Dysfunctional Lens Syndrome. The Future of Premium Cataract Surgery · Dysfunctional Lens Syndrome....

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Transcript of Dysfunctional Lens Syndrome. The Future of Premium Cataract Surgery · Dysfunctional Lens Syndrome....

  • 6/22/2015

    1

    Dr. Joaqun Fernndez

    @joaquinfernandezoft

    aboutme/drjoaquinfernandez

    Dysfunctional Lens Syndrome. The Future of Premium Cataract Surgery

    Needs of Baby Boomers

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    Needs of Baby Boomers

    57% < CN1

    Dysfunctional Lens Syndrome

    35% CN2

    8% > CN2

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    Success in Premium Surgery

    DLSExpectations

    Considerations about Satisfaction

    Adatia, F. (2015)

    Patients tend to feel that the second cataract surgery is a more negative experience. We recommend preoperative counseling for all patients before their second cataract extraction.

    The improvement in visual function experienced by a patient did not at all significantlycorrelate with overall satisfaction, a finding that runs counter to common expectations.

    Patients had very high expectations for postoperative function 96.1% with 60% of patients selecting 100%

    Pager, C. K. (2004)

    VF-14 Questionnaire

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    Considerations about Satisfaction

    Patients who already wear spectacles expect to need them after cataract surgery. Those not already wearing spectacles do not expect to need them. Free of glasses is very important in general for patients.

    Hawker et al. (2005) (Monofocal IOLs)

    Nijkamp (2010) (Monofocal IOLs)

    Predictors of satisfaction:

    Preoperative expectations of medical outcome were met (r = 0.407) Satisfaction with quality of care (r = 0.669) Evaluation of patient counseling (r = 0.674). Patient education and counseling were more strongly correlated with

    overall satisfaction than medical outcome (r = 0.669 versus r = 0.543).

    Labiris et al. (2014) (Mini-monovision versus multifocal intraocular lens implantation)

    Multifocal IOL insertion was associated with less dependence on glasses overall but significantly more dysphotopsia.

    Positive Candidates

    Braga-Mele, R., Chang, D., Dewey, S., Foster, G., Henderson, B. A., Hill, W., Yoo, S. (2014). Multifocal intraocular lenses: Relativeindications and contraindications for implantation. J Cataract Refract Surg, 40(2), 313322.

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    Negative Candidates

    Braga-Mele, R., Chang, D., Dewey, S., Foster, G., Henderson, B. A., Hill, W., Yoo, S. (2014). Multifocal intraocular lenses: Relativeindications and contraindications for implantation. J Cataract Refract Surg, 40(2), 313322.

    Future exclusion criteria

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    Success in Premium Surgery

    DLSExpectations

    Vision CompromiseMIOLs

    Vision Compromise of MIOLs

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    Vision Compromise of MIOLs

    Success in Premium Surgery

    DLSExpectations

    Vision CompromiseMIOLs

    Visual Performance Assessment

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    Visual Performance Assessment

    16%

    62%

    96% 99% 99%100%

    9%

    59%

    100%

    0%

    20%

    40%

    60%

    80%

    100%

    20/12.5 20/16 20/20 20/25 20/32 20/40

    Cum

    ula

    tive %

    Of Eyes

    Cumulative Snellen Visual Acuity (20/x or better)

    Postop UDVA

    Preop CDVA

    Visual Performance Assessment

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    Standardization is required

    Optical Quality vs Visual Performance

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    Optical Quality vs Visual Performance

    x x x x x x x x

    Visual Acuity (logMAR)

    Co

    ntr

    ast

    (lo

    g u

    nit

    s)

    Optical Quality vs Visual Performance

    x

    x

    x

    x

    x

    x

    x

    x

    x

    x

    Visual Acuity (logMAR)

    Co

    ntr

    ast

    (lo

    g u

    nit

    s)

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    The Solution

    Standardization and Automatization for reporting DC

    Automated method which

    does not depend on

    the experimenter

    Based on

    Visual acuity or Contrast

    Adaptative Optics Simulator

    Adaptive Optics based Visual Simulator

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    Light-distortion

    LDI: Ratio of the area of points missed by the subject and the total area explored and is expressed as a percentage.

    AT Lisa 839M AT Lisa 909MP Tecnis ZCB00

    HLMP-CW47-RU000,Agilent Technologies

    Success in Premium Surgery

    DLSExpectations

    Vision CompromiseMIOLs

    Visual Performance Assessment

    ObjectiveClassification

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    Objective Classification. Based on Scattering

    Artal, P., Benito, A., Prez, G. M., Alcn, E., de Casas, ., Pujol, J., & Marn, J. M. (2011). An objective scatter indexbased on double-pass retinal images of a point source to classify cataracts. PLoS ONE, 6(2), 17.

    Objective Classification. Based on Scattering

    Visual Function Index-14 score correlations

    1. OSI r=-0.712. DCVA (logmar) r=-0.653. Lens Opacities Classification System III r=-0.604. Average Lens Density (PNS) r=-0.395. Modulation Transfer Function cut-off r= 0.47

    Pan, A., Wang, Q., Huang, F., Huang, J., Bao, F., & Yu, A. (2015). Correlation Among Lens Opacities Classification System III Grading, Visual Function Index-14, Pentacam Nucleus Staging, and Objective Scatter Index for Cataract Assessment. Am J Ophthalmol, 159(2), 241247.e2. doi:10.1016/j.ajo.2014.10.025

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    Objective Classification. Based on Scattering

    OSI improvements required

    We cannot compare the OSI before surgery and after surgery even though some papers currentlydo: Infrared systems (780nm) differ from IOL wavelenght

    desings (550nm). Diffractive rings inside 2 mm affect to the first pass.

    Imprecission in the PSF.

    New instruments are in development. Faster, wavelenght near to 550 nm, and with higher field.

    Ginis, H., Sahin, O., & Artal, P. (2015). Fast optical measurement of intraocular straylight. SPIE BiOS. International Society for Optics and Photonics, 93070R93070R.

    Success in Premium Surgery

    DLSExpectations

    Vision CompromiseMIOLs

    Visual Performance Assessment

    ObjectiveClassification

    Surgical Decissions

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    Premium Surgical Techniques. FLACS

    CapsulerhexisImprovement by FLACS

    ImprovingCentering and Position

    New Victus software offers the possibility of centering capsulerhexis on the first purkinje image. This could be a future option for increasingpredictability and improving visual performance.

    Soda, M., & Yaguchi, S. (2012). Effect of decentration on the optical performance in multifocal intraocular lenses. Ophthalmologica, 227, 197204.

    Premium Surgical Techniques. FLACS

    +4D +4D

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    Effective Phacoemulsification Time

    ECLHigh Power

    Long Duration

    Gonen T, Sever O. Reply to letter by Agarwal A, Ashok Kumar D, Agarwal A. Gas-forced infusionprevents endothelial cell loss in phacoemulsification. J Cataract Refract Surg 2013: 39:481482

    Ultrasound is the main risk factor for Endothelial Cell Loss

    Femtosecond Laser and Zero Phaco

    ZERO PHACO

    (1) 4R8CA(2) 4R4C(2) 4R6C

    (7) 4R8CA(2) 4R8CB(4) 4R6C

    4R (5,5mm) 8C (3,5mm)

    4R8C (4 mm)

    72

    % n

    =13

    28

    % n

    =5

    YES NO

    CNCN

    Pattern [TFE mean] 4R8CA [TFE=1.50], 4R6C [TFE=1.36], 4R4C [TFE=2.28]

    (Supo4ST y Supo3) (Supo4ST)

    CN=2

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    There isnt a well documented treatmentnormogram which defines the laser parametersdepending on a Cataract Classification System.

    but

    Can we reduce our current requirement of ultrasound?

    Zero Phaco

    Dick, H. B., & Schultz, T. (2013). On the way to zero phaco. J Cataract Refract Surg, 39(9), 14421444.

    1. Reduction of the grid size.2. Reduction of the safety zone for the posterior

    capsule.3. Flared tip to a so-called thin tip (B&L). Fitted

    to cubes cut.4. Aspiration device (Geuder AG) with an oval

    design and a greater opening lumen of 0.5 mm.5. Higher vacuum with a maximum of 600 mmHg

    and a bottle height of 100 cm approximately.

    What can we do to reduce the US requirement?

    Zero Phaco

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    Micro Incision Cataract Surgery (MICS)

    What do we want to achieve?

    1. Less post-operative ocular inflammation.2. Less or none induced astigmatism.3. Reduction of surgical time.4. Short time of post-operative recovery

    (corneal wound healing)

    Combine Phaco Zero with Micro Incision of 1mm

    Conclusion

    DLSExpectations

    Vision CompromiseMIOLs

    Visual Performance Assessment

    ObjectiveClassification

    Surgical Decissions

    Future of Premium Cataract Surgery involves a multifactorial analysis of different variables. From the measurement of Visual Functionand Satisfaction to the decision of applying

    the new Surgical Techniques