what the Medicare and Medicaid guidelines were So in conclusion Although our case series is not complete yet It seems like the interlaced laser is likely a safe effective and economical Alternative to corrective astigmatism surgery at the time of cataract surgery there's a Quite large price difference between the interlaced laser and the femto second laser and Many of these costs are due to the initial Per use and maintenance fees Also, there's an issue of room to house a large laser and A great thing about the laser we have at the Moran Center is that it's paid for and there isn't a yearly maintenance fee on it So it works very economically both for surgeons and for the patients To use the existing interlaced laser Future directions that we can see this project headed in is a head-to-head Comparison with other astigmatic correction techniques on effectiveness safety and outcomes It will also be interesting to see the impact on coronial aberrations That exists with interlaced surgery versus conventional surgery techniques So a big thank you to Dr. Unbi for his help and guidance with this project Also, I'd like to thank Alicia for setting up the time for me to speak to you today and Chandler crane for arranging all the files that I needed for this project So are there any questions? Yes, sir Just It's good I Was saying I'll be much more economic for everyone that'd be great Okay, and I apologize I should have said astigmatic heritage me instead of instead of limbo relaxing incisions for thank you Everyone