Aqualase and BSS
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Perfect Vision's Dr Con Moshegov presentation on: Aqualase and BSS

Perfect Vision's Dr Con Moshegov presentation on: Aqualase and BSS

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  • The Array is a refractive IOL with five zones all offering near, intermediate and distance vision utilising 100% of available light. Zones 1,3 and 5 are weighted for distance and 2 and 4 are weighted for near.
  • Halos Mean values ReSTOR = 1.07 Control = 0.34

Aqualase and BSS Presentation Transcript

  • 1. Con Moshegov FRANZCO, FRACS Alcon: Optimising Cataract Surgery Outcomes Con Moshegov Sydney Aqualase, ReSTOR and BSS for the Refractive Cataract Surgeon.
  • 2. Relief of presbyopia
    • Difficulties to deal with:
    • Monovision not acceptable to all
    • Monovision is a compromise
    • Dry eyes more common in presbyopes
    • Nuclear sclerosis and cataract
    • LASIK and CK temporary solutions
  • 3. Refractive Lens Exchange (RLE) with ReSTOR
    • Monovision not necessary
    • BSCVA less likely to suffer
    • Dry eyes much less common
    • Permanent solution
    • Leaming ASCRS survey 2004: routine RLE performed by 31% of surgeons (6% in 2003).
  • 4. RLE with ReSTOR
    • Harder to sell
    • More expensive to patient (if not 42702)
    • One eye at a time
    • Risks of intraocular surgery
    • Pseudoaccomodative IOLs will never be as good
    • as a young natural lens
    • Very little room for error
  • 5. AquaLase TM Technology
  • 6.  
  • 7. AquaLase TM Technology
    • Fluid pulses propelled in front of tip to delaminate tissue
    • 4 miclolitre
    • ~60º C
      • up to 50 PPS
    • This “cutting” action is not a mechanical touching of tissue like in phaco
  • 8. AquaLase TM Handpiece/Tip
    • Titanium Handpiece
    • Single Use Tip
            • Smooth, soft bevel
  • 9. Intraocular Response - Temperature Conservative Aspiration Settings Conditions Porcine cadaver eye Fast responding thermocouple Aspiration flow rate: 12 cc/min AquaLase™ Power: 100 % Power Pulse rate 100 per second
  • 10. Intraocular Response - Pressure
    • The following demonstrate the effect on IOP during application
    • Bottle height: 55-65 cm
    • AquaLase™ Fluctuations ± 3 mmHg
    • Data collected via fast responding miniature pressure sensor placed in anterior chamber of porcine cadaver eyes
    • 1 Collins, CC, Miniature Passive Pressure Transensor for Implanting in the Eye, IEEE Trans on Bio-Med Engin , 14 (2):74-83, 1967.
    • 2 Coleman, DJ and Trokel, S, Direct-Recorded Intraocular Pressure Variations in a Human Subject, Arch Ophthal 82 :637-640, 1969.
  • 11. AquaLase TM Bottle
    • Balanced Salt Solution
    • 90 ml bag in the bottle
    • Pressurized from Infiniti™ console
  • 12.
    • Learning curve nothing like learning phaco
    • Incision no different
    • In the bag technique
    • Divide and conquer or chop
    • Less mechanical movement/manipulation during sculpting than with phaco
      • need time for pulses to delaminate tissue
      • don’t push on the tissue
      • debulk the centre
    Transition to Aqualase
  • 13.
    • Stable fluidics
    • Excellent outcomes with “quiet” eyes
    • Easier to seal wounds
    • Clearer corneas next day
    Transition to Aqualase
  • 14. Transition to Aqualase
    • Patient selection is the key to success
      • Start with very soft lens
      • Progress to 2+ and softer grade 3
      • Patients younger than 70 are good choices
      • Convert to ultrasound if conditions are not ideal
  • 15. Visualizing Parameters Pulse Magnitude Pulse Rate (pulses per second)
  • 16. Parameters - Burst
    • Helps to better enable occlusion during quad or chop
    • Percentage of pulses that will be delivered within a 200 ms burst width
    • 0% no pulses - 100% which is all pulses
  • 17. Visualizing Burst Burst Control (100%) Burst Control (25%) Burst Control (50%) Same rate Fewer pulses
  • 18. Set Up
    • Pull irrigation sleeve down onto tip
      • Turning might crimp irrigation sleeve (corkscrew) and result in priming/tuning error
      • Need less tip exposure than with phaco
  • 19. Corneal Endothelium
  • 20. Endothelial Cell Function
    • Endothelial cells contain ion transport systems that facilitate the transfer of water out of the corneal stroma.
    • The NA +/K+ -ATPase ion pump is the exchange mechanism and takes place at the basolateral membrane of the cells.
    • The movement of water between the intracellular and extracellular compartments is largely controlled by each compartment's osmolality.
  • 21. Endothelial Cell Function
  • 22. History of Ocular Irrigants
    • Normal saline used for intraocular surgery by 1950’s
    • But saline is toxic
    • BSS was invented by Alcon in 1962
    • Needed to resemble aqueous humor and contained the essential ions of Na, K and Mg.
    • By 1970’s new surgical techniques necessitated optimal irrigant
  • 23. History of Ocular Irrigants
    • It was found that Ringer’s solution with glutathione would maintain corneal thickness by maintaining integrity of endothelial cells
    • So, Alcon added glutathione as well as bicarbonate, phosphate and glucose to BSS to make BSS ‘Plus’.
    • Further, they removed citrate and acetate, unnatural buffers from the new solution relying on the bicarbonate to do the job
  • 24. Ingredients table (mmol/L)
  • 25. Na+, K+ and Mg
    • Na is the major extracellular ion of plasma and aqueous, is essential to maintaining cellular tonicity and is necessary for the metabolic pump to function within the endothelium.
    • K is the major intracellular ion of cells that is actively transported across the cell membrane. The inward transfer of K+ is coupled with the outward transport of Na+ by the Na+, K+ - ATPase enzyme.
    • Mg is a cofactor for some ATPase’s.
  • 26. Ca++
    • Calcium ion is essential to the endothelium for maintenance of the barrier function of the apical junctional complexes.
    • Natural extracellular buffer.
    • Resists changes in pH.
    • Contributes to corneal endothelial pump
    • Also supports retinal function
    Bicarbonate (HCO3)
  • 27. Glucose
    • All cells metabolise glucose for the production of energy necessary for normal function.
    • Corneal endothelium is particularly dependent on aerobic glycolysis
  • 28. Glutathione
    • Protects corneal endothelium from ATP depletion
    • May also combat the effects of free radicals.
  • 29.
    • BSS Plus contains all of the essential ingredients to maintain endothelial cell integrity and hence reduce biochemical stress on the cornea during surgery.
  • 30. BSS Plus
    • Unequivocal evidence that endothelial cells stay viable for longer with BSS Plus than BSS, saline, Ringers solution and any other commercially available ocular irrigant
    • Numerous studies demonstrate clearer corneas after surgery with BSS plus than other irrigants
  • 31. The ARRAY ® IOL Refractive Multifocal IOL Design
    • Five concentric zones
    • Each zone has a near or distance weighting
  • 32. Weaknesses of the ARRAY ® IOL
    • Glare and halos at night
    • Frequently pupil dependent
    • Not all can read
  • 33. Accomodating IOLs
    • Biosil (3 rd generation silicone)
    • 4.5mm optic
    • Flexible hinged plate haptics
    • Two polyamide flexible loop
    • extensions
    • Vaults posteriorly but moves
    • forward with ciliary muscle contraction
  • 34. Crystalens (Daya)
    • 93% see 6/12 or better
    • 7% J1 or better @ 6 months
    • 52% J3 or better
    • 74% J5 or better @ 6 months
    • (@ 1 month 72% could read no better than J7 and at 3 months less than half could read J7)
    • i.e. takes time
  • 35.  
  • 36.  
  • 37. Crystalens (Stasiuk)
    • PCO requiring YAG: 20 (59%)
    • Refractive outcome less predictable than with monofocal lenses
    • LASIK required in 5 (15%)
    • Posterior vaulting in 6 (18%)
    • 2 patients complaining of marked glare and night vision disturbance
  • 38. ReSTOR pseudoaccomodating IOL
  • 39.  
  • 40. Schematic Diffractive Lens Placing the diffractive grating on the anterior surface of a convex lens causes light to converge to two points
  • 41. Apodized Diffractive Optic
    • Precise reduction in diffractive step heights from center to periphery of diffractive region
      • higher steps direct more light to near (centre)
      • lower steps direct more light to distance (periphery)
      • gradual energy blend between powers
    Magnification = 80X 1.3 micron step
  • 42. US Core Study Overview
    • 340 bilateral ReSTOR MA60D3 subjects
    • 225 bilateral monofocal MA60BM subjects
    • 125 bilateral ReSTOR SA60D3 subjects
    • Contrast, driving, and defocus substudies
    • 16 investigators:
    • Brint
    • Cionni
    • Crandall
    • Davison
    • Grosinger
    • Hunkeler
    • Lehmann
    • MacDonald
    • Mackool
    • Maxwell
    • Reiser
    • Solomon
    • Tipperman
    • Wallace
    • Weinstein
    • Whitsett
  • 43. Distance VA Binocular – 6 Months Postop 20/20 20/25 20/16
  • 44. Near VA Binocular – 6 Months Postop 20/20 20/25 20/40 20/50 20/16 20/32 20/63 20/80
  • 45. AcrySof ® ReSTOR ® IOL Binocular Photopic Contrast Sensitivity Clinical Significance  0.3 log units at 2 or more Spatial Frequencies Vector Vision CSV1000 0.20
  • 46. AcrySof ® ReSTOR ® IOL Binocular Mesopic Contrast Sensitivity Clinical Significance  0.3 log units at 2 or more Spatial Frequencies Largest difference = 0.17 log units Vector Vision CSV1000
  • 47. Photic Phenomena Glare Night Vision Problems Halos
  • 48. Con Moshegov FRANZCO, FRACS Alcon RESTOR Australian Clinical Outcomes and Results
  • 49.
    • 120 eyes with up to 15 months follow up
    • IOL Master
    • Haigis and SRK-T formulae
    • Leaning towards SRK-T
    • A constant= 118.2
  • 50.
    • Clear corneal incision
    • Topical anaesthesia
    • Centred CCC about 5mm
    • Phacoemulsification or aqualase
  • 51. Moshegov n = 74 @1 month n = 43 @ 3 months n = 17 @ 6 months Almost 80% have UNCVA of 6/9 by one month
  • 52. Moshegov n = 63 @1 month n = 32 @ 3 months n = 16 @ 6 months Can almost guarantee reading ability
  • 53.
    • Near point 20 to 40 cm from eyes
    • Average near point 32 cm
    • +1.00D ‘add’ moves near point out!
  • 54.
    • 15% patients not happy with intermediate VA
    • 5% patients still rely on glasses for some tasks
  • 55.
    • Factors associated with satisfaction and good results:
    • Presbyopic hypermetropes
    • Pre op UNCVA worse than 6/18
    • Post op SE of plano to +0.50
    • Post op cyl of less than 0.75D
    • People who do little computing
  • 56.
    • Experience suggests the ReSTOR ® IOL:
    • Reduces (almost eliminates) spectacle dependence
    • Much less trouble with halos or glare than with Array
    • Almost instant gratification as able to read straight away
    • No atropinisation required as with Crystalens
  • 57. Conclusions
    • Popularity of refractive lens exchange as a refractive procedure will continue to grow
    • Attention to technique, safety and refractive accuracy will be essential
    • Aqualase is a step forward in safe operating technique
    • IOL technology and choices are improving
    • Pseudoaccomodating IOLs will gain market prominence