7/8/2021

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Cutting Edge Cataract Care

Paul C. Ajamian, O.D.

Board Certified, American Board of Optometry

Omni Eye Services of Atlanta

The most important factor that determines if a patient is ready for cataract surgery in the eyes of CMS is:

A. Visual acuity

B. Glare testing

C. Lifestyle complaint

D. Density of cataract

History: important but often unreliable

OD: Hand Motion

72 M with history

of GPVAL OD x 1

month only, with

problems driving

and reading out of that eye

OS: 20/20 NO APD!

And just this afternoon….

“My eye was fine

until that optometrist put

“those drops” in, and two days later

I couldn’t see”

Before you refer:

Send a letter

No not this letter!

Before you refer: Send a letter

Ahhhh Much better!

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Vision and Refraction

Visual Acuity (D & N)

Pinhole should be part of vision

Monocular diplopia or glare alleviated?

Glare testing or BAT (medium setting), or

“Ambient Light” (room lights on)

for any patient who is 20/40 or better

If that doesn’t work, try this………………….

Ocular Health

Slit Lamp

Dilated Fundus Exam

BEFORE YOU REFER: STOP AND THINK!

What can affect the results of

cataract surgery and premium IOL’s?

Surface disease/MGD

Chalazia

Pterygia

Corneal dystrophies and degenerations

Undetected pre-op retinal conditions

You wouldn’t send

this…..

So why send this? Could this be a problem?

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Clean Up Crew

Bumpy Corneas could mean Bumpy Post-Op Refraction 55 y/o F c/o months of

monocular f.b. sensation,

contact lens intolerance,

tearing, and mild decrease

in vision

BEFORE AND AFTER:

BCL in placeNSAID and antibiotic

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MILKY NS

Where are We?

Cataract Surgery is now refractive

Patients deserve to know about the newest technologies

Doctors of Optometry should be the authority, not just the referrer

Has surgery changed that much?

NOT REALLY….UNTIL 2012 WHEN THE

LASER CAME ALONG TO BUMP AHEAD

OF PHACO

AND A GLIMPSE INTO THE FUTURE……

3D SURGERY!

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The Changing Face of Cataract Surgery

Large, rapidly growing demographic

Educated, financially secure

Increased life expectancy

Longer working careers

Demand high quality vision (reading,

distance, night vision)

New requirement for near vision (computers)

Unwilling to compromise active lifestyles

The Baby Boomer Generation: 10,000/day reaching 65

LSX11513SK

Femtosecond

Laser Assisted

Cataract

Surgery (FLACS)

“Are you going to do the surgery with the laser?”

The future of cataract surgery available now…ALTHOUGH MANY SURGEONS DON’T THINK THEY NEED IT!

OCT Guided Refractive Cataract Surgery

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Reproducible Primary and Secondary Incisions

Computer programmed

incisions

• % depth

• Length & position

• Visualization of placement

Real time Corneal thickness

Customizable “planed”

incisions (up to 3)

Laser Arcuate Incisions: For Best

Unaided Distance vision

• Square edge

• Uniform depth (no ripples)

• Precise, reproducible

– Arc shape

– Arc length

– Diameter

Steinert RF, Application of the Femtosecond Laser in Cataract Surgery for the Creation of Multi-Planar, Self-Sealing Incisions, ASCRS 2010, Boston

Manual Arcuate Incisions

Manually executed by “tracing” corneal marks with handheld diamond knife

Inconsistent depth control

Unpredictable effect due to imprecise wound architecture and depth

MANY STILL DOING THIS FOR THE $$$$$

LSX11513SK

Laser Corneal Incisions- Astigmatism Management

Precise incisions made in the O.R.

Ability to titrate amount of correction

May be opened intraoperatively

May be opened postoperatively

Opening an Incision In-Office

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Laser Capsulotomy

Precise and reproducible

• Geometrically superior circle (vs. Manual

Capsulorhexis)

Automatic Centration and Size

• Based on limbus and (dilated / undilated) pupil

Capsular Edges

• Closest to manual capsulorhexis in terms of edge

uniformity*

* Bala C, Meades K. SEM of femtosecond laser capsulotomy edge: An inter-platform

comparison. Accepted for publication in Journal of Cataract and Refractive Surgery

Why Is Capsulotomy Size

Important?

▪ Effective lens position (ELP) more predictable

▪ Refractive outcome more predictable

▪ Less frequent PCO

▪ Less chance for anterior capsule phimosis

Impact of ELP on IOL Predictability

If IOL is 0.5 mm posterior to the

assumed plane, a 21 D lens will

produce only 20 D of correction

If IOL is 0.5 mm anterior to the

assumed plane, a 21 D lens

will produce 22 D of correction

Hyperopic Myopic

1Norrby S, Sources of error in intraocular lens power calculation,J Cataract Refract Surg, 2008;34:368-376.

Additional Lens Fragmentation for Versatility

Customizable Lens Fragmentation based on lens characteristics or surgeon preference

Cylinder Chop Hybrid Frag

Benefits of Lowering CDE(Cumulative Dispensed Energy)

Less ultrasound energy (CDE)

Short term

* decreased k edema 1 day post-op

* faster visual recovery

* decreases complications intra-op

Long term

* decreased rate of endothelial cell loss

* pseudophakic bullous keratopathy less likely

LSX13070SK 42

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FLACS Video FLACS Video- Narrow Angle

Ring Around the RosieFLACS Video-OR

How to Present to Patients?

Laser makes more precise, accurate incisions

3D OCT Image guided surgery vs manual procedure

Customized for the patient’s eye

Less energy/less inflammation

Manage low to moderate astigmatism

Potentially safer

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Laser Cataract Surgery:

Who is a candidate?

Premium lens patients

Astigmatism less than 1 diopter

Guttata/Fuch’s /Mature/Traumatic cataracts

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Important to Explain

What’s covered

❑ Cataract removal❑ Monofocal lens

resulting in good

distance vision if no astigmatism

❑ Will need readers

What’s not covered

❑Astigmatism Tx with laser

❑Toric lenses❑Multifocal lenses

❑Additional testing❑ Interoperative

Aberrometry

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And to Make Something Good Even Better….The Cataract

Refractive Suite

Minimize opportunities for error

Multiple technology integration

1. A scan

2. Topography

3. Femtosecond cataract laser

4. Operating microscope

Preoperative and intraoperative

Better multifocal centration/toric alignment

Improve outcomes

Cataract Refractive Suites

Verion (Alcon)

1. Only fully integrated system available (LenSx)

2. Intraoperative aberrometry (Ora) soon

Callisto (Zeiss)

1. No FSL compatibility, (?Optimedica in future)

2. No intraoperative aberrometry

Cassini/TrueVision 3D

1. Collaboration with LensAR

2. Not commercially available

Cirle 3-D/ Spectria

1. Collaboration with Victus (B&L)

2. Not commercially available

The Verion™ Image Guided System

Designed to help consistently achieve the

cataract refractive target.

VERION™ Image Guided System

GUIDE

VERION™ DIGITAL

MARKER

VERION™ REFERENCE

UNIT

VERION™ Image Guided SystemACQUIRE IMAGE

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VERION™ Image Guided SystemTRANSFER TO PLANNER

Image Guided Technology

OR Video- Toric Alignment Verion- Multifocal Centration

The Argos™ Image Guided System

Designed to help consistently achieve the

cataract refractive target.ARGOS®

Swept Source-OCT Biometer

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Superior Acquisition Rate Even in Dense Cataract

• In the dense cataract cases, acquisition rates with ARGOS are 26% higher compared to

IOLMaster 700, thereby reducing the need for Ultrasound biometry by 72% (Figure 2)

Sources: 1. Tamaoki A et al. Ophthalmic Res. 2019 Mar 19:1-13.

2. Mylonas G et al. Acta Ophthalmol. 2011 May;89(3):e237-41.

Figure 2. Acquisition rates comparison between ARGOS and IOLMaster 700 in ≥Grade IV cataract

patients#

#The acquisition rates were sourced from a large, retrospective, single-center study conducted in six hundred and twenty-two eyes of 622 Japanese

patients, who had undergone biometry (before cataract surgery) with ARGOS, IOLMaster 700 and OA-2000 biometers2

Tamaoki

20191

(N = 99 eyes)

Tamaoki

20191

(N = 99 eyes)

89.9%

63.6%

26 %

More

36.4%

P<0.0001*

*Cochran Q test ARGOS

ARGOSARGOS IOLMaster

700

IOLMaster

700

IOLMaster 700

Ac

qu

isit

ion

Su

cc

es

s R

ate

s

Acq

uis

itio

n f

ailu

re

rate

s

72 %

Lower

10.1%

Leave it free for chapter bar menuOutline Cataract Optical Biometry SummaryComparative EvidenceBiometers

Argos Specialty Lens Planning

The ORA System® with VerifEye®:

• The ORA™ System uses wavefrontaberrometry data in the measurement and analysis of the refractive power of

the eye (i.e. sphere, cylinder, and axis measurements)

• Real-time, intraoperative refractometer

• Measures anterior and posterior corneal astigmatism

• Minimizes post-op refractive surprises

The ORA™ System with VerifEye®

Technology

The ORA System® with VerifEye®: Real-time, streaming feedback and guidance

Streaming data to select proper IOL, position toric IOLs within 1° and decide if a toric is necessary

In your ocular On your monitor

©2016 Novartis 05/16 US-ORA-16-E-1963

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62 WF….”may need Toric” OD .5 OS: .7

Who wins? Topography vs

Biometry K’s

SISTER:I WOULD HAVE PLANNED FOR LENSX OD AND TORIC OS

What did ORA SAY?:

TORIC OD

NO TORIC OS

3 wks P/O:

Unaided VA

OD: 20/20OS : 20/20

OD’s Role IS Crucial in IOL Decision

Be involved in decision

making PREOP

It all starts with patient

goals and topography

?Monovision

?Eliminate distance Rx

?Eliminate Rx totally

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Patients Want YOUR advice

Easier conversion ,

better experience

Embarrassing if they

hear it for first time from surgeon

Prepare them regarding out-of-

pocket costs

Acrysof Toric- Extended Power Range

SN6AT3- 1.03D corneal plane

SN6AT4- 1.55D

SN6AT5- 2.06D

SN6AT6- 2.57D

SN6AT7- 3.08D

SN6AT8- 3.60D

SN6AT9- 4.11D

Technis Symfony lens The first toric presbyopiclens: up to 2.75 cylinder

Avoid this lens with:

Myopes with large pupils

Anyone who does a lot of night driving/activities at night

Problems with lens?

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Technis Symfony Plus (J & J Vision) in the pipeline

Stronger near power for reading

Reduced dysphotopsias

Violet light blocker

PanOptix Trifocal IOL Approved on August 27, 2019:ReStor taken off market soon after

THE FIRST AND ONLY TRIFOCAL IOL IN THE U.S.

AcrySof® IQ PanOptix® and AcrySof® IQ PanOptix® Toric IOLs are innovative trifocal lenses that offer you the thrill of delivering a level of refractive performance that breaks free from tradition.

• 20/20 near, intermediate and distance vision

is now possible*,†,1

Proprietary ENLIGHTEN® Optical Technology

99.2% of patients would have had the same

lens implanted again**,2

Available in toric for astigmatism correction

•

•

•

*Based on mean value of binocular defocus curve at near, intermediate and

distance at 6 months (n=127).†Snellen VA was converted from logMAR VA. A Snellen notation of 20/20-2 or better indicates a logMAR VA of 0.04 or better, which means 3 or more of the

5 ETDRS chart letters in the line were identified correctly.

**Response to the following question on IOLSAT questionnaire (Ver. 1.0, Dec. 20,

2018) at 6 months post-op: “Given your vision today, if you had to do it all over,

would you have the same lenses implanted again?”

© 2019 Alcon Inc. 8/19 US-ACP-1900019

UNDENIABLE PATIENT SATISFACTION2

Data collected 6 months post-op:

99.2%of patients would have had the

same lens implanted again.‡,§,2

‡ n=127§Response to the following question on IOLSAT questionnaire (Ver. 1.0, Dec. 20, 2018) at 6 months post-op: “Given your vision today, if you had to do it all over, would you have the same lenses implanted

again?”

© 2019 Alcon Inc. 8/19 US-ACP-1900019

PanOptix candidates

Are candidates for bilateral implantationHave not undergone refractive surgery

Do not have glaucoma or retinal pathology

Have a healthy cornea

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THE GOOD:

72 F PhD R.N. understands nothing perfect in healthcare, plays Bridge constantly, doesn’t want to wear glasses and IS A VERY RELAXED PERSONALITY

THE BAD:

54 F PhD in Physics, spent 50 minutes with her on surgery day answering questions, IS NOT AT ALL RELAXED, tried talking her out of lens, she demanded it and when we checked BP 240/125

THE UGLY:

61 M that the OD referred

without a letter, knew that he was demanding and rejects every CL and Spectacle Rx change, but doesn’t tell us….and we do a ReStor on

patient which he hates

OUR PATIENTOUTCOMES SO FAR..300 pts

.~..a..o

..w

. . . . . . . 00

,.

"

...-·

AlconAlcon

•

© 2019 Alcon Inc. 8/19 US-ACP-1900019

VIVITY

READY FOR LAUNCH

MEDIA RELEASE – THURSDAY, MARCH 12, 2020

Alcon Announces European Launch of Vivity, the Only Presbyopia-correcting Intraocular Lens With X-WAVE

Technology

US LAUNCH OCTOBER 1: OMNI LAUNCH SEPTEMBER 9

LENS AVAILABLE TO MOST SURGEONS AT THE START OF ‘21

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55 YO white male

Moderate drusen in both eyes, Mom lost central vision to wet AMD

at age 60, on AREDS formula for 3 years

Really wants the PanOptix, has a friend who got it and is thrilled, has

been waiting his whole life to get rid of glasses

Devastated at June visit to hear he was not a candidate…..so he

postponed the surgery until September, the day after Vivity

approved!

1 day post op

No glare

20/25 (drusen and pigment changes explain that) and J2 at near

with decent range

Visual disturbance profile similar to a monofocal

He knows he will need “light reading glasses” at times

BOTTOM LINE: YOU CAN USE THIS LENS ON ANYONE YOU WOULD PUT

A MONOFOCAL LENS IN

Light Adjustable Lens Drawbacks

Corrects only small amount of cylinder

The month after surgery is labor intensive for doctor and patient

NO UV EXPOSURE

3 POST OP VISITS

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Light Adjustable Lenses: So What’s the Point?

Designed for surgeons who won’t use technology like ORA and FEMTO

But they are probably the last who will take on this project

Its not a multifocal

It does nothing more than a regular IOL

SO…Why not use technology and get the Rx right initially

IN THE

PIPELINE:

FineVision Triumf (PhysIOL) Trifocal

IC-8 IOL (AcuFocus)

LENSES FOR THE FUTURE

Juvene (LensGen) Curvature changing

fluid optic IOL

enVista Trifocal (B & L)

Eyhance and Eyhance Toric (J and J)

Eyhance: not approved as a premium lens, but is it?

Johnson & Johnson Vision Receives FDA Approval For Next Generation Monofocal Intraocular Lens - TECNIS Eyhance™ And TECNIS Eyhance™ Toric II IOLs - For The

Treatment Of Cataract Patients

First innovation in monofocal technology in 20 years is designed to slightly extend the depth of focus[1]

Pricing at $195 compared to an average monofocalprice of $60 to $100, but you cannot bill the difference

Lens chosen…….time to refer

Selecting The Right Surgeon

Closest not always the best

Very skilled/consistent results

Communicates well with patient & OD

Understands comanagement/history of

supporting optometry/makes you look good

Welcomes OR observation

Organized/efficient practice

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Post-Op Care

Don’t abdicate it to someone else

Post-Op management of premium IOL’s

and LACS fairly straightforward

Be positive on Day 1: its early, results

won’t always be perfect

Why not do post op care?

I’m not on Medicare

“I’m not set up for it”

Takes too much time for the $120 I get from Medicare

Just not interested in doing this, let the

surgeon do it even though patient lives 10 minutes from you and an hour from MD

Once you drill it down….

Medications are the

real time drain on post-op care!

CASE IN POINT: 68 YO

No Trimoxi due to Levaquin allergy

Seen 6.18.20 for her

second eye surgery

s/p PCIOL OD 6.1.20

with good result until Saturday 6.13.20

when she noted significant light sensitivity

Review of drops:

Tobramycin

Pred Forte

Bromsite

Confused on use of drops…so….”may I see them?” I didn’t bring Review of drops:

Tobramycin: used as directed, sort of (still using)

Pred Forte: is in the Bromsite box, using BID

Bromsite: is in the Pred box, using QID but ran out

2+ cell and flare Other options? Less Drops

CatarActiv3

Designer Drugs

Chattanooga

888-935-2930

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Imprimis Dropless Therapy™

The modality of “Dropless” therapy involves the injection of an eye-compatible compound at the end of the cataract case as prophylaxis against inflammation and infection.

Currently, there are 2 combinations available only from Imprimis:

Tri-Moxi: triamcinolone acetonide and moxifloxacin hydrochloride

Tri-Moxi-Vanc: triamcinolone acetonide, moxifloxacin hydrochloride and vancomycin

Imprimis Dropless Therapy™

The modality of “Dropless” therapy involves the injection of an eye-

compatible compound at the end of the cataract case as

prophylaxis against inflammation and infection.

Currently, there are 2 combinations available only from Imprimis:

Tri-Moxi: triamcinolone acetonide and moxifloxacin

hydrochloride

Tri-Moxi-Vanc: triamcinolone acetonide, moxifloxacin

hydrochloride and vancomycin

Case in Point

88 YO FEMALE presents for surgery on her

second eye

Where did you get your first eye done?

Rome, GA

Arthritis prevented her from using drops, daughter had to drive 50 miles each way

several times a day to get at least two

doses of drops in, often spending the day to do all 4 sets

Refused to have second eye done

OPTOMETRIST: WHY?

PATIENT: I can’t deal with the drops and will not burden my daughter again

OPTOMETRIST: I KNOW A PRACTICE IN

ATLANTA THAT DOES DROPLESS SURGERY

PATIENT: GREAT! SIGN ME UP!

Dropless Therapy™ Patient Benefits

Physically/mentally challenged patients

Eliminate compliance challenges of drops

Lift burden from family members/caregivers

Put patients with “Eye Drop Phobia” at ease

Avoid pharmacy issues: refills, generics

Help patients in nursing facilities

Aid patients without insurance, money or

access to sample drops

➢ Osteoarthritis

➢ Rheumatoid Arthritis

➢ Scoliosis

➢ Parkinson’s

➢ Kyphosis

➢ Alzheimer’s

➢ Dementia

➢ Drop Therapy with branded medications can cost over $400

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Just hanging around!

FOR COAG PATIENTS WITH CATARACTS…….

MIGS

Too many options!

Istent G1

Istent Inject

Hydrus Microstent

Kahook Dual Blade Goniotomy

OMNI Procedure

Xen Stent (bleb forming)

MIGS characteristics:

Ab-interno

Clear cornea

No stitches

Recovery is quick

Safety is excellent

Esp compared to Tubes/Trabs

Purpose is to help control IOP and reduce drop burden

I-Stent

Bypass of trabecular meshwork

G1

Modest pressure reduction, decreased dependence of meds

G2 = I-stent Inject

Smaller stents with different design

Injector preloaded with two Istent inject stents

Two stents better than one!

iStent coming attractions!

iStent INFINITE 3 iStents instead of 2 , covering 8 clock hours instead of 5…….. coming 2021

iStent SA for STAND ALONE……..can be done without cataract surgery….coming 2023

iStent W …for wide flange….available this year

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Istent Inject Hydrus Microstent

8mm long

Nitinol material (Nickel Titanium alloy)

Wider device = creates a scaffold of schlemm’s canal

SCAFFOLD

Schlemm’s Canal in Natural State

Schlemm’s Canal with Hydrus

Hydrus (Ivantis): 78% of pts medication-free after 3 yearsPATIENT DOES NOT NEED TO BE ON ANY MEDICATION (0-4 MEDS) FOR APPROVAL OF THIS DEVICE

Kahook Dual Blade (KDB) Goniotomy

Performs an

excisional goniotomy

Strip of trabecular

meshwork excised

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OMNI Procedure

OMNI is a device that performs two

distinct procedures

1. Viscocanaloplasty

2. Trabeculotomy

Reimbursement Realities of MIGS

Medicare YES

Commercial insurance…VARIABLE

but often NO

Important to know if its covered

before you promise it to patients

Take Home Points

Work with leading surgeons who are on cutting edge of technology

Go visit their office and ASC and see for yourself what patients will see

Be involved in post op care: we earned it

Compliance with glaucoma and post op meds a nightmare…now we have some answers!

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