Making Cataract Surgery Refractive Surgery

1
Making Cataract Surgery Refractive Surgery

• Eric E. Schmidt, O.D.
• Bladen Eye Center
• Elizabethtown, NC

2
Cataract Surgery

• It is considered to be the most successful
  surgery in the world! SO..
• Why do we want to mess with success?
• Whats all the fuss about?
• What do we really want to achieve?

3
Goals Of Surgery

• Visual improvement maximum achievable visual
  acuity
• 20/20 w/out eyeglasses!
• No anisometropia
• Remember though 20/20 may not always be possible
• Plano may not always be the best desired end
  point

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Uncorrected 20/20 begins with you

• Choosing the right surgeon
• Counseling your patient
• Keep abreast of new stuff
• Guide your surgeon to become proficient at new
  stuff
• Keep your staff up-to-date on the new stuff
• Identify patients who would benefit from new
  stuff
• You need to understand that cataract surgery
  should be considered refractive surgery

5
Why Bother With Co-Management?

• Enhance px success
• Continuity of care
• Logistic concerns
• They are your patients
• Builds practice image
• It is certainly not a monetary issue!!!

6
Pre-operative procedures

• Set realistic goals for each individual patient
• Perform detailed binocular refraction
• Determine desired endpoint for the patients
  visual system
• Choose the best procedure to achieve this
• Perform all the necessary pre-op tests
• A-Scan
• PAM
• BAT
• DFE
• Retinal imaging
• Wavefront testing

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Pre-operative management

• Px counseling
• Describe the procedure, anesthesia
• Describe the post-op course
• Choose the surgeon
• Schedule the appt
• Pre-op regimen
• Prescribe the pre-op meds
• Discuss case w/ surgeon

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A-Scan

• Biometry- this is the key to choosing the correct
  IOL power.
• IOL chosen based on desired endpoint refraction,
  axial length and keratometry
• A-Scan ultrasound very easy to perform
• CPT code 76516 76519
• Should this be done by the referring OD?

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IOL MASTER

• Zeiss
• Not ultrasonography
• High resolution partial coherence interferometry
• Easy to perform (lt1minute, non-contact)
• Yields extremely precise axial length (0.02mm),
  white-to-white, AC depth (/- 0.1mm) and
  keratometry
• Costs more, same reimbursement, but allows us to
  pinpoint endpoint refractive error.

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IOL MASTER

• Traditional SRK and Holladay Formulas, but ..
• Haigis formula
• Surgeon specific
• IOL specific
• Allows a new level of mathematical flexibility in
  calculating IOL power
• Greatly increases accuracy and precision as
  compared to A-scan

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IOL Master

• This renders a 5-fold increase in accuracy
• Solves some A-scan issues
• Posterior staphyloma
• Long eyes (gt24.5mm)
• Short eyes (lt22mm)
• Silicone oil
• Asteroid hyalosis

12
Cataract Surgery- Weve Come A Long Way Baby!

• ICCE
• ECCE
• Phacoemulsification
• No-stitch, no patch

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Surgical Incisions

• Is one type really better than another?
• Scleral tunnel
• Clear cornea
• Micro-incision (1mm)

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Phacoemulsification

• No new advances in this until now!
• 2 new instruments
• Less energy, less heat
• No need for irrigation
• Sleeveless allows for micro-incisions
• Capsulorhexis technique is very important

15
Current Phaco Energy Sources

• Ultrasound
• Efficiently emulsifies cataracts of any hardness
• Rapid motion of phaco tip creates friction/heat
• Laser
• Efficiently emulsifies only 1 or 2 cataracts
• Rests between laser bursts allow cooling
• Sonic
• Efficiently emulsifies only 1 or 2 cataracts
• Less tip motion and friction/heat than ultrasound

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Micro-incisions need micro IOL!!!

• Super thin IOL
• Injectable IOL
• Liquid IOL
• Lens refilling procedure

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Post-operative regimen

• Not much new to talk about EXCEPT
• The incidence rate of endophthalmitis is tripling
• 0.66 in clear cornea
• 0.25 in scleral tunnel
• Can we prevent this?
• Why is this happening?

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Post-operative regimen

• Antibiotic 4th generation fluoroquinolone QID
• Steroid prednisolone acetate 1 QID (or more)
• NSAID
• Intraocular steroid Dex DSS
• Post-op visits
• 1 day
• 1 week
• 3-4 weeks (DFE)

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Clear Corneal Incisions Dont Leak

• They Suck!!!!

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Endophthalmitis

• Increase due to natural endogenous flora from
  lids
• 75-90 gram positives
• Staph. Epidermidis (42)
• Staph. Aureus,Enterococcus
• Pay close attention to the lids pre- and
  post-operatively

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To reduce endophthalmitis incidence

• Fluoroquinolone QID 4 days prior to surgery
• Lid scrubs if needed
• Artificial tears
• Betadine prep peri-operatively
• May need to leave px on topical antibiotics
  longer post-operatively
• Orals ??

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Post-op concerns

• Glare and haloes
• Internal reflections
• Anisometropia
• 2nd eye management
• Post. Capsule opacification

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What About Astigmatism?

• Toric IOL
• Astigmatic Keratotomy
• Who are candidates?
• Are there refractive limitations?
• What can the patient (and us ) realistically
  expect?

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Toric IOL

• STAAR Surgical silicone plate lens
• Corrects 1.4 2.3 D of cyl at the spectacle
  plane
• Corrects the astigmatism at the nodal point
• Lessens distortion
• Better qualitative visual acuity
• Improved contrast sensitivity
• There are some axis considerations

25
Toric IOL Success

• Depends upon
• Surgical skill the surgery must be
  astigmatically neutral
• Proper IOL positioning
• IOL maintaining a stable position in the bag
• Aggressive post-operative monitoring

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Toric IOL

• Post-op considerations
• Must be able to detect IOL rotation
• If this occurs it must be corrected by 3 weeks
• IOL may have to be rotated by surgeon
• Patient must be dilated at 2 weeks to detect this

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Astigmatic keratotomy

• Relaxing incision made nasally
• Shallow (lt150 microns)
• Useful for pre-operative WTR cylinder
• -1.00 to -2.50 cylinder
• How effective is it?

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Astigmatic Keratotomy

• When should you recommend it?
• Plano in other eye
• Px does not like to wear specs
• CL wearer
• Those picky patients
• WTR cylinder (170 010)
• High cylinder pxs
• Post-op considerations

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Astigmatic keratotomy

• What are the drawbacks?
• Poor predictability
• Limited range of correction
• Post-operative FB sensation

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So an optometrists walks into an exam room to see
a post-op px

• O.D.- Howre those eyes doing Mr. Jones?
• Px Not so great.
• O.D. Whaddaya mean , not so great? Youre
  seeing 20/20 in each eye without glasses!
• Px Yeah, but I cant see my newspaper!

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What to do about presbyopia?

• Monovision IOL
• Presbyopic Lens Exchange (PRELEX)
• Multifocal IOL
• Accommodating IOL

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Multifocal IOL options

• Monovision
• Refractive
• Diffractive
• Accommodative

33
The Ideal Multifocal IOL Patient

• Baby Boomer
• 50s to the mid 60s
• Cataract starting to compromise quality of vision
• Active lifestyle
• Concerned about their appearance quality of
  life
• Do not want to get old
• Spending billions on lifestyle enhancing
  procedures
• Realistic Expectations
• Motivated
• Asks lots of questions

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Whos A Candidate? / Clinical

• Hyperopic
• Loss of accommodation
• Cataract
• Unilateral traumatic cataract
• Congenital cataract
• Astigmatism (can be corrected)
• High myopes (surgeon preference)

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Whos A Candidate? / Motivation

• Wants to be less dependent on glasses
• Understands the limitations of the Array visual
  system
• Willing to accept several months to adapt to
  their new visual system

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Whos Not A Candidate?

• Significant dry eyes
• Corneal scarring
• Mild to moderate myopia
• Pupil size lt 2.5 mm
• Monofocal implant in first eye
• Uncorrected post-op astigmatism gt 0.5 D
• Unstable capsular support
• Someone who demands perfect vision

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ReZoom Multifocal IOL (AMO)

• Refractive lens
• 2nd generation acrylic IOL
• Delivers good near, distance and intermediate
  vision

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Is The ReZoom Perfect?

• The most common concerns
• Distance blur
• Monocular diplopia
• Object glow
• Ghosting
• Halos at night
• These are the biggest post-op challenges

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Acrysof ReStor IOL (Alcon)

• Diffractive technology
• Silicone material
• Uses apodization to soften blur and sharpen
  vision
• Provides excellent VA at near, distance and
  intermediate ranges

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Strengths of the AcrySof ReSTOR IOL

• High quality uncorrected near and distance vision
  with 20/40 or better intermediate vision without
  movement of the IOL
• 80 Overall Spectacle Freedom
• Nearly 94 of patients would have the lens again

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Aspheric Multifocal IOL Technology
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Do We currently have any aspheric multifocal IOLs?

• Tecnis multifocal (AMO)
• Sofport AO (Bausch Lomb)

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Explain the WOW! Factor(or lack thereof)

• Haloes and glaare at night are common- these
  diminish with time
• Longer adaptation period may take weeks or
  months for pxs to accept their new visual
  system
• Near vision may be fuzzy to myopes
• May need reading specs for prolonged nearpoint
  work

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Accomodative IOL

• Crystalens- eyeonics
• Silicone IOL with hinged optics
• IOL moves forward or back depending on ciliary
  muscle tone
• Implanted using phaco technique
• Capsulorhexis is critical
• Pre-op biometry crucial

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Enter Accommodating Lens
A New Paradigm In Vision Correction

• The first accommodating lens technology approved
  as safe effective by the Food Drug
  Administration
• Manufactured by eyeonics
• A USA company
• The lens uses the natural focusingability of the
  eye to provide a single focal point throughout a
  full range of vision from far, through
  intermediate to near seamlessly

(In contrast with multifocal IOLs which use a
dual simultaneous focus or monovision where one
eye is set for distance one eye for near)
eyeonics crystalens
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The Ideal Crystalens Patient

• Baby Boomer
• 50s to the mid 60s
• Cataract starting to compromise quality of vision
• Active lifestyle
• Concerned about their appearance quality of
  life
• Do not want to get old
• Spending billions on lifestyle enhancing
  procedures
• Realistic Expectations
• Motivated
• Asks lots of questions

47
Crystalens Post-Op Considerations

• 1 Atropine day of surgery 1 day PO
• Otherwise standard post-op regimen
• Distance vision stable 1 week
• Near vision begins to return _at_ 2 weeks
• No significant glare or halos after 10 days
• Must follow more often

48
Crystalens Post-op

• Post-op 10-14 days post-op
• Keratometry
• Uncorrected distance and near visual acuity
• Controlled maximum plus refraction
• Distance and near visual acuity through distance
  correction
• Gradual Plus Build-up to J1 to determine add.
• Verify refractive findings with cycloplegic
  refraction

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Spectacle Use Survey
Bilateral Implanted Subjects
Wearing Spectacles n/n ()
I do not wear spectacles 33/128 (25.8)

73.5
Almost none of the time 61/128 (47.7)
26 to 50 of the time 20/128 (15.6)
51 to 75 of the time 8/128 (6.3)
76 to 100 of the time 6/128 (4.7)
Night Spectacles n/n ()
No 110/128 (84.6) Yes 20/130 (15.4)
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Is There A WOW Factor?
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Cataract Surgery- Whats on the horizon?

• Adjustable IOL-
• Material is fixed w/ laser to -0.75
• Take to phoropter, refract to plano
• Fix that w/ longer laser light
• ICL
• Clear Lens Extraction
• Impeller extraction technique
• Lens filling system