Slide 1. Slide 2. Slide 3. Cataract Surgery: A Look Ahead. Component 1: History. Paul C. Ajamian, O.D., F.A.A.O. UK SECO October, 2013

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UK SECO October, 2013 Slide 2 Slide 3 Component 1: History Eye: functional history such as problems with

1 Slide 1 Cataract Surgery: A Look Ahead Paul C. Ajamian, O.D., F.A.A.O. UK SECO October, 2013 Slide 2 Slide 3 Component 1: History Eye: functional history such as problems with glare/tv/driving at night Activities of Daily Living: MUST BE DOCUMENTED! Social History:?chronic depression, bipolar, anxiety disorders Observation during exam: ambivalence, excessive questioning, unrealistic expectations, wanting guarantees

2 Slide 4 Past Eye and Medical History Critical Medications: Flomax? Contact Lens Wearer? Prednisone (PSC) Trauma Family history of cataracts at a young age Diabetes/Hypertension How long have you had it What do you take for it Is it under control/when last checked Doctor s name Slide 5 Component 2: Vision and Refraction Visual Acuity (D & N) Pinhole should be part of vision Monocular diplopia or glare alleviated? Glare testing or BAT (medium setting), or Ambient Light (room lights on) for any patient who is 20/40 or better Slide 6

3 Slide 7 Component 3: Ocular Health Slit Lamp Dilated Fundus Exam Slide 8 Slide 9

4 Slide 10 When in doubt about the retina, get an OCT..especially with premium lenses! Slide Korean Female 20/40 OD/OS with 2+ cortical spoking, and cc my vision is worse in right eye Slide 12 Watch out for Epiretinal Membranes

5 Slide 13 Slide 14 Slide 15

Slide 16 Slide 17 Slide 18 68 AA F Cataract Evaluation VA 20/25 with 1+ NS GAT 19/20

6 Slide 16 Slide 17 Slide AA F Cataract Evaluation VA 20/25 with 1+ NS GAT 19/20 Pachs 571/586 Right disc.7 with superior notch Left disc.5 with normal visual field/oct

7 Slide 19 Slide 20 Slide 21 And along the way you might also find

like to rely less on glasses Plan: Schedule bilateral Restor IOL s OD then OS

8 Slide 22 Slide 23 Slide 24 Time to Write Down Your Impression and Plan Impression: Cataracts OD > OS with difficulty reading OU 2+ NS consistent with reduced VA Would like to rely less on glasses Plan: Schedule bilateral Restor IOL s OD then OS Premium IOL discussed, patient not interested/schedule conventional monofocal IOL OD then OS

IOL s OD then OS Patient denies Toric Slide 26 Communication Key!

9 Slide 25 Or.. Impression: Cataracts OU, night driving problems 3+ NS consistent with reduced VA 2 diopters of cylinder Plan: IOL s OD then OS Patient denies Toric Slide 26 Communication Key! Communicate pertinent findings directly to surgeon don t leave it to chance! Meds (Flomax) and Conditions (Pseudoexfoliation Syndrome, Glaucoma) Ocular Surface Disease Visit the surgeon so you know what patients will experience Slide 27 You wouldn t send this..

10 Slide 28 So why send this? Slide 29 Topography Helpful: Rule Out Multifocal Candidates and Rule In Toric Candidates Slide 30 Could this be a problem?

11 Slide 31 Clean Up Crew Slide 32 Slide 33 Another procedure prior to cataract? Map Dot Fingerprint

12 Slide 34 Salzmann s Nodules Slide 35 Salzmann s Nodules Follows episodes of keratitis Collagen plaques with hyalinization Anterior to Bowman s Irregular epithelium F.B. sensation/photophobia Superficial keratectomy Slide 36 Superficial Keratectomy for Salzmann s nodules

13 Slide 37 Slide 38 Slide 39

Slide 40 Slide 41 Two Weeks s/p Superficial

Lasik Patients! Central K from Topo x 1.1-6.

14 Slide 40 Slide 41 Two Weeks s/p Superficial Keratectomy Slide 42 Let Surgeon Know About Lasik Patients! Central K from Topo x Modified Maloney Formula Gives you K s that will go into A Scan Still need to warn patient they have a chance of needing an IOL exchange!

15 Slide 43 New technology for better outcomes Slide 44 Slide 45 Surgical Techniques Excuse me Doctor, is it done with the laser?

16 Slide 46 Laser Refractive Cataract Surgery Slide 47 Slide 48

$Slide 49 Refractive Results: A more precise capsulotomy Precise capsulotomy More accurate & repeatable IOL positioning Better IOL performance Better visual outcomes$ $5mm axial plane deviation from intended ELP results in 1D of refractive error² 1Yanoff M, Duker J: Ophthalmology: Expert Consult 3 rd edition, Mosby, 2008.$

17 Slide 49 Refractive Results: A more precise capsulotomy Precise capsulotomy More accurate & repeatable IOL positioning Better IOL performance Better visual outcomes The size, shape, and positioning of the capsulorhexis is a key determinant for effective lens position¹ A 0.5mm axial plane deviation from intended ELP results in 1D of refractive error² 1Yanoff M, Duker J: Ophthalmology: Expert Consult 3 rd edition, Mosby, Cekic O, Batman C: The relationship between capsulorhexis size and anterior chamber depth relation. Ophthalmic Surg Lasers 1999, 30(3): Slide 50 Laser Fragmentation Mechanism of Action Chop Patterns Liquefy Patterns Slide 51

due to imprecise wound architecture and depth Slide 53 Arcuate Incisions Slide 54

18 Slide 52 Limbal Relaxing Incisions Traditional, Handheld Diamond Knife Manually executed by tracing corneal marks Inconsistent depth control Unpredictable effect due to imprecise wound architecture and depth Slide 53 Arcuate Incisions Slide 54 Frosting on the Cake Preop = xo 180 One day post op: plano sc 20/20!

19 Slide 55 What does the future hold? Femtosecond cataract lasers exist in 34 countries Each with their own financial and regulatory framework. Just as femtolasik coexists with mechanical microkeratomes, so does LACS coexist with manual surgery. There is a place for both, but the more precise and expensive technology will eventually dominate. Slide 56 Slide 57 Believe in the Technology Go watch a case Truly understand the implications of Safer Better Refractive outcomes What does that mean for your patients and how does that reflect your practice

20 Slide 58 Fees Monofocal LenSx: (for astigmatic correction) $1500 Toric Lens (no LenSx): $1400 Toric Lens (with LenSx): $2200 Restor Lens (always with LenSx): $3300 Slide 59 Slide 60

$Slide 61 IOL discussion and selection The old days of sending the patient on to your surgeon and not thinking about the refractive result are over You$ $Technology or Premium Lenses, 2013 Multifocal / Accommodating IOLs Accommodating (Crystalens) Diffractive Multifocal (Restor and Technis) Toric IOL$

21 Slide 61 IOL discussion and selection The old days of sending the patient on to your surgeon and not thinking about the refractive result are over You know more about their refractive history than anyone else, so be involved and stay involved Slide 62 Presbyopia: The Start of Middle Age EVERYONE hates presbyopia Significant impact on Quality of Life Be sure that presbyopes are informed of all the available options Slide 63 The Choices in High Technology or Premium Lenses, 2013 Multifocal / Accommodating IOLs Accommodating (Crystalens) Diffractive Multifocal (Restor and Technis) Toric IOL (AcrySof)

Slide 64 Available here but not in the U.S. TORIC RESTOR

Specifications + 4 add so intermediate an issue People do

experience: a lot of enhancements needed due to lack of

22 Slide 64 Available here but not in the U.S. TORIC RESTOR Slide 65 TECNIS Multifocal Acrylic IOL Model ZMA00 Specifications + 4 add so intermediate an issue People do well with it for the most part 65 Slide 66 Crystalens Our experience: a lot of enhancements needed due to lack of predictability of final visual outcome Still being used, limited place

23 Slide 67 Who Should You Discuss Premium Lenses with? Everyone! Tell the non candidates why they are not Document in chart Embarrassing if the MD is the first person telling them about Premium IOLs Slide 68 Counseling IOL Patients Slide 69

24 Slide 70 Slide 71 Slide 72

25 Slide 73 Slide 74 Slide 75

26 Slide 76 Slide 77 Slide 78 Using the Right Terminology Premium lens Lifestyle lens High Technology Lens Multifocal lens Bifocal lens

lasik ou, now has cataracts ou Patient has >2 diopters of cylinder Slide 81 Who should you watch out for?

27 Slide 79 Or you can stick with the Standard Government Issued Lens Free IOL s for All Slide 80 Good Candidates? Cataract patient presents with one pseudophakic eye (monofocal lens) and a cataract in the other eye, or a cataract in one eye only Patient presents with s/p lasik ou, now has cataracts ou Patient has >2 diopters of cylinder Slide 81 Who should you watch out for? Patients that are hypercritical with unrealistic expectations Patients with over 1 D of cylinder Patients who drive at night for a living or with long term glare complaints Patients who want guarantees, and think that the price includes glasses and care for life

Slide 82 1. Are you interested in seeing well at distance without glasses after surgery? Prefer no distance glasses.

Are you interested in seeing well at near without glasses after surgery? Prefer no reading glasses. Not important to me.

We divide vision into 5 Zones of Vision Near Far Zone 1 Zone 2 Zone 3 Zone 4 Zone 5 (12-20 in) (2-4 ft.) (6-20 ft.) (20-100 ft.

+) Newsprint Headlines Indoors Day-far Night-far Phone book Computer TV Driving Night driving Maps Menus Cooking Golf Movies

28 Slide Are you interested in seeing well at distance without glasses after surgery? Prefer no distance glasses. Not important to me. I wouldn t mind wearing distance glasses. 2. Are you interested in seeing well at near without glasses after surgery? Prefer no reading glasses. Not important to me. I wouldn t mind wearing reading glasses. 3. Zones of Vision. We divide vision into 5 Zones of Vision Near Far Zone 1 Zone 2 Zone 3 Zone 4 Zone 5 (12-20 in) (2-4 ft.) (6-20 ft.) ( ft.) (100 ft.+) Newsprint Headlines Indoors Day-far Night-far Phone book Computer TV Driving Night driving Maps Menus Cooking Golf Movies Sewing Price tags Cleaning Road signs Star gazing Which group of Zones of Vision is the most important group to you? Please choose only one of the following three options of Group A, B or C: dell survey Slide 83 Bad Candidate Slide 84 Be at the top of your game! Proper cataract evaluations Working with high quality surgeons Keep up with new technology Premium IOLs

29 Slide 85 Thank You!

Guide to modern day cataract surgery

Guide to modern day cataract surgery What are Cataracts? What are Cataracts? Cataracts are a natural clouding of the lens of the eye. Cataracts form usually because of age, but there are eye injuries and