INTRAOCULAR CONTACT LENS HKMA Structured CME Program John Chang, MD Director of Guy Hugh Chan...
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Transcript of INTRAOCULAR CONTACT LENS HKMA Structured CME Program John Chang, MD Director of Guy Hugh Chan...
INTRAOCULARINTRAOCULARCONTACTCONTACT
LENSLENSHKMA Structured CME Program
John Chang, MDJohn Chang, MD
Director of Guy Hugh Chan Refractive Surgery CentreDirector of Guy Hugh Chan Refractive Surgery Centre
Hong Kong Sanatorium and HospitalHong Kong Sanatorium and Hospital9 August 2007
LASIK is not the best option for every patient
• Dioptre removal/optical zone & quality of vision trade-off• Large pupils• Dry eyes• Steep / flat corneas• « Funny corneas » / Keratoconus• Thin corneas
We all have those patients !
Phakic IOLs
Advantages
– Preserves Corneal topography.
– No induced aberrations
– => Better quality of vision
– High predictability.
– Stable refractive outcome.
– Safe in eyes with suspicious corneas.
– Removable
– Minimal capital expenses.
IntroductionIntroduction
• Posterior Chamber Sulcus Fixated Lens
• Version 4
• Myopia -3.00 D to > -20.00 D
• Hyperopia +3.00 D to +17.00 D
Lower left Leading right
Loading the ICL
• The ICL is marked to ensure proper orientation in the eye as it unfolds
Alignment Marks
Clear Corneal Incision
• Temporal, clear corneal incision orients best to iris plane
Video - ICL Injection
ICL Positioning
• Use the paracentisis
Video: ICL Positioning
• Rotate using the edge of the lens or on the haptic “body”
• OK to use footplates
73 Eyes73 Eyes
Since 6th May 2002
• Age : 23 to 47
• Mean age : 34.33 ± 6.37 yrs
• Male : 12
• Female : 36
Pre-Op MRSEPre-Op MRSE
• Range : -7.00 D to -24.75 D
• Mean : -14.38 ± 3.45 D
Follow upFollow up
• 1 day, 1 week, 1 month, 3 month, 6 month,
and 1 year and beyond
• Dilated slit lamp & fundus exam (DFE) for all eyes at 6 months
• Range: 2 weeks to 43.8 months
• Mean: 15.9 months
Predictability of RefractionPredictability of Refraction
Planned Refraction
• Within ± 0.50 D : 45 (61.6 %)
• Within ± 1.00 D : 59 (80.8 %)
Post-Op UCVAPost-Op UCVA
Those eyes with 20/20 or better Pre-Op BCVA
20/15 19 (48.7 %)
20/20 or better 31 (79.5 %)
20/25 or better 36 (92.3 %)
20/40 or better 39 (100.0 %)
Worse than 20/40 0 (0 %)
Total 39
Stability of refractionStability of refraction
Mean MSE at each follow up
-14.38
-0.39-0.14-0.3-0.19-0.1-0.1-0.23
-18
-14
-10
-6
-2
2
pre-op 1 wk 1 m 3 m 6 m 12 m 18 m 24 m
Follow up time
Dio
pte
r
mean MSE
SafetySafety
Pre- vs Post- BCVA
gained 2 or more lines 14 (19.2 %)
gained 1 line 39 (53.4 %)
no change 18 (24.7 %)
lost 1 line 2 (2.7 %)
Lost > 1 line 0 (0%)
Lost 1 lineLost 1 line
• Age: 39 M
• Pre-op MRSE: -10 D 20/20
• Post-op MRSE: +0.13 D 20/25
• Follow up: 1 month
Patient complaint of difficulty with reading and elected to
have ICL removed despite near VA J2 after 1 month.
Lost 1 lineLost 1 line
• Age: 39 F
• Pre-op MRSE: -13.88 D 20/15
• Post-op MRSE: -0.50 D 20/20
• Follow up: 14.9 months
Post-op BCVA varied between follow up visits from 20/15
to 20/20. No other complication was noted.
Complications Complications
Out of 73 eyes:
• 1 (1.4 %) ICL size too small – observe
• 1 (1.4 %) brow ache for 2 months
• 1 (1.4 %) ICL removed after 1 month ( pt didn’t like it)
39 year old male, c/o near vision problem
MRSE at 1 month: +0.13 D
• 1 (1.4 %) overcorrect by +1.5 D (VD not at 12mm)
ComplicationsComplications
• 1 eyes (1.4 %) complained of seeing extra light from P.I.
• 17 eyes (23.3 %) developed transient IOP rise within
2 month post op;
– range 23 to 30 mmHg;
– all controlled by timolol;
– all resolved by 1 month;
– only 3 eyes in 2006, all other before 2005
ComplicationsComplications
• 2 eyes (2.7 %) developed ASCMean pre-op MSE -9.28 D -11.25 D
MSE at last visit -3.00 D 20/20 -1.25 20/20
UCVA 20/150 20/25
ACD 3.2 3.18
WTW 11.5 11
Lens type ICM125V4 ICM115V4
Comment onset at 20 month onset 13 days, visually significant at 18 months
Early result: Toric ICLEarly result: Toric ICL
25 eyes (since June 2004)
• Age range: 23 to 44• Mean age: 32.0 ± 6.8 yrs • M : F 4 : 14• Mean follow up: 7.5 ± 4.4 months
(range 1.4 to 18.8 months)
Early result: Toric ICLEarly result: Toric ICL
Mean ICL power: Sphere -18.44 ± 3.22 DCylinder +3.68 ± 1.20 D
Pre-op Post-op
Mean sphere -13.85 ± 3.20 D -0.20 ± 0.51 D
Mean cylinder +2.95 ± 1.07 D +0.64 ± 0.47 D
Mean MSE -12.36 ± 3.06 D +0.03 ± 0.34 D
Early result: Toric ICLEarly result: Toric ICL
Post-op mean MSE at each follow up
-12.36
-0.060.030.180.210.36
-16
-12
-8
-4
0
4
pre-op 1 wk 1 m 3 m 6 m 12 m
Follow up
Dio
pte
r
mean MSE
Early result: Toric ICLEarly result: Toric ICL
Cumulative post-op BCVA and UCVA
20/20 or better pre-op BCVA
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
20/15 20/20 20/25 20/30 20/40
Post-op UCVA
Post-op BCVA
AdvantagesAdvantages
ICL vs LASIK
• No / Minimal night vision problems
• Stability /Faster recovery.
• Correct much higher ranges of myopia (-3.0 D to -20.0 D)
• Also correct hyperopia (+3.0 D to +17.0 D)
• Reversible
• No ectasia
AdvantagesAdvantages
ICL vs LASIK
• 2 patients had ICL in one eye (-19 D, -17 D) and LASIK in the
other eye(-14 D, -13 D)
• Higher myopia in the eyes with ICL
• Both patients report better quality vision with ICL despite the
higher myopia
• Stability – no initial overcorrection.
AdvantagesAdvantages
ICL vs ACIOL
• No endothelial cell loss, no AC reaction
• Small self-sealing incision
-No/less induced astigmatism
• No need to pre-cut flap in bioptics
• Can correct astigmatism at the same time
-(LRI or Toric ICL)
The Verisyse anterior-chamber Lens
Picture from www.gutsehen.de/gfx/iol_verisyse.jpg
DisadvantagesDisadvantages
• Clinically significant ASC 1.3%*
• Sizing can be difficult, Orbscan not always reliable
• Glaucoma? Pigment dispersion?
• Expensive
• 2 Procedures: Laser P.I. First (uncomfortable), then lens implantation
*5 year follow up US FDA MICL Clinical Trial – in press
ConclusionConclusion
• ICL and Toric ICL results very encouraging
• Transient IOP rise 2° to Occucoat?
• Accuracy as good / better than LASIK for high myopia
• Much better immediate and long term stability than Lasik.
• Technically not difficult (Avg surgery time 25 mins)
• No / Minimal night vision problems
• Short learning curve –easier than Phaco
What if one develops a cataract extraction leads to
immediate presbyopia?
Multi-Focal IOL
*Diagrams from AMO
Refractive IOL - Array
*Diagrams from AMO
*Diagrams from AMO
*Diagrams from AMO
*Diagrams from AMO
*Diagrams from AMO
Adjustment byhuman eyeto Multi-Focal IOL
*Diagrams from AMO
Basic Theory Basic Theory
• Diffractive MIOL - Tecnis MF
far focusnear focus
*Diagrams from AMO
*Diagrams from AMO
TecnisMF
Array
far focus
near focus
ReZoom
*Diagrams from AMO
PatientsPatients
No. of patients
No. of eyes
Mean age
Range
Array 59 95 54 + 11.9 35 to 85
ReSTOR 27 43 65 + 9.7 50 to 84
TecnisMF 130 179 59 + 13.3 7 to 87
RefractionRefractionArray ReSTOR TecnisMF
Preop mean MRSE (D)
-10.00 -0.60 -6.18
STD ±7.9 ±3.07 ±5.29
Range+7.75 to -
31.25+4.00 to -
6.75+5.63 to -
18.00
Postop mean MRSE (D)
-0.22 -0.26 0.04
STD ±1.01 ±0.68 ±0.57
Range +2.38 to -6.63+1.00 to -
2.00+2.00 to -2.25
3 IOLs 3 IOLs ComparisonComparison
Cumulative Postop UCVA
3 IOLs 3 IOLs ComparisonComparison
Cumulative Postop BCVA
SafetySafetyPreop vs Postop BCVA: Gain / Loss
3 IOLs 3 IOLs ComparisonComparison
Cumulative Postop Near UCVA
QuestionnaireQuestionnaire
Night glare*
Halo*Satisfaction#
Array 1.51 (32%) 1.68 (36%) 3.72 (92%)
ReSTOR 1.03 (21%) 1.47 (30%) 3.77 (87%)
TecnisMF 1.88 (44%) 1.99 (44%) 3.70 (93%)
* the higher the score, the more the severity (from 0-5)# the higher the score, the higher the satisfaction (from 0-5)(%) percentage of eyes had score ≥3
TecnisMF TecnisMF QuestionnaireQuestionnaire
% of time spectacles are required0% <50%
>50%Reading 100% 0 0(including newspaper, books, documents)Near tasks 100% 0 0(including SMS, watch, etc)Distance 100% 0 01 patient requires spectacles for computer
Mix and Match- Early Mix and Match- Early resultresult
Ave. Time Spent
Yes No
Distance ---- 0% 100%
Reading 2.8 hr 0% 100%
Computer
5.2 hr 0% 100%
Spectacles dependence
All patients are 100% of time SPECTACLES FREE
Thank You