Comanagement of Cataract Surgery and premium IOLs
J. Alberto Martinez, M.D.Visionary Ophthalmology
May 18, 2014
Visionary Ophthalmology’s criteria for Co-management
• Is it MORAL?• Is it ETHICAL?• Is it LEGAL• If this three criterion are met, then we ask
another question: Is it PROFITABLE?• Then it is OK to do
Why Comanage with VO?
• We have a well deserved reputation for excellent outcomes
• In technology, we are two years ahead of the competition.
• We have one of the best operating rooms in the planet• We are continuously seeking to improve our outcomes• Loving kindness is the driving force at VO
Refractive cataract surgery
• Cataract surgery has become the most sophisticated “refractive” procedure
• Patient expectations are increased • “Close” is no longer “good enough” • Astigmatism is the biggest buzzword now• The promise of effective astigmatism
correction is here!
Why do we treat astigmatism?
• Quality of vision after cataract surgery
• Quality of life after cataract surgery
Astigmatism in the Population
• Astigmatism – According to Dr. Hill’s analysis, 37.8% of patients
with cataract have more than 1.0 D of preexisting corneal astigmatism
Surgical Correction of Astigmatism
• Methods of correcting astigmatism – Operating on steep axis – Limbal relaxing incisions – Astigmatic Keratotomy – LenSx Laser – Toric IOLs – Toric phakic IOLs (Visian)– Post operatively – Laser refractive surgery – Astigmatic Keratotomy
LenSx arcuate incisions
Astigmatism: first question
• Is the astigmatism corneal or lenticular? • Cataract evaluation: current glasses
-3.00 +1.25 x 90 • Keratometry: 45.00/45.50 x 90 • Cataract evaluation: must obtain
keratometry/topography before the patient sees the doctor
Astigmatism: caveat
• The post-lasik patient who has been emmetropic for years may have lenticular astigmatism
• Cataract surgery will UNMASK this corneal astigmatism that was created with the lasik to treat the lenticular astigmatism
• Review topography carefully
Patient Selection: Toric IOL
• Cataract patient with ≥ 0.75 diopter of pre-existing corneal astigmatism
• Consider surgically induced astigmatism – Size and location of your incision – How much cylinder do you induce (Mine is 0.50 D)
• What is the expected residual cylinder post-operatively
Toric IOLs
• Visian Toric ICL (Not approved yet)• Acrysoft Toric IOL• Tecnis Toric IOL• (Staar toric) IOL (Old, not used anymore
Staar Toric IOL
-Rotated after placement-Popular 10 years ago-Set back for Torics IOLs -No one uses it anymore
Visian Toric ICL• This is a PHAKIC IOL• Visian is a great lens for high myopes not
correctable with LASIK• An advisory panel just approved the Toric
version• Long awaited in the US
Visian Toric ICL
Visian Toric ICL
• More than 100,000 placed worlwide• 2% chance of cataract formation (Risk factors:
higher myopes and age )• Easy to rotate into place• Rotationally Stable• Learning curve: Must take a course to learn
the nuances.
AcrySof Toric IQ Design Characteristics
• Design – Acrylic Single-Piece
platform – Posterior toricity – Toric axis marks
Understanding AcrySof® IQ Toric IOL Benefits
• Toricity – Rotational stability – Reduction of residual refractive cylinder – Increased spectacle-independent distance
vision – Wide range of cylinder powers
• Asphericity – Enhanced image quality
• Reduction in spherical and total higher order aberrations
• Increased contrast sensitivity • Improved functional vision
– Thinner edge profile
Rotational Stability• Generally, for every 1º of IOL
rotation, 3.3% of lens cylinder power is lost2
• A complete loss of cylinder power can occur with a rotation of >30º2
• Check the axis of the IOL post-op
Cylinder Powers
A wide range of cylinder powers means more candidates can benefit from AcrySof® IQ Toric IOL.
Toric Calculator
• Easy Input – Patient data – Keratometry – IOL spherical power – Surgically induced
astigmatism – Incision location
Toric Calculator, continued
• Powerful output – Recommended IOL model
and spherical equivalent power
– Optimal axis placement – Magnitude and axis of
anticipated – residual astigmatism
Pearls for the Toric
1. Keratometry
2. Pre-operative marking
3. Operative marking and final orientation
Hitting the Post-Operative Refractive Target : Keratometry
• One to one relationship in potential error – A 1 diopter error in K readings can yield a 1
diopter error in refractive outcome • IOL Master K’s: version 5 (2.6mm OZ) • LenStar K’s (2.3mm OZ) • Manual keratometry (3.2mm OZ) – Skilled technician required – Calibrate keratometer daily
Pearls for the Toric
• Compare topography astigmatism axis to keratometry axis
Hitting the Post-Operative Refractive Target
Keratometry • The most common error in keratometry is
secondary to ocular surface disease (OSD)
• Treat OSD before referring patient for cataract surgery
Pearls for the Toric
1. Keratometry
2. Pre-operative marking
3. Operative marking and final orientation
Posterior Corneal Astigmatism• A mystery being revealed• Generally as we age we get more against the
rule• Rule of thumb: Subtract 0.25 D to with the
rule• Add 0.50 D to against the rule astigmatism
Toric marking at the slit lamp
Pearls for the Toric
1. Keratometry 2. Pre-operative marking
3. Operative marking and final orientation
Preop marking: Verion system
ORA: Optiwave refractive Analysis
• httphttp://getorasystem.com/
ORA- Verify
IOL Alignment • Gross Alignment – Rotate IOL clockwise to
approximately 15 degrees short of desired position
– Completed while the IOL is unfolding in the capsular bag
– Can be rotated after IOL has unfolded, if needed, but take care to have capsular bag inflated with OVD
IOL Alignment
• Final Alignment – Carefully rotate IOL
clockwise onto the intended axis of alignment
– Tap IOL down into capsular bag to seat lens in place
Lens Based Treatment for Astigmatism
Acrysof Toric IQ • Precise and Accurate • Predictable Outcomes • Permanent • Safe and Convenient • Aspheric Optics
Toric IOL
• Post-operative spherical equivalent • Post-operative refractive astigmatism
Residual Astigmatism after Toric IOL
• Measure post-operative refractive astigmatism • Confirm axis of Toric IOL with Toric IOL
Calculator • Rotate Toric IOL to the correct axis
Technis Toric-Three point touchRotational Stability (2.7 degrees)-Newer in market, less experience-Higher Abbe number= less chromatic aberration-Does not block blue light (improved scotoptic sensitivity)
Presbyopic IOL Options/Optics
“Presbyopic” IOL’s
• Crystalens AO (B&L) • Tecnis Multifocal (AMO) • ReSTOR Aspheric (Alcon) – SN60D1 (3.0)
Diffraction
• The spreading and bending of light as it passes through discontinuities (i.e. steps or edges)
• In an optical system, light can be diffracted to form multiple focal points or images
• AcrySof® ReSTOR® Aspheric • AMO Tecnis Multifocal
Restor Platform
• Refractive optics • Diffractive optics • Apodization: the treatment of the diffractive
optics • Aspheric optics
Apodization
• Definition: A gradual modification in the optical properties of a lens from its center to its edge.
• Apodization is used in microscopy and astronomy to improve image quality.
• The ReSTOR apodized diffractive design controls both image quality and energy balance
Restor Platform
• Refractive optics • Diffractive optics • Apodization: the treatment of the diffractive
optics • Aspheric optics
Positive Spherical Aberration
• Glare/halos • Decreased contrast sensitivity
Anatomy of the Aspheric Apodized Diffractive +3.0 Technology
Restor Toric
Soon to be approved in the US, will eliminate many of the problems associated with post Restor astigmatism
Under Promise….Over Deliver
• Tell the patient that they are still going to have to wear glasses with any IOL option – Low lighting – Night driving – Reading a novel
• Tell patients that they will see rings around lights with a multifocal IOL
Patients to Avoid: Unrealistic Expectations
• Demand ‘perfect’ vision • Expect ‘perfect’ vision at all points, in all places, all
of the time • Not willing to accept the potential complications
of cataract surgery • Not willing to accept the possibility of glare/halos
at night • Demand immediate results: may need lasik/prk
enhancement
Who Are NOT Good Candidates for Multifocal IOLs
• Those who want to wear glasses • Poor “general alertness” • Occupational night drivers • High astigmatism* • Poor candidates for PRK: thin corneas, elevated
posterior float, irregular astigmatism • Unrealistic expectations • Ocular pathology
Ocular Pathology
• Ocular surface disease
Ocular Pathology
• Macular degeneration (AMD) • Epiretinal membrane – Baseline macular OCT pre-op
• Diabetic maculopathy • Advanced glaucoma • Amblyopia
Multifocal Post-operative Care
Purple Glasses
Pearl
• Have patient read near card with purple glasses (-2.25) to demonstrate what vision would have been like if they had not chosen the ReSTOR
Problems Reading?
• Teach patient the importance of good light • Demonstrate the “sweet spot” • Check pupil size: > 3 mm, try Pilo 0.5%
Multifocal Pearls
1) Treat residual refractive errors 2) Early yag capsulotomy 3) Aggressively treat ocular surface disease 4) Look for cystoid macular edema (CME)
Myth
• Presbyopic IOL patients will tolerate small refractive errors
Treat residual refractive errors
• Astigmatism – LRI’s – Keratotomy incisions – LenSx – PRK or Lasik
• Spherical errors – PRK or Lasik – IOL exchange
Treat residual refractive errors
• Trial frame • Temporary glasses
Preparing Patients for Lasik or PRK
• Pre-op cylinder greater than 2 D may need an enhancement
• Topography • Pachymetry
Multifocal Pearls
• Treat residual refractive errors • Early yag capsulotomy • Aggressively treat ocular surface disease • Look for cystoid macular edema (CME)
Yag Capsulotomy
• 30-50% or all mutifocal patients will need a yag capsulotomy
Multifocal Pearls
• Treat residual refractive errors • Early yag capsulotomy • Aggressively treat ocular surface disease • Look for cystoid macular edema (CME)
Pearl
Most visual fluctuation is generally caused by ocular surface disease
Diagnostic Tools
Multifocal Pearls
• Treat residual refractive errors • Early yag capsulotomy • Aggressively treat ocular surface disease • Look for cystoid macular edema (CME)
Prevention of CME
Optical Coherence Tomography (OCT)
• Can measure even subtle postoperative retinal thickening
• Gaining popularity for diagnosis of CME
“Presbyopic” IOL’s
• Crystalens AO (B&L) • Tecnis Multifocal (AMO) • ReSTOR Aspheric (Alcon) – SN60D1 (3.0)
Crystalens® AT-45SE August 2005
• 360 degree square edge • Round to the right loop configuration
Proposed Mechanism of Action:
• The accommodating lens is implanted like standard IOL
• Lens vaults backwards, correcting distance vision
Accommodating Lens
• As objects move closer to the eye – The ciliary muscle expands exerting pressure on
the vitreous
Accommodative Lens
• The displaced mass of the vitreous forces the crystalens forward
• Images at arms length (intermediate) are clear
Accommodative Lens • Reading increases contraction of the ciliary
muscle • Lens is forced further forward – Intermediate & near images are clearer
Restor, Crystalens or Toric IOL with LenSx
• Know the post-operative refractive goal • One week exam: refraction of the first eye • Must “clear the patient for the second eye
surgery” • 1 - 3 months: final refraction to track the
resultant spherical equivalent • 1 – 3 months: keratometry/Lenstar to track
astigmatism result after LenSx
The Doctor Encounter Patient Selection
Make a Recommendation
Make this an exciting opportunity for your patients • This is a great time to have cataract surgery as we
can offer you so much more than several years ago • This is your one opportunity to select your
intraocular lens • You must do your homework • We will give you the information you need and
help you make this important decision
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