The American Academy of Ophthalmology is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The American Academy of Ophthalmology designates this enduring material for a maximum of 10 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME expiration date: June 1, 2017. AMA PRA Category 1 Credits™ may be claimed only once between June 1, 2014, and the expiration date.

BCSC® volumes are designed to increase the physician’s ophthalmic knowledge through study and review. Users of this activity are encouraged to read the text and then answer the study questions provided at the back of the book.

To claim AMA PRA Category 1 Credits™ upon completion of this activity, learners must demonstrate appropriate knowledge and participation in the activity by taking the posttest for Section 13 and achieving a score of 80% or higher. For further details, please see the instructions for requesting CME credit at the back of the book.

The Academy provides this material for educational purposes only. It is not intended to represent the only or best method or procedure in every case, nor to replace a physician’s own judgment or give specific advice for case management. Including all indications, contraindications, side effects, and alternative agents for each drug or treatment is beyond the scope of this material. All information and recommendations should be verified, prior to use, with current information included in the manufacturers’ package inserts or other independent sources, and considered in light of the patient’s condition and history. Reference to certain drugs, instruments, and other products in this course is made for illustrative purposes only and is not intended to constitute an endorsement of such. Some material may include information on applications that are not considered community standard, that reflect indications not included in approved FDA labeling, or that are approved for use only in restricted research settings. The FDA has stated that it is the responsibility of the physician to determine the FDA status of each drug or device he or she wishes to use, and to use them with appropriate, informed patient consent in compliance with applicable law. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise from the use of any recommendations or other information contained herein.

AAO, AAOE, American Academy of Ophthalmology, Basic and Clinical Science Course, BCSC, EyeCare America, EyeNet, EyeSmart, EyeWiki, Focal Points, IRIS, ISRS, OKAP, ONE, Ophthalmic Technology Assessments, Ophthalmology, Preferred Practice Pattern, ProVision, SmartSight, The Ophthalmic News & Education Network, and The Eye M.D. Association are, among other marks, the registered trademarks and trademarks of the American Academy of Ophthalmology.

Cover image: From BCSC Section 12, Retina and Vitreous. Ultra-wide-field fundus photograph from a patient with von Hippel–Lindau disease. Courtesy of Colin A. McCannel, MD.

Copyright © 2015

American Academy of Ophthalmology

All rights reserved

Basic and Clinical Science Course

Louis B. Cantor, MD, Indianapolis, Indiana, Senior Secretary for Clinical Education Christopher J. Rapuano, MD, Philadelphia, Pennsylvania, Secretary for Ophthalmic

Knowledge

George A. Cioffi, MD, New York, New York, BCSC Course Chair

Section 13

Faculty

M. Bowes Hamill, MD, Chair, Houston, Texas

Gregg J. Berdy, MD, St Louis, Missouri

Richard S. Davidson, MD, Denver, Colorado

Parag A. Majmudar, MD, Chicago, Illinois

J. Bradley Randleman, MD, Atlanta, Georgia

Neda Shamie, MD, Beverly Hills, California

Renato Ambrósio Jr, MD, PhD, Consultant, Rio de Janeiro, Brazil

The Academy wishes to acknowledge the American Society of Cataract and Refractive Surgeons (ASCRS) for recommending faculty members to the BCSC Section 13 committee.

The Academy also wishes to acknowledge the following committees for review of this edition:

Committee on Aging: Holly B. Hindman, MD, Rochester, New York

Vision Rehabilitation Committee: Janet S. Sunness, MD, Baltimore, Maryland

Practicing Ophthalmologists Advisory Committee for Education: Bradley D. Fouraker, MD, Primary Reviewer, Tampa, Florida; Edward K. Isbey III, MD, Chair, Asheville, North Carolina; Hardeep S. Dhindsa, MD, Reno, Nevada; Robert G. Fante, MD, Denver, Colorado; Dasa V. Gangadhar, MD, Wichita, Kansas; James M. Mitchell, MD, Edina, Minnesota; James A. Savage, MD, Memphis, Tennessee; Robert E. Wiggins Jr, MD, Asheville, North Carolina

European Board of Ophthalmology: Jesper Hjortdal, MD, PhD, EBO Chair, Aarhus, Denmark; MarieJosé Tassignon, MD, PhD, FEBO, EBO Liaison, Antwerp, Belgium; Roberto Bellucci, MD, Verona, Italy; Daniel Epstein, MD, PhD, Bern, Switzerland; José L. Güell, MD, FEBO, Barcelona, Spain; Markus Kohlhaas, MD, Dortmund, Germany; Rudy M.M.A. Nuijts, MD, PhD, Maastricht, the Netherlands

Financial Disclosures

Academy staff members who contributed to the development of this product state that within the past 12 months, they have had no financial interest in or other relationship with any entity discussed in this

course that produces, markets, resells, or distributes ophthalmic health care goods or services consumed by or used in patients, or with any competing commercial product or service.

The authors and reviewers state that within the past 12 months, they have had the following financial relationships:*

Dr Ambrósio: Abbott Medical Optics (C), Alcon Laboratories (C, L), Allergan (L), Bausch + Lomb (L), Carl Zeiss (L), Mediphacos (L), Oculus (C, L)

Dr Bellucci: Alcon Laboratories (C), Bausch + Lomb Surgical (C)

Dr Berdy: Alcon Laboratories (C, L), Allergan (C, L), Bausch + Lomb Surgical (C, L), Merck & Co (C, L), QLT Phototherapeutics (C, L)

Dr Davidson: Alcon Laboratories (C, L), Queensboro Publishing Company (O)

Dr Fouraker: Addition Technology (C, L), Alcon Laboratories (C, L), KeraVision (C, L), Ophthalmic Mutual Insurance Company (C, L)

Dr Güell: Alcon Laboratories (C), Calhoun Vision (O), Carl Zeiss (C), OPHTEC, BV (C)

Dr Hamill: OPHTEC (S)

Dr Hjortdal: Carl Zeiss Meditec (L)

Dr Isbey: Allscripts (C), Medflow (C)

Dr Majmudar: Alcon Laboratories (C), Allergan (C), Bausch + Lomb Surgical (C), CBX Ophthalmics (O), Mobius Therapeutics (C), Rapid Pathogen Screening (O), TearScience (C, S)

Dr Nuijts: Alcon Laboratories (L, S), ASICO (P), Bausch + Lomb (C)

Dr Savage: Allergan (L)

Dr Shamie: Allergan (C, L), Bausch + Lomb (C, L), Merck & Co (C, L)

Dr Sunness: Acucela (C), Alcon Laboratories (C), Cell Cure (C), Genentech (C), GlaxoSmithKline (C), Neurotech (C), Novartis Pharmaceuticals (C), Ophthotech (C), Pfizer (C)

Dr Tassignon: Morcher GmbH (P)

Dr Wiggins: Medflow/Allscripts (C), Ophthalmic Mutual Insurance Company (C)

The other authors and reviewers state that within the past 12 months, they have had no financial interest in or other relationship with any entity discussed in this course that produces, markets, resells, or distributes ophthalmic health care goods or services consumed by or used in patients, or with any competing commercial product or service.

*C = consultant fees, paid advisory boards, or fees for attending a meeting; L = lecture fees (honoraria), travel fees, or reimbursements when speaking at the invitation of a commercial sponsor; O = equity ownership/stock options of publicly or privately traded firms (excluding mutual funds) with manufacturers of commercial ophthalmic products or commercial ophthalmic services; P = patents and/or royalties that might be viewed as creating a potential conflict of interest; S = grant support for the past year (all sources) and all sources used for a specific talk or manuscript with no time limitation

Recent Past Faculty

Brian S. Boxer Wachler, MD

Elizabeth A. Davis, MD

Eric D. Donnenfeld, MD

Contents

Title Page

Copyright Page

Faculty and Disclosures

General Introduction

Visual Acuity Chart

Objectives

Introduction

1 The Science of Refractive Surgery

Corneal Optics

Refractive Error: Optical Principles and Wavefront Analysis Measurement of Wavefront Aberrations and Graphical Representations Lower-Order Aberrations

Higher-Order Aberrations Corneal Biomechanics

Corneal Imaging for Keratorefractive Surgery Corneal Topography

Corneal Tomography

Indications for Corneal Imaging in Refractive Surgery The Role of Corneal Topography in Refractive Surgery

Corneal Effects of Keratorefractive Surgery Incisional Techniques

Tissue Addition or Subtraction Techniques Alloplastic Material Addition Techniques Collagen Shrinkage Techniques

Laser Biophysics Laser–Tissue Interactions

Fundamentals of Excimer Laser Photoablation Types of Photoablating Lasers

Corneal Wound Healing

2 Patient Evaluation

Patient History

Patient Expectations

Social History

Medical History

Pertinent Ocular History

Patient Age, Presbyopia, and Monovision

Examination

Uncorrected Visual Acuity and Manifest and Cycloplegic Refraction

Pupillary Examination

Ocular Motility, Confrontation Fields, and Ocular Anatomy

Intraocular Pressure

Slit-Lamp Examination

Dilated Fundus Examination

Ancillary Tests

Corneal Topography

Pachymetry

Wavefront Analysis

Calculation of Residual Stromal Bed Thickness After LASIK

Discussion of Findings and Informed Consent

3 Incisional Corneal Surgery

Incisional Correction of Myopia

Radial Keratotomy in the United States

Incisional Correction of Astigmatism

Coupling

Arcuate Keratotomy and Limbal Relaxing Incisions

Instrumentation

Surgical Techniques

Outcomes

Complications

Ocular Surgery After Arcuate Keratotomy and Limbal Relaxing Incisions

4 Onlays and Inlays

Keratophakia

Homoplastic Corneal Inlays

Alloplastic Corneal Inlays Epikeratoplasty

Intrastromal Corneal Ring Segments Background

Instrumentation Technique Outcomes

Intacs and Keratoconus

One or Two Intacs Segments? Complications

Ectasia After LASIK

Uses for Intrastromal Corneal Ring Segments After LASIK Orthokeratology

5 Photoablation: Techniques and Outcomes

Excimer Laser

Background Surface Ablation LASIK

Wavefront-Optimized and Wavefront-Guided Ablations Patient Selection for Photoablation

Special Considerations for Surface Ablation Special Considerations for LASIK

Surgical Technique for Photoablation Calibration of the Excimer Laser

Preoperative Planning and Laser Programming Preoperative Preparation of the Patient

Preparation of the Bowman Layer or Stromal Bed for Excimer Ablation Application of Laser Treatment

Immediate Postablation Measures Postoperative Care

Refractive Outcomes Outcomes for Myopia Outcomes for Hyperopia

Wavefront-Guided and Wavefront-Optimized Treatment Outcomes for Myopia and Hyperopia Re-treatment (Enhancements)

6 Photoablation: Complications and Adverse Effects

General Complications Related to Laser Ablation Overcorrection

Undercorrection Optical Aberrations Central Islands Decentered Ablations

Corticosteroid-Induced Complications Central Toxic Keratopathy

Infectious Keratitis

Complications Unique to Surface Ablation Persistent Epithelial Defects

Sterile Infiltrates Corneal Haze

Complications Unique to LASIK Microkeratome Complications Epithelial Sloughing or Defects Flap Striae

Traumatic Flap Dislocation LASIK-Interface Complications

Visual Disturbances Related to Femtosecond Laser LASIK Flaps Ectasia

Rare Complications

7 Collagen Shrinkage and Crosslinking Procedures

Collagen Shrinkage

History

Laser Thermokeratoplasty

Conductive Keratoplasty

Collagen Crosslinking

8 Intraocular Refractive Surgery

Phakic Intraocular Lenses Background Advantages Disadvantages

Patient Selection Surgical Technique Outcomes Complications

Refractive Lens Exchange Patient Selection

Surgical Planning and Technique

IOL Power Calculations in Refractive Lens Exchange Complications

Advantages Disadvantages

Monofocal Intraocular Lenses Toric Intraocular Lenses

Patient Selection

Planning and Surgical Technique Outcomes

Complications Specific to Toric IOLs Light-Adjustable Intraocular Lenses Accommodating Intraocular Lenses Multifocal Intraocular Lenses

Patient Selection Surgical Technique Outcomes

Adverse Effects, Complications, and Patient Dissatisfaction with Multifocal IOLs Bioptics

9 Accommodative and Nonaccommodative Treatment of Presbyopia

Introduction

Theories of Accommodation

Nonaccommodative Treatment of Presbyopia

Monovision Conductive Keratoplasty Multifocal IOL Implants

Custom or Multifocal Ablations

Corneal Intrastromal Femtosecond Laser Treatment Corneal Inlays

Accommodative Treatment of Presbyopia Scleral Surgery

Femtosecond Lens Relaxation Accommodating IOLs

Other IOL Innovations on the Horizon

10 Refractive Surgery in Ocular and Systemic Disease

Introduction

Ocular Conditions

Ocular Surface Disease

Herpesvirus Infection

Keratoconus

Post–Penetrating Keratoplasty

Ocular Hypertension and Glaucoma

Retinal Disease

Amblyopia and Strabismus in Adults and Children

Systemic Conditions

Human Immunodeficiency Virus Infection

Diabetes Mellitus

Connective Tissue and Autoimmune Diseases

11 Considerations After Refractive Surgery

IOL Calculations After Refractive Surgery

Eyes With Known Preand Post-Refractive Surgery Data

Eyes With No Preoperative Information

The ASCRS Online Post-Refractive IOL Power Calculator

Retinal Detachment Repair After LASIK

Corneal Transplantation After Refractive Surgery

Contact Lens Use After Refractive Surgery

Indications

General Principles

Contact Lenses After Radial Keratotomy

Contact Lenses After Surface Ablation

Contact Lenses After LASIK

Glaucoma After Refractive Surgery

12 International Perspectives in Refractive Surgery

Introduction

Global Estimates of Refractive Surgery International Trends in Refractive Surgery

International Regulation of Refractive Surgery Practices and Devices

Appendix 1: The Role of the FDA in Refractive Surgery

Appendix 2: Sample Informed Consent Forms

Basic Texts

Related Academy Materials

Requesting Continuing Medical Education Credit

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