Refractive surgery for GP's

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Perfect Vision's Dr Con Moshegov presentation on: Refractive surgery for GP's

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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.
  • Refractive surgery for GP's

    1. 1. Con Moshegov FRANZCO, FRACS Con Moshegov FRANZCO, FRACS Refractive Eye Surgeon Refractive Surgery What a GP should know
    2. 7. Refractive Error <ul><li>Myopia: can’t see in the distance </li></ul><ul><li>Hypermetropia: can’t see at near </li></ul><ul><li>Astigmatism: blurred at any focal length </li></ul><ul><li>Presbyopia: need for longer arms to read </li></ul>
    3. 8. Cornea too steep
    4. 9. Correction of Refractive Error <ul><li>Glasses </li></ul><ul><li>Contact Lenses </li></ul><ul><li>Surgery: </li></ul><ul><ul><li>Incisional (RK, AK, ‘T cuts’) </li></ul></ul><ul><ul><li>Cataract Surgery </li></ul></ul><ul><ul><li>Implantation of phakic (contact) lens </li></ul></ul><ul><ul><li>Excimer Laser PRK </li></ul></ul><ul><ul><li>LASIK </li></ul></ul><ul><ul><li>VISX Wavefront guided customised treatment </li></ul></ul>
    5. 11. Radial Keratotomy <ul><li>No longer used </li></ul><ul><li>Weakens cornea: danger in sports </li></ul><ul><li>Glare and haloes at night </li></ul><ul><li>Diurnal fluctuation in vision </li></ul>
    6. 12. Astigmatic Keratotomy (AK) <ul><li>Arcuate incisions in cornea </li></ul><ul><li>‘ Relax’ the tight steep axis to relieve astigmatism </li></ul><ul><li>Can be straight (transverse) – T cuts </li></ul>
    7. 17. PRK
    8. 20. <ul><li>Does not occur if laser is applied directly onto stroma </li></ul>
    9. 21. LASIK
    10. 22. LASIK
    11. 23. Advantages of LASIK over PRK <ul><li>No risk of haze </li></ul><ul><li>Much reduced degree of regression </li></ul><ul><li>Almost no pain </li></ul><ul><li>More accurate </li></ul><ul><li>More rapid recovery of vision </li></ul>
    12. 24. Microkeratomes
    13. 26. LASIK using the Amadeus
    14. 27. Complications <ul><li>With creation of flap: </li></ul><ul><ul><li>Incomplete </li></ul></ul><ul><ul><li>Free </li></ul></ul><ul><ul><li>Damaged </li></ul></ul><ul><ul><li>Epithelial defect </li></ul></ul>
    15. 28. Complications <ul><li>With laser ablation of bed: </li></ul><ul><ul><li>under or over correction </li></ul></ul><ul><ul><li>regression can still occur </li></ul></ul><ul><ul><li>decentration </li></ul></ul><ul><ul><li>glare, haloes, starbursts, especially at night </li></ul></ul><ul><ul><li>excessive thinning </li></ul></ul>
    16. 30. LASIK induced ectasia
    17. 31. Contraindications <ul><li>Absolute: Keratoconus </li></ul><ul><ul><li>Ectasia </li></ul></ul><ul><ul><li>Thinning and forward protrusion </li></ul></ul><ul><ul><li>Results in myopia and astigmatism </li></ul></ul><ul><ul><li>Associated with atopy </li></ul></ul>
    18. 35. Complications <ul><li>With interface </li></ul><ul><ul><li>Implantation of foreign matter or epithelial cells </li></ul></ul><ul><ul><li>Inflammation under the flap </li></ul></ul><ul><ul><li>Infection (extremely rare) </li></ul></ul>
    19. 36. <ul><li>Most common causes for dissatisfaction: </li></ul><ul><ul><li>Not surgical complications, rather…. </li></ul></ul><ul><ul><li>1. Dry eyes </li></ul></ul><ul><ul><li>2. Lack of independence from reading glasses </li></ul></ul>
    20. 37. Day of Consultation (pre-operative evaluation)
    21. 38. Consent Video <ul><li>Video outlining </li></ul><ul><ul><li>process of procedure </li></ul></ul><ul><ul><li>potential risks & complications </li></ul></ul>
    22. 39. Pre-operative Evaluation <ul><li>Answering of any questions arising from video </li></ul><ul><li>Medical and eye h istory </li></ul><ul><li>Atlas topography </li></ul><ul><li>Orbscan </li></ul><ul><li>Check previous or current glasses </li></ul><ul><li>Autorefraction </li></ul><ul><li>Manual r efraction </li></ul>
    23. 40. Doctors Assessment <ul><li>Review corneal maps </li></ul><ul><li>Refraction </li></ul><ul><li>Confirm suitability </li></ul><ul><li>Comprehensive eye exam </li></ul><ul><li>Informed consent </li></ul><ul><ul><li>risks & complications </li></ul></ul><ul><ul><li>specific statistics related to individual </li></ul></ul><ul><li>Given time to consider </li></ul>
    24. 41. The Day of Treatment
    25. 42. <ul><li>Valium tablet - tranquiliser </li></ul><ul><li>- muscle relaxant </li></ul><ul><li>Anaesthetic drops </li></ul><ul><li>Reiterate details of what to expect </li></ul>Preparation of the patient
    26. 43. <ul><li>Lid speculum : blinking not a problem </li></ul><ul><li>2 . Pressure and loss of vision with suction </li></ul><ul><li>3 . Sound of motor of microkeratome </li></ul><ul><li>4. Odour during lasering </li></ul><ul><li>5. M ovement won’t blind: 3D tracker </li></ul><ul><li> </li></ul>‘ you can expect’
    27. 44. <ul><li>antibiotic and anti-inflammatory drops for 7 days </li></ul><ul><li>lubricating drops as necessary </li></ul><ul><li>shield at night for 2 nights </li></ul><ul><li>avoid swimming and eye make up for 2 weeks </li></ul>Post operative regime
    28. 45. Follow up <ul><li>Next day </li></ul><ul><li>2 to 3 weeks </li></ul><ul><li>3 months </li></ul><ul><li>12 months </li></ul><ul><li>Life time post operative support </li></ul>
    29. 46. Technolas 217z
    30. 47. VISX Star S4
    31. 48. Customised ablation Wavefront technology
    32. 49. Wavefront: Basics focuses incoming rays with a plane wavefront ... ... to one point. Ideal Optical System
    33. 50. Wavefront: Basics Outgoing light rays from a focal point have again ... ... a plane wavefront.
    34. 51. Wavefront: Basics Outgoing light rays from a system with Aberrations have ... ... a deformed wavefront.
    35. 52. Wavefront: Basics Incoming Wave Lens System to generate a point at the retina LASER BEAM
    36. 53. CCD-Camera Lens Array Outgoing Wave CCD-Image Wavefront: Basics
    37. 54. Wavefront: Basics CCD-Image Example for a measured signal to reconstruct the wavefront!
    38. 55. Integration of WaveScan ® WaveFront System with the VISX STAR ActiveTrak ™
    39. 56. Limit ations of LASIK <ul><li>Extremes of refractive error </li></ul><ul><li>T hin corneas </li></ul><ul><li><32D or >50D after treatment </li></ul><ul><li>Irregular astigmatism </li></ul><ul><li>Narrow orbit and deep set eyes </li></ul>
    40. 57. Alternative Options <ul><li>PRK </li></ul><ul><li>C lear lens extraction </li></ul><ul><li>P hakic IOL </li></ul><ul><li>Combinations of the above </li></ul>
    41. 58. CLE <ul><li>Definition </li></ul><ul><li>Removal of non cataractous crystalline lens </li></ul><ul><li>Implantation of IOL </li></ul><ul><li>Purely for refractive purposes </li></ul><ul><li>Not chargeable to Medicare </li></ul>
    42. 59. CLE <ul><li>Concerns: </li></ul><ul><li>Risks of intraocular surgery </li></ul><ul><li>retinal detachment </li></ul><ul><li>endophthalmitis </li></ul><ul><li>Eliminates accomodation </li></ul>
    43. 60. CLE <ul><li>Retinal Detachment after Clear Lens Extraction for High Myopia Seven year follow up </li></ul><ul><li>Colin J, Robinet A, Cochener B. </li></ul><ul><li>Ophthalmology 1999; 106:2281-2285 </li></ul><ul><li>52 eyes with myopia > -12.0D </li></ul><ul><li>RD in 2% at 4years and 8% at 7 years </li></ul><ul><li>nearly double estimated for similar unoperated eyes </li></ul><ul><li>despite prophylactic laser </li></ul>
    44. 61. CLE <ul><li>Typical patient: </li></ul><ul><li>Over 40 years </li></ul><ul><li>Hyperopic </li></ul><ul><li>Desperately wanting freedom from glasses </li></ul>
    45. 62. <ul><li>Surgery </li></ul><ul><li>phacoemulsification </li></ul><ul><li>topical anaesthetic </li></ul><ul><li>small incision (no sutures) </li></ul>
    46. 63. <ul><li>Limbal relaxing incisions </li></ul><ul><li>deep incisions in peripheral cornea </li></ul><ul><li>guarded diamond blade </li></ul><ul><li>500 to 600 micrometers deep </li></ul>
    47. 64. CLE <ul><li>Residual refractive error </li></ul><ul><li>Bioptics </li></ul><ul><ul><li>LASIK </li></ul></ul><ul><ul><li>3 months post op </li></ul></ul>
    48. 65. Array Multifocal IOL Silicone 3 piece lens
    49. 66. The ARRAY ® IOL Refractive Multifocal IOL Design <ul><li>Five concentric zones </li></ul><ul><li>Each zone has a near, intermediate and distance </li></ul><ul><li>weighting </li></ul><ul><li>Odds = weighted distance </li></ul><ul><li>Evens = weighted near </li></ul>
    50. 67. Accommodating IOL
    51. 68. Myth <ul><li>My cataract was removed with a laser </li></ul>
    52. 69. Myth <ul><li>They had to take my eye out to remove the cataract and then they put it back again </li></ul>
    53. 70. Myth <ul><li>The advertisement said they can make me do away without the need for reading glasses </li></ul><ul><li>Monovision </li></ul><ul><li>(non laser methods) </li></ul>
    54. 71. Myth <ul><li>Laser eye surgery will fix my eyesight forever </li></ul>
    55. 72. Take home points <ul><li>LASIK is the most popular form of refractive surgery </li></ul><ul><li>Complications can occur but are rarely devastating </li></ul><ul><li>New developments include customised or wavefront treatments and sophisticated 3D trackers </li></ul>
    56. 73. Take home points <ul><li>Cataract surgery is an alternative refractive procedure but is less accurate </li></ul><ul><li>Cataract extraction is now possible under topical anaesthetic </li></ul><ul><li>The cataract is removed using mechanical fragmentation at ultrasonic frequencies not laser </li></ul><ul><li>New developments include multifocal and accomodating implants </li></ul>
    57. 74. Conclusion <ul><li>Refractive surgery, both laser and lens procedures, is said to be the most rapidly evolving subspecialty not only of ophthalmology but medicine! </li></ul><ul><li>So ongoing education is essential. </li></ul><ul><li>I hope this presentation will help General Practitioners have a better appreciation of it’s scope. </li></ul>

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