2014 monterey symposium - cataract surgery.pdf · or things that make you go hmmm 80 million baby...
TRANSCRIPT
![Page 1: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/1.jpg)
2014 Monterey Symposium
Cataract Surgery in Patients with Previous Refractive Surgery
Jimmy Jackson, OD, FAAO
President
InSight Lasik
![Page 2: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/2.jpg)
Acknowledgements
I have received honoraria from Alcon
Laboratories, Inc for speaking engagements.
I have received research support from Alcon
Laboratories, Inc and Refractec.
![Page 3: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/3.jpg)
Why would you want to see these patients?
They need your help and expertise
More likely to have fee for service component
Your successes often will become your best referrers
Challenges can be fun
![Page 4: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/4.jpg)
Why would you NOT want to see these patients?
They require lots of chair time
Success can be elusive
Quality of vision may already be compromised
Many of these patients have exacting visual goals
Challenges are not always fun
![Page 5: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/5.jpg)
National Statistics - Trends
Market Scope
Monthly Newsletter
ASCRS/ISRS/AAO Surveys
R.J. Duffey, MD
1997-2013
![Page 6: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/6.jpg)
U.S. Statistics…..Or things that make you go hmmm
80 million baby boomers began turning 60 in 2006
Ostrich egg going through a python
In 2012 estimate 43 million > age of 65
By 2020 will increase to 55 million > 65
By 2025 ~ 60% of US population > 55
Over 50% > age 65 have visually significant cataracts
Currently estimated that cataracts affect > 22 million in USThat number is expected to increase to > 30 million by 2020
Currently 3 million+ cataract surgeries per year in USIncreasing ~ 4%/year for last few years
![Page 7: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/7.jpg)
Hmmmmm…..Part deux
Incidence of cataract surgery increasing
Even when age and sex adjusted
• Improved access to surgery
• More surgeons
• Adoption of widening indications for surgery
Between 1998–2004 28% of patients had 2nd eye sx by 90 d
Between 2005-2011 increased to 60%
In 2001 cataract sx < 2X refractive
In 2014 cataract sx > 6x refractive
![Page 8: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/8.jpg)
The Baby Boomer Generation
- Large, rapidly growing demographic
- Educated, financially secure
- Increased life expectancy
- Longer working careers
- Demand high quality vision
- New requirement for near vision (computers)
- Unwilling to compromise active lifestyle
- Higher BMC quotient?
Born between 1946 - 1964
3
![Page 9: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/9.jpg)
US Ophthalmic Surgeries 2013Market Scope 2014
![Page 10: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/10.jpg)
Quarterly US Cataract ProceduresQ1 10 through Q2 14
Source: Market Scope June 2014
![Page 11: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/11.jpg)
Quarterly US Lasik/PRK ProceduresQ1 01 through Q1 14
0000
50505050
100100100100
150150150150
200200200200
250250250250
300300300300
350350350350
400400400400
450450450450
Q1 0
1
Q1 0
1
Q1 0
1
Q1 0
1Q1
02
Q1 0
2
Q1 0
2
Q1 0
2Q1
03
Q1 0
3
Q1 0
3
Q1 0
3Q1
04
Q1 0
4
Q1 0
4
Q1 0
4Q1
05
Q1 0
5
Q1 0
5
Q1 0
5Q1
06
Q1 0
6
Q1 0
6
Q1 0
6Q1
07
Q1 0
7
Q1 0
7
Q1 0
7Q1
08
Q1 0
8
Q1 0
8
Q1 0
8Q1
09
Q1 0
9
Q1 0
9
Q1 0
9Q1
10
Q1 1
0
Q1 1
0
Q1 1
0Q1
11
Q1 1
1
Q1 1
1
Q1 1
1Q1
12
Q1 1
2
Q1 1
2
Q1 1
2Q1
13
Q1 1
3
Q1 1
3
Q1 1
3Q1
14
Q1 1
4
Q1 1
4
Q1 1
4
Sx/qt Sx/qt Sx/qt Sx/qt
Source: Market Scope May 2014
![Page 12: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/12.jpg)
Cataract surgery
Typical cataract surgery involves:
Primary and secondary (smaller) incisions
Capsulorhexis
Lens fragmentation
Phacoemulsification
Intraocular lens (IOL) insertion
Incision closure
![Page 13: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/13.jpg)
![Page 14: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/14.jpg)
TerminologyPrimary Incision - bladed
Clear Corneal – 50%/Limbal – 35%/Scleral tunnel – 15%
Femtosecond Laser Cataract Surgery (FLCS)Primary & secondary corneal incisions – Medicare allows upchargeCapsulorhexisPartial lens fragmentationFor Q1 2014 risen to 5%
Intra-operative abberometryORA (ORange Wavefront Abberometer) – WaveTecAssists IOL selection & guidance w toric IOLs & LRIs
Premium IOLIncludes toric IOLs and presbyopia correcting IOLs (PC-IOLs)
Presbyopia correcting IOLsIncludes multifocal and accommodating IOLs
Refractive Cataract SurgeryFLCS and/or ORA Premium IOLS
![Page 15: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/15.jpg)
Refractive Procedures you may seeHistorical notes
J. Barraquer developed Keratomileusis in 60’s. Briefly performed in USALK was more popular but still not widely performed
RK (Radial Keratotomy)/AK (Astigmatic Keratotomy)Did not require FDA approval as didn’t utilize new technologyEstimated about 2 million procedures performed in US
PRK (Photorefractive Keratectomy)
LASIK (Laser Assisted Keratomileusis in Situ)Over 20 million procedures (PRK + LASIK) have been performed in US
CK (Conductive Keratoplasty)
Intacs corneal rings
ICLs (Intraocular contact lens)
Procedures with refractive implications for cataract surgeryPK (Penetrating Keratoplasy)Corneal Cross-LinkingScleral Buckle
![Page 16: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/16.jpg)
LASIK/PRK/ASA/LASEK/Epi-LasikWhat’s the chance you’ll see a patient with the procedure?
Very high – over 20 million procedures performed in US
How can you tell?Patient history is best guideOften quite subtle – topography very helpful
Implications for cataract surgeryNo impact on the actual procedure clinicallyComplicates the IOL calculation
Not as much as some maintain
Most still avoid multifocal IOLS That thinking is changing
If custom + femto flap we consider multifocalCertainly consider CrystaLens and torics
Nice to know amount of treatment – old records/Rx helpful
FLCS +/-
ORA - definitely
![Page 17: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/17.jpg)
RK/AKWhat’s the chance you’ll see a patient with the procedure?
High – over 2 million procedures performed in US 1978-????LRI’s (limbal relaxing incisions) still being performed
How can you tell?Patient history is best guideClinical appearance hard to miss
Implications for cataract surgeryComplicates corneal wound construction
May have to use scleral tunnel
Complicates the IOL calculationWould avoid multifocal IOLS
Fluctuations/glare/quality +/-
Would consider CrystaLens
FLCS – avoid corneal useIf use only for capsulorhexis/lens fragmentation can’t upcharge
ORA - definitely
![Page 18: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/18.jpg)
![Page 19: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/19.jpg)
CKWhat’s the chance you’ll see a patient with the procedure?
Moderate – less than 500,000 procedures performed in USRarely performed today
How can you tell?Patient history is best guideClinical appearance hard to miss
Implications for cataract surgeryRarely impacts corneal wound construction Complicates the IOL calculationWould avoid multifocal IOLS Would consider CrystaLens
FLCS – consensus is to avoid corneal use
ORA – yes
![Page 20: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/20.jpg)
Conductive Keratoplasty - CK
Treats hyperopia/presbyopia
Uses high frequency radio waves
Produces heat => collagen shrinkage
8-24 spots placed in mid-peripheral ring
Creates band(s) of tightening in mid-periphery
Causes central steepening
![Page 21: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/21.jpg)
![Page 22: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/22.jpg)
Corneal InlaysWhat’s the chance you’ll see a patient with the procedure?
Very low – not approved in US
How can you tell?Patient history is best guideClinical appearance hard to miss
Implications for cataract surgeryPerhaps noneTheoretically would remove the inlay
FLCS – if removed should not impact, so yes
ORA - yes
![Page 23: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/23.jpg)
Kamra Corneal Inlay
Received FDA panel approval 6/14
Full FDA approval????Approved in 50 countries
Creates a pinhole effectInsert non-dominant eye
Form of monovision
Inserted under a ‘Lasik flap’
Theoretically reversible
LSX12241SK
19
![Page 24: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/24.jpg)
ICLsWhat’s the chance you’ll see a patient with the procedure?
Low to moderate – < 1% of current US refractive procedures
How can you tell?Patient history is best guideClinically depends upon which type
Implications for cataract surgeryTypically remove the ICL
In that case none
All procedures are optionsAll lenses are options
Just don’t want to miss it
FLCS – yes
ORA - yes
![Page 25: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/25.jpg)
ICLs
Iris clip lens – Verisyse
Posterior chamber lens - Visian
Verisyse Visian ICL
![Page 26: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/26.jpg)
![Page 27: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/27.jpg)
ICL placement and vault
![Page 28: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/28.jpg)
10:30 1:30
Place two small PI’s
Usually LPIs but may be surgical PI
![Page 29: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/29.jpg)
IntacsWhat’s the chance you’ll see a patient with the procedure?
Low – less than 100,000 implanted in USCurrently used in conjunction (sometimes) with cross-linking
How can you tell?Patient history is best guideFairly easy to spot at slit-lamp
Implications for cataract surgeryIf inserted for myopia correction would remove
In that case none andAll procedures are optionsAll lenses are options
If inserted as adjunct to cross-linkingKeratoconus patientAvoid all premium IOLsORA should help
![Page 30: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/30.jpg)
INTACS
PMMA semi-rings
Inserted in mid-periphery of cornea
Flattens cornea
Began as primary treatment for myopia
Never a popular option
Now used in keratoconus patients
Moves thinnest spot centrally
In conjunction with corneal cross-linking
Can be removed
![Page 31: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/31.jpg)
Corneal Cross LinkingWhat’s the chance you’ll see a patient with the procedure?
Low but should expect to rise
How can you tell?Patient history is best quideIf no Intacs will be similar to PRK so very difficult to tell at SLETopography is best way to tell clinically
Implications for cataract surgeryStick to standard mono-focal IOLs
FLCS – avoid
ORA – looking for any help with calculations
![Page 32: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/32.jpg)
Pentatrating KeratoplastyWhat’s the chance you’ll see a patient with the procedure?
Low to moderate
How can you tell?Pretty much can’t miss
Implications for cataract surgeryStick to standard mono-focal IOLsReason to avoid toric IOLs
Easier to fit CLs (rigid/Scleral) if no toric to content with
FLCS – avoid
ORA – looking for any help with calculations
![Page 33: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/33.jpg)
Scleral buckleWhat’s the chance you’ll see a patient with the procedure?
Low Moving away from buckles to gas bubbles
How can you tell?Patient history is your best optionPeripheral retinal evaluation will revealPossible to see externally in extreme gaze
Implications for cataract surgeryIt lengthens the eye ball so complicates calculationsAll premium IOLs should be in play
Femto – yes
ORA – yes
![Page 34: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/34.jpg)
Cataract surgery
Typical cataract surgery involves:
1. Primary and secondary (smaller) incisions
2. Capsulorhexis
3. Lens fragmentation
4. Phacoemulsification
5. Intraocular lens (IOL) insertion
6. Incision closure
![Page 35: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/35.jpg)
Refractive Cataract Surgery Requires different mindset/mode of practice
Medicare model forces physicians to treat for
pathology in a high-volume, low cost
approach to medicine that emphasizes
efficiency.
Refractive cataract model is elective and
demands a more patient-oriented business
model where the focus is on quality of life
rather than quantity of patients.
It’s the refractive surgery model.
![Page 36: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/36.jpg)
Now most patients are looking for ‘perfect’ surgery…….like their friend got
• We need to lower their expectations
• While doing all we can to maximize outcomes
• Any previous ocular surgery complicates
• Our mantra is under promise & over deliver
• We need to pay attention to every detail
![Page 37: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/37.jpg)
As with all surgeries….focus on the basics
• It begins with the tear film• Poor quality tear film compromise the outcome
• Rehab all corneas prior to surgery
• Restasis
• Punctal plugs
• Omega 3 supplements
• Aggressively treat marginal lid disease
• It ends with the retina• Most pathology will r/o PC-IOLs
![Page 38: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/38.jpg)
Femtosecond Laser technologyFemtosecond Laser Cataract Surgery (FLCS)
![Page 39: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/39.jpg)
FLCS• Currently very expensive way to:
• Make corneal incisions
• Create capsulorhexis
• Partially fragment lens
• Upcharge to patient ~ $1000/eye
• It’s true that capsulorhexis is critical
• Centration
• Size – make smaller than optic of IOL
• Many wonder, will patients pay extra for it???
• Yes…yes they will
• But it’s the corneal incisions that we charge for
• And that is what resonates/excites patients
![Page 40: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/40.jpg)
FLCS
Address Major Requirements for Improved Refractive
Procedure
IOL Position
Predictability
• Uniform Shape and
Size Capsulotomy
Corneal
Astigmatism
• Reproducible
Corneal Entry and
Arcuate Incisions
Early Wow
Factor
• Reduced Phaco
Power and Corneal
Edema
Hill WJ, J Cataract Refract
Surg 2008;34:364–367
Norrby SJ, J Cataract Refract
Surg 2008;34:368–376
Devgan U, Current Opinions in
Ophthalmology 2011;18:19–22.
7
![Page 41: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/41.jpg)
Capsulorrhexis centration is very important with all premium IOLS!
But it is the ‘no blade–laser cataract sx’ that excites patients
![Page 42: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/42.jpg)
FLCS
![Page 43: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/43.jpg)
Femtosecond Laser technology
![Page 44: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/44.jpg)
Arcuate Incisions
• Square edge
• Uniform depth (no ripples)
• Precise, reproducible
– Arc shape
– Arc length
– Diameter
![Page 45: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/45.jpg)
One Day Post-Op
![Page 46: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/46.jpg)
Intra-operative abberometer
![Page 47: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/47.jpg)
Intra-operative abberometer•Provides intra-operative biometry which assists in the lens power selection
• Enables real-time surgical course correction
• Compatible with and attached directly to the existing surgical microscope
• Provides axial guidance for use during toric IOL and LRI placement
• Also an upcharge
• Typically ~ $500/eye
![Page 48: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/48.jpg)
Four Simple Characteristics Four Simple Characteristics Four Simple Characteristics Four Simple Characteristics Four Simple Characteristics Four Simple Characteristics Four Simple Characteristics Four Simple Characteristics
Widely
Opened
Eye
Well
Hydrated
Eye
Well
Pressurized
Eye
Well
Aligned
Eye
Eye Prep for Successful Measurement
![Page 49: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/49.jpg)
FLCS and ORA are fast growing options
• Outcomes are slightly better
• Particularly with ORA
• Especially in patients with previous sx
• Laser Cataract Surgery resonates w patients
![Page 50: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/50.jpg)
Presbyopia Correcting IOLs (PC-IOLs)
Tremendous Early Excitement
PatientsPresbyopia correction is the ‘Holy Grail’CrystaLens hits the market in 2003New designs launched by Alcon & AMO in early 2005
Surgeons Looking to reverse downward trends in reimbursementLandmark Medicare ruling
Patients allowed to pay a premium for P-IOLs
85%+ of US cataract surgeons trained/certified
IOL Companies Hoped to make more money
![Page 51: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/51.jpg)
P-IOL Market Below Expectations
Demand disappointing for all major lenses
Alcon – ReSTOR 3.0
Largely replaced ReSTOR 4.0
AMO – Tecnis
Similar to ReSTOR 4.0
Eyeonics – Crystalens
Best distance vision. Poorest near vision.
Market leader is Alcon
![Page 52: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/52.jpg)
Monofocal – Meaning one focal length.
Usually set for distance.
Toric – Corrects for astigmatism.
Multifocal – Restores the patients distance
and near vision.
Lens Options
![Page 53: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/53.jpg)
Multifocal
ReSTOR, Technis MFReSTOR, Technis MFReSTOR, Technis MFReSTOR, Technis MF
Accommodative
Crystalens
![Page 54: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/54.jpg)
Stuff to know
• Crystalens provides best distance vision
• Crystalens degrades image quality the least
• Crystalens has poorest near vision• That’s why it’s NOT the market leader
• Tecnis and ReSTOR 4.0 have closest near points
• ReSTOR 3.0 combines good near with good intermediate
• ReSTOR and Tecnis coming out with lower add options• Trend is toward better intermediate
• Most patients want to limit use of readers
• All lens involve compromise
![Page 55: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/55.jpg)
Astigmatism Correction
• Intraoperatively
• Incision at steep axis – ~ 0.25-0.50 D
• LRIs (limbal relaxing incisions) – imprecise, regress
• Duh, it is RK
• Femtosecond laser for relaxing incisions
• Toric IOL
• Postoperatively
• Glasses or CLs – good luck with that
• LRIs – it’s still RK
• Excimer laser
• Lasik at 3 mon s/p
• PRK if reason not to perform Lasik
![Page 56: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/56.jpg)
Residual Astigmatism = BMCing
• #1 reason sx patients unhappy w/ results
• Has to be addressed
![Page 57: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/57.jpg)
Keys for best outcomes• Learn as much as possible re old sx
• Get old records if available
• Even old Rx/glasses can be beneficial
• Understand the patients’ mindset
• I’m looking for improvement
• I’m looking for a miracle
• I’m looking for a lawyer
• Exceptional surgeon/surgery team required
• Experience w similar patients is vital
• Advanced technologies is vital
• Attention to detail is vital
• Has to be great communication bwt offices
![Page 58: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/58.jpg)
Keys for best outcomes
• Understand goal of patient
• OK w glasses full time
• OK w reading glasses
• Desires spectacle independence
• Realistic expectations are critical
• What can be and what cannot be achieved
• You and patient must be prepared for surprises
• Surgical plan/technique may be altered DOS
• Surgeon must communicate w patient
• Surgeon must communicate w you
![Page 59: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/59.jpg)
You must understand
• There will be hand holding
• Expect lots of chair time
• How will you be compensated?
• Success may be incremental
• Healing may be slow
• Enhancements are likely
• Predicting BCVA s/p surgery often difficult
![Page 60: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/60.jpg)
Patient must understand…..due to their previous surgery
• Some procedures are off limits
• Some drop off from perfect is expected
• They are absolutely in the best hands
• You are their advocate
• Success may be incremental
• Healing may be slow
• Enhancements are likely
• Predicting BCVA s/p surgery often difficult
![Page 61: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/61.jpg)
Keys to Success
Under promise
Over deliver
Be very realistic
Be supportive
Individualize
Enhance early & often
Work with patients you like
Work with surgeons you trust
Get compensated for your time
![Page 62: 2014 Monterey Symposium - Cataract Surgery.pdf · Or things that make you go hmmm 80 million baby boomers began turning 60 in 2006 Ostrich egg going through a python In 2012 estimate](https://reader034.vdocuments.site/reader034/viewer/2022050115/5f4bdcd2a1255259b8571add/html5/thumbnails/62.jpg)
Thanks All Y’all