Clinical Success with Advanced IOL Technologies

Transcription

1 The News Magazine of the American Society of Cataract & Refractive Surgery Clinical Success with Advanced IOL Technologies Supplement to EyeWorld July 2008 Developed from an EyeWorld Symposium held at ASCRS ASOA 2008 in Chicago Robert Cionni, M.D., presented real cases from his practice and asked the panelists how they would manage each case. The common thread for the cases was decisions concerning refractive IOLs. Moderator Robert Cionni, M.D., is medical director, Cincinnati Eye Institute, Cincinnati, Ohio. Case 1: 73-year-old female who does beadwork, wants spectacle freedom Panelists Warren E. Hill, M.D., is in private practice in East Mesa, Ariz. Bonnie An Henderson, M.D., is in private practice in Boston, Mass., and an assistant clinical professor of ophthalmology, Harvard Medical School, Cambridge, Mass. Gary Foster, M.D., is in private practice in Ft. Collins, Colo. Stephen G. Slade, M.D., is in private practice in Houston, Texas. Supported by an unrestricted educational grant from Alcon, Inc. Case 1 Dr. Cionni: This case is a 73-year-old female with symptomatic cataract in both eyes. She is 20/30 in the right eye and 20/40 in the left eye, but glare makes her vision a little worse. Her K-readings show 0.75 of in the right eye and 0.50@002 in the left eye. Her pupils are 4 mm, and she has 3+ nuclear sclerotic cataracts. She desires decreased spectacle wear. She reads quite a bit and spends some time at a desktop computer. Her hobby is doing beadwork. She s more concerned about not wearing spectacles than glare and halos, but she really doesn t want glare and halos. What would you recommend? Dr. Hill: This profile is almost a slam dunk for the ReSTOR (Alcon, Fort Worth, Texas). Halos are less of an issue with the new ReSTOR Aspheric. With the old ReSTOR, I used to ask patients post-op what it s like at night, and I would step back and wait for them to tell me. With the new ReSTOR, patients say that they sometimes see halos but that they re not significant. The only thing that would make this patient more perfect for a ReSTOR is if she was a hyperope. These people name grandchildren after you. They re so happy. This would be an ideal patient for the new ReSTOR Aspheric IOL. Clinical Success with Advanced IOL Technologies Dr. Henderson: I agree, this is a classic case for a bilateral ReSTOR IOL implantation. One thing I want to share is that with all accommodating or multifocal IOL patients, I give them a post-op expectations sheet that I created. This is one of the best things I ve ever done. On this sheet, I specifically write continued on page 8 Before surgery, you can use a near vision test card and have them circle the smallest line that they can read. Then, after surgery, have them complete the test on the same card to see their increase. Stephen Slade, M.D. 1

2 Case 2: Accountant with significant PSC, mild epiretinal membrane, and diabetic retinopathy Dr. Cionni: This patient, a 58-year-old male accountant, has symptomatic cataracts in both eyes. His visual acuity is 20/50 in the right eye but 20/200 with glare, and 20/30 in the left eye but 20/60 with glare. He has a significant posterior subcapsular cataract (PSC) in each eye, but it is more prominent in the right eye. He also has mild epiretinal membrane in the left eye and mild diabetic retinopathy in both eyes. Keratometry readings show about the same cylinder and axis in both eyes 2.00@0.82 in the right eye and 2.25@118 in the left eye. The patient desires decreased spectacle wear. He does not want to see halos around headlights. Dr. Slade: I don t think this patient has forme fruste. As this patient has cataract and astigmatism, a toric IOL would make sense. Dr. Foster: I d love to use a Pentacam (Oculus, Lynnwood, Wash.) and make sure I m pleased with his posterior float. If I was convinced it wasn t forme fruste, then a toric IOL would be a good option. I don t like to put multifocal IOLs in anyone with an epiretinal membrane. Dr. Cionni: The toric lens in this patient is a slam dunk, and that s what we used. There s no downside to implanting a toric IOL even with macular pathology. This patient was very happy, and we nailed the implant power. The patient is 20/20 distance, and his intermediate vision is good, but he does wear readers for near vision. If this patient had pristine maculas and no diabetic retinopathy, and he doesn t want to read with glasses, what would you do differently? Dr. Slade: I would consider a presbyopic IOL. Remember, this patient is at an increased risk for cystoid macular edema. You would need to make sure to use non-steroidal anti-inflammatory drugs and watch the patient carefully with ocular coherence tomography. Dr. Cionni: If you re going to put in a presbyopic IOL and the patient has 2 D of astigmatism, how would you manage that? Dr. Slade: I would do post-op LASIK. I m not as big of a fan of the LRIs as a lot of people are. We have lasers, and I m used to that. I did a lot of AK in the RK days. We tend to go to the laser. I think for premium IOL patients, the accuracy and comfort is more of what they re after. I don t see any contraindications for this fellow. Dr. Cionni: How long between eyes do you wait before implantation of IOLs? Does this length of time differ between an accomodative and a multifocal IOL? Dr. Hill: I ve changed my approach with this since the new ReSTOR Aspheric IOL has become available. Now I implant them in rapid succession. I see use of the ReSTOR as a bilateral approach. I think the neuroadaptation proceeds very quickly. I like to get the lenses in quickly one to two weeks apart and allow the brain the opportunity to quickly sort out this new optical system. Dr. Foster: I usually do these one to two weeks apart. It helps patients minimize the inconvenience on their life of the anisometropia. Dr. Henderson: The time between implantations is probably more like two to three weeks for me. Dr. Slade: I wait about three or four weeks between implantations. It may depend on the insurance. Dr. Cionni: Do you like to look at the first eye and tweak the results in the second eye if you don t meet Case 2 the target refraction? Let s say you have 1 in the first eye, and you were shooting for Do you take a less powerful lens and put it in that second eye for a similar discrepancy in the target refraction? Personally, if all my numbers look good, I might repeat the measurements, but I don t think I would change my plan. Dr. Slade: In corneal refractive surgery, we got in the habit of looking at the first eye, but I agree, you can t necessarily adjust the second eye based on the first. Dr. Cionni: Do you use a toric lens in keratoconic patients with 5 D of astigmatism? Dr. Slade: A lot would depend on what I could correct with spectacles before. It depends on how much of the astigmatism is regular, how stable the eye is, how I thought it would progress, how much is irregular, and how much I could correct. If his astigmatism was mostly regular without a lenticular component, I would consider it. The problem is if you have to do a graft later with the toric lens. continued on page 3 There s no downside to implanting a toric IOL even with macular pathology. Robert Cionni, M.D. Patient topography 2 Clinical Success with Advanced IOL Technologies

3 Case 3: A monofocal eye and cataract in the fellow eye Dr. Cionni: This patient is a 62-year-old man with a 3+ PSC in his right eye. His left eye was operated on many years earlier, and a SA60AT (Alcon) monofocal IOL was implanted. He has a perfectly centered PC IOL and a clear capsule. He s about plano, with just a little astigmatism in the left eye and 2.50 myopia in the cataractous right eye. He wants a presbyopic IOL. He understands that he can t read with his left eye. He can read with his right eye because he s a little myopic, but then he developed the significant PSC. What would you recommend? Dr. Henderson: In this patient, I would go with monofocal monovision. He already has a monofocal in one eye and a little bit of myopia in the other eye. This patient has always been living this way. I think he d be much happier with a very clear monofocal lens in the right eye, corrected at a 2. I think he d be happy with the end result. Dr. Foster: Most of these folks choose this if they like their monovision. That s usually the path of least resistance. As a general rule, it s easier to put in what they re used to. Dr. Cionni: How about if instead of 2.50 in the right eye, the patient was +2.50? You re not certain he would tolerate monovision. Would you have a different solution? Dr. Henderson: I d do a contact lens trial first with that hyperopic eye becoming myopic, seeing if that eye would tolerate it for a week or so. If the patient Case 2 from page 2 Case 3 likes it, I think it would be a reasonable approach. I have had a handful of patients with a pseudophakic monofocal lens in one eye, and I ve had lengthy discussions about the benefits and disadvantages. They had a multifocal IOL implanted in the second eye, knowing they won t have the best reading vision binocularly. As long as patients are counseled well ahead of time to know what to expect, they have been happy with a little extra intermediate and a little extra near. Dr. Cionni: We ve had a series of about 50 patients who have a monofocal IOL or no cataract in one eye and a multifocal IOL in the second eye. They do quite well. We counsel these patients before surgery and tell them that these IOLs are usually meant for both eyes and to expect some decreased spectacle wear, but the result won t be as fantastic as if it were in both eyes. As long as they understand that, accept it, and are willing to proceed, they re quite satisfied with the results. Dr. Henderson: I would like to mention one last point in patients with monofocal/multifocal IOLs. Some of them might read for eight hours or so a day, and they ask how the lens combination will affect them. These patients have used bilateral +3 readers over the counter, even over their multifocal eyes, and they haven t had any trouble. Usually I tell them they will be able to read more clearly out of one eye, and they don t seem to have any trouble with that combination. Case 2 result Dr. Henderson: I agree. The topography is very important, so you know if it s regular or irregular. The toric IOL, as long as enough of the astigmatism is regular, is the best option here. An intraocular solution is a possibility. Dr. Foster: I make that decision based on how likely the patient is to have to wear a gas permeable lens. If there s a chance he ll need to wear a gas permeable lens, I don t want the toric lens in there confounding things. If I think that he s going to wear spectacles and he was doing so pre-op, that s a reasonable option. Dr. Hill: Also, with the toric IOL, we re creating lenticular astigmatism. What I look for is whether the astigmatism is regular and if it ll change later on. If it ll change later on, you may have painted yourself in a corner. Dr. Slade: You wouldn t want to have a patient close to graft, do a graft, and then have to compensate for lenticular astigmatism. Then you ve gone in the other direction. Clinical Success with Advanced IOL Technologies We tell [patients] that these IOLs are usually meant for both eyes and to expect some decreased spectacle wear, but the result won t be as fantastic as if it were in both eyes. Robert Cionni, M.D. 3

4 Case 4: Managing a problematic result Dr. Cionni: We don t always end up with the perfect result after a single procedure. We re going to touch on some patients who were not happy with their results. This particular patient is a 59-year-old male who has significant glare, cannot drive at night anymore, and is unhappy. He has moderate cortical cataract, pupils that are 3 mm in the ambient light, and he has a history of laser iridotomy in both eyes. He is very interested in less spectacle wear. He is a long, tall guy. He is an avid golfer and rides a motorcycle. He s also a very good friend of a local optometrist. His K-readings show 0.75 D of cylinder in the right eye and 1.12 D in the left eye, both againstthe-rule. His axial length is in the right eye and in the left eye. I chose a Crystalens (Bausch & Lomb, Rochester, N.Y.) for 0.11 in the right eye and a Crystalens for 0.60 in the left eye. His surgery was uneventful. A month after surgery, he was very unhappy. His refraction was 1.50 in the right eye and 2.75 in the left eye. How would you manage the patient? Also, why were my original measurements so far off? Dr. Slade: Where are the lenses? Dr. Cionni: The lenses are posterior and back, right where I d expect them to be. My thought on this is that the target refraction with the Crystalens is difficult to nail, especially in the higher powered IOLs. Since we re not certain of the capsular bag size, we just don t know where the effective lens position would be. The stronger the power of the implant, the more likely that it will sit a little anterior or posterior from where you d expect. Of my last 14 patients with Crystalens IOLs, three were at least a diopter off. After discussing these results with Steve Dell, [M.D., Austin, Texas], he suggested striving for a larger capsulotomy and a vertical orientation each time. Doing so will help to achieve the desired refractive error, yet I still discuss with the patient a more likely need for enhancement when using a Crystalens. Dr. Foster: Was his pre-op topography normal? Dr. Cionni: It was unremarkable. Dr. Hill: If you are looking for the quickest visual rehabilitation, you could put in a piggyback lens on top of the Crystalens. The difficulty in predicting the refractive outcome with the Crystalens is that, by design, it s axially unstable. One thing that Jack Singer, [M.D., Randolph, Vt.] and I found with his data is that it s almost as if the Crystalens requires different lens constants for different powers. The lower powers seem to require higher lens constants than the higher lens powers. Once again, this lens is axially unstable as part of its design, which makes lens calculations problematic. A quick solution would be an AQ5010V (STAAR, Monrovia, Calif.) placed on top of it. Dr. Foster: I d do a YAG capsulotomy first and see if you get any posterior movement that helps decrease the myopia. Once that stabilizes, I d experiment with a contact lens for distance in the left eye to see if the patient would accept modified monovision, so you only have to do a procedure in one eye. If he would accept laser in the left eye and nothing Case 4 in the right eye, you bring him down to one procedure. If not, you ll have to do PRK on both eyes. Dr. Cionni: That s exactly what we did. We did the YAG first, and then PRK in the left eye. Ideally, you wouldn t have to do anything to the right eye. However, this patient is going to have PRK in the right eye soon. continued on page 5 The target refraction with the Crystalens is difficult to nail, especially in the higher powered IOLs. Robert Cionni, M.D. Case 4 result 4 Clinical Success with Advanced IOL Technologies

5 Case 5: Improving the results for a formerly hyperopic female Dr. Cionni: This patient is a 67-year-old woman with moderate nuclear sclerotic cataracts. Her vision justified cataract surgery. She is hyperopic, at in the right eye and in the left eye, and she has a little astigmatism. She has planned ReSTOR IOL implantation in both eyes. The surgery in her right eye was uneventful. One week after surgery, she was a little underwhelmed with the result, which was I was shocked. My standard deviation with this lens is 0.25 D. We typically get the target refraction we expect. Before proceeding with the second eye, we repeated K-readings, axial length measurements, and Holladay II calculations. These were all the same as before. All calculations indicated that this should be the right lens for this patient. There wasn t capsular bag distention syndrome, as the bag was not distended. However, the implant seemed to be right against the posterior iris. Dr. Hill: Obviously the lens is vaulting forward, and that s affecting its power. When you change a lens and move it closer to the cornea, you increase its power. I d want to know the reason why the lens ended up more anterior. This would be a great opportunity to use UBM and take a look at the anterior segment. Dr. Cionni: We did just what Dr. Hill suggested, and the lens was right up against the iris. Case 5 Dr. Foster: What was the pressure? Dr. Cionni: I expected it to be high from aqueous misdirection, but it was 22 mm Hg. Dr. Foster: I think having a retinal colleague take a look at the ciliary body to see if there s a uveal fusion or choroidals would be the first thing I would do if I didn t think it was aqueous misdirection. Dr. Cionni: I have seen cases of uveal effusion that resulted in 2.0 D of myopia which resolved after oral steroids but in this case, the ciliary body was not rotated forward. We surmised that the patient had mild aqueous misdirection that vaulted everything forward. Our retinal colleagues agreed. Dr. Henderson: There have been reports of doing a YAG capsulotomy with aqueous misdirection instead of a real vitrectomy. Dr. Cionni: We performed a vitrectomy, and everything fell back very nicely. The patient achieved the refraction we thought she should, but then we had to do the other eye. UBM showed the cataractous lens to be vaulted just like the first eye. I removed the cataract and put in a ReSTOR IOL, and my retinal colleague did the vitrectomy as a combined case. We met our target refraction, and she did very well. After vitrectomy Case 4 from page 4 Dr. Slade: It s helpful to do a YAG with Crystalens in a myopic patient because you may get some movement. But with someone like this, if he s unhappy, always make sure with the use of a trial of glasses or contact lenses in the office that the patient will be satisfied with the end result. Dr. Cionni: That is an excellent point. Before you do any enhancement, put on trial contacts or frames to show results after the enhancement. If the patient looks through that and says it s great, proceed. If he says it still isn t wonderful, I d be reluctant to move forward until I figure out why. Dr. Henderson: If I do a YAG and change the position, I d also use ultrasound biomicroscopy (UBM) with the patient and see how the lens is sitting there. Often you get some vaulting or movement of the hinges. Get a UBM before doing anything else to see what both haptics are doing. One other point is to make sure the eye is lubricated. I think a dry surface always makes patients with sunlight, glare, and halos unhappy. Another important factor is time. I think it s extremely important to give these patients, whether multifocal or accommodating IOL patients, enough time to adjust to their vision. If we don t wait long enough, they re going to fail. Sometimes it is best to wait several months before we think of doing something to enhance their vision. Have patience and tell your patients to wait. Clinical Success with Advanced IOL Technologies One other point is to make sure the eye is lubricated. I think a dry surface always makes patients with sunlight, glare, and halos unhappy. Bonnie An Henderson, M.D. 5

6 Case 6: Problems caused by inaccurate pupil measurements ReSTOR Aspheric Pearls Pre-op Tell patients they may need glasses for certain activities Tell patients that their vision will continue to improve over the next few months Bilateral implantation provides a high level of patient satisfaction Have patients read through 3 D trial lenses and inform them that this would be the quality of the near vision with a traditional monofocal Surgical Pearls Aggressive cylinder management CCC larger than diffractive rings but smaller than optic Center IOL in pupil Dr. Cionni: This case is a 60-year-old woman with cataract in both eyes and 4.5-mm pupils. Her intermediate needs are a little greater than her near needs. We put a ReZoom IOL (Advanced Medical Optics, AMO, Santa Ana, Calif.) in her first eye with a good refractive result, 20/20 distance, but she was bitterly unhappy with her near vision, which is J7. Measurements were repeated, and her pupils actually weren t 4.5 mm they were 3 mm in fairly dim light. What do you recommend? Dr. Slade: I would think of exchanging the first eye and getting her happy there. Dr. Henderson: I disagree. I would not do an IOL exchange in the first eye. I d leave it alone. I d put a ReSTOR in the second eye. I d do that because she s happy with the distance vision in the first eye, she just wants to read a little better. If she s still unhappy with the first eye, I d consider an IOL exchange at that point. Case 6 Dr. Foster: I would also dilate the pupil and see if she could read with the pupil dilated. If she could, I d do a pupilloplasty with the argon laser in the first eye. The results from that would drive the rest of my decision. Dr. Cionni: I put a ReSTOR in the second eye, and she is much happier with her second eye. In fact, she prefers her ReSTOR eye. We could have exchanged the first eye because she wasn t happy, but we knew we d be doing something with the second eye anyway. We decided to put the solution for the first eye into that second eye. It helped avoid a subsequent procedure. I put a ReSTOR in the second eye, and [the patient] is much happier with her second eye. In fact, she prefers her ReSTOR eye. Robert Cionni, M.D. Case 6 result 6 Clinical Success with Advanced IOL Technologies

7 The ReSTOR difference and clinical pearls Dr. Cionni: Some new independent lab data from Jim Schwiegerling, Ph.D., University of Arizona, shows us the quality of the new ReSTOR Aspheric IOL. MTF values basically tell us how similar the image in front of a lens looks to the image after it passes through the lens. You can see that when the ReSTOR IOL is compared with a Crystalens, it actually looks quite similar, if not better. When you look Comparing IOLs using Air Force target images at Air Force target images through a 546-nm model eye with a 6-mm aperture, the ReSTOR Aspheric quality of vision looks better than ReZoom, the multifocal Tecnis, and a little better than the Crystalens. Dr. Schwiegerling also studied quality of vision using pinhole images through a model eye. The amount of glare and halos is superior to what patients get with the ReZoom or Crystalens. Dr. Cionni: What s the smallest pupil you d consider for an aspheric IOL? Dr. Foster: I haven t been limited. I think the lens works beautifully with smaller pupils. If the pupil was smaller than 2 mm, I would be concerned, and I would address that at the time of surgery anyway. With the ReZoom, we have to be concerned that the pupil isn t large enough to reach the first reading zone. With the ReSTOR lens, we wouldn t be limited by that. Dr. Cionni: It is unlikely that the pupil could be small enough to cause difficulty with the ReSTOR diffractive optic. It s a different case with the ReZoom, where the center portion of the IOL is distance only. Dr. Hill: It s very confusing to look at all of the information about how the lenses perform. What I find most helpful is to look at the MTF plot. That s the business end of seeing better. What the MTF plot shows is the ability of a lens system to transfer from the object to the image its contrast, and at the end of the day it all comes down to contrast sensitivity. A loss of contrast sensitivity is far more debilitating than a loss of best focus. How a lens performs is contained in the MTF plot. That s something with which we all need to become more comfortable and more familiar. Dr. Cionni: Does the ReSTOR Aspheric do a better job at intermediate than original ReSTOR? Dr. Henderson: Even with the original, I thought it was very time related. In the first month post-op, 50% had difficulty with intermediate vision. However, if you followed them for six months, most developed intermediate distance. With the new ReSTOR Aspheric, I find that the time to adjust is less. I find it s very unusual for someone to not have intermediate vision more quickly. I find the results are age related, too. The younger the patient, the more likely he or she is going to have a full range of function at near, intermediate, and distance. I had a patient who was a 22-year-old college student and had bilateral dense PSCs with new onset diabetes. We talked a lot about what lenses to use because he drives and uses the computer a lot. Obviously, we did not want to put in monofocals bilaterally in this young patient. We put in bilateral aspheric ReSTOR, thinking originally that we would put the ReSTOR in the nondominant eye and see how he did with the reading. Then if he needed a little extra help with intermediate vision, we d put in the ReZoom. What happened continued on page 8 When you increase the MTF, the brain is better able to have this edge detection system and can fill in the blanks and have a crisper image. Warren Hill, M.D. Comparing IOLs using pinhole images through a model eye Clinical Success with Advanced IOL Technologies 7

8 ReSTOR difference from page 7 edge detection system and the crisper the image, the better job the brain can do in processing the information and filling in the blanks. One thing Jay McDonald, [M.D., Fayetteville, Ark.] taught us is that when you increase the MTF, the brain is better able to have this edge detection system and can fill in the blanks and have a crisper image. This is probably where some of the improved intermediate vision comes from. I ve been impressed by how quickly patients neuroadapt with the new ReSTOR Aspheric. We used to implant the regular ReSTOR, hold patients hands through refractive purgatory, and then put in the second lens. Now we re putting in the two lenses in rapid succession. The intermediate vision develops even more quickly than I had expected. As Dr. Henderson pointed out, it used to be four to six months, but now it s much quicker. There s some last kernel that pops in the processing system of the brain that is allowing for this form of enhanced vision that we are seeing. Dr. Slade: We took all of our ReSTOR Aspheric patients and sent them a survey. It was impressive how happy they were. Dr. Cionni: Do you mix IOLs very often? Dr. Slade: We do with ReSTOR and Crystalens. Modulation transfer function for the ReSTOR versus Crystalens IOLs is we put in the ReSTOR and gave it time, and he had no trouble with intermediate vision. He has perfect vision at all distances. Dr. Cionni: There s some thought that if you put in an aspheric lens, because you have a crisper yet limited focal area around the retinal plane, depth of focus would be less. Do you think this might be an issue with the ReSTOR Aspheric multifocal? Dr. Hill: Of course, we don t see with our eyes, we see with our brain. The eyes are like a sophisticated Dr. Henderson: I do occasionally. I ll mix the ReSTOR and the ReZoom. With the UV-allowing Crystalens, I worry about the younger patients who are active golfers and skiers. I worry about whether we re blocking enough UV light. I stay away from that lens for younger patients. Case 1 from page 1 what they may experience post-op. The first item reads, You will have some glare and sunbursts. Even if they don t, by reading this sheet, they expect to have those. This sheet is helpful because patients only hear about 10% of what you tell them pre-op, and then they forget the rest. When they take this home and go through their medication instructions, they ll read the expectations sheet again. If they know they ll have glare or intermittent vision and that it might take months to get accustomed to the lenses, they feel much more reassured. Dr. Hill: Also, if you explain to them what to expect after surgery, and something happens that you already discussed with them, it s not your fault. If something else happens, in the patients eyes, it is your fault. Dr. Slade: Besides just talking with them, you can help patients compare their visual results before and after surgery. Before surgery, you can use a near vision test card and have them circle the smallest line that they can read. Then, after surgery, have them complete the test on the same card to see their increase. Case 1 result Dr. Cionni: With this patient, we implanted ReSTOR Aspheric IOLs bilaterally, and she was extremely happy with the resultant 20/20 distance, J2 intermediate, and J1 near. This supplement was produced by EyeWorld under an educational grant from Alcon, Inc. Copyright 2008 ASCRS Ophthalmic Corporation. All rights reserved. The views expressed here do not necessarily reflect those of the editor, editorial board, or the publisher and in no way imply endorsement by EyeWorld or ASCRS. 8 Clinical Success with Advanced IOL Technologies ACR583