A multifocal IOL good enough for Mom, surgeon says

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1 Importance of selecting the appropriate platform for optimal patient outcomes Supported by Alcon Inc ASCRS ASOA Boston Show Daily Supplement A multifocal IOL good enough for Mom, surgeon says S Sydney Tyson, M.D. Elective IOLs are here to stay, and if you are offering them, you should believe they are good enough for your parents, too hortly before Sydney Tyson, M.D., Eye Associates, N.J., was to perform a cataract surgery a little over a year ago, the patient he was about to operate on had this to say: Good luck, and do your best. While not what most surgeons are accustomed to hearing before scrubbing in, the encouragement made perfect sense to Dr. Tyson. The patient was his mother. Some of my colleagues might wonder why I would operate on my mom s eyes, Dr. Tyson said recently. She always wanted me to be the one to do it. I know my skill set and I know what technology I have available. So I wanted to be the one to take care of her. Approximately 2,000 cataract surgeries are performed in Dr. Tyson s practice each year, 25% of which involve elective IOLs. In 90 95% of those cases, the AcrySof IQ ReSTOR 3.0 (Alcon, Fort Worth, Texas) lens is used. He and his mother chose the lens for her, too, for bilateral implantation. Dr. Tyson practices in New Jersey and his mother lives in Florida, but for quite some time he had been examining her eyes at least annually when she came to visit. He watched her cataracts gradually develop until they reduced her visual acuity to 20/50 and then six months later to 20/80. Mom is 76 years old, and she s into everything, Dr. Tyson explained. She s an avid reader, but she also exercises every day. Living in Florida, she does a lot of driving. She takes two or three trips a year to exotic locations. She s very active and vibrant, and she had been noticing a decrease in her vision, particularly at nighttime. She reached the point where things were starting to get dim. She wasn t comfortable any more with her vision for driving or her trips. It was definitely time for surgery. Obviously Dr. Tyson knew ahead of time the types of vision needs this patient had, but he counseled her exactly as he counsels all of his cataract surgery patients. He asked whether she wanted a standard lens, which would mean she d have to continue using reading glasses, or whether she was interested in having him try to eliminate the glasses. It was a no-brainer for her, he said. She said, Get rid of the glasses. I want the best. Dr. Tyson was confident the lens he was using would allow him to deliver on his offer of spectacle independence and provide maximum satisfaction. When you put in enough premium IOLs, you learn the nuances of each technology, which allows you to tailor each surgery to the individual. You know that some lenses don t give a full range of quality vision, which is what many patients want. That had been disappointing to me because patients pay a lot for elective IOL Dr. Tyson and his mother traveling in Alaska surgery and I don t want them to have to lose something. The AcrySof IQ ReSTOR 3.0 has been the most satisfying for me and my patients. It provides functional vision at near, intermediate, and distance, and because it s aspheric, the quality of vision is extremely good. We didn t have that ability with many of the previous multifocal or accommodating lenses. This is a product that gives us everything we ve been asking for. It was a bit nerve-wracking operating on his own mother, but I just did what I normally do and things turned out great for her, Dr. Tyson said. Within a couple of days post-op, she was ecstatic. She had a plaque made for me to commemorate the event. She took a trip soon after surgery and when she got back, she said it was one of her best because she was able to see the detail and color she had been missing for so long. She was so appreciacontinued on page 3

2 2 ASCRS ASOA Boston, Show Daily Supplement Importance of selecting the appropriate platform for optimal patient outcomes Excellent results achieved with three laser platforms in prospective study V Daniel Durrie, M.D. Our data confirm that the Wavefront Optimized procedure is as good as the WFG procedure for patients with less than 0.4 microns of higher-order aberrations pre-op isual acuity and quality of vision outcomes were outstanding in a recent prospective study involving three different excimer laser platforms, Wavefront Optimized and wavefront-guided (WFG) LASIK procedures, according to lead investigator Daniel Durrie, M.D., clinical professor of ophthalmology, University of Kansas, Overland Park, Kan. Dr. Durrie and Karl Stonecipher, M.D., medical director, TLC, Greensboro, N.C., conducted the study to evaluate current thinking on which patients should undergo a WFG treatment and which should have a Wavefront Optimized treatment. In general, surgeons who use the Allegretto Wave Eye-Q 400 Excimer Laser System (Alcon, Fort Worth, Texas) the only platform approved in the United States for both types of treatment base who gets what procedure on pre-op levels of higherorder aberrations. Taking into consideration FDA data and experience, Durrie Vision surgical suite featuring the Allegretto Wave Eye-Q Laser System they recommend WFG for those who have 0.4 or higher RMSh and Wavefront Optimized for those who have less than that. Patients were divided into two groups for the study. In one group, one eye of each patient received either a wavefront-guided or Wavefront Optimized treatment Summary of safety and effectiveness data from the U.S. Food and Drug Administration

3 Importance of selecting the appropriate platform for optimal patient outcomes ASCRS ASOA Boston, Show Daily Supplement 3 Dr. Durrie performs a Wavefront Optimized treatment with the Allegretto Wave Eye-Q laser (based on pre-op RMSh level) and the other eye received a WFG treatment with the LADARVision 4000 laser (Alcon). In the second group, one eye of each patient received either a WFG or Wavefront Optimized treatment with the Allegretto Wave Eye-Q laser (based on pre-op RMSh level) and the other eye received a WFG treatment with the VISX STAR S4 IR laser (Abbott Medical Optics, Santa Ana, Calif.). Thirty-eight eyes were treated with the Allegretto Wave Eye-Q laser, 19 eyes were treated with the LADARVision 4000 laser, and 19 eyes were treated with the VISX STAR S4 IR. The range of refractive error treated was myopia from 1 D to 7 D and astigmatism up to 3 D. All eyes were targeted for plano, and no monovision was allowed. All patients were very carefully assessed and determined to be ideal candidates for LASIK, Dr. Durrie said. At one and three months after surgery, there were no statistically significant differences in results among the three laser platforms. At one month and three months, all eyes treated with all lasers had uncorrected visual acuity (UCVA) of 20/25 or better. At three months, the percentage of eyes with 20/20 UCVA ranged from %, and the percentage of eyes with 20/16 UCVA ranged from 78 86%. As far as the rates of 20/20 and 20/16 uncorrected vision, all of the laser platforms performed off the scales, Dr. Durrie said. Also, because this was a contralateral eye study, we were able to collect detailed data about patients subjective quality of vision. Pre-op and at one week, one month, and three months post-op, patients were asked to rate the following: glare at night, glare during the day, haze in vision, halos, clarity of vision at night, and clarity of vision during the day. According to Dr. Durrie, in all categories, patients reported being the same or better than they were before surgery. When asked to compare the quality of their pre-op best-corrected vision with their post-op UCVA at all of the same time periods, they reported their post-op vision to be better than with glasses or contact lenses preop. In addition, patients were asked whether they experienced ocular dryness, and if they did how often and how severe. Their responses indicated no increase in ocular dryness compared with pre-op. Our data confirm that the Wavefront Optimized procedure is as good as the WFG procedure for patients with less than 0.4 microns of higher-order aberrations pre-op. This is an excellent option for 90% or more of patients who have lower values, Dr. Durrie said. Furthermore, we did not find any visual disturbances such as halo and glare in this study. Drs. Durrie and Stonecipher will continue to follow the study patients for one year to determine if the speed of the laser has a positive effect on visual rehabilitation. Their preliminary findings may suggest that it does. Durrie: ; ddurrie@durrievision.com continued from page 1 tive to have that ability, and now hunting around for reading glasses is one less thing she has to do. For Dr. Tyson, working with his mother reinforced the importance of good pre-op counseling, as well as how far premium IOL technology has come. It doesn t matter whether it s your parents or a brand-new patient. You have to go through the same process of explaining these technologies in order to get the best result, which is complete satisfaction, he said. Elective IOLs are here to stay, and if you are offering them, you should believe they are good enough for your parents, too. It would be disingenuous if I were willing to put an elective IOL in my patients but not my mom. Tyson: ; sydtyson@comcast.net Visual acuity and quality of vision outcomes were outstanding in a recent prospective study

4 4 ASCRS ASOA Boston, Show Daily Supplement Importance of selecting the appropriate platform for optimal patient outcomes Torsional phaco has gotten smarter, surgeon says A Stephen S. Lane, M.D. OZil IP is a relatively revolutionary change that, while seemingly minor, improves the consistency and efficiency of the procedure, both of which foster better results recently introduced energy management software package for the INFINITI Vision System (Alcon, Fort Worth, Texas) is getting high marks from surgeons who have incorporated it into their cataract procedures, such as Stephen S. Lane, M.D., Associated Eye Care, Stillwater, Minn. OZil Intelligent Phaco (IP) is designed to further improve the cutting efficiency of OZil torsional phacoemulsification, as well as increase the followability of lens material. Dr. Lane began using OZil IP as soon as it became available late last year. He described the upgrade as a relatively revolutionary change that, while seemingly minor, improves the consistency and efficiency of the procedure, both of which foster better results. OZil torsional phaco is more efficient than traditional longitudinal phaco because of its side-to-side oscillatory shearing action. Lens material is cut in both directions, rather than only on a forward stroke. Efficiency is further enhanced by an improvement in followability provided by the inherent nonrepulsive nature of the sideto-side motion. The purpose of the OZil IP software is to keep lens material at the ideal shearing plane, which is just at the distal end of the phaco tip. When OZil IP is enabled, the INFINITI system continuously monitors a vacuum threshold, which is preset by the surgeon. When vacuum rises to that threshold, indicating that the tip is near occlusion, OZil IP engages. It delivers short pulses of longitudinal ultrasound energy in order to reposition the lens material. Like the vacuum threshold, the duration, strength, and number of pulses are predetermined by the surgeon. Because the pulses are short, the repulsion and heat generally associated with longitudinal phaco are diminished. Because OZil IP repositions lens material at the ideal cutting location, the tip seldom reaches full occlusion during emulsification. As a result, flow is not interrupted, the peristaltic pump continues to draw lens material toward and through the tip, and post-occlusion surge is reduced, allowing for a more efficient procedure. As Dr. Lane explained, one of the benefits of OZil IP technology is that it produces less energy than longitudinal phaco. Now that surgeons are moving toward smaller incisions and smaller instrumentation, there is a tendency for the phaco needle to clog when we re working with dense cataracts. The lens material is not pulverized into little pieces like it is with longitudinal phaco. With OZil IP, I don t have to be concerned about the needle clogging, which would unnecessarily slow down the procedure and potentially compromise safety. Dr. Lane s phaco tip of choice is a 20-degree angled mini-flared KELMAN tip with a 30-degree bevel (Alcon). The 20-degree angled tip gives me more oscillatory motion and therefore more cutting effectiveness and efficiency. I like the ergonomics of the KELMAN angulation, and I like the size because it fits easily through a mm incision. The transition to OZil IP was seamless, Dr. Lane said. IP automatically detects early occlusion, so there is nothing the surgeon has to do. The tip does it all for you. The beauty of IP is you don t even know it s being applied. Other than feeling a bit of handpiece vibration, you don t notice anything different. What you see is the difference at the tip where you get better followability and efficiency without the concern of clogging the tip. With both OZil and OZil IP, eyes are quiet and corneas are clear the day after surgery, Dr. Lane said. Because less energy is put into the eye by OZil torsional phaco and less BSS solution (Alcon) is needed com- pared with traditional phaco, eyes look great the next day. New single-use Polymer I/A tips Dr. Lane has also been taking advantage of another recent innovation for use with the INFINITI Vision System single-use Polymer I/A tips (Alcon). Silicone tips for irrigation and aspiration were a significant improvement over metal tips in terms of safety because their smoothness made it virtually impossible to tear the capsule, he said. My one concern with silicone tips is that they are less durable than desired. With repeated cleaning, the silicone can bend over the metal of the inner sleeve and tear at that spot. You have to be careful putting the silicone irrigation sleeve over the tip so you won t damage it. The polymer tip has the advantage of durability like a metal tip but also the gentleness and smoothness of a silicone tip, even for polishing the capsule. Additionally, it enters the eye smoothly, and I don t have to worry about the leading edge of the irrigating sleeve catching the wound edge. Dr. Lane also likes the fact that the new Polymer I/A tips are singleuse. Sterility is never a question, and the ability to have a brand new tip for every case ensures quality and intraoperative safety, he said. The new Polymer I/A tips are compatible with all MicroSmooth irrigation sleeves (Alcon) and Ultraflow handpieces (Alcon). They are available in three configurations: a 20-degree curved tip, a 35-degree bent tip, and a straight tip. Lane: ; sslane@associatedeyecare.com

5 Importance of selecting the appropriate platform for optimal patient outcomes ASCRS ASOA Boston, Show Daily Supplement 5 A new generation of optical biometry arrives H. John Shammas, M.D. I have used the instrument for IOL power calculation in hundreds of cases. The axial length measurements and K readings it provides are extremely precise, and ACD measurements are highly accurate Anew optical biometer approved by the FDA in October 2009 is designed to provide more accurate measurements for IOL power calculations and refractive surgery procedures than was previously possible and streamline practice workflow at the same time. The Lenstar LS 900 (Haag-Streit USA, Mason, Ohio) utilizes optical lowcoherence reflectometry (OLCR) and 820-µm super luminescent diode technology to capture nine measurements in a single scan: keratometry white-to-white distance pachymetry anterior chamber depth lens thickness pupillometry axial length eccentricity of the visual axis retinal thickness. Unlike the optical biometer that preceded it in the U.S. market (IOL Master, Carl Zeiss Meditec Inc., Dublin, Calif.), the Lenstar LS 900 captures all biometric measurements on the patient s visual axis. H. John Shammas, M.D., medical director of the Shammas Eye Medical Center, Lynwood, Calif., and clinical professor of ophthalmology at University of Southern California s Keck School of Medicine, participated in a study comparing biometric measurements obtained with the Lenstar and IOL Master in 50 cataractous eyes and 50 eyes with clear lenses. 1 We found a high correlation between the axial length and keratometry (K) measurements obtained by the two instruments, he said. There were statistically, but not clinically, significant differences. We also found the Lenstar to measure slightly deeper anterior chamber depth (ACD). This was expected because it measures in the optical zone rather than by lateral slit illumination as is done by the IOL Master. The Lenstar ACD values are accurate and tend to be longer compared to the IOL Master as described in two recent publications (Rabsilber et al. J Cataract Refract Surg 2010; 36: and Buckhurst et al. Br J Ophthalmol 2009; 93: ). The device measures corneal thickness from epithelium to endothelium and separately measures aqueous depth as the distance from the endothelium to the front surface of the crystalline lens. Accurate determination of ACD can be especially important in shorter eyes when the surgeon is using a latest-generation IOL power formula. Other researchers who compared measurements from the Lenstar LS 900 with measurements from the IOL Master and other devices have reported similar conclusions, 2-4 although one study found no statistically significant difference in measurements of axial The compact footprint of the Lenstar LS 900 optical biometer length, corneal power, or anterior chamber depth between the instruments. 5 Dr. Shammas explained that the Lenstar LS 900 is the only optical biometer that measures lens thickness in addition to other ocular parameters. Newer formulas, such as the Holladay II and Olsen, use lens thickness as one of the variables for calculating IOL power. Surgeons using these new formulas continued on page 6

6 6 ASCRS ASOA Boston, Show Daily Supplement Importance of selecting the appropriate platform for optimal patient outcomes Surgeon supports use of blue light-filtering IOLs S Bonnie Henderson, M.D. I was relieved to find that the vast majority of literature supports that these lenses are beneficial and do not appear to be harmful ince intraocular lenses that filter blue light were introduced in the U.S. nearly 10 years ago, whether the benefits they provide for patients are outweighed by the disadvantages has remained a matter of debate. It is generally accepted that excessive exposure to blue light, although how much is not certain, damages retinal pigment epithelial cells, a precursor to several ocular diseases, including age-related macular degeneration. Blue light has also been shown to stimulate the proliferation of choroidal melanoma cells in vitro. Proponents of blue light-filtering IOLs maintain they should be routinely used because they can protect the retina from these potential hazards as well as reduce glare sensitivity and cyanopsia and increase contrast sensitivity in ambient light conditions for post-cataract surgery patients. Those who do not advocate routine use of blue light-filtering IOLs don t necessarily doubt their benefits, but they question whether the benefits come at the expense of visual acuity, color vision, contrast sensitivity in scotopic light conditions, and perhaps interference with patients natural circadian rhythms. For Bonnie Henderson, M.D., assistant clinical professor of ophthalmology, Harvard Medical School, Boston, Mass., following the opposing viewpoints was more than a theoretical exercise. Her monofo- cal IOL of choice is the AcrySof IQ IOL (Alcon, Fort Worth, Texas), a blue light-filtering lens designed to simulate the light transmission characteristics of the noncataractous human crystalline lens. I wanted to take a comprehensive, objective look at all available literacontinued on page 7 Filtering both UV and high energy blue light, the proprietary AcrySof IOL chromophore more closely approximates the light transmission of a human lens continued from page 5 and the IOL Master must measure lens thickness in a separate step with immersion ultrasound biometry or estimate it by patient age. This is not necessary when using the Lenstar, which improves efficiency in the clinic. Time is also saved by the Lenstar LS 900 because it does not require moving patients to obtain separate measurements of central corneal thickness or pupil diameter in ambient light, which is an important consideration for premium IOL candidates, Dr. Shammas said. With regard to axial length measurement, like the IOL Master, the Lenstar measures from the anterior corneal surface to the retinal pigment epithelium and uses a correction factor to determine distance to the internal limiting membrane. Furthermore, with an additional 10second step, the Lenstar can obtain exact retinal thickness at the point of the patient s line of sight. This is useful information for surgeons screening candidates for premium IOL procedures. In general, the Lenstar LS 900 software is easy to use, Dr. Shammas said. It can directly communicate with electronic medical records packages, and it reduces the risk of transcription error because it automatically populates data fields in IOL formulas and calculators. Dr. Shammas feels that the Lenstar LS 900 may also offer more precise K readings than previously available optical biometers with integrated keratometry. It measures closer to the central visual axis using 32 reference points in two concentric rings of 1.65 and 2.3 mm. Dr. Shammas s experience is that this might be an advantage, for example, in eyes that have smaller functional optical zones due to previous corneal refractive surgery. He summarized his clinical experience with the Lenstar LS 900: I have used the instrument for IOL power calculation in hundreds of cases. The axial length measurements and K readings it provides are extremely precise, and ACD measurements are highly accurate. All values obtained are very reproducible. Furthermore, the Lenstar LS 900 is easy to use and simplifies the use of the latest and most accurate IOL power calculation formulas. Shammas: ; jshammas@shammaseye.com References 1. Hoffer KJ, Shammas HJ, Savini G. Comparison of two laser instruments for measuring axial length. J Cataract Refract Surg. In print. 2. Rohrer K, Frueh BE, Walti R, et al. Comparison and evaluation of ocular biometry using a new noncontact optical low-coherence reflectometer. Ophthalmology 2009;116(11): Cruysberg LPJ, Doors M, Verbakel F, et al. Evaluation of the Lenstar LS 900 allin-one non contact biometry meter. Br J Ophthalmol published online August 18, doi: /bjo Naroo L, Berrow EJ, Buckhurst PJ, et al. A new optical low coherence reflectometry device for ocular biometry in cataract patients. Br J Ophthalmol published online April 19, doi: /bjo Holzer MP, Mamusa M, Auffarth GU. Accuracy of a new partial coherence interferometry analyzer for biometric measurements. Br J Ophthalmol published online March 15, doi: /bjo

7 Importance of selecting the appropriate platform for optimal patient outcomes ASCRS ASOA Boston, Show Daily Supplement 7 Surgeon recommends toric IOL for patients with low corneal astigmatism N Warren E. Hill, M.D. Using the toric IOL was more likely to result in full spectacle independence for distance vision in patients with low degrees of corneal astigmatism oting that toric IOLs have been shown to effectively reduce postop refractive astigmatism and spectacle dependence following cataract surgery, a group of investigators sought to clarify the benefits of the AcrySof Toric IOL (model SN60T3, Alcon, Fort Worth, Texas) in patients with low amounts of corneal astigmatism. Statham, et al., performed a retrospective chart audit of 12 patients who received the AcrySof Toric IOL in both eyes and 10 patients who received an AcrySof spherical IOL (model SA60) in both eyes.1 The average baseline level of corneal astigmatism for both groups was approximately 1.00 D. Using the magnitude of the Astigmatic Power Vector (APV) as a measure of astigmatism, the investigators found post-op refractive astigmatism to be significantly less in the toric IOL group. They reported that the difference was equivalent to a mean reduction in post-op refractive astigmatism of 0.54 D, which was clinically significant given the low level of baseline astigmatism. They also reported that post-op uncorrected visual acuity was significantly better in the toric IOL group (0.046 logmar) compared with the spherical IOL group (0.278 logmar). They concluded that while the difference in spherical equivalent between the two groups played a small role, the improvement in UCVA was more likely due to the difference in postop refractive astigmatism (0.88 D in the AcrySof SA60 IOL group and 0.33 D in the AcrySof Toric IOL group). They further concluded that the reduction in refractive astigmatism achieved by using the toric IOL was more likely to result in full spectacle independence for distance vision in patients with low degrees of corneal astigmatism than using a spherical IOL. Warren E. Hill, M.D., East Valley Ophthalmology, Mesa, Ariz., said the distribution of corneal astigmatism has been well established by multiple studies. In the U.S. population, the majority of people are of European descent and have low amounts of corneal astigmatism. Dr. Hill recently compiled pre-op astigmatism data on 6,000 patients, which demonstrated a similar distribution (Figure 1). High amounts of corneal astigmatism are relatively uncommon, he said. The peak is at relatively low magnitudes, with approximately 28% of people in the United States having corneal astigmatism between 1 D and 2 D. A toric IOL is an ideal option for that group. Dr. Hill first implanted the original AcrySof Toric IOL as part of the Phase III FDA study eight years ago. He now uses the aspheric AcrySof IQ Toric IOL and has enjoyed consistently accurate and predictable results with both versions. He credits his success to meticulous attention to detail of the three fundamental steps required for accurate results with a toric IOL: measuring the cornea, marking the cornea, and lens placement. Precise execution of those three steps is even more important in treating low magnitudes of corneal astigmatism, he said. Each time you measure continued on page 8 continued from page 6 ture on the issue, she said. She independently initiated a review of all peer-reviewed published studies regarding the impact of blocking the transmission of blue light. The project was not suggested by any lens manufacturer and she did not receive any payment or funding from industry. The results of Dr. Henderson s literature review were published recently in Survey of Ophthalmology.1 I was relieved to find that the vast majority of literature supports that these lenses are beneficial and do not appear to be harmful, she said. In the course of her review, Dr. Henderson found 56 reports, published from 1962 to 2009, on subjects related to blue light-filtering lenses, including sleep disturbance, visual outcomes, cataract surgery, lens transmittance, and sunlight exposure. Eleven reports specifically compared visual outcomes between blue light-filtering IOLs and nonblue light-filtering IOLs. Of those 11 reports, 10 concluded that an IOL that filters blue light has no significant detrimental effect on various measures of visual performance, including visual acuity, contrast sensitivity, color perception, and photopic, mesopic, and scotopic sensitivities. Only one group of authors reported that the use of such IOLs may have detrimental effects on scotopic vision and circadian rhythms. While these opposing studies are certainly valid, I question whether the amount of contrast sensitivity degradation is clinically relevant, Dr. Henderson said. Maybe sensitivity is reduced in a laboratory setting, but none of the studies that evaluated patients realworld vision with a blue-blocking IOL showed they had any difficulty with visual function or any trouble with activities of daily living because of the lens. In fact, they found the filtering of blue light actually improved contrast sensitivity and sensitivity to glare. The reported negative effects on circadian rhythms also appear to be minimal and may not be clinically relevant. Dr. Henderson s review was not intended to evaluate the relationship between blue light and macular disease, so the debate about whether or not filtering blue light in pseudophakic individuals protects from AMD continues, she said. Since this paper was written in early 2009, many new studies on this topic have been published. Based on the original literature review that was performed and with the additional new studies that have been published evaluating the performance of blue light-filtering lenses, I have continued to implant the AcrySof IQ IOL with the confidence that it is a safe and effective choice for my patients. Henderson: ; bahenderson@eyeboston.com Reference 1. Henderson BA, Grimes KJ. Blue-blocking IOLs: a complete review of the literature. Surv Ophthalmol 2009; published online 30 October.

8 8 ASCRS ASOA Boston, Show Daily Supplement Importance of selecting the appropriate platform for optimal patient outcomes continued from page 7 1,150 1, % 89% 17.1% the cornea, mark the cornea, and place the lens, you run the risk of a large or small angular error. An error early in the process will be perpetuated at every subsequent step. Treating low magnitudes of corneal astigmatism means all three steps have to be as accurate as possible, or an undercorrection at an unanticipated axis will result. Dr. Hill explained the aspects of his protocol for using toric IOLs that he considers most important for achieving excellent outcomes. Prevalance of Astigmatism Prior to Cataract Surgery 19.1% 14.8% 12.0% < > 3.00 Figure 1. Prevalence of astigmatism prior to cataract surgery 7.8% 5.5% 3.7% A surgeon s protocol Step one is determining by topography that the patient s corneal astigmatism is regular. Placing a toric IOL in an eye with obvious irregular astigmatism will often result in an undercorrection of astigmatism, as well as the possibility of introducing higher-order aberrations, such as vertical or horizontal coma. Next, Dr. Hill calculates the spherical power of the IOL using keratometry and axial length obtained with an optical biometer. However, for determining the steep axis and calculating the amount of corneal astigmatism that is to be corrected, manual keratometry is best, he said. While automated keratometry and manual keratometry will often give a similar average central corneal power, their measurement of the power difference between the two principal meridians and the steep axis may differ. This is because some auto keratometry devices sample a 2.5- mm zone and manual keratometry samples a 3.0-mm or 3.2-mm zone. Because the astigmatic cornea is shaped more like the tip of a football than the top of a basketball, this slightly larger zone will typically give different values and generally correlates better with the amount of astigmatism that we are looking to correct with the toric IOL. Furthermore, with manual keratometry, it is possible to take as much time as necessary to measure the power and align the steep and flat axes. Auto keratometry is akin to a digital camera, which bases everything on an instantaneous snapshot. Knowing the amount of astigmatism his cataract incision induces is another key to accurate outcomes, Dr. Hill said. Surgeons who have not determined their personal surgically induced astigmatism can use the Surgically Induced Astigmatism Calculator available on Dr. Hill s 2.9% n = 6, % 1.3% 0.9% 2.2% Warren E. Hill, MD, FACS Courtesy of W. Hill, M.D. Web site to do so ( Once he has obtained steep and flat K values, the corresponding axes and the IOL spherical power, Dr. Hill enters them, along with his surgically induced astigmatism amount and incision location, into the AcrySof Toric IOL Calculator (acrysoftoriccalculator.com, Alcon). If the calculator helps to determine that there will be some amount of residual astigmatism, the calculation can be re-run using different incision locations until the anticipated residual astigmatism is at its lowest value. For example, operating on the steep axis is one way to extend the range of the AcrySof IQ Toric IOL by approximately 0.50 D, Dr. Hill said. Prior to surgery, Dr. Hill places reference marks on the cornea at the 3 and 9 o clock positions using a Blakewell BubbleLevel (Mastel Precision, Rapid City, S.D.). In order to avoid a cyclotorsion error when the patient moves to the supine position, the patient should be sitting upright and looking at a distant target for this step. In the OR, under the microscope, Dr. Hill aligns a Gimbel/Mendez fixation ring (Mastel Precision) with these previously placed reference marks and then uses a Boris meridian marker (Mastel Precision) to mark the incision location (if in a location other than 3 or 9 o clock) and the axis of implantation. Dr. Hill noted that Robert Osher, M.D., is currently involved in the development of several new methods for toric IOL implantation axis identification and alignment that should allow for an even higher degree of accuracy. After phacoemulsification, cortex removal, capsule polishing, and inflation of the capsular bag with viscoelastic, the toric IOL is implanted with 360 degrees of anterior capsule overlap and rotated to a position 10 to 20 degrees counterclockwise from the previously marked axis of implantation. The lens is stabilized with an instrument such as a Sinskey hook while the viscoelastic from both behind the IOL and the anterior chamber is removed. Then, the toric IOL is carefully rotated to its final position and very gently pushed posterior to allow the posterior surface of the IOL to interact with the posterior capsule. This final step, along with the removal of all viscoelastic, reduces the likelihood of subsequent rotation. Time well spent Successfully treating low amounts of corneal astigmatism with a toric IOL hinges on multiple, sequential steps, all carried out as precisely as possible. Dr. Hill emphasized that in his experience, for the initial corneal measurements it is best to resist the temptation to automate and delegate. I rely on manual keratometry, which I personally perform, for measuring corneal astigmatism because this sets the accuracy of everything downstream. Hill: ; hill@doctor-hill.com Reference 1. Statham M, Apel A, Stephensen D. Comparison of the AcrySof SA60 spherical intraocular lens and the AcrySof Toric SN60T3 intraocular lens outcomes in patients with low amounts of corneal astigmatism. Clin Exp Ophthalmol 2009;37(8):

9 Importance of selecting the appropriate platform for optimal patient outcomes ASCRS ASOA Boston, Show Daily Supplement 9 Overcoming barriers in the LASIK environment A Shareef Mahdavi Motivated and happy employees are crucial to excellent customer service. Take care of your employees; they ll take care of your customers, and your income will take care of itself Kay Coulson, M.B.A. Patients still want to know that the procedure is safe and accurate, but how those messages are conveyed has to change ccording to the business advisors who endeavor to help them succeed, refractive surgery practices wondering how to make it through the current prolonged downturn in volume need to start by embracing a key fact LASIK is not dead. People are still spending money. They re just a lot more careful and selective about how they spend it, said Shareef Mahdavi, president of SM2 Strategic Inc., Pleasanton, Calif. Mahdavi and Kay Coulson, M.B.A., president of Elective Medical Marketing, Boulder, Colo., shared what practices should be doing to not only survive but thrive. Historically, in communicating with prospective patients, practices talked about technology and surgical skill and relied on procedure financing to drive volume. That has limited effectiveness right now, Coulson said. Patients still want to know that the procedure is safe and accurate, but how those messages are conveyed has to change. Coulson said. You have to be authentic with them. Then they are willing to tell their friends about you. Now is the right time to evaluate the practice cost structure for providing LASIK, Coulson said. Your cost structure may be holding you back from making the changes necessary to compete. Look at the space you rent, the number of people you employ. Do you need it all? How are you re-evaluating and allocating your marketing budget so that it truly attracts interested prospects? It s about them, not us Now is also the time for surgeons to make sure the results they are providing are extraordinary, Coulson said. One hundred percent of patients need to be 20/happy. For one patient that may mean 20/happy monovision, for another it may mean 20/20 distance. Perhaps it is 1 D in both eyes for the 48-year-old who spends most of the day at a computer. Patient-preferred vision is the goal. In fact, according to both Coulson and Mahdavi, if practices expect to improve their circumstances, the goal needs to be patient-preferred everything. All types of businesses are learning that the same old branding tricks just aren t working, Mahdavi said. The companies that have the most fanatical customers are the ones who are obsessed with the customer continued on page 10 The audience is changing Surgeons must address a younger audience now, Coulson said. The baby boomers are moving out of the LASIK loop into the elective lens arena. They re being replaced by the 20- to 30-year-old boomlets, also known as Generation Y or the Millennials. Reaching out to this younger second wave of potential LASIK patients requires new media and an adjusted message, Coulson said. She advises practices to have a good online presence with an engaging Web site that ranks well on search engines and to use and Facebook* marketing, but she steers them away from blogging and Twitter.* Blogging is dead. Twitter is dead or will be within a year, she said. Those tools are not really relevant to elective medical practices. It s not enough to try to look hip. Surgeons have to adjust how they re talking to people via the new media. Group participation is attractive to this audience, so strategies such as buddy programs, where LASIK candidates can have surgery together, make sense. Furthermore, because they are tech-savvy, 20- to 30-year-olds do a lot more research before they contact a practice. You can t ignore their questions, When surgeons define quality, they tend to look at one thing: outcomes. That is, how well did the patient s procedure turn out and how well can he see Patients, however, define quality with a much wider lens. They are answering a whole series of questions when they are being asked to spend thousands of dollars on a purchase that is discretionary

10 10 ASCRS ASOA Boston, Show Daily Supplement Importance of selecting the appropriate platform for optimal patient outcomes Allegretto Wave Eye-Q laser provides excellent outcomes for hyperopes, surgeon says T Karl Stonecipher, M.D. The Allegretto Wave Eye-Q system is my platform of choice for hyperopia and hyperopic astigmatism he combination of PerfectPulse Technology and fast speed make the Allegretto Wave Eye-Q 400 Excimer Laser System (Alcon, Fort Worth, Texas) an ideal platform for treating hyperopia, especially in patients who are also astigmatic, according to Karl Stonecipher, M.D., medical director, TLC, Greensboro, N.C. These two features in particular have allowed us to tighten our predictability and outcomes, he said. While results with this laser s predecessor, the 200-Hz Allegretto Wave laser, were excellent for Dr. Stonecipher s patients, outcomes are even better at the 400-Hz speed. Because the laser operates at 400 Hz, Dr. Stonecipher said he can treat a diopter of hyperopia in two Wavelight Allegretto Wave Eye-Q continued from page 9 experience, like Zappos.* Zappos is an online seller of shoes, clothing, and other merchandise. The company focuses on a list of 10 core values, the first of which is Deliver WOW Through Service. Internally, its employees have a saying, We are a service company that happens to sell shoes, handbags, etc. Zappos credits its relentless focus on customer service for growing sales from $1.6 million in 2000 to more than $1 billion in Mahdavi s company helps practices assess the customer service they provide by evaluating their Web sites, phone answering techniques, and patient consults. Based on that research, there aren t a lot of practices that give a great overall customer experience, he said. The surgery itself is great, but practices have a lot of work to do as far as how they treat customers at each and every touchpoint. They need to make candidates feel like they really want to spend their time and money with the practice. Elective medical procedures come with the inherent challenge that they are not a repeat buy. After surgery, patients are gone. That puts the onus on the practice to figure out how to stay connected with these people, who are the best source of referrals, Mahdavi said. How do you spark a fire under the 7 million people who have been treated with well over 90% satisfaction? Why aren t they doing more work for practices in terms of feeding the fire with new customers? Patients need to feel special. They need to feel as if LASIK was unlike any medical procedure they ve ever had and a better investment than other things they could have spent money on. Those feelings need to be rekindled long after the procedure takes place. It s up to the refractive practice to build and maintain the customer relationship. Where to begin? Start by making everything convenient for patients, Coulson said. Be on time, reduce your enhancement rate, check on patients by phone instead of making them come into the office when possible. Also, patients want to be able to see the doctor within a couple days of their initial contact with the practice and have surgery within a week to 10 days of their decision to proceed. Don t make paying for the procedure a problem by, for example, not accepting personal checks. That feels to patients like we don t trust them, which is a bad message to send in a down economy. Along those lines, Mahdavi added, everything the practice does communicates a message to the customer. It doesn t work to expect people to pay retail-like prices for a service but keep them in a heavily medical environment by calling them patients and asking them to sit in a waiting room. Consumers in 2010 aren t patient for anything. Surgeons and their staff members should re-evaluate every interaction with LASIK candidates, down to the forms they have them fill out. Why force people to sit in your office and complete poor-looking, repeatedly copied forms? Digitize them so they can be filled out at each person s convenience. Mahdavi offered a final piece of advice: Motivated and happy employees are crucial to excellent customer service. Take care of your employees; they ll take care of your customers, and your income will take care of itself. Coulson: ; kay@electivemed.com Mahdavi: ; shareef@sm2strategic.com *Trademarks are the property of their respective owners.

11 Importance of selecting the appropriate platform for optimal patient outcomes ASCRS ASOA Boston, Show Daily Supplement 11 Hyperopic treatment on the Wavelight showing a true 6.5 OZ Dr. Stonecipher s WaveLight hyperopia results seconds. Procedure time is extremely fast, which leaves less time for external influences to come into play during treatment, he said. The effects of factors such as humidity and dehydration are reduced. Dr. Stonecipher also credits the precision of the Allegretto Wave Eye-Q 400 Hz laser s PerfectPulse Technology with helping to improve patients post-op quality of vision. The energy stability of the laser pulses is continuously monitored and adjusted from the time of generation to ensure they are applied to the cornea in a uniform fashion. At the same time, a highspeed eye tracker follows the eye s fastest movements. The laser does not fire the pulse unless the eye is in the proper position, he said. The laser delivers additional pulses in the periphery so that the cornea maintains its natural prolate shape. Where all of this helps is in creating a more gradual transition zone, Dr. Stonecipher said. The smoother the transition zone, the less likely patients are to experience problems such as glare or halos. Successfully treating hyperopes requires a somewhat different approach than with myopes, Dr. Stonecipher said. Most present as latent hyperopes, meaning they had been able to see relatively well until they were no longer able to accommodate. It s not until presbyopia begins to set in that they are no longer happy with their vision. First we have to establish where they want to be able to see after surgery, at near or distance. Realistically, they may be looking for a distance vision alternative, especially males. Females are more likely to be using a monovision solution prior to surgery, which makes monovision a great option for surgery, too. However, if patients say they want good vision at all distances, we need to consider whether refractive lensectomy might be a better strategy for them than LASIK. Dr. Stonecipher may also recommend refractive lensectomy for hyperopes in cases where LASIK would require steepening the cornea to a point where other problems, such as dry eye, could arise. I don t like to make a cornea too steep. I avoid going beyond K, he said. The Wavelight laser is approved to treat up to 6 D spherical equivalent in hyperopes, which is a nice range, and many surgeons treat to that maximum with great success. However, I tend to not perform LASIK for corrections higher than +3 D. In addition, he assesses how much influence the patient s lens is having on overall refractive error. We ve learned over time that we don t want to treat a lens problem on the cornea. Some patients may also have early nuclear sclerotic changes, so we don t want to perform a procedure that is of shortlived benefit. In cases where LASIK is a better fit than refractive lens exchange, the Allegretto Wave Eye-Q 400 Hz laser gives surgeons the distinct advantage of being able to choose between a wavefront-guided or Wavefront Optimized approach. Dr. Stonecipher recommends a wavefront-guided procedure for patients whose RMSh value is 0.4 or higher. That s the beauty of this platform. You can choose between the two options based on the individual patient, he said. My recommendations for hyperopes revolve around presbyopia and what each patient needs or wants. Once the pre-op assessment and discussions with the patient lead us to choose LASIK, the Allegretto Wave Eye-Q system is my platform of choice for hyperopia and hyperopic astigmatism. Stonecipher: ; StoneNC@aol.com This supplement was produced by EyeWorld under a grant from Alcon. Copyright 2010 ASCRS Ophthalmic Corporation. All rights reserved. The views expressed here do not necessarily reflect those of the editor, editorial board, or the publisher, and in no way imply endorsement by EyeWorld or ASCRS.