Advanced Technology IOLs – Multi-focal Implants (Part 2)

Dr. M. Ronan ConlonMidwest Eye Care Institute

SaskatoonFebruary 2nd, 2012 – Saskatoon

Club

Objectives

Share my experience with multi-focal implants

Patient video – highlighting many of features of multi-focal implants

Patient selection/Education C0-Management Managing the Unhappy Patient

Canadian Projected Population by Age Group2010 to 2031

60 t

o 6

4

65 t

o 6

9

70 t

o 7

4

75 t

o 7

9

80 t

o 8

4

85 t

o 8

9

90 t

o 9

4

95 t

o 9

9

>100

0.0

500.0

1000.0

1500.0

2000.0

2500.0

3000.0

201020212031

Mill

ions

Population trends in Canada predict a significant increase in patients requiring cataract surgery in the next 15 years

Advanced technologies are now available to these patients to enhance their visual function

Projected population by age group and sex according to three projection scenarios for 2010, 2011, 2016, 2021, 2026,2031 and 2036, at July 1. Statistics Canada.

Age Group

A brief review

Advanced Technology Lenses (Part 1) – Toric implants – presented September 15th, 2011

It is estimated that 35% of the population has clinically significant

astigmatism

Cylinder Distribution

0.0

10.0

20.0

30.0

40.0

50.0

<.5 <1 <1.5 <2 <2.5 <3 <3.5 >3.5

Moderate 1.0

– 2.0D 25%

Severe >2.0 D

10%

Cylinder D ( < )

% o

f P

ati

en

ts

N = 10,411

AcrySof® IQ TORIC IOL: Astigmatism Correction

7

Rotational Stability

81.1% of patients were ≤5º of intended axis

97.1% of patients were ≤10º of intended axis

less than 4º average rotation 6 months after implantation

Cylinder Powers

9*Based on average pseudophakic human eye.

Estimated Percent of Cataract Patients with Astigmatism

0.5D 4D+

Toric Implants – My Practice

700 (87%)

94 (12%)

11 (1.0%)

2010 – 805 Cataract Cases

Aspheric

Toric

ReSTOR

ReSTOR Toric 54

6 (65%)

166

(20%)

73 (9%)

47 (6%)

2011 - 850 Cataract Cases

AsphericToricReSTORReSTOR Toric

Dilated exam post Toric Implantation

Toric Implant at axis 90 degrees

• Toric lenses are designed to work with the shape of your cornea to focus light to a single point at the back of your eye to improve your quality of vision.

• By doing this, Toric lenses will make you less dependant on your glasses for distance vision

• Toric lenses only correct astigmatism and do not correct presbyopia

• You will have to wear reading glasses after cataract surgery

Key points for patients to understand

• Toric lenses have become the standard of care for astigmatic cataract patients in my practice

• Patients see better if they have a toric implant – it’s that simple

• These lenses work extremely well

Key points for patients to understand

Multifocal IOLs

The Goal: To make patients less dependant on their glasses for all distances

Multifocal Implants

Diffractive ReSTOR +3.0 Technis AcriLisa (Europe)

Zonal Refractive ReZoom

Accommodating Crystalens Synchrony

What is Apodization … how does it work?

It’s a light management system

Microscopic steps sends light where you need it, when you need it

Apodization

Anterior Apodized Diffractive Aspheric Surface

9 apodized diffractive steps for +3.0D add power and balanced light energy management

Negative 0.1 micron spherical aberration factor corrects for the positive spherical aberration of the cornea

Posterior Toric Lens Surface Posterior toric surface with axis

marks Allows the lens to correct pre-

existing corneal astigmatism

18

Correction Ranges Detail

IOL Model Cylinder Power @ IOL Plane

Cylinder Power@ Corneal Plane*

Recommended Corneal Astigmatism

Correction Range(Online Calculator Limits)

SND1T2 1.00 0.68 0.50 to 0.89 D

SND1T3 1.50 1.03 0.90 to 1.28 D

SND1T4 2.25 1.55 1.29 to 1.80 D

SND1T5 3.00 2.06 1.81 to 2.32 D

19*Based on an average pseudophakic human eye

AcrySof® IQ ReSTOR® IOL +3.0 D [N=116]Mean Defocus Curve for AcrySof® IQ +3.0 D ReSTOR® IOL

Binocular, Best Case, 6 Months Postoperative

Source: AcrySof® IQ ReSTOR® IOL Package Insert

Binocular Defocus Curve

∞

Refraction (D)

70 cm50 cm

40 cm33 cm

20/25

20/32

20/40

20/50

20/63

20/80

20/100

20/20

+1.00 +0.50 0.00 -0.50 -1.00 -1.50 -2.00 -2.50 -3.00 -3.50 -4.00

20

Premium Implants – My Practice 55 bilateral ReSTOR

implantations so far

30 have completed 6 month Late Outcome Assessments – measuring UCDVA, UCNVA, BCDVA, BCNVA, refraction and survey of visual activities and function

546

(65%)

166

(20%)

73 (9%)

47 (6%)

2011 - 850 Cataract Cases

As-pheric

Toric

ReSTOR

ReSTOR Toric

Premium Implants - Results 98% would have same implants again Mean UCDVA 20/25 (range 20/20+ to

20/30-, UCNVA 20/25 (range 20/20+ to 20/40)

All of the patients with UCVA worse than 20/25 are due to uncorrected astigmatism >0.75 D; all correct to 20/20 near and distance with this cylinder corrected

Success with Premium IOLs

Richard L. Lindstrom – August 2009 OSN

Perspective• Careful patient selection• Reducing patient expectations• Achieving the desired refractive

result

Success with Premium IOLs

Richard L. Lindstrom – August 2009 OSN

My conclusion after 25 year of studying the premium IOL field, is that the level of patient satisfaction is NOT dependent of careful patient selections

I do NOT believe that patient satisfaction is really significantly influenced by extensive efforts to reduce patient expectations

Patient selection is LESS IMPORTANT THAN SURGEON PERFORMANCE if spectacle independence is the desired outcome

Success with Premium IOLs

Richard L. Lindstrom – August 2009 OSN

Every refractive cataract surgeon must appreciate that it is the REFRACTIVE OUTCOME THEY GENERATE, NOT THE PATIENT or EVEN THE TECHNOLOGY they select, that is the primary determinant of patient satisfaction and word of mouth referrals.

Surgivision/Datalink

40,000 premium lens implants

60% (24,000) eyes left with > 0.75D untreated residual K astigmatism

Minimum goal less than 0.50

Correction of cylinder is extremely important

Patient Education

What can you do?

Optometry has a key role in the education and counsel of patients seeking guidance in new implant technology

Change in Mindset

Acceptance and Embracement of a change in practice model From medicare model – “treatment for

pathology”▪ High volume, efficient, low cost care

Patient orientated model – “treatment for Quality of Life”▪ High quality, personalized to patients needs,

expectations, and desires, patient pay

Mindset of the Presbyopic Refractive Patient

Patients are interested in lifestyle, not pathology and are happy to pay for the enhanced quality of life

Old paradigm: Patient want to see better than they did with their cataracts

New paradigm: Patients want to see better than they did before they developed cataracts

Define• Clouding of the natural

lens that allows less light to pass through to the retina

Symptoms• Blurred vision• Dull colors• Poor night vision• Sensitivity to light

Treatment• ONLY treatment is to

have it surgically removed and replaced with an artificial lens

Patient Education

Multi-focal Implant• Designed to correct vision

near, far, and in-between, for the best chance at freedom from glasses.

Toric Implants• Designed to correct both

cataracts and astigmatism at the time of surgery. Glasses will likely be needed for near vision.

Multifocal Toric Implants• Provides clear distance

vision. Glasses will likely be needed for near vision and possibly for distance vision.

Explain Their IOL Options

Take into account:▪ Lifestyle▪ Astigmatism▪ Preexisting ocular conditions, i.e. dry eye▪ Pathology – rule out retinal pathology

Consider Their Needs

Astigmatism

Basic IOL

Toric IOL

ReSTOR Toric

No Astigmatism

Basic IOL

ReSTOR• regular astigmatism

• healthy eye?

• <2.5D of

cy pre-opShared Decision

Making!

Key points for patients to understand

• ReSTOR is a multifocal lens which make you less dependant on glasses after cataract surgery at all distances

• Although 20/20 vision is not guaranteed, 80% of patients report not needing glasses after surgery

• 20% of patients report needing glasses for specific activities such as working on a computer or reading in dim light

• Glare and halo around lights at night may be reported after surgery, most patients adapt within a few weeks

• Adequate light is recommended for ideal reading vision

C0-Management – Pre and Post Operative Care

C0-Management OD/MD

Expansion of patient variety and opportunity for practice growth

With the development of toric, multi-focal, and multi-focal toric IOL’s cataract surgery has evolved into “refractive cataract surgery”

Shared practice experience and opportunity for higher degrees of patient satisfaction

Optometrists play an integral role in selecting and recommending IOL technologies

Saskatchewan has a larger geographical area and travel is a significant issue for patients

Before referring your patient

Patient should discontinue contact lens wear two weeks prior to axial length and keratometry measurements – more accurate IOL measurements

Discuss with your patient the various IOL options – regular, toric, multi-focal, and multi-focal toric

Advise your surgeon and what you think would work best – make a recommendation

Before referring your patient Manage Ocular

Surface Disease Treat Dry Eye Manage Eyelid

Margin Disease

What to Expect After Surgery – One Day Post Op

• Many cataract surgeons now perform same day post evaluations, and patient go home same day

• Examination• Vision is usually 20/40 or better• Anterior segment – cornea generally clear to mild edema,

AC inflammation minimal +1, eye should be comfortable, AC deep, wound sealed

• Lens centered• IOP – 10 to 25 (contact surgeon if outside these

parameters)• Post Medications – Vigamox TID x 1 week, Maxidex TID x 4

weeks, Nevanac TID x 4 weeks• Follow visit in 3-4 weeks, and sooner if concerns

Complications – Day 1 visit IOP spike

25 – 30 mmHg – Alphagan P BID x 1 week > 30 mmHg – contact surgeon

Bullous keratopathy Lubricated surface, consider Muro 128 qhs Usually related to increased IOP, endothelial comprise

Tilted IOL Not an emergency, but contact surgeon

Peaked Pupil Not an emergency, but contact surgeon, check IOP and wound leak

Retain lens fragment Increased steroid 6X/day, and contact surgeon

Retinal detachment Urgent – contact surgeon

What to Expect After Surgery – One Month

• Conduct a dilated fundus exam to check for cystoid macular edema (CME)

• Discontinue drops• Prescribe spectacles, if necessary

• 20% of multi-focal toric implant patients require spectacles for some activities

• Decreased Vision• Check for ocular surface disease – dry eye,

MGD, EBMD• IOP• Fundus - CME

What to Expect After Surgery – One Month – Potential Problems

Lens tilted Inferior lens out of

bag May or may not

require adjustment

Persistent Bullous Keratopathy Control IOP Muro 128 gtts/ung

What to Expect After Surgery – Three Months

• Patient should have bilateral lenses

• Check visual acuities at appropriate distances

• Survey the patient for their satisfaction

When to Refer to the Ophthalmologist

Posterior capsular opacification (PCO)• Treated with a Nd:YAG laser

Persistent tear film abnormalities unless you are comfortable managing it

Residual refractive error if the patient is interested in a surgical solution

The Unhappy Patient!

Cylinder and Residual Refractive Error

Cornea and OSN Capsule CME Centered

Ocular Surface Disease

Optimizing the ocular surface very important

Options Artificial tears Restasis Serum based tears Punctal plugs Nutritional

supplements – omega 3’s

Eyelid Disease

Lid hyperthermia Hot compresses or lid

scrubs Nutritional

supplements Topical azithromycin

bid 2 days then qd for 1 month

Tobradex Severe cases

Oral doxycycline 50 mg PO daily

Capsule Opacification

Consider Yag laser Avoid Yag laser if

explantation still a consideration!

Cystoid macular edema

NSAID’s mandatory

Significant reduction post operative CME

Thank You