Co Management Made Easier IOL

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By. Dr. Alberto Martinez

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Co Management Made Easier IOL

  1. 1. Comanagement of Cataract Surgery and premium IOLs J. Alberto Martinez, M.D. Visionary Ophthalmology May 18, 2014
  2. 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. 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. 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. 5. Why do we treat astigmatism? • Quality of vision after cataract surgery • Quality of life after cataract surgery
  6. 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. 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. 8. LenSx arcuate incisions
  9. 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. 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. 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. 12. ToricIOLs • VisianToric ICL (Not approved yet) • AcrysoftToric IOL • TecnisToric IOL • (Staartoric) IOL (Old, not used anymore
  13. 13. StaarToric IOL -Rotated after placement -Popular 10 years ago -Set back for ToricsIOLs -No one uses it anymore
  14. 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. 15. VisianToric ICL
  16. 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. 17. AcrySofToric IQ Design Characteristics • Design – Acrylic Single-Piece platform – Posterior toricity – Toric axis marks
  18. 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. 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. 20. Cylinder Powers A wide range of cylinder powers means more candidates can benefit from AcrySof® IQ Toric IOL.
  21. 21. Toric Calculator • Easy Input – Patient data – Keratometry – IOL spherical power – Surgically induced astigmatism – Incision location
  22. 22. Toric Calculator, continued • Powerful output – Recommended IOL model and spherical equivalent power – Optimal axis placement – Magnitude and axis of anticipated – residual astigmatism
  23. 23. Pearls for the Toric 1. Keratometry 2. Pre-operative marking 3. Operative marking and final orientation
  24. 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. 25. Pearls for the Toric • Compare topography astigmatism axis to keratometry axis
  26. 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. 27. Pearls for the Toric 1. Keratometry 2. Pre-operative marking 3. Operative marking and final orientation
  28. 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. 29. Toric marking at the slit lamp
  30. 30. Pearls for the Toric 1. Keratometry 2. Pre-operative marking 3. Operative marking and final orientation
  31. 31. Preop marking: Verion system
  32. 32. ORA: Optiwave refractive Analysis • httphttp://getorasystem.com/
  33. 33. ORA- Verify
  34. 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. 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. 36. Lens Based Treatment for Astigmatism AcrysofToric IQ • Precise and Accurate • Predictable Outcomes • Permanent • Safe and Convenient • Aspheric Optics
  37. 37. Toric IOL • Post-operative spherical equivalent • Post-operative refractive astigmatism
  38. 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. 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. 40. Presbyopic IOL Options/Optics
  41. 41. “Presbyopic” IOL’s • Crystalens AO (B&L) • Tecnis Multifocal (AMO) • ReSTOR Aspheric (Alcon) – SN60D1 (3.0)
  42. 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. 43. Restor Platform • Refractive optics • Diffractive optics • Apodization: the treatment of the diffractive optics • Aspheric optics
  44. 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. 45. Restor Platform • Refractive optics • Diffractive optics • Apodization: the treatment of the diffractive optics • Aspheric optics
  46. 46. Positive Spherical Aberration • Glare/halos • Decreased contrast sensitivity
  47. 47. Anatomy of the Aspheric Apodized Diffractive +3.0 Technology
  48. 48. RestorToric Soon to be approved in the US, will eliminate many of the problems associated with post Restor astigmatism
  49. 49. 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
  50. 50. 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
  51. 51. 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
  52. 52. Ocular Pathology • Ocular surface disease
  53. 53. Ocular Pathology • Macular degeneration (AMD) • Epiretinal membrane – Baseline macular OCT pre-op • Diabetic maculopathy • Advanced glaucoma • Amblyopia
  54. 54. Multifocal Post-operative Care
  55. 55. Purple Glasses
  56. 56. 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
  57. 57. Problems Reading? • Teach patient the importance of good light • Demonstrate the “sweet spot” • Check pupil size: > 3 mm, try Pilo 0.5%
  58. 58. Multifocal Pearls 1) Treat residual refractive errors 2) Early yagcapsulotomy 3) Aggressively treat ocular surface disease 4) Look for cystoid macular edema (CME)
  59. 59. Myth • Presbyopic IOL patients will tolerate small refractive errors
  60. 60. Treat residual refractive errors • Astigmatism – LRI’s – Keratotomy incisions – LenSx – PRK or Lasik • Spherical errors – PRK or Lasik – IOL exchange
  61. 61. Treat residual refractive errors • Trial frame • Temporary glasses
  62. 62. Preparing Patients for Lasik or PRK • Pre-op cylinder greater than 2 D may need an enhancement • Topography • Pachymetry
  63. 63. Multifocal Pearls • Treat residual refractive errors • Early yagcapsulotomy • Aggressively treat ocular surface disease • Look for cystoid macular edema (CME)
  64. 64. YagCapsulotomy • 30-50% or all mutifocal patients will need a yagcapsulotomy
  65. 65. Multifocal Pearls • Treat residual refractive errors • Early yagcapsulotomy • Aggressively treat ocular surface disease • Look for cystoid macular edema (CME)
  66. 66. Pearl Most visual fluctuation is generally caused by ocular surface disease
  67. 67. Diagnostic Tools
  68. 68. Multifocal Pearls • Treat residual refractive errors • Early yagcapsulotomy • Aggressively treat ocular surface disease • Look for cystoid macular edema (CME)
  69. 69. Prevention of CME
  70. 70. Optical Coherence Tomography (OCT) • Can measure even subtle postoperative retinal thickening • Gaining popularity for diagnosis of CME
  71. 71. “Presbyopic” IOL’s • Crystalens AO (B&L) • Tecnis Multifocal (AMO) • ReSTOR Aspheric (Alcon) – SN60D1 (3.0)
  72. 72. Crystalens® AT-45SE August 2005 • 360 degree square edge • Round to the right loop configuration
  73. 73. Proposed Mechanism of Action: • The accommodating lens is implanted like standard IOL • Lens vaults backwards, correcting distance vision
  74. 74. Accommodating Lens • As objects move closer to the eye – The ciliary muscle expands exerting pressure on the vitreous
  75. 75. Accommodative Lens • The displaced mass of the vitreous forces the crystalens forward • Images at arms length (intermediate) are clear
  76. 76. Accommodative Lens • Reading increases contraction of the ciliary muscle • Lens is forced further forward – Intermediate & near images are clearer
  77. 77. 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
  78. 78. The Doctor Encounter Patient Selection Make a Recommendation
  79. 79. 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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