Advances in IOL Technology -Muliti-Focal Impants

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A slideshow presentation reviewing the features of multi-focal implants. Pertinent information is presented to help eye care providers to help them guide their patients, on the selection of multi-focal implant. Co-management pearls are provided regarding the post operative care of these patients.

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  • This slide illustrates that within the next 10 to 20 years there will be a proliferation of patients. The cataract patient base will almost double.Increasingly patients are coming in with a high expectation of care and this is anticipated to only increase over the next 10 years. In order to best care for these patients, ophthalmologists and optometrists need to partner on patient education and satisfaction.
  • We know a signficant component of the population has astigmatism
  • May want to stress the use of the phrase “less dependant” and touch on how you can not guarantee complete spectacle independence for every patient as you are going to demonstrate in the upcoming slides. However by setting patient expectations appropriately you help them make the right choice for them and ultimately help ensure patient satisfaction after surgery. SETTING APPROPRIATE PATIENT EXPECTATIONS BEFORE SURGERY IS THE KEY TO SUCCESSFUL POST OPERATIVE OUTCOMES!
  • I am starting to see this shift every day in my practice
  • You are all familiar with discussing the nature of cataract surgery with your patients, there are many good educational materials available feel free to contact my office if you would samples of these materials for your practice.
  • These lens options are available to patients. As noted, one can’t promise an outcome to a patient, only provide the general likelihood of dependence on spectacles for distance or near vision. Patient selection criteria and patient motivation will also influence the options appropriate for a patient.
  • When considering the IOL options for a patient there are numerous factors that will influence the decision.A desire to reduce dependence on spectacles is an important consideration for choosing eitherToric or Multi-focal implants
  • Basically there are two categories of patients: enough astigmatism to treat those with minimal astigmatismAstigmatic patients can be happy with a basic IOL as long as they don’t mind wearing glasses or contacts all the timeBut for those who would like to be less dependant on glasses, they may be good candidate for a ToricA Toric can be an option as long as their astigmatism is not irregular and they have no other exclusionary eye problemsIt’s important they understand that they will still have to wear glasses to read as the Toric lens will not correct for thisTo not be dependant on glasses to read, they can consider a ReSTORToric as long as they have less than 2.5D of cylMaking them less dependant on glasses at all distances while correcting their astigmatism at the same timeFor patients with no astigmatism, they can be happy with a basic IOL as long they don’t mind wearing glasses to readBut for those who would prefer not to wear glasses to read and have a healthy eye, they can consider a ReSTOR lensThe key to finding the best choice for each patient is shared decision making. Patients deserve to know their choices and with adequate education they can choose the lens that best suits their lifestyle
  • Same as ReSTOR – you may want to not that correcting the pre op cyl also brings an additional “wow” factor for these patients.
  • Optimize the ocular surface, artificial tears, Restasis, nutritional supplements
  • Advances in IOL Technology -Muliti-Focal Impants

    1. 1. Dr. M. Ronan Conlon Midwest Eye Care Institute SaskatoonFebruary 2nd, 2012 – Saskatoon Club
    2. 2.  Share my experience with multi-focal implants Patient video – highlighting many of features of multi-focal implants Patient selection/Education C0-Management Managing the Unhappy Patient
    3. 3.  Population trends in 3.0 Canada predict a 2.5 significant increase in 2.0 patients requiring cataract surgery in the Millions 2010 1.5 2021 next 15 years 1.0 2031  Advanced technologies are now available to 0.5 these patients to 0.0 enhance their visual 70 to 74 >100 85 to 89 60 to 64 65 to 69 75 to 79 90 to 94 80 to 84 95 to 99 function Age GroupProjected population by age group and sex according to three projection scenarios for2010, 2011, 2016, 2021, 2026,2031 and 2036, at July 1. Statistics Canada.
    4. 4.  Advanced Technology Lenses (Part 1) – Toric implants – presented September 15th, 2011
    5. 5. 50.0 Moderate 1.0 – 2.0D 25%% of Patients 40.0 30.0 Severe >2.0 D 20.0 10% 10.0 0.0 <.5 <1 <1.5 Cylinder D <2 <2.5 ( < ) <3 <3.5 >3.5N = 10,411
    6. 6. AcrySof® IQ TORIC IOL:Astigmatism Correction 7
    7. 7.  81.1% of patients were ≤5º of intended axis 97.1% of patients were ≤10º of intended axis less than 4º average rotation 6 months after implantation
    8. 8. Cylinder Powers Estimated Percent of Cataract Patients with Astigmatism 0.5D 4D+*Based on average pseudophakic human eye. 9
    9. 9. 2010 – 805 Cataract Cases 2011 - 850 Cataract Cases 47 11 (6%) 94 73 (1.0%) Aspheric(12%) Aspheric (9%) Toric Toric ReSTOR 546 ReSTOR 700 (65%) (87%) ReSTOR 166 ReSTOR Toric (20%) Toric
    10. 10.  Toric Implant at axis 90 degrees
    11. 11. Key points for patients to understand • Toric lenses are designed to work with the shape of your cornea to focus light to a single point at the back of your eye to improve your quality of vision. • By doing this, Toric lenses will make you less dependant on your glasses for distance vision • Toric lenses only correct astigmatism and do not correct presbyopia • You will have to wear reading glasses after cataract surgery
    12. 12. Key points for patients to understand • Toric lenses have become the standard of care for astigmatic cataract patients in my practice • Patients see better if they have a toric implant – it’s that simple • These lenses work extremely well
    13. 13. Multifocal IOLsThe Goal: To make patients less dependant on their glasses for all distances
    14. 14.  Diffractive  ReSTOR +3.0  Technis  AcriLisa (Europe) Zonal Refractive  ReZoom Accommodating  Crystalens  Synchrony
    15. 15.  It’s a light management system Microscopic steps sends light where you need it, when you need it
    16. 16. Anterior Apodized Diffractive Aspheric Surface  9 apodized diffractive steps for +3.0D add power and balanced light energy management  Negative 0.1 micron spherical aberration factor corrects for the positive spherical aberration of the cornea Posterior Toric Lens Surface Posterior toric surface with axis marks Allows the lens to correct pre-existing corneal astigmatism 18
    17. 17. IOL Model Cylinder Power Cylinder Power Recommended @ IOL Plane @ Corneal Plane* Corneal Astigmatism Correction Range (Online Calculator Limits) SND1T2 1.00 0.68 0.50 to 0.89 D SND1T3 1.50 1.03 0.90 to 1.28 D SND1T4 2.25 1.55 1.29 to 1.80 D SND1T5 3.00 2.06 1.81 to 2.32 D*Based on an average pseudophakic human eye 19
    18. 18. Binocular Defocus Curve ∞ 20/20 20/25 20/32 20/40 20/50 20/63 20/8020/100 +1.00 +0.50 0.00 -0.50 -1.00 -1.50 -2.00 -2.50 -3.00 -3.50 -4.00 Refraction (D) AcrySof® IQ ReSTOR® IOL +3.0 D [N=116] Mean Defocus Curve for AcrySof® IQ +3.0 D ReSTOR® IOL Binocular, Best Case, 6 Months Postoperative Source: AcrySof® IQ ReSTOR® IOL Package Insert 20
    19. 19.  55 bilateral ReSTOR 2011 - 850 Cataract Cases implantations so far 47 (6%) 73 30 have completed 6 (9%) Aspheric month Late Outcome Toric Assessments – measuring ReSTOR 546 (65%) UCDVA, UCNVA, BCDV 166 ReSTOR (20%) A, BCNVA, refraction Toric and survey of visual activities and function
    20. 20.  98% would have same implants again Mean UCDVA 20/25 (range 20/20+ to 20/30- , UCNVA 20/25 (range 20/20+ to 20/40) All of the patients with UCVA worse than 20/25 are due to uncorrected astigmatism >0.75 D; all correct to 20/20 near and distance with this cylinder corrected
    21. 21. Richard L. Lindstrom – August 2009 OSNPerspective• Careful patient selection• Reducing patient expectations• Achieving the desired refractive result
    22. 22. Richard L. Lindstrom – August 2009 OSN My conclusion after 25 year of studying the premium IOL field, is that the level of patient satisfaction is NOT dependent of careful patient selections I do NOT believe that patient satisfaction is really significantly influenced by extensive efforts to reduce patient expectations Patient selection is LESS IMPORTANT THAN SURGEON PERFORMANCE if spectacle independence is the desired outcome
    23. 23. Richard L. Lindstrom – August 2009 OSN Every refractive cataract surgeon must appreciate that it is the REFRACTIVE OUTCOME THEY GENERATE, NOT THE PATIENT or EVEN THE TECHNOLOGY they select, that is the primary determinant of patient satisfaction and word of mouth referrals.
    24. 24. 40,000 premium lens implants 60% (24,000) eyes left with > 0.75D untreated residual K astigmatism Minimum goal less than 0.50 Correction of cylinder is extremely important
    25. 25.  What can you do? Optometry has a key role in the education and counsel of patients seeking guidance in new implant technology
    26. 26.  Acceptance and Embracement of a change in practice model  From medicare model – “treatment for pathology” ▪ High volume, efficient, low cost care  Patient orientated model – “treatment for Quality of Life” ▪ High quality, personalized to patients needs, expectations, and desires, patient pay
    27. 27.  Patients are interested in lifestyle, not pathology and are happy to pay for the enhanced quality of life Old paradigm: Patient want to see better than they did with their cataracts New paradigm: Patients want to see better than they did before they developed cataracts
    28. 28. Define • Clouding of the natural lens that allows less light to pass through to the retinaSymptoms • Blurred vision • Dull colors • Poor night vision • Sensitivity to lightTreatment • ONLY treatment is to have it surgically removed and replaced with an artificial lens
    29. 29. Multi-focal Implant • Designed to correct vision near, far, and in-between, for the best chance at freedom from glasses.Toric Implants • Designed to correct both cataracts and astigmatism at the time of surgery. Glasses will likely be needed for near vision.Multifocal Toric Implants • Provides clear distance vision. Glasses will likely be needed for near vision and possibly for distance vision.
    30. 30. Take into account:▪ Lifestyle▪ Astigmatism▪ Preexisting ocular conditions, i.e. dry eye▪ Pathology – rule out retinal pathology
    31. 31. Astigmatism No Astigmatism Basic IOL Basic IOL • regular astigmatism Toric IOL • healthy eye? ReSTOR ReSTORToric Shared Decision Making!
    32. 32. Key points for patients to understand • ReSTOR is a multifocal lens which make you less dependant on glasses after cataract surgery at all distances • Although 20/20 vision is not guaranteed, 80% of patients report not needing glasses after surgery • 20% of patients report needing glasses for specific activities such as working on a computer or reading in dim light • Glare and halo around lights at night may be reported after surgery, most patients adapt within a few weeks • Adequate light is recommended for ideal reading vision
    33. 33.  Expansion of patient variety and opportunity for practice growth With the development of toric, multi-focal, and multi-focal toricIOL’s cataract surgery has evolved into “refractive cataract surgery” Shared practice experience and opportunity for higher degrees of patient satisfaction Optometrists play an integral role in selecting and recommending IOL technologies Saskatchewan has a larger geographical area and travel is a significant issue for patients
    34. 34.  Patient should discontinue contact lens wear two weeks prior to axial length and keratometry measurements – more accurate IOL measurements Discuss with your patient the various IOL options – regular, toric, multi-focal, and multi-focal toric Advise your surgeon and what you think would work best – make a recommendation
    35. 35.  Manage Ocular Surface Disease Treat Dry Eye Manage Eyelid Margin Disease
    36. 36. • Many cataract surgeons now perform same day post evaluations, and patient go home same day• Examination • Vision is usually 20/40 or better • Anterior segment – cornea generally clear to mild edema, AC inflammation minimal +1, eye should be comfortable, AC deep, wound sealed • Lens centered • IOP – 10 to 25 (contact surgeon if outside these parameters) • Post Medications – Vigamox TID x 1 week, Maxidex TID x 4 weeks, Nevanac TID x 4 weeks • Follow visit in 3-4 weeks, and sooner if concerns
    37. 37.  IOP spike  25 – 30 mmHg – Alphagan P BID x 1 week  > 30 mmHg – contact surgeon Bullouskeratopathy  Lubricated surface, consider Muro 128 qhs  Usually related to increased IOP, endothelial comprise Tilted IOL  Not an emergency, but contact surgeon Peaked Pupil  Not an emergency, but contact surgeon, check IOP and wound leak Retain lens fragment  Increased steroid 6X/day, and contact surgeon Retinal detachment  Urgent – contact surgeon
    38. 38. • Conduct a dilated fundus exam to check for cystoid macular edema (CME)• Discontinue drops• Prescribe spectacles, if necessary • 20% of multi-focal toric implant patients require spectacles for some activities• Decreased Vision • Check for ocular surface disease – dry eye, MGD, EBMD • IOP • Fundus - CME
    39. 39.  Lens tilted  Inferior lens out of bag  May or may not require adjustment Persistent BullousKeratopathy  Control IOP  Muro 128 gtts/ung
    40. 40. • Patient should have bilateral lenses• Check visual acuities at appropriate distances• Survey the patient for their satisfaction
    41. 41.  Posterior capsular opacification (PCO) • Treated with a Nd:YAG laser Persistent tear film abnormalities unless you are comfortable managing it Residual refractive error if the patient is interested in a surgical solution
    42. 42.  Cylinder and Residual Refractive Error Cornea and OSN Capsule CME Centered
    43. 43.  Optimizing the ocular surface very important Options  Artificial tears  Restasis  Serum based tears  Punctal plugs  Nutritional supplements – omega 3’s
    44. 44.  Lid hyperthermia  Hot compresses or lid scrubs Nutritional supplements Topical azithromycin bid 2 days then qd for 1 month Tobradex Severe cases  Oral doxycycline 50 mg PO daily
    45. 45.  Consider Yag laser Avoid Yag laser if explantation still a consideration!
    46. 46.  NSAID’s mandatory Significant reduction post operative CME

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