Advances in IOL Technology -Muliti-Focal Impants
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Transcript of Advances in IOL Technology -Muliti-Focal Impants
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