Providing Optimal Optics For Your Astigmatic Cataract Patients. While the cornea remains relatively stable and prolate throughout life

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1 Providing Optimal Optics For Your Astigmatic Cataract Patients David I. Geffen, OD, FAAO Why keep the crystalline lens? While the cornea remains relatively stable and prolate throughout life Unless we do refractive surgery on the cornea The crystalline lens is constantly changing in size and shape (more spherical) throughout life due to its retention of epithelial cells resulting in increasing spherical aberrations. The lens is a cruel thing! It adds spherical aberrations beyond ~ 20 and then continues to compromise qualitative vision; and Beyond 40ish, we all know what happens: Presbyopia The harbinger of aging! Eventual cataracts Hooray you have a cataract! New paradigm shift Earlier treatment of cataracts Refractive surgical procedure Preoperative treatment Lens options Post-operative strategies Conclusion The New Cataract Surgery Cataract surgery IS refractive surgery

2 Goal is a specific refractive outcome Excellent uncorrected distance Reduced dependence on glasses Monovision Multifocality It s all about better vision, faster Population Growth Population Growth U.S. Eyecare Supply & Demand Market for Refractive Cataract Surgery What is the Refractive Endpoint of your IOL calculation? PLANO SPHERICAL EQUIVALENT If K s 42.00/44.00, and target is plano the postop refraction will be X The postoperative visual acuity with 2.00 cylinder will unlikely be 20/20 Astigmatism Over 50% of patients over 60 years of age exhibit at least 1 Diopter of Astigmatism* Hoffer reports over 23% have over 1.50 D of Astigmatism* Vitale S, Ellwein L, Cotch MF, Ferris FL 3rd, Sperrduto R. Prevalence of refractive error in the United States, Arch. Ophthalmol. 126, (2008).

3 Hoffer KJ. Biometry of 7500 cataractous eyes. Am. J. Ophthalmol. 90, (1980). Astigmatism Manual Clear Corneal Incisions Wound architecture limited by hand-held instruments, manual incisions - imprecise tunnel length and geometry Frequently require stromal hydration to seal Can result in cascading intraoperative difficulties - fluid control, anterior chamber maintenance Recent literature suggests an increased incidence of post-op infection 1 Incisions may be unstable at low IOPs 2 Peripheral Corneal Relaxing Incisions or LRI s RISKS: Incision gape Patient discomfort Inadvertent corneal perforation Neurotrophic keratopathy Arcuate Incisions Traditional, Handheld Diamond Knife Manually executed by tracing corneal marks Inconsistent depth control

4 Unpredictable effect due to imprecise wound architecture and depth No image-guided surgical planning or visualization Laser Arcuate Incision Preoperative: 20/20 or 20/Happy? Refracting a cataract patient to 20/20-30 does not necessarily mean that patient has good, functional vision Long before patients lose acuity they may lose Contrast Color Comfort (quality of living) If you see a cataract, test for glare regardless of refraction and BCVA Aggressively manage OSD Why Treating OSD/Dry Eye Is Important Most post-cataract visual fluctuation is due to ocular surface disease Dry eye treatment options: Over-the-counter Prescription Punctal Occlusion Preoperative management may reduce or eliminate postoperative problems TORIC IOL s

5 The Next Step in Toric Technology The AcrySof IQ Toric IOL: Builds on a long line of innovation from Alcon Takes the trusted platform for precise astigmatism correction and adds the enhanced image quality of an aspheric lens* Designed for a Wide Range of Astigmatic Patients AcrySof IQ Toric IOL is designed to accommodate a variety of cataract patients with astigmatism Dramatically Reduces Residual Refractive Cylinder 63% of patients achieved 0.50 diopters of residual refractive cylinder 1 87% of patients achieved 1.00 diopters of residual refractive cylinder 1 Improves Uncorrected Distance Visual Acuity 94% of patients implanted achieved uncorrected distance visual acuity of 20/40 or better 1 Top Three Things to Tell Your Patients about Toric IOLs STAAR TORIC IOL Two models 1.50 D and 2.25D Silicone, one piece design Toric IOL S Main concern with Toric IOL s is misalignment

6 3 degrees off = loss of 10% of toric power 10 degrees off = loss of 33% of toric power 20 degrees off = loss of 66% of toric power Traditional Cataract Surgery Capsulotomy size directly related to Effective Lens Position 1,2 Corneal incisions are manually executed and imprecise High level of phaco power can be associated with post-op complications Cataract surgery complications are 10X that of LASIK 3,4 The LenSx Laser Laser-precise formation of: Main cataract incision Side port incision(s) Anterior capsulorhexis Arcuate incisions Laser-efficient dissection of the crystalline lens: Precision fragmentation of the lens cortex Reduces the total ultrasound energy required for cataract surgery LenSx Laser Arcuate Incisions Image-guided surgical planning with 3D visualization Real time corneal thickness Computer programmed incisions - % depth - incision length and position - 3D visualization of incision placement

7 Predictable incision width, tunnel length Titratable incisions - adjustable during surgical procedure - adjustable post-op at slit lamp Laser Refractive Cataract Surgery ORA System : Designed to Optimize Every Cataract Procedure ORA s all new Optiwave technology takes intraoperative wavefront aberrometry to a new level of precision providing surgeons a higher level of confidence ORA System (Optiwave Refractive Analysis) Provides intra-operative refractive information Attaches to most surgical microscopes for on-demand intraoperative measurements of sphere, cylinder and axis Enables real-time surgical course correction Get it right right on the table the first time Every ORA system connects live to WaveTec servers to capture every procedure and push software upgrades ORA System Helps Surgeons Optimize Outcomes for ALL Cataract Patients IOL power calculations using aphakic refraction Guides IOL selection o Post-refractive IOL power calculations o Standard monofocal and aspheric IOLs o Presbyopic IOLs

8 Guides toric IOL cases Guides LRI cases o Toric IOLs (SE power) o Cylinder power & axis o Whether done in the phakic, aphakic, and/or pseudophakic mode Sample ORA Screen Shots ORA Toric IOL Results Cumulative Post-op Refractive Cylinder Today s Modern Cataract Surgery Is it really refractive? Only 50% of cataract patients get within 0.50 D of attempted correction* ORA System Enables Refractive Outcomes While Over 80% of ORA patients get within 0.50 D of attempted correction What to Expect After Surgery Day One Look for a quiet anterior chamber Continue prescribed therapy (e.g., antibiotics, steroids, NSAIDs) Check ocular surface What to Expect After Surgery One Week Test visual acuity Manifest Refraction should be performed Helps quantify residual refraction

9 May help in the IOL power selection for the second eye Look for a quiet anterior chamber Monitor prescribed therapy (some drops may be discontinued) Evaluate the ocular surface, treat aggressively if necessary What to Expect After Surgery One Month Patient should have bilateral lenses If vision is not as expected: Remind patient it can take 1-3 months to adapt to lens technology Assess the optical pathway (ocular surface, anterior capsule, posterior capsule) Check for cystoid macular edema (CME) Thoroughly assess posterior and anterior capsule for ANY opacification May prescribe spectacles, if necessary If a multifocal patient show them what their near and intermediate vision would be like without the lens (ie: -3.0 at the phoropter) What to Expect After Surgery Three Months ACO, PCO? Ocular surface? Check visual acuities at appropriate distances If acuity is not as expected Residual refractive error? Manage, or refer (e.g. LASIK for Rx correction, YAG) Consider a patient satisfaction survey, to aid in future IOL recommendations (or discussions with surgeons) Checking Visual Acuity

10 logmar acuity is the most accurate, important for near and intermediate acuity Know the distance to the chart Know the distance the chart is calibrated for Check visual acuities at appropriate distances (distance/intermediate/near/preferred) Monitoring patient outcomes related to VA will help your next patient(s) Communicate with the Surgeon Posterior capsular opacification (PCO) Treated with a Nd:YAG laser Residual refractive error if the patient is interested in a surgical solution Surgically-related ocular pathology (e.g., CME) Unhappy patient with no apparent cause, or a cause you cannot manage Possible Complications Post-op Cataract Surgery Dry Eye Residual Refraction PCO Capsular Fibrosis Aggressive YAG Capsular Contraction IOL Centration/Rotation/Vault Night Vision Disturbances

11 Neuroadaptation Dysphotopsia CME Endophthalmitis Patient Outcomes Post-operative success is directly related to pre-operative expectations 5 minutes preoperative discussion may avert 30 minutes postoperative explanation Review the pros and cons of all of the lens technologies so they are prepared for their visit to the surgeon and there are no surprises Set realistic expectations, then meet or exceed them QUESTIONS

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