The Promise of No Glasses

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Laurence Greer
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1 The Promise of No Glasses 4/10/2016 JTH 1 or Contact Lenses! Jack T. Holladay, MD, MSEE, FACS Clinical Professor of Ophthalmology Baylor College of Medicine Houston, Tx Financial Disclosure I have the following financial interests or relationships to disclose: Abbott Medical Optics: C; AcuFocus, Inc.: C,O; Alcon Laboratories, Inc.: C; ArcScan: C,O; Carl Zeiss Inc: C; Elenza: C,O; Oculus, Inc.: C; Visiometrics: C,O; Wavetec: C AMERICAN ACADEMY OF OPHTHALMOLOGY 0 4/10/2016 JTH 5 Handouts 7 4/10/2016 JTH 6 Centration Accurate Biometry Optical (IOL Master or LenStar) 4/10/2016 JTH 7 Multifocal IOL Optimal Location Cannot place on Pupil Center & Visual Axis (near P1) where axial ray is perpendicular to foveola. Optimal location is different for each patient and somewhere between Pupil Center & P1. 4/10/2016 JTH 8 Clinical Angle Kappa Pupil Center to Visual Axis NOSE Jack T. Holladay MD MSEE FACS Page 1 of 9

2 Horizontal Angle & Alpha & Kappa < α < Κ Good centration, optimal optical performance? OC PC VA Decentration: halos Poor vision for far and near Courtesy Paolo Vinciguerra M.D. 4/10/2016 JTH 9 4/10/2016 JTH 10 Courtesy Paolo Vinciguerra M.D. 4/10/2016 JTH 11Diffraction Rings are perfectly concentric with patient s pupil 4/10/2016 JTH 12 4/10/2016 Jack T. Holladay, MD, MSEE, FACS 4/10/2016 Jack T. Holladay, MD, MSEE, FACS 4/10/2016 JTH 13 9 T S1 SS7 4/10/2016 JTH 14 9 T S1 SS7 Jack T. Holladay MD MSEE FACS Page 2 of 9

3 N = 37 Zero = 25 Non zero = 12 (R 2 = 0.26, P = 0.029) Regression plot between the photic phenomenon of haloes (x axis) and the kappa angle (y axis). N = 37 Zero = 30 Non zero = 7 (R 2 = 0.26, P = 0.033) Regression plot between the photic phenomenon of glare (x axis) and the kappa angle (y axis) Horizontal Angle & Alpha & Kappa < α OC PC < Κ VA BEST CENTRATION OF IOL Horizontal Angle & Alpha & Kappa Angle Kappa on IOL Master, LenStar and penlight ~ 0.33 mm < Κ If > 0.70 mm then concern! VA PC Karhanová M, Marešová K, Pluháček F, Mlčák P, Vláčil O, Sín M. Cesk Slov Oftalmol. The importance of angle kappa for centration of multifocal intraocular lenses Jun;69(2):64-8. [Article in Czech] G Prakash, DR Prakash, A Agarwal, DA Kumar, A Agarwal and S Jacob. Predictive factor and kappa angle 4/10/2016 JTH 18 analysis for visual satisfactions in patients with multifocal IOL implantation. Eye (2011) 25, Ideal Location Left Eye LENSTAR HAAG-STREIT Between Pupil Center and Purkinje Image 1 (Vertex Normal Light Reflex) Slightly NASAL to Pupil Center (~ 0.15 mm) 4/10/2016 JTH 20 4/10/2016 Jack T. Holladay, MD, MSEE, FACS 4/10/2016 JTH 19 Jack T. Holladay MD MSEE FACS Page 3 of 9

4 IOL MASTER 500 ZEISS Version 7.1 IOL MASTER 500 ZEISS Version 7.1 4/10/2016 JTH 21 4/10/2016 JTH 22 IOL MASTER 700 ZEISS Version 1.1 4/10/2016 JTH 23 4/10/2016 JTH 24 Subtract from Ascan measured Axial Length ~ 0.8 mm Zaldivar-Holladay JCRS May 2000 Zeiss 4/10/2016 JTH 25 - IOL Master /10/2016 JTH 26 J Cataract Refract Surg 2011; 37: Jack T. Holladay MD MSEE FACS Page 4 of 9

5 Measured mm Linear Regression to compensate for AVERAGE Index of Refraction in Long Eyes 4/10/2016 JTH 27 4/10/2016 JTH 28 Accurate Biometry IOL Master 4/10/2016 JTH 29 IOL Power Calculations Pentacam can measure FRONT & BACK SURFACE POWER Can Calculate: Equivalent K-Reading (EKR) 65% Mean, Peak & Average NET POWER EKR Reports Keratometry value but adjusts for Back Surface Power from Normal (Current IOL Formulas) If corneal front surface is 7.5 mm (45 D), but if back surface -0.3 D > normal: EKR = = 44.7 D Note: Net Power = 43.3 D 4/10/2016 JTH 30 EKR65 J Cataract Refract Surg Feb 2015; 41: /10/2016 JTH 31 Holladay 4/10/2016 JTH 32 Report Equivalent K-Reading Jack T. Holladay MD MSEE FACS Page 5 of 9

6 4/10/2016 JTH 33 4/10/2016 JTH 34 IOL Calcs Abnormal Cornea (Use 65% MEAN EKR) Post Refractive Surgery Post PKP Keratoconus Corneal Scar Any Irregular Astigmatism Use 65% Mean EKR 4.5, 4 & 3 mm zones) Normal LASIK RK 41 to 44 D 3 D Range 36 to 41 D 5 D Range 32 to 45 D 13 D Range 4/10/2016 JTH 35 4/10/2016 JTH 36 4/10/2016 JTH 37 POST LASIK Post LASIK CALC K mean = 39.8 D Used 39.8 D => SEQ = D ( X 155 = 20/20) 65% mean = 38.8 D => D Use 65% mean K 4/10/2016 JTH 38 Jack T. Holladay MD MSEE FACS Page 6 of 9

7 4/10/2016 JTH 39 Conclusions EKR Use 65% Mean for all IOL Calcs smaller zones than 4.5 mm if pupil very small (< 3.0 mm in dim light) 4/10/2016 JTH 40 Accurate Biometry IOL Master Vergence Formula IOL ALELP 1336 ELP 1000 K(Post R) 1000 DPostRx V 4/10/2016 JTH 41 4/10/2016 JTH 42 Anterior Segment Size Large Normal Small 4/10/2016 JTH 43 CONCLUSION: 9 EYES Megalocornea Large Eye + axial Megalocornea Buphthalmos hyperopia (0%) (2%) Megalocornea + axial myopia (10%) axial hyperopia normal axial myopia (80%) (96%) (90%) Small eye Microcornea Nanophthalmia Microcornea + axial mopia (20%) (2%) (0%) Short Normal Long Axial Length 4/10/2016 JTH 44 Measurements taken for Predictors of ELP Axial Length Average K (Pre Ref) Horizontal WTW ACD LT Pre-opRefraction Age Jack T. Holladay MD MSEE FACS Page 7 of 9

8 Mean Absolute Error (D) 4/10/2016 JTH 45 FORMULA PERFORMANCE N = Axial Length (mm) Holladay 1 Hoffer Q SRK/T Holladay 2 4/10/2016 JTH 46 Accurate Biometry IOL Master 4/10/2016 JTH 47 Personalized Lens Constant Never use Manufacturer s Constant except to start 20 to 40 cases and continue Factors IOL Style Lens placement Post op medications Biometer, keratometer, Accurate Biometry IOL Master 4/10/2016 JTH 48 TORIC IOL Calculations Commercial Calculators use a constant ratio (1.46) for the corneal cylinder to the IOL cylinder Exact Calculation depends on IOL SEQ Power and ELP to correct 2D of corneal astigmatism 10 D IOL => 3.5 D Cylinder 22 D IOL => 2.9 D Cylinder 34 D IOL => 2.4 D Cylinder A 1.1 D difference from 10 D to 34 D! 4/10/2016 JTH 50 Jack T. Holladay MD MSEE FACS Page 8 of 9

9 Toric Optimization 4/10/2016 JTH 51 4/10/2016 JTH 52 PREOP 6 D Toric IOL LEF PREOP 6 D Toric IOL -- OD LEF 4/10/2016 JTH 53 4/10/2016 JTH 54 PREOP 6 D Toric IOL -- OS LEF!Thank You! 4/10/2016 JTH 55 4/10/2016 JTH 56 Jack T. Holladay MD MSEE FACS Page 9 of 9

ADVANCED IOL POWER CALCULATIONS. Jack T. Holladay, MD, MSEE, FACS

Jack T. Holladay, M.D., M.S.E.E., F.A.C.S. ADVANCED IOL POWER CALCULATIONS Jack T. Holladay, MD, MSEE, FACS I. Formulas and Measurements A. Variables Used to Predict ACD 1. Binkhorst 2-1981 - AL 2. Holladay