STAR S4 IR Excimer Laser System and iDesign Advanced WaveScan Studio System

{0} # SUMMARY OF SAFETY AND EFFECTIVENESS DATA (SSED) ## I. GENERAL INFORMATION | Device Generic Name: | Ophthalmic Excimer Laser System Ophthalmic Refractometer | | --- | --- | | Device Trade Name: | *iDESIGN® Advanced WaveScan Studio* System *STAR S4 IR®* Excimer Laser System | | Device Procode: | LZS | | Applicant's Name and Address: | AMO Manufacturing USA, LLC. 510 Cottonwood Drive Milpitas, CA 95035 | | Date of Panel Recommendation: | None | | Premarket Approval Application (PMA) Number: | P930016/S048 | | Date of FDA Notice of Approval: | June 30, 2017 | The *iDESIGN® Advanced WaveScan Studio* System was approved with the *STAR S4 IR®* Excimer Laser System for wavefront-guided LASIK for the correction of myopic refractive errors on May 6, 2015, in P930016/S044 and on November 14, 2016, in P930016/S045, for the correction of mixed astigmatic refractive errors. This Panel-Track Supplement P930016/S048 expands the indication for use to include wavefront-guided LASIK in patients with hyperopia, with and without astigmatism. The updated clinical data to support the expanded indication is provided in this summary. ## II. INDICATIONS FOR USE The *STAR S4 IR®* Excimer Laser System and *iDESIGN® Advanced WaveScan Studio* System is indicated for wavefront-guided laser assisted in situ keratomileusis (LASIK) in patients: - with hyperopia with and without astigmatism as measured by *iDESIGN® Advanced WaveScan Studio®* System up to +4.00 D spherical equivalent, with up to 2.00 D cylinder - with agreement between manifest refraction (adjusted for optical infinity) and *iDESIGN® Advanced WaveScan Studio®* System refraction as follows: - Spherical Equivalent: Magnitude of the difference is less than 0.625 D - Cylinder: Magnitude of the difference is less than or equal to 0.5 D PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 1 {1} • 18 years of age or older, and • with refractive stability (a change of ≤1.0 D in sphere or cylinder for a minimum of 12 months prior to surgery). ### III. CONTRAINDICATIONS The device is contraindicated: • in patients with collagen vascular, autoimmune, or immunodeficiency diseases. • in pregnant or nursing women. • in patients with corneal abnormalities including signs of keratoconus, abnormal corneal topography, epithelial basement membrane disease (EBMD) and degenerations of the structure of the cornea. • in patients with symptoms of significant dry eyes. If the patients have severely dry eyes, LASIK may increase the dryness. This may or may not go away. Severe eye dryness may delay healing of the flap or interfere with the surface of the eye after surgery. It may result in poor vision after LASIK. • in patients whose corneal thickness would cause anticipated treatment would violate the posterior 250 microns (μm) of corneal stroma. • in patients with advanced glaucoma. • in patients with uncontrolled diabetes. ### IV. WARNINGS AND PRECAUTIONS The warnings and precautions can be found in the STAR S4 IR® Excimer Laser System and iDESIGN® Advanced WaveScan (AWS) Studio System labeling. ### V. DEVICE DESCRIPTION A. iDESIGN® AWS Studio System The iDESIGN® AWS Studio System incorporates wavefront aberrometry, auto-refractometry, corneal topography, keratometry, and pupillometry. The System measures the refractive error and wavefront aberrations of the human eye using a high-definition Hartmann-Shackwavefront sensor. The measurements can be used to determine regular (sphero-cylindrical) refractive errors and irregularities (aberrations) that may cause decreased or blurry vision in the human eye. The function of the Hartmann-Shack sensor is to measure the refractive error of the eye by evaluating the deflection of rays emanating from a small beam of light projected onto the retina and reflected back to the sensor off of the retina. To control the natural PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 2 {2} accommodation of the eye during iDESIGN® AWS Studio system imaging, the system incorporates a fogged fixation target. The iDESIGN® AWS Studio System optical head projects a beam of light onto the retina. The light reflects back through the optical path of the eye and into the wavefront device. The reflected beam is imaged by a lenslet array onto the charge-coupled device (CCD). Each lens of the array gathers light information (deflection information) from a different region of the pupil to form an image of the light that passes through that region of the pupil. An array of spots is imaged on the CCD sensor. The system compares the locations of the array of spots gathered from the CCD to the theoretical ideal (the ideal plane wave). The iDESIGN® AWS System software uses these data to compute the eye's refractive errors and wavefront aberrations using Fourier Transform analysis. The system displays the refractive errors and wavefront aberrations as the optical path difference (OPD) between the measured outgoing wavefront and the ideal plane wave. The iDESIGN® AWS System software subtracts the refractive errors from the wavefront errors map and displays the higher order aberrations as OPD errors. Regions of the pupil with positive OPD are in front of the ideal plane wave and areas with negative OPD are behind the ideal plane wave. The target treatment shape is automatically calculated by the iDESIGN® AWS System from the wavefront data. Once the target shape is established, the software generates the commands for the laser to create the target shape on the cornea. Corneal geometry, represented by the keratometry values, is taken into account in computing the laser instructions. Advanced CustomVue ablations for hyperopia with and without astigmatism are approved for an optical zone of 6.0 mm, and an ablation zone of 9.0 mm. No treatments with a minimum optical zone greater than 6.0 mm were attempted in the U.S. Clinical Trial. The maximum iDESIGN® AWS System pupil size for treatment is 9.5 mm. All treatments utilized a variable repetition rate to a maximum of 20 Hz. Advanced CustomVue ablations for this PMA are locked out by the AMO Treatment Card above 6.0 D spherical equivalent and above 4.0 D cylinder as measured by iDESIGN® AWS System. The final commercial release versions for Advanced CustomVue are iDESIGN® AWS System software version 1.3 and STAR S4 IR® software version 5.32. The iDESIGN® AWS System software is capable of calculating hyperopia treatments with an optical zone up to 6.5 mm with total ablation zone up to 9.5 mm. # B. STAR S4 IR® Excimer Laser System The STAR S4 IR® Laser System is a 193 nm excimer laser system that delivers spatially scanning ultraviolet pulses of variable shape and size on to the cornea. Pulse shapes may be circles of variable diameter or slits of variable width and orientation. The range of diameters and slit widths available during treatments is 0.65 mm to 6.5 mm. An auto-centering dual camera infrared eye tracking system (ActiveTrak), together with the PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 3 {3} delivery system, aligns the treatment to the eye, and compensates for eye movements during laser correction to maximize the corneal reshaping accuracy. An operating microscope is used to observe the patient procedures and to facilitate accurate focus and laser beam alignment. A debris- removal system is designed to evacuate the debris plume that occurs during ablation. The operating chair and fixation LED align the patient, while a video camera and monitor records the patient treatment. The variable spot scanning (VSS) feature of the laser, used for Advanced CustomVue treatments delivers variable diameter ultraviolet pulses to precise locations by the scanning delivery system. The VSS algorithm optimizes the ablation pattern by choosing the best combination of beam diameters and locations to achieve a target shape. Wavefront-guided treatments using the STAR S4 IR® and iDESIGN® AWS and WaveScan WaveFront Systems utilize an automated iris registration system. The angle of rotation of the patient's eye under the laser is determined by comparing features of the iris on the aberrometer image to the same features located in the image of the iris taken using the STAR S4 IR® camera. Features and components of the STAR S4 IR® System include: - Excimer Laser - Gas Management System - Laser Beam Delivery System - Patient Management System - Computer Control - Treatment Card PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 4 {4} ### C. Microkeratome The *Advanced CustomVue* procedure required the use of a commercially available keratome that has been cleared for marketing via premarket notification. The keratomes used in this study consisted of femtosecond ophthalmic surgical lasers that create a LASIK flap through precise individual microphotodisruptions of tissue, created by tightly focused ultrashort pulses which are delivered through a disposable applanation lens while fixating the eye under very low vacuum. ## VI. ALTERNATIVE PRACTICES AND PROCEDURES There are several other alternatives for the correction of hyperopia. Alternative methods of correcting of visual correction include: glasses, contact lenses, conventional LASIK, PRK and incisional cornea surgeries. Each alternative has its own advantages and disadvantages. A patient should fully discuss these alternatives with his/her physician to select the method that best meets expectations and lifestyle. ## VII. MARKETING HISTORY The *iDESIGN® AWS* System is currently approved in the United States for wavefront-guided LASIK in patients with myopia and mixed astigmatism. The *iDESIGN® AWS* System is marketed in approximately 40 countries including; Algeria, Australia, Austria, Belgium, Brazil, Bulgaria, Canada, Chile, Colombia, Czech Republic, Denmark, Egypt, Finland, France, Germany, Great Britain, India, Indonesia, Iraq, Ireland, Italy, Japan, Jordan, Malaysia, Mexico, the Netherlands, New Zealand, Poland, Qatar, Singapore, Saudi Arabia, South Africa, South Korea, Spain, Taiwan, Tunisia, Turkey, United Arab Emirates and Yemen. The *STAR S4 IR®* Excimer Laser System is on market in 70 countries. Neither device has been withdrawn from any country or market for reasons of safety or effectiveness. ## VIII. POTENTIAL ADVERSE EFFECTS OF THE DEVICE ON HEALTH Below is a list of the potential adverse effects (e.g., complications) associated with the use of the device. Potential adverse reactions associated with LASIK include: loss of best spectacle corrected visual acuity (BSCVA), worsening of patient complaints such as double vision, sensitivity to bright lights, increased difficulty with night vision, fluctuations in vision, increase in intraocular pressure, corneal haze, secondary surgical intervention, corneal infiltrate or ulcer, corneal epithelial defect, corneal edema, problems associated with the flap including a lost, misplaced or misaligned flap, retinal detachment, and retinal vascular accidents. For the specific adverse events that occurred in the clinical study, please see Section X below. PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 5 {5} ## IX. SUMMARY OF NONCLINICAL STUDIES For a summary of the nonclinical studies, please refer to the SSED of the original PMA P930016 (http://www.accessdata.fda.gov/cdrh_docs/pdf/p930016.pdf) and P930016/S44 (http://www.accessdata.fda.gov/cdrh_docs/pdf/P930016S044b.pdf). ## X. SUMMARY OF PRIMARY CLINICAL STUDY The applicant performed a clinical study to establish a reasonable assurance of safety and effectiveness of Wavefront-guided LASIK Correction of Hyperopic Refractive Errors with the iDESIGN® AWS System and STAR S4 IR® Excimer Laser System in the US under IDE # G120164. Data from this clinical study were the basis for the PMA approval decision. A summary of the clinical study is presented below. ### A. Study Design Subjects were treated between December 2012 and November 2014. The database for this Panel Track Supplement reflected data collected through March 24, 2016 and included 135 eyes (of 69 subjects). There were 8 investigational sites. As refractive stability was reached at 12 months (and confirmed at 24 months), the key safety and effectiveness endpoints are evaluated at 12 months, and will be considered the critical time point for analysis for the PMA supplement submission. The study was a 2-year, prospective, multi-center, open-label, non-randomized clinical study. Descriptive statistics (including sample size (n), mean, standard deviation (SD), minimum, maximum, as appropriate) and frequency distributions were used to summarize clinical outcomes. Statistical tests and resulting p-values were reported as two-sided and assessed at a 0.05 significance level. For analysis of refractive outcomes, the sphere component of the manifest refraction (as tested at 4.0 m) was adjusted for optical infinity by adding -0.25 D to the sphere magnitude. Similarly, manifest refraction spherical equivalent (MRSE) was calculated using the adjusted manifest sphere value. Additionally, all refractions were converted to plus cylinder format and adjusted for vertex distance (12.5 mm). #### 1. Clinical Inclusion and Exclusion Criteria Enrollment in the STAR-111-IDHP study was limited to patients who met the following inclusion criteria. Subjects who agreed to participate provided informed consent and underwent the required screening procedures to determine eligibility. To qualify for enrollment, subjects were to meet all eligibility criteria for each eye. In general, eyes were to be healthy with iDESIGN® AWS System measured hyperopia with and without astigmatism with spherical equivalent up to +6.00D with cylinder between 0.00 and +4.00 D cylinder. PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 6 {6} # Subject Inclusion Criteria - At least 18 years of age and give written informed consent. - The refractive error, based on the iDESIGN® System displayed refraction selected for treatment ("4.0 Rx calc" at 12.5 mm) must be hyperopia with or without astigmatism with a maximum spherical equivalent of +6.00 D and cylinder between 0.00 and +4.00 D. - Anticipated postoperative stromal bed thickness of at least 250 microns. - BSCVA of 20/20 or better. - Difficulty maintaining Uncorrected Visual Acuity (UCVA) of 20/40 as evidenced by the need for constant contact lens or spectacle wear. - Less than or equal to 0.75 D difference between cycloplegic and manifest refraction sphere. - A stable refractive error over the last 12 months as defined by a change of ≤1.00 D in sphere or cylinder. - Demonstration of refractive stability for subjects who wear contact lenses: rigid or toric lenses must be removed for at least 3 weeks and soft contact lenses for at least 1 week prior to the first refraction to establish stability. - Agreement between manifest refraction (adjusted for optical infinity) and iDESIGN® AWS System refraction chosen for treatment Patients were not permitted to enroll in the STAR-111-IDHP study if they met any of the following exclusion criteria: - Women who are pregnant, breast-feeding, or intend to become pregnant over the course of the study, as determined by verbal inquiry. - Concurrent use of systemic (including inhaled) medications that may impair healing (e.g., corticosteroids). - History of any of the following medical conditions, or any other condition that could affect wound healing: collagen vascular disease, autoimmune disease, immunodeficiency diseases, ocular herpes zoster or herpes simplex, endocrine disorders (including, but not limited to, unstable thyroid disorders and diabetes), lupus, rheumatoid arthritis, and diabetes (regardless of type, duration, severity or control). - Subjects with a cardiac pacemaker, implanted defibrillator or other implanted electronic device. - History of prior intraocular or corneal surgery (including cataract extraction), active ophthalmic disease or abnormality (including, but not limited to, symptomatic blepharitis, recurrent corneal erosion, dry eye syndrome, neovascularization > 1 mm from limbus), retinal detachment/repair, clinically significant lens opacity, clinical evidence of trauma, corneal opacity within the central 9 mm and visible on topography, at risk for developing strabismus, or with evidence of glaucoma or propensity for narrow angle glaucoma. - Evidence of keratoconus, corneal dystrophy or irregularity, or abnormal topography. PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 7 {7} 2. Follow-up Schedule All patients were scheduled to return for follow-up examinations as follows: # Clinical Study Visit Schedule | EXAM | VISIT WINDOW | | --- | --- | | Preoperative Evaluation | | | Operative | 1-120 days following preoperative exam | | 1 Day Postoperative Exam | 12-26 hours postoperative | | 1 Week Postoperative Exam | 5-9 days postoperative | | 1 Month Periodic Exam | 3-5 weeks postoperative | | 3 Months Periodic Exam | 10-14 weeks postoperative | | 6 Months Periodic Exam | 21-26 weeks postoperative | | 9 Months Periodic Exam | 35-43 weeks postoperative | | 12 Months Periodic Exam | 11-14 months postoperative | | 24 Months Periodic Exam | 23-27 months postoperative | Study procedures included uncorrected distance visual acuity, best spectacle corrected distance visual acuity, contrast sensitivity, manifest refraction, cycloplegic refraction, keratometry, intraocular pressure, corneal pachymetry, corneal topography, iDESIGN® AWS System measurements, slit-lamp evaluation of the anterior segment, subjective questionnaires, and determination of adverse events (AEs) and complications. Treatment plans were based on preoperative iDESIGN® AWS System measurements and all eyes were targeted for emmetropia. Preoperatively, study procedures included: - Directed symptom assessment (monocular assessment) - The National Eye Institute-Refractive Error Quality of Life instrument (NEI-RQL-42) subjective questionnaire (binocular assessment) - iDesign system measurement (refraction, aberrometry, topography, keratometry, pupillometry) - Distance UCVA - Manifest refraction - Distance BSCVA - Auto or manual keratometry - Corneal topography - Contrast sensitivity - Anterior segment examination - Applanation tonometry - Pachymetry (ultrasound) - Cycloplegic refraction - Dilated fundus examination PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 8 {8} Postoperatively, the objective parameters measured during the study included: - Directed symptom assessment - UCVA - Manifest refraction - BSCVA (1 week only) - Anterior segment examination - NEI-RQL-42 subjective questionnaire (at 3-, 6-, 12-, and 24-month exams) - iDESIGN System measurement (refraction, aberrometry, topography, keratometry, pupillometry) - Distance UCVA - BSCVA (if ≥2 line loss in BSCVA at 3 months or later, a rigid contact lens over refraction or pin-hole visual acuity should be obtained) - Auto or manual keratometry - Corneal topography - Contrast sensitivity (at 3-, 6-, 12-, and 24-month exams) - Anterior segment examination - Applanation tonometry - Pachymetry (ultrasound) (at 6-month exam only) - Cycloplegic refraction (at 6-, 12-, and 24-month exams) - Dilated fundus examination (at 6-, 12-, and 24-month exams) AEs and complications were recorded at all visits. The key timepoints are shown below in the tables summarizing safety and effectiveness. ### 3. Clinical Endpoints With regards to safety, the key endpoint targets, evaluated at the time of refractive stability, are: a) PRIMARY: <5% of eyes with a loss of >2 lines of BSCVA b) <1% of eyes with a BSCVA of 20/20 or better preoperatively that have a BSCVA of worse than 20/40 (Note: All eyes had to have BSCVA of 20/20 or better for study inclusion.) c) <5% of eyes with induced manifest refractive astigmatism >2.00 diopters (D) d) <1% of eyes with an AE (serious, non-flap related) With regards to effectiveness, the key endpoint targets, evaluated at the time of refractive stability, are: PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 9 {9} a) PRIMARY: 85% of eyes with an UCVA of 20/40 or better b) 50% of eyes with a MRSE within 0.50 D of intended correction c) 75% of eyes with an MRSE within 1.00 D of intended correction d) 95% of eyes achieve refractive stability Other endpoints included contrast sensitivity, higher order aberrations, complications, visual symptoms, visual functioning and well-being, keratometric analyses, and vector and non-vector analyses of manifest refractive cylinder. The key outcome variables were assessed postoperatively at the periodic exams. Refractive stability was achieved at 12 months and confirmed at the 24 month visit; therefore, the key safety and effectiveness study endpoints were evaluated at 12 months as the primary study analysis. ### B. Accountability of PMA Cohort At the time of database lock, of 69 patients enrolled in the PMA study, 97% (131/135) patients are available for analysis at the completion of the study, the 12-month visit post-operative visit. 88 eyes (65.2%; 88/135) completed the 24-month exam. The majority of subjects were bilaterally treated; 66 subjects (95.7%; 66/69) had both eyes treated, and three subjects (4.3;3/69) had a single eye treated. Table 1 presents the accountability to date for the 135 eyes treated in this study. PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 10 {10} **Accountability of All Hyperopic Eyes (N=135)** | Subject Status | 1 day | | 1 week | | 1 month | | 3 months | | 6 months | | 9 months | | 12 months | | 24 months | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | n | % | n | % | n | % | n | % | n | % | n | % | n | % | n | % | | **Available for Analysis** | 135 | 100 | 135 | 100 | 134 | 99.3 | 135 | 100 | 134 | 99.3 | 130 | 96.3 | 131 | 97.0 | 88 | 65.2 | | - In Interval - (included in - analysis) | 135 | 100 | 133 | 98.5 | 130 | 96.3 | 135 | 100 | 134 | 99.3 | 128 | 94.8 | 124 | 91.9 | 88 | 65.2 | | - Out of Interval - (included in - analysis) | 0 | 0.0 | 2 | 1.5 | 4 | 3.0 | 0 | 0.0 | 0 | 0.0 | 2 | 1.5 | 7 | 5.2 | 0 | 0.0 | | **Missing** | 0 | 0.0 | 0 | 0.0 | 1 | 0.7 | 0 | 0.0 | 1 | 0.7 | 5 | 3.7 | 4 | 3.0 | 19 | 14.1 | | - Discontinued | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 1* | 0.7 | 2* | 1.5 | | - Missed visit | 0 | 0.0 | 0 | 0.0 | 1 | 0.7 | 0 | 0.0 | 1 | 0.7 | 4 | 3.0 | 2 | 1.5 | 0 | 0.0 | | - Not seen but - accounted for | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | | - Lost-to- - follow-up | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 1 | 0.7 | 1 | 0.7 | 17 | 12.6 | | **Active** | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 28 | 20.7 | | - Active (not - yet in visit interval) | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 12 | 8.9 | | - In interval or - past interval (form - not yet received) | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 16 | 11.9 | | Percent Accountability* (ANSI Z80.11-2012) | | | 100% | | 100% | | 99.3% | | 100% | | 99.3% | | 96.3% | | 97.8% | 83.8% | | *Percent Accountability = (Available for Analyses x 100) / (Enrolled [treated] – Discontinued – Active) | | | | | | | | | | | | | | | | | | * A total of two eyes were retreated with the *iDESIGN*® System during the study and are considered discontinued from the original-treatment study following retreatment. Both eyes were followed through 12 months after retreatment in accordance with the protocol. | | | | | | | | | | | | | | | | | ### C. Study Population Demographics and Baseline Parameters The demographics of the study population are typical for a hyperopic study performed in the US. Subject demographics are presented in **Table 2**. The mean age was 42.7 years (SD 11.8 years) and the majority of subjects were Caucasian (84.1; 58/69). There were approximately equal numbers of males (49.3%; 34/69) and females (50.7%; 35/69). Most subjects (72.5%; 50/69) did not wear contact lenses preoperatively. PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 11 {11} **Demographic Characteristics** | Category | Classification | All Subjects (n=69) | | --- | --- | --- | | Gender | Male | 34 (49.3%) | | | Female | 35 (50.7%) | | Race | Caucasian | 58 (84.1%) | | | Black/African Descent | 4 (5.8%) | | | Native American/Inuit | 0 (0.0%) | | | Asian | 1 (1.4%) | | | Pacific Islander | 0 (0.0%) | | | Other^{a} | 6 (8.7%) | | Age (Years) | Mean | 42.7 | | | SD | 11.8 | | | Min | 19 | | | Max | 62 | | Contact Lens History | No | 50 (72.5%) | | | Soft | 14 (20.3%) | | | Rigid/Toric | 5 (7.2%) | $^{a}$ Other race includes Indian and Hispanic. **Table 3** presents the mean preoperative manifest and *iDESIGN$^{®}$ AWS Studio* System measured refractive error for the 135 treated eyes. Mean preoperative refractive measurements were comparable between manifest refraction and *iDESIGN$^{®}$ AWS Studio* System refraction. **Mean Preoperative Manifest and *iDESIGN$^{®}$ AWS* Refractive Errors in Diopters, All Hyperopic Eyes (N=135)** | Refractive Variable | Mean | Std Dev | Median | Min | Max | | --- | --- | --- | --- | --- | --- | | Manifest Refraction Spherical Equivalent (MRSE) | 2.66 | 1.23 | 2.38 | 0.38 | 5.38 | | Manifest Refractive Cylinder (MRC) | 1.00 | 0.91 | 0.50 | 0.00 | 3.75 | | *iDESIGN^{®}* Spherical Equivalent (IDSE) | 2.91 | 1.31 | 2.58 | 0.53 | 5.81 | | *iDESIGN^{®}* Refractive Cylinder (IDC) | 1.01 | 0.89 | 0.69 | 0.08 | 3.89 | **Tables 4 and 5** present the preoperative refractive error bin distributions for the study population based on preoperative *iDESIGN$^{®}$ AWS Studio* System measurements. PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 12 {12} **Preoperative Refractive Error Stratified by *iDESIGN*$^{®}$ AWS Sphere and Cylinder. All Hyperopic Eyes (N=135)** | *iDESIGN*^{®} Sphere | *iDESIGN*^{®} Cylinder | | | | | | Total n % | | --- | --- | --- | --- | --- | --- | --- | --- | | | >0 to ≤0.5 D | >0.5 to ≤1 D | >1 to ≤2 D | >2 to ≤3 D | >3 to ≤4 D | | | | | n % | n % | n % | n % | n % | n % | | | **0 to +1 D** | 3 2.2% | 5 3.7% | 3 2.2% | 4 3.0% | 5 3.7% | | 20 14.8% | | **>+1 to +2 D** | 11 8.1% | 15 11.1% | 9 6.7% | 2 1.5% | 2 1.5% | | 39 28.9% | | **>+2 to +3 D** | 18 13.3% | 8 5.9% | 2 1.5% | 1 0.7% | 2 1.5% | | 31 23.0% | | **>+3 to +4 D** | 4 3.0% | 10 7.4% | 7 5.2% | 3 2.2% | 1 0.7% | | 25 18.5% | | **>+4 to +5 D** | 7 5.2% | 6 4.4% | 2 1.5% | 0 0.0% | 0 0.0% | | 15 11.1% | | **>+5 to +6 D** | 3 2.2% | 2 1.5% | 0 0.0% | 0 0.0% | 0 0.0% | | 5 3.7% | | **Total** | **46 34.1%** | **46 34.1%** | **23 17.0%** | **10 7.4%** | **10 7.4%** | | **135 100%** | % Percentage is calculated by dividing the total number of eyes in the bin (n)/ by the total number of eyes N(135) **Preoperative Refractive Error Stratified by *iDESIGN*$^{®}$ AWS Spherical Equivalent (SE), and Cylinder, All Hyperopic Eyes (N=135)** | *iDESIGN*^{®} Spherical Equivalent | *iDESIGN*^{®} Cylinder | | | | | | Total n % | | --- | --- | --- | --- | --- | --- | --- | --- | | | >0 to ≤0.5 D | >0.5 to ≤1 D | >1 to ≤2 D | >2 to ≤3 D | >3 to ≤4 D | | | | | n % | n % | n % | n % | n % | n % | | | **0 to +1 D** | 1 0.7% | 2 1.5% | 1 0.7% | 0 0.0% | 0 0.0% | | 4 3.0% | | **>+1 to +2 D** | 11 8.1% | 15 11.1% | 5 3.7% | 3 2.2% | 2 1.5% | | 36 26.7% | | **>+2 to +3 D** | 19 14.1% | 9 6.7% | 6 4.4% | 1 0.7% | 4 3.0% | | 39 28.9% | | **>+3 to +4 D** | 5 3.7% | 11 8.1% | 2 1.5% | 2 1.5% | 2 1.5% | | 22 16.3% | | **>+4 to +5 D** | 4 3.0% | 5 3.7% | 8 5.9% | 4 3.0% | 2 1.5% | | 23 17.0% | | **>+5 to +6 D** | 6 4.4% | 4 3.0% | 1 0.7% | 0 0.0% | 0 0.0% | | 11 8.1% | | **Total** | **46 34.1%** | **46 34.1%** | **23 17.0%** | **10 7.4%** | **10 7.4%** | | **135 100%** | % Percentage is calculated by dividing the total number of eyes in the bin (n)/ by the total number of eyes N(135) PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 13 {13} # **D. Safety and Effectiveness Results** As refractive stability was achieved at 12 months, and confirmed at 24 months, the key safety and effectiveness study endpoints were evaluated at 12 months for all treated eyes (N = 135). # 1. Safety Results The analysis of safety was based on the safety cohort of 135 subject eyes available for the 12 month evaluation. The key safety outcomes for this study are presented below in Tables 6 to 12. Adverse effects are reported in Table 8. a) Less than 5% of eyes with a loss of >2 lines BSCVA: At 12 months, 2/131 eyes (1.5%) lost >2 lines of BSCVA, meeting the safety criterion of <5% of eyes with a loss of >2 lines of BSCVA. b) Less than 1% of eyes with a BSCVA of 20/20 or better preoperatively that have a BSCVA of worse than 20/40: No eyes (0%; 0/131) had preoperative BSCVA of 20/20 or better but worse than 20/40 postoperatively at 12 months, meeting the safety endpoint target of <1% of eyes with preoperative BSCVA of 20/20 or better having BSCVA worse than 20/40 postoperatively. c) Less than 5% of eyes with induced manifest refractive astigmatism >2.00 diopters: At 12 months, no eyes (0%; 0/131) had induced manifest refractive astigmatism >2.00 D, meeting the safety criterion of <5% of eyes with induced manifest refractive astigmatism >2.00 D. d) Less than 1% of eyes with AEs (serious, non-flap related): The serious, non-flap related AE target rate was <1% per type. Two eyes experienced serious AEs of different types. PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 14 {14} **Key Safety Variables Over Time All Hyperopic Eyes (N=135)** | Safety Variable | 1 week (n=135) | | 1 Month (n=134) | | 3 Months (n=135) | | 6 Months (n=134) | | 9 Months (n=130) | | 12 Months (n=131) | | 24 Months (n=88) | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | n | % | n | % | n | % | n | % | n | % | n | % | n | % | | Loss of > 2 lines BSCVA^{a} | 6 | 4.4% | 0 | 0.0% | 1 | 0.7% | 2 | 1.5% | 1 | 0.8% | 2 | 1.5% | 0 | 0.0% | | Loss of ≥ 2 lines BSCVA | 20 | 14.8% | 3 | 2.2% | 2 | 1.5% | 4 | 3.0% | 3 | 2.3% | 4 | 3.1% | 0 | 0.0% | | BSCVA worse than 20/25 | 8 | 5.9% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 1 | 0.8% | 0 | 0.0% | | BSCVA worse than 20/40^{b} | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | | Induced Manifest Cylinder >2.0 D^{c} | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 1 | 0.7% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | | Serious, non-flap related AE^{d} | 0 | 0.0% | 0 | 0.0% | 1 | 0.7% | 0 | 0.0% | 0 | 0.0% | 1 | 0.8% | 0 | 0.0% | $^{a}$ **Safety endpoint target:** <5% of eyes with loss of >2 lines BSCVA vs. preoperative $^{b}$ **Safety endpoint target:** <1% of eyes with BSCVA of 20/20 or better preoperative have BSCVA of worse than 20/40 postoperative. All eyes had preoperative BSCVA of 20/20 or better. $^{c}$ **Safety endpoint target:** <5% of eyes with induced manifest refractive astigmatism >2.00 D $^{d}$ **Safety endpoint target:** <1% of eyes with an adverse event (serious, non-flap related) by type (1 eye experienced loss of BSCVA > 2 or more lines at 3 months not caused by irregular astigmatism, and 1 eye experienced severe glare and cataract at an unscheduled visit following the 12 month exam) % Percentage is calculated by dividing the number of eyes in the cell / by the total number of eyes per time period. # e) *BSCVA Preservation* **Table 7** shows that 97% of the pateints in the clinical study saw 20/20 or better with glasses at 12 months after treatment. **Table 7. Change of Visual Acuity After Treatment** | Visual Acuity | 1 Month (n=134) | 3 Months (n=135) | 6 Months (n=134) | 9 Months (n=130) | 12 Months (n=131) | 24 Months (n=88) | | --- | --- | --- | --- | --- | --- | --- | | 20/12.5 or better | 10% | 13% | 13% | 15% | 11% | 13% | | 20/16 or better | 50% | 56% | 57% | 62% | 58% | 53% | | 20/20 or better | 88% | 91% | 96% | 99% | 97% | 98% | | 20/25 or better | 100% | 100% | 100% | 100% | 99% | 100% | The change in lines of BSCVA postoperatively compared to preoperatively for all hyperopic eyes is presented in **Table 8**. At 12 months, 79.4% (104/131) of eyes had either no change or an improvement in BSCVA compared to preoperative. Two eyes (1.5%; 2/131) had a decrease in BSCVA of >2 lines, which met the primary endpoint safety target of <5% of eyes with a loss of >2 lines of BSCVA. PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 15 {15} **TABLE 8. Change in BSCVA Over Time vs. Preoperative | Acuity | 1 Week (n=135) | | 1 Month (n=134) | | 3 Months (n=135) | | 6 Months (n=134) | | 9 Months (n=130) | | 12 Months (n=131) | | 24 Months (n=88) | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | n | % | n | % | n | % | n | % | n | % | n | % | n | % | | Decrease =4 lines | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 1 | 0.8% | 0 | 0.0% | | Decrease =3 lines | 6 | 4.4% | 0 | 0.0% | 1 | 0.7% | 2 | 1.5% | 1 | 0.8% | 1 | 0.8% | 0 | 0.0% | | Decrease =2 lines | 14 | 10.4% | 3 | 2.2% | 1 | 0.7% | 2 | 1.5% | 2 | 1.5% | 2 | 1.5% | 0 | 0.0% | | Decrease =1 line | 40 | 29.6% | 43 | 32.1% | 37 | 27.4% | 23 | 17.2% | 22 | 16.9% | 23 | 17.6% | 18 | 20.5% | | No Change | 65 | 48.1% | 67 | 50.0% | 66 | 48.9% | 78 | 58.2% | 69 | 53.1% | 74 | 56.5% | 48 | 54.5% | | Increase =1 line | 10 | 7.4% | 19 | 14.2% | 28 | 20.7% | 27 | 20.1% | 34 | 26.2% | 27 | 20.6% | 19 | 21.6% | | Increase =2 lines | 0 | 0.0% | 2 | 1.5% | 2 | 1.5% | 2 | 1.5% | 2 | 1.5% | 3 | 2.3% | 3 | 3.4% | | Increase =3 lines | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | | Not Reported | 0 | | 0 | | 0 | | 0 | | 0 | | 0 | | 0 | | | Total | 135 | | 134 | | 135 | | 134 | | 130 | | 131 | | 88 | | % Percentage is calculated by dividing the number of eyes in the cell / by the total number of eyes per time period. # f) Adverse effects that occurred in the PMA clinical study: A summary of serious and non-serious AEs (following the ANSI Guidance Document for Corneal Reshaping, Z80.11-2012) is presented in **Table 9**. During the study, the most frequent AEs were severe glare, dry eye or halos at 3 months or later (with a cumulative rate of 8.1%; 11 eyes/135 eyes). At the stability time point of 12 months, the most frequent AEs were also severe glare, dry eye or halos (1.5%; 2/131 eyes). Some eyes experienced more than one event. Seven eyes experienced decrease in BSCVA of greater than or equal to 2 lines ($\geq 10$ letters ETDRS). One of the seven eyes was considered an AE because it was a decrease in BSCVA of greater than or equal to 2 lines ($\geq 10$ letters ETDRS) not due to irregular astigmatism as shown by hard contact lens refraction (or pin hole acuity if hard contact lens refraction is not medically advisable) at 3 months or later. One eye with loss of 3 lines of vision improved with hard contact lens refraction, two eyes with loss of 2 and 3 lines of vision improved with pinhole, and PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 16 {16} three eyes with loss of 2 and 3 lines of vision did not undergo hard contact lens refraction or pinhole because of adequate postoperative BSCVA (20/20 or better) after 6 months. **TABLE 9: Summary of AEs Over Time; All Hyperopic Eyes\* (N=135)** | Adverse Event | <1 Month (n=135) | | 1 Month (n=134) | | 3 Months (n=135) | | 6 Months (n=134) | | 9 Months (n=130) | | 12 Months (n=131) | | 24 Months (n=88) | | Cumulative (n=135) | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | n | % | n | % | n | % | N | % | n | % | n | % | n | % | n | % | | Corneal infiltrate or ulcer | 0 | 0.0 | 0 | 0.0 | 1 | 0.7 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 1 | 0.7 | | Any persistent corneal epithelial defect at 1 month or later | | | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | | Corneal edema at 1 month or later (specify 'flap', 'bed', or both) | | | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | | Epithelium in the interface with loss of 2 lines (10 letters) or more of BSCVA | 0 | 0.0 | 1 | 0.7 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 1 | 0.7 | 0 | 0.0 | 2 | 1.5 | | Miscreated flap (decentered, lost, incomplete, too thin, or other) | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | | Melting of the flap | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | | IOP with increase >10 mmHg above baseline on two consecutive examinations or an IOP >30 mmHg on two consecutive examinations | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | | Haze beyond 6 months with loss of 2 lines or greater (≥10 letters) | | | | | | | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | | Ocular penetration | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | | Severe glare, dry eye, or halos at 3 months or later | | | | | 2 | 1.5 | 4 | 3.0 | 2 | 1.5 | 2 | 1.5 | 0 | 0.0 | 11 | 8.1 | | **Decrease in BSCVA of greater than or equal to 2 lines (≥10 letters ETDRS) not due to irregular astigmatism, at 3 months or later | | | | | 1 | 0.7 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 1 | 0.7 | | Any other vision-threatening event | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | | Diffuse Lamellar Keratitis (DLK, grade 3 or above) | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | | Retinal detachment | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | | Retinal vascular accidents | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | | Other adverse events: | | | | | | | | | | | | | | | | | | Blepharitis requiring medication treatment | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 2 | 1.5 | 0 | 0.0 | 0 | 0.0 | 2 | 1.5 | | Erythema of the lid | 0 | 0.0 | 2 | 1.5 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 2 | 1.5 | | Cataracts | 0 | 0.0 | 0 | 0.0 | 2 | 1.5 | 0 | 0.0 | 0 | 0.0 | 1 | 0.8 | 0 | 0.0 | 3 | 2.2 | | Epiretinal membrane | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 1 | 0.7 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 1 | 0.7 | | Epithelial ingrowth requiring non-refractive intervention | 0 | 0.0 | 3 | 2.2 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 3 | 2.2 | | Trace DLK requiring medication treatment | 1 | 0.7 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 1 | 0.7 | Shaded areas represent time frames outside event definition. \*Some eyes experienced more than one event. % Percentage is calculated by dividing the number of eyes in the cell / by the total number of eyes per time period. \*\*Six eyes also experienced decrease in BSCVA of greater than or equal to 2 lines (≥10 letters ETDRS): a. One eye with loss of 3 lines of vision improved with hard contact lens refraction. b. 2 eyes with loss of 2 and 3 lines of vision improved with pinhole. c. 3 eyes with loss of 2 and 3 lines of vision did not undergo hard contact lens refraction or pinhole because of adequate postoperative BSCVA (20/20 or better) after 6 months PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 17 {17} # g) *Postoperative Complications* Complications are defined as anticipated, transient, and non-sight-threatening events. **Table 10** presents a summary of complications (per the statistical plan and consistent with the ANSI Guidance Document for Corneal Reshaping, Z80.11-2012) over time for all hyperopic eyes. There were no reports of corneal epithelial defects or diffuse lamellar keratitis (DLK; grade 2 or less) at 1 month or later. One case of trace DLK at 1 week required medication treatment and was reported as an AE. There were reports of epithelium in the interface (epithelial ingrowth) over time (0.8% at 12 months). At approximately 1 month postoperatively, three cases of epithelial ingrowth underwent non-refractive intervention and were reported as AEs. There were also reports of foreign body sensation and pain at 1 month or later (3.1 % and 7.6% at 12 months, respectively) but most of these were reported as mild. **Summary of Complications Over Time All Hyperopic Eyes (N=135)** | Complication | | <1 Month (n=135) | | 1 Month (n=134) | | 3 Months (n=135) | | 6 Months (n=134) | | 9 Months (n=130) | | 12 Months (n=131) | | 24 Months (n=88) | | Cumulative (n=135) | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | n | % | n | % | n | % | n | % | n | % | n | % | n | % | n | % | | Corneal edema between 1 week and 1 month after procedure | Total^{a} | 0 | 0.0 | | | | | | | | | | | | | | | | | Cornea | 0 | 0.0 | | | | | | | | | | | | | | | | | Flap | 0 | 0.0 | | | | | | | | | | | | | | | | Peripheral corneal epithelial defect at 1 month or later (location of defect to be identified as on, off, or across the flap) | | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | | Epithelium in the interface (epithelial ingrowth; trace/mild) | Total^{a} | 3 | 2.2 | 7^{b} | 5.2 | 5 | 3.7 | 3 | 2.2 | 2 | 1.5 | 1 | 0.8 | 1 | 1.1 | 8 | 5.9 | | | Cornea | 2 | 1.5 | 4^{b} | 3.0 | 3 | 2.2 | 3 | 2.2 | 2 | 1.5 | 1 | 0.8 | 1 | 1.1 | 6 | 4.4 | | | Flap | 1 | 0.7 | 3^{b} | 2.2 | 2 | 1.5 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 5 | 3.7 | | Diffuse Lamellar Keratitis (DLK, Grade 2 or less) | Total^{a} | 3^{c} | 2.2 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 3^{d} | 2.2 | | | Cornea | 3^{c} | 2.2 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 3^{d} | 2.2 | | | Flap | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | | Foreign body sensation at 1 month or later | | | | 19 | 14.2 | 16 | 11.9 | 12 | 9.0 | 9 | 6.9 | 4 | 3.1 | 6 | 6.8 | 47^{e} | 34.8 | | Pain at 1 month or later | | | | 3 | 2.2 | 12 | 8.9 | 1 | 0.7 | 1 | 0.8 | 10 | 7.6 | 4 | 4.5 | 23^{f} | 17.0 | Shaded areas represent time frames outside complication definition. $^{a}$ Finding noted on cornea and flap; no duplicate reports at the same visit. $^{b}$ Three eyes experienced epithelial ingrowth requiring non-refractive intervention at approximately 1 month (2 on cornea, 1 on flap) which were reported as adverse events. $^{c}$ One eye experienced trace diffuse lamellar keratitis requiring medication treatment at 1 week which was reported as an adverse event. $^{d}$ All reports of DLK were Grade 1 (trace). $^{e}$ Most reports were mild; moderate reports: 2 at 1, 6, 9 and 12 months; marked reports: 2 at 3 months; severe reports: 2 at 1 and 6 months. $^{f}$ Most reports were mild; moderate reports: 2 at 1 month and 1 at 9 months; marked reports: 2 at 3 months and 12 months; no severe reports. % Percentage is calculated by dividing the number of eyes in the cell / by the total number of eyes per time period. PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 18 {18} # h) *Intraoperative Complications* The majority of treated eyes (97.0%, 131/135) underwent uneventful treatment procedures with no significant complications. Two treated eyes (1.48%, 2/135) experienced a significant opaque bubble layer, which occurred in the superior one-third region in both cases. One treated eye (0.74%, 1/135) had intraoperative flap lift complications related to suction loss during the flap procedure. One treated eye (0.74%, 1/135; #10542) was noted to have a slightly temporal flap decentration, but full ablation was completed in the bed. There were no occurrences (0%, 0/135) of other problems with the flap or bed. Of the 135 treated eyes, most eyes (77.0%, 104/135) were treated with iris registration engaged for the duration of treatment. Thirty-one eyes (23.0%, 31/135) underwent treatment without iris registration engaged. Laser treatment for two eyes was interrupted and resumed after a gas boost was performed. Two eyes had small epithelial defects at the hinge. One was noted as not clinically significant and the other received a bandage contact lens following surgery. Temporary, 3-month punctal plugs were inserted into 8 eyes of 4 subjects at one site during the surgical procedure to help with postoperative dryness. # i) *Visual Functioning and Well-being* The NEI-RQL-42 was administered to subjects at the periodic study exams. The NEI-RQL-42 was not found to be a valid assessment of safety outcomes by the FDA. Results of the NEI-RQL-42 questionnaire assessing binocular subjective visual functioning and well-being showed no worsening following treatment with the *iDESIGN® AWS Studio* System. PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 19 {19} # j) *Directed Visual Symptoms* **Table 11** presents subjective visual symptoms at preoperative, 6 months and 12 months from the “directed symptom assessment.” **Summary of symptoms at at Preoperative, 6 Months, and 12 Months:** | Symptom | Visit | None | | Mild | | Moderate | | Marked | | Severe | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | n | % | n | % | n | % | n | % | n | % | | Pain | Preop | 130 | 96.30% | 5 | 3.70% | 0 | 0.00% | 0 | 0.00% | 0 | 0.00% | | | 6 Months | 133 | 99.25% | 1 | 0.75% | 0 | 0.00% | 0 | 0.00% | 0 | 0.00% | | | 12 Months | 121 | 92.37% | 8 | 6.11% | 0 | 0.00% | 2 | 1.53% | 0 | 0.00% | | Tearing | Preop | 126 | 93.33% | 8 | 5.93% | 1 | 0.74% | 0 | 0.00% | 0 | 0.00% | | | 6 Months | 124 | 92.54% | 8 | 5.97% | 0 | 0.00% | 2 | 1.49% | 0 | 0.00% | | | 12 Months | 112 | 85.50% | 17 | 12.98% | 2 | 1.53% | 0 | 0.00% | 0 | 0.00% | | Photophobia | Preop | 127 | 94.07% | 6 | 4.44% | 2 | 1.48% | 0 | 0.00% | 0 | 0.00% | | | 6 Months | 108 | 80.60% | 20 | 14.93% | 4 | 2.99% | 2 | 1.49% | 0 | 0.00% | | | 12 Months | 113 | 86.26% | 12 | 9.16% | 6 | 4.58% | 0 | 0.00% | 0 | 0.00% | | Foreign Body Sensation | Preop | 133 | 98.52% | 2 | 1.48% | 0 | 0.00% | 0 | 0.00% | 0 | 0.00% | | | 6 Months | 122 | 91.04% | 8 | 5.97% | 2 | 1.49% | 0 | 0.00% | 2 | 1.49% | | | 12 Months | 127 | 96.95% | 2 | 1.53% | 2 | 1.53% | 0 | 0.00% | 0 | 0.00% | | Dryness | Preop | 83 | 61.48% | 40 | 29.63% | 10 | 7.41% | 2 | 1.48% | 0 | 0.00% | | | 6 Months | 49 | 36.57% | 65 | 48.51% | 16 | 11.94% | 2 | 1.49% | 2 | 1.49% | | | 12 Months | 61 | 46.56% | 48 | 36.64% | 14 | 10.69% | 6 | 4.58% | 2 | 1.53% | | Fluctuation of Vision | Preop | 116 | 85.93% | 17 | 12.59% | 2 | 1.48% | 0 | 0.00% | 0 | 0.00% | | | 6 Months | 70 | 52.24% | 46 | 34.33% | 16 | 11.94% | 2 | 1.49% | 0 | 0.00% | | | 12 Months | 83 | 63.36% | 41 | 31.30% | 4 | 3.05% | 2 | 1.53% | 1 | 0.76% | | Day Glare | Preop | 118 | 87.41% | 13 | 9.63% | 2 | 1.48% | 0 | 0.00% | 2 | 1.48% | | | 6 Months | 112 | 83.58% | 16 | 11.94% | 4 | 2.99% | 0 | 0.00% | 2 | 1.49% | | | 12 Months | 113 | 86.26% | 12 | 9.16% | 4 | 3.05% | 2 | 1.53% | 0 | 0.00% | | Night Glare | Preop | 92 | 68.15% | 33 | 24.44% | 8 | 5.93% | 0 | 0.00% | 2 | 1.48% | | | 6 Months | 83 | 61.94% | 36 | 26.87% | 13 | 9.70% | 0 | 0.00% | 2 | 1.49% | | | 12 Months | 94 | 71.76% | 29 | 22.14% | 6 | 4.58% | 2 | 1.53% | 0 | 0.00% | | Binocular Diplopia | Preop | 135 | 100.00% | 0 | 0.00% | 0 | 0.00% | 0 | 0.00% | 0 | 0.00% | | | 6 Months | 124 | 92.54% | 6 | 4.48% | 4 | 2.99% | 0 | 0.00% | 0 | 0.00% | | | 12 Months | 124 | 94.66% | 5 | 3.82% | 2 | 1.53% | 0 | 0.00% | 0 | 0.00% | | Monocular Diplopia | Preop | 135 | 100.00% | 0 | 0.00% | 0 | 0.00% | 0 | 0.00% | 0 | 0.00% | | | 6 Months | 129 | 96.27% | 3 | 2.24% | 2 | 1.49% | 0 | 0.00% | 0 | 0.00% | | | 12 Months | 128 | 97.71% | 3 | 2.29% | 0 | 0.00% | 0 | 0.00% | 0 | 0.00% | PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 20 {20} | Symptom | Visit | None | | Mild | | Moderate | | Marked | | Severe | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | n | % | n | % | n | % | n | % | n | % | | Ghosting | Preop | 133 | 98.52% | 2 | 1.48% | 0 | 0.00% | 0 | 0.00% | 0 | 0.00% | | | 6 Months | 118 | 88.06% | 7 | 5.22% | 7 | 5.22% | 0 | 0.00% | 2 | 1.49% | | | 12 Months | 117 | 89.31% | 9 | 6.87% | 5 | 3.82% | 0 | 0.00% | 0 | 0.00% | | Halos | Preop | 72 | 53.33% | 44 | 32.59% | 15 | 11.11% | 4 | 2.96% | 0 | 0.00% | | | 6 Months | 72 | 53.73% | 43 | 32.09% | 14 | 10.45% | 1 | 0.75% | 4 | 2.99% | | | 12 Months | 72 | 54.96% | 50 | 38.17% | 7 | 5.34% | 2 | 1.53% | 0 | 0.00% | | Driving at night | Preop | 72 | 53.33% | 40 | 29.63% | 18 | 13.33% | 5 | 3.70% | 0 | 0.00% | | | 6 Months | 83 | 61.94% | 37 | 27.61% | 12 | 8.96% | 2 | 1.49% | 0 | 0.00% | | | 12 Months | 87 | 66.41% | 32 | 24.43% | 10 | 7.63% | 2 | 1.53% | 0 | 0.00% | | Other Sensations | Preop | 133 | 98.52% | 0 | 0.00% | 2 | 1.48% | 0 | 0.00% | 0 | 0.00% | | | 6 Months | 134 | 100.00% | 0 | 0.00% | 0 | 0.00% | 0 | 0.00% | 0 | 0.00% | | | 12 Months | 129 | 98.47% | 1 | 0.76% | 1 | 0.76% | 0 | 0.00% | 0 | 0.00% | | Blurry Vision | Preop | 135 | 100.00% | 0 | 0.00% | 0 | 0.00% | 0 | 0.00% | 0 | 0.00% | | | 6 Months | 131 | 97.76% | 1 | 0.75% | 1 | 0.75% | 1 | 0.75% | 0 | 0.00% | | | 12 Months | 131 | 100.00% | 0 | 0.00% | 0 | 0.00% | 0 | 0.00% | 0 | 0.00% | | Itchy | Preop | 131 | 97.04% | 4 | 2.96% | 0 | 0.00% | 0 | 0.00% | 0 | 0.00% | | | 6 Months | 134 | 100.00% | 0 | 0.00% | 0 | 0.00% | 0 | 0.00% | 0 | 0.00% | | | 12 Months | 131 | 100.00% | 0 | 0.00% | 0 | 0.00% | 0 | 0.00% | 0 | 0.00% | % Percentage is calculated by dividing the number of eyes in the cell (n) / by the total number of eyes (N) #### k) *Contrast Sensitivity* Monocular best corrected distance contrast sensitivity was evaluated preoperatively and postoperatively at 3, 6 and 12 months under mesopic (3 cd/m²) conditions with and without glare and photopic (85 cd/m²) conditions without glare at 4 spatial frequencies (3, 6, 12, and 18 cycles per degree, cpd). As shown in **Table 12**, at 12 months, mean changes in contrast sensitivity vs. preoperative ranged between -0.01 to >-0.09 log units under photopic without glare conditions, between >0.05 and <-0.06 log units under mesopic without glare conditions and between <-0.01 and ≥-0.03 log units under mesopic with glare conditions. None of the mean changes in contrast sensitivity at 12 months vs. preoperative under any of the three lighting conditions were statistically significant after adjusting for multiplicity. PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 21 {21} **Mean Change in Contrast Sensitivity at 12 Months From Preoperative** | Lighting Condition | Mean Change | | | | | --- | --- | --- | --- | --- | | | 3 cpd | 6 cpd | 12 cpd | 18 cpd | | **Photopic Without Glare** | | | | | | Mean (Log units) | -.01 | -.04 | >-.09 | -.08 | | Standard error | 0.023 | 0.029 | >0.038 | 0.034 | | **Mesopic without Glare** | | | | | | Mean (Log units) | -.04 | <-.06 | >0.01 | >0.05 | | Standard error | 0.023 | >0.037 | >0.048 | >0.043 | | **Mesopic with Glare** | | | | | | Mean (Log units) | -.03 | -.02 | <-.01 | >-.03 | | Standard error | 0.022 | 0.035 | >0.046 | >0.041 | Note: Positive values for “change from preoperative” represent increase in contrast sensitivity scores. Note: Data for eyes that were unable to see the reference patterns were imputed. Mean scores contain a greater than (&gt;) symbol when more eyes were unable to see the reference pattern preoperatively than postoperatively. Mean scores contain a less than (&lt;) symbol when more eyes were unable to see the reference patterns post-operatively than preoperatively. As shown in **Table 13**, most eyes (&gt;68%) had either no change or clinically significant improvements in contrast sensitivity (0.30 log units or more at two or more spatial frequencies) under all lighting conditions at 12 months vs. preoperative. At 12 months, under all lighting conditions, approximately 30% of eyes experienced clinically significant decreases in contrast sensitivity at 12 months under each of the lighting conditions (31.3% [41/131] under photopic conditions without glare; 28.2% [37/131] under mesopic conditions without glare; and 29.8% [39/131], under mesopic conditions with glare). Overall, postoperatively, the mean changes in contrast sensitivity at 12 months vs. preoperative were not statistically significant. **Clinically Significant Changes$^{a}$ in Contrast Sensitivity at 12 Months from Preoperative All Hyperopic Eyes (N=131)** | Lighting Condition | Decrease | | No change | | Increase | | | --- | --- | --- | --- | --- | --- | --- | | | n | % | n | % | n | % | | **Photopic without Glare** | 41 | 31.3% | 71 | 54.2% | 19 | 14.5% | | **Mesopic without Glare** | 37 | 28.2% | 56 | 42.7% | 38 | 29.0% | | **Mesopic with Glare** | 39 | 29.8% | 64 | 48.9% | 28 | 21.4% | $^{a}$ A difference of $\geq 0.30$ log units from preoperative at 2 or more spatial frequencies is considered a clinically significant change in contrast sensitivity. % Percentage is calculated by dividing the number of eyes in the cell (n) / by the total number of eyes N (131) ## 2. Effectiveness Results The analysis of effectiveness was based on the 131 evaluable eyes the 12-month time point. Key effectiveness outcomes are presented in **Tables 14 to 24**. PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 22 {22} a) 85% of eyes with a UCVA of 20/40 or better: At 12 months, UCVA of 20/40 or better was achieved in 93.9% (123/131) of eyes, exceeding the primary study effectiveness endpoint target of 85% of eyes with 20/40 or better UCVA. Overall, the proportions of eyes that achieved UCVA of 20/40 or better exceeded the target rate (85%) across all postoperative study visits. b) Proportion of eyes with an MRSE within 0.50 D and 1.00 D of intended correction: The secondary effectiveness endpoints pertaining to the accuracy of treatment were met at 12 months with 63.4% (83/131) of eyes having MRSE within 0.50 D of emmetropia and 83.2% (109/131) within 1.00 D, exceeding the study endpoint targets of 50% within 0.50 D and 75% within 1.00 D. TABLE 14 Key Effectiveness Variables Over Time All Hyperopic Eyes (N=135) | Effectiveness Variable | 1 Month (n=134) | | 3 Months (n=135) | | 6 Months (n=134) | | 9 Months (n=130) | | 12 Months (n=131) | | 24 Months (n=88) | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | n | % | n | % | n | % | n | % | n | % | n | % | | UCVA 20/20 or better | 62 | 46.3% | 71 | 52.6% | 74 | 55.2% | 74 | 56.9% | 86 | 65.6% | 57 | 64.8% | | **UCVA 20/40 or better^{a}** | 125 | 93.3% | 126 | 93.3% | 129 | 96.3% | 124 | 95.4% | 123 | 93.9% | 85 | 96.6% | | Sphere +/- 0.50 D | 50 | 37.3% | 55 | 40.7% | 56 | 41.8% | 58 | 44.6% | 65 | 49.6% | 50 | 56.8% | | Sphere +/- 1.00 D | 86 | 64.2% | 89 | 65.9% | 96 | 71.6% | 98 | 75.4% | 102 | 77.9% | 71 | 80.7% | | Cylinder +/- 0.50 D | 83 | 61.9% | 91 | 67.4% | 82 | 61.2% | 85 | 65.4% | 93 | 71% | 59 | 67% | | Cylinder +/- 1.00 D | 120 | 89.6% | 121 | 89.6% | 121 | 90.3% | 114 | 87.7% | 120 | 91.6% | 79 | 89.8% | | **MRSE +/- 0.50 D^{b}** | 71 | 53% | 65 | 48.1% | 75 | 56% | 78 | 60% | 83 | 63.4% | 61 | 69.3% | | **MRSE +/- 1.00 D^{c}** | 101 | 75.4% | 104 | 77% | 107 | 79.9% | 107 | 82.3% | 109 | 83.2% | 77 | 87.5% | $^{a}$ Study endpoint target: 85% of eyes 20/40 or better UCVA $^{b}$ Study endpoint target: 50% of eyes within 0.50 D MRSE $^{c}$ Study endpoint target: 75% of eyes within 1.00 D MRSE % Percentage is calculated by dividing the number of eyes in the cell / by the total number of eyes per time period. PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 23 {23} The key effectiveness variables at 12 months stratified by preoperative IDSE are presented in **Table 15**. **Key UCVA and MRSE Variables at 12 Months by Preop *iDESIGN*$^{®}$ AWS Spherical Equivalent (IDSE) All Eyes (N=131)** | Preoperative IDSE Diopter Group (n) | UCVA 20/20 or better | UCVA 20/40 or better^{a} | MRSE within 0.50 D^{b} | MRSE within 1.00 D^{c} | | --- | --- | --- | --- | --- | | | n % | n % | n % | n % | | 0 to +1 D (n=4) | 3 75.0% | 4 100% | 4 100% | 4 100% | | >+1 to +2 D (n=32) | 26 81.3% | 32 100% | 21 65.6% | 30 93.8% | | >+2 to +3 D (n=39) | 30 76.9% | 39 100% | 30 76.9% | 37 94.9% | | >+3 to +4 D (n=22) | 12 54.5% | 21 95.5% | 15 68.2% | 18 81.8% | | >+4 to +5 D (n=23) | 10 43.5% | 17 73.9% | 9 39.1% | 13 56.5% | | >+5 to +6 D (n=11) | 5 45.5% | 10 90.9% | 4 36.4% | 7 63.6% | | **Total (n=131)** | **86 65.6%** | **123 93.9%** | **83 63.4%** | **109 83.2%** | $^{a}$ Study endpoint target: 85% of eyes 20/40 or better UCVA $^{b}$ Study endpoint target: 50% of eyes within 0.50 D MRSE $^{c}$ Study endpoint target: 75% of eyes within 1.00 D MRSE % Percentage is calculated by dividing the number of eyes in the cell / by the total number of eyes per diopter row The key effectiveness variables at 12 months stratified by preoperative IDC are presented in **Table 16**. **Key UCVA and MRSE Variables at 12 Months by Preoperative *iDESIGN*$^{®}$ AWS Cylinder (IDC), All Eyes (N=131)** | Preoperative IDC Diopter Group (n) | UCVA 20/20 or better | UCVA 20/40 or better^{a} | MRSE within 0.50 D^{b} | MRSE within 1.00 D^{c} | | --- | --- | --- | --- | --- | | | n % | n % | n % | n % | | >0 to <=0.5D (n=45) | 31 68.9% | 43 95.6% | 30 66.7% | 41 91.1% | | >0.5 to <=1D (n=44) | 29 65.9% | 43 97.7% | 30 68.2% | 39 88.6% | | >1 to <=2D (n=23) | 14 60.9% | 21 91.3% | 12 52.2% | 15 65.2% | | >2 to <=3D (n=10) | 6 60.0% | 7 70.0% | 6 60.0% | 8 80.0% | | >3 to <=4D (n=9) | 6 66.7% | 9 100% | 5 55.6% | 6 66.7% | | **Total (n=131)** | **86 65.6%** | **123 93.9%** | **83 63.4%** | **109 83.2%** | $^{a}$ Study endpoint target: 85% of eyes 20/40 or better UCVA $^{b}$ Study endpoint target: 50% of eyes within 0.50 D MRSE $^{c}$ Study endpoint target: 75% of eyes within 1.00 D MRSE % Percentage is calculated by dividing the number of eyes in the cell / by the total number of eyes per diopter row PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 24 {24} # c) *UCVA* **Table 17** presents the distribution of UCVA results over time for all eyes. Postoperatively, the proportions of eyes that achieved UCVA of 20/40 or better ($\geq 93\%$) exceeded the target rate ($\geq 85\%$) across all postoperative study visits. Furthermore at 12 months, 65.6% (86/131) of eyes were 20/20 or better. **UCVA Over Time, All Hyperopic Eyes (N=135)** | Acuity | Preoperative (n=135) | | 1 Month (n=134) | | 3 Months (n=135) | | 6 Months (n=134) | | 9 Months (n=130) | | 12 Months (n=131) | | 24 Months (n=88) | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | n | % | n | % | n | % | n | % | n | % | n | % | n | % | | 20/10 or better | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | | 20/12.5 or better | 0 | 0.0% | 5 | 3.7% | 8 | 5.9% | 6 | 4.5% | 6 | 4.6% | 6 | 4.6% | 7 | 8.0% | | 20/16 or better | 0 | 0.0% | 24 | 17.9% | 35 | 25.9% | 38 | 28.4% | 40 | 30.8% | 43 | 32.8% | 28 | 31.8% | | 20/20 or better^{a} | 0 | 0.0% | 62 | 46.3% | 71 | 52.6% | 74 | 55.2% | 74 | 56.9% | 86 | 65.6% | 57 | 64.8% | | 20/25 or better | 0 | 0.0% | 101 | 75.4% | 107 | 79.3% | 102 | 76.1% | 102 | 78.5% | 104 | 79.4% | 73 | 83.0% | | 20/32 or better | 0 | 0.00% | 114 | 85.1% | 115 | 85.2% | 118 | 88.1% | 114 | 87.7% | 118 | 90.1% | 81 | 92.0% | | 20/40 or better^{b} | 33 | 24.4% | 125 | 93.3% | 126 | 93.3% | 129 | 96.3% | 124 | 95.4% | 123 | 93.9% | 85 | 96.6% | | 20/50 or better | 58 | 43.0% | 130 | 97.0% | 132 | 97.8% | 131 | 97.8% | 130 | 100% | 129 | 98.5% | 88 | 100% | | 20/63 or better | 78 | 57.8% | 133 | 99.3% | 134 | 99.3% | 132 | 98.5% | 130 | 100% | 131 | 100% | 88 | 100% | | 20/80 or better | 96 | 71.1% | 134 | 100% | 135 | 100% | 134 | 100% | 130 | 100% | 131 | 100% | 88 | 100% | | 20/100 or better | 118 | 87.4% | 134 | 100% | 135 | 100% | 134 | 100% | 130 | 100% | 131 | 100% | 88 | 100% | | Worse than 20/100 | 17 | 12.6% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | $^{a}$ Preoperatively, 0.0% (0/135) of eyes achieved UCVA of 20/20 $^{b}$ Preoperatively, 24.4% (33/135) of eyes achieved UCVA of 20/40 % Percentage is calculated by dividing the number of eyes in the cell / by the total number of eyes per time period **Table 18** presents the differences in postoperative UCVA achieved compared to preoperative BSCVA for all eyes. At 12 months, 47.3% (62/131) of eyes achieved the same or better acuity level postoperatively without correction as preoperatively with correction. PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 25 {25} **Postoperative UCVA Compared to Preoperative BSCVA, All Hyperopic Eyes (N=135)** | Acuity | 1 Month (n=134) | | 3 Months (n=135) | | 6 Months (n=134) | | 9 Months (n=130) | | 12 Months (n=131) | | 24 Months (n=88) | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | n | % | n | % | n | % | n | % | n | % | n | % | | 3 lines better | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | | 2 lines better | 1 | 0.7% | 2 | 1.5% | 2 | 1.5% | 2 | 1.5% | 1 | 0.8% | 3 | 3.4% | | 1 line better | 11 | 8.2% | 14 | 10.4% | 14 | 10.4% | 13 | 10.0% | 17 | 13.0% | 10 | 11.4% | | No change | 23 | 17.2% | 34 | 25.2% | 37 | 27.6% | 36 | 27.7% | 44 | 33.6% | 30 | 34.1% | | 1 lines worse | 39 | 29.1% | 33 | 24.4% | 32 | 23.9% | 34 | 26.2% | 30 | 22.9% | 22 | 25.0% | | 2 lines worse | 31 | 23.1% | 24 | 17.8% | 20 | 14.9% | 20 | 15.4% | 16 | 12.2% | 12 | 13.6% | | ≥ 3 lines worse | 29 | 21.6% | 28 | 20.7% | 29 | 21.6% | 25 | 19.2% | 23 | 17.6% | 11 | 12.5% | % Percentage is calculated by dividing the number of eyes in the cell / by the total number of eyes per time period # d) Accuracy of Manifest Refraction **Table 19** presents residual MRSE at all postoperative time points stratified by preoperative MRSE. A greater amount of residual MRSE was observed for eyes with higher preoperative MRSE. Overall, there was an overcorrection of MRSE of -0.43 D at 12 months postoperative. **Residual MRSE at each Postoperative Visit Stratified by Preoperative MRSE** | Preoperative MRSE | Residual MRSE | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | 1 Month | | 3 Months | | 6 Months | | 9 Months | | 12 Months | | 24 Months | | | | N | Mean | N | Mean | N | Mean | N | Mean | N | Mean | N | Mean | | >0 to <=1 | 8 | -0.24 | 8 | -0.39 | 8 | -0.33 | 8 | -0.21 | 6 | -0.17 | 3 | -0.04 | | >1 to <=2 | 48 | -0.64 | 49 | -0.53 | 48 | -0.49 | 48 | -0.49 | 47 | -0.39 | 31 | -0.17 | | >2 to <=3 | 29 | -0.61 | 29 | -0.54 | 29 | -0.38 | 28 | -0.28 | 29 | -0.32 | 22 | -0.24 | | >3 to <=4 | 28 | -0.74 | 28 | -0.80 | 28 | -0.78 | 28 | -0.51 | 28 | -0.53 | 16 | -0.65 | | >4 to <=5 | 16 | -0.78 | 16 | -1.03 | 16 | -0.71 | 15 | -0.54 | 16 | -0.58 | 12 | -0.49 | | >5 to <=6 | 5 | -1.00 | 5 | -1.38 | 5 | -1.10 | 3 | -0.92 | 5 | -0.68 | 4 | -0.31 | | All | 134 | -0.66 | 135 | -0.67 | 134 | -0.57 | 130 | -0.45 | 131 | -0.43 | 88 | -0.32 | PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 26 {26} **Table 20** presents the proportions of eyes with residual manifest cylinder magnitude at 12 months and the absolute shift in axis from preoperative. The table includes all eyes (n=86) in the cohort with nonzero preoperative astigmatism. At 12 months, an axis shift of >30° from preoperative was noted for 60.4% (52/86) of eyes; of which 20 eyes (38.5%; 20/52) had a residual cylinder magnitude >0.50 D. **Residual Manifest Refractive Astigmatic Error at 12 Months** | Residual Cylinder Magnitude | Absolute Shift in Axis | Total (n=86) | | --- | --- | --- | | 0° (n=20) | >0° to ≤ 5° (n=1) | >5° to ≤ 10° (n=5) | >10° to ≤ 15° (n=4) | >15° to ≤ 30° (n=4) | >30° (n=52) | | n | % | n | % | n | % | n | % | n | % | n | % | | 0.0 D | 17* | 85.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 17 | 19.8% | | >0 to ≤ 0.5 D | 1 | 5.0% | 1 | 100% | 2 | 40.0% | 2 | 50.0% | 3 | 75.0% | 32 | 61.5% | | >0.5 to ≤ 1.0 D | 0 | 0.0% | 0 | 0.0% | 2 | 40.0% | 2 | 50.0% | 0 | 0.0% | 13 | 25.0% | | >1.0 to ≤ 2.0 D | 2 | 10.0% | 0 | 0.0% | 1 | 20.0% | 0 | 0.0% | 1 | 25.0% | 5 | 9.6% | | >2.0 to ≤ 3.0 D | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | 2^{a,b} | 3.8% | | **Total** | **20** | **100** | **1** | **100** | **5** | **100** | **4** | **100** | **4** | **100** | **52** | **100** | | *Note: The axis shift is defined to be zero when the residual cylinder magnitude is zero. | | ^{a} Eye: Preoperative MR +2.75 D +1.00 D x 004; 12 Month MR -1.50 D +3.00 D x 58; 12 Month UCVA 20/40 | | ^{b} Eye: Preoperative MR +3.50 D +1.00 D x 170; 12 Month MR -2.75 D +2.25 D x 60; 12 Month UCVA 20/50 | Advanced CustomVue Hyperopia with and without Astigmatism Treatment Professional Use Manual 0030-XXXX Rev XA 3-7 # e) *Stability of Outcome* # i. *Stability of MRSE* **Table 21** presents the stability of MRSE across visits for all eyes with at least two consecutive study visits. The defined criteria for refractive stability were met at the 12-month visit and confirmed at the 24-month visit. At least 95.0% of eyes had ≤1.00 D change in MRSE between 9 and 12 months and between 12 and 24 months, meeting the criterion of at least 95% of the treated eyes having a change of ≤1.00 D in MRSE at any two refractions performed at least 3 months apart. PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 27 {27} **Table 21. Stability of Manifest Refraction Spherical Equivalent (MRSE): All Hyperopic Eyes Consecutive Cohort** | Distributions | Between 1 and 3 Months (n=134) n % | Between 3 and 6 Months (n=134) n % | Between 6 and 9 Months (n=130) n % | Between 9 and 12 Months (n=127) n % | Between 12 and 24 Months (n=88) n % | | --- | --- | --- | --- | --- | --- | | Change in MRSE by ≤ 0.5 D | 104 77.6% | 109 81.3% | 102 78.5% | 106 83.5% | 70 79.5% | | Change in MRSE by ≤1.0 D | 124 92.5% | 128 95.5% | 121 93.1% | 121 95.3% | 84 95.5% | | Mean Outcomes | D +/- SD | D +/- SD | D +/- SD | D +/- SD | D +/- SD | | Mean Change in MRSE | -0.016 +/- 0.680 | 0.109 +/- 0.535 | 0.127 +/- 0.512 | 0.009 +/- 0.433 | 0.121 +/- 0.583 | | Mean Change Per Month | -0.008 | 0.036 | 0.042 | 0.003 | 0.010 | | Change is defined as current visit value minus previous visit value. Confidence Interval is calculated based on Clopper-Pearson Exact method. * Includes only eyes with data at two consecutive visits. | | | | | | # *ii. Stability of Refractive Cylinder* **Table 22** presents the stability of absolute (non-vector) cylinder across visits for all eyes with data at two or more consecutive study visits. The defined criteria for refractive cylinder stability were met at the 12-month visit, and confirmed at the 24-month visit. For refractive cylinder stability, at least 96.1% (122/127) of eyes had ≤1.00 D change in MRC between consecutive visits, meeting criterion of at least 95% of the treated eyes having a change of ≤1.00 D in MRC between visits. PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 28 {28} Table 22. Stability of Absolute (Non-vector) Cylinder, All Hyperopic Eyes Consecutive Cohort | Magnitude of Change in Non-vector Cylinder Distributions | Between 1 and 3 Months (n=134) | | Between 3 and 6 Months (n=134) | | Between 6 and 9 Months (n=130) | | Between 9 and 12 Months (n=127) | | Between 12 and 24 Months (n=88) | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | n | % | n | % | n | % | n | % | n | % | | Eyes with ≤0.5D Change | 110 | 82.1% | 124 | 92.5% | 117 | 90.0% | 116 | 91.3% | 81 | 92.0% | | Eyes with ≤1.0D Change | 130 | 97.0% | 132 | 98.5% | 127 | 97.7% | 122 | 96.1% | 87 | 98.9% | | **Mean Outcomes (D)** | | | | | | | | | | | | Mean Change between Visits | -0.011 | | 0.047 | | -0.035 | | -0.026 | | 0.014 | | | SD | 0.448 | | 0.392 | | 0.376 | | 0.469 | | 0.387 | | | Mean Change Per Year | -0.067 | | 0.187 | | -0.138 | | -0.102 | | 0.014 | | | Mean Change Per Month | -0.006 | | 0.016 | | -0.012 | | -0.009 | | 0.001 | | | Change is defined as current visit value minus previous visit value. * includes only eyes with data at two consecutive visits. | | | | | | | | | | | # f) Effectiveness of Correction of Astigmatism Vector analysis summary statistics at 12 months are presented in Table 23. With correction ratios (CR) above 1.0, the results indicate a systematic overcorrection of cylinder for eyes with preoperative cylinder of ≤1.00 D. Table 23 Vector analysis Summary at 12 Months for All Eyes, (N=131) | Preoperative Cylinder | n | |IRC|^ (Mean +/- SD) | |SIRC|^ (Mean +/- SD) | |EV| (Mean +/- SD) | CR (Mean +/- SD) | ER (Mean +/- SD) | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | All (N) | 131 | 0.99 +/- 0.91 | 1.20 +/- 0.99 | 0.52 +/- 0.47 | 1.33 +/- 0.73 | 0.78 +/- 0.84 | | >0.0D to ≤0.5D | 66 | 0.36 +/- 0.18 | 0.53 +/- 0.30 | 0.39 +/- 0.30 | 1.40 +/- 0.83 | 1.03 +/- 0.97 | | >0.5D to ≤1.0D | 29 | 0.87 +/- 0.13 | 1.40 +/- 0.78 | 0.82 +/- 0.72 | 1.58 +/- 0.81 | 0.93 +/- 0.78 | | >1.0D to ≤2.0D | 18 | 1.56 +/- 0.25 | 1.65 +/- 0.55 | 0.51 +/- 0.33 | 1.06 +/- 0.34 | 0.34 +/- 0.23 | | >2.0D to ≤3.0D | 10 | 2.53 +/- 0.25 | 2.38 +/- 0.76 | 0.70 +/- 0.54 | 0.95 +/- 0.30 | 0.28 +/- 0.21 | | >3.0D to ≤4.0D | 8 | 3.41 +/- 0.19 | 3.59 +/- 0.44 | 0.34 +/- 0.19 | 1.05 +/- 0.09 | 0.10 +/- 0.05 | | IRC = intended refractive change SIRC = surgically induced refractive change EV = error vector (IRC-SIRC) | | | | CR = correction ratio (SIRC/IRC) ER = error ratio (EV/IRC) | | | PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 29 {29} # g) Higher Order Aberrations (HOA) (HOA) The higher order aberration (HOA) root mean square (RMS) values over time for all hyperopic eyes with 4 mm standardized wavefront diameters are presented in Table 24. There was an increase in mean HOA RMS (ranging from +0.14 to +0.17 μm) at all postoperative visits compared to preoperative. The increases in HOA RMS were mostly associated with increases in mean coma (+0.13 to +0.16 μm). Table 24. HOA RMS (μm) Over Time Eyes with 4mm Standardized Wavefront Diameters-All Hyperopic Eyes | | Preoperative (n=135) Mean +/- SD | 1 Month (n=126) Mean +/- SD | Months (n=128) Mean +/- SD | Months (n=126) Mean +/- SD | 9 Months (n=126) Mean +/- SD | 12 Months (n=126) Mean +/- SD | 24 Months (n=77) Mean +/- SD | | --- | --- | --- | --- | --- | --- | --- | --- | | HOA RMS (μm) | 0.13 +/- 0.04 | 0.28 +/- 0.15 | 0.28 +/- 0.15 | 0.27 +/- 0.15 | 0.27 +/- 0.15 | 0.28 +/- 0.15 | 0.30 +/- 0.16 | | Coma | 0.07 +/- 0.04 | 0.21 +/- 0.13 | 0.20 +/- 0.13 | 0.20 +/- 0.13 | 0.20 +/- 0.13 | 0.20 +/- 0.13 | 0.23 +/- 0.15 | | Spherical Aberration | 0.04 +/- 0.03 | 0.11 +/- 0.09 | 0.12 +/- 0.10 | 0.11 +/- 0.09 | 0.11 +/- 0.09 | 0.12 +/- 0.10 | 0.12 +/- 0.10 | | Trefoil | 0.07 +/- 0.04 | 0.09 +/- 0.07 | 0.09 +/- 0.07 | 0.08 +/- 0.06 | 0.08 +/- 0.05 | 0.08 +/- 0.06 | 0.09 +/- 0.06 | | Secondary Coma | 0.01 +/- 0.00 | 0.02 +/- 0.02 | 0.02 +/- 0.02 | 0.02 +/- 0.02 | 0.02 +/- 0.02 | 0.02 +/- 0.02 | 0.02 +/- 0.02 | | Secondary Astigmatism | 0.02 +/- 0.02 | 0.06 +/- 0.04 | 0.06 +/- 0.04 | 0.06 +/- 0.04 | 0.05 +/- 0.04 | 0.05 +/- 0.04 | 0.05 +/- 0.04 | | Secondary Spherical Aberration | 0.00 +/- 0.00 | 0.01 +/- 0.01 | 0.01 +/- 0.01 | 0.01 +/- 0.01 | 0.01 +/- 0.01 | 0.01 +/- 0.01 | 0.01 +/- 0.01 | | Tetrafoil | 0.01 +/- 0.01 | 0.01 +/- 0.01 | 0.01 +/- 0.01 | 0.01 +/- 0.01 | 0.01 +/- 0.01 | 0.01 +/- 0.01 | 0.01 +/- 0.01 | | Fifth Order | 0.01 +/- 0.01 | 0.03 +/- 0.02 | 0.03 +/- 0.02 | 0.03 +/- 0.02 | 0.03 +/- 0.02 | 0.03 +/- 0.02 | 0.03 +/- 0.02 | | Sixth Order | 0.01 +/- 0.01 | 0.02 +/- 0.01 | 0.02 +/- 0.01 | 0.02 +/- 0.01 | 0.02 +/- 0.01 | 0.02 +/- 0.01 | 0.02 +/- 0.01 | | Spherical Aberration Signed | 0.04 +/- 0.03 | -0.11 +/- 0.10 | -0.12 +/- 0.10 | -0.11 +/- 0.10 | -0.11 +/- 0.10 | -0.12 +/- 0.10 | -0.12 +/- 0.10 | | IDESIGN® Spherical Equivalent (D)* | 2.91 +/- 1.31 | -0.22 +/- 0.85 | -0.22 +/- 0.79 | -0.16 +/- 0.88 | -0.09 +/- 0.74 | -0.06 +/- 0.75 | 0.12 +/- 0.70 | | IDESIGN® Cylinder magnitude (D)* | 1.01 +/- 0.89 | 0.72 +/- 0.44 | 0.67 +/- 0.43 | 0.68 +/- 0.44 | 0.62 +/- 0.43 | 0.66 +/- 0.47 | 0.66 +/- 0.40 | | * Low order aberrations from 4.0 mm IDESIGN® measurements collected by sites. | | | | | | | | PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 30 {30} # h) *Refractive Retreatments* Two eyes of two subjects underwent retreatment, one after the 9-month visit, and another after the 12-month visit. Data from these eyes, prior to retreatment, are included in all analyses. Two retreatments are insufficient to yield clinically useful information; however, caution should be taken to assure refractive stability before performing additional procedures. # 3. Subgroup Analyses The following preoperative characteristics were evaluated for potential association with outcomes: gender and site. Evaluation of site homogeneity showed statistically significant differences among sites for race, age and preoperative IDSE. These differences were not unexpected, and using logistic regression while controlling for site in the covariate analyses showed that these factors were not significant predictors of outcomes; therefore, data from all sites are considered poolable. Some statistically significant differences were found in the key effectiveness study outcomes at 12 months among gender, preoperative *iDESIGN*® refractive parameters (IDSE, IDS, and IDC), laser room temperature, site/surgeon, and clinically relevant protocol deviations. Based on covariate analyses, there were no statistically significant site interactions with any of these factors, whereas gender differences were found. The female population had better outcomes with respect to MRSE within 0.50 D. There was a statistically significant effect of gender on achieving MRSE within 0.50 D ($p=0.0308$) with results for females improved (73%; 46/63) over males (54.4%; 37/68), however, the results for both genders exceeded the target value of 50%. There were no other statistically significant differences between males and females and both genders achieved the targets for the remaining key effectiveness or safety parameters. # 4. Pediatric Extrapolation In this premarket application, existing clinical data was not leveraged to support approval of a pediatric patient population. # 5. Device Failures and Replacements There were no laser failures or replacements during the course of this study. There were five (5) *iDESIGN*® *AWS Studio* System failures during the course of this study. None of these replaced units impacted patient outcomes or were associated with adverse events. Two returns were not related to a device failure or malfunction. The first return was due to user dissatisfaction with the Hartman- PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 31 {31} Shack display screen on the device. The second return was for root cause analysis of a user workflow issue. The remaining four *iDESIGN® AWS Studio* System were replaced due to software issue or hardware malfunction/failure isolated to the specific device. Two hardware related failures were due to a faulty USB port. The third failure was due to the installed software that was not enabled. ### **E. Financial Disclosure** The Financial Disclosure by Clinical Investigators regulation (21 CFR 54) requires applicants who submit a marketing application to include certain information concerning the compensation to, and financial interests and arrangement of, any clinical investigator conducting clinical studies covered by the regulation. The pivotal clinical study included 9 investigators. None of the clinical investigators had disclosable financial interests/arrangements as defined in sections 54.2(a), (b), (c), and (f). The information provided does not raise any questions about the reliability of the data ## **XI. SUMMARY OF SUPPLEMENTAL CLINICAL INFORMATION** One (1) prior clinical investigation on LASIK correction using the *iDESIGN® AWS Studio* System was conducted that included the treatment of eyes with hyperopia. An AMO-sponsored, prospective clinical investigation was conducted in Canada in 2011 under an Investigational Testing Authorization to evaluate performance and acceptability of LASIK treatment using the *iDESIGN® AWS Studio* System. Of the 143 eyes treated in the study, 19 underwent treatment for hyperopia and were evaluated through 6 months. All eyes (100%; 19/19) achieved UCVA of 20/40 or better and 84.2% (16/19) achieved 20/20 or better. Intended versus achieved MRSE met FDA target values, with 73.7% within 0.50 D and 89.5% within 1.00 D. Evaluation of safety included the percentage of eyes that lost more than 2 lines of BSCVA (5.2%), the percentage of eyes that have a BSCVA worse than 20/40 (0%), and the percentage of eyes with induced manifest refractive astigmatism greater than 2.00 D of absolute cylinder power (0%). Based on this limited dataset, device performance and safety for the treatment of hyperopia was found to be acceptable. ## **XII. PANEL MEETING RECOMMENDATION AND FDA'S POST-PANEL ACTION** In accordance with the provisions of section 515(c)(3) of the act as amended by the Safe Medical Devices Act of 1990, this PMA was not referred to the Ophthalmic Devices Panel, an FDA advisory committee, for review and recommendation because the information in the PMA substantially duplicates information previously reviewed by this panel. ## **XIII. CONCLUSIONS DRAWN FROM PRECLINICAL AND CLINICAL STUDIES** ### **A. Effectiveness Conclusions** In the clinical investigation of wavefront-guided LASIK correction of hyperopia with and without astigmatism with the *iDESIGN® AWS Studio* System and *STAR S4 IR®* PMA P930016/S048: FDA Summary of Safety and Effectiveness Data Page 32 {32} Excimer Laser System, effectiveness outcomes exceeded study targets. Refractive stability was achieved at 12 months; at this time, the proportion of eyes with a UCVA of 20/40 or better (Target ≥85%; iDESIGN® AWS 93.9%), and the proportions of eyes that achieve MRSE within 0.50 D (Target ≥50%; iDESIGN® AWS 63.4%) and 1.00 D (Target ≥75%; iDESIGN® AWS 83.2%) also exceeded the target values. Overall, study outcomes for the accuracy of treatment exceeded the key endpoint targets at 12 months for hyperopic eyes. **B. Safety Conclusions** The risks of the device are based on data collected in a clinical study conducted…