making cataract surgery refractive surgeryhandout

8/12/2019 Making Cataract Surgery Refractive Surgeryhandout

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Making Cataract Surgery

Refractive SurgeryEric E. Schmidt, O.D.

Bladen Eye CenterElizabethtown, NC


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Cataract Surgery

It is considered to be the most successfulsurgery in the world! SO..

Why do we want to mess with success? Whats all the fuss about?

What do we really want to achieve?


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Goals Of Surgery

Visual improvement maximumachievable visual acuity

20/20 w/out eyeglasses! No anisometropia

Remember though; 20/20 may not alwaysbe possible

Plano may not always be the best desiredend point


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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 newstuff

You need to understand that cataract surgeryshould be considered refractive surgery


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Pre-operative procedures Set realistic goals for each individual patient Perform detailed binocular refraction Determine desired endpoint for the patients 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


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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


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A-Scan

Biometry- this is the key to choosing thecorrect IOL power.

IOL chosen based on desired endpointrefraction, axial length and keratometry

A-Scan ultrasound very easy to perform

CPT code 7651676519 Should this be done by the referring OD?


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IOL MA STER

Zeiss Not ultrasonography High resolution partial coherence

interferometry Easy to perform (


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IOL MA STER

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 precisionas compared to A-scan


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IOL Master

This renders a 5-fold increase in accuracy Solves some A-scan issues

Posterior staphyloma Long eyes (>24.5mm) Short eyes (


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Cataract Surgery- Weve Come ALong Way Baby!

ICCE ECCE

Phacoemulsification No-stitch, no patch


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Surgical Incisions

Is one type really better than another?

Scleral tunnel Clear cornea Micro-incision (1mm)


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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


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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


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Micro-incisions need micro IOL!!!

Super thin IOL Injectable IOL

Liquid IOL Lens refilling procedure


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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?


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Post-operative regimen

Antibiotic 4 th generation fluoroquinoloneQID

Steroid prednisolone acetate 1% QID (ormore)

NSAID Intraocular steroid Dex DSS

Post-op visits 1 day 1 week

3-4 weeks (DFE)


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Clear Corneal Incisions Dont

Leak

They Suc k !!!!


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Endophthalmitis

Increase due to natural endogenous florafrom lids

75-90% gram positives Staph. Epidermidis (42%) Staph. Aureus,Enterococcus

Pay close attention to the lids pre- andpost-operatively


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To reduce endophthalmitisincidence

Fluoroquinolone QID 4 days prior tosurgery

Lid scrubs if needed Artificial tears Betadine prep peri-operatively

May need to leave px on topical antibioticslonger post-operatively Orals ??


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Post-op concerns

Glare and haloes Internal reflections

Anisometropia 2nd eye management Post. Capsule opacification


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What About Astigmatism?

Toric IOL

Astigmatic Keratotomy

Who are candidates?

Are there refractive limitations? What can the patient (and us ) realistically

expect?


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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


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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


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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


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Astigmatic keratotomy

Relaxing incision made nasally Shallow (


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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


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Astigmatic keratotomy

What are the drawbacks? Poor predictability

Limited range of correction

Post-operative FB sensation


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So an optometrists walks into anexam room to see a post-op px

O.D.- Howre those eyes doing Mr. Jones? Px Not so great.

O.D. Whaddaya mean , not so great?Youre seeing 20/20 in each eye withoutglasses!

Px Yeah, but I cant see my newspaper!


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What to do about presbyopia?

Monovision IOL

Presbyopic Lens Exchange (PRELEX)

Multifocal IOL

Accommodating IOL


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Multifocal IOL options

Monovision

Refractive

Diffractive

Accommodative


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The Ideal Multifocal IOL Patient

Baby Boomer 50s to the mid 60s 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


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Whos A Candidate? / Clinical

Hyperopic

Loss of accommodation Cataract Unilateral traumatic cataract

Congenital cataract Astigmatism (can be corrected) High myopes (surgeon preference)


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Whos 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


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Whos 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


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ReZoom Multifocal IOL (AMO)

Refractive lens 2nd generation acrylic IOL

Delivers good near, distance andintermediate vision


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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


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Acrysof ReStor IOL (Alcon)

Diffractive technology

Silicone material

Uses apodization to soften blur and sharpenvision

Provides excellent VA at near, distance andintermediate ranges


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Strengths of the AcrySof

ReSTOR

IOL High quality uncorrected near anddistance vision with 20/40 or betterintermediate vision without movement ofthe IOL

80% Overall Spectacle Freedom

Nearly 94% of patients would have thelens again


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Aspheric Multifocal IOL Technology


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Do We currently have any asphericmultifocal IOLs?

Tecnis multifocal (AMO)

Sofport AO (Bausch & Lomb)


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Explain the WOW! Factor(or lack thereof)

Haloes and glaare at night are common-these diminish with time

Longer adaptation period may takeweeks or months for pxs to accept theirnew visual system

Near vision may be fuzzy to myopes May need reading specs for prolonged

nearpoint work


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Accomodative IOL

Crystalens- eyeonics Silicone IOL with hinged optics

IOL moves forward or back depending onciliary muscle tone Implanted using phaco technique

Capsulorhexis is critical Pre-op biometry crucial


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Enter: Accommodating Lens

The first accommodating lens technologyapproved 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 asingle focal point throughout a full

range of vision from far, throughintermediate to near seamlessly

A New Paradigm In Vision Correction

(In contrast with multifocal IOLs which use adual simultaneous focus or monovision whereone eye is

set for distance & one eye for near) eyeonics crystalens


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The Ideal Crystalens Patient

Baby Boomer 50s to the mid 60s Cataract starting to compromise quality of

vision

Active lifestyle Concerned about their appearance & qualityof life

Do not want to get old Spending billions on lifestyle enhancing

procedures

Realistic Expectations Motivated Asks lots of questions


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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


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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


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Spectacle Use Survey

Bilateral Implanted SubjectsWearing Spectacles n/n (%)

I do not wear spectacles 33/128 (25.8%)

Almost none of the time 61/128 (47.7%)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%)

73.5 %}


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Is There A WOW Factor?


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Cataract Surgery-Whats 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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