Learn Connect Succeed JCAHPO Regional Meetings 2017
Cataract Surgery in 2017 DARBY D. MILLER, MD MPH CORNEA, CATARACT AND REFRACTIVE SURGERY ASSISTANT PROFESSOR OF OPHTHALMOLOGY MAYO CLINIC FLORIDA Natural lens becomes cloudy Light scatters throughout the eye instead of focusing on the retina Causes Aging Diabetes Steroid use Injury/trauma Genetics Cataracts Symptoms of Cataracts Slowly worsening near and distance vision Vision is not correctable with glasses Glare, particularly at night while driving Needing more light when reading Halos around lights Double vision in one eye Fading or yellowing of colors Sensitivity to light Types of Cataracts: Nuclear Sclerosis (most common) 1
Types of Cataracts: Cortical Types of Cataracts: Posterior Subcapsular Cataract Surgery When do I need surgery? When the negative impact on vision compromises the patient s lifestyle May effect driving, watching television, playing golf or tennis, reading Generally occurs when vision approaches 20/40 or worse Risks of Cataract Surgery Low complication rate overall Risks include Bleeding Infection Elevated intraocular pressure Retinal tear or detachment Dropped lens requiring further surgery Droopy eyelid Loss of vision or loss of eye Inflammation Posterior capsular opacification, aka Secondary cataract Visits and Medications Visits: Pre-op visit for testing Astigmatism, lens discussion Day of surgery Post-op visits: 1 day, 1 week and 1 month after surgery Medications (drops): Antibiotic drop for 1 week Anti-inflammatory drop taken for 5 weeks with slow taper What to expect the day of surgery Outpatient procedure in Mayo Hospital Light IV sedation with topical anesthesia Surgery takes approximately 30 min Hospital time is around 3 to 4 hours Should not have any discomfort during surgery Clear shield over the eye after surgery 2
Standard Cataract Surgery: Phacoemulsification Laser-assisted Cataract Surgery (LACS) Intraoperative OCT Photodisruption: air bubbles FDA approved Standard vs. Laser-assisted Cataract Surgery Laser assisted cataract surgery in specific patients Fuchs Dystrophy Pseudoexfoliation History of trauma Flomax with good dilation White cataract Narrow angles Previous vitrectomy Dense cataracts FLACS Advantages: Capsulotomies Clinical studies (in vitro and in vivo) indicate that capsulotomies created with the femtosecond laser are significantly more precise in size and reproducibility Continuous curvilinear capsulorhexis (CCC) created with a femtosecond laser results in a more stable refractive result with less IOL tilt and decentration than a manual CCC FLACS Advantages: Lens Fragmentation Less effective phacoemulsification time is needed to emulsify the lens following lens fragmentation by the femtosecond laser Less endothelial cell loss due to the shorter phacoemulsification times and less fluid entering and exiting the eye during surgery Beneficial in complex cases such as hypermature cataracts or loose zonular fibers in which less energy expenditure would potentially provide a much better patient outcome 3
FLACS Advantages: Incisions Masket et al. demonstrated greater architectural stability and reproducibility with femtosecond laser assisted corneal incisions in cadaver eyes Ability to precisely treat astigmatism with astigmatic keratectomies which can be titrated post operatively FLACS Advantages: Macular Edema Nagy et al. compared subclinical macular edema after uneventful femtosecond laser assisted cataract surgery versus conventional surgery The study demonstrated small but statistically significantly less thickening of the outer nuclear layer of the retina following femtosecond laser assisted cataract surgery than following conventional phacoemulsification FLACS Disadvantages In terms of secondary surgical end points, there was a statistically significant difference in favor of FLACS over MCS for: Effective phacoemulsification time (WMD, 3.03; 95% CI, 3.80 to 2.25; P < 0.001) Capsulotomy circularity (WMD, 0.16; 95% CI, 0.11e0.21; P < 0.001) Postoperative central corneal thickness (WMD, 6.37; 95% CI, 11.88 to 0.86; P = 0.02) Corneal endothelial cell reduction (WMD, 55.43; 95% CI, 95.18 to 15.69; P = 0.006) Cost Not covered by insurance Out of pocket expense to patient Not every patient is a candidate Studies showing Similar visual outcomes Variable complication rates Not cost effective Ophthalmology 2016; 123:178-182. Table 4: Perioperative Complications No clinically meaningful visual benefit of FLACS over PCS Mean BCVA slightly better with FLACS FLACS 20/24.5 vs. PCS 20/26.4 Although UCVA better with PCS Authors explanation for data LCS with better baseline VA Higher toric IOL percentage in FLACS Complication rate much higher with FLACS FCS does have clear clinical benefits (for zonular compromise, compromised corneas, mature cataracts), but is not cost-effective 4
Table 5: Postoperative Complications All ocular HTN, corneal edema and CME resolved by post op month 6 with medical therapy Randomized, prospective clinical trial with over 2000 patients in France with 12 months of follow up. Good visual acuity with LCS Refractive error less than 1D in 95% Less than 0.75D in 82% Less than 0.5D in 68.9% Less than 0.25D in 47.5% LCS with higher complication rates 16.7% overall Posterior capsular rupture: 3.3% Corneal edema: 3.3% Leaking corneal incision: 9.5% Ocular HTN: 0.9% Certain patients may NOT be candidates for LACS Corneal pathology Scar ABMD Keratoconus Small pupils (do not dilate) Deep set orbit Small interpalpebral fissure Prominent brow History of glaucoma surgery Discussion with your doctor Options Traditional cataract surgery vs. Laser assisted cataract surgery (LACS) LACS is an option If interested, the doctor will make sure you are a candidate for surgery Cost: LACS is not covered by insurance Intraocular lens options Monofocal, toric, multifocal Combined procedures Glaucoma, Retina, Cornea, etc. Types of Intraocular Lenses (IOLs) Monofocal IOL Monofocal Standard IOL, covered by insurance Clear distance, reading glasses for near vision Toric Monofocal and corrects astigmatism Not covered by insurance Multifocal and accommodative Corrects distance and near but not astigmatism Technology limited, still need readers for fine print Not covered by insurance Toric multifocal 5
Toric IOL Corrects astigmatism Still need reading glasses Accommodative IOL Multifocal IOLs Toric Multifocal IOLs ReStor By Alcon Tecnis By AMO Intraoperative aberrometry Why intraoperative aberrometry? Refractive surgery is commonly performed worldwide More than 1 million surgeries per year and 16 million surgeries to date The number of patients requiring cataract surgery after prior refractive surgery is growing Selection of the correct IOL power for these patients presents a challenge for the cataract surgeon In one study, >45% of eyes will fall outside ±0.5 D of the intended target refraction Intraoperative aberrometry Optiwave Refractive Analysis (ORA) System HOLOS System Employs intraoperative refractive biometry to measure axial length and keratometry Determines aphakic refraction and IOL power using a proprietary formula based on anatomic measurements for estimation of anterior chamber depth 6
Intraoperative aberrometry study at NYEEI (ASCRS 2015) IRB (ORA system) predicted IOL power more accurately than PCI (IOL Master) in post-myopic LASIK eyes Although not statistically significant, IRB is beneficial in predicting IOL power in virgin eyes IRB is particularly useful for predicting IOL power in high myopic or high hyperopic virgin eyes IRB can be used to confirm PCI calculated IOL powers (ie dense lens where PCI measurements may be unreliable) Combined procedure with cataract surgery Cornea Corneal transplants Glaucoma Trabeculectomy Trabectome Ahmed valve MIGS Retina Retinal detachment Epiretinal membrane After Cataract Surgery Vision clears over first 1-3 days after surgery Mild discomfort first 1-2 days after surgery Scratchy or itchy feeling Mild soreness Redness Wear clear shield when sleeping Limitations No vigorous exercise No heavy lifting or bending over No pool, spa, or ocean THANK YOU! QUESTIONS? Mayo Clinic Florida Ophthalmology 7