The Bionic Patient, By Sandar Lora Cremers, MD FACS

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  • 1. The Bionic Patient: Intraocular Lenses Multifocal Options Sandra Lora Cremers, MD, FACS Visionary Ophthalmology November 10, 2013
  • 2. Sandra Lora Cremers, MD, FACS Cell/Text 443-535-2268
  • 4. PATIENT
  • 5. PATIENT
  • 6. Why Should I Pay Attention? 1. Great all around care to your patients 2. For friends, family members, for yourself 3. Co-management
  • 7. Objectives: 1. History & Types of Multifocal IOLs 2. Indications, Goals, & Contraindications 3. Managing the unhappy IOL patient 4. Future
  • 8. History & Types
  • 9. Timeline of Eye Surgery:
  • 10. Timeline of Intraocular Lenses 2012 2013 LAL Calhoun 2014 2015 2016 AT LISA TRI Fluidvision Synchrony Dual Optic Tetraflex 1CU Akkommodative
  • 11. Timeline of Refractive Cataract Surgery IOLs: IOL Materials: PMMA->Silicone->Hydrophilic Acrylic->Hydrophobic Acrylic->NanotubesMacromolecules; Liquid Crystal IOL Design: Plate Haptic 3-piece 1-piece Foldable Injectable IOL Optic: UV Filter Aspheric Multifocal Accommodating Toric
  • 12. Market Share
  • 13. Rate of Baby Boomers Turning 65 yrs in US: • 2.7 million per year • 7,584 per day
  • 14. Silent Generation (born between 1925-1942): hard working, economically conscience, and trusting of the government. They were very optimistic about the future and held a strong set of moral obligations. Baby Boom Generation (1943-1960): strong set of ideals and traditions, and are regarded as being very family-oriented. They are fearful of the future, relatively active and liberal socially but conservative politically. Generation X (1961-1981) or (1965-1976): Live in the present, likes to experiment, and expects immediate results. Xers are selfish and cynical, and depend a lot on their parents. They question authority and feel they carry the burden of the previous generations. Generation Y (1979-1994) (1977-1994) (1989-1993) & Millennials (1982-) materialistic, selfish, disrespectful; but also very aware of the world and very technologically literate. They are trying to grow-up too quickly, and have no good role models to look towards.
  • 15. Types of Multifocal IOLS
  • 16. DIFFRACTIVE IOL Closely spaced stepped rings (ring no. & height varies) spit incoming light (diffract) into multiple beams: add together in phase at predetermined near point; overall curvature gives distance VA REFRACTIVE IOL Zones of different optical powers, commonly in alternating rings of Near & Far foci juxtaposed achieve multifocality 2 Key Types of MIOLs ReSTOR -refraction, diffraction, & apodization TECNIS -Pupil independent -Pupil dependent: if distance central zone, loose near in bright light; ARRAY REZOOM -a refractive, distance-dominant multifocal optic
  • 17. Multifocal Optic
  • 18. DIFFRACTIVE IOL ReSTOR TECNIS REZOOM AcrySof ReSTOR SA60D3 The Tecnis Multifocal Foldable acrylic apodized diffractive IOL Foldable acrylic diffractive IOL 6.0 mm optic 6.0 mm optic Add power of 3.00 or 4.00 D 3.6 mm center of concentric diffractive steps Combines diffractive optic technology with an aspheric modified prolate anterior surface designed to reduce spherical aberrations Identical periphery to monofocal acrylic IOL. Dffraction pattern creates 2 major focal points that are 4.00 D apart Hybrid diffractive–refractive optic REFRACTIVE IOL
  • 19. ReSTOR 3.0 Tecnis MTF
  • 20. ReSTOR
  • 21. Chromatic Aberration: • Occurs when light is separated into its separate components • These wavelengths refract differently, creating multiple focal points
  • 22. ReSTOR 3.0 Tecnis MTF
  • 23. Indications
  • 24. Goals of Refractive Cataract Surgery: 1. 20/20 Distance, Intermediate, Near 2. No pain 3. Immediate return of vision 4. 100% safe, 0% complications 5. No long term issues: i.e. PCO
  • 25. Extra Attention Prior to Cataract Surgery: 1. Contact Lens: hold till stable refraction: Min: Soft 2wk; Hard 1 mo 2. Dry eyes, MGD must be assessed & treated 3. Angles-Gonio, Pentacam; Lens Type; Macula OCT; Nerve HVF 4. Triple check A’s & K’s, Belin-Ambrosio Enhanced Ectasia Display 5. Check Eye Dominance 6. Check for Angle Kappa 7. Cataract Questionnaire
  • 26. Pre-Operative OCT 1. Gold standard for detecting (3-4% incidence in routine surgery) 1. ERM (Epiretinal Membranes) 2. Lamellar Holes 2. Macular Thickness >230 microns before surgery correlates with worse visual acuity after surgery
  • 27. ANGLE KAPPA The Angle between the Visual Axis and the Pupillary Axis
  • 28. CHOICES FOR CATARACT SURGERY by Sandra Lora Cremers, MD, FACS New Standard for “Forever Young” Option* Old Standard or Government Option Phaco -Traditional -More energy needed -More loss of corneal cells; High-tech implants are designed to give you a greater better ability to drive, see your phone, and read without glasses, though they do not guarantee a life without any glasses. Monofocal -Only gives one range of vision; (ie, will need reading glasses); Risk of halo/glare (1%, 2%); Covered by insurance CRYSTALENS -Good for distance & computer, night vision;can take up to one year to fully improve; -Good Contrast Sensitivity -Less halos/glare vs other MIOL; harder to exchange -May need reading glasses especially for smaller print. LenSx LASER Accommodating -Lower energy needed; Less endothelial cell loss; less complication -not covered by insurance -Less Halos, glare risk; better contrast sensitivity -Best choice if: -history of LASIK -glaucoma -macular issues. RESTOR DRIVING VISION OPTION: Astigmatism Correction: Toric, Limbal Relaxing Incision (LRI) TORIC Multifocal Option to have chance to be free from reading glasses; Avoid if pilot, full time night driver, h/o macular degeneration, severe dry eye, severe glaucoma, type A+ -implant that only corrects astigmatism, not reading -no reported increase in halos, glare TECNIS -Eliminate need for full time glasses use in 97%; Best for good Distance Vision -Function comfortably without glasses (20/40 or better); 99% distance; 90% intermediate; 74% reading (20/25 or better); Risk: halos/glare (5%)(usually go Pupil independent; Best for Reading; Comfortably without glasses: 96.9 % near, 89.7% intermediate, 95.5% distance; 88% no dependence on glasses at 6mo; Risks: 3.7% surgical away but can be permanent); Loss of contrast sensitivity possible. Not good if pupil>2.5 -May still need glasses for small print. -Easier IOL to remove if unhappy reintervention; 2.6% macular edema; 0.3% hypopyon, eye infection, persistent high eye pressure requiring drops LRI -incisions on cornea to decrease astigmatism; can be combined with implant REZOOM -Better for Computer distance; Moderate reading range vision (if pupil <2. 5mm, not as good for reading); Not as good for night vision -May have halos or glare (usually go away but can be permanent) -Easier IOL to remove if unhappy Alternatives: No surgery/Observe: this can increase risk of surgery in future (increases energy needed & following risks); Risks: less than 1%: risk of infection: loss of vision, loss of eye; second surgery (due to infection, residual refractive error, IOL displacement; retinal problem from vitreous loss, residual lens material; intolerable haloes, glare); 10-30% risk (over 3yrs) of Posterior Capsule Opacification needing short laser procedure (covered by insurance); 5% risk of IOL exchange due to halo/glare from Multifocal IOL; Information presented above do not guarantee results.*
  • 29. Contraindications
  • 30. Complications
  • 31. Complications with MIOL: the Usual... And… 1/20 desire IOL exchange to due haloes/glare
  • 32. Managing the Unhappy Patient -Post Multifocal IOL
  • 33. Main Cause of Complaints: (Glare, Haloes, Contrast Sensitivity Loss)
  • 34. Why do Multifocal Intraocular Lenses Cause Glare, Haloes?
  • 35. 6 Causes of Complaints: (Glare, Haloes, Contrast Sensitivity Loss) 1. Cylinder, residual astigmatism, refractive error 2. Corneal disease (i.e., Dry Eye, MGD, OSD) 3. CME 4. Capsular opacification (i.e., PCO, phimosis) 5. Centered issue: (i.e., decentration, angle kappa) 6. Crazy (i.e., your surgeon …to use an MIOL on patient)
  • 36. Dry Eye: Various Treatments
  • 37. Treating Positive Angle Kappa Patient if Unhappy:
  • 38. Future
  • 40. What do you need to tell patients?
  • 41. Key Questions: 1. Do you mind using glasses to see both distance & near? 2. Do you mind wearing glasses for reading? 3. What do you want & expect from your vision? 4. What activity will you be using your eyes the most? 5. If you could see well without glasses, but had haloes & glare around lights, would that bother you?
  • 42. Summary: 1. MIOLs work well for selected patients 2. No guarantees with any IOL 3. Haloes and/or glare around lights possible 4. Small risk will not be happy with first IOL 5. Majority are happy with MIOLs
  • 43. Co-Management Carolina Clavijo Office Manager Cell & Text: 240-676-7267
  • 44. Thank you for your attention. Acknowledgements: Alberto Martinez, MD Eric Donnenfeld, MD, FACS Jason Wang, MD