Richard L. Lindstrom, MDFounder and Attending Surgeon:

Minnesota Eye ConsultantsAdjunct Clinical Professor Emeritus:

University of Minnesota: Department of OphthalmologyAssociate Director: Minnesota Lions Eye Bank

Board Member: University of Minnesota FoundationVisiting Professor: UC Irvine: Gavin Herbert Eye Institute

Acufocus, Inc. C,I,R

, Abbott Medical Optics, Inc. C,I,, Advanced Refractive Technologies CAlcon Laboratories, Inc.

C, AqueSys C,I Bausch +

Lomb, Inc. C,I,R,

Bio Syntrx C,I Calhoun Vision Inc, C,I Clarity Ophthalmics C,I,

Clear Sight C,I, Confluence Acquisition Partners I, Inc. I, Curveright, LLC I, CXL Ophthalmics, LLC I, EBV Partners C,I, EGG Basket Ventures C,I,

ELENZA, C, Encore C,I

Evision Photography, C,I, Evision Medical Laser , I, Eyemaginations, Inc. C,I

, ForSight, C,

Forsight Vision 6, Inc. C

Foresight Venture Fund #3, C,I, Fziomed I, Glaukos

Corporation C,I

, HEAVEN Fund I, Healthcare Transaction Services

I, High Performance Optics

C,I,

Hoya Surgical Optics C , ISTA, C, Lensar C,I

Lifeguard Health, C,I , Lumineyes, Inc. C , Minnesota Eye Consultants, P.A. C,I

,

NASA –Vision for Mars Program,C

Nicox, C

NuLensC,I

Ocular Surgery News/Slack,c

, Ocular Optics C,I

Ocular Therapeutix, C,I, Oculeve, Inc. C, ,

Omega Eye Health,C,I, Omeros Corp., C

OnPoint, I, Quest C,I.R, Rainwater Healthcare I, Refractec C,I, MD, Revision Optics,I,

Revital Vision C, I,, Schroder Life Science Venture Fund C,1, Sight Path, C, I

3D Vision Systems C,I

, Tearlabs, Inc. C,I, Tracey Technologies C,I

, Transcend

Medical, Inc,C,I

, True Vision, C,I, Versant C

ViradaxI, Vision Solutions Technologies C,I,

*C=Consultant *I= Investor * MD= Medical Director *R= Royalty

THIS PRESENTATION MAY CONTAIN DISCUSSION OF OFF LABEL USE OF FDA APPROVED DRUGS AND/OR DEVICES

“This presentation represents the speaker’s professional experience.”“Products/procedures not approved by the FDA and off label use of FDA approved products/procedures may be discussed.”

Financial Disclosures

Incidence and Prevalence of Presbyopia/Near Vision Dysfunction

• Universal after the age of 45

• 40% of USA population

• 110-120 million people

• 24% myopic (>-1.00)

• 26% hyperopic (>+1.00)

• 50% emmetropic (+0.875 to -0.875)

• 30% also have astigmatism over 1 diopter

A Few Important Concepts:

Accommodation: The eyes dynamic ability to focus under CNS control through a range in power of the eye as the distance to the object being observed varies. (Usually measured in diopters or an accommodative amplitude).

A Few Important Concepts:

Depth of Focus: The range in distance or diopters over which an individual eye or optical system can see specific target (usually 20/40 and J3)

Monovision Blended Vision:

A. Most popular approach to enhance near vision worldwide

B. Gives highest quality of vision.

C. Aspheric IOL’s or custom ablation stabilization preferred by me.

D. Visual target.

1. Distance eye: Plano to -0.50

2. Near eye: -1.25 to -1.75

Multifocal Optics

A. Second most popular approach to enhance near vision with corneal or lens based refractive surgery worldwide.

B. Multifocal Optics can be refractive, diffractive, or a hybrid.

C. Multifocal Optics can be distance dominant, near dominant, or symmetrical.

AcrySof® IQ Monofocal AcrySof® IQ ReSTOR +3 AcrySof® IQ Toric

TECNIS Multifocal Family of IOLsNEW NEW

AT LISA TRI / Toric

Add: 3.33 D / 1.66 D Optic: Aspheric trifocal/ bifocal

diffractive

Material: 25% hydrophilic acrylicwith hydrophobic surface

Filtration: UV blocker

Optic body diameter: 6 mm

Overall diameter: 11 mm

Angulation: -

from +0D to +32D (0.5D steps)

Toric from -10D to +24D (0.5D steps)

Quellen: Herstellerangaben

AT LISA TRI / Toric

Trial Physiol Trifocal IOL

N=40 eyes of 20 patients, 6 months follow-up

Cataract surgery

Alio et al, JRS 2013

TECNIS® Symfony IOL merges two complementary enabling technologies

1. Unique echelette design feature extends the range of continuous vision1

2. Proprietary achromatic technology reduces chromatic aberration for enhanced contrast sensitivity1

1. TECNIS Symfony DFU

TECNIS® Symfony IOL is not FDA approved for use in the US

Elongated Focus

Echelette design feature

Clinically Significant Increased Range of Vision( Depth of Focus)With Reduced Halo and Glare

TECNIS® Symfony IOL delivers:

- Sustained mean visual acuity of 20/20 or better through 1.5 D of defocus

- Full range of functional (20/40 or better) vision through 2.5 D of defocus

- Halo and glare levels comparable to that of a monofocal IOL due to the lack of a distinct second focus, coupled with achromat technology

1. 166 Data on File_Extended Range of Vision IOL 3-Month Study Results (NZ)

1.5 D

Mean VA of 20/20 or better though 1.5 D of defocus

2.5 D

VA of 20/40 or better through 2.5 D of defocus

TECNIS® Symfony IOL is not FDA approved for use in the US

Multifocal LASIK

• Currently there are three general methods for Multifocal LASIK

(No method is FDA approved in the U.S.)

VISX Aspherical Treatment Design(Center-Near)

CustomVue

Multifocal Ablation

CustomVue + Multifocal

+2.00+0.50x125

INTRACOR Post-Op Photos (same eye)

a) 30 min

b) 1 day

Intracorneal Inlays for Enhanced Near

Vision

AcuFocus KAMRA inlay reduces aperture size and increases depth of field. The inlay harnesses useful light and allows only focused rays to reach the retina through an uninterrupted pathway.

Presbia Flexivue Microlens and Neoptics Icolens are multifocal optics. The outer zone on both inlays provides near vision and the central zone has a neutral power to provide distance vision. Both inlays come in a range of powers to address the progression of near vision dysfunction over time.

ReVision Optics (RVO) Raindrop Near Vision Inlay increases the steepness of the cornea centrally to provide near vision.

Current Corneal Inlays

Small Aperture Inlay

1.6mm Aperture

5 μm thick

Made from Polyvinylidene

Fluoride (PVDF)

8,400 holes (5-11 μm)

Inlay matches corneal curvature

3.8mm Diam

Inlay DesignPresbyo

pia

With Inlay

Inlay

Lens cannot

accommodate

Depth of Focus

Inlay in vivoImage courtesy of Dr. Minoru TomitaShinagawa LASIK Center

RVO: Raindrop Near Vision Inlay

Stromal Cushion100 µm

• Design:– A 2mm hydrogel inlay– Create a multifocal cornea– Proprietary hydrogel is

permeable allowing for nutrient flow through the inlay

• Surgical Procedure:– Implanted ~150 microns deep– Under a corneal flap

• Method of Action:– Central 2mm provides near

vision – Results in a 2-3mm central

corneal steepening– Peripheral cornea provides

distance– Transition zone provides

intermediate vision• Patient Candidates:

– Emmetropes

Presbia: Flexivue Microlens

Design: Disc shape bifocal inlay with

refractive power Central 0.15mm hole for

nutrient flow

Surgical Procedure: Implanted 280-300 microns

deep Inserted into a pocket

Method of Action: Central zone provides

distance vision Peripheral zone provides

near Peripheral corneal also

provides distance vision

Patient Candidates: Ametropes between -1.00D

to +1.50D

Thickness*: 15 µm Diameter: 3.2 mm

Peripheral zone with refractive

power: +1.5 D to +3.5 D

Central zone

without refractive

power*Thickness varies based on power

Neoptics: Icolens Design:

Disc shape bifocal inlay with refractive power

Central 0.15mm hole for nutrient flow

Surgical Procedure:

Inserted into a pocket

Inlay preloaded into an inserter

Method of Action:

Central zone provides distance vision

Peripheral zone provides near

Peripheral corneal also provides distance vision

Patient Candidates:

Ametropes between -1.00D to +1.50D

Inlay

Accommodating IOL’s

A. Third most common approach to lens based refractive surgery to enhance intermediate and near vision.

B. The mechanism of action of accommodating IOL’s, like normal accommodation, is multifactorial and includes increased depth of focus benefits of pseudo-accommodation and accommodation.

C. Quality of vision issues are significantly less than in a multifocal IOL, but slightly greater than with an aspheric monofocal IOL.

(ARMD, glaucoma, previous refractive surgery, etc are therefore less of an issue.)

Built on an Innovative Platform

Crystalens® AOOct 2009

AT-45/AT-45SENov 2003

AT-Five-0Nov 2006

AT-HDJuly 2008

TRULIGN™

Toric IOLMay 2013 o

o

FluidVision Lens Design

6.0 mm optic diameter

10.0 mm overall diameter

Haptic height 3.0 mm

RI = 1.48

The optic is suspended between the haptics

Thought on the Future

A. Monovision/blended vision will remain an attractive option.

B. Multifocal development is maturing and growth in use will continue for several years and then plateau. (2020)

C. Accommodating IOL development is less mature than multifocal, but advancing steadily and may eventually dominate. ( 2020)

D. By 2020 Accommodating IOL’s or those that increase depth of focus will become more popular, but not completely replace monovision and multifocal optics.

Thank you for your attention