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Managing Premium Intraocular Lenses
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Managing Premium Intraocular Lenses

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This is a presentation that will allow all professionals to gain a great understanding on advance technology implants.

This is a presentation that will allow all professionals to gain a great understanding on advance technology implants.

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  • (listen to the patients and they will tell you what is wrong – J. Lawton Smith)

Transcript

  • 1. Optimizing outcomes with Premium Lens Patients and Traditional Lens Patients Donny Reeves, MD [email_address]
  • 2. We had unintentional consequenses! COPE Course ID: 28746-PO
  • 3. Our objective today
    • Discuss the background to premium lenses
    • Optometrist role
    • Ophthalmologist role
    • What is vision in todays times
    • Outcomes
    • Setting realistic expectations
    • Choosing the right patient
    • You must recommend!!
    • Identifying and managing problems
    • Dealing with happy and unhappy refractive patients
  • 4. Financial Interest
    • I have no financial interest related to the discussion of any of the products discussed
    • Alcon Laboratories, consultant
    • Bausch & Lomb, consultant
    • Allergan Inc, speakers bureau
    • Investigator, Abbott Medical Optics
  • 5. Background
    • Premium IOLs date back to late 1990s (Array)
      • Restor +4 add 2005 Non-aspheric then aspheric
      • Crystalens 2005
      • Rezoom 2005
      • Crystalens 5.0 2007
      • Crystalens HD 2008
      • Restor +3 add 2009 Aspheric
      • Acrysof Toric 2009
      • Technis 2009
  • 6. We have learned a lot!
    • Experience with these lenses has taught providers a tremendous amount about visual function of all lens patients
    • We have learned how to manage them with good outcomes and make sure we take steps to continue making them better
  • 7.
    • Adding premium IOLs to your optometric practice is key to remaining competitive in modern refractive surgery
    • Managing patient expectations and proper education is critical to its success
  • 8. Current Refractive Surgery
    • LASIK(and variants)
    • PRK
    • Conductive Keratoplasty
    • Implantable contact lens
      • Visian ICL
      • Staar ICL
    • Clear lens exchange
    • Cataract Surgery
      • presbyopia correction
      • Distance spectacle improvement
      • Desired correction
      • Monovision
      • Astigmatism correction
  • 9. Times have changed…
    • Cataract surgery is rapidly evolving
    • Patient expectations have increased and we need to keep up with those expectations
  • 10. The Growing Expectations of Patients
    • Patient expectations for almost any type of eye surgery have been shaped by dramatic improvements in technology.
    • Patient expectations now include:
      • High success rate with low complications
      • Superior quality of vision
      • Excellent uncorrected visual acuity outcomes
      • Decreased dependence on glasses in all activities
  • 11. Two Cataract Surgeon Categories
    • Traditional Surgeon
    • Traditional cataract surgeon profile most ophthalmologist –
      • implants non-aspheric monofocals
      • Do not decrease spectacle independence
      • Late adopter of technology
    • Refractive Surgeon
    • Refractive cataract surgeon
      • LASIK/PRK (Custom)
      • Astigmatism correction expert
      • Aspheric/non-asperic user
      • Toric IOL user
      • Accommodative IOL expert
      • Multifocal IOL expert
  • 12. Types of Premium Lenses
    • Accomodative IOL (CrystaLens)
    • Multifocal IOL
      • Diffractive IOL – apodized diffraction
      • Refractive IOL
    • Toric IOL
  • 13. Optometrists role
    • Many pts have been seeing optometrists for many years and have a close relationship
    • Relationship is ongoing beyond cataract surgery
    • Improving refractive correction does not eliminate role in optometric care
  • 14. Optometrist role cont.
    • We have been told that it has been difficult introducing this new technology to patients
  • 15. Ophthalmologist role
    • Focus on and manage disease pathology
    • Surgical management of visual function
  • 16. Ophthalmologist role cont…
    • Despite our small role the patient may perceive surgery to solve 100% of the problem
      • Process starts with education and setting realistic expectations
      • Choose the right surgeon
      • Surgeon chooses the right IOL for the patient
  • 17. Visual Function is multifaceted
    • Ocular surface
      • DES,Blepharitis,MGD
    • Astigmatism
    • Lens
    • Retina
    • Optic nerve
    • Contrast sensitivity
    • Visual axis (intra-cranial)
    • Patient perception of vision
  • 18. No one is perfect…
    • In medicine we still are limited on what we have control of
      • Patient compliance
      • Disease severity and response to treatment
      • Disease progression
  • 19. Really… No one is perfect
    • Endophthalmitis
    • Cystoid Macular edema
    • Large residual refractive error
    • Posterior capsular rupture
    • Corneal edema
  • 20. Outcomes
    • Establishing predictable results with the traditional lens surgery is critical before converting a cataract patient into a refractive patient
      • Modern biometry
      • Modern formulas
      • Advance cataract surgery techniques
  • 21. Patient Expectations
    • Ensure that you set the bar at the appropriate level
    • The principle is the same for ALL refractive surgery
    • Establish value with lifestyle improvement and lesser on cost
  • 22. Start out with the low hanging fruit
    • Start with Toric IOLs
      • Easy to explain
      • Easy to manage
      • Most patients know what astigmatism is
      • Most are 20/happy
      • No promise for spectacle freedom (near)
      • Very little abberations
  • 23. Under promise and over deliver
    • Educate with positive attitudes
    • When you educate well, more people will choose the implant that best suits them
    • Simply converting them to a premium lens patient without education is a setup for problems
  • 24. Which lens to choose…Don’t Worry about it
    • Find the right surgeon who is experienced!
    • The key is to educate them with the right information – Short and to the point
    • Too much information can confuse the patient
  • 25. Pick the best candidate
    • Everyone is a good candidate unless pathology excludes him/her
    • Look for cylinder (cutoff for multifocals is >1.5D)
    • Vision questionaire
    • Exercise caution in patients with previous refractive surgery
      • Postoperative surprise in LASIK/RK patients
      • Need different formulas for IOL calculations
  • 26. Considerations
    • Ocular surface issues
    • High astigmatism
      • >1.5 D Premium IOLs
      • >4.00 for Torics including an LRI **
    • Previous refractive surgery
    • ARMD (Yes-Toric, No-Premium)
    • Moderate glaucoma
    • Optic nerve issues
    • Diabetic retinopathy
    • Fuch’s dystrophy
    • Severe behavioral issues
    • Patient’s with extremely high visual demands/expectations
      • Engineer, chemist, preacher
  • 27. Recommend!
    • The patient still wants to be told which option is best for them!
    • A strong, well informed recommendation is the key to assisting the patient with a lens choice.
    • This is the most important slide!
  • 28. Once they choose
    • I can advise them about issues with these lenses
      • Glare/halos
      • Small print
      • Need for additional procedures during recovery period
  • 29. Improving Surgical Outcomes
      • Most common causes for post-op surprises
      • Axial eye length error
      • Erroneous K-readings
      • IOL position- capsulorrhexis dependant
  • 30. Erroneous K-readings
    • 1 diopter error in K= 1 diopter error in post-op
    • If measured too steep=hyperopia
    • If measured too flat=myopia
  • 31. Avoiding erroneous axial length
    • NEVER use contact method--- is considered OBSOLETE!!!
    • Studies have shown 0.14-0.36 mm error due to corneal depression. Immersion is QUICKER, but requires more skill.
    • We use IOL Master (5.4 version which has great updates) or Immersion A-scan
    • Using B-Biometry (B-scan) to confirm lengths
  • 32. Erroneous axial length readings
    • 0.1 mm error=approx 0.25 diopter p/o surprise in average length eye(1mm=2.5 diopter surprise)
    • In longer eyes (30mm) 1.0mm=1.75 diopter surprise
    • In shorter eyes (20mm) 1.0mm=3.75 diopter surprise= VERY UNHAPPY PATIENT, especially a multifocal pt
    • In extremely short eyes 0.1mm error as much as 0.75 diopter surprise
  • 33. Postoperative care
    • The optometrist can provide either one day post op or 2 week post op
      • Discuss blurred vision after surgery that will improve (corneal edema, inflammation)
      • Use -2.50 purple glasses to test reading
        • Test monocular if 1 st eye
      • Then test reading without purple glasses
  • 34. 1 week post op –Premium lens patients
    • Surgeon determines if power is close to predicted and make adjustments
    • I use this for counseling about the process and answer questions
      • They get an additive effect with both eyes done
  • 35. The companies don’t practice what they preach
  • 36.   They flex like your eye's natural lens, allowing you to see better at all distances.
  • 37. Rezoom
  • 38. ReStor
    • Finally, the opportunity for freedom from reading glasses and bifocals.
    • Until recently, life without reading glasses or bifocals wasn't an option for most  cataract patients.  You now have that option . The AcrySof ®  IQ ReSTOR ®   IOL  is a unique technological innovation that can provide you with enhanced image quality and a full range of vision – near, far and everywhere in-between – for increased independence from reading glasses or bifocals!
  • 39. Restor
    • +4.00 add
    • +3.00 add
      • I use the +3.00 add due to best performance in most situations (90%)
  • 40. +4.00 Restor
    • Good spectacle independence
      • 80%
      • Intermediate vision difficulty is common
      • Fewer halos than Rezoom
      • Mixing lenses were more common about 2 years ago (Rezoom/Restor), (Restor/Crystalens)
  • 41. +3.00 Restor
    • 90% spectacle freedom rate
    • Intermediate issue has been resolved
  • 42. Crystalens
    • 1 st implant approved
    • Good distance acuity
    • Good intermediate acuity
    • Fair reading vision
    • Predictability can be difficult and more refractive surprises and more hand holding
    • Z-syndrome
  • 43. Tecnis multifocal
    • +4.0 add
    • Aspheric IOL
    • Diffractive IOL on posterior surface
    • Near point closer to the retina
    • Outcomes are good
    • More pupil independent readi ng
    • Intermediate similar to +4 Restor
  • 44. So What about Astigmatism?
    • In the past it was left untreated during cataract surgery.
    • How can we treat it?
  • 45. Toric
    • Patients who are able to have lens surgery and also have significant regular corneal astigmatism
    • Multifocal contraindications are less important
      • Dry eye, diabetic retinopathy, macular disease, glaucoma, personality difficulties
      • Does not decrease contrast sensitivity
  • 46. Astigmatism Greater than 2D
    • Can combine technique
      • Toric + LRI at time of surgery
      • Toric + postop LRI
      • Toric + laser vision correction
      • Can do all 3
    • Most patients are happy(even with residual cylinder) and enhancement rate is much lower!
    • Most have known about astigmatism all his/her life!
  • 47. Toric IOL
    • Safe and predictable way to improve patient’s distance visiion and decrease spectacle dependance
  • 48. TORIC Availability
    • What patients qualify?
      • Any patient with .75 – 2.0+ D of Cylinder.
      • T3 – 1.00 D
      • T4 – 1.50 D
      • T5 – 2.00 D
    ? Toric IOL
  • 49. Spectacle Freedom for Distance p<0.0001 CMH test 97% of patients with bilateral AcrySof Toric IOL implantation (N=37) *
  • 50. Traditional Lens Surgery
    • Treat them with the same way except no enhancement option
    • Advise them of coexisting pathology
    • Allows the patient a better understanding of their visual function
  • 51. Infection/inflammation/pain control
    • Strongest therapy(expensive)
      • Durezol 4x/day for 1 week
      • Nevanac 4x/day for 2 weeks
      • 4 th generation fluoroquinolone for 2 weeks
    • Common sense/practical therapy
      • Still standard of care
      • Generic prednisolone acetate
      • Generic ketorolac (beware of medicare doughnut hole- out of pocket still up to 100.00)
      • 4 th generation fluorquinolone
  • 52. Postop
    • You and the patient have picked the best lens for them.
    • The surgery has been done, and the patient is unhappy.
    • What next?
  • 53. Well it must be the surgery, right?
    • You do not help the patient or your practice by arguing with the patient.
      • “ Well maam, everything looks good and nothing is wrong with your eyes.”
      • “ There must be something wrong with your surgery.”
  • 54. Team based approach
    • “ Patients do not care how much you know until they know how much you care.” Johnny Gayton, MD
    • You have to have a caring, compassionate team to help a patient with concerns
  • 55. Common non-medical causes for an unhappy patient
    • Set unrealistic expectations
      • The don’t understand neuroadaptation
      • Don’t understand other eye problems
        • DES, residual refractive error, POAG
      • All companies state to underpromise and overdeliver; They don’t practice what they preach!
    • Do not understand the technology; Use the -2.50 lenses
  • 56. Ocular surface disease
    • Excellent vision starts with a healthy tear film
    • Decreases contrast sensitivity
    • All refractive surgery outcomes are diminished by disruption of the ocular surface
  • 57. Ocular surface disease
    • Listen to the patient
      • They will only tell you their vision is blurred.
      • Ask about vision fluctuation throughout the day
      • DES classic symptoms with blurred vision
  • 58. CME
    • The most frequent cause of visual decline following uncomplicated cataract surgery
    • Look for late onset (4 to 6 weeks post-op) 1
    • Estimate to occur in 12% of low risk cataract cases 2
    • Due to prostoglandin-mediated breach of blood-retinal barrier 3
    • 1. Samiy N, Foster CS. The role of nonsteroidal antiinflammatory drugs in ocular inflammation. Int Ophthalmol Clin . 1996;36(1):195-206. 2. McColgin AZ, Raizman MB. Efficacy of topical Voltaren in reducing the incidenceof post operative cystoid macular edema. Invest Ophthmol Vis Sci . 1999; 40 S289. 3. Mishima H, Masuda K, etal. The putative role of prostaglandins in cystoid macular edema. Prog Clin Res 1989;31:251-264.
  • 59.  
  • 60. CME
    • CME Flourescein angiogram picture
  • 61. CME
    • Angiographic CME
    • – May not be associated with significant Snellen visual
    • loss
    • – Can cause loss of contrast and refractive error
    • (hyperopia and/or astigmatism)
    • Clinical CME
    • – Described as vessel leakage associated with visual
    • acuity of 20/40 or worse
    • – Today’s definition is becoming stricter (20/25 or
    • worse) due to higher expectations and designer IOLs
    • Heier JS, Topping TM, et al. Ketorolac versus Prednisolone versus Combination Therapy in Treatment of
    • Acute Pseudophakic Cystoid Macular Edema. American Academy of Ophthalmology. 2000;107(11):2034-9.
  • 62. Residual refractive error
    • Residual Astigmatism (even small amounts)
    • can markedly decrease the effectiveness of
    • multifocal lenses.
  • 63. Residual refractive error
    • Can perform LRI post op
    • Wait for stability of refraction
    • Anything >0.75 diopters
  • 64. Residual refractive error
    • LASIK/PRK is included with the surgery
    • Enhancement rate is between 10-20%
    • 1 month post op
  • 65. Glare/Halos
    • Can occur in multifocal patients
      • Reassure that symptoms improve with neuroadaptation
      • Look for signs of dry eye giving abberations; PF artificial tears
      • Alphagan P sample
      • 0.5% percent pilocarpine
      • Look for PCO
      • Look for residual refractive error >-0.50
        • Surgeon dependant threshhold for treatment
  • 66. Summary
    • Get everyone on the same sheet of music (optometrist, ophthalmologist, all staff)
    • Our standard IOL patients have directly benefitted from the use of these lenses
    • Co-management is possible but does have some new challenges
    • Recommend what is best for the patient which is often a traditional lens
    • This option should be discussed as a part of informed consent
  • 67. Summary
    • This is the future of refractive surgery
    • Thanks
    • [email_address]
    • Email will usually get you a timely response.
    • 423-722-1311