Techniques for Enhancing Cataract Surgery Patients with Residual Refractive Error. Director of Cornea Center For Excellence In Eye Care Miami, FL

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1 Techniques for Enhancing Cataract Surgery Patients with Residual Refractive Error William Trattler, MD Director of Cornea Center For Excellence In Eye Care Miami, FL 1

2 Financial Disclosures Consulting Fees: Abbott Medical Optics, Allergan, Bausch + Lomb, CXLO, LensAR Speakers Bureau: Abbott Medical Optics, Allergan, Bausch + Lomb, Oculus Contracted Research: Bausch + Lomb, TearScience Ownership Interest: CXLO, LensAR

3 How successful are you at achieving 20/25 or better UCVA with surgery? % of healthy eyes 20/25 or better with LASIK? Cataract surgery? 3

4 How successful are you at achieving 20/25 or better UCVA with cataract surgery? Comparison: LASIK Open-label, multicenter (7 sites) Prospective, non-comparative evaluation of 131 patients (262 eyes) Bilateral primary LASIK (CustomVue ilasik) Inclusion: Myopia between -0.5 to -6.0 D, cylinder up to -3 D MRSE of -6D. William Trattler, MD, Miami, FL Charles Reilly, MD; Lackland AFB TX Stephen Coleman, MD; Albuquerque, NM David Schneider, MD; Cincinnati, OH Eric Donnenfeld, MD; Darden City, NY Robert Maloney, MD; Los Angeles CA Larry Katzen, MD; Miami Beach, FL 4

5 s of Eyes % o UCVA at Months 1 and 3: ilasik

6 LASIK Dissatisfaction & UCVA S. Schallhorn MD, Optical Express Data n=22,194 pts, Nov 09 July 10 % Dissat tisfied wit thin each Category y15% 10% 5% 0% 0.4% 0.7% 86% of eyes attained at least 20/20 UCVA 1.6% 3.6% 5.5% 10.3% 20/12 20/16 20/20 20/25 20/32 >= 20/40 Uncorrected Visual Acuity at 1 month

7 How successful are you at achieving 20/25 or better UCVA with cataract surgery? What % of eyes reach 20/25 or better? 50%? 70%? 85%? Assume Normal macula Normal Corneal topography Target Rx = plano 7

8 What % of eyes reached 20/25 or better (TMF)? Only 50% of eyes are 20/25 or better % 90.00% TMF: UCDVA 91.60% Percent of Eyes 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 49.60% 76.30% 20.00% 10.00% 0.00% 12.20% 20/20 20/25 or better 20/30 or better 20/40 or better Uncorrected Distance Visual Acuity Data from Center for Excellence In Eye Care 8 Miami, FL

9 What % of eyes reached 20/25 or better (Restor D1)? Only 50% of eyes are 20/25 or better % ReSTOR D1: UCDVA 90.00% 80.00% 70.00% 76.90% 87.70% Percent of Ey yes 60.00% 00% 50.00% 40.00% 30.00% 20.00% 24.60% 49.20% 10.00% 00% 0.00% 20/20 20/25 or better 20/30 or better 20/40 or better Uncorrected Distance Visual Acuity Data from Center for Excellence In Eye Care Miami, FL 9

10 Treatment Options? Glasses/CTL PRK LASIK Piggyback IOL IOL Exchange Other less common procedures: Mini-RK CK Note: Enhancement technique can vary by: Postop Refraction Length of time since surgery Whether there were complications during the primary surgery

11 Awareness: Postoperative Refractive Surprise Situations Patients at risk Previous Refractive Surgery Corneal disease Long/Short Axial Length Disagreement in measuring axis of astigmatism

12 Evaluation of Patients who are off target and unhappy following cataract surgery Key: Patients requires a comprehensive workup Topography: Ensure topography is normal OCT of the macula: Ensure that there are no surprises following surgery Evaluation of the ocular surface Dry eye and MGD are very common postop Cause blurred vision and fluctuation of vision

13 If you are off target is it a problem? If you are off target following a Presbyopic IOL - how effective are you are achieving 20/30 or better with PRK or LASIK enhancements? Pretty good - Virtually 90% will get to 20/30 or better Fantastic: Virtually 100% will get to to 20/30 or better Not so great about 20% will still be 20/40 or worse 13

14 Unhappy IOL patients with residual refractive error Evaluate and treat dry eye and MGD Topical steroids and cyclosporine Treatment of MGD Place plugs

15 Unhappy IOL patients with residual refractive error If planning PRK or LASIK enhancements do you recommend Yag prior?

16 Unhappy IOL patients with residual refractive error After treating for dry eye/mgd and yag: Bring back and repeat topo and refraction For multifocal our typical refractive goal is plano For Crystalens the target may be slight myopia

17 Procedure choice Refractive Surgery: PRK/LASIK Piggyback IOL IOL Exchange

18 Evaluate Topography Carefully Previous LASIK Centered Optical Zone Significant regular astigmatism PRK/LASIK enhancement or Piggyback IOL PRK/LASIK enhancement or AK/LRI

19 Evaluate Topography Carefully Thoughts? Small Optical Zone Piggyback IOL

20 Retrospective Review of PRK or LASIK to Enhance Presbyopic IOLs Single Center, Miami, FL (N = 137 eyes) IOL types Crystalens (multiple versions) (N = 35) Multifocal IOLS (102) Restor (73) Restor Aspheric+3 add: N = 37 Restor aspheric +4 add: N = 31 Restor non-aspheric +4 add N = 5 Tecnis Multifocal N = 29 PRK (N = 123 eyes): Conventional (not wavefront) Laser: conventional ablation LASIK (N = 14): Conventional (not wavefront) Femto flap with conventional ablation 20

21 Retrospective Review of PRK or LASIK to Enhance Presbyopic IOLs Single Center, Miami, FL (N = 137 eyes) Question: Out of 123 eyes with either Crystalens or Multifocal IOL who were off target What % of eyes reached 20/30 or better with PRK? 21

22 Visual outcomes with PRK to enhance presbyopic IOLs (N = 123 eyes) Distance UCVA 22 Data from Center for Excellence In Eye Care Miami, FL

23 Retrospective Review of PRK or LASIK to Enhance Presbyopic IOLs Single Center, Miami, FL (N = 137 eyes) Eyes that ended up 20/40 or worse Only 3 of 29 had previous refractive surgery IOL make up Crystalens: Restor TMF 7 eyes 20 eyes 3 eyes Question: Out of 24% of eyes with either Crystalens or Multifocal IOL who ended up 20/40 or worse of a PRK enhancement What % of eyes had 1D or more of residual astigmatism Answer: 45% 23

24 Visual outcomes with LASIK to enhance presbyopic IOLs (N = 14 eyes) Distance UCVA /20 or better 20/25 or better 20/30 or better 20/40 or better 20/50 or worse 24 Data from Center for Excellence In Eye Care Miami, FL

25 Conclusion: Laser Vision i Correction for Presbyopic IOLs PRK and LASIK Enhancements have the potential to improve results Only 50% of eyes reach 20/25 or better UCVA at our Center Approximately 25 % of eyes after conventional laser enhancement remain with 20/40 or worse UCVA Recommendation Work really hard to end up on target so that PRK or LASIK is not needed. 25

26 Conclusions Troubleshoot unhappy IOL patients with residual refractive error Optimize the ocular surface Perform Yag prior to performing laser vision correction Enhancement Options can be effective But - Laser Vision correction enhancements when off target with Presbyopic IOLs can still leave approximately 24% of eyes with 20/40 or worse UCVA. Special Thanks to: Shannon McCabe Carlos Buznego, MD 26

27 South Beach, FL Acknowledgements Special Thanks to: Shannon McCabe Carlos Buznego, MD MM3003 William Trattler, MD 27

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