The document discusses the evolving landscape of cataract and refractive surgery, emphasizing the importance of premium intraocular lenses (IOLs) and the roles of optometrists and ophthalmologists in patient education and expectation management. It highlights the advancements in premium lenses since the 1990s, the need for thorough patient selection, and the necessity of addressing issues such as residual refractive error and ocular surface disease. Establishing clear communication about surgical outcomes and patient satisfaction is critical for successful implementation and management of premium lens technology in modern ophthalmology.

1. Optimizing outcomes with Premium Lens Patients and Traditional Lens Patients Donny Reeves, MD [email_address]

2. We had unintentional consequenses! COPE Course ID: 28746-PO

3. Our objective today Discuss the background to premium lenses Optometrist role Ophthalmologist role What is vision in todays times Outcomes Setting realistic expectations Choosing the right patient You must recommend!! Identifying and managing problems Dealing with happy and unhappy refractive patients

4. Financial Interest I have no financial interest related to the discussion of any of the products discussed Alcon Laboratories, consultant Bausch & Lomb, consultant Allergan Inc, speakers bureau Investigator, Abbott Medical Optics

5. Background Premium IOLs date back to late 1990s (Array) Restor +4 add 2005 Non-aspheric then aspheric Crystalens 2005 Rezoom 2005 Crystalens 5.0 2007 Crystalens HD 2008 Restor +3 add 2009 Aspheric Acrysof Toric 2009 Technis 2009

6. We have learned a lot! Experience with these lenses has taught providers a tremendous amount about visual function of all lens patients We have learned how to manage them with good outcomes and make sure we take steps to continue making them better

7. Adding premium IOLs to your optometric practice is key to remaining competitive in modern refractive surgery Managing patient expectations and proper education is critical to its success

8. Current Refractive Surgery LASIK(and variants) PRK Conductive Keratoplasty Implantable contact lens Visian ICL Staar ICL Clear lens exchange Cataract Surgery presbyopia correction Distance spectacle improvement Desired correction Monovision Astigmatism correction

9. Times have changed… Cataract surgery is rapidly evolving Patient expectations have increased and we need to keep up with those expectations

10. The Growing Expectations of Patients Patient expectations for almost any type of eye surgery have been shaped by dramatic improvements in technology. Patient expectations now include: High success rate with low complications Superior quality of vision Excellent uncorrected visual acuity outcomes Decreased dependence on glasses in all activities

11. Two Cataract Surgeon Categories Traditional Surgeon Traditional cataract surgeon profile most ophthalmologist – implants non-aspheric monofocals Do not decrease spectacle independence Late adopter of technology Refractive Surgeon Refractive cataract surgeon LASIK/PRK (Custom) Astigmatism correction expert Aspheric/non-asperic user Toric IOL user Accommodative IOL expert Multifocal IOL expert

12. Types of Premium Lenses Accomodative IOL (CrystaLens) Multifocal IOL Diffractive IOL – apodized diffraction Refractive IOL Toric IOL

13. Optometrists role Many pts have been seeing optometrists for many years and have a close relationship Relationship is ongoing beyond cataract surgery Improving refractive correction does not eliminate role in optometric care

14. Optometrist role cont. We have been told that it has been difficult introducing this new technology to patients

15. Ophthalmologist role Focus on and manage disease pathology Surgical management of visual function

16. Ophthalmologist role cont… Despite our small role the patient may perceive surgery to solve 100% of the problem Process starts with education and setting realistic expectations Choose the right surgeon Surgeon chooses the right IOL for the patient

17. Visual Function is multifaceted Ocular surface DES,Blepharitis,MGD Astigmatism Lens Retina Optic nerve Contrast sensitivity Visual axis (intra-cranial) Patient perception of vision

18. No one is perfect… In medicine we still are limited on what we have control of Patient compliance Disease severity and response to treatment Disease progression

19. Really… No one is perfect Endophthalmitis Cystoid Macular edema Large residual refractive error Posterior capsular rupture Corneal edema

20. Outcomes Establishing predictable results with the traditional lens surgery is critical before converting a cataract patient into a refractive patient Modern biometry Modern formulas Advance cataract surgery techniques

21. Patient Expectations Ensure that you set the bar at the appropriate level The principle is the same for ALL refractive surgery Establish value with lifestyle improvement and lesser on cost

22. Start out with the low hanging fruit Start with Toric IOLs Easy to explain Easy to manage Most patients know what astigmatism is Most are 20/happy No promise for spectacle freedom (near) Very little abberations

23. Under promise and over deliver Educate with positive attitudes When you educate well, more people will choose the implant that best suits them Simply converting them to a premium lens patient without education is a setup for problems

24. Which lens to choose…Don’t Worry about it Find the right surgeon who is experienced! The key is to educate them with the right information – Short and to the point Too much information can confuse the patient

25. Pick the best candidate Everyone is a good candidate unless pathology excludes him/her Look for cylinder (cutoff for multifocals is >1.5D) Vision questionaire Exercise caution in patients with previous refractive surgery Postoperative surprise in LASIK/RK patients Need different formulas for IOL calculations

26. Considerations Ocular surface issues High astigmatism >1.5 D Premium IOLs >4.00 for Torics including an LRI ** Previous refractive surgery ARMD (Yes-Toric, No-Premium) Moderate glaucoma Optic nerve issues Diabetic retinopathy Fuch’s dystrophy Severe behavioral issues Patient’s with extremely high visual demands/expectations Engineer, chemist, preacher

27. Recommend! The patient still wants to be told which option is best for them! A strong, well informed recommendation is the key to assisting the patient with a lens choice. This is the most important slide!

28. Once they choose I can advise them about issues with these lenses Glare/halos Small print Need for additional procedures during recovery period

29. Improving Surgical Outcomes Most common causes for post-op surprises Axial eye length error Erroneous K-readings IOL position- capsulorrhexis dependant

30. Erroneous K-readings 1 diopter error in K= 1 diopter error in post-op If measured too steep=hyperopia If measured too flat=myopia

31. Avoiding erroneous axial length NEVER use contact method--- is considered OBSOLETE!!! Studies have shown 0.14-0.36 mm error due to corneal depression. Immersion is QUICKER, but requires more skill. We use IOL Master (5.4 version which has great updates) or Immersion A-scan Using B-Biometry (B-scan) to confirm lengths

32. Erroneous axial length readings 0.1 mm error=approx 0.25 diopter p/o surprise in average length eye(1mm=2.5 diopter surprise) In longer eyes (30mm) 1.0mm=1.75 diopter surprise In shorter eyes (20mm) 1.0mm=3.75 diopter surprise= VERY UNHAPPY PATIENT, especially a multifocal pt In extremely short eyes 0.1mm error as much as 0.75 diopter surprise

33. Postoperative care The optometrist can provide either one day post op or 2 week post op Discuss blurred vision after surgery that will improve (corneal edema, inflammation) Use -2.50 purple glasses to test reading Test monocular if 1 st eye Then test reading without purple glasses

34. 1 week post op –Premium lens patients Surgeon determines if power is close to predicted and make adjustments I use this for counseling about the process and answer questions They get an additive effect with both eyes done

35. The companies don’t practice what they preach

36. They flex like your eye's natural lens, allowing you to see better at all distances.

37. Rezoom

38. ReStor Finally, the opportunity for freedom from reading glasses and bifocals. 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!

39. Restor +4.00 add +3.00 add I use the +3.00 add due to best performance in most situations (90%)

40. +4.00 Restor Good spectacle independence 80% Intermediate vision difficulty is common Fewer halos than Rezoom Mixing lenses were more common about 2 years ago (Rezoom/Restor), (Restor/Crystalens)

41. +3.00 Restor 90% spectacle freedom rate Intermediate issue has been resolved

42. Crystalens 1 st implant approved Good distance acuity Good intermediate acuity Fair reading vision Predictability can be difficult and more refractive surprises and more hand holding Z-syndrome

43. Tecnis multifocal +4.0 add Aspheric IOL Diffractive IOL on posterior surface Near point closer to the retina Outcomes are good More pupil independent readi ng Intermediate similar to +4 Restor

44. So What about Astigmatism? In the past it was left untreated during cataract surgery. How can we treat it?

45. Toric Patients who are able to have lens surgery and also have significant regular corneal astigmatism Multifocal contraindications are less important Dry eye, diabetic retinopathy, macular disease, glaucoma, personality difficulties Does not decrease contrast sensitivity

46. Astigmatism Greater than 2D Can combine technique Toric + LRI at time of surgery Toric + postop LRI Toric + laser vision correction Can do all 3 Most patients are happy(even with residual cylinder) and enhancement rate is much lower! Most have known about astigmatism all his/her life!

47. Toric IOL Safe and predictable way to improve patient’s distance visiion and decrease spectacle dependance

48. TORIC Availability What patients qualify? Any patient with .75 – 2.0+ D of Cylinder. T3 – 1.00 D T4 – 1.50 D T5 – 2.00 D ? Toric IOL

49. Spectacle Freedom for Distance p<0.0001 CMH test 97% of patients with bilateral AcrySof Toric IOL implantation (N=37) *

50. Traditional Lens Surgery Treat them with the same way except no enhancement option Advise them of coexisting pathology Allows the patient a better understanding of their visual function

51. Infection/inflammation/pain control Strongest therapy(expensive) Durezol 4x/day for 1 week Nevanac 4x/day for 2 weeks 4 th generation fluoroquinolone for 2 weeks Common sense/practical therapy Still standard of care Generic prednisolone acetate Generic ketorolac (beware of medicare doughnut hole- out of pocket still up to 100.00) 4 th generation fluorquinolone

52. Postop You and the patient have picked the best lens for them. The surgery has been done, and the patient is unhappy. What next?

53. Well it must be the surgery, right? You do not help the patient or your practice by arguing with the patient. “ Well maam, everything looks good and nothing is wrong with your eyes.” “ There must be something wrong with your surgery.”

54. Team based approach “ Patients do not care how much you know until they know how much you care.” Johnny Gayton, MD You have to have a caring, compassionate team to help a patient with concerns

55. Common non-medical causes for an unhappy patient Set unrealistic expectations The don’t understand neuroadaptation Don’t understand other eye problems DES, residual refractive error, POAG All companies state to underpromise and overdeliver; They don’t practice what they preach! Do not understand the technology; Use the -2.50 lenses

56. Ocular surface disease Excellent vision starts with a healthy tear film Decreases contrast sensitivity All refractive surgery outcomes are diminished by disruption of the ocular surface

57. Ocular surface disease Listen to the patient They will only tell you their vision is blurred. Ask about vision fluctuation throughout the day DES classic symptoms with blurred vision

58. CME The most frequent cause of visual decline following uncomplicated cataract surgery Look for late onset (4 to 6 weeks post-op) 1 Estimate to occur in 12% of low risk cataract cases 2 Due to prostoglandin-mediated breach of blood-retinal barrier 3 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.

60. CME CME Flourescein angiogram picture

61. CME Angiographic CME – May not be associated with significant Snellen visual loss – Can cause loss of contrast and refractive error (hyperopia and/or astigmatism) Clinical CME – Described as vessel leakage associated with visual acuity of 20/40 or worse – Today’s definition is becoming stricter (20/25 or worse) due to higher expectations and designer IOLs Heier JS, Topping TM, et al. Ketorolac versus Prednisolone versus Combination Therapy in Treatment of Acute Pseudophakic Cystoid Macular Edema. American Academy of Ophthalmology. 2000;107(11):2034-9.

62. Residual refractive error Residual Astigmatism (even small amounts) can markedly decrease the effectiveness of multifocal lenses.

63. Residual refractive error Can perform LRI post op Wait for stability of refraction Anything >0.75 diopters

64. Residual refractive error LASIK/PRK is included with the surgery Enhancement rate is between 10-20% 1 month post op

65. Glare/Halos Can occur in multifocal patients Reassure that symptoms improve with neuroadaptation Look for signs of dry eye giving abberations; PF artificial tears Alphagan P sample 0.5% percent pilocarpine Look for PCO Look for residual refractive error >-0.50 Surgeon dependant threshhold for treatment

66. Summary Get everyone on the same sheet of music (optometrist, ophthalmologist, all staff) Our standard IOL patients have directly benefitted from the use of these lenses Co-management is possible but does have some new challenges Recommend what is best for the patient which is often a traditional lens This option should be discussed as a part of informed consent

67. Summary This is the future of refractive surgery Thanks [email_address] Email will usually get you a timely response. 423-722-1311