Making Cataract Surgery Refractive Surgery

Eric E. Schmidt, O.D.

Bladen Eye Center

Elizabethtown, NC

Cataract Surgery

• It is considered to be the most successful surgery in the world! SO…..

• Why do we want to mess with success?

• What’s all the fuss about?

• What do we really want to achieve?

Goals Of Surgery

• Visual improvement – maximum achievable visual acuity

• 20/20 w/out eyeglasses!• No anisometropia

• Remember though; 20/20 may not always be possible

• Plano may not always be the best desired end point

Uncorrected 20/20 begins with you

• Choosing the right surgeon• Counseling your patient • Keep abreast of “new stuff”• Guide your surgeon to become proficient at “new

stuff”• Keep your staff up-to-date on the “new stuff”• Identify patients who would benefit from “new stuff”• You need to understand that cataract surgery

should be considered refractive surgery

Why Bother With Co-Management?

• Enhance px success

• Continuity of care

• Logistic concerns

• They are your patients

• Builds practice image

• It is certainly not a monetary issue!!!

Pre-operative procedures

• Set realistic goals for each individual patient• Perform detailed binocular refraction• Determine desired endpoint for the patient’s visual

system• Choose the best procedure to achieve this• Perform all the necessary pre-op tests

– A-Scan– PAM– BAT– DFE– Retinal imaging – Wavefront testing

Pre-operative management

• Px counseling– Describe the procedure, anesthesia– Describe the post-op course

• Choose the surgeon

• Schedule the appt

• Pre-op regimen

• Prescribe the pre-op meds

• Discuss case w/ surgeon

A-Scan

• Biometry- this is the key to choosing the correct IOL power.

• IOL chosen based on desired endpoint refraction, axial length and keratometry

• A-Scan ultrasound – very easy to perform

• CPT code – 76516 76519

• Should this be done by the referring OD?

IOL MASTER

• Zeiss• Not ultrasonography• High resolution partial coherence

interferometry• Easy to perform (<1minute, non-contact)• Yields extremely precise axial length

(0.02mm), white-to-white, AC depth (+/- 0.1mm) and keratometry

• Costs more, same reimbursement, but allows us to pinpoint endpoint refractive error.

IOL MASTER

• Traditional SRK and Holladay Formulas, but ..

• Haigis formula – – Surgeon specific– IOL specific– Allows a new level of mathematical flexibility in

calculating IOL power

• Greatly increases accuracy and precision as compared to A-scan

IOL Master

• This renders a 5-fold increase in accuracy

• Solves some A-scan issues– Posterior staphyloma– Long eyes (>24.5mm)– Short eyes (<22mm)– Silicone oil– Asteroid hyalosis

Cataract Surgery- We’ve Come A Long Way Baby!

• ICCE

• ECCE

• Phacoemulsification

• No-stitch, no patch

Surgical Incisions

• Is one type really better than another?

• Scleral tunnel

• Clear cornea

• Micro-incision (1mm)

Phacoemulsification

• No new advances in this ; until now!

• 2 new instruments

• Less energy, less heat

• No need for irrigation

• Sleeveless allows for micro-incisions

• Capsulorhexis technique is very important

Current Phaco Energy Sources

• Ultrasound– Efficiently emulsifies cataracts of any hardness– Rapid motion of phaco tip creates friction/heat

• Laser– Efficiently emulsifies only +1 or +2 cataracts– Rests between laser bursts allow cooling

• Sonic– Efficiently emulsifies only +1 or +2 cataracts– Less tip motion and friction/heat than ultrasound

Micro-incisions need micro IOL!!!

• Super thin IOL

• Injectable IOL

• “Liquid” IOL– Lens refilling procedure

Post-operative regimen

• Not much new to talk about EXCEPT…– The incidence rate of endophthalmitis is

tripling• 0.66% in clear cornea• 0.25% in scleral tunnel

– Can we prevent this?– Why is this happening?

Post-operative regimen

• Antibiotic – 4th generation fluoroquinolone QID• Steroid – prednisolone acetate 1% QID (or

more)• NSAID• Intraocular steroid – Dex DSS• Post-op visits

– 1 day– 1 week– 3-4 weeks (DFE)

Clear Corneal Incisions Don’t Leak…

They Suck!!!!

Endophthalmitis

• Increase due to natural endogenous flora from lids

• 75-90% gram positives– Staph. Epidermidis (42%)– Staph. Aureus,Enterococcus

• Pay close attention to the lids pre- and post-operatively

To reduce endophthalmitis incidence

• Fluoroquinolone QID 4 days prior to surgery

• Lid scrubs if needed

• Artificial tears

• Betadine prep peri-operatively

• May need to leave px on topical antibiotics longer post-operatively

• Orals ??

Post-op concerns

• Glare and haloes

• Internal reflections

• Anisometropia

• 2nd eye management

• Post. Capsule opacification

What About Astigmatism?

• Toric IOL

• Astigmatic Keratotomy

• Who are candidates?• Are there refractive limitations?• What can the patient (and us ) realistically

expect?

Toric IOL

• STAAR Surgical silicone plate lens

• Corrects 1.4 – 2.3 D of cyl at the spectacle plane

• Corrects the astigmatism at the nodal point

• Lessens distortion

• Better qualitative visual acuity

• Improved contrast sensitivity

• There are some axis considerations

Toric IOL Success

• Depends upon:– Surgical skill – the surgery must be

astigmatically neutral– Proper IOL positioning– IOL maintaining a stable position in the bag– Aggressive post-operative monitoring

Toric IOL

• Post-op considerations– Must be able to detect IOL rotation– If this occurs it must be corrected by 3 weeks – IOL may have to be rotated by surgeon– Patient must be dilated at 2 weeks to detect

this

Astigmatic keratotomy

• Relaxing incision made nasally

• Shallow (<150 microns)

• Useful for pre-operative WTR cylinder

• -1.00 to -2.50 cylinder

• How effective is it?

Astigmatic Keratotomy

• When should you recommend it?– Plano in other eye– Px does not like to wear specs– CL wearer– Those “picky” patients– WTR cylinder (170 – 010)– High cylinder pxs

• Post-op considerations

Astigmatic keratotomy

• What are the drawbacks?– Poor predictability

– Limited range of correction

– Post-operative FB sensation

So an optometrists walks into an exam room to see a post-op px

O.D.- How’re those eyes doing Mr. Jones?

Px – Not so great.

O.D. – Whaddaya mean , not so great? You’re seeing 20/20 in each eye without glasses!

Px – Yeah, but I can’t see my newspaper!

What to do about presbyopia?

• Monovision IOL

• Presbyopic Lens Exchange (PRELEX)

• Multifocal IOL

• Accommodating IOL

Multifocal IOL options

• Monovision

• Refractive

• Diffractive

• Accommodative

The Ideal Multifocal IOL Patient

• Baby Boomer – 50’s to the mid 60’s– Cataract starting to compromise quality of vision– Active lifestyle– Concerned about their appearance & ‘quality of

life’• Do not want to ‘get old’• Spending billions on lifestyle enhancing procedures

– Realistic Expectations– Motivated– Asks lots of questions

Who’s A Candidate? / Clinical

• Hyperopic

• Loss of accommodation

• Cataract

• Unilateral traumatic cataract

• Congenital cataract

• Astigmatism (can be corrected)

• High myopes (surgeon preference)

Who’s A Candidate? / Motivation

• Wants to be less dependent on glasses

• Understands the limitations of the Array® visual system

• Willing to accept several months to adapt to their new visual system

Who’s Not A Candidate?

• Significant dry eyes• Corneal scarring• Mild to moderate myopia• Pupil size < 2.5 mm• Monofocal implant in first eye• Uncorrected post-op astigmatism > 0.5 D• Unstable capsular support• Someone who demands perfect vision

ReZoom Multifocal IOL (AMO)

• Refractive lens

• 2nd generation acrylic IOL

• Delivers good near, distance and intermediate vision

Is The ReZoom Perfect?

• The most common concerns– Distance blur– Monocular diplopia– Object glow– Ghosting– Halos at night

• These are the biggest post-op challenges

Acrysof ReStor IOL (Alcon)

• Diffractive technology

• Silicone material

• Uses “apodization” to soften blur and sharpen vision

• Provides excellent VA at near, distance and intermediate ranges

Strengths of the AcrySof® ReSTOR® IOL

• High quality uncorrected near and distance vision with 20/40 or better intermediate vision without movement of the IOL

• 80% Overall Spectacle Freedom

• Nearly 94% of patients would have the lens again

Aspheric Multifocal IOL Technology

Do We currently have any aspheric multifocal IOLs?

• Tecnis multifocal (AMO)

• Sofport AO (Bausch & Lomb)

Explain the WOW! Factor(or lack thereof)

• Haloes and glaare at night are common- these diminish with time

• Longer adaptation period – may take weeks or months for pxs to accept their “new” visual system

• Near vision may be fuzzy to myopes

• May need reading specs for prolonged nearpoint work

Accomodative IOL

• Crystalens- eyeonics

• Silicone IOL with hinged optics

• IOL moves forward or back depending on ciliary muscle tone

• Implanted using phaco technique

• Capsulorhexis is critical

• Pre-op biometry crucial

Enter: Accommodating Lens

• The first accommodating lens technology approved as safe & effective by the Food & Drug Administration– Manufactured by eyeonics

• A USA company

• The lens uses the natural focusingability of the eye to provide a single focal point throughout a full range of vision from far, through intermediate to near seamlessly

A New Paradigm In Vision Correction

(In contrast with multifocal IOL’s which use a dual simultaneous focus or monovision where one eye is set for distance & one eye for near) eyeonics crystalens

The Ideal Crystalens Patient

• Baby Boomer – 50’s to the mid 60’s– Cataract starting to compromise quality of vision– Active lifestyle– Concerned about their appearance & ‘quality of life’

• Do not want to ‘get old’• Spending billions on lifestyle enhancing procedures

– Realistic Expectations– Motivated– Asks lots of questions

Crystalens Post-Op Considerations

• 1% Atropine day of surgery & 1 day PO

• Otherwise standard post-op regimen

• Distance vision stable 1 week

• Near vision begins to return @ 2 weeks

• No significant glare or halos after 10 days

• Must follow more often

Crystalens Post-op

Post-op: 10-14 days post-op• Keratometry• Uncorrected distance and near visual acuity• Controlled maximum plus refraction• Distance and near visual acuity through

distance correction• Gradual Plus Build-up to J1 to determine

add. • Verify refractive findings with cycloplegic

refraction

Spectacle Use Survey

Bilateral Implanted Subjects

Wearing Spectacles n/n (%)

I do not wear spectacles 33/128 (25.8%)

Almost none of the time 61/128 (47.7%)

26% to 50% of the time 20/128 (15.6%)

51% to 75% of the time 8/128 (6.3%)

76% to 100% of the time 6/128 (4.7%)

Night Spectacles n/n (%)

No 110/128 (84.6%)Yes 20/130 (15.4%)

73.5%}

Is There A WOW Factor?

Cataract Surgery- What’s on the horizon?

• Adjustable IOL-– Material is fixed w/ laser to -0.75– Take to phoropter, refract to plano– “Fix” that w/ longer laser light

• ICL

• Clear Lens Extraction

• Impeller extraction technique

• Lens filling system