Premium Implant Options for the Cataract Patient Justin Schweitzer, OD, FAAO Vance Thompson Vision Sioux Falls, South Dakota
Glaukos Bausch and Lomb Alcon Allergan Bio- Tissue TearScience Reichert
Trends In Cataract Care Innovations preop, surgery and postop IOL technologies Higher patient expectations for visual outcome Standard Cataract Surgery vs Advanced Cataract Surgery
When Is A Cataract Visually Significant?
Cataract Surgery is not just Rehabilitative Surgery
Cataract Surgery is Refractive Surgery
What Do We Look For in a Cataract Evaluation
Age and Dominant Eye Reassure if young Important for monovision, doing a multifocal tandem and IOL calculation target
MRx, BCVA and Glare Acuity Myope, Hyperope or Astigmat BCVA Glare Test Most important indicator of how cataract is affecting vision and function
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
Dry Eye Evaluation Tear Lab Lipiview or Lipiscan
Slit Lamp Exam Lids Cornea Lens Vitreous
OCT Optic Nerve Retina and Macula
Refractive Considerations Refractive Endpoint Monovision Nearpoint target Distant target
Refractive Considerations Astigmatism typically pre- op and post- op corneal astigmatism are similar Other considerations placement of incision toric IOL Laser vision correction
Refractive Considerations Discuss monofocal vs toric vs presbyopia correcting IOLs
Refractive Laser Assisted Cataract Surgery (ReLACS) or Femtosecond Laser- Assisted Cataract Surgery (FLACS)
Is Femto Helpful? Standard Complex ReLACS
How Does Femto Help? Decreased Ultrasound Energy (30%) Reproducibility Rhexis Incisions Astigmatic Keratotomies Effective Lens Position? Refractive Outcomes?
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):1053-1060
Centration Stability Symmetric capsular forces Asymmetric capsular forces
Effective Lens Position with Premium Lens Three Month Variability in Effective Lens Position (ELPo) 0.84 Standard Deviation (mm) 0.82 0.8 0.78 0.76 0.74 0.72 LenSx (n=31) Manual (n=30) *Using Warren Hill ELPo Calculator http://doctor- hill.com/iol- main/elp.htm p=< 0.05 22
Chang, D. (2016, May). Perfecting CAPSULOTOMY. Ophthalmology Times, 41(8), 1.
Intraoperative Aberrometry (ORA) ORA System Optiwave Refractive Analysis Aphakic Refraction Toric Implants Surgically Induced Astigmatism Posterior K Astigmatism
Why trust Aberrometry? Surgically Induced Astigmatism Posterior Corneal Curvature The Data
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
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
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.
TLACS 12 YO Male VA HM Traumatic Cataract from stick injury 2 weeks prior
Is Femto Meaningful? Standard Complex ReLACS Not Yet Yes Probably
Toric Tecnis Toric, AcrySof IQ Toric Cylinder powers 0.75-4.11 Residual astigmatism can be a problem Rotate IOL Laser Fine Tune LRI s Glasses or Contacts
Astigmatic Keratotomy vs. Limbal Relaxing Incision AK central = bigger effect 1:1 LRI Peripheral = less effect Hyperopic Shift
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
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 2.05 30deg 100% 1.03D 4.11D
Residual Astigmatism Toric Misalignment of T9 0 5 10 15
Other Piece of the Puzzle
Implant Options
ReSTOR +2.5 w/ ACTIVEFOCUS ReSTOR 2.5 w/ ACTIVEFOCUS Toric Central portion 100% dedicated to distance
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.
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
Tecnis Monofocal Tecnis Multifocal Tecnis Symfony EDOF
Symfony EDOF
Light Adjustable Lens- What s Special? regular silicone polymers + mobile, silicone subunits, called macromers photosensitive
Adding Power to the LAL Iris light light lock-in Increased power => change in radii of curvature => change in power
The LAL FDA Clinical Trials Accuracy No patient seeing less than 20/20 uncorrected
Patient Satisfaction = Results - Patients Expectations
Thank You! justin.schweitzer@vancethompsonvision.com