Making Cataract Surgery Refractive Surgery by mikeholy

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									Making Cataract Surgery
  Refractive Surgery
   Eric E. Schmidt, O.D.
    Bladen Eye Center
    Elizabethtown, NC
          Cataract Surgery
• It is considered to be the most successful
  surgery in the world! SO…..

• Why do we want to mess with success?
• What‟s all the fuss about?
• What do we really want to achieve?
         Goals Of Surgery
• Visual improvement – maximum
  achievable visual acuity
• 20/20 w/out eyeglasses!
• No anisometropia

• Remember though; 20/20 may not always
  be possible
• Plano may not always be the best desired
  end point
Uncorrected 20/20 begins with you
• Choosing the right surgeon
• Counseling your patient
• Keep abreast of “new stuff”
• Guide your surgeon to become proficient at
  “new stuff”
• Keep your staff up-to-date on the “new stuff”
• Identify patients who would benefit from “new
  stuff”
• You need to understand that cataract surgery
  should be considered refractive surgery
Why Bother With Co-Management?
•   Enhance px success
•   Continuity of care
•   Logistic concerns
•   They are your patients
•   Builds practice image

• It is certainly not a monetary issue!!!
        Pre-operative procedures
• Set realistic goals for each individual patient
• Perform detailed binocular refraction
• Determine desired endpoint for the patient‟s visual
  system
• Choose the best procedure to achieve this
• Perform all the necessary pre-op tests
   –   A-Scan
   –   PAM
   –   BAT
   –   DFE
   –   Retinal imaging
   –   Wavefront testing
     Pre-operative management
• Px counseling
    – Describe the procedure, anesthesia
    – Describe the post-op course
•   Choose the surgeon
•   Schedule the appt
•   Pre-op regimen
•   Prescribe the pre-op meds
•   Discuss case w/ surgeon
                 A-Scan
• Biometry- this is the key to choosing the
  correct IOL power.
• IOL chosen based on desired endpoint
  refraction, axial length and keratometry
• A-Scan ultrasound – very easy to perform
• CPT code – 76516
                76519
• Should this be done by the referring OD?
            IOL MASTER
• Zeiss
• Not ultrasonography
• High resolution partial coherence
  interferometry
• Easy to perform (<1minute, non-contact)
• Yields extremely precise axial length
  (0.02mm), white-to-white, AC depth (+/-
  0.1mm) and keratometry
• Costs more, same reimbursement, but
  allows us to pinpoint endpoint refractive
              IOL MASTER
• Traditional SRK and Holladay Formulas,
  but ..
• Haigis formula –
  – Surgeon specific
  – IOL specific
  – Allows a new level of mathematical flexibility
    in calculating IOL power
• Greatly increases accuracy and precision
  as compared to A-scan
              IOL Master
• This renders a 5-fold increase in accuracy
• Solves some A-scan issues
  – Posterior staphyloma
  – Long eyes (>24.5mm)
  – Short eyes (<22mm)
  – Silicone oil
  – Asteroid hyalosis
    Cataract Surgery- We‟ve Come A
            Long Way Baby!
•   ICCE
•   ECCE
•   Phacoemulsification
•   No-stitch, no patch
          Surgical Incisions
• Is one type really better than another?

• Scleral tunnel
• Clear cornea
• Micro-incision (1mm)
          Phacoemulsification
•   No new advances in this ; until now!
•   2 new instruments
•   Less energy, less heat
•   No need for irrigation
•   Sleeveless allows for micro-incisions

• Capsulorhexis technique is very important
  Current Phaco Energy Sources
• Ultrasound
   – Efficiently emulsifies cataracts of any hardness
   – Rapid motion of phaco tip creates friction/heat
• Laser
   – Efficiently emulsifies only +1 or +2 cataracts
   – Rests between laser bursts allow cooling
• Sonic
   – Efficiently emulsifies only +1 or +2 cataracts
   – Less tip motion and friction/heat than ultrasound
 Micro-incisions need micro IOL!!!
• Super thin IOL
• Injectable IOL
• “Liquid” IOL
  – Lens refilling procedure
      Post-operative regimen
• Not much new to talk about EXCEPT…
  – The incidence rate of endophthalmitis is
    tripling
    • 0.66% in clear cornea
    • 0.25% in scleral tunnel



  – Can we prevent this?
  – Why is this happening?
       Post-operative regimen

• Antibiotic – 4th generation fluoroquinolone
  QID
• Steroid – prednisolone acetate 1% QID (or
  more)
• NSAID
• Intraocular steroid – Dex DSS
• Post-op visits
  – 1 day
  – 1 week
  – 3-4 weeks (DFE)
Clear Corneal Incisions Don‟t
          Leak…

               !!!!
       They Suck
           Endophthalmitis
• Increase due to natural endogenous flora
  from lids
• 75-90% gram positives
  – Staph. Epidermidis (42%)
  – Staph. Aureus,Enterococcus
• Pay close attention to the lids pre- and
  post-operatively
     To reduce endophthalmitis
             incidence
• Fluoroquinolone QID 4 days prior to
  surgery
• Lid scrubs if needed
• Artificial tears
• Betadine prep peri-operatively
• May need to leave px on topical antibiotics
  longer post-operatively
• Orals ??
            Post-op concerns
•   Glare and haloes
•   Internal reflections
•   Anisometropia
•   2nd eye management
•   Post. Capsule opacification
     What About Astigmatism?
• Toric IOL



• Astigmatic Keratotomy

• Who are candidates?
• Are there refractive limitations?
• What can the patient (and us ) realistically
  expect?
                Toric IOL
• STAAR Surgical silicone plate lens
• Corrects 1.4 – 2.3 D of cyl at the spectacle
  plane
• Corrects the astigmatism at the nodal
  point
• Lessens distortion
• Better qualitative visual acuity
• Improved contrast sensitivity
• There are some axis considerations
          Toric IOL Success
• Depends upon:
  – Surgical skill – the surgery must be
    astigmatically neutral
  – Proper IOL positioning
  – IOL maintaining a stable position in the bag
  – Aggressive post-operative monitoring
                 Toric IOL
• Post-op considerations
  – Must be able to detect IOL rotation
  – If this occurs it must be corrected by 3 weeks
  – IOL may have to be rotated by surgeon
  – Patient must be dilated at 2 weeks to detect
    this
         Astigmatic keratotomy
•   Relaxing incision made nasally
•   Shallow (<150 microns)
•   Useful for pre-operative WTR cylinder
•   -1.00 to -2.50 cylinder

• How effective is it?
      Astigmatic Keratotomy
• When should you recommend it?
  – Plano in other eye
  – Px does not like to wear specs
  – CL wearer
  – Those “picky” patients
  – WTR cylinder (170 – 010)
  – High cylinder pxs

• Post-op considerations
       Astigmatic keratotomy
• What are the drawbacks?
  – Poor predictability

  – Limited range of correction

  – Post-operative FB sensation
 So an optometrists walks into an
 exam room to see a post-op px
O.D.- How‟re those eyes doing Mr. Jones?
Px – Not so great.
O.D. – Whaddaya mean , not so great?
 You‟re seeing 20/20 in each eye without
 glasses!
Px – Yeah, but I can‟t see my newspaper!
 What to do about presbyopia?
• Monovision IOL

• Presbyopic Lens Exchange (PRELEX)

• Multifocal IOL

• Accommodating IOL
        Multifocal IOL options
• Monovision

• Refractive

• Diffractive

• Accommodative
The Ideal Multifocal IOL Patient
• Baby Boomer
  – 50‟s to the mid 60‟s
  – Cataract starting to compromise quality of
    vision
  – Active lifestyle
  – Concerned about their appearance &
    „quality of life‟
      • Do not want to „get old‟
      • Spending billions on lifestyle enhancing
        procedures
  – Realistic Expectations
  – Motivated
  – Asks lots of questions
Who‟s A Candidate? / Clinical

•   Hyperopic
•   Loss of accommodation
•   Cataract
•   Unilateral traumatic cataract
•   Congenital cataract
•   Astigmatism (can be corrected)
•   High myopes (surgeon preference)
       Who‟s A Candidate? /
            Motivation

• Wants to be less dependent on glasses
• Understands the limitations of the Array®
  visual system
• Willing to accept several months to adapt
  to their new visual system
       Who‟s Not A Candidate?
•   Significant dry eyes
•   Corneal scarring
•   Mild to moderate myopia
•   Pupil size < 2.5 mm
•   Monofocal implant in first eye
•   Uncorrected post-op astigmatism > 0.5 D
•   Unstable capsular support
•   Someone who demands perfect vision
 ReZoom Multifocal IOL (AMO)
• Refractive lens
• 2nd generation acrylic IOL
• Delivers good near, distance and
  intermediate vision
      Is The ReZoom Perfect?

• The most common concerns
  – Distance blur
  – Monocular diplopia
  – Object glow
  – Ghosting
  – Halos at night
• These are the biggest post-op challenges
    Acrysof ReStor IOL (Alcon)
• Diffractive technology

• Silicone material

• Uses “apodization” to soften blur and sharpen
  vision

• Provides excellent VA at near, distance and
  intermediate ranges
   Strengths of the AcrySof®
        ReSTOR® IOL
• High quality uncorrected near and
  distance vision with 20/40 or better
  intermediate vision without movement of
  the IOL
• 80% Overall Spectacle Freedom
• Nearly 94% of patients would have the
  lens again
Aspheric Multifocal IOL Technology
Do We currently have any aspheric
        multifocal IOLs?
• Tecnis multifocal (AMO)

• Sofport AO (Bausch & Lomb)
      Explain the WOW! Factor
          (or lack thereof)
• Haloes and glaare at night are common-
  these diminish with time
• Longer adaptation period – may take
  weeks or months for pxs to accept their
  “new” visual system
• Near vision may be fuzzy to myopes
• May need reading specs for prolonged
  nearpoint work
        Accomodative IOL
• Crystalens- eyeonics
• Silicone IOL with hinged optics
• IOL moves forward or back depending on
  ciliary muscle tone
• Implanted using phaco technique
• Capsulorhexis is critical
• Pre-op biometry crucial
     Enter: Accommodating Lens
       A New Paradigm In Vision Correction
• The first accommodating lens technology
  approved as safe & effective by the Food &
  Drug Administration
   – Manufactured by eyeonics
      • A USA company
• The lens uses the natural focusing
  ability of the eye to provide a
  single focal point throughout a full
  range of vision from far, through
  intermediate to near seamlessly
(In contrast with multifocal IOL’s which use a
dual simultaneous focus or monovision where
one eye is
set for distance & one eye for near)             eyeonics crystalens
  The Ideal Crystalens Patient
• Baby Boomer
  – 50‟s to the mid 60‟s
  – Cataract starting to compromise quality of
    vision
  – Active lifestyle
  – Concerned about their appearance & „quality
    of life‟
      • Do not want to „get old‟
      • Spending billions on lifestyle enhancing
        procedures
  – Realistic Expectations
  – Motivated
  – Asks lots of questions
Crystalens Post-Op Considerations

 •   1% Atropine day of surgery & 1 day PO
 •   Otherwise standard post-op regimen
 •   Distance vision stable 1 week
 •   Near vision begins to return @ 2 weeks
 •   No significant glare or halos after 10 days
 •   Must follow more often
          Crystalens Post-op

Post-op: 10-14 days post-op
• Keratometry
• Uncorrected distance and near visual acuity
• Controlled maximum plus refraction
• Distance and near visual acuity through
  distance correction
• Gradual Plus Build-up to J1 to determine
  add.
• Verify refractive findings with cycloplegic
  refraction
      Spectacle Use Survey
    Bilateral Implanted Subjects
  Wearing Spectacles           n/n (%)
I do not wear spectacles   33/128 (25.8%)
Almost none of the time    61/128 (47.7%)
                                             }73.5%
26% to 50% of the time     20/128 (15.6%)
51% to 75% of the time      8/128 (6.3%)
76% to 100% of the time     6/128 (4.7%)

  Night Spectacles             n/n (%)
No                         110/128 (84.6%)
Yes                         20/130 (15.4%)
Is There A WOW Factor?
           Cataract Surgery-
          What‟s on the horizon?
• Adjustable IOL-
    – Material is fixed w/ laser to -0.75
    – Take to phoropter, refract to plano
    – “Fix” that w/ longer laser light
•   ICL
•   Clear Lens Extraction
•   Impeller extraction technique
•   Lens filling system

								
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