Premium Implant Options for the Cataract Patient. Justin Schweitzer, OD, FAAO Vance Thompson Vision Sioux Falls, South Dakota

Transcription

1 Premium Implant Options for the Cataract Patient Justin Schweitzer, OD, FAAO Vance Thompson Vision Sioux Falls, South Dakota

2 Glaukos Bausch and Lomb Alcon Allergan Bio- Tissue TearScience Reichert

3 Trends In Cataract Care Innovations preop, surgery and postop IOL technologies Higher patient expectations for visual outcome Standard Cataract Surgery vs Advanced Cataract Surgery

4 When Is A Cataract Visually Significant?

5 Cataract Surgery is not just Rehabilitative Surgery

6 Cataract Surgery is Refractive Surgery

7 What Do We Look For in a Cataract Evaluation

8 Age and Dominant Eye Reassure if young Important for monovision, doing a multifocal tandem and IOL calculation target

9 MRx, BCVA and Glare Acuity Myope, Hyperope or Astigmat BCVA Glare Test Most important indicator of how cataract is affecting vision and function

10 Nidek OPD Scan Avg. corneal power Uncorrected Vision after Cat Sx Refraction at different OZs Steep Axis and Pupil size Angle Kappa >0.4 Avoid Multifocal Vision with astigmatism corrected (glasses, AK, Toric IOL) Corneal HOAs >0.4 means poorer image quality after Cat Sx

11 Dry Eye Evaluation Tear Lab Lipiview or Lipiscan

12 Slit Lamp Exam Lids Cornea Lens Vitreous

13 OCT Optic Nerve Retina and Macula

14 Refractive Considerations Refractive Endpoint Monovision Nearpoint target Distant target

15 Refractive Considerations Astigmatism typically pre- op and post- op corneal astigmatism are similar Other considerations placement of incision toric IOL Laser vision correction

16 Refractive Considerations Discuss monofocal vs toric vs presbyopia correcting IOLs

17 Refractive Laser Assisted Cataract Surgery (ReLACS) or Femtosecond Laser- Assisted Cataract Surgery (FLACS)

18 Is Femto Helpful? Standard Complex ReLACS

19 How Does Femto Help? Decreased Ultrasound Energy (30%) Reproducibility Rhexis Incisions Astigmatic Keratotomies Effective Lens Position? Refractive Outcomes?

20 Femtosecond Precise Capsulotomy Perfect centration Precision diameter: < ± 0.25 mm No radial tears Easy and complete removal of capsule No adverse events Nagy Z, Takacs A, Filkorn T, Sarayba M. Initial clinical evaluation of an intraocular femtosecond laser in cataract surgery. J Refract Surg. 2009;25(12):

21 Centration Stability Symmetric capsular forces Asymmetric capsular forces

22 Effective Lens Position with Premium Lens Three Month Variability in Effective Lens Position (ELPo) 0.84 Standard Deviation (mm) LenSx (n=31) Manual (n=30) *Using Warren Hill ELPo Calculator hill.com/iol- main/elp.htm p=<

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25 Chang, D. (2016, May). Perfecting CAPSULOTOMY. Ophthalmology Times, 41(8), 1.

26 Intraoperative Aberrometry (ORA) ORA System Optiwave Refractive Analysis Aphakic Refraction Toric Implants Surgically Induced Astigmatism Posterior K Astigmatism

27 Why trust Aberrometry? Surgically Induced Astigmatism Posterior Corneal Curvature The Data

28 Intraoperative Aberrometry (ORA) Aphakic Refraction 84% 86% ORA System - Routine Cases % of Patients within.50d 60% Literature** ORA w VerifEye ATIOLs N=3380 **Anders Behndig, M.D., Ph.D., et al, Swedish National Cataract Registry. J Cataract Refract Surg. (July) 2012 N=1329 N=683

29 When to Trust Aberrometry Astigmatism 25.0% More than 0.5D of Residual Astigmatism 23.4% 20.0% 15.0% 10.0% 10.8% 5.0% 0.0% With ORA Convetional Approach

30 T- LACS Therapuetic Laser- Assisted Cataract Surgery 24 eyes with complex cataracts including capsular scars, phacodonesis, and white cataracts. 4 patients had posterior capsule tears during 79% of patients achieved a BCVA of 20/40 or better.

31 TLACS 12 YO Male VA HM Traumatic Cataract from stick injury 2 weeks prior

32 Is Femto Meaningful? Standard Complex ReLACS Not Yet Yes Probably

33 Toric Tecnis Toric, AcrySof IQ Toric Cylinder powers Residual astigmatism can be a problem Rotate IOL Laser Fine Tune LRI s Glasses or Contacts

34 Astigmatic Keratotomy vs. Limbal Relaxing Incision AK central = bigger effect 1:1 LRI Peripheral = less effect Hyperopic Shift

35 Causes of Residual Astigmatism Wrong Location Poor Measurements Poor Calculations Surprising SIA Posterior Ks IOL Rotated Poor IOL Placement Wrong Lens Poor Measurements Poor Calculations Surprising SIA Posterior Ks Wrong Eye Ocular Surface Disease ABMD Irregular Astigmatism Treat Disease

36 Toric IOL Misalignment Misalignment % Loss T3 (1.03D) Absolute Loss T9 (4.11D) 0deg 0% 0D 0D 5deg 17.5% 0.18D 0.71D 10deg 35% 0.36D 1.43D 15deg 50% 0.51D deg 100% 1.03D 4.11D

37 Residual Astigmatism Toric Misalignment of T

38 Other Piece of the Puzzle

39 Implant Options

40 ReSTOR +2.5 w/ ACTIVEFOCUS ReSTOR 2.5 w/ ACTIVEFOCUS Toric Central portion 100% dedicated to distance

41 Tecnis Multifocal Anterior aspheric wavefront= Less spherical aberration Posterior diffractive surface Whitsett, J., & Chang, D. (2015). TECNIS MULTIFOCAL FAMILY OF 1-PIECE IOLs. In Abbott- Tecnis Family of IOLs. Retrieved August 29, 2016.

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43 Tecnis Symfony Extended depth- of- focus lens (EDOF) Better near distances than monofocal, but not as well as well as multifocal Glare and halo minimal comparable to monofocal Diffractive optics to Correct chromatic aberration Extend the range of quality vision

44 Tecnis Monofocal Tecnis Multifocal Tecnis Symfony EDOF

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46 Symfony EDOF

47 Light Adjustable Lens- What s Special? regular silicone polymers + mobile, silicone subunits, called macromers photosensitive

48 Adding Power to the LAL Iris light light lock-in Increased power => change in radii of curvature => change in power

49 The LAL FDA Clinical Trials Accuracy No patient seeing less than 20/20 uncorrected

50 Patient Satisfaction = Results - Patients Expectations

51 Thank You!