Document 6492286

How to be Fabulously Successful with
Premium IOL’s
Randy J. Epstein, MD
“Cataract” Surgery vs.
Refractive Lens Exchange “R.L.E.”
Professor, Dept. of Ophthalmology
Rush University Med
Med. Center
Center, Chicago IL
CEO, Chicago Cornea Consultants, Ltd.
Chicago/Highland Pk./Hoff. Est., IL
Similarities:
Surgical procedure
IOL s
IOL’s
Differences:
Indication for surgery
Who is paying
The Key Elements of Success
“Up-charging” for enhanced services:
“UPGRADES”
Your entire practice must have a
“refractive mindset” in order to be
successful with refractive IOL’s for
BOTH groups, (even
(
if you JUST do
d
cataracts), including:
1) Enhanced “customer” orientation
2) Receptive population
3) EASY availability of financing
• Now a well established Medicare paradigm
• “Concierge” internal medicine practices
have solidified the concept,
concept which is
growing (you get what you PAY for)
• Patients are more accustomed to paying
“out of pocket” for more of their healthcare
needs (“fee for service”)
Refractive IOL’s approved by the
FDA in active use in USA
Good candidates for
Multi-focal IOL’s
Multi-focals:
– Alcon ReSTOR
– AMO Technis
– B&L Crystalens
Torics:
– STAAR AA4203TL
– Alcon Acrysof SN60T* series
• Patient is interested in decreasing
dependence on reading glasses- (Steinert,
‘08: “The patient has to care”)
• Young cataract patients
• Most refractive lens exchange (RLE)
patients (especially hyperopes)
• Willing to accept possible halos
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Multi-focal IOL’s:
Best for Hyperopic Presbyopes
• Easiest to please as they have TWO
optical problems
• Greatest margin for error
• Low risk of RD
RLE: My Preferred Refractive Procedure
in “Older” Presbyopes (over 60)
• Azar study, 2008: LASIK is “OK”
• RLE with a multi-focal IOL addresses both
distance and near issues most effectivelyy
• Treats lens-induced HOA’s and avoids postLASIK disappointment
• Eliminates “post-LASIK” IOL calculation
hassle for cataract surgery
• (Retinal consults for high myopes)
Subjective Exclusion Criteria for
Bad candidates for
Multi-focal IOL’s
• Astigmats (>1.5D of corneal astigmatism)
• Macular pathology (ERM’s, drusen)
• Abnormal corneas
– Keratoconus, prior refractive or corneal surgery
– Ocular surface disease (EBMD, dry eyes)
Multi-focal IOL’s
•
•
•
•
Hypercritical patients
Patients with unrealistic expectations
Occupational night drivers
? Pilots
• Mono-focal IOL in the other eye?
• Glasses-wearing low myopes (they like to
read ‘sc’ and IOL’s never exceed this)
Relative Contraindications for
Toric IOL’s- NOT MANY!
• Fewer ocular issues- (OK to use with GLC,
ARMD, post-ops, etc.). KC +/- now…
• Ocular surface disease (EBMD
(EBMD, dry eyes)
• ? High residual astigmatism in other eye
(unless you are prepared to deal with it)
• Surgical complications
Multi-focal IOL’s: Pre-op
considerations
• 1) Pre-op topography is essential
• 2) ? Match IOL color in contra-lateral
y ((chromophore/clear)
p
) ??
multifocal eye
• 3) Plan/discuss need for N/C post-op
PRK/LASIK “touch-ups” in advance.
• (This is factored into the “up-charge”).
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Refractive IOL’s: Pre-op
considerations: Our patient
education routine
Our Patient Education Carrels:
Patient Education Concepts, Inc.
• All patients watch Patient Education
Concepts
p ((P.E.C.)) DVD or computer
p
program, and take the quiz (for
documentation) while they are dilating
• Brochures, etc.
• Detailed, written informed consent
• Finance plans (CareCredit, etc.)
Computer version
Alcon “ReSTOR” +4.00D add
Multifocal IOL
FDA Approval: April, 2005
• “Pseudo-accommodative”
• Reading center weighted
• Light
Li ht energy is
i equally
ll divided
di id d between
b t
distance
di t
and near for small pupils
• Becomes distance-dominant for large pupils
• Aspheric optics
• Near point TOO CLOSE for many patients
AcrySof® ReSTOR®
Aspheric IOL Design
AcrySof® IQ ReSTOR® +3.0D add IOL
The AcrySof® ReSTOR®
Aspheric IOL is designed with
negative spherical aberration.
SN6AD3
SN6AD1
Add Power: +4.0 D
Spectacle Plane: +3.2 D
Range: +10.0 D to +34.0 D
A-Constant: 118.9
Add Power: +3.0 D
Spectacle Plane: +2.5 D
Range: +6.0 D to +34.0 D
A-Constant: 118.9
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Aspheric Optics with AcrySof®
ReSTOR® Aspheric
“Deliberate use of unequal adds
with ReSTOR”
• Osher JCRS 35:1646, 2009
• Patient #1: ReSTOR +4, had computer
problems
• Patient #2: ReSTOR +3, and unable to read
fine print
• Both patients “20/Happy” after getting other
IOL in second eye
Aspheric IOL
Aspheric optics align the light rays to compensate for positive
corneal spherical aberration, with enhanced image quality.
SN6AD1 Design Characteristics
Apodization
• “Cutting off the feet” (Greek)
• Small pupils: Equal distribution of near and
distance Rx
• Large pupils: Distance dominant
• Utilizes existing IQ ReSTOR® IOL +4.0 D
platform with identical asphericity, energy
distribution profile, and shape factor
• Add power modified to +3.0 D
– 9 diffractive steps vs. 12 diffractive steps
– Slightly wider step spacing to modify the add power
22
Uncorrected Intermediate Photopic VAs
Average Near Best Distance
100
90
80
70
60
50
40
30
20
10
0
38
Centim
meters (cm)
% off Subjects
All Implanted, 3 month postoperative, 50 cm
36
34
32
30
28
26
20/25 or better
20/32 or better
20/40 or better
Uncorrected
IQ ReSTOR® IOL +3.0 D [N=138]
IQ ReSTOR® IOL +3.0 D [N=138]
IQ ReSTOR® IOL +4.0 D [N=131]
IQ ReSTOR® IOL +4.0 D [N=131]
Provides a one line or more improvement in binocular intermediate VA.
Source: AcrySof® IQ ReSTOR® IOL Package Insert
Source: AcrySof® IQ ReSTOR® IOL Package Insert
4
Over 95% of ReSTOR® IOL +3.0 D Patients Would
Have the Same Implant Again
Binocular Defocus Curve
Percent off Subjects
∞
20/20
20/25
Snellen
20/32
20/40
20/50
20/63
20/80
20/100
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
IQ ReSTOR® IOL +3.0 D [N=138]
IQ ReSTOR® IOL +4.0 D [N=131]
No
+1.00
+0.50
0.00
-0.50
-1.00
-1.50
-2.00
-2.50
-3.00
-3.50
IQ ReSTOR® IOL +3.0 D [N=117]
Yes
-4.00
Would you have the same implant again?
Refraction (D)
IQ ReSTOR® IOL +4.0 D [N=114]
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Source: AcrySof® IQ ReSTOR® IOL Package Insert
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Source: AcrySof® IQ ReSTOR® IOL Package Insert
AcrySof ® IQ ReSTOR® IOL Conclusions
Refractive IOL’s: Surgical
Considerations
True performance at near, intermediate, and distance
• 1 – 1.5 line(s) improvement in intermediate VA in favor of
SN6AD1 vs SN6AD3
• Best near distance approximately 7 cm (3 in) out for
IQ ReSTOR® IOL +3.0 D
• Contrast sensitivity measured between SN6AD1 and SN6AD3
demonstrated clinical equivalence
• No clinically relevant increase in visual disturbances between
SN6AD1 and SN6AD3
• High rate of patient satisfaction and spectacle independence
• Mark steep axis on eyeball with patient
sitting up (before sedation/block)
• Incision placement: I always prefer STEEP
AXIS SURGERY when possible
• LRI’s
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Multifocal IOL’s: Surgical
Considerations
If STEEP AXIS incision placement is NOT
possible, must do LRI if patient has preexisting
g with-the-rule cylinder
y
to avoid
post-op astigmatic surprises!
Refractive IOL Complications
• Power errors
• Mis-communications (mono-vision, etc.)
• Surgical complications
– Back-up IOL’s need to be available (on axis
surgery especially critical for astigmats as there
IS no backup for toric IOL)
– Alcon MN60D3= 3 piece multifocal
• Post-op complications
5
Long-Term ReSTOR- JCRS 9/08:
80% spectacle independent at 3 yrs.
Multifocal IOL’s:
Post-op issues
• Have Alcon’s minus Rx
glasses handy for patients
to use for demonstration
• Use topography to illustrate residual
astigmatism, which is usually the issue
• Low threshold for offering NO CHARGE
PRK/LASIK touch-ups (included with
‘up-charge’)
When to fix astigmatism? Always
takes precedence over presbyopia
“You have three problems, we can only fix
two” (in the following order):
– 1) Cataract
– 2) Astigmatism
– 3) Presbyopia
Common “Astigmatism Trap”:
Refractive- ATR, K-WTR
Common “Astigmatism Trap”
Example
•
•
•
•
MR= +1.00 + 1.00 x 180 OU
WITH the-rule astigmatism on topography
WITH the rule astigmatism on IOLMaster
= “Lenticular Astigmatism”!
Lenticular Astigmatism: Solution
• Incision made in steep (90 degree) axis(Superior scleral tunnel)
• Outcome: Spherical cornea,
cornea happy patient
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Toric IOL’s: Pre-op considerations
• LRI’s: online calculators
AcrySof® IQ Toric IOL Calculator
Makes precise surgical planning easy!
– ASCRS calculator: (www.ascrs.org)
• Surgical planning
• Incision placement (S.I.A.)
• Alcon’s online toric IOL calculator takes into
account YOUR surgically induced astigmatism
(“S.I.A.”)
• (www.acrysoftoriccalculator.com)
Alcon Acrysof Toric IOL
Model #SN60t*
• No rotation problems
• +10 to +30D of spherical refractive error
• 1.0D
1 0D (t3)
(t3), 11.5
5 (t4)
(t4), or 22.0(t5)
0(t5) D of corneal
astigmatism
• Must factor in lenticular astigmatism (i.e.,
IGNORE it)!
• Higher powers available in near future
Acrysof Toric IOL: Axis marks at
haptic insertion points
Intuitive input
› Patient data
› Keratometry
› IOL spherical power
› Surgically induced astigmatism
› Incision location
Powerful output
› Recommended IOL model and
spherical equivalent power
› Optimal axis placement
› Magnitude and axis of anticipated
residual astigmatism
AcrySof® IQ Toric IOL
Newest monofocal IOL
builds on long line of
innovation from Alcon
Takes the trusted
platform for precise
astigmatism correction
and adds the enhanced
image quality of an
aspheric lens
Bring topography to O.R.
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Put axis marks ON the eye freehand,
using topography as a guide
When to fix astigmatism?
Case in point
• High pre-existing astigmatism (>5.0D OU)
• Cataract surgery OD elsewhere, adding to
that astigmatism
• Presents with cataract OS
OD: post-op
OS: pre-op
OS Phaco, toric IOL, LRI
Surgery OS: Toric IOL, LRI,
under-correction of myopia
Post-op Rx=1.8D corneal cyl.
OD= -3.25+6.00x20
OS= -1.25 sph.
Patient tolerating Rx in
glasses
8
55 year old requested LASIK 8 years agoWears glasses, mild c/o halo/glare OU
Myopic Astig. with mild cataracts,
with-the rule cylinder: Pre-op
– MR:
• OD -5.75 + 1.50 x 103=20/20
• OS: -6.00 + 2.25 x 85=20/25
– TMS:
• OD: + 1.57 x 103, OS: +2.1 X 90
– Mild ant. stellate cortical cat noted OS > OD
– BAT (Med.): 20/40 OD, 20200 OS
– Cataract surgery “medically indicated”
Surgical plan:
Clear corneal temporal incisions OU
Post-op: 20/20 sc OU and plano
“Never saw better in my life”
• Left eye operated on first, with
– SN60 t5 (+3.0D cyl. at IOL plane)
• Right eye operated on next,
next with
– = SN60t4 (+2.25 cyl. at IOL plane)
Recent long-term post-op TORIC
outcomes: JCRS 9-08: 90% >20/40
Toric IOL’s: Surgical Considerations
– Don’t evacuate visco
till done positioning
– Leave 45 degrees short
of endpoint for final ‘spin’
when visco is removed
- Additive with LRI’s
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Dr. Laurie Sullivan’s spreadsheet:
“laurence.sullivan@gmail.com”
(Dotted red= IOL + cyl. axis, green=residual + cyl.)
Refractive IOL’s: Economic
Considerations
• “Upgrade” must include ALL post-op
‘touch-ups’- LRI’s, PRK, LASIK, etc.
Thanks for your attention!
e-mail: “repstein@chicagocornea.com”
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