Managing Premium Intraocular Lenses


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

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