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Surgeon experiences good results withLenSx Laser over the past year

www.eyeworld.org Revolutionary technologyfor revolutionary cataract surgery

2 0 1 1 A S C R S • A S O A S a n D i e g o S h o w D a i l y S u p p l e m e n t Supported by Alcon Inc.

Dr. Slade reports bettersafety, precision, and reproducibility with femtosecond laser technology in cataract surgery

Stephen Slade, M.D.,Slade & Baker Vision Cen-ter, Houston, has beenusing a femtosecond laserto perform laser refractive

cataract surgery routinely for morethan a year now in his practice, andin that time, he has learned a lotabout the technology.

“We use it on almost all of ourcases,” said Dr. Slade. He uses theLenSx Laser (Alcon, Fort Worth,Texas) for all of his advanced tech-nology IOL cases. During such cases,the femtosecond laser is utilized tomake incisions, create the capsu-lorhexis, perform lens chopping,and create arcuate cuts, he said.

“The precision is tighter, and Ibelieve it is safer,” Dr. Slade said.

For instance, in terms of creat-ing the capsulorhexis, “It allows meto make the capsule perfectly circu-lar and centered wherever I want,”said Dr. Slade. “It allows me to makethe same rhexis every time.”

Hence, the LenSx Laser makesthat surgical buzzword “repro-ducibility” real. “Once you get re-producibility, you can tighten yourcalculations,” Dr. Slade said.

The LenSx Laser has a signifi-cant impact on effective lens posi-tion. “Right now, we can measurethe length of the eye, the curvature… but [before the LenSx Laser] wecouldn’t control capsular contrac-tion,” Dr. Slade said. Researchershave identified some factors that im-pact capsular contraction, such asthe size of the lens, but until re-cently, the contraction itself evadedcontrol.

The LenSx Laser helps in that itleaves a more precise capsular bag inplace, Dr. Slade said. “A small capsu-lotomy will contract more, while abig one contracts less,” Dr. Slade

said. “If surgeons do it by hand, thesize will vary. If they do it by laser, itwon’t vary.”

No longer having to worryabout capsular contraction, ophthal-mologists can be more confident intheir positioning of lenses. “Sur-geons can center the capsulotomy orplace it where they want it,” Dr.Slade said. “Because of this moreprecise placement, the standard de-viation of the spherical componentof the lens is much tighter.”

Dividing the nuclear segmentvia quick laser treatment, the LenSxLaser reduces surgical manipulationinside the eye. “The laser treatmentof the lens prior to phacoemulsifica-tion reduces phaco time and powersignificantly,” Dr. Slade said.

When Dr. Slade explored en-dothelial cell counts post-op, hefound that there was less endothelialcell loss compared to publishednorms when the LenSx Laser wasutilized.

That said, the LenSx Laser does-n’t replace ultrasound. While theLenSx Laser could be responsible fordividing a lens into quadrants, a sur-geon still uses his or her preferredmethod of ultrasound delivery toemulsify the nucleus.

“The LenSx Laser provides ahigher level of precision and safetyfor the cataract procedure,” Dr. Sladesaid.

In December 2009, ZoltanNagy, M.D., Budapest, Hungary, andcolleagues, published a report in theJournal of Refractive Surgery evaluat-ing the LenSx Laser for cataract sur-gery.

His reason for doing so wascompelling. “Manual capsulorhexisresults in capsular tears in approxi-mately 1% of cases and has limiteddiameter predictability, which canaffect IOL centration, postoperativeanterior chamber depth, and poste-rior capsular opacification rates,” Dr.Nagy wrote.

“The laser treat-ment of the lensprior to pha-

coemulsificationreduces phacotime and powersignificantly”

Stephen Slade, M.D.

continued on page 3

The LenSx Laser, FDA cleared in October 2010

This supplement was produced by EyeWorld under an educational grant fromAlcon Inc.

Copyright 2011 ASCRS Ophthalmic Corporation. All rights reserved. The views expressed here do not necessarily reflect those of the editor, editorial board, or the publisher, and in no way imply endorsement by EyeWorld or ASCRS.

2 EW San Diego 20112

New technologies in a practice

Ensuring everyone in apractice is educated aboutnew technologies will easetheir introduction, surgeonsays

Advances in technologyhave helped expandcataract surgery beyondthe older, Medicare-basedpatient base to younger

people who want spectacle inde-pendence and are willing to pay out-of-pocket for the added benefit.With cuts in Medicare reimburse-ment to ophthalmic surgeons con-tinuing yearly and the sustainablegrowth rate cuts looming each year,surgeons need to abandon the mind-set that if 10% cuts are enacted, allthey need to do is increase their pa-tient base by 10% to cover the cuts,said Robert J. Cionni, M.D., med-ical director, The Eye Institute ofUtah, Salt Lake City.

Educate yourself on newer technologiesBefore making the decision to incor-porate the latest technology into apractice—whether it’s the newestgeneration of multifocal or accom-modating intraocular lenses (IOLs),the femtosecond laser for cataractsurgery, or wavefront analyzers andtopographers for refractive surgerycandidates—“you need to educateyourself about it,” Dr. Cionni said.In his opinion, limiting your educa-tion to peer-reviewed journals is in-sufficient because of the time delayfrom submission to publication. In-stead, he highly recommends at-tending user meetings and largeconferences, and reading some ofthe non-peer-reviewed magazines.

“The reason I could bring someof the technology to my practice be-fore others even knew about it wasbecause I’ve gone to meetings likeASCRS,” he said. Introducing newtechnology into a practice should bea two-pronged approach, he said.First and foremost, educate yourselfand “educate your staff—anyonewho has any phone or personal con-tact with your patients—to makesure the same message is being pre-sented at each step,” he said.

“If patients have been receivinga consistent message from the get-

go, it’s very likely that when I sitdown with them, they already wantthe newest technology lenses, leav-ing it up to me to tell them if they’regood candidates.” Even those whoare not candidates may end upbeing the best publicity for yourpractice, he said, as they often rec-ommend friends and family tophysicians they deem more knowl-edgeable about what is available.

In his practice, staff will sendpotential advanced technology lenspatients information about what thelens implants are, how each differs,what patients can expect from thepre-op exams through the post-opfollow-up period, etc. For his refrac-tive patients, he includes informa-tion not just about LASIK but alsoabout refractive lens options, toricIOLs, and implantable correctivelenses (ICLs).

“I’ve used every advanced tech-nology lens that’s come on the mar-ket, and I’ve gone to corporate-sponsored courses for each. Biasnotwithstanding, these courses offersome of the best pearls and tips for

successful use of the lenses,” Dr.Cionni said.

Because patients are now arriv-ing in the office “already informedby friends and family who havenewer technology lenses or proce-dures, any surgeon who doesn’t atleast discuss the technology is goingto watch those patients jump ship.”That said, a good 70% of the pa-tients in Dr. Cionni’s practice do notqualify for the newer technologylenses (mostly due to co-morbidi-ties).

He recommended keeping allthe testing equipment in one centrallocation in an office so when newmachines are purchased, the overalloffice footprint does not drasticallychange.

Sharing knowledgeIn the past 5 years, there has been a“paradigm shift” in how cataractsurgeons treat their patients. “Whenwe start presenting results from thefemtosecond cataract laser on alarger scale, I think we’ll see thisnew technology utilized more com-

“Educate yourselfand educate yourstaff to make surethe same messageis being presented

at each step”

Robert J. Cionni, M.D.

The LenSx Laser in Dr. Cionni’s practice

Sunday, March 27, 2011

monly for cataract surgery,” he said.“I’m confident we’ll start hearinghow much more consistent resultsare. This latest advance in cataractsurgery eliminates inter- and intra-surgeon variability,” he said.

Practices that are consideringadding new technologies—whetherit’s a new type of laser or a new diag-nostic tool—have to manage thecosts. “It takes some careful plan-ning by the practitioner to ensurethe monies are there for a large in-vestment such as a laser,” Dr. Cionnisaid.

Dr. Cionni plans to incorporatethe femtosecond cataract laser intohis practice by “opening up the lasercenter to other surgeons in the area.This way, we’re all using a commonfacility and fixed assets. We’ll letother surgeons use it for a nominal

EW San Diego 2011 3

capsulotomy and phacofragmenta-tion procedures in ex vivo porcineeyes, proceeding to an initial seriesof nine patients undergoing cataractsurgery.

“For an intended 5 mm capsu-lorhexis in porcine eyes, averageachieved diameters were 5.88+/–0.73mm using a standard manual tech-nique and 5.02+/–0.04 mm usingthe femtosecond laser,” Dr. Nagy re-ported. “Scanning electron mi-croscopy revealed equally smoothcut edges of the capsulotomy withthe femtosecond laser and manualtechnique. Compared to controlporcine eyes, femtosecond laser pha-cofragmentation resulted in a 43%reduction in phacoemulsificationpower and a 51% decrease in pha-coemulsification time. In a small se-ries of human clinical procedures,femtosecond laser capsulotomiesand phacofragmentation demon-strated similarly high levels of accu-racy and effectiveness, with nooperative complications.”

In December 2010, William Culbertson, M.D., Bascom PalmerEye Institute, University of Miami,and colleagues, published a reporton femtosecond laser-assistedcataract surgery in Current Opinion inOphthalmology, which supported Dr.Nagy’s results.

“Although they only had a lim-ited number of patients, they

demonstrated that femtosecondlaser systems for cataract surgery ap-peared to be well tolerated for use,”the researchers wrote.

They also suggested that thefemtosecond laser will do forcataract surgery what it has alreadydone for LASIK.

“With the advent of multifocaland accommodating intraocularlenses and patients pursuing surgeryearlier with less tolerance for visualimpairment, cataract surgeons arefacing increasingly high patient expectations for refractive out-comes,” they noted. “Today, the goalof cataract surgery is to achieve nearemmetropia. Just as for LASIK, femtosecond laser technology candeliver remarkable gains in repro-ducibility, centration, and safety incataract surgery, delivering the nec-essary accuracy and precision to im-prove beyond current clinicaloutcomes.”

So far, Dr. Slade has experiencedthese femtosecond laser refractivecataract surgery innovations first-hand with the LenSx Laser. Ophthal-mologists eager to embraceinnovation may soon follow hislead.

Contact informationSlade: [email protected]

Revolutionary technology for revolutionary cataract surgery

continued from page 1

fee, but it will still take careful plan-ning to determine what we passalong to the patient in terms ofcost.”

As surgeons purchase new tech-nologies in the clinic or the OR,they have to find a way to pay forthem. “Sometimes these costs mustbe passed on to patients if they arerelated to non-covered services suchas refractive surgery,” Dr. Cionnisaid.

All told, educating yourself,your staff, and your patient base isthe only way to successfully incor-porate the latest technology intoany practice, he said.

Contact information Cionni: 801-266-2283, [email protected]

Additionally, he reported, “Thesurgical challenges posed by nuclearchopping techniques have hinderedwidespread adoption, despite evi-dence that they reduce ultrasoundrequirements relative to traditionalphacoemulsification.”

Meanwhile, he noted that fem-tosecond laser precision “exceedsthat of highly sophisticated mechan-ical devices, with fewer likely collat-eral tissue effects.”

But would that necessarily bethe case in cataract surgery? Dr.Nagy put the LenSx Laser to the test,and the answer was affirmative. “Ini-tial results with an intraocular fem-tosecond laser demonstrate higherprecision of capsulorhexis and re-duced phacoemulsification power inporcine and human eyes,” Dr. Nagywrote.

Dr. Nagy began research bylooking at the LenSx Laser anterior

The LenSx Laser uses a real-time OCT imaging system to map the eye and place the incisions, capsulotomy, and nuclear cuts. A video image of the surgeon’s view is overlaidwith “drag and drop” incisions and the capsulotomy’s parameters (left). An OCT sectionof the cornea in which a multiplaned incision is planned and positioned (top right). Asection through the anterior segment shows the lens for planning and placement of thenuclear cuts (bottom right)

4

Preliminary analysis suggests a better patientsatisfaction level with theReSTOR IOL and better nearand intermediate vision

How well a presbyopia-cor-recting lens will performdepends on numerousfactors, including cornealastigmatism (both pre-op

and surgically induced), biometry,pupil size, lens position predictabil-ity, residual refractive error, and pa-tient selection/expectations. Thefirst prospective, randomized, head-to-head comparison of two multifo-cal IOLs found several notabledifferences, said Kerry Solomon,M.D., in private practice, CarolinaEyecare Physicians LLC. In thisprospective study, 62 patients werebilaterally implanted with either theAcrySof IQ ReSTOR +3.0 IOL (Alcon,Fort Worth, Texas) or the TecnisZMB00 (Abbott Medical Optics,Santa Ana, Calif.). The study tookplace at four sites in the U.S. with a3-month post-op follow-up, andwhile surgeons were not masked for

obvious reasons, the patients were.Each patient was implanted bilater-ally with the same lens model.

“We wanted to find out if therewas a difference in terms of what wemeasure—defocus curves, visual acu-ity, sphere, and cylinder—and whatpatients notice,” Dr. Solomon said.

At their simplest, defocus curvesmeasure the lens function withoutaccounting for variables such as bio-metric accuracy or surgical variabil-ity, he explained. In the Food andDrug Administration studies, thedrop-off in intermediate range wasless for the ReSTOR +3 IOL than forthe ReSTOR +4 (an earlier iteration).Dr. Solomon said he expected simi-lar outcomes between the TecnisZMB00 and ReSTOR +3 IOL. In the-ory, the defocus curve is the primarymeans of ensuring each lens startsoff equivalent to every other lensand provides an objective measureof expected vision across a wide vari-ety of distances.

For this study, Dr. Solomonnoted the inherent differences in thetwo lenses would suggest the Tecniswould allow patients to see finerprint more clearly, while the ReSTORwould offer more comfortable read-ing distances and intermediate vi-sion. The ReSTOR lens is a 3 add,while the Tecnis is a 4 add; the

ReSTOR is a diffractive lens withrings out “to about the middle ofthe lens,” while the Tecnis has con-centric rings out to the edge of theoptic, he said. (The ReSTOR +3 lensreduced the overall number of ringsfrom 12 to 9, according to companyinformation, and has slightly widerring spacing to achieve the addpower.)

In theory, he said, “The Tecnisshould have better near vision andallow patients to see finer print. Thedownside to the +4 is that patientshave to hold objects closer than istypically comfortable in order toread. The ReSTOR +3 lens should bemore functional and offer a morecomfortable reading distance, some-thing like 18-20 inches instead ofthe 12 or 14 inches the Tecnis is ex-pected to provide.”

Similarly, the advantage of hav-ing the concentric rings out to theedge of the optic means the lens isless pupil-dependent and may offerthe ability to read in lower lightingsituations, but the trade off is worsehalo and glare. The periphery of theReSTOR IOL is a standard asphericoptic, Dr. Solomon said, whichshould provide better night vision,but because the rings do not encom-pass the whole lens, patients may

EW San Diego 20114

“Post-operativeuncorrected VAwas excellent inboth groups. Ourresults mirroredthe defocus curvedata from the FDAstudies, with inter-

mediate visiontesting better on

the ReSTOR lens”

Kerry Solomon, M.D.

Surgeon says ReSTOR +3 offers advantageover other presbyopia-correcting IOLs

continued on page 5

Figure 1


In a patient satisfactionstudy, patients preferredthe ReSTOR +3.0 IOL overan accommodative option

Presbyopia-correcting IOLscan help provide patientswith more spectacle inde-pendence, according toRobert R. Rivera, M.D., in

private practice, Barnet DulaneyPerkins Eye Center, Phoenix, Ariz. Assurgical experience with these spe-

cialty lenses—or advanced technol-ogy IOLs, as some call them— im-proves, surgeons have alsodetermined which candidates makebetter patients, Dr. Rivera said. Forinstance, those candidates with se-vere dry eye, blepharitis, macularproblems, or unusual topographiesmight not have the same visual out-comes as candidates without thosemorbidities, and some symptomaticside effects (night vision complaints)may be exaggerated, he said.

EW San Diego 2011 5Revolutionary technology for revolutionary cataract surgery

Study finds multifocal IOLs preferredover accommodating IOLs

The question of which lenstype—accommodative or multifo-cal—is capable of offering the bestvision at all distances has remainedelusive. Results of a new study com-paring patient outcomes in near andintermediate visual acuity betweenthe AcrySof IQ ReSTOR +3.0 IOL(Alcon, Fort Worth, Texas) and theCrystalens HD or AO (Bausch &Lomb Surgical, Aliso Viejo, Calif.) in-dicated that patients preferred themultifocal technology to the accom-modative platform, Dr. Rivera said.

Patient preferences, study details“What we want to do with ourprospective study is be able to say toour patients, ‘Based on our clinicalresults, this is what you should ex-pect,’” Dr. Rivera said. The compara-tive study occurred across four sitesin the U.S. General inclusion factorswere visually significant cataractwith less than 1.00 D of astigma-tism. Refractive error was not calcu-lated, as the patients’ primary visualcomplaint was cataract, Dr. Riverasaid. At baseline, the mean age ofthe patients was 64.19 years, and thefemale to male ratio was about60:40. Patients enrolled were maskedabout which of the three lenses they would receive (the CrystalensHD500 or AO or the IQ ReSTOR +3.0

“When patientswith the samenumbers and acuity outcomeswith multifocallenses were asked,they were happieroverall with theirvision”

Robert R. Rivera, M.D.


need to rely on better lighting toread comfortably.

Study results Baseline patient demographics wereabout the same, with the exceptionof intermediate visual acuity. For thepurposes of this study, best correctedvisual acuity (BCVA) was measuredat typical distance, 70 cm for inter-mediate vision and 40 cm for nearvision. At baseline, patients in theReSTOR IOL group (n=33) had amean BCVA of 0.31±0.14 logMAR atintermediate, while those in the Tecnis group (n=31) had a meanBCVA of 0.19±0.14 logMAR (P<.001).This difference was statistically sig-nificant at the 1-month post-opvisit. Dr. Solomon discussed the pre-liminary 1-month results.

“Post-operative uncorrected VAwas excellent in both groups,” Dr.Solomon said. “We would expectthat from the defocus curve data.Our results mirrored the defocus

curve data from the FDA studies,with intermediate vision testing bet-ter on the ReSTOR lens.”

Both lenses performed equallyat distance vision, Dr. Solomon said.For near vision, however, theReSTOR IOL’s 0.08±0.11 (P<.001)was slightly better compared to theTecnis 1-month UCVA of 0.17±0.09(P<.001).

“Multifocal lenses provide verypredictable outcomes,” he said. “Pa-tients will be less spectacle depend-ent with a multifocal lens thanothers, and for now, this is the bestway we have to treat presbyopia.”

It is imperative, however, thatpatients understand the compro-mises of the lenses. The best candi-dates, in Dr. Solomon’s opinion, arethose with less than 1.00 D of astig-matism at baseline and those with ahealthy macula and retina.

Patients were also asked to as-sess the difficulty of performing vari-ous tasks at various distances with

each lens without wearing spectaclesand rate the outcomes on a scale of1 (no difficulty) to 5 (extremely dif-ficult). The 1-month interim resultsshowed the ReSTOR +3 IOL outper-forming the Tecnis in three keymeasures: effectively and safely per-forming near tasks, effectively andsafely performing intermediate tasks,and driving confidently and safely atnight (see Figure 1). In all cases, thestandard deviation was tighter withthe ReSTOR IOL as well, “whichmeans we had greater predictabilitywith the lens,” Dr. Solomon said.

Knowing how the defocus curvetranslates into functional vision andleaving patients with minimal resid-ual astigmatism will help surgeonsmaximize patient satisfaction in thepost-op period.

Contact informationSolomon: 843-881-3938,[email protected]

continued on page 7

6

Delivering on the promiseof reduced spectacle dependence will keep patients happy

Astudy was recently per-formed to evaluate andcompare the visual per-formance outcomes ofthree presbyopia-correct-

ing IOLs: the AcrySof IQ ReSTOR +3IOL (Alcon, Fort Worth, Texas), theTecnis Multifocal (Abbott MedicalOptics, Santa Ana, Calif.), and theCrystalens AO and HD (Bausch &Lomb Surgical, Aliso Viejo, Calif.).The goal was to evaluate satisfactionin patients with early cataract under-going refractive IOL surgery, saidTrevor Woodhams, M.D., in privatepractice, Woodhams Eye Clinic, At-lanta.

The Tecnis Multifocal lens has afull-optic, posterior diffractive de-sign with an aspheric surface. TheAcrySof IQ ReSTOR +3 IOL (also amultifocal design) has an apodized,diffractive center with a refractiveperiphery. These allow for selectivenear, intermediate, and far distribu-tion of light passing through thepupil and being focused on the mac-ula. The Crystalens 5.0 (both the HD and AO version) is an accommo-dating IOL, which works by a combination of anterior/posteriordisplacement and vaulting of thecentral portion of the IOL optic withciliary body contraction.

Study detailsThe study was designed to targetemmetropia for each patient. Pa-tients were disqualified from thestudy if they had more than 1 D ofcorneal astigmatism, Dr. Woodhamssaid. The study protocol did notallow for any post-op keratorefrac-tive procedures for residualametropic correction with the excep-tion of YAG laser for capsular opaci-fication.

“Eliminating significant cornealpre-op astigmatism allowed usgreater accuracy in achieving closeto emmetropia at distance,” he said.“About 95% of the patients in theReSTOR and Tecnis groups achieveda binocular 20/20, which was spec-tacular. The Crystalens group wassomewhat different—we targetedpost-op vision based on the recom-

mendations of Bausch & Lomb,which were plano in the dominanteye and –0.75 D of myopic under-correction in the non-dominant eyeto enhance near magnification.”This particular study did not addressthe issues of reduced contrast sensi-tivity, glare, halos, starbursts, orother optical side effects.

In the first phase of the study,39 patients were randomized to re-ceive either the ReSTOR +3 (16 pa-tients) or the Crystalens. Because ofthe change in design during thestudy from the AO to the HD (withan aspheric surface), 13 received theHD and 10 the AO Crystalens. In thesecond phase, 15 patients were ran-domized to receive either the sameReSTOR +3 IOL (n=9) or the TecnisMultifocal (n=6). Dr. Woodhamsnoted he was speaking only aboutthe 54 patients enrolled at his site(there were three other sites in-cluded in the study).

“One thing about the study wefound interesting was that patientsatisfaction seemed inversely propor-tional to the degree of pre-operativerefractive error,” Dr. Woodhamssaid. “Those with a higher pre-op re-fraction, whether hyperopic or my-opic, tended to be more satisfiedoverall than those in whom we werecorrecting very little distance refrac-tive error. This was true for all theIOL models.” High myopes and hy-peropes seem to be more tolerantthan lower myopes or emmetropesof undesirable optical side effects in-herent in any IOL, he said.

“With emmetropes, it’s muchmore likely they will complain ofsomething no matter what degree ofreading and distance vision they getwith the surgery,” Dr. Woodhamssaid. “We can measure how small aline of letters can be identified at 12or 14 inches, but that’s not how wellthey can read. A reading speed test ismuch more reflective of satisfactionlevels.”

A reading speed test is muchmore reflective of visual perform-ance at near than a near card ofJaeger letters; “this involves readingaloud grammatical sentences ofequal length at progressively smallerfont sizes. The time it takes to complete each short block of text isrecorded with adjustments made formissed words,” he said. “The dis-tance at which reading speed wasrecorded varied for each IOL type:33 cm for the Tecnis Multifocal and40 cm for the ReSTOR IOL and Crystalens, based on their somewhatdifferent near points.”

Dr. Woodhams said in hisgroup, the best magnification forreading was with the Tecnis, fol-lowed closely by the ReSTOR IOL,“although the Tecnis reading dis-tance was felt to be too close bymany patients. Remarkably, none ofthe patients in the multifocal groupsneeded reading glasses at their opti-mal near reading distances. TheCrystalens was the least reliable forsatisfactory, unaided reading at near.Many of the patients in that groupneeded supplemental, low-poweredreading glasses, although this same

EW San Diego 20116

Surgeon finds spectacle independence, patient satisfaction linked with presbyopia-correcting IOLs

“We’re such acomputer-intensivesociety now that

intermediate visionis just as importantas distance andreading vision”

Trevor Woodhams, M.D.

Source: Trevor Woodhams, M.D.


lens performed the best at interme-diate distances, e.g., computer moni-tor reading.”

Diffractive technology advantagesIn today’s refractive lens environ-ment, providing a patient with good

distance vision is important, but “it’sequally important to provide goodreading and intermediate vision,”Dr. Woodhams said. “The ability tohave satisfied patients depends ongreat distance vision—it has to be atleast as good as what they had withspectacles.

“We’re such a computer-inten-sive society now that intermediatevision is just as important as dis-tance and reading vision,” he said.

In his opinion, lens centrationwith a multifocal lens is “far moreimportant” than surgeons mightotherwise think. “My advice is toconstrict the pupil and visualize the


Surgeon finds spectacle independence, patient satisfaction linked with presbyopia-correcting IOLs


coaxial light; move the lens arounduntil you know it’s centered cor-rectly,” he said.

Contact informationWoodhams: 770-394-4000,[email protected]

IOL), and they were followed for 6months post-op to gauge overall sat-isfaction with the lenses and to de-termine if that correlated with theexpected outcomes. The IQ ReSTOR+3.0 IOL is an apodized, diffractivelens, the HD500 is a spherical ac-commodating lens, and the AO is anaspheric accommodating lens.

“We’ve thought for a while thatthe accommodative lenses movearound the visual axis, and thatmight lead to more refractive sur-prises than we would get with multi-focal lenses,” Dr. Rivera said. In thisstudy, surgeons were able to hit thetarget refraction more consistentlywith the IQ ReSTOR +3.0 IOL thanwith either version of the Crystalens.

“That might have to do with ef-fective lens position (ELP), or wherethe lens resides in the eye. When wepick lenses pre-operatively, we wantthem to reside on a predeterminedspot inside the eye,” Dr. Rivera ex-plained. “If the lens ends up a littlerfarther posterior or anterior to ourpredetermined spot, that will affectvisual outcomes. There’s more flexi-bility in movement with accommo-dating IOLs, so the workinghypothesis is that flexibility willmake a lens less likely to stabilizewhere the surgeon wants it to be.”Multifocal lenses center well in thecapsular bag and are more likely tostay put, Dr. Rivera said.

This study evaluated all patientsat 3 months to assess range of visionand overall patient satisfaction withthe lenses. Patients also underwentbinocular defocus testing and wereevaluated for overall spectacle wear,Dr. Rivera said.

At 40 cm, visual acuity was signifi-cantly better with the IQ ReSTOR +3.0IOL (–0.02 logMAR or slightly betterthan 20/20; n=41) than the CrystalensHD (0.37 logMAR; n=37) or CrystalensAO (0.43 logMAR, n=40). At 50 cm,VA with the ReSTOR +3.0 IOL was sig-nificantly better than with either theHD or AO lens (0.05 vs. 0.22 and 0.29,respectively).

Earlier analyses before this studyshowed “there were more surprisesin visual outcomes with the accom-modating IOL. We often had timeswhen patients looked good onpaper, but they would complainabout the quality of their vision.When patients with the same num-bers and acuity outcomes with mul-tifocal lenses were asked, they werehappier overall with their vision,”Dr. Rivera said. In this study, whileall patients had good overall vision,the IQ ReSTOR +3.0 IOL patientswere happier overall than eithergroup of Crystalens patients.

On a scale of 1-10, where “10”was considered the best vision, pa-tients rated the ReSTOR +3.0 IOL at8.43, the Crystalens HD at 7.08, andthe Crystalens AO at 7.94 (there wasa statistically significant differencebetween the ReSTOR IOL and theCrystalens HD). Under good lighting(daytime), those in the IQ ReSTOR+3.0 IOL group had the leastamount of difficulty with vision (0.5on a scale of 0-4), while those in theAO group had slightly more diffi-culty (0.78), and those in the HDgroup reported the most difficulty(1.05). Likewise, the least troublewith nighttime vision was reportedwith the IQ ReSTOR +3.0 IOL group(0.68), followed by the AO group(0.9) and the HD group (1.32).

Additionally, overall spectacleindependence was greater with theIQ ReSTOR +3.0 IOL as well, Dr.Rivera said. At 3 months, 77.3% ofthe patients in the ReSTOR +3.0 IOLgroup (n=44) reported overall spec-tacle independence, compared with37.8% in the HD group (n=37) and37.5% in the AO group (n=40).

Surgical pearlsAs someone who has implanted“hundreds” of these advanced tech-nology IOLs, Dr. Rivera had somesuggestions for those who are justbeginning to gain experience withthe lenses.

“First, don’t be afraid of theseIOLs,” he said. “We can and do endup with extremely happy patients.”

Second, “make sure you have agood capsulorhexis that will holdthe edge of the optic in place,” hesaid. “You need to ensure the lens isbeing held in a good position in thecapsular bag. That is the last area ofwide variability among surgeons andmay have to do with effective lenspositioning.”

Do what you can to correct any

residual refractive error as well, hesaid. For this group of patients withincreased expectations, it is unac-ceptable to leave them with a halfdiopter of cylinder or sphere, Dr.Rivera said.

“You can recommend theseIOLs, and if you’re not comfortablewith refractive surgery, partner withsomeone who is,” he said.

Contact informationRivera: 602-955-1000, [email protected]

8

Using a low power toric lens allows more consistent astigmatic correction

Treating astigmatism haspresented challenges in thepast, as limbal relaxing in-cisions are not always pre-dictable or stable, and the

U.S. has only had toric IOLs avail-able since the latter half of the lastdecade. Now that toric IOLs arewidely available, surgeons have amuch safer, more predictable, andmore stable option, according toPaul Ernest, M.D., founder of TLCMichigan. Surgeons are now able toimprove visual outcomes for numer-ous patients by treating their cornealastigmatism at the time of cataractsurgery; toric IOLs are able to correcta wide range of astigmatism—insome cases up to 2.00 D of astigma-tism and as low as 0.75 D. Dr. Ernestsaid the key to keeping residualastigmatism to a minimum is to cre-ate a square wound, place it moreposteriorly than typical, and keep asmall incision size (he prefers 2.2–2.4 mm).

The AcrySof IQ Toric T3 lens(Alcon, Fort Worth, Texas) is de-signed to treat between 0.75 D and1.25 D of astigmatism at the cornealplane, Dr. Ernest said. “Conven-tional wisdom” tells surgeons that0.5 D of astigmatism equates toabout 0.25 D of spherical error andcan affect high contrast visual acuityas well, Dr. Ernest said. In addition,the lens is aspheric, “which gives abetter level of contrast sensitivityafter implantation,” he said.

“I’ve used the lens to treat be-tween 0.87 D and 1.25 D,” he said.In a recent study1 of 323 eyes withastigmatism ranging from 0.75 D to1.38 D, 185 eyes were implantedwith the AcrySof Toric T3 IOL, andthe rest received the AcrySof IQspherical power lens. (The T3 hasthe lowest cylinder power of 1.5 D atthe IOL plane and just over 1.00 Dat the corneal plane, Dr. Ernest said.)

Overall, no complications re-lated to the implantation or the lenswere reported, and none of the sur-geries involved sutures for woundclosure, showing the importance ofproper wound construction.

Know your SIA levels“We wanted to calculate the surgi-cally induced astigmatism (SIA) for asubset of eyes (n=38) with post- op-erative keratometry results as well,”Dr. Ernest said. Simulations of thelens after 0.5 D of surgically inducedastigmatism suggested the lenswould have a low likelihood forovercorrection. With an estimated65% of the population having someamount of corneal astigmatism upto 1.25 D, reducing the amount ofinduced astigmatism is paramount,he said.

“When we look at some of theother lenses—the T4 or T5—we seethey have lower residual astigma-tism than the T3 (0.6 D on the T3compared to about 0.5 D with theothers),” he said. “We wanted tofind out why a lens would create alower amount of astigmatism thanany other.”

The simple answer is “surgicallyinduced astigmatism. In my experi-ence, square wounds induce lessastigmatism. When you induce a sig-nificant amount of astigmatism, itgreatly alters the effect of the lenson visual outcomes in those patientswith lower levels of corneal astigma-tism,” Dr. Ernest said. For example,if a surgeon’s typical induced astig-matism rate is 1.00 D, that will havea much more clinically relevant out-come if the patient had 1.00 D ofpre-op astigmatism than if the pa-

tient had 2.50 D of pre-op astigma-tism, he said.

Dr. Ernest’s typical surgically in-duced astigmatism rates with the T3are about 0.25 D with a standard de-viation of 0.14 D. Because his levelsof induced astigmatism are consis-tent between lens types and modelnumbers, Dr. Ernest said he did notadjust for lens power in the T3study.

“I’m able to achieve those lowrates not only because the lens isgood, but because using a posteriorlimbal incision did not induce theamount of astigmatism that wouldoffset letting the lens do its job,” Dr.Ernest said. In fact, he said opting touse a posterior limbal incision willinduce about half the astigmatism asa clear corneal incision, even with atemporal, 2.2-mm square incision.His technique involves making anincision in the posterior limbus“without getting into sub-Tenon’sspace,” he said.

Overall, 92% of those implantedwith the T3 had no more than 0.50D of residual refractive astigmatism,compared with 13% of the patientsin the spherical IOL group. Wherethe astigmatism is located may affectoutcomes as well, Dr. Ernest said,noting that with-the-rule astigmaticshad more than 1.00 D of refractiveastigmatism post-op, compared to

EW San Diego 20118

“My woundplacement lets the

lens correct astigmatism theway it has been

designed to do, andI’m not adding a

significant amountof astigmatism

with mytechnique”

Paul Ernest, M.D.

Surgeon says AcrySof IQ Toric IOLcorrects lower levels of astigmatism

Dr. Ernest shows his temporal, 2.2-mm square posterior limbal incision technique Source: Paul Ernest, M.D.

continued on page 9



First U.S. study comparing LRIto aspheric toric IOL implants

Preliminary results indicatebetter outcomes with theaspheric toric IOL implant

Treating astigmatism hasbeen a challenge for sur-geons—limbal relaxing in-cisions (LRIs) are notnecessarily the most con-

sistent option for patients with morethan 1.00 D of astigmatism, andlonger-term results have not alwaysbeen reliable. Some estimates predict

half the people over 60 years oldhave at least 1.00 D of astigmatism,and almost one-quarter of those un-dergoing cataract surgery have morethan 1.50 D of astigmatism. In gen-eral, astigmatism of as little as half adiopter can be visually disturbing.

There are two surgical ap-proaches to changing refractive astig-matism, said Anna F. Fakadej, M.D.,in private practice at Carolina Eye As-sociates. Surgeons can either changethe corneal anatomy by LRI or bylaser, or they can implant a toric IOL.

“In either case, the pre-operativeevaluation is paramount for a qual-ity outcome,” she said. “Once theevaluation has determined regularcorneal astigmatism without ectasia,the decision becomes one of whichtechnique would better address theastigmatism.”

Studies outside the United Stateshave found toric implants can pro-vide better consistency and offer pa-tients better visual outcomes thanLRIs, she said.1 Dr. Fakadej believesthe inconsistencies between the twoprocedures are due to the “inherent “With a toric

implant, we takethat unknown out ofthe equation. We arenot counting on thecornea to react inthe way we predict but ratherusing an optic,which is intraocular,to correct the astigmatism”

Anna F. Fakadej, M.D.


against-the-rule astigmatics who hadabout 0.70 D.

“It’s not enough to pick up thislens and use it—even though this isan easy lens to insert and place dueto its platform,” he said. “If surgeonsare creating clear corneal incisions,they may be inducing enough astig-matism that nailing the refractive re-sults might be more difficult.”

He attributes his low levels ofsurgically induced astigmatism to“incisions that are small, square, andmore posterior. It’s not because I’m abetter surgeon than others, it’s be-

cause my wound placement lets thelens correct astigmatism the way ithas been designed to do, and I’m notadding a significant amount of astig-matism with my technique,” he said.

The addition of the T3 to his ar-mamentarium allows Dr. Ernest “toprovide a real visual benefit to thecandidates with lower levels of astig-matism—when surgeons start talk-ing about patients in the 0.75 D to1.25 D range, that’s a large number.If surgeons want to offer treatmentto these patients, they’ll have to alsoprovide a clinical difference for

them. There is a huge difference inperceived vision with a residual errorof 0.75 D and one that’s 0.5 D orless.”

Reference1. Ernest P, Potvin R. The effects of preopera-tive corneal astigmatism orientation on resultswith a low cylinder power toric IOL. Article inpress. J Cataract Refract Surg.

ContactErnest: 517-782-9436,[email protected]

Figure 1. Preliminary visual acuity results on the first 50 patients to reach 1 month of follow-up

continued on page 11

10

For patients who are notcandidates or not inter-ested in toric or multifocaltechnology, aspheric IOLscan offer improved visual

outcomes. The AcrySof IQ IOL(Alcon, Fort Worth, Texas) incorpo-rates an aspheric, thinner centralposterior optic (9% thinner than thestandard AcrySof lens) on the single-piece hydrophobic acrylic lens,which results in a slightly net posi-tive spherical aberration, enhancingimage quality.

Aberrations normally lead todegradation of vision even when re-fractive error is corrected withglasses or contact lenses. In ayounger eye, the crystalline lens hasnegative spherical aberration whilethe cornea has positive sphericalaberration. As one ages, the compen-sating negative spherical aberrationof the lens decreases. When the crystalline lens is removed incataract surgery, surgeons need to

offset some of the positive cornealaberration with a negative sphericalaberration lens, said Bonnie An Henderson, M.D., partner at Oph-thalmic Consultants of Boston, andassistant clinical professor of oph-thalmology, Harvard MedicalSchool, Boston. “We can’t correct for these types of corneal aberrationswith traditional glasses,” Dr. Henderson said. “That’s the idea be-hind the aspheric intraocular lens.”

The AcrySof platform was al-tered to thin the center of the lensand flatten the posterior side, and“those two changes cause a net neg-ative asphericity of the lens itself,enough to counteract the majorityof the positive spherical aberrationof the cornea,” Dr. Henderson said.The average cornea has +0.275 mi-crons spherical aberration, and theAcrySof IQ IOL has –0.20 micronsspherical aberration, leaving the eyewith about +.08 microns sphericalaberration. Leaving the eye slightlypositive benefits patients by increas-ing contrast sensitivity. The IQ IOL

also reduces both spherical and totalhigher-order aberrations, so thefunctional vision delivered by thislens is noticeable for patients, ac-cording to Dr. Henderson.

Since the lens is a monofocaloptic, indications for implantationare the same as for non-asphericmonofocal IOLs. Dr. Henderson saidthat when choosing a lens, however,surgeons should consider pupil size.

“The larger the pupil, the moreaberration the patient will experi-ence,” she said. “Light rays are over-refracted at the periphery of the lensand cornea so the larger the pupil,the greater the aberration. Therefore,eyes with larger pupils in particularbenefit more from an aspheric IOL.”

Predictability, stabilityAlthough all of the newer genera-tion IOLs offer patients better out-comes, “the AcrySof stands outbecause the soft, gummy materialopens slowly and predictably in theeye,” Dr. Henderson said. “Implanta-tion is so controlled, the risk of

EW San Diego 201110

Surgeon describes unique benefits of AcrySof IOL

Implantation of AcrySof IQ IOLSource: Alcon Inc.

“The IQ IOL reduces both

spherical and totalhigher-order

aberrations, so thefunctional visiondelivered by thislens is noticeablefor patients”

Bonnie An Henderson, M.D.


breaking a capsule during implanta-tion is significantly minimized. Ifthe haptic is rotated or curled, itdoesn’t matter since you can manip-ulate the lens as it unrolls in thebag.” She notes the time—about 3seconds for haptic-to-haptic un-rolling—helps the lens maintain itsstability, but also allows surgeons tomanipulate the lens as it’s unfurlingwithout causing subsequent damageto the eye.

Other IOLs incorporate stifferhaptics that can open abruptly, shesaid.

An additional benefit of theAcrySof IOL material is “the ‘sticki-ness’ of the lens, which allows thelens to stay where you need it to,”Dr. Henderson said. “Proper lensplacement is very important for cen-tration, and the stability of this lensdecreases the risk of IOL tilt.”

Dr. Henderson prefers DuoVisc(Alcon) as her viscoelastic because ofthe versatility of two differentagents. “Being able to use a disper-

sive [VISCOAT OVD, sodium chon-droitin sulfate, sodium hyaluronate]at the beginning of the case to pro-tect the endothelium but thenswitching to a cohesive [ProViscOVD, sodium hyaluronate] to inflatethe capsular bag and maintain space for IOL implantation is ideal.ProVisc is easy to remove after IOLimplantation because it adheres toitself and is aspirated quickly.”

Enhanced satisfactionPatients are satisfied with the excel-lent visual performance of theAcrySof IQ IOL, from performingvarious everyday activities to themost challenging tasks such as driv-ing under mesopic conditions. TheIOL delivers improved contrast sen-sitivity in low light situations andimproved image quality due to theamount of spherical aberration cor-rected. There have been 55 millionAcrySof IOLs implanted since its in-troduction, and the consistency,

ease of implantation for the sur-geon, and proven benefits for thepatient in terms of increased visualperformance have led to enhancedsatisfaction.

Contact information Henderson: 617-957-9279,[email protected]



unknown with LRIs about how anindividual patient’s cornea willheal.” Even with nomograms thatcan offset the surgeon’s inducedastigmatism, “the patient may fi-brose the cornea quickly and the LRImay be ineffectual.” Conversely, apatient may have more relaxing andbe overcorrected.

“With a toric implant, we takethat unknown out of the equation.We are not counting on the corneato react in the way we predict butrather using an optic, which is in-traocular, to correct the astigmatism.Additionally, having the correctioncloser to the nodal point of the eyetypically improves the visual quality.Another inherent problem with theLRI is the risk of perforation andwith that increased risk of infec-tion,” she said.

Preliminary results: LRI vs. toric IOLDr. Fakadej was part of a team thatconducted the first prospective, ran-domized, contralateral eye studycomparing the AcrySof IQ Toric IOL(Alcon, Fort Worth, Texas) with anLRI incision with an AcrySof IQ IOLon 69 patients scheduled to undergophacoemulsification. Mean age was

67 years old; 68% were female. Pre-op corneal cylinder was limited tono more than 2.5 D, and patients inthe toric arm received one of threelenses: the AcrySof IQ Toric T3, T4,or T5 IOL, depending upon pre-opcylinder. (Those in the LRI arm re-ceived a monofocal AcrySof IQ IOLand LRI). The study will follow pa-tients for 6 months; Dr. Fakadej dis-cussed the preliminary 1-monthresults.

“Most of the patients had verysymmetric corneal astigmatism be-tween both eyes,” she said. “The ap-proach to correct astigmatism wasrandomly chosen for the first eyeand the other procedure was per-formed on the second eye. We founda reduction in the post-operative re-fractive astigmatism in most pa-tients. However, we found that thepost-op refractive astigmatism wasreduced more consistently with thetoric IOL. We found that post-opera-tive uncorrected and corrected visualacuity was better with the toric IOLthan the LRI by at least one butmore often greater than two lines.”(See Figure 1.)

She added the preliminary re-sults in this study are mimickingthose found outside the U.S. and ex-

pects that trend to continue oncethe 3- and 6-month evaluations arecompleted.

Precision countsIn general, Dr. Fakadej said LRIs arereliable “if performed by the samesurgeons with the same nomograms,but for increasing amounts ofcorneal astigmatism, the LRI be-comes less reliable.” A general ruleof thumb, she suggested, is to useLRIs on patients who have less than1.00 D of astigmatism.

“You can get good outcomeswith LRIs in cases of residual astig-matism.” Additionally, patients whohave previously undergone refrac-tive surgery may be problematicwith either LRIs or toric implants,Dr. Fakadej said. “Another comor-bidity that might look like regularcorneal astigmatism is anterior base-ment membrane dystrophy. Thosepatients can be tricky, but they canbe treated with other methods.”

She also advised ensuring “any-thing that’s cornea-based” such asdry eye or Fuchs’ dystrophy be ad-dressed clinically before implantinga toric lens or opting for LRIs.

Dr. Fakadej has implanted“about 800 eyes” with the toric lens

and offered some additional pearls.“If you have the luxury of mark-

ing the cornea at the slit lamp in anupright position, that’s my personalpreference,” she said. “There arecorneal marking instruments thatcan help orient the toric lens to the3 and 9 o’clock position.” Intraoper-atively, she recommends leaving thetoric lens “a little counterclockwiseof the marking.” During viscoelasticremoval, keep the I/A tip on the lensto prevent its “quivering” and usethe hook to settle it into place afterall the visco is removed. Her vis-coelastic of choice is ProVisc(sodium hyaluronate, Alcon) for theentire operation except in cases offloppy iris or corneal endothelial dis-ease where she’ll opt for DuoViscOVD (Alcon) instead.

Reference1. Mingo-Botin D, Munoz-Negrete FJ, KimHRW, Morcillo-Laiz R, Rebolleda G, Oblanca N.Comparison of toric intraocular lenses and pe-ripheral corneal relaxing incisions to treatastigmatism during cataract surgery. JCataract Refract Surg. 2010;36:1700-1708.

Contact informationFakadej: 910-295-2100, [email protected]

Filtering both UV and high energy blue light, the proprietary AcrySof IOL chromophore more closely approximates the light transmission of a human lens

MCA11553JS1

surgeon experiences good results with lensx laser over the ... · inside the eye. “the laser...

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