Education is the key to understanding

www.eyeworld.org Highlights from 2007 ASCRS ASOA Symposium & Congress June 2007 2007 ASCRS ASOA San Diego Show Daily Supplement AcrySof ReSTOR Lens and ReZoom: The First 15 Patients Supported by an unrestricted educational grant from Alcon, Inc. A Patient Push For Presbyopia-Correcting IOLs Physician says both lenses reduce spectacle dependence but have distinct differences Many studies have analyzed the benefits of presbyopia-correcting IOLs, but a new analysis by David F. Chang, M.D., clinical professor of ophthalmology, University of California, San Francisco, is something off the beaten path. Dr. Chang performed a prospective study comparing the benefits of bilateral AcrySof ReSTOR IOL (Alcon, Fort Worth, Texas) to bilateral ReZoom in patients younger than 70. This population was a bit more demanding in its visual needs, as they are more active people. Younger patients, after all, tend to be out more at night and use the computer more, he said. Although the study was prospective, it was not randomized because the lenses have different characteristics, and Dr. Chang wanted to match what he thought was the best lens for the particular patient. All the testing was also done at six months because it takes time to adapt to halos, for example, he said. This was presumably enough time to get used to unwanted images and to learn to use the new visual system, Dr. Chang said. Dr. Chang s study was also exceedingly comprehensive it not only focused on patients distance, intermediate, and near vision, it focused on distance-corrected near and intermediate vision. The idea of testing near and intermediate vision with the best distance correction was an attempt to measure the intrinsic properties of the optic by eliminating any residual sphere and astigmatism, he explained. Further, he performed contrast sensitivity tests and a lifestyle vision evaluation and administered a quality-of-life questionnaire. Ultimately, Dr. Chang found that both the ReZoom and ReSTOR lenses provide good uncorrected distance, near, and intermediate vision, that the lifestyle function of the IOLs performed well, and that patient satisfaction was equally good. Both of these lenses perform very well at reducing dependence on spectacles, Dr. Chang said. Of course, there were also differences. Based on a logmar analysis, Dr. Chang found that the ReSTOR lens performed better with near vision at 31 cm and near vision at best distance, both in terms of uncorrected visual acuity (UCVA) and best-spectacle corrected visual acuity (BSCVA). While intermediate was continued on page 4 Based on a logmar analysis, Dr. Chang found that ReSTOR lens performed better with near vision at 31 cm and near vision at best distance in terms of UCVA. Intermediate was shown to be slightly better with ReSTOR lens, but based on other testing, Dr. Chang said bilateral intermediate vision was generally similar between the two lenses. ReZoom performed better in terms of distance vision for UCVA. Software demonstrates a full range of vision to patients and helps convince them to opt for advanced IOL technology Education is the key to understanding that standard IOLs may no longer be the best option for many presbyopic cataract patients, according to Robert Watson, founder and president of Patient Education Concepts, Houston. "After people hear the word 'surgery,' they start thinking, 'Am I going to go blind, and how long am I going to be in hospital?'" Mr. Watson said. "They [don't] understand the importance of the decision between IOLs they are going to make." Mr. Watson has provided a unique education solution to this dilemma: the IOL Counselor. This patient-education software was "created to significantly increase the relatively low conversion ratio of patients from standard monofocal IOLs to premium IOLs," Mr. Watson said. Convincing patients The IOL Counselor is a computerbased tool that includes Stephen Dell's (M.D., Texan Eye Care, Austin) vision assessment questionnaire (VAQ), which is filled out by patients before consultation. The software also comes with a six-minute patient video, IOL-simulated scenarios, an acceptance form, a tutorial video about how to use the IOL Counselor, and a printable training manual. The VAQ helps physicians suggest particular IOLs to patients based on their lifestyle and personality, in addition to conventional measures such as visual acuity and candidacy for an upgrade to a presbyopia-correcting lens. The IOL Counselor also simulates how monofocal IOLs compare to presbyopia-correcting IOLs via reallife situations such as being at a supermarket or on a baseball field or city street. Patients can compare seeing through cataracts to seeing with presbyopia and with normal vision. These important scenes acquaint the patient with how a presbyopia-correcting IOL can provide a full range of vision for patients, unlike standard IOLs. The day scenes and night scenes are another IOL Counselor benefit, said Mr. Watson. Multifocal IOLs, for instance, generate some degree of halos at night, which can create problems if patient expectations are not set properly. "We can show patients in advance what this looks like," said Mr. Watson, who noted patients also could be told that "as the brain adapts, visual symptoms will become less and less noticeable. Further, they are not going to prevent you from driving." Animated surgeries also can be shown with the IOL Counselor to better explain cataract surgery and accompanying procedures such as limbal-relaxing incisions. Finally, the acceptance form that comes with the IOL Counselor does at least two important things: asks patients to acknowledge that the simulator does not guarantee individual post-operative visual acuity, and if they are deciding against presbyopiacorrecting lenses, it causes them to rethink the importance of making a decision that will affect their quality of vision for the rest of their lives. An ardent advocate Mr. Watson is convinced that upgrading to presbyopia-correcting IOLs is in many patients' best interest. "We came across very happy people with these lenses," he said. "The satisfaction level was well above 95% with each one of the IOLs." But he sees problems with the current environment of converting more patients from using standard IOLs to using presbyopia-correcting ones. One problem is how physicians view the time they spend in clinics. Mr. Watson said many ophthalmologists often think they have to see more patients to make money because of Medicare cutbacks, and they don't want to spend 20 minutes talking to patients about the benefits of presbyopia-correcting IOLs because of this. Further, clinic staff members such as surgical counselors are not well versed in selling the new technology. "They are not well trained in presenting [options] or selling," Mr. Watson said. "They are not skilled like refractive counselors are in selling and closing." The IOL Counselor allows surgical staff to become more proficient in continued on page 4

2 ASCRS San Diego, Show Daily Supplement Highlights from 2007 ASCRS ASOA Symposium & Congress Bilateral Implants Better Than Mixing and Matching One study finds that using a single lens such as the ReSTOR IOL is preferable to mixing and matching IOLs Theoretically, mixing and matching IOLs could increase spectacle independence for a lot of patients, said Paul Mann, M.D., Mann Eye Institute and Laser Center, Houston. After all, the AcrySof ReSTOR lens (Alcon, Fort Worth, Texas) is known to give patients very good near vision, and ReZoom is known for its ability to provide intermediate vision, Dr. Mann said. Some reports came out as early as 18 months ago suggesting that mixing and matching indeed provide such benefits, he said. But a recent study that Dr. Mann performed revealed something different. The study, in which 210 patients were surveyed, pitted the long-term results of bilateral ReSTOR lenses against bilateral ReZoom, bilateral crystalens, and ReSTOR lens in one eye and ReZoom in the other. When the results came in, the ReSTOR lens in one eye and ReZoom in the other led to spectacle independence in 55% of patients, Dr. Mann said. But clearly, the bilateral ReSTOR lens and bilateral ReZoom group had better vision, he said. Seventy-eight percent of bilateral ReSTOR lens patients achieved spectacle independence, and 65% of ReZoom patients achieved spectacle independence, he said. Mixing and matching only came out ahead of bilateral crystalens (which led to spectacle independence in 49% of patients), he said. "The ReSTOR lens gives very good near vision, excellent distance vision, and sufficient intermediate vision, but a lot of people are motivated to be glasses free, so they just move objects around and try to see clearly." Interestingly, even with crystalens, while the rate of spectacle independence was clearly lower, patients were still happy with it, Dr. Mann said, adding, "That's due to patient education." His clinic counseled these patients. When they try to see upclose, they probably are going to The ReSTOR lens gives very good near vision and excellent distance vision.... Paul Mann, M.D. Bilateral implantation of a presbyopia-correcting IOL, especially with ReSTOR, generally leads to more spectacle independence than mixing and matching IOLs. need reading glasses, he said. Therefore, these patients were prepared to not be entirely spectacle free, so they were still pleased with their results, he said. It's important to note that in spite of our excellent results with bilateral ReSTOR lens, not all patients should receive this lens, Dr. Mann said. If a 48-year-old patient who worked on computers a lot came in, Dr. Mann said he would not recommend bilateral ReSTOR lenses because intermediate vision is not optimal. Instead, he would recommend trying either bilateral ReZoom although there is more halo effect at night or crystalens, which doesn't provide excellent near vision, he said. The bottom line, though, is that Dr. Mann's clinic is not doing much mixing and matching of the ReSTOR lens and ReZoom anymore, he said. He is much more confident with bilateral implantation of one type of lens and frequently that lens is the ReSTOR lens. Paul Mann, M.D. is in private practice, Mann Eye Institute and Laser Center, Houston. Contact him at 713-580- 2568 or paul.mann@manneye.com. Not All Multifocals Are Equal Headlight halos are minimized with AcrySof ReSTOR IOL Aheadlight simulation has shown that prebyopia-correcting IOLs are not all the same in terms of halo effects. Clinically, these results suggest the ReSTOR lens will produce the least amount of visual disturbance. Richard Tipperman, M.D. A headlight simulation shows the halo with the ReSTOR lens (left) is minimized while halos with the ReZoom lens (center) and Tecnis MF lens are larger. Richard Tipperman, M.D., Wills Eye Hospital, Philadelphia, compared pinhole images obtained through a modified ISO model eye using a 5-mm aperture and a white light source for three different multifocal IOL designs. The light intensity was equivalent to a headlight source from a 2006 Honda measured at 18 degrees offaxis and at 360 meters away. All the lenses yield some rings, but AcrySof ReSTOR lens (Alcon, Fort Worth, Texas) yields the least, Dr. Tipperman said. He compared the ReSTOR IOL to the ReZoom and the Tecnis Multifocal. Indeed, from the images taken, the Tecnis Multifocal halo has the largest diameter, followed by the ReZoom lens. Halos from the ReSTOR lens looked minimal. The results make sense in light of the lens designs, he said. While all multifocal lenses have the potential for producing glare and halos because they split incoming light to near and distance focal points, Dr. Tipperman said the ReSTOR lens design minimizes visual symptoms, in part because of its apodized diffractive lens design and partly because this portion of the lens also is located more centrally and does not go out into the periphery. Intrinsic to the multifocal IOL design is stray light arc caused by misdirection of light to the near image, Dr. Tipperman said. The apodized diffractive steps of the continued on page 5

Highlights from 2007 ASCRS ASOA Symposium & Congress ASCRS San Diego, Show Daily Supplement 3 Great Distance Vision With New Toric Lens Astigmatics do much better with a toric than a standard IOL It s no surprise that in a trial of the AcrySof Toric IOL (Alcon, Fort Worth, Texas) versus AcrySof Natural (Alcon), the former did a much better job at correcting astigmatism, said Stephen S. Lane, M.D., clinical professor, University of Minnesota. But it s notable that with minor adjustments in technique, surgeons can be giving patients with astigmatism better uncorrected distance vision than they could get with a normal IOL, he said. What we found was that in a very high percentage of people with binocular implantation of the toric, lens vision was good enough without any spectacle correction for distance, Dr. Lane said. In a study of 211 AcrySof Toric IOL patients versus 209 controls (implanted with AcrySof Natural), the toric group consistently had less residual astigmatism after implantation, Dr. Lane said. Nearly 90% had less than or equal to 1 D of residual astigmatism versus about 50% in the control group, Dr. Lane said. Further, more than 60% had less than or equal to 0.5 D of astigmatism compared to about 20% in controls, he said. More than 90% achieved 20/40 uncorrected distance visual acuity (UCVA) or better in the AcrySof Toric lens group; less than 80% achieved 20/40 in the control group, Dr. Lane said. Nearly 40% achieved 20/20 or better versus about 20% in the control group, he said. More importantly, 97% of AcrySof Toric IOL patients achieved spectacle freedom with binocular implantation Drive Safer With Aspheric IOLs Once implanted, the AcrySof Toric lens rotates less than the STAAR Toric IOL. versus only 50% in controls, Dr. Lane said. What s more, the AcrySof Toric IOL demonstrates excellent rotational stability, which is a concern for the STAAR Toric IOL, he added. When one study of the STAAR device was compared to a separate study of the AcrySof Toric IOL, the AcrySof Toric lens rotated less than or equal to 10 degrees in 97.4% of patients; the STAAR Toric IOL rotated One of the key features of the AcrySof Toric lens is how rotationally stable it is. Stephen S. Lane, M.D. less than or equal to 10 degrees in only 76% of patients, Dr. Lane said. One of the key features of the AcrySof Toric lens is how rotationally stable it is, Dr. Lane said. Finally, little adjustment is necessary to implant the AcrySof Toric IOL compared to implanting a standard AcrySof Single-Piece IOL (Alcon), Dr. Lane said. The AcrySof Toric is a foldable, injectable lens, as is the AcrySof Natural lens, he said. The only difference is that once the lens is implanted, it must be rotated into proper position, he said, which can easily be achieved via Sinskey hook. Stephen S. Lane, M.D. is clinical professor, University of Minnesota, and in private practice, St. Paul, Minn. Contact him at 800-846-1877 or sslane@associatedeyecare.com. Lens recipients detect, identify road targets more quickly Contrast sensitivity is critical, and that s most apparent while driving at night, said Robert Lehmann, M.D., clinical associate professor of ophthalmology, Baylor College of Medicine, Houston, and in private practice, Lehmann Eye Center, Nacogdoches, Texas. Good contrast sensitivity could allow a driver more time to react and stop before hitting an object or causing an accident, he said. Further, In every case every parameter of the study the aspheric lens came out ahead of the spherical lens. Robert Lehmann, M.D. in a recent study, the AcrySof IQ IOL (Alcon, Fort Worth, Texas) demonstrated superior functional performance in contrast sensitivity with a nighttime-driving simulator, he added. In every case every parameter of the study the aspheric lens came out ahead of the spherical lens, Dr. Lehmann said. This aspheric posterior surface, when compared to an AcrySof spherical IOL, demonstrated clinically relevant advantages in the amount of time to react to targets, Dr. Lehmann said. In a study of 44 subjects, the AcrySof IQ lens consistently performed better than the AcrySof Natural lens (SA60AT), from detection to identification of targets, in both city and rural situations, Dr. Lehmann said. For example, in a city setting, eyes implanted with the AcrySof IQ lens detected and identified pedestrians in fog and glare conditions and road signs in glare conditions at least a halfsecond before their AcrySof Natural lens counterparts did, he said. A half-second is considered very significant when driving, he said. In the study, a half-second additional reaction time equated to 25 feet, he said. In a rural setting, IQ eyes also detected warning signs in fog and In a city setting, eyes implanted with the AcrySof IQ IOL identified pedestrians in fog, road signs in glare conditions, and pedestrians in glare conditions at least a half-second before their AcrySof Natural IOL counterparts did. pedestrians and warning signs in glare conditions at least a half-second before the other group. They also identified warning signs in fog, glare, and in normal conditions at least a full second before AcrySof Natural eyes. Across the board, in all instances of night-driving simulator testing, the AcrySof IQ performed better than the spherical control, Dr. Lehmann said. The specific instances mentioned were the ones in which the better continued on page 6

4 ASCRS San Diego, Show Daily Supplement Highlights from 2007 ASCRS ASOA Symposium & Congress continued from page 1 communicating to patients the benefits and fees of premium IOLs, Mr. Watson said. But the software is only part of the equation, so he recommends that physicians educate patients about the benefits of presbyopia-correcting IOLs. He suggests We took practices converting 5% up to 30%. One practice that was converting 30% is now way up to 80%. Robert Watson that patients are mailed or given collateral materials at the front desk and shown videos in the reception area, which should take about 10 to 30 minutes. Technicians working up the patient should explain options, benefits, and fees in-depth during 40- to 60-minute sessions. In addition, the surgeon should have two to five minutes for further explanation. Finally, the surgical counselor should spend five to 20 minutes with the patient going over any additional questions and concerns and uses the IOL Counselor to help close the sale. Success in the making Mr. Watson said practices that use the IOL Counselor are finding that conversion rates from standard IOLs to presbyopia-correcting IOLs are higher than ever. "We took practices converting 5% up to 30%," Mr. Watson said. "One practice that was converting 30% is now all the way up to 80%. The IOL Counselor is a highly effective tool for increasing conversions for practices." Mr. Watson intends to make the IOL Counselor an internationally beneficial, introducing foreign-language software at this ASCRS ASOA Symposium & Congress. Languages that will be available include Spanish, Portuguese, French, and German. Posters, DVDs, and other material will also be available at the convention. He also intends to make some elements of IOL Counselor available on The IOL Counselor vision simulator begins with this page. the Web to provide even easier patient access to the information. Robert Watson is founder and president of Patient Education Concepts Inc., Houston. Contact him at: 800-436-9126 or robertw@patientedconcepts.com. continued from page 1 One out of four patients in both groups stated that he had to wear glasses all the time to read the computer. also shown to be slightly better with the ReSTOR lens, based on a variety of testing, Dr. Chang said bilateral intermediate vision was generally similar between the two lenses. The ReZoom performed better in terms of distance vision for UCVA and BSCVA. Dr. Chang said there was no measurable difference in photopic and mesopic contrast sensitivity between the lenses. Regarding lifestyle testing, Dr. Chang said both groups performed well watching television without glasses as well as reading traffic, street, and store signs in daylight without glasses. Performing fine handiwork was a bit harder for everyone, he said. Many ReZoom patients (57%) had no difficulty, but the other 43% had extreme difficulty, he said. In the ReSTOR group, 38% had no difficulty, 37% had a little difficulty, and 25% had moderate difficulty. No ReSTOR patients had extreme difficulty in this area. The ReSTOR lens performed better than the ReZoom lens in terms of patients reading a menu in dim light Both of these lenses perform very well at reducing dependence on spectacles. David F. Chang, M.D. without glasses. When reading was tested with best distance correction, both groups performed well with magazine print, but ReSTOR lens patients did better reading stock prices. ReSTOR patients had less difficulty than ReZoom patients when writing checks, paying bills, and filling out forms. Both patient groups performed fine in terms of shaving or styling one s hair. Both groups also did well cooking without glasses. Computers were a problem for a number of people in both groups, Dr. Chang said. One out of four patients in both groups stated that he had to wear glasses all the time to read the computer. Although 60% of the patients in both groups noticed halos, the severity of halos was worse with the ReZoom lens. Two ReZoom patients could not tolerate halos, and despite being 20/20 and J1, one had his ReZoom explanted; the other patient delayed his second eye s IOL surgery. Because these patients could not complete the study, they were not included in the six-month data. Seventy-two percent of ReSTOR lens patients said they achieved complete spectacle freedom from surgery compared to 50% of ReZoom patients. I think that these percentages were lower than those in other studies because these patients were all younger than 70, said Dr. Chang. For example, it is easier to make older cataract patients spectacle independent if they don t use computers or drive at night. Again, overall satisfaction with vision was very high, and 100% in both groups said they would have the same IOL again. This was a very important finding, Dr. Chang said. I believe that because I stressed preoperatively that most patients will still need glasses for some activities, the satisfaction rate was very high despite the fact that so many patients in this younger age group did not achieve spectacle independence with bilateral multifocal IOLs. David F. Chang, M.D. is clinical professor of ophthalmology, University of California, San Francisco. Contact him at 650-948-9123 or dceye@earthlink.net. Special Note: David F. Chang, M.D. won a Best Paper of Session award at the ASCRS ASOA Symposium & Congress for this presentation.

Selling the Presbyopic Lens Idea Better Highlights from 2007 ASCRS ASOA Symposium & Congress ASCRS San Diego, Show Daily Supplement 5 More effective selling requires more discussion with patients, more time for surgeons Creating a block [of time] in which the patient is evaluated, diagnosed, educated, and scheduled in less than two hours will increase total cataract surgeries by at least 10%. Kay Coulson continued from page 2 [ReSTOR lens] gradually apportion more light to the far image as pupil size increases, effectively limiting nighttime arc caused by stray light. The Tecnis Multifocal lens also includes diffractive rings, but these are not apodized and are located in the lens periphery (and centrally), he said. The ReZoom lens, he said, has zonal refractive rings that also lead into the periphery; therefore, these two lenses tend to produce more visual side effects. Simulating car headlights at nighttime, a pinhole image viewed Kay Coulson, president of Elective Medical Marketing, helps physicians quantify their "lifestyle IOL" financial opportunity, in part, by measuring the performance of their practice. While presbyopia-correcting IOLs are a proven boon to many patients, only 20% of ophthalmic practices have embraced this upgraded technology, said Kay Coulson, president of Elective Medical Marketing, Boulder, Colo. The remaining 80% of surgeons were certified in one or more of the lenses but are implanting very few and have not made upgrades a significant priority within their practices, said Ms. Coulson, who has numerous suggestions that would allow the surgical community to more effectively embrace this beneficial technology. through three IOLs demonstrated that the apodized diffractive design resulted in the best image quality for large pupils at nighttime, Dr. Tipperman said. Clinically, these results suggest the ReSTOR lens will produce the least amount of visual disturbance. Richard Tipperman, M.D. is in practice, TLC Laser Eye Centers, and is a member of the active teaching staff, Wills Eye Hospital, Philadelphia. Contact him at rtipperman@mindspring.com. Moving up the food chain One successful method to transition to presbyopia-correcting IOLs is what Ms. Coulson refers to as moving up the food chain. To do this, she said, first diagnose the cataract. Second, have patients agree that it is time for surgery. Third, review the risks and benefits. Lastly, move into the IOL option discussion. The transition to options is often handled by saying: If this were three years ago, we d agree on your surgery I d cover the risks, and you d be done, Ms. Coulson said. Today, however, you have options. Key areas the surgeon should probe to evaluate the right IOL combination include computer use, reading activity, hobbies and sports, and driving requirements that require distance vision or night-vision clarity, she said. The IOL options should be presented in a way that progresses from most glasses wear to least glasses wear, Ms. Coulson said. The IOL options could be highlighted as follows, she said: The monofocal method is first. The surgeon could note that this is a tried-and-true solution, but you ll continue to wear glasses for virtually all tasks. The toric lens is second. The ophthalmologist could mention that this is a good distance solution, and you ll regain some intermediate vision, but you will still wear glasses for near tasks. Obviously, if the patient has no corneal astigmatism, toric is left out of the discussion, but it is otherwise presented. The multifocal lens is third. This final option is the best of all worlds improved distance, intermediate, and near vision, with the least reliance on any glasses. We re finding with this progressive approach that most people want to move right past the base monofocal option to either toric or multifocal lenses, Ms. Coulson continued. Toric has been an easier conversation than we expected because so many patients know they have astigmatism and have considered it almost a disease all these years. Their response is, Of course, I want that corrected. Penciling them in Upgrading to more advanced IOL technology isn t just about convincing patients, it s about finding enough time to do it. The single biggest barrier to success right now in any ophthalmology practice is the appointment calendar, Ms. Coulson said. For years, ophthalmology practices have operated with essentially no appointment definition other than short [visit] and long visit. The schedule is driven by whomever calls. Glaucoma and post-surgical patients are often filling up time that otherwise might be taken up explaining lens options to cataract patients. Proactive lens surgeons, particularly those focused on upgraded lenses, are seizing the opportunity to clarify their practice focus, Ms. Coulson said. They will see only surgical patients or those developing into surgical patients. Hence, glaucoma patients are switched to glaucoma specialists, and post-surgical lens patients can be shifted to a wellness doctor within the practice retained for annual exams, she continued. I also advocate creating scheduling blocks on which cataract evaluations are seen on certain days or at certain times, Ms. Coulson said. Eliminating other visits allows each member of the team to focus on a single category: cataract patients. The front desk and staff will be more focused, the surgeon will relax into a rhythm of conversation with similar patients, and the office will run on time. Ms. Coulson is confident such changes would increase both cataract patient satisfaction and practice revenue. Creating a block [of time] in which the patient is evaluated, diagnosed, educated, and scheduled in less than two hours will increase total cataract surgeries by at least 10% and increase upgrades to 25% to 40% of total surgeries, she said. In several practices I work with, we ve seen cataract upgrades in the 25% to 55% range of total surgeries, with roughly one-fourth of the upgrades coming from astigmatism management and the remaining three-fourths from presbyopic lenses. For a 50-eye-per-month cataract practice generating $450,000 annually in surgical revenue, similar changes will almost double surgical revenue to $850,000. Kay Coulson is president and president, Elective Medical Marketing, Boulder, Colo. Contact her at 303-994-0014 or kay@electivemed.com.

6 ASCRS San Diego, Show Daily Supplement Highlights from 2007 ASCRS ASOA Symposium & Congress 500 ReSTOR IOL Cases Speak Volumes About Lens Unaided 20/20 vision is typical, but careful patient selection is a must While most surgical practices are not yet using presbyopia-correcting IOLs, Con Moshegov, FRANZCO, medical director, Perfect Vision Laser Correction, Sydney, Australia, has experience implanting more than 500 eyes, giving him a unique perspective on how well such patients turn out and who the best candidates are. His perspective is a very positive one. The standard with the AcrySof ReSTOR lens (Alcon, Fort Worth, Texas) is 20/20 without glasses in my hands, Dr. Moshegov said. Specifically, Dr. Moshegov found 76% of eyes seeing 20/20 uncorrected visual acuity (UCVA) or better, 94% seeing 20/30 or better, and all seeing 20/40 or better. Dr. Moshegov tempered his good results with some concessions, including that many of his patients were refractive lens exchange patients, not patients with macular degeneration, glaucoma, or other visually disabling diseases. Therefore, I d like to stress to people that I think the ReSTOR IOL is a fabulous lens that is underused. Con Moshegov, FRANZCO The ReSTOR lens implanted in both eyes leads to greater spectacle independence than pairing the lens with another type of lens. mediate vision with the ReSTOR lens is not optimal, eyes perform reasonably well when they both are implanted. In one subset of 54 patients pitting bilateral ReSTOR lenses against mixing and matching ReSTOR/ReZoom and ReSTOR/Array IOLs, the mixtures did not improve performance. The bilateral ReSTOR IOL alone achieved spectacle independence in more then 80%. Those with ReSTOR lens and ReZoom combinations achieved just more than 60% spectacle independence. And those with the ReSTOR lens and Array combinations achieved less than 60% spectacle independence. I feel better keeping things symmetrical and using ReSTOR lenses in both eyes, Dr. Moshegov said. Dr. Moshegov has fixated on particular candidates he considers ideal for ReSTOR lens implantation. The best candidates are hypermetropic, starting to lose distance vision despite being hypermetropic, have unaided vision less than 20/40 or 20/60, and perhaps have a little astigmatism. These should be otherwise perfectly healthy eyes without a hint of macular trouble. People who are not ideal candidates for these lenses are low myopes -1 to -2, Dr. Moshegov said. They know their vision post-restor lens is not as good as natural vision for reading, and improvement in their distance vision is not quite good enough [to make them happy]. If they do have dense cataracts, however, they still could be good ReSTOR lens candidates. Patients with large amounts of astigmatism also do not do well with the ReSTOR lens, he said. The manufacturers of the ReSTOR lens have done a good job at keeping halo complaints at bay, Dr. Moshegov said. Apodization, the technology that makes the ReSTOR lens possible, was designed so that not as many severe unwanted visual aberrations such as halos occur. There is one trade-off with this technology, Dr. Moshegov said: When light levels are low, it is more difficult for patients to read without glasses. I d like to stress to people that I think the ReSTOR IOL is a fabulous lens that is underused, he said. You have to be careful in selecting patients. If you implant presbyopia-correcting lenses liberally, without good case selection, you will be disappointed. But overall, Dr. Moshegov said, the ReSTOR lens is a very powerful tool in treating presbyopia. Con Moshegov, FRANZCO is medical director, Perfect Vision Laser Correction, Sydney, Australia. Contact him at 612-9482-5155 or con@perfectvision.com.au. unlike an ordinary cataract population, his patients were prone to achieve better results. But the fact remains that the ReSTOR IOL is an excellent lens, he said. In their 40s, people face presbyopia and need reading glasses or bifocals that irritates them, Dr. Moshegov said. That s when they come to us and seek some help. If you perform laser eye surgery, that can give distance vision, but reading vision won t be the best. The ReSTOR lens is a very viable option in that situation. There were also some pleasing findings in Dr. Moshegov s study. One pleasant surprise is that vision gets better as time goes on, he said. At one month, quite a substantial proportion of patients about onethird needs glasses. That proportion goes down over six months. Dr. Moshegov also found that while intercontinued from page 3 In a rural setting, AcrySof IQ eyes identified warning signs in fog, glare, and in normal conditions at least a full second before AcrySof Natural eyes. performance achieved statistical significance. This all makes sense in the context of a study of patient contrast sensitivity comparing the two lenses, he said. Eyes implanted with the AcrySof IQ lens had better contrast sensitivity, Dr. Lehmann said. At 3 cpd without glare, the AcrySof IQ lens had 1.79 log units of contrast sensitivity versus 1.69 log units with the AcrySof Natural lens, he said. At 6 cpd without glare, the AcrySof IQ lens had 1.77 log units versus 1.68 in the AcrySof Natural IOL group. The AcrySof IQ lens also performed better at 3 cpd and 6 cpd with glare, although the differences did not reach statistical significance. The reason that the statistical significance was achieved in the aspheric lens without glare is because a glare device would cause constriction of the pupil, Dr. Lehmann said. You would expect with a small pupil that the asphericity of the implant would have less impact. The results of this study support what Dr. Lehmann does in clinical practice: use the AcrySof IQ lens in all patients who do not desire accommodative or multifocal technology or who have not previously undergone hyperopic LASIK. Robert Lehmann, M.D. is clinical associate professor of ophthalmology, Baylor College of Medicine, Houston, and in private practice, Lehmann Eye Center, Nacogdoches, Texas. Contact him at 936-679-7500 or doctorlehmann@gmail.com.

Highlights from 2007 ASCRS ASOA Symposium & Congress ASCRS San Diego, Show Daily Supplement 7 Match, Don t Mix Surgeon finds the ReSTOR lens works better bilaterally than in combination with another lens Mixing and matching IOLs is a topic of intense discussion. But recently it has received some serious scientific study, and the results aren t looking so good, according to Richard Mackool, M.D., senior attending surgeon, New York Eye and Ear Institute, New York. Dr. Mackool performed a randomized study in 30 eyes (15 patients), implanting the ReSTOR lens (Alcon, Fort Worth, Texas) in one eye and ReZoom in the other two to four weeks later. Twenty-six eyes (13 patients) were cataract patients, and four eyes (two patients) were refractive lens exchange patients. One patient was lost during the follow-up period. The patients were advised that they could have an IOL exchange of either eye to their lens of choice. Dr. Mackool considered both objective and subjective outcomes. He measured patient best-corrected visual acuity (BCVA) at one and three months post-operatively, specifically looking at best spectacle corrected distance visual acuity; intermediate visual acuity at 50 cm, 60 cm, and 70 cm; and near vision at patients preferred distance with best distance correction. Dr. Mackool found that if you want a high percentage of patients that wants great vision, you have to do both eyes [with the same lens]. If If you want a high percentage of patients that wants great vision, you have to do both eyes [with the same lens]. Richard Mackool, M.D. Aspheric IOL Decreases Higher-Order Aberrations Five patients requested to have an IOL exchanged they chose to explant ReZoom and implant the ReSTOR lens every time you mix, one disadvantage is less near vision, he said. There is also a much lower percentage of patients that can read with 20/20 vision or better. I m sure they re going to read slower, he said. There is less stereopsis at intermediate. Vision will also be de-focused in one eye compared to the other. Dr. Mackool also found that there was no objective or subjective continued on page 8 Differences are noticeable with AcrySof IQ, most prominently at nighttime with large pupils Aspheric IOLs are considerably beneficial in reducing quality-of-vision aberrations, according to Shady T. Awwad, M.D., director, refractive surgery division, American University of Beirut Medical Center, Beirut, Lebanon. Dr. Awwad looked at 52 eyes of 36 patients that received either the AcrySof IQ IOL (Alcon, Fort Worth, Texas) or the AcrySof Natural IOL (Alcon). Twenty-seven eyes were in AcrySof IQ seems to provide better mesopic contrast sensitivity profile at high-grating frequencies. Shady T. Awwad, M.D. the AcrySof IQ IOL group; 25 were in the AcrySof Natural group. Under photopic conditions, there was no significant difference in contrast sensitivity. But under mesopic conditions, at 12 cpd and 18 cpd, contrast sensitivity was statistically significantly better with the AcrySof IQ IOL (although there was no statistical difference at 3 cpd and 6 cpd). Further, with both 4-mm and 6-mm pupils, total higher-order aberrations (HOAs) and spherical aberration were statistically significantly higher in the AcrySof Natural IOL group. However, differences were more pronounced with the larger pupil size. Interestingly, this means that the population that would likely benefit most from this lens would be a younger group. Pupils in the younger population are usually larger, Dr. Awwad said. AcrySof IQ lens does decrease spherical aberration with concomitant decrease in HOAs, more so over large nighttime pupils than smaller daytime pupils. The AcrySof IQ IOL seems to provide better mesopic contrast sensitivity profile at high-grating frequencies. Further, he said, Subclinical decentration and/or tilt of AcrySof IQ lens does not seem to affect coma levels as compared to the AcrySof Natural lens. This study also adds a dimension that other studies have not: an Under mesopic conditions, at 12 cpd and 18 cpd, contrast sensitivity was statistically significantly better with the AcrySof IQ lens than with the AcrySof Natural IOL. apples-to-apples comparison. The current study compared two identical IOLs, except for the optic design: spheric versus aspheric, Dr. Awwad said. That s an advantage over other studies in the literature. Shady T. Awwad, M.D. is director, Refractive Surgery Division, American University of Beirut Medical Center, Beirut, Lebanon. Contact him at sawwad@eyeweb.org.

8 ASCRS San Diego, Show Daily Supplement Highlights from 2007 ASCRS ASOA Symposium & Congress Eye Simulator Compares Multifocal Halos All multifocals produce halos, but some are less pronounced than others One way to study the impact of glare and halos is simply to ask patients about them. But Jim Schwiegerling, Ph.D., Department of Ophthalmology and Vision Sciences, University of Arizona, Tucson, has a totally different method. He uses a portable digital imaging system that consists of an eye model attachment comprised of an artificial cornea and wet cell for mounting IOLs, a macro lens, and a commercial Nikon digital SLR camera to detect such visual symptoms. The system mimics the vergence and imaging properties of the human eye, Dr. Schwiegerling said. This device was particularly useful when comparing three different IOL designs: the AcrySof ReSTOR lens (Alcon, Fort Worth, Texas), the ReZoom, and the Tecnis MF. We have looked at a lot of different multifocal IOLs because they re the most problematic in terms of side effects, Dr. Schwiegerling said. In order to get two distances, you have to give up something, give up quality of night vision with large pupils especially. There are also quality-of-vision differences among such lenses because their designs are different, as Dr. Schwiegerling s study showed. All three lenses are multifocals based on different design philosophies, Dr. Schwiegerling said. The ReZoom is a zonal refractive lens, the Tecnis MF is a full aperture diffractive lens, and the ReSTOR lens is an apodized diffractive lens. The diffractive elements tend to cause continued from page 7 difference with the ReSTOR lens or ReZoom with best corrected distance vision at three months. However, ReZoom performed better than the ReSTOR lens objectively and subjectively at intermediate vision at three months. For near vision at three months, the ReSTOR lens performed better than ReZoom objectively and subjectively. Five patients also requested to have an IOL exchanged they chose to explant ReZoom and implant the ReSTOR lens every time. Reasons for the change included poor near vision (five patients), poor intermediate vision (one patient), poor distance vision (two patients), and glare/halo (two patients). One month after the exchange, none of the patients had any complaints with the new ReSTOR lens. In these cases, the ReSTOR lens tends to minimize the side effects [halos] compared to the other two lenses. Jim Schwiegerling, Ph.D. arcs around bright light sources in nighttime scenes, whereas the zonal refractive causes a continuous flare. Dr. Schwiegerling commented on images taken with each lens more specifically, the first being photos of a car s headlights, with a series of red lights in the background at night with a 6-mm pupil. The picture through the ReZoom lens showed arc-like halo portions that appeared smeared. Not being diffractive causes continuous smearing of light, he said. Meanwhile, the red-light arc was stretched out a bit more with the Tecnis lens, but it was not smeared. The arcs were the most minimal with the ReSTOR lens. The car headlight halos were also most pronounced with the ReZoom, less so with the Tecnis MF, and least so with the ReSTOR lens. In another series of photos, Christmas lights at nighttime through a simulated 6-mm pupil, which Dr. Schwiegerling described as a worstcase-scenario, the ReSTOR lens again came out ahead of the competition. Further, Dr. Mackool said there are many disadvantages to only one speculated advantage of mixing multifocal IOLs: There is a decrease in near vision, a decrease in near vision stereopsis, a decrease in intermediate vision stereopsis, and an increase in glare symptoms. The one touted advantage, which is questionable, is an increase in intermediate visual acuity. Ultimately, if a practice is mixing and matching IOLs, said Dr. Mackool, it s making the ReSTOR lens look worse. Richard Mackool, M.D. is senior attending surgeon, New York Eye and Ear Institute, New York. Contact him at 718-228-3400 or mackooleye@aol.com. The ReSTOR lens produces the least visual side effects caused by a car's headlights and background red lights. This nighttime scene of Christmas lights causes the least amount of visual side effects with a ReSTOR lens. In these cases, the ReSTOR lens tends to minimize the side effects [halos] compared to the other two lenses, he said. In the final series of photos, again, Christmas lights at nighttime, side effects were minimized because the images were taken through a simulated 4-mm pupil. Still, the other lenses do not perform as well as ReSTOR lens in terms of eliminating visual symptoms. These results clearly have real-life significance, Dr. Schwiegerling said. I think patients who are driving at night with the ReSTOR lens are going to have less stress and fewer side effects of arcs in their field of view, so they benefit in terms of being able to see street signs, navigating, and reducing risks of accidents, he said. The ReSTOR lens provides additional comfort and confidence while driving. However, Dr. Schwiegerling noted that while his test is a simulation of what the eye sees under such circumstances, neuroprocessing is involved in the actual eye, which likely further minimizes these quality-ofvision symptoms. The brain is very good at taking really bad images and seeing well, he explained, so these images are probably more worst-case scenarios because people take images and fil- ter out extraneous stuff. Nonetheless, when comparing the lenses side by side in terms of nighttime visual disturbances in real eyes, the AcrySof ReSTOR lens still should come out ahead, he said. Dr. Schwiegerling said all of the lenses are designed to give both near vision and distance vision and that all work in normal daylight conditions. He also said that while he has heard reports suggesting ReZoom provides better intermediate vision, he considers the safety of the ReSTOR lens to be more important because it reduces nighttime visual symptoms that could be dangerous while driving. Jim Schwiegerling, Ph.D. is associate professor of ophthalmology, Department of Ophthalmology and Vision Sciences, University of Arizona, Tucson. Contact him at 520-621-8688 or jschwieg@u.arizona.edu. These sessions from the 2007 ASCRS ASOA Symposium & Congress were reported and written by Matt Young, EyeWorld Contributing Editor.