Dysfunctional Lens Syndrome. The Future of Premium Cataract Surgery

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1 Dysfunctional Lens Syndrome. The Future of Premium Cataract Surgery Dr. Joaquín aboutme/drjoaquinfernandez Needs of Baby Boomers 1

2 Needs of Baby Boomers Dysfunctional Lens Syndrome 57% < CN1 35% CN2 8% > CN2 2

3 Success in Premium Surgery Epectations DLS Considerations about Satisfaction Pager, C. K. (2004) The improvement in visual function eperienced by a patient did not at all significantly correlate with overall satisfaction, a finding that runs counter to common epectations. Patients had very high epectations for postoperative function 96.1% with 60% of patients selecting 100% VF-14 Questionnaire Adatia, F. (2015) Patients tend to feel that the second cataract surgery is a more negative eperience. We recommend preoperative counseling for all patients before their second cataract etraction. 3

4 Considerations about Satisfaction Hawker et al. (2005) (Monofocal IOLs) Patients who already wear spectacles epect to need them after cataract surgery. Those not already wearing spectacles do not epect to need them. Free of glasses is very important in general for patients. Labiris et al. (2014) (Mini-monovision versus multifocal intraocular lens implantation) Multifocal IOL insertion was associated with less dependence on glasses overall but significantly more dysphotopsia. Nijkamp (2010) (Monofocal IOLs) Predictors of satisfaction: Preoperative epectations of medical outcome were met (r = 0.407) Satisfaction with quality of care (r = 0.669) Evaluation of patient counseling (r = 0.674). Patient education and counseling were more strongly correlated with overall satisfaction than medical outcome (r = versus r = 0.543). Positive Candidates Braga-Mele, R., Chang, D., Dewey, S., Foster, G., Henderson, B. A., Hill, W., Yoo, S. (2014). Multifocal intraocular lenses: Relative indications and contraindications for implantation. J Cataract Refract Surg, 40(2),

5 Negative Candidates Braga-Mele, R., Chang, D., Dewey, S., Foster, G., Henderson, B. A., Hill, W., Yoo, S. (2014). Multifocal intraocular lenses: Relative indications and contraindications for implantation. J Cataract Refract Surg, 40(2), Future eclusion criteria 5

6 Success in Premium Surgery Vision Compromise MIOLs Epectations DLS Vision Compromise of MIOLs 6

7 Vision Compromise of MIOLs Success in Premium Surgery Visual Performance Assessment Vision Compromise MIOLs Epectations DLS 7

8 Cumulative % Of Eyes 6/22/2015 Visual Performance Assessment 100% 100% 96% 99% 99% 100% 80% 60% 62% 59% 40% 20% 16% 9% Postop UDVA Preop CDVA 0% 20/ /16 20/20 20/25 20/32 20/40 Cumulative Snellen Visual Acuity (20/ or better) Visual Performance Assessment 8

9 Standardization is required Optical Quality vs Visual Performance 9

10 Contrast (log units) Contrast (log units) 6/22/2015 Optical Quality vs Visual Performance Visual Acuity (logmar) Optical Quality vs Visual Performance Visual Acuity (logmar) 10

11 The Solution Standardization and Automatization for reporting DC Automated method which does not depend on the eperimenter Based on Visual acuity or Contrast Adaptative Optics Simulator Adaptive Optics based Visual Simulator 11

12 Light-distortion HLMP-CW47-RU000, Agilent Technologies LDI: Ratio of the area of points missed by the subject and the total area eplored and is epressed as a percentage. AT Lisa 839M AT Lisa 909MP Tecnis ZCB00 Success in Premium Surgery Visual Performance Assessment Vision Compromise MIOLs Objective Classification Epectations DLS 12

13 Objective Classification. Based on Scattering Artal, P., Benito, A., Pérez, G. M., Alcón, E., de Casas, Á., Pujol, J., & Marín, J. M. (2011). An objective scatter inde based on double-pass retinal images of a point source to classify cataracts. PLoS ONE, 6(2), 1 7. Objective Classification. Based on Scattering Visual Function Inde-14 score correlations 1. OSI r= DCVA (logmar) r= Lens Opacities Classification System III r= Average Lens Density (PNS) r= Modulation Transfer Function cut-off r= 0.47 Pan, A., Wang, Q., Huang, F., Huang, J., Bao, F., & Yu, A. (2015). Correlation Among Lens Opacities Classification System III Grading, Visual Function Inde-14, Pentacam Nucleus Staging, and Objective Scatter Inde for Cataract Assessment. Am J Ophthalmol, 159(2), e2. doi: /j.ajo

14 Objective Classification. Based on Scattering OSI improvements required We cannot compare the OSI before surgery and after surgery even though some papers currently do: Infrared systems (780nm) differ from IOL wavelenght desings (550nm). Diffractive rings inside 2 mm affect to the first pass. Imprecission in the PSF. New instruments are in development. Faster, wavelenght near to 550 nm, and with higher field. Ginis, H., Sahin, O., & Artal, P. (2015). Fast optical measurement of intraocular straylight. SPIE BiOS. International Society for Optics and Photonics, 93070R 93070R. Success in Premium Surgery Visual Performance Assessment Vision Compromise MIOLs Objective Classification Epectations DLS Surgical Decissions 14

15 Premium Surgical Techniques. FLACS Capsulerheis Improvement by FLACS Improving Centering and Position New Victus software offers the possibility of centering capsulerheis on the first purkinje image. This could be a future option for increasing predictability and improving visual performance. Premium Surgical Techniques. FLACS +4D +4D Soda, M., & Yaguchi, S. (2012). Effect of decentration on the optical performance in multifocal intraocular lenses. Ophthalmologica, 227,

16 72% n=13 28% n=5 6/22/2015 Effective Phacoemulsification Time Ultrasound is the main risk factor for Endothelial Cell Loss ECL High Power Long Duration Gonen T, Sever O. Reply to letter by Agarwal A, Ashok Kumar D, Agarwal A. Gas-forced infusion prevents endothelial cell loss in phacoemulsification. J Cataract Refract Surg 2013: 39: Femtosecond Laser and Zero Phaco YES ZERO PHACO CN=2 NO CN CN (7) 4R8CA (2) 4R8CB (4) 4R6C (Supo4ST y Supo3) 4R8C (4 mm) 4R (5,5mm) 8C (3,5mm) (1) 4R8CA (2) 4R4C (2) 4R6C (Supo4ST) Pattern [TFE mean] 4R8CA [TFE=1.50], 4R6C [TFE=1.36], 4R4C [TFE=2.28] 16

17 Zero Phaco There isn t a well documented treatment normogram which defines the laser parameters depending on a Cataract Classification System. but Can we reduce our current requirement of ultrasound? Zero Phaco What can we do to reduce the US requirement? 1. Reduction of the grid size. 2. Reduction of the safety zone for the posterior capsule. 3. Flared tip to a so-called thin tip (B&L). Fitted to cubes cut. 4. Aspiration device (Geuder AG) with an oval design and a greater opening lumen of 0.5 mm. 5. Higher vacuum with a maimum of 600 mmhg and a bottle height of 100 cm approimately. Dick, H. B., & Schultz, T. (2013). On the way to zero phaco. J Cataract Refract Surg, 39(9),

18 Micro Incision Cataract Surgery (MICS) What do we want to achieve? 1. Less post-operative ocular inflammation. 2. Less or none induced astigmatism. 3. Reduction of surgical time. 4. Short time of post-operative recovery (corneal wound healing) Combine Phaco Zero with Micro Incision of 1mm Conclusion Visual Performance Assessment Objective Future of Premium Cataract Surgery involves Classification a multifactorial analysis of different variables. From the measurement of Visual Function and Satisfaction to the decision of applying Vision Compromise MIOLs Epectations DLS the new Surgical Techniques Surgical Decissions 18