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  • RLE (Refractive Lens Exchange)- Bootcamp

    Christopher Blanton, MD April 28,2018

  • Financial Disclosure

    Paid consultant: Johnson & Johnson, Inc.- Star S4/iFS IntraLase Medical Monitor Integra LifeSciences, Inc. One Legacy Organ and Tissue


  • RLE -definition Also known as Clear Lens Extraction or Lens

    Replacement Surgery Replacing a clear natural lens with a synthetic

    intraocular lens for the correction of refractive error and +/- presbyopia

  • Goals To understand the considerations for RLE

    surgery patients- Candidacy/Lens options To properly select patients and describe the

    steps required to deliver outstanding pre-operative and post-operative care

  • 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

  • Treatment of Astigmatism & Presbyopia in Cataract Surgery

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

    % of Patients receiving PC IOL



    PC IOL 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

  • Who Sees Cataract Patients First?

    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


    88M (85%)

    16M (15%)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


  • Who/What makes a good candidate? Always review options- glasses,

    contact lenses or surgery Two most primary considerations Refractive error and Age

  • Who/What makes a good candidate?Myopia Considerations

    The vast majority of myopes with clear lenses will be best treated with a corneal refractive procedure.

    Some high myopes will be better served with a phakic IOL. Rarely, a high myope may be considered, but remember,

    these are often the most challenging lens extraction patients because of abnormal anatomy and risk of retinal detachment

  • Who/What makes a good candidate?Mixed Astigmatism Considerations

    The vast majority of mixed astigmats with clear lenses will be best treated with a corneal refractive procedure.

    Why???-typically they have very low spherical equivalents

  • Who/What makes a good candidate?Hyperopia Considerations

    The vast majority of clear lens extractions are going to be done on HYPEROPES.

    Why???- the limitations of corneal refractive surgery in this group of patients

    Presbyopic Symptoms

  • Who/What makes a good candidate?Age Considerations

    Begin thinking of this procedure when patients reach their late 30s.

    Why???- Presbyopia is right around the corner. The more hyperopic they are, the more a younger patient makes

    sense. Upper age limit ~~60ish,but this is arbitrary- meaning that at

    some point we are just going to be talking about cataract development.

  • Current IOL Options Monofocal IOLs Monofocal Toric IOLs

    The FDA recently approved a different class of lens: Extended Depth of Focus (EDOF)

    Presbyopia-Correcting IOLfor patients with and without Astigmatism

    Accommodating IOLs

    Accommodating Toric IOLs

    Multifocal IOLs

    Multifocal Toric IOLs

  • Diffractive Technology

    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

  • Extended Depth of Focus


    The echelette is the relief or profile of the lens (height differential) within each ring The height, spacing, and profile of theechelettesto create a diffractive patternfor an elongated focus The proprietary echelette design introduces a novel pattern of light diffraction that elongates the focus of

    the eye1

  • Delivering Elongation of Focus

    Monofocal IOL

    1 Data on File._Data on File_Tecnis Symfony Green Light Bundle Bench Test DOF2014CT0005. Abbott Medical Optics Inc. 2014

    Multifocal IOL


  • 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. Longitudinal Chromatic aberration of a monofocal TECNIS Achromat IOL. 3.Weeber et al. Differences in Chromatic Aberration of IOLs, ESCRS 2016.

    What is Chromatic Aberration?

  • The impact of chromatic aberration on image quality

  • Achromatic Technology

    A diffractive IOL with achromatic technology can correct chromatic aberration of the eye

    Typical IOL

    TECNIS Symfony Diffractive Technology


    + =


    + =

  • Discussion

    When is it time to discuss with a patient?

  • Protocols and ProceduresReferral Provide documentation and communicate

    Pre-op Discuss surgical options Determine what testing will be performed in your office

    Post-op Schedule Preferred Meds Appropriate intervention

  • Patient Education1. Explain the conditionscataract vs. clear lens, astigmatism and presbyopia

    2. Discuss the options Introduce condition-specific category options Prepare the patient for the choice hell have to make when he visits the surgeon Provide education materials for review at home

    3. Set realistic expectations Educate BEFORE surgery Prepare the patient for the surgical consult

  • Patient CandidacyLifestyle Considerations:

    Occupational activities Leisure activities Nighttime activities Spectacle use expectations

    Surgical Considerations: Ocular pathology Preoperative refraction Amount of astigmatism Previous surgical history

    Patients to Avoid: Previous refractive surgery

    Corneal disease

    Irregular astigmatism

    Patients with unrealistic expectations

  • Discussion

    When is it time to refer the patient?

  • Our Role in Optimizing OutcomesWhen needed, pre-treat the ocular surface

    Why prepare the ocular surface?Better topography images/Improved Biometry (better Ks)Potential for reduced risk of infection/less corneal stainingMore comfortable patient Faster healingOutcomes

  • Dry Eye Prevalence in Patients Scheduled for Cataract Surgery1

    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






    Level 0 Level 1 Level 2 Level 3 Level 4







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    f Pa



  • Hot Spots and Flat Spots Are Abnormal


  • Irregularly Shaped Or Smudgy Placido Disk Is Abnormal


  • Take A Closer Look If Average K Values Are Different


  • Post-Dry Eye Treatment: K Values Are Much More Similar


  • Patient Education

    Are we prepared to talk to patients about extended depth of focus?

  • Patient EducationEducate BEFORE surgery Clear, continuous vision from the computer on out You may need +1.00D magnifiers for near For the first few weeks, youll see lights around headlights Vision wont be perfect on day 1

  • Explain NeuroadaptationEDOF is a DIFFERENT kind of lens

    The brain needs to get used to the extended depth of focus opticsHelp patient understand how EDOF technology works

    Emphasize that the goal is to achieve QUALITY of vision

    Explain that theres always a trade-offYou may continue to need reading glasses on occasion, but you will likely have a greater range of vision

    PREPARE the patient not to expect vision to be perfect at Day 1

  • Post-op Day 1 Review medications IOP Checkconcern 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 gardeningNormal to be off balance

    Fax results to surgeon

  • Post-op Week 1 Review history/chief complaints and confirm meds Check uncorrected vision at distance and near w/ good lighting Refract-


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