co management made easier iol

Comanagement of Cataract Surgery and premium IOLs

J. Alberto Martinez, M.D.Visionary Ophthalmology

May 18, 2014

Visionary Ophthalmology’s criteria for Co-management

• Is it MORAL?• Is it ETHICAL?• Is it LEGAL• If this three criterion are met, then we ask

another question: Is it PROFITABLE?• Then it is OK to do

Why Comanage with VO?

• We have a well deserved reputation for excellent outcomes

• In technology, we are two years ahead of the competition.

• We have one of the best operating rooms in the planet• We are continuously seeking to improve our outcomes• Loving kindness is the driving force at VO

Refractive cataract surgery

• Cataract surgery has become the most sophisticated “refractive” procedure

• Patient expectations are increased • “Close” is no longer “good enough” • Astigmatism is the biggest buzzword now• The promise of effective astigmatism

correction is here!

Why do we treat astigmatism?

• Quality of vision after cataract surgery

• Quality of life after cataract surgery

Astigmatism in the Population

• Astigmatism – According to Dr. Hill’s analysis, 37.8% of patients

with cataract have more than 1.0 D of preexisting corneal astigmatism

Surgical Correction of Astigmatism

• Methods of correcting astigmatism – Operating on steep axis – Limbal relaxing incisions – Astigmatic Keratotomy – LenSx Laser – Toric IOLs – Toric phakic IOLs (Visian)– Post operatively – Laser refractive surgery – Astigmatic Keratotomy

LenSx arcuate incisions

Astigmatism: first question

• Is the astigmatism corneal or lenticular? • Cataract evaluation: current glasses

-3.00 +1.25 x 90 • Keratometry: 45.00/45.50 x 90 • Cataract evaluation: must obtain

keratometry/topography before the patient sees the doctor

Astigmatism: caveat

• The post-lasik patient who has been emmetropic for years may have lenticular astigmatism

• Cataract surgery will UNMASK this corneal astigmatism that was created with the lasik to treat the lenticular astigmatism

• Review topography carefully

Patient Selection: Toric IOL

• Cataract patient with ≥ 0.75 diopter of pre-existing corneal astigmatism

• Consider surgically induced astigmatism – Size and location of your incision – How much cylinder do you induce (Mine is 0.50 D)

• What is the expected residual cylinder post-operatively

Toric IOLs

• Visian Toric ICL (Not approved yet)• Acrysoft Toric IOL• Tecnis Toric IOL• (Staar toric) IOL (Old, not used anymore

Staar Toric IOL

-Rotated after placement-Popular 10 years ago-Set back for Torics IOLs -No one uses it anymore

Visian Toric ICL• This is a PHAKIC IOL• Visian is a great lens for high myopes not

correctable with LASIK• An advisory panel just approved the Toric

version• Long awaited in the US

Visian Toric ICL

Visian Toric ICL

• More than 100,000 placed worlwide• 2% chance of cataract formation (Risk factors:

higher myopes and age )• Easy to rotate into place• Rotationally Stable• Learning curve: Must take a course to learn

the nuances.

AcrySof Toric IQ Design Characteristics

• Design – Acrylic Single-Piece

platform – Posterior toricity – Toric axis marks

Understanding AcrySof® IQ Toric IOL Benefits

• Toricity – Rotational stability – Reduction of residual refractive cylinder – Increased spectacle-independent distance

vision – Wide range of cylinder powers

• Asphericity – Enhanced image quality

• Reduction in spherical and total higher order aberrations

• Increased contrast sensitivity • Improved functional vision

– Thinner edge profile

Rotational Stability• Generally, for every 1º of IOL

rotation, 3.3% of lens cylinder power is lost2

• A complete loss of cylinder power can occur with a rotation of >30º2

• Check the axis of the IOL post-op

Cylinder Powers

A wide range of cylinder powers means more candidates can benefit from AcrySof® IQ Toric IOL.

Toric Calculator

• Easy Input – Patient data – Keratometry – IOL spherical power – Surgically induced

astigmatism – Incision location

Toric Calculator, continued

• Powerful output – Recommended IOL model

and spherical equivalent power

– Optimal axis placement – Magnitude and axis of

anticipated – residual astigmatism

Pearls for the Toric

1. Keratometry

2. Pre-operative marking

3. Operative marking and final orientation

Hitting the Post-Operative Refractive Target : Keratometry

• One to one relationship in potential error – A 1 diopter error in K readings can yield a 1

diopter error in refractive outcome • IOL Master K’s: version 5 (2.6mm OZ) • LenStar K’s (2.3mm OZ) • Manual keratometry (3.2mm OZ) – Skilled technician required – Calibrate keratometer daily

Pearls for the Toric

• Compare topography astigmatism axis to keratometry axis

Hitting the Post-Operative Refractive Target

Keratometry • The most common error in keratometry is

secondary to ocular surface disease (OSD)

• Treat OSD before referring patient for cataract surgery

Pearls for the Toric

1. Keratometry

2. Pre-operative marking

3. Operative marking and final orientation

Posterior Corneal Astigmatism• A mystery being revealed• Generally as we age we get more against the

rule• Rule of thumb: Subtract 0.25 D to with the

rule• Add 0.50 D to against the rule astigmatism

Toric marking at the slit lamp

Pearls for the Toric

1. Keratometry 2. Pre-operative marking

3. Operative marking and final orientation

Preop marking: Verion system

ORA: Optiwave refractive Analysis

• httphttp://getorasystem.com/

ORA- Verify

IOL Alignment • Gross Alignment – Rotate IOL clockwise to

approximately 15 degrees short of desired position

– Completed while the IOL is unfolding in the capsular bag

– Can be rotated after IOL has unfolded, if needed, but take care to have capsular bag inflated with OVD

IOL Alignment

• Final Alignment – Carefully rotate IOL

clockwise onto the intended axis of alignment

– Tap IOL down into capsular bag to seat lens in place

Lens Based Treatment for Astigmatism

Acrysof Toric IQ • Precise and Accurate • Predictable Outcomes • Permanent • Safe and Convenient • Aspheric Optics

Toric IOL

• Post-operative spherical equivalent • Post-operative refractive astigmatism

Residual Astigmatism after Toric IOL

• Measure post-operative refractive astigmatism • Confirm axis of Toric IOL with Toric IOL

Calculator • Rotate Toric IOL to the correct axis

Technis Toric-Three point touchRotational Stability (2.7 degrees)-Newer in market, less experience-Higher Abbe number= less chromatic aberration-Does not block blue light (improved scotoptic sensitivity)

Presbyopic IOL Options/Optics

“Presbyopic” IOL’s

• Crystalens AO (B&L) • Tecnis Multifocal (AMO) • ReSTOR Aspheric (Alcon) – SN60D1 (3.0)

Diffraction

• The spreading and bending of light as it passes through discontinuities (i.e. steps or edges)

• In an optical system, light can be diffracted to form multiple focal points or images

• AcrySof® ReSTOR® Aspheric • AMO Tecnis Multifocal

Restor Platform

• Refractive optics • Diffractive optics • Apodization: the treatment of the diffractive

optics • Aspheric optics

Apodization

• Definition: A gradual modification in the optical properties of a lens from its center to its edge.

• Apodization is used in microscopy and astronomy to improve image quality.

• The ReSTOR apodized diffractive design controls both image quality and energy balance

Restor Platform

• Refractive optics • Diffractive optics • Apodization: the treatment of the diffractive

optics • Aspheric optics

Positive Spherical Aberration

• Glare/halos • Decreased contrast sensitivity

Anatomy of the Aspheric Apodized Diffractive +3.0 Technology

Restor Toric

Soon to be approved in the US, will eliminate many of the problems associated with post Restor astigmatism

Under Promise….Over Deliver

• Tell the patient that they are still going to have to wear glasses with any IOL option – Low lighting – Night driving – Reading a novel

• Tell patients that they will see rings around lights with a multifocal IOL

Patients to Avoid: Unrealistic Expectations

• Demand ‘perfect’ vision • Expect ‘perfect’ vision at all points, in all places, all

of the time • Not willing to accept the potential complications

of cataract surgery • Not willing to accept the possibility of glare/halos

at night • Demand immediate results: may need lasik/prk

enhancement

Who Are NOT Good Candidates for Multifocal IOLs

• Those who want to wear glasses • Poor “general alertness” • Occupational night drivers • High astigmatism* • Poor candidates for PRK: thin corneas, elevated

posterior float, irregular astigmatism • Unrealistic expectations • Ocular pathology

Ocular Pathology

• Ocular surface disease

Ocular Pathology

• Macular degeneration (AMD) • Epiretinal membrane – Baseline macular OCT pre-op

• Diabetic maculopathy • Advanced glaucoma • Amblyopia

Multifocal Post-operative Care

Purple Glasses

Pearl

• Have patient read near card with purple glasses (-2.25) to demonstrate what vision would have been like if they had not chosen the ReSTOR

Problems Reading?

• Teach patient the importance of good light • Demonstrate the “sweet spot” • Check pupil size: > 3 mm, try Pilo 0.5%

Multifocal Pearls

1) Treat residual refractive errors 2) Early yag capsulotomy 3) Aggressively treat ocular surface disease 4) Look for cystoid macular edema (CME)

Myth

• Presbyopic IOL patients will tolerate small refractive errors

Treat residual refractive errors

• Astigmatism – LRI’s – Keratotomy incisions – LenSx – PRK or Lasik

• Spherical errors – PRK or Lasik – IOL exchange

Treat residual refractive errors

• Trial frame • Temporary glasses

Preparing Patients for Lasik or PRK

• Pre-op cylinder greater than 2 D may need an enhancement

• Topography • Pachymetry

Multifocal Pearls

• Treat residual refractive errors • Early yag capsulotomy • Aggressively treat ocular surface disease • Look for cystoid macular edema (CME)

Yag Capsulotomy

• 30-50% or all mutifocal patients will need a yag capsulotomy

Multifocal Pearls

• Treat residual refractive errors • Early yag capsulotomy • Aggressively treat ocular surface disease • Look for cystoid macular edema (CME)

Pearl

Most visual fluctuation is generally caused by ocular surface disease

Diagnostic Tools

Multifocal Pearls

• Treat residual refractive errors • Early yag capsulotomy • Aggressively treat ocular surface disease • Look for cystoid macular edema (CME)

Prevention of CME

Optical Coherence Tomography (OCT)

• Can measure even subtle postoperative retinal thickening

• Gaining popularity for diagnosis of CME

“Presbyopic” IOL’s

• Crystalens AO (B&L) • Tecnis Multifocal (AMO) • ReSTOR Aspheric (Alcon) – SN60D1 (3.0)

Crystalens® AT-45SE August 2005

• 360 degree square edge • Round to the right loop configuration

Proposed Mechanism of Action:

• The accommodating lens is implanted like standard IOL

• Lens vaults backwards, correcting distance vision

Accommodating Lens

• As objects move closer to the eye – The ciliary muscle expands exerting pressure on

the vitreous

Accommodative Lens

• The displaced mass of the vitreous forces the crystalens forward

• Images at arms length (intermediate) are clear

Accommodative Lens • Reading increases contraction of the ciliary

muscle • Lens is forced further forward – Intermediate & near images are clearer

Restor, Crystalens or Toric IOL with LenSx

• Know the post-operative refractive goal • One week exam: refraction of the first eye • Must “clear the patient for the second eye

surgery” • 1 - 3 months: final refraction to track the

resultant spherical equivalent • 1 – 3 months: keratometry/Lenstar to track

astigmatism result after LenSx

The Doctor Encounter Patient Selection

Make a Recommendation

Make this an exciting opportunity for your patients • This is a great time to have cataract surgery as we

can offer you so much more than several years ago • This is your one opportunity to select your

intraocular lens • You must do your homework • We will give you the information you need and

help you make this important decision