Advanced Technology IOLs

Introduction Advanced Technology IOLs Stephen V. Scoper, MD Virginia Eye Consultants 2013 Cataract surgery has a refractive element Patient expectations are increased Close is no longer good enough The promise of effective astigmatism correction is here! Why do we treat astigmatism? Quality of vision after cataract surgery Quality of life after cataract surgery Astigmatism in the Population Astigmatism According to Dr. Hill s analysis, 37.8% of patients with cataract have more than 1.0 D of preexisting corneal astigmatism Courtesy of W. Hill, M.D. Surgical Correction of Astigmatism LenSx arcuate incisions Methods of correcting astigmatism Operating on steep axis Limbal relaxing incisions Astigmatic Keratotomy LenSx Laser Toric IOLs Post operatively Laser refractive surgery Astigmatic Keratotomy 1

Astigmatism: first question Is the astigmatism corneal or lenticular? Cataract evaluation: current glasses -3.00 + 1.25 x 90 Keratometry: 45.00/45.50 x 90 Cataract evaluation: must obtain keratometry/topography before the patient sees the doctor Astigmatism: caveat The post-lasik patient who has been emmetropic for years may have lenticular astigmatism Cataract surgery will manifest this corneal astigmatism that was created with the lasik to treat the lenticular astigmatism Review topography carefully Patient Selection: Toric IOL Cataract patient with 0.75 diopter of pre-existing corneal astigmatism Consider surgically induced astigmatism What is your incision How much cylinder do you induce AcrySof Toric IQ Design Characteristics Design Acrylic Single-Piece platform Posterior toricity Toric axis marks What is the expected residual cylinder post-operatively Understanding AcrySof IQ Toric IOL Benefits Toricity Rotational stability Reduction of residual refractive cylinder Increased spectacle-independent distance vision Wide range of cylinder powers Asphericity Enhanced image quality Reduction in spherical and total higher order aberrations Increased contrast sensitivity Improved functional vision Thinner edge profile Rotational Stability Generally, for every 1º of IOL rotation, 3.3% of lens cylinder power is lost 2. A complete loss of cylinder power can occur with a rotation of >30º 2. Check the axis of the IOL post-op 2

Cylinder Powers A wide range of cylinder powers means more candidates can benefit from AcrySof IQ Toric IOL. ALCON LENS MODELS SN6AT3 SN6AT4 SN6AT5 SN6AT6 SN6AT7 SN6AT8 SN6AT9 Cylinder Power IOL Plane 1.50 D 2.25 D 3.00 D 3.75 D 4.50 D 5.25 D 6.00 D Corneal Plane* 1.03 D 1.55 D 2.06 D 2.57 D 3.08 D 3.60D 4.11 D Toric Calculator Easy Input Patient data Keratometry IOL spherical power Surgically induced astigmatism Incision location Recommended Corneal Astigmatism Correction Range 0.75 D to 1.54 D 1.55 D to 2.05 D 2.06 D to 2.56 D 2.57 D to 3.07 D 3.08 D to 3.59 D 3.60 D to 4.10 D 4.11 D and up Toric Calculator, continued Powerful output Recommended IOL model and spherical equivalent power Optimal axis placement Magnitude and axis of anticipated residual astigmatism Pearls for the Toric 1. Keratometry 2. Pre-operative marking 3. Operative marking and final orientation Hitting the Post-Operative Refractive Target : Keratometry One to one relationship in potential error A 1 diopter error in K readings can yield a 1 diopter error in refractive outcome IOL Master K s: version 5 (2.6mm OZ) LenStar K s (2.3mm OZ) Pearls for the Toric Compare topography astigmatism axis to keratometry axis Manual keratometry (3.2mm OZ) Skilled technician required Calibrate keratometer daily 3

Hitting the Post-Operative Refractive Target Keratometry The most common error in keratometry is secondary to ocular surface disease Treat OSD before referring patient for cataract surgery Pearls for the Toric 1. Keratometry 2. Pre-operative marking 3. Operative marking and final orientation Toric marking at the slit lamp Pearls for the Toric 1. Keratometry 2. Pre-operative marking 3. Operative marking and final orientation IOL Alignment Gross Alignment IOL Alignment Final Alignment Rotate IOL clockwise to approximately 15 degrees short of desired position Completed while the IOL is unfolding in the capsular bag Carefully rotate IOL clockwise onto the intended axis of alignment Can be rotated after IOL has unfolded, if needed, but take care to have capsular bag inflated with OVD Tap IOL down into capsular bag to seat lens in place 4

Lens Based Treatment for Astigmatism Acrysof Toric IQ Precise and Accurate Predictable Outcomes Permanent Safe and Convenient Aspheric Optics Toric IOL Post-operative spherical equivalent Post-operative refractive astigmatism Residual Astigmatism after Toric IOL Measure post-operative refractive astigmatism Confirm axis of Toric IOL with Toric IOL Calculator Rotate Toric IOL to the correct axis THE PLAYERS Presbyopic IOL Options/Optics Presbyopic IOL s Crystalens AO (B&L) Tecnis Multifocal (AMO) ReSTOR Aspheric (Alcon) SN60D1 (3.0) Performance of presbyopia-correcting intraocular lenses in distance optical bench tests. Maxwell A., Lane S, Zhou F. J Cataract Refract Surg 2009; 35:166 171 5

Diffraction Restor Platform The spreading of light Occurs when light passes through discontinuities (i.e. steps or edges) In an optical system, light can be diffracted to form multiple focal points or images AcrySof ReSTOR Aspheric AMO Tecnis Multifocal Refractive optics Diffractive optics Apodization: the treatment of the diffractive optics Aspheric optics Apodization Apodization Definition: A gradual modification in the optical properties of a lens from its center to its edge. Apodization is used in microscopy and astronomy to improve image quality. The ReSTOR apodized diffractive design controls both image quality and energy balance from Nikon website Gradual reduction or blending of the diffractive step heights. Optimally manages light energy delivered to the retina as it distributes the appropriate amount of light to near and distant focal points, regardless of the lighting situation. Designed to improve image quality while minimizing visual disturbances as compared to prior multifocal technologies. 1.3 micron step Source: Data on File, Alcon Labs. RES717 Restor Platform Positive Spherical Aberration Refractive optics Diffractive optics Apodization: the treatment of the diffractive optics Aspheric optics Glare/halos Decreased contrast sensitivity 6

The Problem Spherical Optics The Solution- Aspheric Optics Aspheric IOL Spherical aberration occurs when marginal rays are overrefracted, resulting in a region of defocused light which can decrease image quality. Aspheric optics align the light rays to compensate for positive corneal spherical aberration, resulting in enhanced image quality. * Smith, G., Atchinson D.A., (1997) The Eye and Visual Optical Instruments. Cambridge University Press, Cambridge, United Kingdom, pp. 667. RES717 * Smith, G., Atchinson D.A., (1997) The Eye and Visual Optical Instruments. Cambridge University Press, Cambridge, United Kingdom, pp. 667. RES717 Quality of Vision Anatomy of the Aspheric Apodized Diffractive +3.0 Technology Spherical Aberration Aspheric Correction Central 3.6 mm apodized diffractive structure Step heights decrease peripherally from 1.3 0.2 microns Anterior aspheric optic A +3.0 add at lens plan equaling +2.4 D at spectacle plane Outer refractive zone RES717 Under Promise.Over Deliver Tell the patient that they are still going to have to wear glasses with any IOL option Low lighting Night driving Reading a novel Tell patients that they will see rings around lights with a multifocal IOL The Doctor Encounter Patient Selection 7

Patients to Avoid: Unrealistic Expectations Demand perfect vision Expect perfect vision at all points, in all places, all of the time Not willing to accept the potential complications of cataract surgery Not willing to accept the possibility of glare/halos at night Demand immediate results: may need lasik/prk enhancement Who Are NOT Good Candidates for Multifocal IOLs Those who want to wear glasses Poor general alertness Occupational night drivers High astigmatism* Poor candidates for PRK: thin corneas, elevated posterior float, irregular astigmatism Unrealistic expectations Ocular pathology Ocular Pathology Ocular Pathology Ocular surface disease Macular degeneration (AMD) Epiretinal membrane Baseline macular OCT pre-op Diabetic maculopathy Advanced glaucoma Amblyopia Purple Glasses Multifocal Post-operative Care 8

Pearl Problems Reading? Have patient read near card with purple glasses (-2.25) to demonstrate what vision would have been like if they had not chosen the ReSTOR Teach patient the importance of good light Demonstrate the sweet spot Check pupil size: > 3 mm, try Pilo 0.5% Multifocal Pearls 1) Treat residual refractive errors 2) Early yag capsulotomy 3) Aggressively treat ocular surface disease 4) Look for cystoid macular edema (CME) Myth Presbyopic IOL patients will tolerate small refractive errors Treat residual refractive errors Astigmatism LRI s Keratotomy incisions LenSx PRK or Lasik Spherical errors PRK or Lasik IOL exchange Treat residual refractive errors Trial frame Temporary glasses 9

Preparing Patients for Lasik or PRK Pre-op cylinder greater than 2 D may need an enhancement Topography Pachymetry Multifocal Pearls Treat residual refractive errors Early yag capsulotomy Aggressively treat ocular surface disease Look for cystoid macular edema (CME) Yag Capsulotomy 30-50% or all mutifocal patients will need a yag capsulotomy Multifocal Pearls Treat residual refractive errors Early yag capsulotomy Aggressively treat ocular surface disease Look for cystoid macular edema (CME) Pearl Diagnostic Tools All visual fluctuation is due to ocular surface disease Tear Film Break-Up Time Injection Rose Bengal Staining Lissamine Green Staining Fluorescein Staining Blink Rate Schirmer Testing Osmolarity 10

Multifocal Pearls Treat residual refractive errors Early yag capsulotomy Aggressively treat ocular surface disease Look for cystoid macular edema (CME) CME is the most frequent cause of visual decline following uncomplicated cataract surgery Late on-set (4 to 6 weeks post-operatively) 1 Estimated to occur in 12% of low-risk cataract cases 2 CME development is due in part to prostaglandinmediated breach of bloodretinal barrier 3 Prevention of CME 1. Samiy N, Foster CS. The role of nonsteroidal antiinflammatory drugs in ocular inflammation. Int Courtesy of University of Pittsburgh Visual Imaging Ophthalmol Clin. 1996;36(1):195-206. 2. McColgin AZ, Raizman MB. Efficacy of topical Voltaren in reducing the incidence of post operative cystoid macular edema. Invest Ophthmol Vis Sci. 1999; 40 S289. 3. Mishima H, Masuda K, et al. The putative role of prostaglandins in cystoid macular edema. Prog Clin Res 1989;31:251-264. Optical Coherence Tomography (OCT) Can measure even subtle postoperative retinal thickening Gaining popularity for diagnosis of CME Presbyopic IOL s Crystalens AO (B&L) Tecnis Multifocal (AMO) ReSTOR Aspheric (Alcon) SN60D1 (3.0) Courtesy of University of Pittsburgh Visual Imaging Heier, JS. Preventing Post-Cataract Extraction CME: Early identification of patients at risk and prophylactic treatment may avert vision loss. Ophthalmology Management 2004;63-72. Crystalens AT-45SE August 2005 Proposed Mechanism of Action: The accommodating lens is implanted like standard IOL Lens vaults backwards, correcting distance vision 360 degree square edge Round to the right loop configuration Distance Vision 11

Accommodating Lens As objects move closer to the eye The ciliary muscle expands exerting pressure on the vitreous Accommodative Lens The displaced mass of the vitreous forces the crystalens forward Images at arms length (intermediate) are clear Arms Length Accommodative Lens Reading increases contraction of the ciliary muscle Lens is forced further forward Intermediate & near images are clearer Crystalens Five-O 5.0 mm Bi-Convex Accommodating Silicone IOL Near Crystalens AT 45 S.E. Crystalens Five-O 106 Crystalens AO Properties Has 2 polyimide loop haptics at the end of each plate One is round and the other is oval to facilitate correct anterior/posterior positioning of the lens Hinges are present at the junction of the (optic) and plate on each side to enable forward vaulting of the implant with accommodation Crystalens AO Introduction 5 th generation Crystalens Lineage: AT-45, AT-45SE, Five-O, HD Aberration free optic design Aspheric surface on anterior and posterior surfaces Less sensitive to decentration Improved quality of vision 109 12

100% of light rays at all distances 113 115 Crystalens Dominant Eye: plano Average result of 1 D of accommodation Non-dominant Eye: -0.50 to -0.75 Good distance and intermediate vision Patients must understand that they will need reading glasses for near (+1.25 D) Post-Operative Refraction Pearls In the initial post-operative period, the accommodative change between distance and near may be slow. Refract your Crystalens patients as you would a young myope different from routine regular monofocal IOL post-ops. To prevent accommodative spasm, instruct the patient not to read before the examination and evaluate all distance measurements before taking intermediate and near acuities. Post-Operative Refraction Pearls Measure the uncorrected distance vision (UCDVA) giving the patient time to blink and focus Auto-refractors tend to over-minus, DO NOT use this sphere as your starting point Crystalens Post-op Care Atropine at time of surgery and at 1 day visit Steroid drops for 6-8 weeks post op No reading for 1-2 weeks after surgery +2.00 readers for near vision for 1-2 weeks after surgery Refraction: do not over minus 13

Restor, Crystalens or Toric IOL with LenSx Know the post-operative refractive goal One week exam: refraction of the first eye Must clear the patient for the second eye surgery 1-3 months: final refraction to track the resultant spherical equivalent 1 3 months: keratometry/lenstar to track astigmatism result after LenSx The Doctor Encounter Patient Selection Make a Recommendation Make this an exciting opportunity for your patients This is a great time to have cataract surgery as we can offer you so much more than several years ago This is your one opportunity to select your intraocular lens You must do your homework We will give you the information you need and help you make this important decision Stephen V. Scoper, MD www.virginiaeyeconsultants.com OD Resources Portal User name: virginiaeyeconsultants Password: 142 14