Anew aspheric AcrySof IQ

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1 Asia-Pacific The News Magazine of the Asia-Pacific Association of Cataract & Refractive Surgeons Supplement to EyeWorld Asia-Pacific June 2009 APACRS New Paradigms and Options in Cataract & Refractive Surgery Supported by an unrestricted educational grant from Alcon, Inc. Functional outcomes of the AcrySof IQ ReSTOR +3.0 D Intermediate vision and defocus curves indicate the +3.0 D add power lens is more effective than the +4.0 D add power lens Anew aspheric AcrySof IQ ReSTOR IOL (Alcon, Fort Worth, TX, USA/ Hünenberg, Switzerland) has been tested in a prospective, randomized trial of 279 patients. As one of the investigators of this study, Kerry Solomon, MD, Magill Vision Center, Charleston, SC, USA, reported on the functional vision outcomes of 279 patients enrolled in this trial. The first aspheric IQ ReSTOR lens developed has a +4.0 D add power, which produces peak near vision around 33 cm (13 in). A new lens has now been developed with similar design characteristics but a reduced add power. In the new lens, the AcrySof IQ ReSTOR +3.0 D IOL, a shift is observed for the near peak of the aspheric (2.5 D) when compared to the +4.0 D ( 3.0 D), Dr. Solomon said. The shift is very clinically relevant, Dr. Solomon said. On the defocus curve, while near acuities in both lenses are intact, the best area of focus is 13 inches for the +4.0 D add lens, but for the +3.0 D add, it s 16 to 20 inches. This translates to patients being able to hold things a bit farther away and maintain focused vision, he said. Patients tend to be more comfortable reading a newspaper in their laps than in front of their faces, and that s what the +3.0 gives them. Clinical results Dr. Solomon noted patients were bilaterally implanted with either the AcrySof IQ ReSTOR +4.0 or +3.0 D IOL. Patient follow-up continued for six months after second IOL implantation, although results are presented for the three-month trial. The aspheric multifocal +3.0 add power IOL demonstrated a mean of 20/32 or better in the intermediate vision range, an improvement of >1 line compared to the aspheric multifocal +4.0 D add power IOL, Dr. Solomon said. The overall range of vision is better with the +3.0, he said. The +4.0 has a good range of vision, but the optimal vision is reached at 13 inches. Functional vision outcomes were tested six months after second IOL implantation using defocus testing, in which patients were defocused by measuring their visual acuity through both minus and plus power phoropter lenses. Technically, defocus testing is a systemic application of different spherical powers to defocus a patient, Dr. Solomon continued on page 2 Patients are reporting a better range of vision at intermediate, like reading their s or the newspaper on their laps. Kerry Solomon, MD The AcrySof IQ ReSTOR +3 has a more comfortable near to intermediate range without compromising distance vision compared to the IQ ReSTOR +4

2 2 New Paradigms and Options in Cataract & Refractive Surgery IQ ReSTOR +3.0 D delivers improved VA at all distances Robert P. Lehmann, MD, clinical associate professor of ophthalmology at Baylor College of Medicine in Houston and in private practice in Southlake and Nacogdoches, TX, USA, was an investigator for a recent AcrySof IQ ReSTOR study comparing two aspheric AcrySof ReSTOR IOLs: the AcrySof IQ ReSTOR +3.0 IOL and the AcrySof IQ ReSTOR +4.0 IOL. The primary difference between these two lenses is the decreased add power of the AcrySof IQ ReSTOR +3.0 D IOL, which increases the optimal near distance for reading. Dr. Lehmann described several key study findings. When patients pay a premium for the multifocal technology, they want what they view is the best vision possible, he said. The reality is we have a technology now that offers good distance, good intermediate, and good reading/near vision, and that s the IQ ReSTOR +3. The botcontinued on page 3 Combined distance, intermediate, and near VA at best corrected, with near measured at patient s best distance and intermediate at 50 cm (20 in) Solomon from page 1 Two thirds of the patients with AcrySof IQ ReSTOR +3.0 D IOLs had 20/25 or better vision at all distances. Robert Lehmann, MD said. Using manifest refraction at baseline, defocus testing began with visual acuity assessment with a 5.0 D phoropter lens; the lenses were then stepped down in 0.5 D increments until zero power was reached. Defocus testing resumed with a +2.0 D phoropter lens, again moving in 0.5 D increments toward emmetropia. Because diopters can be converted to effective viewing distance, defocus curves contain visual acuity measurements at numerous effective viewing distances, providing an overall picture of a patient s functional range of vision. Defocus curves will show us where the optimal viewing distance is, so it s very clinically relevant, Dr. Solomon said. Defocus testing revealed that, while patients in both groups achieved an average near vision peak of 20/20, the effective distance at which this was achieved differed. Patients with the AcrySof IQ ReSTOR +4.0 D had best near vision at an effective viewing distance of 31.3 cm; the +3.0 D patients achieved best near vision at 38.4 cm, 7 cm farther than the +4.0 D IOL. The major difference, however, between the two AcrySof IQ ReSTOR lenses was observed in the intermediate vision portion of the defocus curves. Patients implanted with the reduced add power IOL enjoyed at least a 1.5 line increase in intermediate visual acuity, reaching an average intermediate vision of 20/25 compared with an average of 20/40 for patients in the +4.0 D group. The theoretical design of this lens was planned to give better vision at 16 to 20 inches, and the lens does, Dr. Solomon said. Patients are reporting a better range of vision at intermediate, like reading their s or the newspaper on their laps. In short, Dr. Solomon said, when comparing the two lenses, intermediate vision was much better with the +3.0 D than the +4.0 D, the +3.0 provided patients with a broader near distance range of vision, and patients were able to move items within a range at near while maintaining 20/20 vision. Solomon: ; solomonk@musc.edu

3 New Paradigms and Options in Cataract & Refractive Surgery 3 Lehmann from page 2 tom line: Patients have that increased range of vision with this lens. In my practice, that has led to even greater patient satisfaction than they could achieve with the original ReSTOR. This randomized trial included 279 patients who were bilaterally implanted with either the AcrySof IQ ReSTOR +3.0 D IOL or the AcrySof IQ ReSTOR +4.0 D IOL. Visual acuity across distances was measured. Both groups achieved approximately 20/25 distance corrected near VA at their best distance. However, as expected based on the lens design, patients with the new AcrySof IQ ReSTOR +3.0 D IOL had an average optimal near vision at about 37 cm, while those with the AcrySof IQ ReSTOR +4.0 D IOL on average had optimal near vision at about 31 cm. This lens offers excellent contrast sensitivity, good functional near to intermediate vision, and I ve had no complaints from patients about not being able to read up close, Dr. Lehmann said. One of the primary differences between outcomes for the two lenses was apparent in the area of intermediate vision, such as computer use, dashboard viewing, and grocery shopping. Patients with the AcrySof IQ ReSTOR +3.0 D IOL had uncorrected intermediate VA that was nearly 1 to 1.5 lines better than that of patients with the AcrySof IQ ReSTOR +4.0 D IOL. Patients in both groups filled out the same survey, Dr. Lehmann said. In this study, there were no adverse events and no complications in either group. Both lenses produced excellent distance vision, with both IOL groups achieving 20/20 uncorrected distance visual acuity. Looking at visual acuity findings across distances, investigators found that patients with the AcrySof IQ ReSTOR +3.0 D IOL enjoyed a broader range of vision, as measured by combined near, intermediate, and distance visual acuities, than those with the AcrySof IQ ReSTOR +4.0 D IOL. Two thirds of the patients with AcrySof IQ ReSTOR +3.0 D IOLs had 20/25 or better vision at all of these distances, while nearly a fourth of those with the AcrySof IQ ReSTOR +4.0 D IOL had 20/25 or better at these distances. Nearly everyone (96%) with the AcrySof IQ ReSTOR +3.0 D IOL achieved functional vision at least 20/40 at each distance compared with 66% of patients implanted with the AcrySof IQ ReSTOR +4.0 D IOL. Patient satisfaction in this study in both groups was very high. Once surgeons get used to implanting this lens in clinical practice, I think they ll find it s going to be a better match for more patients than other lenses, Dr. Lehmann said. Lehmann: ; lehmanneyecenter@suddenlinkmail.com Mean uncorrected intermediate VA binocular at 6 months post-op was 1 to 1.5 lines better for IQ ReSTOR +3.0

4 4 New Paradigms and Options in Cataract & Refractive Surgery Patients report reduced glare and halo with the ReSTOR +3.0 and +4.0 Study findings confirm previous reports that patient satisfaction with AcrySof ReSTOR lenses is high, surgeon says In addition to visual acuity measures, patient-reported outcomes provide a vital component of the overall assessment of presbyopia-correcting lenses. These patient-focused measures can be distinct from visual acuity outcomes, such as with the reporting of visual disturbances, or they can be more closely related to visual acuity, such as with patient-reported vision or overall satisfaction of outcomes. Robert Cionni, MD, medical director, Cincinnati Eye Institute, OH, USA, was one of the investigators for a recent randomized trial comparing two AcrySof IQ ReSTOR IOLs. Dr. Cionni presented several patient-reported outcomes to evaluate patients experiences with these lenses. One of the key patient-reported outcomes Dr. Cionni described was whether patients reported experiencing glare and halo. Patients with any style implant can have glare complaints, Dr. Cionni said. Patients with multifocal IOLs do typically have a higher incidence of glare and halos relative to a monofocal IOL, but most patients feel the glare and halos are mild to moderate and not severe. The multicenter study included 279 patients who received bilateral implants of the AcrySof IQ ReSTOR +4.0 D IOL or the AcrySof IQ ReSTOR +3.0 D IOL. The main difference between the two lenses is the reduced add power of the AcrySof IQ ReSTOR +3.0 D IOL. Study patients completed questions from the Cataract TyPE questionnaire both pre-op and at six months after the second IOL implantation. Patients who wore glasses prior to surgery were included in the pre-op analysis and those who were spectacle-independent following surgery were included in the post-op analysis. These questionnaires assessed whether patients reported glare and halo, effects of bright lights, and trouble with their vision; they also assessed patients satisfaction with their vision. The questions address patient experience with glare for usual daily activities, reading text on shiny paper, daytime driving, nighttime driving, outdoor activities, and reading signs in stores and supermarkets, Dr. Cionni said. On a scale of 0 (no trouble) to 4 (overwhelming), patient glare and halo ratings decreased from average pre-op scores of about 2.2 to 2.3 to an average post-op score of < 1, with either of the AcrySof IQ ReSTOR IOLs. When patients were asked about glare in the presence of oncoming headlights, a particularly problematic situation, average pre-op scores were high 3.1 in both groups but post-op scores dropped more than twofold, to The importance in this study is that patient complaints of glare in both the +3.0 and +4.0 diopter groups were significantly less than before cataract surgery, yet not different from each other, Dr. Cionni said. That s understandable. The ReSTOR utilizes an apodized diffractive lens that minimizes halos and glare. Post-op, approximately 70% of patients with IQ ReSTOR +3.0 D IOLs reported an improvement or no effect relative to the effects of bright light. Both IQ ReSTOR continued on page 5 ReSTOR utilizes an apodized diffractive lens that minimizes halos and glare. Robert Cionni, MD Pre-op trouble with glare and halo with glasses with regard to driving toward oncoming headlights compared to post-op without glasses. Scale of 0 to 4. 0=no trouble, 4=overwhelming

5 New Paradigms and Options in Cataract & Refractive Surgery 5 Cionni from page 4 IOL groups demonstrated a significant post-op decrease in difficulty with bright light conditions from the pre-op assessment. When considering post-op changes in patient-reported trouble with vision, Dr. Cionni and colleagues discovered approximately a 2.5- fold improvement in both IOL groups. These findings applied to both daytime vision and nighttime vision. Finally, patients reported nearly a twofold increase in overall satisfaction with their vision after bilateral IOL implantation, with mean ratings of 3.3 in both IOL groups, on a scale of 0 (not at all satisfied) to 4 (completely satisfied). These findings confirmed previous reports that patient satisfaction with AcrySof ReSTOR lenses is high. Subjective outcomes better illustrate patient satisfaction in meeting their expectations, Dr. Cionni said. Cionni: rcionni@cincinnatieye.com What you should know about glare and halos after AcrySof IQ ReSTOR implantation: Patient complaints of glare in both the +3.0 and +4.0 D groups were significantly less than before cataract surgery yet not different from each other. On a scale of 0 (no trouble) to 4 (overwhelming), the score for glare in the presence of oncoming headlights dropped more than 2-fold to in both IQ ReSTOR groups. Post-op, about 70% of patients with IQ ReSTOR +3.0 D IOLs noted an improvement or no effect relative to the effects of bright light. Source: Robert Cionni, MD Apodization optimally manages light energy delivered to the retina as it distributes the appropriate amount of light to near and distant focal points

6 6 New Paradigms and Options in Cataract & Refractive Surgery Patient satisfaction with the IQ ReSTOR +3.0 D Improved intermediate vision makes this lens most impressive, surgeon says Some of the first patients in the world to receive bilateral implantation of the AcrySof IQ ReSTOR +3.0 D multifocal IOL (Alcon, Fort Worth, TX, USA/ Hünenberg, Switzerland) were treated at the Eagle Eye Center at the Mount Alvernia Hospital in Singapore. The first group of 19 Chinese patients presented with all combinations of presbyopia and cataract.* These were motivated patients, said Julian Theng, MBBS, FRCS, FRCOphth, medical director, as they were looking for a cure for the presbyopia, and were very frustrated with adjusting their spectacles. In this first group, pre-op best corrected visual acuity (BCVA) ranged from 20/20 to 20/15. About 65% were 20/20 or 20/25, 25% were 20/30 to 20/40 BCVA, and less than 10% were worse than 20/40. Dr. Theng has now implanted more than 100 patients with the lens and said his initial impression that intermediate vision was excellent has been confirmed with the subsequent implantations. None of the original study participants complained about difficulty with near vision tasks. Upon occasion, there is a patient who might complain, but Dr. Theng said it s a rarity. While other lenses have promised good intermediate results, Dr. Theng has not been as impressed as he was with this lens. It has the best satisfaction rate by the patients of all the lenses I ve implanted. It was impressive, he said. Post-op, these initial patients were followed for six months and were asked to fill out a questionnaire about the quality of vision. Uncorrected visual acuity averaged better than 20/40 at near and intermediate distance. On the patient questionnaires, 80% reported no difficulty or minimal difficulty with activities like reading, shaving, applying makeup, using a computer, or using a cell phone. No patient reported severe difficulty with any of the daily life activities. Visual aberrations Problems with halo can occur with some multifocal IOLs. I am always concerned about these potential visual side effects at night. In this patient group, there was no residual night glare or halo complaints anywhere from six weeks to the six month follow-up. Like other multifocals, there is a postoperative adjustment period for the patients, but this tends to decrease with time, he said. In Dr. Theng s study, at the final, six month assessment, 50% of patients had no difficulty or minimal difficulty with halo, and 45% of patients had only moderate difficulty with halo. For glare, 70% of patients had no difficulty or minimal difficulty, and 30% of patients had only moderate difficulty. According to Dr. Theng, the ReSTOR +3.0 D lens night vision symptoms were much less significant than not only other versions of the ReSTOR, but other lenses as well. At the six month time point, the average satisfaction score was 8 out of 10. I suspect some of these patients who were not completely satisfied with the lens may have had very mild cases of posterior capsule opacification. It may have made their visual symptoms seem more dramatic or affected their visual quality. Also, some may have experienced an increase in dry eye, which often happens after phaco. Those same patients, though, are now much happier well beyond the six month time point. They have neuroadapted to the lens and all report they are very satisfied, he said. At the end of the initial trial, Dr. Theng had one patient with a swollen cornea during the first few post-op days. I believe it was related to the antibiotics and not the lens, he said. The issue resolved after one month, and the patient is extremely happy. In that first group of patients, I have performed YAG on two. There was minimal, if any, decentration of the lens. It s common to induce a little bit of decentration if you re not totally centered on the pupil. This lens has never given me the sense that it correlates with negative visual continued on page 7 It has the best satisfaction rate by the patients of all the lenses I ve implanted. It was impressive. Julian Theng, MBBS, FRCS, FRCOphth Patient satisfaction and spectacle dependence

7 Using toric lenses for low levels of corneal astigmatism New Paradigms and Options in Cataract & Refractive Surgery 7 Astigmatism as low as 0.75 D can be successfully treated with an IOL When treating cataractous eyes with moderate to high levels of corneal astigmatism more than 1.5 D, for example most surgeons don t hesitate to recommend a toric IOL. It s eyes with low levels of pre-op corneal astigmatism that sometimes cause surgeons to hesitate when deciding among treatment options. Ophthalmic surgeons have several choices to treat corneal astigmatism: toric IOLs with low levels of cylinder power, limbal relaxing incisions (LRIs), opposite clear corneal incisions, or steep axis incisions. Incisionbased strategies can yield highly variable outcomes that are dependent on surgical technique (a controllable factor) and healing patterns unique to each eye (an uncontrollable factor). In years past, I ve tended to perform LRIs on patients with lower levels of pre-op astigma- Dilating patients on post-op day one will allow surgeons to check the axis orientation of the AcrySof Toric IOL tism, especially in patients receiving multifocal lenses, said Paul H. Ernest, MD, TLC Eye Care of Michigan, Jackson, MI, USA. If the patient opted for monofocal vision, I would tend to continue to put him in spectacles. One of my main concerns with the LRI approach is that the results are unpredictable. In my hands, I could end up with a perfect result, or I could end up inducing astigmatism on a different axis. LRIs can sometimes be ineffective and not correct the astigmatism. So either they work great, they do nothing, or they induce astigmatism. continued on page 8 Theng from page 6 symptoms aside from what we typically expect in a small number of the multifocal patients. Pearls for implantation The IQ ReSTOR +3.0 D is easier to implant for surgeons who are just beginning to use multifocals, Dr. Theng believes. Part of it is that the patient satisfaction level and comfort post-operatively is better than older designs. That does not mean that surgeons can treat this lens like a monofocal, though. Patient counseling, managing patient expectations, and educating the patient about the lens and its limitations is still important, he said. Dr. Theng offers the following pearls: Surgeons should ensure that the capsulorhexis is not too large. The haptics hold the lens nicely in place, and decentration should not be an issue. LASIK is easy to do after this multifocal implantation, if needed. Some surgeons may steer clear of it because of the potential for night vision symptoms, but there s a slim chance patients are going to have severe symptoms. Minor symptoms do decrease over time, he said. I was looking forward to this lens and how different it is from other multifocals. In this case, the post-operative intermediate vision was much better and lived up to my expectations for this lens. I can say that the IQ ReSTOR +3.0 D has taken over most of my presbyopic practice. It s lived up to and exceeded my expectations, he said. *Editor s note: The AcrySof IQ ReSTOR +3.0 D lens was approved in the United States in Dec for cataract surgery in patients with presbyopia. Theng: 011 (65) ; juliantheng@eagleeyecentre.com.sg One of my main concerns with the LRI approach is that the results are unpredictable. Paul Ernest, MD The AcrySof IQ ReSTOR +3.0 D placed in the eye for the correction of presbyopia and cataract

8 8 New Paradigms and Options in Cataract & Refractive Surgery Ernest from page 7 As a result of the inconsistency, Dr. Ernest, along with Edward J. Holland, MD, professor of ophthalmology, University of Cincinnati, and director of cornea service, Cincinnati Eye Institute, Cincinnati, OH, USA, worked together to find a good, stable, and predictable treatment for cataractous eyes with low levels of preoperative corneal astigmatism, Dr. Ernest said. Study inclusion data allowed patients who had as little as D, but most were The AcrySof Toric Calculator can help surgeons determine which lens to use Approximately 97% of bilateral patients implanted achieved spectacle-independent distance vision around 1.0 D. For cataract patients whose eyes had pre-op corneal astigmatism of 0.75 D to 1.03 D, the surgeons implanted the SN60T3 model of the AcrySof Toric IOL (Alcon, Fort Worth, TX, USA/Hünenberg, Switzerland). The SN60T3 has a cylinder power of 1.50 D, yielding 1.03 D of cylinder power at the corneal plane. Incision/insertion techniques Dr. Ernest used an incision that tunneled from the posterior limbus, and entered a value of 0 D for surgically induced astigmatism into the AcrySof Toric Calculator (Alcon, calculator.com). Dr. Holland used 2.4-mm clear corneal incisions, and entered the default value of 0.5 D for the surgically induced astigmatism parameter in the AcrySof Toric Calculator. The technique and removal of a cataract in a patient with pre-op astigmatism is similar to someone without astigmatism, Dr. Ernest said. When using a toric lens, there are a couple of caveats the novice surgeon should learn, he added. For instance, surgeons need to have some idea of their average amount of surgically induced astigmatism. Dr. Ernest uses a 2.2-mm x 2.2-mm incision that creates a square wound. This incision is astigmatically neutral. Starting in the limbal area causes no flattening of the cornea. Flattening of the cornea can result in induced astigmatism, which takes about a week to clear. If surgeons prefer a different incision technique, whether it s geometrically non-square or if the incision starts more anteriorly, I highly recommend using the Toric Calculator, he said. In my hands, the square incision technique allows surgeons to operate and place the lens on the steepest axis without having to consult the calculator. He opts to mark the eye twice (once at 3 and 9 pre-op, and again intraoperatively). Surgeons should mark the pre-op eye while the patient is sitting to avoid cyclotorsion. Once the lens is placed in the eye, remove the viscoelastic so the lens is less likely to rotate. To position the toric lens I use a two-hand approach; one hand is positioning the lens and the other is irrigating. The two-hand technique maintains a constant anterior chamber depth and avoids any chamber shallowing which can cause a slight rotation of the toric lens. Study results In the pooled results from both surgeons, the patients had corneal cylinder that remained essentially constant at about 1.0 D across the one-, three-, and sixmonth post-op time points. The average refractive astigmatism was significantly lower than corneal astigmatism: 0.5 ± 0.4 D for the 30 patients who had completed the three-month follow-up, and 0.3 ± 0.4 D for the 23 patients who had completed the six month follow-up. This is attributed to the lens ability to compensate for corneal astigmatism. Post-op uncorrected distance visual acuity was significantly better than at baseline, averaging worse than 20/60 preop but better than 20/30 at three months post-op and better than 20/25 at six months post-op. Of patients who completed the follow up to six months, 95% rated the quality of their post-op vision as better than their pre-op vision. Only 5% of patients rated the quality of their vision the same as pre-op, and no patients rated the quality of their vision as worse than before surgery. Similarly, at the six month time point, 95% of patients stated that they had been able to function comfortably without glasses for distance vision during the last month of the study. What s nice about this platform is that it does not rotate, Dr. Ernest said. Part of that is the lens design, with its propensity to adhere to the capsule. If it rotates at all, it will be in the first 24 hours. Ernest: ; paul.ernest@tlcmi.com

9 Clinical outcomes of AcrySof Toric IOLs in complex cases New Paradigms and Options in Cataract & Refractive Surgery 9 Surgeon says Toric IOL ideal for complicated cases The private practice office of Johnny Gayton, MD, Eyesight Associates, Warner Robins, GA, USA, is in the trenches of ophthalmology. It s not like a clinical trial site, where all the patients are carefully prescreened ideal candidates. Dr. Gayton accepts many referrals for real-world patients with complicated eyes. His cataract patients have comorbid problems like glaucoma or agerelated macular degeneration, or they have histories of ocular surgery that complicate IOL selection and implantation. I get cataract patients referred in who have had RK [radial keratotomy], Dr. Gayton said. RK patients make for difficult lens implant calculations. Their K readings are very difficult to determine. At this year s ASCRS ASOA Symposium & Congress, Dr. Gayton presented a poster about his cataract patients with astigmatism, many of whom had a variety of ocular comorbidities. They were consecutive recipients of AcrySof Toric IOLs (Alcon, Fort Worth, TX, USA/Hünenberg, Switzerland) in 231 of their eyes. For the patients presented in his poster, about half of the eyes were good candidates, with no comorbid ocular conditions and with mild to moderate astigmatism (astigmatism that was low enough to be managed by the AcrySof Toric IOL alone, up to 2.75 D). The other half of the population had a variety of complexities including retinal/macular problems, angle/pressure problems, floppy iris, Fuchs dystrophy, corneal scarring, nystagmus, strabismus, and amblyopia. Some patients had previous ocular surgeries like corneal reshaping or transplantations, surgical treatments for glaucoma, or surgical treatments for retinal problems. Dr. Gayton even scheduled some of the patients for secondary ocular procedures concurrent with the extraction of the cataract and implantation of the AcrySof Toric IOL. Secondary procedures were treatments such as adjunctive limbal relaxing incisions (LRIs) for high astigmatism or endolaser for glaucoma. It didn t matter what the complexity was; if the patient needed an AcrySof Toric IOL, Dr. Gayton implanted it. He s more than pleased that he did. My director of research came to me about a year ago and said, Of all the research projects our practice has done, and of all the lenses our practice has used and there have been many we have never had as good a result as with the Toric lens, Dr. Gayton said. There s an incredible wow factor. The Toric wow The results presented in his poster show that the AcrySof Toric IOLs did compensate for corneal cylinder in most cases. Astigmatism was reduced about 80% in all groups (the average pre-op corneal astigmatism was about 2 D), except for the high astigmatism adjunctive LRI group (where the average pre-op corneal astigmatism was about 4 D). Even in the high astigmatism adjunctive LRI group, astigmatism still was reduced 60%. For visual outcomes, as might be expected, good candidates were continued on page 11 Of all the research projects our practice has done, we have never had as good a result as with the Toric lens. Johnny Gayton, MD Figure 1: Uncorrected distance visual acuity after implantation of an AcrySof Toric IOL

10 10 New Paradigms and Options in Cataract & Refractive Surgery Toric positioning pearls: The helmet OVD technique As the technology of intraocular implants evolves, so must the techniques for implanting them. Ideally, the methods would maximize post-op function, provide immediate visual restoration, and optimize safety. With this era of premium surgical options, it is beneficial that the techniques to implant them are as innovative as the lenses themselves. David M. Kwiat, MD, medical director, Amsterdam Eye Center, Amsterdam, NY, USA, and assistant clinical professor, Albany Medical Center, Albany, NY, USA, describes a simple approach, called the helmet technique, to provide a reliable and practical surgical environment for premium lens patients, he said. David V. Leaming, MD, Palm Springs, CA, USA, described a technique in the September 2008 issue of EyeWorld that utilizes a viscous dispersive viscoelastic (DisCoVisc, Alcon, Fort Worth, TX, USA/Hünenberg, Switzerland) in a snowman fashion prior to lens insertion. The viscoelastic is stacked in a snowman fashion from the bag to the anterior chamber and then to the wound. The unique combination of cohesive and dispersive properties afforded by this OVD are a key factor in making the technique work as it provides both needed space and the retention that is required to hold the balanced salt solution (BSS, Alcon) in the bag in the next step, Dr. Leaming said. In that step, the base of the snowman can be substituted for balanced salt solution. In this manner, premium lenses such as the AcrySof Toric IOL (Alcon) placed inside only BSS can unfold faster and suffer less rotational forces due to decreased need for posterior viscoelastic removal, Dr. Leaming said. This ultimately improves the accuracy and efficiency of the Toric lens. In the same article, Richard Burns, MD, San Diego, CA, USA, went on to describe a related method that coated the endothelial surface of the cornea and the wound with viscous dispersive viscoelastic and then filled the bag with BSS. Dr. Kwiat found both methods to be beneficial, but he hasn t been able to apply them comfortably in all cases. When implanting Toric lenses I am focused on lens alignment compared to my more routine cases, and I haven t found these techniques to be as stable as I hoped, Dr. Kwiat said. The main issues are capsular stability and protection prior to and during lens placement, Dr. Kwiat said. Removal of the cannula after filling the bag with BSS may result in an egress of saline and subsequent destabilization of the capsule. Dr. Kwiat found this happens even with application of Dr. Leaming s proposed zigzag cannula removal. Where Dr. Kwiat has found these techniques to falter is in patients where the posterior capsule is exceptionally mobile (such as advanced cataracts and older patients). The posterior capsular surface has the potential to prolapse beyond the anterior capsular rim. This is especially pronounced if there is even a small amount of posterior pressure from patient factors such as anxiety. This results in shallowing of the A/C with lens insertion which could result in anterior capsule migration while the lens is being placed and possible contact with the corneal endothelium, Dr. Kwiat said. Beginning cataract surgeons are taught to fill the bag and the continued on page 11 I ve found this new technique to be ideal for implanting Toric lenses. David Kwiat, MD Premium lenses such as the AcrySof Toric IOL placed inside only BSS can unfold faster and suffer less rotational forces due to decreased need for posterior viscoelastic removal

11 New Paradigms and Options in Cataract & Refractive Surgery 11 Kwiat from page 10 Toric helmet technique Following cortical removal, the entire anterior chamber is filled with DisCoVisc, effectively stabilizing the chamber and protecting the endothelium. Once the helmet of DisCoVisc is in place, the bag is filled with BSS. Potential misalignment of Toric is minimized. anterior chamber with viscoelastic to provide the most stability and protection during intraocular lens placement. Though I admire the convenience and efficiency of the previously described techniques, I wanted the best of both worlds, Dr. Kwiat said. I was looking to bridge the advantages of facilitated viscoelastic removal from Dr. Leaming s technique and the safety that Dr. Burns approach afforded while providing the most stable and therefore safest environment for lens placement. Further, he sought a method that cataract surgeons, regardless of ability level, could apply to all cataract cases but emphasizing the advantages needed for the Toric and ReSTOR (Alcon) lenses, Dr. Kwiat said. He describes the self-named helmet method, which derives both from the half circle (helmet shape) of DisCoVisc he places in the anterior chamber and from the idea of protection that a helmet provides. Following cortical removal, the entire anterior chamber is filled in a distal to proximal fashion. The cannula is placed at the anterior iris plane at a slight upward angle which allows the A/C to fill in a posterior to anterior direction. This helmet effectively stabilizes the anterior chamber, fully protects the corneal endothelium, and seals the incision. With the helmet in place, filling the bag with BSS is now optimized as the viscoelastic directs all the saline into the bag. There may be some migration of the viscoelastic toward the wound, and surgeons can use this as an endpoint and assurance that the bag is adequately inflated, Dr. Kwiat said. Withdrawal of the cannula can be made in the usual manner as there is sufficient wound seal with the viscoelastic placement. Consequently, the chamber and capsule are stable with lens placement. By applying this method, there is both the stability needed for exceptionally protected lens insertion and easy viscoelastic removal, Dr. Kwiat said. Since there is only BSS in the bag, there is no need to insert the tip behind the lens to remove the viscoelastic. Therefore, potential misalignment of the Toric is minimized. In my hands, the helmet approach gives me the confidence that I m operating in a stable environment, he said. The helmet of viscous dispersive OVD protects the cornea and stabilizes the anterior chamber. Keeping the saline in place gives me an enlarged bag optimized for lens implantation. I ve found this new technique to be ideal for implantation of Toric lenses, but it works equally well in other cataract cases. Kwiat: kwiatmd@yahoo.com Gayton from page 9 more likely than complex candidates to have 20/20 UCVA vision (26% versus 15%, respectively). However, the AcrySof Toric IOLs provided uncorrected 20/40 distance vision to close to 80% of patients overall, regardless of whether the candidates were good or complex (see Figure 1). When the patient types were analyzed by subgroups (such as the LRI group, the group with problems relating to angle or pressure, and the group with retinal or macular problems), only the LRI subgroup was statistically different. Even so, about 70% of those LRI plus Toric IOL eyes had 20/40 distance vision. Keep in mind that adding adjunctive LRIs in cases of high astigmatism can yield less predictable and suboptimal outcomes, Dr. Gayton said. Adjunctive LRIs on high-cylinder eyes are not as straightforward as LRIs on lower-cylinder eyes, he said. As far as the learning curve with the Toric IOL, it s easy, Dr. Gayton said. Some surgeons may be concerned about misaligning the Toric IOL axis especially in already complicated patients but their worries are unfounded, he said. You have to be more than 30% off to have no benefit of the Toric lens, Dr. Gayton said. It s very forgiving. But if you re accurate, you ll get great results. Although the Toric IOL isn t a multifocal lens, Dr. Gayton said astigmatic patients can still achieve spectacle independence with monovision techniques or by implanting a Toric IOL in the astigmatic eye and an IOL to correct presbyopia in the other eye. Patients implanted with the Toric IOL only can also be undercorrected slightly and still read quite well, he said. They don t tend to wear glasses a lot, Dr. Gayton said. The introduction of asphericity to the AcrySof Toric IOL should improve the image quality for astigmatism patients. For straightforward cases of astigmatism, the AcrySof Toric IOL is an appropriate tool to have in the cataract surgeon s armamentarium. Beyond that, although not all surgeons get a deluge of complicated cases like those referred to Dr. Gayton s office, most surgeons do treat astigmatic cataract patients who also have problems like partially controlled glaucoma or slight age-related macular degeneration. Dr. Gayton s results show that the AcrySof Toric IOL provides excellent care for these eyes, which clearly need all the extra help they can get. Gayton: ; JLGayton@aol.com This supplement was produced by EyeWorld under an educational grant from Alcon, Inc. Copyright 2009 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, APACRS or ASCRS.

12 Didn t make it to San Francisco? Don t worry CATARACT INNOVATIONS AND REFRACTIVE PEARLS See highlights from Live Surgery Cataract Innovations and Refractive Pearls from the 2009 ASCRS Symposium & Congress San Francisco. The Eye Institute of Utah in Salt Lake City proudly hosted a demonstration of the latest cataract surgical skills in ophthalmology. Must see segments from the program include: Surgical Faculty Robert J. Cionni, MD Host Surgeon Medical Director The Eye Institute of Utah Adjunct Clinical Professor University of Utah Salt Lake City, Utah Volunteer Assistant Professor University of Cincinnati Cincinnati, Ohio Charith Fonseka, MD Consultant Ophthalmologist Eye Hospital Colombo, Sri Lanka Implantation of the new IOL technologies: AcrySof IQ ReSTOR IOL +3.0 D and IQ Toric IOL Key learnings from Karl Stonecipher, MD on the Allegretto Wave Eye-Q Robert P. Lehmann, MD Medical Director Lehmann Eye Center Nacogdoches, Texas Clinical Associate Professor of Ophthalmology Baylor College of Medicine Houston, Texas The 2009 EyeWorld Live Surgery Program is now available at: Faculty Panel Richard J. Mackool, MD Director Mackool Eye Institute and Laser Center Senior Attending Surgeon The New York Eye and Ear Infirmary Clinical Professor New York University Medical Center New York, New York Repurposed in conjunction with Donald N. Serafano, MD - Moderator Paul H. Ernest, MD Robert H. Osher, MD Kerry D. Solomon, MD Karl Stonecipher, MD Abhay Vasavada, MD Sponsored by MCA Alcon, Inc.