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University of Rochester
Clinical Applications of The RochesterNomogram
Scott MacRae MD* Manoj Subbaram PhD,Geun Young Yoon PhD.
*Professor of OphthalmologyProfessor of Visual ScienceCenter for Visual ScienceUniversity of Rochester
University of Rochester
Dr. MacRae is a consultantto Bausch and Lomb
University of Rochester
The Problem – Hyperopic OvercorrectionCustomized LASIK
• Post-Custom LASIK refractive error– Incidence (FDA trial, n = 340 eyes) and range (+/- 2 D)– More over-correction than under-correction (9 X)
20 (5.9%)1 (0.2%)> 1 D
74 (21.8%)8 (2.3%)> 0.5 D
Hyperopia(over-correction)
Myopia(under-correction)
6 months postLASIK SE (D)
University of Rochester
Aberration InteractionCausing HyperopicOvercorrection?
University of Rochester
The Rochester Nomogram
• Unique features– Use of preoperative manifest refraction
• Preop myopia (vector notation: SE, J0, J45)• NOT PPR (wavefront sphere value)
– Derived from analysis on 112 myopic eyestreated by same surgeon with Zyoptix LASIK inFDA trial• Effect of preop HOA on postop refractive error
– Effect of Spherical Aberration– 3rd order aberration– Aberration Interaction
University of Rochester
Aberration Interaction: Preop HOA Influenceon Postop Sphere and Cylinder
trefoil coma coma trefoil
quadrafoil secondary spherical ab.
2nd
3rd
4th
Radialorder
secondary quadrafoil
defocusastigmatism astigmatism
astigmatism astigmatism
Z20Z 2
-2 Z22
Z 3-1 Z3
1Z 3-3 Z3
3
Z40 Z4
2Z 4-2 Z4
4Z 4-4
Lower OrderAberrations
Higher OrderAberrations
University of Rochester
The Rochester Nomogram - Methods
0.53 + 0.160.45 + 0.16Mean Preop HOA (um)
-0.81 + 0.70
(0 to -4.25)
-0.60 + 0.49
(0 to –3.25)
Mean Astigmatism (D)
-4.89 + 2.06
(-1 to –10.25)
-3.41 + 1.44
(-1.25 to –7.50)
Mean preop SE (D)
2.5% NeosynephrineFirst Study(175 eyes)
112 eye FDA StudyParameter
University of Rochester
The Rochester Nomogram:Eliminates Outliers
(N=175)
-0.50
-0.25
0.00
0.25
0.50
0.75
1.00
Sphere SE
Man
ifest
Refr
acti
on
(D
)
Rochester Nomogram
Zyoptix Algorithm
(- 1.04 to(- 1.04 to1.81 D)1.81 D)(+/- 1 D)(+/- 1 D)
-0.11-0.11
0.170.17
0.510.51
0.330.33
0.040.04 0.300.30
0.550.55
0.350.35
University of Rochester
The Rochester Nomogram – Results 0 Outliers > 1.00 D (N=175)
0
5
10
15
20
25
30
35
40
45
93% PPR
Num
ber o
f Eye
s
ROC93% PPR
2 Myopia2 Myopia12 Hyperopia12 Hyperopia
N = 175 eyesN = 175 eyes
SE > 1 DSE > 1 D0.5 < SE < 10.5 < SE < 1DD
10 Myopia10 Myopia5 Hyperopia5 Hyperopia
22.8%22.8%
13 Myopia13 Myopia27 Hyperopia27 Hyperopia
8.6%8.6% 8%8%
00
University of Rochester
The Rochester Nomogram – VA• 93.1% of the eyes had 20/20 or better UCVA• 98.3% of the eyes had 20/20 or better BCVA
University of Rochester
The Rochester Nomogram forPharmacologic vs Non Pharmacologic
Dilated Zyoptix
Scott M. MacRae MDManoj V. Subbaram BS Optom., PhD
Geun Young Yoon PhDUniversity of Rochester
&Ian Cox OD PhD
Bausch and Lomb
University of Rochester
Rochester Nomogram: Pharmacologic vs NonPharmacologic Dilated Zyoptix
• 175 eye 2.5%Neosynephrine DilatedZyoptix
• 90 eye Gulden Black Hood:low mesopic Zywaves
• 6.3 mm pupil diameterminimal (60.7% of eyescould be dilated to 6.3mm)
University of Rochester
Luminance/IlluminationPhotometry Testing
• Tectronics Lumicolor J17 Photometer/Radiometer• Rural Low Light Night Driving 0.15 Candellas/meter_• Zywave Maltese Cross 0.05 Candellas/meter_
(1/3 of night driving illumination)
University of Rochester
Results (ROC nomogram)
-0.63 to +0.50-1 to +1 DRange Sph Eq (D)
-0.08 + 0.23-0.11 + 0.341-month Sph Eq (D)
0.53 + 0.140.53 + 0.16Preop HOA (um)
-0.56 + 0.53-0.81 + 0.70Preop Cyl (D)
-4.11 + 2.04-4.52 + 2.05Preop Sphere (D)
-4.39 + 2.08-4.89 + 2.06Preop Sph Eq (D)
No Neosynephrine (90 eyes)
2.5% Neosynephrine(175 eyes)
Parameter
Standard Deviations of 0.34 or 0.23 D are close Standard Deviations of 0.34 or 0.23 D are close to the SD of manifest refraction repeatabilityto the SD of manifest refraction repeatability
BullimoreBullimore 0.2; 0.2; NizamNizam 0.33 D; 0.33 D; BlackhustBlackhust 0.28 D 0.28 D
University of Rochester
Zyoptix with Rochester Nomogram
Natural mesopicpupil (n = 90)
Pharmacologicaldilation (n =175)
97.8%91.4%71.4%Postop SE < +0.50D
-0.08 + 0.23(-0.63 to +0.50)
-0.11 + 0.34(-1 to +1)
+0.26 + 0.50(-1.04 to +1.81)
Postop SE (D)
94.6%93.1%89.3%Postop UCVA > 20/20
0.53 + 0.140.53 + 0.160.45 + 0.16Preop HOA (um)
-4.39 + 2.08-4.89 + 2.06-3.41 + 1.44Preop SE (D)
Rochester NomogramZyoptix FDA trial(112 eyes)
Parameter
Greater preopMYOPIA & HOA
Better postop VA and SE (both pharmacological dilation &natural mesopic pupil)
University of Rochester
Preop Coma and Postop Astigmatism
0.40 + 0.17 um0.26 + 0.43 umPreop coma
71/175 (40%)104 /175 (60%)Incidence
> 0.50 D< 0.50 DPostop Cyl
p < 0.0001
Ablation Decentration of Coma Induces Astig.
University of Rochester
Postop Astigmatism Risk Factor #2
• Treatment of preoperative Coma– Decentration of Laser ablation induces astigmatism
trefoil coma coma trefoil
defocusastigmatism astigmatismZ20Z 2
-2 Z22
Z 3-1 Z3
1Z 3-3 Z3
3 3rd order
2nd order
University of Rochester
Summary: Customized Ablation withRochester Nomgram
• Aberration Interaction is Important• Zyoptix Refinement: The Rochester Nomogram
– Reduces Outliers: < 1%, 4X’s less likely to have >0.5 D outlier– >93-94% 20/20 or Better Uncorrected Visual Acuity (UCVA) with
or without pharmacologic dilation– Cascade effect of HOA on sphere well compensated
• Further development by refining relationship betweenpreop 3rd order terms and postop astigmatism