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PremiumIOL’sPatientEvaluation,LensChoiceandDealingwithProblems

Douglas K. Devries, ODEye Care Associates of Nevada

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FinancialInterestDisclosure• Douglas K. Devries

• Consultant or Speakers Bureau for • Allergan• Alcon• Akorn• Bausch Health Care• BioTissue• Bruder• BVI• EyeVance• Eyes 4 Lives• Kala• Johnson & Johnson Vision/AMO• Lumenis• OcuSoft• Oyster Point• RySurg• Revision Optics• TearLab• Science Based Health• Shire Pharmaceuticals• Sun Pharmaceuticals

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CourseGoals• Discuss Peri-Operative Management of Cataract Surgery • Patient Education of Dysfunctional Lens Syndrome• IOL Choices & Presbyopia Correction Options

• Multi-Focal• Extended Depth of Focus (EDOF)

• Patient Choices & Toric IOLS

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WhyCo-Manage?

• Discussion:• First and Foremost: Patient Care• Patient Education• Patient Retention• Financial Impact

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Demographics

1. 2015 Comprehensive Report on the Global IOL Market. Market Scope 2. US Census Bureau, 2012 3. gallup.com/poll/166952/baby-boomers.reluctant-retire.aspx 4. NextAvenue, nextavenue.org/hottest-trends-boomer-travel 5. AARP Getting to Know Americans Age 50+, 2014 6. AARP Planning Complete Streets for an Aging America, May 2009

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GrowthofCataractSurgeryPatients• Significant growth of the 65+ yo population

Ann Surg. 2003 Aug; 238(2): 170–177.

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TreatmentAstigmatism&PresbyopiainCataractSurgery

Every patient over the age of 50 is impacted by presbyopia1, yet only 6.5% of patients receive a presbyopia-correcting IOL

67%

8%

25%

33%

% of Patients receiving Toric IOL

■Patients > 1.0D Astigmatism■Patients receiving Toric IOL

1/3 of Patients have > 1.0D of astigmatism but only 1/4 of those patients are receiving a Toric IOL

6.5%

93.5%

% of Patients receiving PC IOL

PC I OL

Monofocal IOL

Patients who do not have astigmatism and presbyopia treated at the time of cataract surgery must treat those conditions with glasses for the rest of their lives.

1. 2016 Market Scope

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WhoSeesCataractPatientsFirst?

ODs perform an estimated 88 million comprehensive eye exams annually of the total of 104 million performed by all eye care professionals, or 85 percent of all comprehensive eye exams.2

2. http://reviewob.com/wp-content/uploads/2016/11/8-21-13stateofoptometryreport.pdf

Optometrists

Ophtha lmologists

88M (85%)

16M (15%)

40,000

18,000

58,000 eye care professionals are licensed to perform comprehensive eye exams1

1. https://www.aoa.org/Documents/news/state_of_optometry.pdf

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• The crystalline lens begins…• CLEAR• COLORLESS• FLEXIBLE

The Dysfunctional Lens

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• … but it doesn’t stay that way.• Lens adds new layers each year• Layers compact• Disulfide bonds accumulate• Lens stiffens• Lens optics change

Dysfunctional Lens Syndrome (DLS)

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Stage 1 DLS Stage 2 DLS

23 year old lens 48 year old lens 55 year old lens

The Dysfunctional Lens

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Stage 1 (mid 40’s – early 50’s)• Lens stiffens and cannot change shape as easily• Loss of accommodation

Dysfunctional Lens Syndrome (DLS)

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• Stage 2 (50’s-60’s)• Increasing lens haze• Yellow discoloration• Scatter of light• Decreased quality of vision

Dysfunctional Lens Syndrome (DLS)

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• Stage 3 (60’s – 80’s)• Cataract: a clouding of the

lens of the eye that obstructs the passage of light

Dysfunctional Lens Syndrome (DLS)

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Treatment Options

1. Reading glasses or multifocal contact lenses

2. Corneal inlays3. Blended Vision LASIK or

PRK4. RLE for High Hyperopes

DLS Stage 1

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Treatment Options

1. Reading glasses or multifocal contact lenses

2. Corneal inlays3. Blended Vision LASIK or

PRK with extra DLS education

4. RLE

DLS Stage 2

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Treatment Options

1. Cataract Surgery• Monofocal IOL• Distance only• Monovision

• Presbyopia Correcting IOL

DLS Stage 3

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Understand your Patient: Expectations for Presbyopia What they say:

What they want:

“I want to be able to read”

Accommodation

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Discussion

Why is it important to prepare the ocular surface before surgery?

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OurRoleinOptimizingOutcomesWhen needed, pre-treat the ocular surface

Why prepare the ocular surface?ü Better topography images/Improved Biometry (better K’s)ü More comfortable patient ü Faster healingü Outcomesü Accurate biometry drives better outcomes

20TFOS Dews Diagnostic Methodology Report. Jones L. et al. et al Ocul Surf. 2017 Jul. 15(3) 575-628

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DryEyePrevalenceinPatientsScheduledforCataractSurgery1

• 22.1% of patients had previously received a diagnosis of Dry Eye Disease• 80.9% of patients had an ITF Dry Eye Level 2* or higher, based on the presence of signs and symptoms

* An ITF level of 2 indicates moderate Dry Eye. 1. Trattler et al. Clinical Study Report: Cataract and Dry Eye: Prospective Health Assessment of Cataract Patients Ocular Surface Study. 2010. (Unpublished study.)

80% of Patients Had Dry Eye Severity Score of Level 2 or Higher

11.0% 8.1%23.5%

54.4%

3.0%0

2040

6080

100

Level 0 Level 1 Level 2 Level 3 Level 4

Per

cen

tag

e o

f P

atie

nts

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PanelDiscussion

When do you treat dry eye?

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“Hot Spots” and “Flat Spots” Are Abnormal

23Im ag es co u rtesy o f K aro lin n e R o ch a, P h D , M D

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Irregularly Shaped Or Smudgy Placido Disk Is Abnormal

24Im ag es co u rtesy o f E lizab eth Y eu , M D

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Take A Closer Look If Average K Values Are Different

25Im ag es co u rtesy o f E lizab eth Y eu , M D

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Post-DryEyeTreatment:KValuesAreMuchMoreSimilar

26Im ag es co u rtesy o f E lizab eth Y eu , M D

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RecommendationstoManageOSD-RelatedPatientExpectations

• Chair time to help patients understand difference between blurred vision from cataracts versus DED

• Cataract surgery can worsen DED for months after surgery1

• Symptoms may not resolve for 3 months or longer

271. TFOS Dews Diagnostic Methodology Report. Jones L. et al. et al Ocul Surf. 2017 Jul. 15(3) 575-628

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OcularSurfaceTesting• Questionnaire• Osmolarity• Inflammation• Meibography• NaFl Staining and TBUT• Meibomian Gland Evaluation

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StandardPatientEvaluationofEyeDryness(SPEED)Questionnaire1

• Evaluates the frequency and severity of symptoms

• Developed as an easy to use fast screening tool for dry eye disease

• SPEED questionnaire is one of the tools used to identify candidates for LipiFlow®

2009_Blackie_The Relationship Between Dry Eye Symptoms and Lipid Layer Thickness_Cornea

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WhyAddressMGDPre-op?

No Significant Structural Change

Duct D ilation, Truncation & Drop Out

Severe Truncation & Drop Out

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Functioningoilgland secretion

Tearscience.com

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Tearscience.com

No oil gland secretion

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Discussion

How often do you find gland involvement in patients with ocular surface disease?

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MGDisaLeadingCauseofDryEye1

In one study, 86% of patients diagnosedwith Dry Eye have symptoms associated with an unstable tear film due tocompromised Meibomian gland function. 2

1.Nichols KK, Foulks GN, Bron AJ, et al. The International Workshop on Meibomian Gland Dysfunction: Executive Summary. Investigative Ophthalmology & Visual Science.2011;52(4):1922-1929.2.Lemp, M. A., Crews, L. A., Bron, A. J., Foulks, G. N., & Sullivan, B. D. Distribution of Aqueous-Deficient and Evaporative Dry Eye in a Clinic-Based Patient Cohort. Cornea, 2012;31(5), 472-478.doi:10.1097/ico.0b013e318225415a.

*Both eyes of 299 healthy patients and those with dry eye disease (218 women, 81 men) were evaluated using Schirmer tests and MGD (Foulks-Bron scoring) across 10 sites in the EU and US. Adapted from: Lemp, M. A., Crews, L. A., Bron, A. J., Foulks,G. N., & Sullivan, B. D. Distribution of Aqueous-Deficient and Evaporative Dry Eye in a Clinic-Based Patient Cohort. Cornea, 2012;31(5), 472-478.doi:10.1097/ico.0b013e318225415a.

86%M G D (n=79)50%

M G Dand aqueous

deficient (n=57) 36%

Aqueous deficient

(n=23) 14%

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VectoredThermalPulsationSystemProvidesHeatandPressuretoLiquefyandEvacuateObstructedGlands

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Lid warmerComposed of a heater, eye insulation, and vaulted shield

Heat is applied to the palpebral surfaces of the upper and lower eyelids directly over the Meibomian glands

A sterile disposable eyepiece connects to a console used by the physician to control the application of heat and pressure to the eyelids

Eye cups

Graded pulsatile pressure is delivered to the outer eyelid

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Magnifying lens

Real-time display of eyelid temperature and

treatment duration

One-button control of heating and compression

Charging stand for internal lithium-ion

battery

Sterile, single-patient use disposable Smart Tip

Precision temperature

sensorsSoft,

biocompatible silicone cover

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Heat itApply LED light to

raise the eyelid temperature and

melt the blockages.

TurnuptheHeatonDryEyeTreatment

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Collins Expressor Forceps (Item 98610)For aggressive expression of the Meibomian gland.

Livengood Expressor PaddlesAngled (Item 98620) & Flat (Item 98630)

For mild or gentle expression of the Meibomian gland.

New! Ophthalmic Surgical Instruments

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Randleman JCRS 2009; 35:992–997

Dry Eye is a Frequent Cause for Dissatisfaction with MF IOLs

ConsiderDryEye

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Question• Do you make specific IOL recommendations that a patient

should discuss with the surgeon?• A Yes

• B No

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• Advise patients about potential glare/halos

• Advise patients about light dependency for near (some multifocals)

• Advise patients of limitations in intermediate vision, (multifocals) or near vision (accommodating)

• Advise patient that one eye will be stronger for distance and one stronger for near, if mono

Patient Counseling & Expectation Management:Incorporate Patient Into the Decision

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WhatDoYouKnowAboutYourPatientthatisBeneficialtotheSurgeon?§ Collect important patient information

that will help define their vision goals• Age• Occupational Activities• Leisure Activities• Nighttime Activities• Spectacle Use Expectations• Night Driving• Obsessive/perfectionists • Demanding• Anxious• Unrealistic 43

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Question• Do you educate patients as to IOL selections?

• A Yes in general terms• B Yes in specific terms as to their needs• C No

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• Patients wanted to see at ALL distances (near, intermediate, & distance vision)

• What were options for intermediate?

MultifocalAccommodating

Multifocality2014 & prior…

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Do not underestimate the importance of good intermediate vision

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• Monofocal IOL Monovision• Mini-monovision with presbyopia IOLs• Mixing and matching presbyopia IOLs• Low add IOLs• EDOF IOLs

Many Evolving Surgical Presbyopia Correcting Options

TecnisMultifocal

ReSTOR CrystalensTecnisSymfony

Low Add MultifocalHigh Add Multifocal

EDOF Accommodating

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Pros• Cost-effective• Monofocal quality of vision• Less sensitivity to IOL

decentration

Cons• Reduced depth perception

• Feeling of imbalance• Limited intermediate vision• Need for spectacles for night

driving and prolonged reading

Monofocal Monovision IOLsIdeal patient candidates:• Contact lens trial• Patients with experience of

monovision contact lenses

• Type B patients

• Patients who do not mind wearing glasses

• Women

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• Pros:• Good distance visual acuity• Good near vision• Limits spectacle

dependence

• Cons:• Glare and halos (but still

better than other options)• Intermediate VA• Neuroadaptation

Ideal patient candidates:• Avid readers

• Patients that want as much spectacle independence as possible

Low add Multifocal IOLs

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Extended Depth of Focus (EDOF) IOLs

Visual quality comparable to monofocal

A New Category: What’s unique about EDOF IOLs?

1.

2.

4.

3.

Depth of focus

Night vision symptoms

Tolerance to residual refractive error

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• Symfony• Unique diffractive echelette design

• Elongated focus• Extended range of vision

• Achromatic for enhanced contrast sensitivity

• Toric EDOF corrects astigmatism

http://www.tecnisiol.com/eu/tecnis-symfony-iol.htm

Extended Depth of Focus (EDOF) IOLs

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DeliveringElongationofFocus

• Monofocal IOL

• Multifocal IOL

• Tecnis Symfony IOL

Extended Depth of Focus (EDOF) IOLs

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• Diffractive technology has been associated with multifocal IOLs, but it can be used in different ways

• Other industries use diffractive lenses (cameras, telescopes, microscopes) to optimize optical performance under constrained conditions

Diffractive Technology

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• The power of the eye is wavelength dependent. Colors that are out-of-focus cause blur and reduce contrast.

• The phakic eye has approximately 1.38 D of chromatic aberration between 450 and 700 nm1. Pseudophakic eyes have between 1.45 and 2 D of chromatic aberration, depending on the dispersion of the IOL material2,3

2. DOF2015OTH0004. 2. Data on file. Longitudinal Chromatic aberration of a monofocal TECNIS Achromat IOL. 3.Weeber et al. Differences in Chromatic Aberration of IOLs, ESCRS 2016.

WhatisChromaticAberration?

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Theimpactofchromaticaberrationonimagequality

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Achromatic Technology

AdiffractiveIOLwithachromatictechnologycancorrectchromaticaberrationoftheeye

Typical IOL

TECNIS Symfony®

Diffractive Technology

Cornea

+ =

Cornea

+ =

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85% of patients wore glasses none or a little bit of the time

Extended Depth of Focus (EDOF) IOLsSpectacle Wear

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What’s Happening at Post-op DAY 1

•Review medications•IOP Check—concern if too high or too low•Check distance vision•Wound secure•Cornea clear/Edema•AC – 1-2+cells / formed•IOL centered•Provide patient instruction:

• Review restrictions – no swimming, no hot tubs, no gardening• Normal to be off balance• Avoid buyers’ remorse

•Fax results to surgeon

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What’s Happening at Post-op WEEK 1

• Review history/chief complaints and confirm meds

• Check uncorrected vision at distance and near w/ good lighting

• Refract

• IOP

• Slit lamp exam should be clear to < grade 2 cell

• Check for infection or increased signs of inflammation

• Fax results to surgeon

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What’s Happening at Post-op MONTH 1

•How is the patient functioning?•Check uncorrected vision at distance and near with good lighting

•What is the final refraction•Check IOP•Slit lamp exam

—Clear cornea/edema—Look for surface disease—AC well formed with no cell—IOL well centered in pupil—Evaluate posterior capsule

•Fundus exam—Confirm that there is no CME—Check peripheral retina

• Fax results to the surgeon

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Extended Depth of Focus (EDOF) IOLsManaging Expectations

Neuroadaptation Reminder

• REMIND patients that it is important to give the lens a little time to settle in

• Neuroadaptation time varies from patient to patient

If a patient believed he would be able to see perfectly at all distances, we failed to do our job of setting appropriate expectations… no matter how

stellar the outcomes

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TheDissatisfiedPatient• Subjective complaints

• Vision quality• Unmatched expectations

• Objective signs• Real or perceived?• Evaluate your data

5 C’sCorneaCentrationCapsuleCMECrazy

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Randleman JCRS 2009; 35:992–997

Dry Eye is a Frequent Cause for Dissatisfaction with MF IOLs

ConsiderDryEye

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Astigmatism:RealPrevalence

• >70% of patients have >0.5 D of pre-op astigmatism

• Critical to address for good uncorrected vision

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AstigmatismandCataractSurgery

More than

of the population has >1 D of astigmatism,but only

1/3

7%of IOLs implantedare toric IOLs1

1. Market Scope, Data as of 2013. Comprehensive Report on Global IOL Market.

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MethodstoTreatAstigmatism

• LRI or Arcuate Incision• Toric IOL• Glasses or CLs• No special astigmatism correction needed

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Regularvsirregularastigmatism• Regular astigmatism

• Generally good candidates for Toric IOLs

• Irregular astigmatism• Often more difficult cases to address with Toric IOLs

RegularAstigmatism

IrregularAstigmatism

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Lenticularvs.CornealAstigmatism• Corneal Astigmatism

• Will continue to impact visual system after cataract surgery

• Lenticular Astigmatism• Will not continue to impact visual system after cataract surgery• However, needs to be understood preoperatively to assess the

true corneal astigmatism levels

CornealAstigmatism

LenticularAstigmatism

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WTRvsATRAstigmatism• With the rule astigmatism

• Many patients can tolerate 1.0D or even 1.25D without significant impact on patient satisfaction and visual quality

• Against the rule/oblique astigmatism• Generally has a greater impact on patient satisfaction and

visual quality• Most patients will benefit from having these levels below 0.5

D

With the ruleAstigmatism

Against the ruleAstigmatism

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AudienceQuestion:ToricorNotoric?• Corneal topography shows 0.5D of corneal astigmatism• Manifest refraction shows 1.75D of overall astigmatism

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CaseAsktheAudience:ToricorNotoric?• Corneal topography shows 1.75D of corneal astigmatism• Manifest refraction shows 0.25D of overall astigmatism

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DISCUSSION

• How would you recommend treating an otherwise healthy cataract surgery patient with 0.75D of with the rule cylinder and an interest in less spectacle wear for distance?

The TECNIS Symfony Toric should not be an option for implantation

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DISCUSSION• How would you recommend treating an otherwise

healthy cataract surgery patient with 0.75D of against the rule cylinder and an interest in less spectacle wear for distance?

The TECNIS Symfony Toric should not be an option for implantation

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ImportanceofHittingTargetwithToricIOLs• 1° rotation = 3.3% decrease effect

• 10° rotation = 33% loss of effect

• 30° rotation = 100% loss of effect

• > 30° degrees = Inducing new astigmatism

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AstigmatismCorrection

• Options at time of Cataract Surgery

• Monofocal IOL with incisional correction

• On-axis incision

• Corneal Relaxing Incisions –Blade vs. Femtosecond

• Toric IOLs• Monofocal• Multifocal / EDOF

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MonofocalToric IOLOptions• Alcon (SNATX)• AMO (ZCT Tecnis monofocal)

• Bausch & Lomb (EnVista Toric)• Staar Surgical (Silicone Plate Haptic)

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PatientSelectionforToricIOLs

• Patient Selection• Desires good uncorrected distance vision without

spectacles• Comfortable with spectacles for near

• Absence of significant or unstable corneal disease affecting the ocular surface or shape

• Astigmatism indications• WTR – Doesn’t need to be treated until up to 1.0D or even

1.25 D• ATR/oblique – Will benefit from getting astig below 0.5 D

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Discussion

What value does the optometrist provide to the surgeon?

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TheFourStagesofPre-OperativeCare• Knows the patients needs and wants• Gather clinical information• Offer education on clinically appropriate options• Pre-treat if indicated

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WhatDoYouKnowAboutYourPatientthatisBeneficialtotheSurgeon?§ Collect important patient information

that will help define their vision goals• Age• Occupational Activities• Leisure Activities• Nighttime Activities• Spectacle Use Expectations• Night Driving• Obsessive/perfectionists • Demanding• Anxious• Unrealistic 80

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PreparethePatientfortheBusySurgicalEnvironment• Review treatment options based on the patient’s situation• Do not make assumptions about financial situation• Explain the possibility of visual complications with each option• Address any questions the patient or family members may

have

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Co-managementrelationship

• Ensure that there is a documented relationship established to co-manage any patient with a surgeon

• Your surgeon should be able to provide you with the documentation

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PARTII:Clinical

Cases:

Post-OpSurprises

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Patient#1

• 84 year old female• Extremely anxious about surgery• Desires UCDVA • MRX OD: +1.75 +0.75 x 015 (20/40)• W OD: +1.00 +0.75 x 006

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Topographies

~1.40 D aligned around 40°

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~2.25 to 2.50 D aligned 28° to 34°

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BarrettToric Calculation

Implanted SN6AT5 21.0 @ 29°

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Patient#1• POM1: right eye

• UCDVA 20/30• MRx: -050 +0.75 x 35 à 20/20 easy

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Patient#1• POM1: right eye

• UCDVA 20/30• MRx: -050 +0.75 x 35 à 20/20 easy

• UNDERCORRECTED within SIMILAR axis• Plan: single 35° manual LRI at 035 degrees

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Patient#1

à POW 1 s/p LRI: 20/20 -1 and HAPPY

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Separate videoexample:Single40°@172degrees

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Patient#2

• 76 yo AAM, desires UCDVA• MRx:

• OD: -1.50 +1.50 x170 (20/30)• OS: -0.75 +1.50 x175 (20/40)

• 2-3+ NSC ou• ERM OS, OD normal

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Patient#2

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Patient#2• OS first: POW 1 20/25 (-0.25 +0.25 x 165) • OD: Implanted T4 19.0 @ 175 degrees

• POM 1 OD: • UCDVA 20/60+• MRX: -0.75 + 1.50 x 150

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Patient#2:Post-opAtlas

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Patient#2

• Toric IOL aligned at 033 degrees• Options:

• AK’s• LASIK/PRK• Rotate the IOL• IOL exchange

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astigmatismfix.com(Drs. John Berdahl and David Hardten)

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Toric IOLReposition

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Patient#3

• 61 yo WF• OD: 3.53 D @ 085

• AL 24.46• -5.00 +3.50 x090

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Patient#3

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Patient#3• Implanted T7 (~3.00D)• POM 1: -0.75 + 1.50 x 045• Huh????• Those with greater WTR anterior corneal astigmatism will

have great amounts of posterior WTR astigmatism, but amount is uncertain

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Patient#3

• Correctly aligned at 090 degrees• Overcorrected or undercorrected?• Options?

• AK’s• IOL exchange• LASIK/PRK• Rotate the IOL

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www.astigmatismfix.com(Drs. John Berdahl and David Hardten)

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CLINICALPEARL

• If the post-op refractive axis changes significantly (oblique to 90 degrees away) and the IOL is aligned correctly, more than likely an OVERCORRECTIONhas occurred• Options:

• LRI, LVC or IOL reposition to weaken effect of toricIOL

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CASE4

• 71 yo WM• PMHx: ALS, wheelchair bound, cognition fully intact,

desires spectacle independence• MRx:

• OD +0.25 +0.75 x 010 (20/30)• OS +0.50 +1.25 x 180 (20/40)

105 106

CASE4

• Plan: single 45 degree FLAC at 010 degrees

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CASE4

• Plan: single 45 degree FLAC at 010 degrees

• POW 1: • UCDVA: 20/80• MRx: OS -0.75 + 1.50 x 150 (20/30+2)

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CASE4:POW2topography

Sim K’s: 1.23 D @ 150°

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CASE4:POW2topography

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Patient:ManagementOptions

• Pooling within 45 degree AK causing ~1.75D flattening effect àslight gaping

• Changed meridian• Patient c/o slight fluctuations in vision• No discomfort

• How to proceed?

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CASE4:POW7s/pBCL:UNCHANGEDFOCALGAPING

Sim K’s: 1.49 D @ 149°

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What would you do for this patient?

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CASE4

• At POM 2.5 àproceeded with IOL exchange for a T4 IOL, aligned at 150

• POW 1 OS à• UCDVA 20/25• OS -0.25 + 0.25 x 085

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ThankYou

• DrDevries@EyeCareAssociatesNV.com

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