Hitting Refractive Targets The Lens Approach

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Cuthbert Blake
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2 Hitting Refractive Targets The Lens Approach Mark Packer, MD, FACS Clinical Associate Professor Department of Ophthalmology Oregon Health & Science University Drs. Fine, Hoffman & Packer, LLC Eugene, Oregon

3 Mark Packer, MD Financial Disclosure February 15, 2010 Abbott Medical Optics, Inc. Advanced Vision Science, Inc. Bausch & Lomb Surgical, Inc. Carl Zeiss Surgical, Inc. Celgene, Inc. GE Healthcare Haag-Streit USA Ista Pharmaceuticals Rayner Intraocular Lenses, Ltd. Surgiview LLC Transcend Medical, Inc. TrueVision Systems, Inc. WaveTec Vision Systems

$Refractive$

4 D Est Cataract Surgery Refractive Lens Exchange

6 Drivers of Satisfaction Knowledge of available IOLs Understanding of patient goals Communication of expectations Accurate preoperative measurements Meticulous surgical technique

7 Drivers of Satisfaction Knowledge of available IOLs

9 Lens Factors Affecting Spectacle Independence Pupil-independence: Full diffractive surface Crisp vision: Zero spherical aberration Lower chromatic aberration Full blue light transmission Range of vision: High-quality intermediate without sacrificing near vision

10 MTF at 50c/mm Full Diffractive Surface = Pupil Independence NEAR VISION TECNIS Multifocal 3-Piece TECNIS Multifocal: Light remains equally distributed between near and distance as the pupil size increases ReSTOR aspheric Pupil diameter (mm) ReSTOR: The apodized diffractive design becomes more distancedominant as the pupil widens, reducing visual quality for near.

$provides 3 points of fixation: Refractive predictability Long-term stability Centration 3-points of fixation Anterior$

11 Updated Single Piece Design The 360 square edge limits LEC migration at the haptic-optic junction Offset haptic design provides 3 points of fixation: Refractive predictability Long-term stability Centration 3-points of fixation Anterior Posterior

12 Lens Glistenings Image courtesy of Dr. Wittpenn Small lens vacuoles Temperature changes allow water to collect in gaps Injection molded vs. lathe-cut material Visible due to differences in refractive index Incidence of vacuoles range from 30% to 100% 1-3 Up to 25% show visual acuity detriment 3 1-Gunenc U, Oner FH, Tongal S, Ferliel M. Effects on visual function of glistening and folding marks in AcrySof intraocular lenses. J Cataract Refract Surg 2001;27(10): Moreno-Montañés J, Alvarez A, Rodríguez-Conde R, Fernández-Hortelano A. Clinical factors related to the frequency and intensity of glistening in AcrySof intraocular lenses. J Cataract Refract Surg 2003;29(10): Christiansen G, Durcan FJ, Olson RJ, Christiansen K. glistening in the AcrySof intraocular lens: Pilot study. J Cataract Refract Surg 2001;27(5):

14 Drivers of Satisfaction Understanding of patient goals Communication of expectations

15 Physician Time with Patients 56 bilateral cataract patients Monofocal (32) Multifocal (13) Accommodative (11) Packer M. Physician Chair Time and Premium IOLs. ASCRS Paper Session 2-B: Intraocular Surgery, Accommodating IOLs. American Society of Cataract and Refractive Surgery Symposium on Cataract, IOL and Refractive Surgery. 3 8 April 2009, San Francisco, CA.

16 Mean Pre Op Physician Time Monofocal (32): 14.4 min Multifocal (13): 11.8 min Accommodative (11): 16.4 min

17 Mean Post Op Visits (90 days) Monofocal (32): 5.2 Multifocal (13): 4.3 Accommodative (11): 4.4

18 Mean Post Op Time per Visit Monofocal (32): 5.0 min Multifocal (13): 5.5 min Accommodative (11): 7.7 min

19 Total Post Op Time (90 days) Monofocal (32): 26.7 min Multifocal (13): 25.5 min Accommodative (11): 34.8 min

20 Drivers of Satisfaction Accurate preoperative measurements

22 For A-scan I use most often Applanation (contact) % Immersion (noncontact) % Partial Coherence Interferometry (IOL Master) % Leaming D Survey of ASCRS Members.

23 Preferred method of Keratometry for IOL calc? Manual % Auto K % IOL Master % Topography/ corneal analyzer % Preferred method of keratometry for Toric IOL calc? Manual % Auto K % IOL Master % Topography/corneal analyzer % What IOL power formula do you primarily use? SRK 4 0.7% SRK II % SRK/T % Holladay % Holladay % Haigis %

26 Preoperative Measurements Immersion Ultrasound IOL Master Partial coherence interferometry measures axial length Keratometry, anterior chamber depth and corneal white-to-white measurements

28 Optical Low Coherence Reflectometry (OLCR) SLD 820 nm interferometry Simultaneous measurements Alignment on visual axis

29 Lenstar --- One Touch Keratometry: 32 markers White to White Distance Pachymetry: ± 2 μ Anterior Chamber Depth Lens Thickness Pupillometry Axial Length Eccentricity of Visual Axis Retinal Thickness

30 IOL Calculations Holladay 2 formula Takes into account disparities in anterior and posterior segment sizes IOL Consultant provides regression analysis and customization

32 ORange Aberrometer Talbot moire interferometry Fourier transform Calculation of spectacle correction

38 Postoperative Characteristics Group 1 Group 2 Mean Sphere Mean MRSE Median UCVA 20/25 20/25 MR Cyl D 10 (27%) 7 (23%) 1.00 D 9 (24%) 2 (6.6%) 1.25 D 4 (11%) 1 (3.3%)

40 Post Op MR Cyl Group 2 (LRI enhanced): K v MR Cyl ORange LRI-ENH Pre Op Delta K

41 Comparison of Enhanced Eyes Non-ORange w/lasik enh n = 6/37 (16.2%) ORange w/lasik enh n = 1/30 (3.3%) ORange w/lri enh n = 8/30 (26.7%) Age:Mean, SD Pre-Op Delta K 1.70 D ( ) 2.61 D 1.75 D ( ) Steep Axis 95º 78º 82º Pre-op 10mm Pachymetry 664 microns 658 microns 655 microns 1.45 D 1.00 D 0.31 D Post LRI ( ) 1 month 1 month ( ) 1 month (n = 6) (n = 1) (n = 8) Post LASIK D 7-16 months (n = 6) 0.42D 6 months (n = 3)

42 ORange Aberrometer Intraoperative wavefront guided enhancement of LRIs reduced the rate of postoperative excimer laser enhancement from 16.2% to 3.3%, an odds ratio of 5.71 (p=0.12).

43 Achieved Correction, D 10 Intended v Achieved Correction crystalens, n = Intended Correction, D

44 Refractive Enhancement PRK/L ASIK Piggyback IOL

45 Piggyback IOLs AQ 5010, CLRFXB HolladayR 1 D 0.7 D Spectacle Plane

47 Crystalens AT-45 RLE Piggybacks 15.7 % (13 of 83) Excluding planned primary or secondary piggybacks and post RK / LASIK eyes

48 Piggyback Outcomes 13 eyes of 8 women, 2 men Pre Op RLE UCDVA 20/280 (20/25 20/800) BCVA 20/22 (20/15 20/40) Mean SE ( ) D

49 Piggyback Outcomes Post Op RLE Mean UCDVA 20/52 (20/25-20/200) Mean UCNVA J 9.5 (J 1 J 16) Mean SE ( ) D Post Op Piggyback Mean UCDVA 20/23 (20/15 20/40) Mean UCNVA J 3.6 (J 1 J 10) Mean SE ( ) D

50 Piggyback IOL Considerations Residual astigmatism Anatomy AC Depth Capsulotomy Available powers Intraocular procedure Cost Risk

51 Piggyback IOL Advantages Rapid rehabilitation Excellent predictability Familiar techniques No additional incisions No ocular surface issues No microkeratome/excimer

52 Future Directions Post LASIK IOL Calculations Direct links to EMR Real time digital imaging & measurement

53 Drivers of Satisfaction Meticulous surgical technique

54 Thank You!

Incision along Steep Axis

Toric IOL An option or a must? ~ 15% cataract surgical patients >1.5 D Options: spectacles, CLs, Incision along steep axis, LRI, AK, toric IOL, Excimer Laser or a combination Walter J. Stark, MD Professor