Aqualase and BSS


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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

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