american society of cataract and refractive...
TRANSCRIPT
1
American Society of Cataract
and Refractive Surgery
06-10 May, 2016
New Orleans, Louisiana Ernest N. Morial Convention Center
Course 10-105 Room 228-230
“Best of the Best : Advanced New Technologies
Cataract Surgery”
Senior Instructor:
Richard L Lindstrom MD Instructor:
Eric Donnenfeld MD Jack Holladay MD MSEE
Stephen S Lane MD Matteo Piovella MD
Steven C Schallhorn MD
Tuesday, May 10, 2016 8.30 AM – 9.30 AM
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INDEX
Femto Laser Assisted cataract Surgery: Virtuosity or
Frontier?
Matteo Piovella MD
Pag. 3
Multifocal Accommodative and Toric IOL Implantation in
Advanced cataract Surgery: 8 Years Up to date
Matteo Piovella MD
Pag. 8
What’s New in Multifocal IOLs
Eric Donnenfeld MD
Pag. 19
Delivering Improved Outcomes for Today's Cataract Patient
Stephen S Lane
Pag. 25
Preliminary Results of Intrastromal Femtosecond
Astigmatism keratotomy
Steve C. Schallhorn MD
Pag. 31
The Promise of No Glasses or Contact Lenses! Jack T Holladay MD, MSEE, FACS
Pag. 34
ADDRESSES Pag. 43
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“Femto Laser Assisted cataract Surgery: Virtuosity or Frontier?”
Matteo Piovella MD
4
5
6
7
8
“Multifocal Accommodative and Toric IOL Implantation in Advanced
cataract Surgery: 9 Years Up to date”
Matteo Piovella MD
9
10
11
12
13
14
15
16
17
18
19
“What’s New in Multifocal IOLs”
Eric D. Donnenfeld MD
20
21
22
23
24
25
“Delivering Improved Outcomes for Today's Cataract Patient”
Stephen S Lane MD
Delivering Improved Outcomes for
Today's Cataract Patient
Stephen Lane, MD
1
DISCLOSURE• Alcon
• ClarVista
• Bausch and Lomb
• Ivantis
• i-Veena
• Kala
• Lifecore
• Mati
• Ocular Therapeutics
• Omeros
• PowerVision
• PRN
• RPS
• Shire
• TearLab
• TearScience
• VisionCare
• WaveTec
Cataract Surgery Outcomes***
CRS15001SK 1
• Patient expectations are at an all-time
high for refractive surgery
• Positive experiences with LASIK have
produced high expectations
– 92.6% of LASIK patients achieve vision of
20/40 or better*
– 95.4% of patients were satisfied with their
outcome after LASIK surgery**
• Cataract surgery outcomes may not be meeting the target of 0.5D that is
considered the standard
41%
55%
97%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
±0.25D ±0.5D ±1.0D
Cataract Surgery Outcomes
*“LASIK Surgery Statistics.” Docshop.com. http://www.docshop.com/education/vision/refractive/lasik/statistics
**Solomon, K et al. (2009) “LASIK world literature review: quality of life and patient satisfaction.” Ophthalmology. 16(4):691-701
***Graph: Data from Dr. Warren Hill & Behndig A, et al. Aiming for emmetropia after cataract surgery: Swedish National Cataract Register study. J Cataract Refract Surg. 2012;38(7):1181-6.
What are the issues that affect hitting
the refractive target?
Pre-operative
• Biometry
• Managing astigmatism
• Transcription errors
• Cyclorotation
• Manual marking
Intra and Post Operative
• Rhexis shape and size?
• Posterior corneal
astigmatism
• Alignment, centration
• A-constant optimization
4
Cataract Refractive Diagnostics
Image Guidance
5
Manual Toric Marking
6
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Removing Ink From the Entire Process
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Courtesy of Michael Jones, MD
The Verion™ Image Guided System
Designed to help you consistently achieve your refractive target.
The VERION™ Image Guided System is designed to add greater accuracy and
efficiency during surgical planning and execution. Consisting of the VERION™
Reference Unit and the VERION™ Digital Marker, it is designed to help you
perform cataract surgery.
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Introducing the VERION™ Image Guidance
VERION™ Reference Unit
IMAGE. PLAN. GUIDE.
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VERION™ Microscope Integrated Display
Capturing the Reference Image
10
Comprehensive
Astigmatism Planner
11
Closing the Loop: Optimization
12
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VERION™ DIGITAL MARKER
Digital Marker Guidance
13
Registration Process at the LenSx® Laser- Digital Marker L
14
Image Guided System and Centration
Visual Axis Center
Limbus Center
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MICROSCOPE INTEGRATED DISPLAY
Location of Incisions Marker Rhexis Marker
Centration Marker Toric Alignment Marker
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Verion Digital Marker M
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Intraoperative Surgical
Aberrometry
18
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“Yardstick” to measure Cataract Surgery
Success
• Driven by LASIK outcomes– Refractive component and Visual Acuity component
• > 95% of outcomes within 0.50 D of nomogrampredicted refractive target
• 90% of eyes achieving UDVA of 20/20 or better
• <3% enhancement rates expected
* Intraoperative aberrometry may help refractive cataract surgery reach the next level by Richard L. Lindstrom, MD, Ocular Surgery News U.S. Edition, December 25, 2010
Outcomes in Modern Cataract Surgery-
Literature • Narvaez / Stulting JCRS Dec. 2006
– 46 % within 0.50 D of formula predicted target
– Mean prediction error: 0.52 D +/- 0.44 D
• Gale et al, Eye Aug. 2007– 55 % of eyes within 0.50 D of formula predicted target
– 85% of eyes within 1.00 D of formula predicted target• Findings considered the benchmark for the NHS in the UK
– Enhancement Rates on Premium IOL cases (Presbyopicand Toric IOLs)
• Range from 10% to 35%
Outcomes in Modern Cataract Surgery
Recent Literature
• Andrs Behndig, M.D., Ph.D.,et al, J
Cataract Refract Surg. (July) 2012 (Swedish
National Cataract Registry.)
–17,056 procedures
–Emmetropia (spherical equivalent −0.5 to
+0.5D and <1.0 D astigmatism) achieved in
55% of eyes planned for emmetropia.
Conventional IOL Power Determination
Approach• Various characteristics of the eye are measured preoperatively
• Axial Length
• Corneal Power
• Other measurements that may be used (formulae dependent)
– Anterior Chamber Depth
– Lens Thickness
– White to White
– Formula applied
ORA System™ by WaveTec
(Optiwave™ Refractive Analysis)
• Provides intraoperative refractive information
• Attaches to most surgical microscopes for on-demand intraoperative measurements of sphere, cylinder and axis
• Enables real-time surgical course correction
• “Get it right – right on the table” the first time
• Every ORA System connects live to WaveTec servers to capture every procedure and push software upgrades
The ORA System® with VerifEye®
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Overview• The ORA System® uses wavefront aberrometry data in the
measurement and analysis of the refractive power of the eye (i.e.
sphere, cylinder, and axis measurements) to support cataract surgical
procedures.
• Accounts for contribution of anterior and posterior corneal astigmatism
in its measurements
• Real-time, intraoperative refractometer plus a working algorithm
supported by a large clinical database (100k+ cases), and a platform
for additional enhancements.
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Improve astigmatic outcomes for your patients
with real-time intraoperative Validation1
• Provides streaming refractive information to determine power, cylindrical magnitude and axis, even for post-refractive-procedure eyes.
• Accounts for contribution of anterior and posterior corneal astigmatism in its measurements.
• Reduces risk of residual postoperative astigmatism.
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Primary Efficacy Result
Residual Refractive Cylinder at 3 Months
31,4
39,2
71,6
90,296,1
3.90102030405060708090
100
0 ≤ 0.25 ≤ 0.50* ≤ 0.75 ≤ 1.00 > 1.00
Pe
rce
nt
Pa
tie
nts
Diopters* 95% CI: 61.8 - 80.1%
Primary Efficacy Result
Residual Refractive Cylinder at 3 Months
1
53,3
81
91,4 92,4
6,7
31,4
39,2
71,6
90,296,1
3,90
10
20
30
40
50
60
70
80
90
100
0 ≤ 0.25 ≤ 0.50 ≤ 0.75 ≤ 1.00 > 1.00
Pe
rce
nt
Pa
tie
nts
Diopters
Anticipated Residual Cylinder based upon Preoperative Calculation
88.4%
from
target
Secondary Efficacy Result
Postoperative MRSE Accuracy at 3 Months
0
40,2
69,6
87,391,2
7,80
102030405060708090
100
0 ≤ 0.25 ≤ 0.50* ≤ 0.75 ≤ 1.00 > 1.00
Pe
rce
nt
Pa
tie
nts
Diopters* 95% CI: 59.7 – 78.3%
Improved astigmatic outcomes with VerifEye®
2. Standard of Care: Conventional biometry measurement of the pre-op corneal astigmatism and toric calculator determination of IOL cylinder power.
3. Results are statistically significant based on McNemar’s test (p=0.006).
This carefully controlled clinical study confirms that the ORA
System® with VerifEye® provides better astigmatic outcomes in
cataract surgery.
Percent of Patients Within ≤ 0.50 D of Intended Target at One Month; n = 111 patients, p = .006
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30
Improved astigmatic outcomes with VerifEye®
*Based on seeing 100 post-op patients per month
53.8% fewer patients were outside the intended target.
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Synergism of Guidance with
Aberrometry and Femtosecond
Cataract Surgery
• Paired with the VERION™ Image Guided System
aberrometry provides the opportunity to address
potential sources of error at each procedural step
imaging, planning, guidance and verification.
• Aberrometry gives you the confidence to effectively
treat astigmatism for toric IOL patients.
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How I use the systems together
• Toric case– Establish initial plan with Verion guidance
• K’s will help establish initial cylinder power and axis – registration will help identify this axis during surgery
• Pre-op will supply preliminary spherical power for the toric lens
– Obtain consistent VerifEye aberrometry aphakic measurements intraoperatively
• Will provide the actual spherical power of the lens, cylinder power and the target axis of placement
– Use Verion guidance to locate axis obtained during pre-op
– Place lens and use VerifEye’s toric pseudophakic aberrometryapplication to refine axis of placement by rotating as directed
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Refractive Cataract Suite
Conclusions
• Aberrometry and Guidance are complimentary
• Using both together results in refined IOL power
selection and astigmatic treatment
35
31
“ Preliminary Results of Intrastromal Femtosecond Astigmatism keratotomy”
Steve C. Schallhorn MD
32
33
34
“ The Promise of No Glasses or Contact Lenses!”
Jack T. Holladay MD, MSEE, FACS
35
36
37
38
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40
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ADDRESSES
RICHARD L LINDSTROM MD Minnesota Eye Consultants,PA Ste 200 9801 Dupont Ave S Bloomington MN 55431-3200
Ph.: 952-567-6051 Fax: 952-567-6182 e-mail: [email protected]
ERIC DONNENFELD MD Ophthalmic Consultants of
Long Island
Garden City, New York
Clinical Professor of Ophthalmology NYU
Trustee Dartmouth Medical School
Ph.: 516-766-2519
e-mail:[email protected]
JACK T HOLLADAY MD MSEE FACS 5108 Braeburn DR, BALLAIRE TX 77401-4902
Ph.: (713) 668 7337 Fax: (713) 669 9153 e-mail: [email protected]
STEPHEN S LANE MD Adjunct Clinical Professor, University of Minnesota Minnesota USA
e-mail: [email protected]
MATTEO PIOVELLA MD C. M. A. Centro Microchirurgia Ambulatoriale Via Donizetti, 24 - 20900 Monza- Italy
Ph.: +39 039389498 Fax:+39 0392300964 e-mail: [email protected]
STEVEN C. SCHALLHORN MD 5 Deerdykes Road Westfield Industrial Estate Cumbernauld
Glasgow G68 9HF
Ph.: 01236 795 010
e-mail: [email protected]