REFRACTIVE SURGERY DECISION MAKING: CANDIDATE SELECTION WITH CASE REPORTS

Transcription

1 REFRACTIVE SURGERY DECISION MAKING: CANDIDATE SELECTION WITH CASE REPORTS DAVID I. GEFFEN, OD, FAAO ANDREW MORGENSTERN, OD, FAAO JIM OWEN, OD, FAAO DEMOGRAPHICS 81 Y/O FEMALE COMPLAINS OF POOR VA OU, WORSE OS, GLARE OU VERY ACTIVE PROPERTY MANAGER BCVA 20/25- OD 20/50 OS NS 1+, PSC1+ OD NS 2+ OS IOP 14 OD 15 OS GOLDMANN FUNDUS NORMAL OCT NORMAL MANIFEST OD X90 OS X95 SURGERY DAY 1 / WEEK 1 PO LENSX RESTOR 3.0 DISCUSSED POTENTIAL FOR GLARE DISCUSSED NEED TO TREAT OD WOW THAT WAS EASY! UCVA 20/40 IOP 25 AC TRACE CELLS WOUND SECURE REVIEW DROPS NO PROBLEM WITH DROPS UCVA 20/40 IOP 14 AC DEEP AND QUIET CORNEA 2+ SPK MANIFEST X180 20/30+ AT QID 1

2 2 MONTH / 3 MONTH PO 4 MONTH VISIT WITH SURGEON THIS VISION IS NOT RIGHT UCVA OD 20/20- OS 20/40 CORNEA TRACE SPK MANIFEST X175 20/30+ CAPSULE - CLEAR OCT - CME IT SEEMS NO BETTER UCVA OD 20/20- OS20/30 CORNEA CLEAR MANIFEST X175 20/25+ OCT NORMAL TRACE - PCO OPENED AK CUT 1 DAY UCVA 20/25+ 1 WEEK UCVA 20/25 PT HAPPY WITH VA MANIFEST SPHERE 20/25 HOW DO YOU TREAT A 58 YR OLD EXAM PT JK 58 Y/O M PRESENTS FOR A REFRACTIVE CONSULTATION, DESIRES TO BE SPECTACLE FREE. AVID GOLFER RX: OD: X X104 20/20 OS: X 67, 20/ ADD J1 OU K S: OD: / X 80 OS: / X 168 SLIT LAMP: CORNEAS CLEAR, LENSES CLEAR, ALL WNL FUNDUS: WNL PACHS: OD: 545 OS: 537 2

3 CHOICES WHY RLE WHAT SURGERY OPTIONS DO WE HAVE LASIK OR PRK TORIC IOL WILL CORRECT ASTIGMATISM TRULIGN WILL GIVE MODERATE NEAR VISION ICL RLE ASTIGMATISM 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). HOFFER KJ. BIOMETRY OF 7500 CATARACTOUS EYES. AM. J. OPHTHALMOL. 90, (1980). IOL master, not refraction, is the critical measurement Some astigmatism change may occur during surgery (typically 0.5D for a 2.2mm clear corneal incision) Depending on location, may increase or decrease existing corneal astigmatism (incision on steep meridian reduces astigmatism) Any suitable cataract patient with >0.75D of resultant preoperative astigmatism may benefit from a toric IOL correction 3

4 ARCUATE INCISIONS TRADITIONAL, HANDHELD DIAMOND KNIFE MANUALLY EXECUTED BY TRACING CORNEAL MARKS INCONSISTENT DEPTH CONTROL UNPREDICTABLE EFFECT DUE TO IMPRECISE WOUND ARCHITECTURE AND DEPTH NO IMAGE-GUIDED SURGICAL PLANNING OR VISUALIZATION Square edgelaser ARCUATE INCISION Uniform depth (no ripples) Precise, reproducible Arc shape Arc length Diameter DESIGNED FOR A WIDE RANGE OF ASTIGMATIC PATIENTS STAAR TORIC IOL ACRYSOF IQ TORIC IOL IS DESIGNED TO ACCOMMODATE A VARIETY OF CATARACT PATIENTS WITH ASTIGMATISM TWO MODELS 1.50 D AND 2.25D SILICONE, ONE PIECE DESIGN 1. Data on file, Alcon Inc. 4

5 TECNIS TORIC IOL: SPECIFICATIONS WAVEFRONT-DESIGNED TORIC ASPHERIC SURFACE +5.0 D TO D IN 0.5 D INCREMENTS Lens Model ZCT150 ZCT225 ZCT300 ZCT400 Cylinder Powers 1.50 D 2.25 D 3.00 D 4.00 D Corneal Plane D 1.55 D 2.06 D 2.74 D Correction Range (Based on combined Corneal Astigmatism ) D D D D 5.0-MM OPTIC BODY BICONVEX SHAPE RECTANGULAR HINGED HAPTICS APPROVED DIOPTRIC POWER RANGE FROM TO D CYLINDER POWERS 1.25, 2.00, AND 2.75 D ROUND-TO-THE-RIGHT ASYMMETRIC POLYIMIDE LOOPS TRULIGN TORIC IOL KEY PROPERTIES o o x 1. Based on average pseudophakic human eye. 2. Preoperative Keratometric cylinder plus surgically-induced astigmatism ME Model Model SPECIFICATIONS Recommended Starting A-constant Recommended Starting ACD Overall Diameter Available Now Diopter Power THE TRULIGN TORIC IOL PROVIDES A BROADER RANGE OF VISION Standard Toric TRULIGN Toric TRULIGN Toric IOL BL1UT 119.1* 5.61 mm* 11.5 mm 17.0 to 25.0 D in 0.50 D steps Cylinder powers IOL plane 1.25, 2.00, 2.75 D Cylinder powers corneal plane 0.83, 1.33, 1.83 D Optic body diameter 5.0 mm Anterior surface Aspheric with axis marks Posterior surface Aspheric toric (cyl at 1.25, 2.00, 2.75 D) Material body and plates Silicone with enhanced UV protection; 10% UV cutoff at 400 nm Material loop (haptics) Polyimide Refractive index at 35 o C 1.43 Edge design 360º posterior square edge Delivery system Crystalsert IOL Delivery System The Bausch + Lomb TRULIGN Toric posterior chamber IOL is a modified plate haptic lens with hinges across the plates adjacent to the optic. Axis marks on the anterior surface denote the flat meridian of the lens. *A-constant and ACD are estimates only. It is recommended that each surgeon develop his or her own values

6 TORIC IOL S MAIN CONCERN WITH TORIC IOL S IS MISALIGNMENT 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 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 PREDICTABLE INCISION WIDTH, TUNNEL LENGTH TITRATABLE INCISIONS - ADJUSTABLE DURING SURGICAL PROCEDURE - ADJUSTABLE POST-OP AT SLIT LAMP ORA SYSTEM (OPTIWAVE REFRACTIVE ANALYSIS) SURGERY 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 AFTER LONG DISCUSSION PT CHOSE RLE OD: B+L TRULIGN WITH LENSX AND LRI OS: B+L TRULIGN WITH LENSX AND LRI 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 GOAL: OD: PL OS:

7 3 MONTH POST-OP PATIENT DEMOGRAPHICS UCVA: OD: 20/15, J3 OS: 20/30, J1 FEELS VISION IS GREAT GOLF GAME IS GREAT! 39 YO MALE NO TOBACCO/ALCOHOL NO GLASSES OHX POKED IN OS BY CHILD 2010 WITH SUBSEQUENT CORNEAL INFILTRATE. RESOLVED WELL NO MED/SURG ORIENTED TO TIME, PLACE AND PERSON EXAMINATION EXAMINATION EOM S FULL RANGE OF MOTION OU PUPILS PERRLA APD VISUAL FIELD FULL TO FINGER COUNT FACIAL AMSLER NORMAL OD AND OS CC: COMP EXAM AND DECREASING VA OD BUT VERY GRADUAL VASC: OD 20/30 OS 20/20 K S OD 001 OS 168 MANIFEST OD /20 OS /20 7

8 EXAMINATION (CONT) DIAGNOSTIC TESTING IOP - GOLDMANN OD 15.0 OS 15.0 SLIT LAMP EXAM ADNEXA, LIDS AND LASHES,CONJUNCTIVA, IRIS, LENS ALL CLEAR OU CORNEA: EBMD OD>OS VITREOUS, MACULAE AND PERIPHERAL RETINA: CLEAR OU OPTIC DISC OD 0.4/0.4 OS 0.5/0.55 OCT OPTIC NERVE AND MACUALE OU FUNDUS PHOTOS OU PENTACAM SPECIFICALLY FOR PACHYMETRY OD 573 UM OS 585 UM RNFL - NONGLAUCOMATOUS 96 UM 100 UM RNFL AND ONH OPTIC DISC CUBE PENTACAM TO CHECK PACHYMETRY 8

9 PENTACAM TO CHECK PACHYMETRY WHATS THE DIAGNOSIS????? TOTAL DUMB LUCK INCIDENCE OF KERATOCONUS COLLAGEN CROSS LINKING REPORTED IN LITERATURE BETWEEN ~1:500 TO ~1:2000 INCREASED FREQUENCY AFTER 1995?? VITAMIN B2 AND UV-A LIGHT RECENT LETTER TO AVEDRO ABOUT POSSIBLE APPROVAL 9

10 WHY DON T MY CONTACTS WORK ANYMORE EXAM 67 Y/O FEMALE SUCCESSFUL ACUVUE BIFOCAL CL WEARER WORE MONOVISION PRIOR TO BIFOCAL NO MEDICAL HISTORY, NO FAMILY HISTORY TRENDS TOWARD EASY GOING ON DELL SURVEY CURRENT COMPLAINT CONTACTS NOT COMFORTABLE NO VISION COMPLAINTS MANIFEST OD SPHERE 20/40 OS X105 20/30- SLE TBUT 4-6 SECOND CORNEAL STAIN WITH FL 2+ OU EROSION ALONG LID MARGIN NUCLEAR SCLEROSIS 1+ OU BRUNES 2+ OU FUNDUS OLD CR SCARS AWAY FROM MACULA TREATMENT 2 WEEK VISIT DISCONTINUE CLS HOT COMPRESS BID AT QID RTO 2 WEEKS PT VERY UPSET ABOUT BEING OUT OF CLS 2 WEEKS BCVA OD 20/40 OS 20/30 SLE TBUT 4-6 SECONDS NO CHANGE IN STAINING NO CHANGE WITH LIDS PATIENT ADMITS WEARING CONTACTS SOME ADD RESTASIS BID RTO 2 WEEKS 10

11 VISITS LENS OPTIONS BETTER AT 2 WEEK VISIT EYES MORE COMFORTABLE OKAY NOT WEARING CL S 1 MONTH AFTER RESTASIS TBUT 6-8 SECONDS CORNEA CLEAR BCVA OD 20/40 OS 20/30 DISCUSSED CE WITH IOL SINGLE VISION IOL LOSES NEAR VISION FROM CL S MONOVISION IOL- GREATER DISPARITY THAN WHEN SUCCESSFUL WITH MONO MULTIFOCAL IOL SIMILAR TO CURRENT CLS ACCOMMODATIVE IOL NEED GLASSES FOR NEAR TREATMENT BINOCULAR DEFOCUS CURVE RESTOR 3.0 IOL OU 20/20 UCVA OD 20/25 OS 20/25 J2OU MANIFEST OD PLANO -0.25X180 20/25+ OS PLANO -0.25X100 20/25+ PT VERY HAPPY WITH VISION Snellen 20/25 20/32 20/40 20/50 20/63 20/80 20/ Refraction (D) IQ ReSTOR IOL +3.0 D [N=117] IQ ReSTOR IOL +4.0 D [N=114] Source: AcrySof IQ ReSTOR IOL Package Insert 44 11

12 HISTORY CLINICAL FINDINGS 50 Y/O WHITE FEMALE (MARRIED) RN FOR BLOOD BANK NO MEDICINES OR MEDICAL ALLERGIES MEDICAL HISTORY NEGATIVE OCULAR HISTORY NEGATIVE FAMILY HISTORY NEGATIVE UCVA OD 20/30 OS 20/30- MANIFEST OD X104 20/20 OS X078 20/20 CYCLOPLEGIC OD X106 20/20 OS X80 20/20 CLINICAL FINDINGS PRE-OP WAVESCANS SLE WNL FUNDUS WNL PACHYMETRY OD 524 OS 533 TBUT > 15 SECONDS K S OD 43.6@ @155 OS 43.9@ @66 DISCUSSED NEED FOR READING GLASSES AT LENGTH 12

13 POST-OP VISITS POST-OP VISITS DAY 1 UCVA OD 20/20-1 OS 20/25 SLE TRACE EDEMA OU RTO 1 WEEK DAY 7 UCVA OD 20/20 OS 20/20- SLE FLAP WELL POSITIONED RTO 3 WEEKS DAY 12 PATIENT REPORTS VERY POOR NEAR VISION UCVA OD 20/20- OS 20/20- SLE TBUT 8 SECONDS OU TRACE SPK OU MANIFEST OD SPH 20/20 OS SPH 20/20 CHANGED AT TO SYSTANE FREE POST-OP WAVESCANS 1 MONTH POST-OP NEAR VISION BETTER BUT STILL CAUSES NAUSEA AND DIFFICULTY AT WORK UCVA OD 20/20 OS 20/20 SLE TBUT 10 SEC OU TRACE SPK OD MANIFEST OD SPH 20/20 OS X90 20/20 13

14 2 MONTH POST-OP STILL HAS NAUSEA WHEN READING UCVA OD 20/20 OS 20/20- SLE TBUT 8-10 SECONDS NO SPK MANIFEST OD SPH 20/20 OS SPH 20/20 ADD GENTEAL GEL AT NIGHT 3 MONTH POST-OP NEAR COMPLAINTS LESS OKAY WITH READERS UCVA OD 20/20 OS 20/20 SLE TBUT SECONDS MANIFEST OD SPHERE OS SPHERE 5 MONTH VISIT VA AT NEAR WORSE UCVA OD 20/25 OS 20/20 SLE WNL MANIFEST OD SPHERE 20/20 OS SPHERE 20/20 TRIAL CONTACT LENS OU PATIENT REPORTS GREATLY IMPROVED VA AT NEAR, NO NAUSUA, CAN READ CHARTS WITHOUT CORRECTION CYCLO OD SPHERE OS SPHERE 14

15 ENHANCEMENT SURGERY TREAT BOTH EYES FULL WAVESCAN TREATMENT OD X116 OS X86 DAY 1 OD 20/20 OS 20/20 VA SEEMS VERY GOOD AT NEAR DAY 7 POST ENHANCEMENT AWOKE WITH VA IN OD BLURRY OD 20/70 OS 20/20 SLE VERTICAL STRAIE OD / DISLODGED FLAP STRIAE STRAIE TREATMENT FLOURESCEIN MAKES IT EASIER TO SEE AS VALLEYS AND MOUNTAINS DIFFERENTIATE WITH NEGATIVE STAINING FLAP LIFT WITH EPITHELIAL DEBRIDEMENT/ HYPOTONIC SALINE DAY 1 FLAP WELL POSITIONED / BANDAGE CONTACT LENS IN PLACE DAY 2 UCVA 20/60 / BANDAGE IN PLACE DAY 4 UCVA 20/50 / BANDAGE CL REMOVED / CELLS AT EDGE OF FLAP? 15

16 PRE EPISCRAPE PHOTO DAY 10 UCVA 20/25- EPITHELIAL INGROWTH ADDED MURO 128 QID 1 MONTH POST FLAP STRETCH UCVA 20/30+ MANIFEST OD X165 20/20 TBUT 4-6 SEC NO CHANGE IN INGROWTH MEDS RESTASIS BID MURO 128 QID AT QID 2 MONTH POST FLAP STRETCH UCVA 20/60 MANIFEST X158 20/20- TBUT SECS NO CHANGE IN INGROWTH 16

17 INSERT PICTURE PRE EPISCRAPE PHOTO POST EPISCRAPE DAY 1 UCVA 20/30 CELLS GONE TBUT 4-6 SECONDS 1 MONTH VISIT UCVA 20/40 CELLS RETURNING ADD MURO 128 MANIFEST OD X165 20/20 PRE PRK WAVESCAN 2 MONTHS POST EPI-SCRAPE UCVA 20/30- MANIFEST X160 20/20 CELLS STABLE TBUT 9-10 SECONDS 3 MONTHS POST EPI-SCRAPE UCVA 20/30- MANIFEST X165 20/30 CELLS STABLE CONSIDER PRK ENHANCEMENT 4 MONTH MANIFEST X168 CYCLO X165 17

18 PRE-PRK TOPOGRAPHY PRE PRK TREATMENT PLAN PRK POST-OP KERATOCONIC PATIENT DAY 1 20/60 BCL IN PLACE DAY 4 20/70 BCL REMOVED / RE-EPITHELIALIZED DAY 15 20/20- CELLS NO CHANGE PATIENT HAPPY WITH NEAR AND FAR VISION 3 MONTH VISIT 20/20 NO CHANGE WITH CELLS MOVING TO ENGLAND BS WHITE MALE DOB 9/17/47 LONG HISTORY OF KERATOCONUS FIRST SEEN 5/21/07 WEARING RGP S 18

19 KERATOCONUS ECTASIA KERATOCONUS IS A PRIMARY EYE DISEASE THAT RESULTS IN A DEFORMATION OF THE CORNEA AND LOSS OF VISION. THE CORNEA THINS AND BECOMES CONE SHAPED THERE IS USUALLY (ALWAYS??) A GENETIC BASIS. LOTS OF THEORIES ABOUT MECHANISM: TISSUE JUST WEAKER THAN NORMAL, UNDERGOES STRUCTURAL FAILURE, WHICH TRIGGERS MANY THINGS THERE IS AN INABILITY TO HANDLE OXIDATIVE STRESS IN THE CORNEA, DUE TO CONGENITALLY ABNORMALLY ENZYMES, WHICH CAUSES OXIDATIVE DAMAGE, APOPTOSIS, AND SO ON ECTASIA IS A CLINICAL STATE THAT HAS THE PROPERTIES AND COURSE OF KERATOCONUS, BUT OCCURS AFTER REFRACTIVE SURGERY MOST COMMONLY, POST LASIK HAS OCCURRED WITH PRK AND PTK MANY THEORIES: SOME CORNEAS ARE WEAKER THAN OTHERS SOME ARE DESTINED TO HAVE KC SOME ARE DUE TO MECHANICAL INACCURACY (FLAP TOO THICK) SURGERY SETS UP AN OXIDATIVE STRESS CASCADE, THAT IN TURN TRIGGERS KC. POST PRK KERATOCYTE APOPTOSIS CAN BE BLOCKED BY ANTIOXIDANTS. ECTASIA ANATOMICAL BASIS MICHAEL SMOLEK, PH.D. OF NEW ORLEANS HAS DETERMINED THE STRUCTURE OF THE CORNEA MAY EXPLAIN WHY ECTASIA IS MORE LIKELY AFTER LASIK ANTERIOR STROMA IS CROSS-LINKED POSTERIOR STROMA IS NOT HISTORY CHRONIC ALLERGIES- EYE RUBBING FAMILY HX- TRANSPLANT, KC REFRACTIVE STABILITY 19

20 EXAM DECREASED BSCVA REFRACTION- MYOPIA >8D US CORNEAL PACHYMETRY RETINOSCOPY MANUAL K S- IRREG, >47 WAVEFRONT- INCREASED COMA ORBSCAN/PENTACAM- POST FLOAT, THICKNESS GRADIENT ASSYMETRY BETWEEN EYES ENHANCEMENTS ECTASIA--SCREENING OTHER THINGS STEEP K: K>47 (RABINOWITZ) I/S RATIO AT 3.0 MM >1.4 ADD PARACENTRAL K INFERIORLY AND SUPERIORLY DIVIDE THE INFERIOR TOTAL BY SUPERIOR TOTAL DIFFERENCE IN K FROM RIGHT TO LEFT HIGH MYOPIA <-9.0? <-8.0? ECTASIA--SCREENING TOPOGRAPHY THE PRIMARY TOOL ASYMMETRICAL ASTIGMATISM AKA FFKC SMILEY FACE PELLUCID MD TOPOGRAPHY A COMMENT NOT EVERY CASE OF ASYMMETRICAL ASTIGMATISM RELATES TO KC OR ECTASIA. OTHER CAUSES INCLUDE DISPLACED CORNEAL APEX OR OTHER FORMS OF MISSHAPED CORNEA. AT LEAST 50% ARE PROBABLY BENIGN. YOU JUST DON T ALWAYS KNOW WHICH 50%. HOWEVER, THE MORE THE CYLINDER, THE HIGHER THE SUSPICION. 20

21 TOPOGRAPHY A COMMENT QUESTION: WHICH PATIENT SHOWS TYPICAL ASYMMETRIC ASTIGMATISM? SUMMARY OF ASYMMETRIC BOWTIE Good Bad Dangerous They are all the same topo of the same person, Just printed with different Scales: A: Automatic Adjustment B: Standard, w/ 0.25D steps C: Standard, w/ 0.50D steps SIGNS AND SYMPTOMS INITIAL TREATMENT PT REPORTS DISCOMFORT WITH CURRENT RGP S REPORTS HALO AND GLARE AT NIGHT CURRENT RGP S OD: 20/40-2 OS: 20/70-1 ADD /25 SLIT LAMP: GRADE STAINING, GRADE 2- GPC MINOR THINNING OD, MODERATE OS, VOGTS STRAIE MR: OD: X 123, 20/25- OS: X 125, 20/80 REFIT INTO NEW RGP S KERATOCONIC DESIGN WITH ACUITY: OD: 20/20-, OS 20/25 PUT ON RESTASIS BID AND BLINK QID OU MUCH BETTER VISION AND IMPROVED COMFORT 21

22 22

23 3 YEARS LATER VISION HAS DECREASED IN OD TO 20/60 PT SAYS EVERYTHING FEELS LIKE LOOKING THRU A FILM GRADE 2+ NS WITH OIL DROPLETS IN OD GRADE 1+ NS IN OS CORNEA RELATIVELY STABLE HOW TO PROCEED? SELECTION WHAT IOL TO SELECT? MONOFOCAL TORIC ACCOMMODATIVE MULTIFOCAL WE PERFORMED SURGERY OD 8/17/10, IMPLANTED CRYSTALENS 50, 4.0 OS 11/16/11, IMPLANTED CRYSTALENS AO 400 LIMBAL INCISIONS MADE TO MINIMIZE ASTIGMATISM HERE IS THE TOPOGRAPHY AFTER 1 MONTH OF NO CL WEAR 23

24 POST OP RESULTS 1 YEAR AFTER SECOND EYE MR: OD: X /25 OS: X 127, 20/30 ADD: +2.00, 20/20 NEAR PT VERY HAPPY WITH JUST WEARING SPECTACLES AND HAS DECIDED TO DISCONTINUE RGP WEAR 24

25 25