4/19/2017 ANATOMY OF THE EYE. THOSE DARN CHEATERS! The Technician s Role in the Care and Management of the Presbyopic Patient

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1 ANATOMY OF THE EYE THOSE DARN CHEATERS! The Technician s Role in the Care and Management of the Presbyopic Patient Nic Jacobs, CCRC, COA, OSA Chu Vision Institute Continuing Education Program for Ophthalmic Medical Personnel May 19,2017 WHAT IS ACCOMMODATION? 3 theories of accommodation loss Accommodation is the ability to focus on near objects Lens stiffening Zonule and ciliary body contractability Increased lens size decreases zonular tension Journal of Cataract and RefraciveSurgery Vol 42, June 2016 SYMPTOMS OF PRESBYOPIA PRESBYOPIA TREATMENT OPTIONS Difficulty focusing at near (fine print, small objects) Worse in low light Read at arm s length Dependency on reading glasses Eyestrain / headaches Worse with prolonged reading Vision blur Transitioning from near-to-far Non-surgical options Corrective eyewear Glasses Reading glasses Bifocal / progressive lenses Specialty contact lenses Monovision contacts Multifocal contacts Surgical options Monovision LASIK / PRK Refractive Lens Exchange / Cataract Corneal Inlays Scleral Implant Procedures CK There are risks associated with any medical procedure. Always read the consent form before proceeding. If you have any questions, ask your doctor to explain. 1

$contact lens use Prior monovision or multifocal Monovision Testing Patient Education and expectations Topographies Pachymetry Refraction with add Loose lens or Trial Frame CL trial$

2 Monovision LASIK / PRK Monovision Evaluation DOMINANT EYE NON-DOMINANT EYE One eye far, one eye near Dominant eye = Distance Non-dominant eye = Near Blended vision NEAR VISION DISTANCE VISION Prior contact lens use Prior monovision or multifocal Monovision Testing Patient Education and expectations Topographies Pachymetry Refraction with add Loose lens or Trial Frame CL trial Limitations/drawbacks: Compromise (less than optimal vision in both eyes) Affects the cornea (visual axis) Irreversible (permanently removes corneal tissue) Loss of distance vision quality Halos & glare Refractive Lens Exchange RLE Evaluation Monofocal IOLs (to create monovision) Multifocal IOLs Presbyopia Correcting IOLs Prior contact lens use Prior monovisionor multifocal To understand what your patients visual demands are, ask them where they have difficulties seeing, what they like to do, what they use their vision for. Y. Ralph Chu,M.D., Ocular Surgery News Vol 24. No.2w Nov.15,2006 2

RLE testing Patient Expectations and Education Topographies HD analyzer Pachymetry IOL master Anterior OCT

They can have good get-around vision that helps them improve their functionality, but they must be prepared

vison This leads us to building proper expectations.

ideal for patients with: No cataract, no distance prescription Optical challenges include: Ghosting, glare,

, Ocular Surgery News Vol 24. No.2w Nov.

near vision by extending depth-of-focus Central aperture is a hole in the inlay and has no power Inlay

3 RLE testing Patient Expectations and Education Topographies HD analyzer Pachymetry IOL master Anterior OCT Spec mic We tell the patients that they have a choice. They can have good get-around vision that helps them improve their functionality, but they must be prepared to accept potential compromises, such as loss of contrast, night vision complaints, poorer intermediate vison This leads us to building proper expectations. We emphasize that none of these lenses is a guarantee for eliminating glasses Limitations/drawbacks: Not ideal for patients with: No cataract, no distance prescription Optical challenges include: Ghosting, glare, halo, depth of focus Risks include: Intraocular surgery (invasive), retinal detachment Y. Ralph Chu,M.D., Ocular Surgery News Vol 24. No.2w Nov.15,2006 Inlay Evaluation KAMRA Inlay Prior contact lens use Prior monovision or multifocal Inlay improves near vision by extending depth-of-focus Central aperture is a hole in the inlay and has no power Inlay provides an unobstructed pathway for focused light to reach the retina Inlay Design 3.8mm Diameter 1.6mm Aperture Made from Polyvinylidene Difluoride (PVDF) 8,400 holes (5-11 µm) 6 µm thick Inlay in vivo Image courtesy of Dr. Minoru Tomita Shinagawa LASIK Center Acufocus Kamra tm Inlay Acufocus Kamra tm Inlay 3

Acufocus Kamra tm Inlay KamraTesting Acutarget HD Purkinje OSI Tear film itrace Pentacam

irritation First week: Variable improvement to near vision Each patient is different First 3

Use AT regularly Fluctuating vision Glare and halo Avoid reading glasses Dim light and fine

Brain adaptation exercises 20-20-20 Constant Reminders Raindrop Near Vision Inlay Designed to

implanted after creating a femtosecond flap Transparent, biocompatible and mimics a healthy

4 Acufocus Kamra tm Inlay KamraTesting Acutarget HD Purkinje OSI Tear film itrace Pentacam Patient Education and Expectations The first 48 hours: Light sensitivity, watery eyes, irritation First week: Variable improvement to near vision Each patient is different First 3 months: Dry eye is common. Use AT regularly Fluctuating vision Glare and halo Avoid reading glasses Dim light and fine print Take medications as prescribed Use Artificial Tears regularly Keep your appointments Brain adaptation exercises Constant Reminders Raindrop Near Vision Inlay Designed to restore near and intermediate vision in presbyopic patients Hydrogel corneal microlens implanted after creating a femtosecond flap Transparent, biocompatible and mimics a healthy cornea Removeable No power, works by corneal curvature change 2 mm diameter, ~30 µm thickness CAUTION: Investigational device. Limited by Federal (United States) law to investigational use. 4

Spec Mic Pachymetry Pupil size MR and CR CL

Resolution OCT Image Case Study #1: 05-036

Can see to read most things, uses readers

$UCDVA: 20/30, UCNVA: J1+ 1 2 Refraction map$ : 05-012 48 yo female 12 month interim Hx

5 Raindrop Testing Topography Raindrop Pentacam Acutarget HD OSI Tear film itrace Spec Mic Pachymetry Pupil size MR and CR CL trial Corneal Cross-section High Resolution OCT Image Case Study #1: yo male 12 months PO. Can see to read most things, uses readers for dim light or small print. UCDVA: 20/30, UCNVA: J Refraction map (from Tracey wavefront data) Case Study #2 : yo female 12 month interim Hx of dryness post implant. Art Tears help clear up vision. Restasis, PPI, OMegas Has to pull things closer to read the last few days. UCDVA: 20/60 UCNVA: J1 <14 inches sph 5

Return for 18 month PO: 05-012 Treatment: 4-week Durezoltaper. d/c 2 wksprior to visit.

1 year post-op CC: Blurry dx and near since implant Case Study 4: 05-022 HX of difficulty

Compliance on gtts in question Patient Education and expectations The VisAbility Scleral

eye, Artificial tear use Visual improvement 1-3 months Post-op drop regimen-3 months

6 Return for 18 month PO: Treatment: 4-week Durezoltaper. d/c 2 wksprior to visit. CC: NVA is better than last visit. 1 year post-op CC: Blurry dx and near since implant Case Study 4: HX of difficulty scheduling. Compliance on gtts in question Patient Education and expectations The VisAbility Scleral implants Slight loss of distance in inlay eye Slight loss of contrast in inlay eye Dry eye, Artificial tear use Visual improvement 1-3 months Post-op drop regimen-3 months Development of corneal haze 45 to 60 years old Generally healthy No glasses for distance vision Need reading glasses No prior eye surgery Willing to return for follow-up exams (2 years) Visability Evaluation Migraines, Headaches 6

Visability Testing Patient Education and expectations UBM IOL Master itrace Pentacam Spec Mic Longer recovery Redness Dry Eye Aesthetics No disruption of visual axis

Flexivue Microlens pharmaceutical options for creating depth of focus through natural pinhole Scleral abalations Currently, there is no perfect option but several

Patient satisfaction will be increased by providing realistic expectations before surgery.

$Sources: Questions Review of Ophthalmology September 2014 Raindrop Near Vision Inlay OD guide Cataract and Refractive Surgery Today, Vol.15, No.$

7 Visability Testing Patient Education and expectations UBM IOL Master itrace Pentacam Spec Mic Longer recovery Redness Dry Eye Aesthetics No disruption of visual axis Corneal surgery or IOL implants still possible PT- improvement is a process Other Presbyopic technologies The bottom line CK- conductive Keratoplasty Multifocal Lasik Flexivue Microlens pharmaceutical options for creating depth of focus through natural pinhole Scleral abalations Currently, there is no perfect option but several options can provide spectacle independence for some patients; however, all options reflect a compromise compared with pre-presbyopic emmetropia. Patient satisfaction will be increased by providing realistic expectations before surgery. Patient selection through strong patient education and the setting of expectations is paramount for all presbyopic technologies. Sources: Questions Review of Ophthalmology September 2014 Raindrop Near Vision Inlay OD guide Cataract and Refractive Surgery Today, Vol.15, No.6, June 2015 Ocular Surgery News U.S. Edition, February 10,2017 Ophthalmology Clinical Pearls, a quick Guide to Crystalens, 2009 Ophthalmology Off the Grid podcast, Up close with Presbyopia solutions 2/28/17 Ophthalmology Off the Grid podcast, Stat of the Union Address on Presbyopia, 6/14/16 nic.jacobs@chuvision.com 7

Clinical experience of 9,000 small aperture Inlays for presbyopia correction

Clinical experience of 9,000 small aperture Inlays for presbyopia correction Minoru Tomita, MD, PhD Shinagawa LASIK Center, Tokyo, Japan September 7 th, 2012, ISOP meeting in Tokyo, JAPAN 1,060,666 Femto