Cataracts 20/20: The Optometrist s Role in Pre and Post-Op Care In The Era Of Specialty Lenses

Transcription

1 Cataracts 20/20: The Optometrist s Role in Pre and Post-Op Care In The Era Of Specialty Lenses Eric E. Schmidt, O.D., F.A.A.O. Omni Eye Specialists Wilmington, NC schmidtyvision@msn.com

2 Cataract Management Visual Acuity 20/50? Glare and Lifestyle Is your patient young and wants refractive Cataract surgery Or is your patient health conscious and wants no risk What is Binocular vision How is their night vision and how often do they drive at night

3 The Future of Cataract Management by Optometry Know the Lens options Know the Patient Match Options to Patient Financial Medical Optical

4 The Future of Cataract Management by Optometry Earlier Referrals Loftier Expectations More Active Role In Pre-Operative Counseling More active Role In Choosing Procedure More Important Than Ever In Assuring Positive Outcomes Changing Post-Op Role Different Co-management Reimbursement Model

5 The Future of Cataract Management by Optometry Understand the fee structure of each modality Develop a personal fee structure There is no 20% rule In fact the majority of the examination and patient guidance is your responsibility and should be compensated There is very little difference in time and expertise to implant a SV, toric, or multifocal. In fact the majority of time spent is pre and Post surgery

6 Cataracts In The Year 2018 Changing Paradigm Earlier Diagnosis Earlier Surgery Loftier Expectations Harder To Manage??

7 Demographics Comprehensive Report on the Global IOL Market. Market Scope 2. US Census Bureau, gallup.com/poll/166952/babyboomers.reluctant-retire.aspx 4. NextAvenue, nextavenue.org/hottest-trends-boomer-travel 5. AARP Getting to Know Americans Age 50+, AARP Planning Complete Streets for an Aging America, May 2009

8 Not All Cataracts Are Created Equal VA is no longer the only criteria for recommending surgery Glare Contrast Sensitivity Night Vision Difficulties

9 Not All Cataract Surgeries Are Created Equal What Does The Patient want (expect)? Spectacle independence? No specs for sports? No reading glasses? No responsibility?

10 Not All Cataract Surgeries Are Created Equal What Do The Doctors Want (Expect)? Surgeon vs Referring Doctor Setting Realistic Expectations Is The Key!!!!!

11 Cataract Surgery Choosing The Right One So Many Choices So Little Time Clear Cornea vs Femtosecond Astigmatic Keratotomy vs Toric IOL Single Vision vs Multifocal Multifocal vs Accomodating IOL What About Monovision???? And What Is Extended Depth of Focus!!!???***

12 Why Use A Femtosecond Laser? Precise Incision Control Managing Astigmatism More Precise Capsulorhexis More Predictable refractive outcome But Is It worth the Extra Cost????

13 Managing Astigmatism Limbal Relaxing Incision Astigmatic keratotomy (laser guided) Toric IOL The choice depends upon amount of pre-operative astigmatism (And the amount of money the patient chooses to spend!!!)

14 Treatment Astigmatism & Presbyopia in Cataract Surgery 1/3 of Patients have > 1.0D of astigmatism but only 1/4 of those patients are receiving a Toric IOL % of Patients receiving Toric IOL 67% 0% 33% 8% Patients > 1.0D Astigmatism Patients receiving Toric IOL 25% Every patient over the age of 50 is impacted by presbyopia 1, yet only 6.5% of patients receive a presbyopia-correcting IOL % of Patients receiving PC IOL 93.5% 6.5% PC IOL Monofocal IOL Patients who do not have astigmatism and presbyopia treated at the time of cataract surgery must treat those conditions with glasses for the rest of their lives Market Scope

15 How Much Cylinder Can we Actually Correct? Lens Model ZCT150 ZCT225 ZCT300 ZCT400 ZCT450 ZCT525 ZCT600 Cylinder Powers 1.50 D 2.25 D 3.00 D 4.00 D 4.50D 5.25D 6.00D Corneal Plane* 1.03 D 1.54 D 2.06 D 2.74 D 3.08D 3.60D 4.11D Corneal Astigmatism Correction Range (PreK Cyl + SIA) D D D D D D D

16 Astigmatism and Cataract Surgery Approximately 37.7% of the patient population has greater than 1D of astigmatism 1 Toric IOLs represent a potential market of approximately 268K procedures in % market penetration forecasted for Fastest growing segment of the premium IOL market the last several years Market Scope, 2013 Comprehensive Report on Global IOL Market. 2. Market Scope, 2014 Global IOL Report. Ophthalmic Market Perspectives. PP2015CT0370

17 Outstanding visual outcomes and patient satisfaction Nearly 9 out of 10 patients achieved 20/32 or better uncorrected distance visual acuity 96.5% of patients would choose to have TECNIS Toric IOL again Would you choose to have the TECNIS Toric IOL again? 96.5% 3.5% Yes No Tecnis Toric ZCT150 IOL (n=101) Control (n=93) TECNIS Toric 1-Piece IOL [package insert]. Santa Ana, Calif: Abbott Medical Optics Inc. PP2015CT0370

18 Postoperatively, 94.1% of patients implanted with the ZCT150 lens achieved 1.00 diopters of residual refractive cylinder. 72.3% achieved 0.50 diopters.* Patients (%) Residual Refractive Cylinder Diopters * In the Randomized Control Arm of the study. TECNIS Toric ZCT 150 IOL (N=101) Control (N=91) Warnings: The clinical study for the TECNIS Toric 1-Piece IOL did not show evidence of effectiveness for the treatment of preoperative corneal astigmatism of less than one diopter. 1. TECNIS Toric 1-Piece IOL [package insert]. Santa Ana, Calif: Abbott Medical Optics Inc. PP2015CT

19 Implanted Eyes (%) Precise correction of astigmatism with excellent postop rotational stability Postop Rotational Stability 1 Mean Axis Change Between Baseline and Six Months 1 1 month vs. 3 months 3 months vs. 6 months N = > 16 Measured Rotation ( ) * N=148 patients with photographic axis data at all visits through six months. Why rotational stability matters: A loss of approximately 3.3% in cylindrical power occurs for every degree of rotation away from the toric IOL s intended axis TECNIS Toric 1-Piece IOL [package insert]. Santa Ana, Calif: Abbott Medical Optics Inc. 2. Kim, Myung Hun, Korean J Ophthalmol 2010; 24(4): PP2015CT0370

20 High spectacle independence 80% of patients reported wearing glasses "none of the time" for far TECNIS Toric 1-Piece IOL [package insert]. Santa Ana, Calif: Abbott Medical Optics Inc. PP2015CT0370

21 What About Presbyopia?? Monofocal IOL w/ Readers Monovision Multifocal IOL Accomodating IOL Extended Depth of Focus IOL Again The Choice Depends Upon The Expectations of The Patient

22 Treatment Astigmatism & Presbyopia in Cataract Surgery 1/3 of Patients have > 1.0D of astigmatism but only 1/4 of those patients are receiving a Toric IOL % of Patients receiving Toric IOL 67% 0% 33% 8% Patients > 1.0D Astigmatism Patients receiving Toric IOL 25% Every patient over the age of 50 is impacted by presbyopia 1, yet only 6.5% of patients receive a presbyopia-correcting IOL % of Patients receiving PC IOL 93.5% 6.5% PC IOL Monofocal IOL Patients who do not have astigmatism and presbyopia treated at the time of cataract surgery must treat those conditions with glasses for the rest of their lives Market Scope

23 Defocus Curve at 6 Months (bilateral subjects) Clinical Data Data: DFU, TECNIS Multifocal 1-Piece IOL, Models ZKB00 and ZLB00, and DFU, TECNIS Multifocal 1-Piece IOL, Model ZMB00. PP2015CT FOR INTERNAL USE ONLY

24 ReSTOR IOL TECNIS Multifocal IOL Alcon ReSTOR IOL +3.0 defocus curve peaks at (40 cm) Alcon ReSTOR IOL +4.0 defocus curve peaks at (33 cm) TECNIS Multifocal IOL IOL defocus curve peaks at (40 cm) TECNIS Multifocal IOL +4.0 IOL defocus curve peaks at (33 cm) Defocus Curve at 6 Months (bilateral subjects) PP2015CT0115 Data: DFU, TECNIS Multifocal 1-Piece IOL, Models ZKB00 and ZLB00, and DFU, TECNIS Multifocal 1-Piece IOL, Model ZMB FOR INTERNAL USE ONLY

25 Patient Reported Outcomes 98% of patients reported an ability to function comfortably without glasses at intermediate and far distances. 97% of patients would elect to have the same IOL again 96% of patients reported an ability to function comfortably without glasses at intermediate and far distances. 94% of patients would elect to have the same IOL again 85% of patients are able to function comfortably without glasses at ALL distances 87% of patients would elect to have the same IOL again The questionnaire was not determined to be a psychometrically valid assessment of the concept of spectacle independence. Data: DFU, TECNIS Multifocal 1-Piece IOL, Models ZKB00 and ZLB00, and DFU, TECNIS Multifocal 1-Piece IOL, Model ZMB00. PP2015CT FOR INTERNAL USE ONLY

26 Current IOL Options Monofocal IOLs Monofocal Toric IOLs Accommodating IOLs Accommodating Toric IOLs Multifocal IOLs Multifocal Toric IOLs The FDA Approves a different class of lens: The first and only Extended Depth of Focus (EDOF) Presbyopia-Correcting IOL for patients with and without Astigmatism

27 Extended Depth of Focus The TECNIS Symfony IOL has unique optics, creating a different visual experience The proprietary echelette design introduces a novel pattern of light diffraction that elongates the focus of the eye 1 The echelette is the relief or profile of the lens (height differential) within each ring The height, spacing, and profile of the echelettes to create a diffractive pattern for an elongated focus TECNIS Symfony IOL DFU

28 Extended Depth of Focus IOL Monofocal IOL Distinct Single Focus Multifocal IOL Two Distinct Foci TECNIS Symfony IOL Elongated Focus 1 Data on File. Tecnis Symfony Green Light Bundle Bench Test DOF2014CT005. Abbott Medical Optics Inc PP2016CT1448 PP2016CT1738

29 What is Chromatic Aberration? The power of the eye is wavelength dependent. Colors that are out-of-focus cause blur and reduce contrast. The phakic eye has approximately 1.38 D of chromatic aberration between 450 and 700 nm1. Pseudophakic eyes have between 1.45 and 2 D of chromatic aberration, depending on the dispersion of the IOL material 2,3 2. DOF2015OTH Data on file. Longitudinal Chromatic aberration of a monofocal TECNIS Achromat IOL. 3.Weeber et al. Differences in Chromatic Aberration of IOLs, ESCRS 2016.

30 The impact of chromatic aberration on image quality

31 Achromatic Technology A diffractive IOL with achromatic technology can correct chromatic aberration of the eye Cornea Typical IOL + = + = Cornea TECNIS Symfony Diffractive Technology

32 Achromatic Technology Results in Contrast Enhancement Achromat technology for the correction of longitudinal chromatic aberration (LCA) causes contrast enhancement. Correction of corneal chromatic aberration results in a sharper focus of light. When combined with correction of spherical aberration, it increases retinal image quality, without negatively affecting depth of focus. 1,2 The benefits of chromatic aberration correction are pupil-size independent 1 1. Weeber, H.A., & Piers, P.A. (2012). Theoretical Performance of Intraocular Lenses correcting both Spherical and Chromatic Aberration. J Refr Surg, 28 (1), ; 2. Artal, P., Manzanera, S., Piers, P., & Weeber, H. (2010). Visual effect of the combined correction of spherical and longitudinal chromatic aberrations. Opt Express, 18 (2),

33 Chromatic aberration nm (diopter) TECNIS Symfony IOL actively corrects chromatic aberration The proprietary achromatic technology of TECNIS Symfony IOL not only reduces chromatic aberration but actually corrects chromatic aberration of the cornea Aphakic Tecnis Symfony IOL corrects chromatic aberration to deliver a sharp image over the entire range of vision TECNIS Symfony TECNIS 1P ReSTOR +2.5D ReSTOR +3D Thibos phakic eye model 1. DOF 2014CT0003 and DOF2015CT0023. Chromatic aberration of the TECNIS Symfony IOL 2. DOF2016CT0029. Chromatic Aberration of the Tecnis Symfony IOL over the range vision

34 Continuous Vision TECNIS Symfony IOL provides continuous, high-quality vision at all distances TECNIS Symfony IOL delivers: Sustained mean visual acuity of 20/25 or better through 1.5 D of defocus Increase of 1.0 D range of vision throughout the defocus curve compared to a monofocal 1. TECNIS Symfony IOL DFU

35 Excellent Vision at All Distances 1 Monocular Distance Corrected vision with TECNIS Symfony IOL improved 2.4 lines for intermediate vision and 2.2 lines for near vision compared to the monofocal control TECNIS Symfony IOL DFU

36 Low Incidence of Halo and Glare Less than 3% of patients spontaneously reported incidence of severe night vision symptoms 1. TECNIS Symfony IOL DFU WARNING: Some visual effects associated with the TECNIS Symfony IOL may be expected due to the lens design that delivers elongation of focus. These may include a perception of halos, glare, or starbursts around lights under nighttime conditions. The experience of these phenomena will be bothersome or very bothersome in some people, particularly in lowillumination conditions. On rare occasions, these visual effects may be significant enough that the patient may request removal of the IOL.

37 Low Spectacle Wear 85% of TECNIS Symfony IOL patients wore glasses none or a little bit of the time* *Although the questionnaire was not determined to be a psychometrically valid assessment of the concept of spectacle independence, data showed that the Symfony IOL achieved the secondary effectiveness endpoint of reduced overall spectacle wear compared to the control monofocal IOL 1. TECNIS Symfony IOL DFU

38 Patient Satisfaction TECNIS Symfony IOL delivers high patient satisfaction 100% 98% 94% 80% 60% 40% 20% 0% Harmony (N=146) Concerto (N=411) Percent of patients who would recommend TECNIS Symfony IOL to friends and family 1,2 1. DOF2016CT0024 Concerto Study Report, 2. DOF2015OTH0009 Symfony Harmony Observational Study

39 Patient Discussions Explain Extended range of vision to them 1. TECNIS Symfony IOL DFU

40 Expectation Setting Conversations There is no perfect lens Distance to computer vision, ability to read a menu Expect to need reading glasses for small print If they don t use reading glasses it s a bonus They will likely need prescription RX for some time of the day, for some specific tasks Day one expect slightly blurry vision, Vision will improve once second eye is done You may notice starbursts around light sources more noticeable at night

41 Preoperative considerations Patient selection Manage expectations Halos/starbursts Dependence on spectacles No perfect lol Under-promise and over-deliver! PP2016CT1738

42 So How Can The Referring Doctors Maximize Success For Their Patients?

43 The Future of Cataract Management by the Optometrist- MANAGING THE OCULAR SURFACE Ocular Surface/Dry Eye Disease Work-up Meibomain Gland Dysfunction Lipiview Lipiflow

44 Future of Cataract Management by the Optometrist itrace or Corneal Topography Pentacam General topography irregular astigmatism, poor optical integrity of the cornea, accurate measurement of irregular astigmatism, map-dot fingerprint/abmd/ebmd, Fuch s Dystrophy Macular OCT ERM, AMD, edema, pseudohole/hole detection prior to surgery, Pre VS Post surgical changes Repeat during post op

45 Competitive advantage: The Future Comprehensive Optometric -Medical Care program One on one relationship with your PATIENTS Health and Wellness Philosophy of practice

46 Ocular Surface Wellness: The Opportunity Active maintenance of the Ocular Surface health supports patients long-term Vision quality Healthy-looking eyes Ocular comfort Successful Cataract surgery Cataract surgery can change the tear film dynamics and the ocular surface 46

47 Our Role in Optimizing Outcomes When needed, pre-treat the ocular surface Why prepare the ocular surface? Better topography images/improved Biometry (better K s) Potential for reduced risk of infection/less corneal staining More comfortable patient Faster healing Outcomes

48 Percentage of Patients Dry Eye Prevalence in Patients Scheduled for Cataract Surgery % of Patients Had Dry Eye Severity Score of Level 2 or Higher % 23.5% 11.0% 8.1% 3.0% Level 0 Level 1 Level 2 Level 3 Level % of patients had previously received a diagnosis of Dry Eye Disease 80.9% of patients had an ITF Dry Eye Level 2* or higher, based on the presence of signs and symptoms * An ITF level of 2 indicates moderate Dry Eye. 1. Trattler et al. Clinical Study Report: Cataract and Dry Eye: Prospective Health Assessment of Cataract Patients Ocular Surface Study (Unpublished study.)

49 Optimizing Vision Efforts to prevent or slow OS pathology help preserve vision Tear film irregularity can affect retinal image quality 16 DE patients experience Reduced contrast sensitivity 17 Fluctuating vision Impact on ease of daily activities (eg, reading, computer, driving, TV) 18 Discomfort after Cataract Surgery 49

50 Optimizing Vision for Ocular Surgery Candidates Refractive and cataract surgery patients have high expectations for postop comfort and vision Visual outcomes (and postop comfort) influenced by preop OS conditions It is our responsibility to prepare our patients for surgery 50

51 The Ocular Surface Objective Testing Can Be Insightful More variability in avg K and anterior corneal astigmatism was observed in the hyperosmolar group, with significant resultant differences in IOL power calculations* *Epitropoulos AT, et. al. J Cataract Refract Surg Aug;41(8): Osmolarity > 322 altered post-op refraction result by d

52 Hot Spots and Flat Spots Are Abnormal 52

53 Irregularly Shaped Or Smudgy Placido Disk Is Abnormal 53

54 Take A Closer Look If Average K Values Are Different 54

55 Post-Dry Eye Treatment: K Values Are Much More Similar 55

56 Threats to Ocular Surface Wellness: Dry Eye and Blepharitis DE and blepharitis among the most common conditions eye physicians encounter 43,44 Using a very restrictive definition, DE affects nearly 5 million Americans aged 50 and older 44 Eye care practitioners may see blepharitis in ~40% of patients 45 56

57 Threats to Ocular Surface Wellness: Dry Eye and Blepharitis Blepharitis comprises a number of inflammatory eyelid conditions and comorbidities 46 Dry eye Chalazion Hordeolum Conjunctivitis Keratopathy MGD (a form of blepharitis) may be the most common cause of evaporative DE 45,47,48 57

58 Threats to Ocular Surface Wellness: Medication Use Some common systemic meds increase risk of DE symptoms Antihistamines Antianxiety medications 63,64 Antidepressants 63,64 Diuretics 62,64 Oral corticosteroids Novartis 58

59 To Maintain and Restore Wellness Look for and Treat Problems Meibomian gland dysfunction Lagophthalmos Epithelial membrane basement dystrophy Conjunctivochalasis Aqueous-deficient dry eye Blink pattern deficiencies Keratitis Stem cell deficiency Tear film abnormalities 2014 Novartis 59

60 Make Use of New Ocular Surface Diagnostic Technology New tests add useful information Tear osmolarity Tear MMP-9 level Interferometry Incomplete blink Gland expression Sjogren s antibody testing Topography Meibography Enable detection of early-stage disease processes and monitoring of the tear film 2014 Novartis 60

61 Discussion Questions How do you communicate to patients the value of a premium IOL? When speaking to patients what are the indicators you look for that give you confidence the patient is a good candidate? What are the most common challenges you face with patient conversion and how do you address? 61 PP2015CT0370

62 What Is The Proper Co-Management Arrangement? Post Op visit Day 1 or Week 1? Co-Management Codes Premium Services Upcharge -

63 Explain Neuroadaptation EDOF is a DIFFERENT kind of lens The brain needs to get used to the extended depth of focus optics Help patient understand how EDOF technology works Emphasize that the goal is to achieve QUALITY of vision Explain that there s always a trade-off You may continue to need reading glasses on occasion, but you will have a greater range of vision PREPARE the patient not to expect vision to be perfect at Day 1

64 Post-Op Considerations Similar to post-op care of standard cataract extraction Topical antibiotic, NSAID and steroid 1 Day, 1 Week, 3 Weeks, 3 Months The Biggest Challenge Is Managing Patient Expectations Reinforce Neuroadaptation Reinforce need for Prescription Eyeglasses Reinforce the Concept Of High Quality Vision What Is The Biggest Post-Operative Complication For These Patients?

65 Good Perioperative Management Relationships Are Built on Mutual Respect Communicate up front/define roles and expectations Select surgeons whose philosophies match your own Communicate your knowledge of the patient to the MD Visit the OR and schedule regular conversations Trade cell phone numbers; you need to be able to reach each other at any time Share all Pre-Op and Post-Op findings

66 More Discussion Questions Why aren t these new technologies being embraced by OD s? How do you handle the co-management fee and upcharges? What techniques can we employ to increase utilization of Premium IOLs?