By. Dr. Alberto Martinez

1. Comanagement of Cataract
Surgery and premium IOLs
J. Alberto Martinez, M.D.
Visionary Ophthalmology
May 18, 2014

2. 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

3. 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

4. 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!

5. Why do we treat astigmatism?
• Quality of vision
after cataract
surgery
• Quality of life after
cataract surgery

6. 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

7. Surgical Correction of Astigmatism
• Methods of correcting astigmatism
– Operating on steep axis
– Limbal relaxing incisions
– Astigmatic Keratotomy
– LenSx Laser
– ToricIOLs
– ToricphakicIOLs (Visian)
– Post operatively
– Laser refractive surgery
– Astigmatic Keratotomy

8. LenSx arcuate incisions

9. 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

10. 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

11. 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

12. ToricIOLs
• VisianToric ICL (Not approved yet)
• AcrysoftToric IOL
• TecnisToric IOL
• (Staartoric) IOL (Old, not used anymore

13. StaarToric IOL
-Rotated after
placement
-Popular 10 years ago
-Set back for
ToricsIOLs
-No one uses it
anymore

14. VisianToric 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

15. VisianToric ICL

16. VisianToric 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.

17. AcrySofToric IQ
Design Characteristics
• Design
– Acrylic Single-Piece
platform
– Posterior toricity
– Toric axis marks

18. 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

19. 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

20. Cylinder Powers
A wide range of cylinder powers means more
candidates can benefit from AcrySof® IQ Toric IOL.

21. Toric Calculator
• Easy Input
– Patient data
– Keratometry
– IOL spherical power
– Surgically induced
astigmatism
– Incision location

22. Toric Calculator, continued
• Powerful output
– Recommended IOL model
and spherical equivalent
power
– Optimal axis placement
– Magnitude and axis of
anticipated
– residual astigmatism

23. Pearls for the Toric
1. Keratometry
2. Pre-operative marking
3. Operative marking and final orientation

24. 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

25. Pearls for the Toric
• Compare topography astigmatism axis to
keratometry axis

26. 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

27. Pearls for the Toric
1. Keratometry
2. Pre-operative marking
3. Operative marking and final orientation

28. 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

29. Toric marking at the slit lamp

30. Pearls for the Toric
1. Keratometry
2. Pre-operative marking
3. Operative marking and final orientation

31. Preop marking: Verion system

32. ORA: Optiwave refractive Analysis
• httphttp://getorasystem.com/

33. ORA- Verify

34. 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

35. 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

36. Lens Based Treatment for
Astigmatism
AcrysofToric IQ
• Precise and Accurate
• Predictable Outcomes
• Permanent
• Safe and Convenient
• Aspheric Optics

37. Toric IOL
• Post-operative spherical equivalent
• Post-operative refractive astigmatism

38. 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

39. TechnisToric
-Three point touch
Rotational Stability (2.7
degrees)
-Newer in market, less
experience
-Higher Abbe number= less
chromatic aberration
-Does not block blue light
(improved scotoptic sensitivity)

40. Presbyopic IOL Options/Optics

41. “Presbyopic” IOL’s
• Crystalens AO (B&L)
• Tecnis Multifocal (AMO)
• ReSTOR Aspheric (Alcon)
– SN60D1 (3.0)

42. 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

43. Restor Platform
• Refractive optics
• Diffractive optics
• Apodization: the treatment of the diffractive
optics
• Aspheric optics

44. 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 ReSTORapodized
diffractive design controls both
image quality and energy
balance

45. Restor Platform
• Refractive optics
• Diffractive optics
• Apodization: the treatment of the diffractive
optics
• Aspheric optics

46. Positive Spherical Aberration
• Glare/halos
• Decreased contrast sensitivity

49. Anatomy of the Aspheric Apodized
Diffractive +3.0 Technology

50. RestorToric
Soon to be approved
in the US, will
eliminate many of the
problems associated
with post Restor
astigmatism

51. 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

52. 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

53. 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

54. Ocular Pathology
• Ocular surface disease

55. Ocular Pathology
• Macular degeneration (AMD)
• Epiretinal membrane
– Baseline macular OCT pre-op
• Diabetic maculopathy
• Advanced glaucoma
• Amblyopia

56. Multifocal
Post-operative Care

57. Purple Glasses

58. 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

59. Problems Reading?
• Teach patient the importance of good light
• Demonstrate the “sweet spot”
• Check pupil size: > 3 mm, try Pilo 0.5%

60. Multifocal Pearls
1) Treat residual refractive errors
2) Early yagcapsulotomy
3) Aggressively treat ocular surface disease
4) Look for cystoid macular edema (CME)

61. Myth
• Presbyopic IOL patients will tolerate small
refractive errors

62. Treat residual refractive errors
• Astigmatism
– LRI’s
– Keratotomy incisions
– LenSx
– PRK or Lasik
• Spherical errors
– PRK or Lasik
– IOL exchange

63. Treat residual refractive errors
• Trial frame
• Temporary glasses

64. Preparing Patients for Lasik or PRK
• Pre-op cylinder greater than 2 D may need an
enhancement
• Topography
• Pachymetry

65. Multifocal Pearls
• Treat residual refractive errors
• Early yagcapsulotomy
• Aggressively treat ocular surface disease
• Look for cystoid macular edema (CME)

66. YagCapsulotomy
• 30-50% or all mutifocal patients will need a
yagcapsulotomy

67. Multifocal Pearls
• Treat residual refractive errors
• Early yagcapsulotomy
• Aggressively treat ocular surface disease
• Look for cystoid macular edema (CME)

68. Pearl
Most visual fluctuation is generally caused by
ocular surface disease

69. Diagnostic Tools

70. Multifocal Pearls
• Treat residual refractive errors
• Early yagcapsulotomy
• Aggressively treat ocular surface disease
• Look for cystoid macular edema (CME)

71. Prevention of CME

72. Optical Coherence Tomography
(OCT)
• Can measure even subtle postoperative retinal
thickening
• Gaining popularity for diagnosis of CME

73. “Presbyopic” IOL’s
• Crystalens AO (B&L)
• Tecnis Multifocal (AMO)
• ReSTOR Aspheric (Alcon)
– SN60D1 (3.0)

74. Crystalens® AT-45SE
August 2005
• 360 degree square edge
• Round to the right loop configuration

75. Proposed Mechanism of Action:
• The accommodating lens is implanted like
standard IOL
• Lens vaults backwards, correcting distance
vision

76. Accommodating Lens
• As objects move closer to the eye
– The ciliary muscle expands exerting pressure on
the vitreous

77. Accommodative Lens
• The displaced mass of the vitreous forces the
crystalens forward
• Images at arms length (intermediate) are clear

78. Accommodative Lens
• Reading increases contraction of the ciliary
muscle
• Lens is forced further forward
– Intermediate & near images are clearer

80. 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

81. The Doctor Encounter
Patient Selection
Make a
Recommendation

82. 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