5/23/2014

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REFRACTIVE SURGERY DECISION MAKING: CANDIDATE

SELECTION WITH CASE REPORTS

DAVID I. GEFFEN, OD, FAAO

ANDREW MORGENSTERN, OD, FAAO

JIM OWEN, OD, FAAO

DEMOGRAPHICS

• 81 Y/O FEMALE

• COMPLAINS OF POOR VA OU, WORSE OS, GLARE OU

• VERY ACTIVE PROPERTY MANAGER

• BCVA 20/25- OD 20/50 OS

• NS 1+, PSC1+ OD NS 2+ OS

• IOP 14 OD 15 OS GOLDMANN

• FUNDUS NORMAL – OCT NORMAL

• MANIFEST OD +0.25-0.50X90 OS -0.50-0.75X95

SURGERY

• LENSX

• RESTOR 3.0

• DISCUSSED POTENTIAL FOR GLARE

• DISCUSSED NEED TO TREAT OD

DAY 1 / WEEK 1 PO

“WOW THAT WAS EASY!”

• UCVA 20/40

• IOP 25

• AC TRACE CELLS WOUND

SECURE

• REVIEW DROPS

“NO PROBLEM WITH DROPS”

• UCVA 20/40

• IOP 14

• AC DEEP AND QUIET

• CORNEA 2+ SPK

• MANIFEST -0.25-0.75X180 20/30+

• AT QID

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2 MONTH / 3 MONTH PO

“THIS VISION IS NOT RIGHT”

• UCVA OD 20/20- OS 20/40

• CORNEA – TRACE SPK

• MANIFEST -0.25-0.75X175

20/30+

• CAPSULE - CLEAR

• OCT - CME

“IT SEEMS NO BETTER”• UCVA OD 20/20- OS20/30

• CORNEA CLEAR

• MANIFEST -0.25-1.00X175

20/25+

• OCT – NORMAL

• TRACE - PCO

4 MONTH VISIT WITH SURGEON

• OPENED AK CUT

• 1 DAY UCVA 20/25+

• 1 WEEK UCVA 20/25 PT HAPPY WITH VA

• MANIFEST -0.25 SPHERE 20/25

HOW DO YOU TREAT A 58 YR OLD

• PT JK

• 58 Y/O M

• PRESENTS FOR A REFRACTIVE CONSULTATION, DESIRES TO BE

SPECTACLE FREE. AVID GOLFER

• RX: OD: -1.25 – 1.25 X X104 20/20

• OS: +0.50 – 3.50 X 67, 20/20

• +2.00 ADD J1 OU

EXAM

• K’S: OD: 44.25 / 43.12 X 80

• OS: 44.00 / 42.75 X 168

• SLIT LAMP: CORNEAS CLEAR, LENSES CLEAR, ALL WNL

• FUNDUS: WNL

• PACHS: OD: 545

• OS: 537

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CHOICES

• WHAT SURGERY OPTIONS DO WE HAVE

LASIK OR PRK

ICL

RLE

WHY RLE

• TORIC IOL WILL CORRECT ASTIGMATISM

• TRULIGN WILL GIVE MODERATE NEAR VISION

ASTIGMATISM

• OVER 50% OF PATIENTS OVER 60 YEARS OF AGE EXHIBIT AT LEAST 1 DIOPTER OF ASTIGMATISM*

• HOFFER REPORTS OVER 23% HAVE OVER 1.50 D OF ASTIGMATISM*

• VITALE S, ELLWEIN L, COTCH MF, FERRIS FL 3RD, SPERRDUTO R. PREVALENCE OF REFRACTIVE ERROR IN THE UNITED STATES, 1999–2004. ARCH. OPHTHALMOL. 126, 1111–1119 (2008).

• HOFFER KJ. BIOMETRY OF 7500 CATARACTOUS EYES. AM. J. OPHTHALMOL. 90, 360–368 (1980).

ASTIGMATISM

• IOL master , not refraction, is the critical measurement

• Some astigmatism change may occur during surgery (typically 0.5D for a 2.2mm clear corneal incision)

• Depending on location, may increase or decrease existing corneal astigmatism (incision on steep meridian reduces astigmatism)

• Any suitable cataract patient with >0.75D of “resultant”preoperative astigmatism may benefit from a toric IOL correction

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ARCUATE INCISIONS

TRADITIONAL, HANDHELD DIAMOND KNIFE

• MANUALLY EXECUTED BY “TRACING”

CORNEAL MARKS

• INCONSISTENT DEPTH CONTROL

• UNPREDICTABLE EFFECT DUE TO

IMPRECISE WOUND ARCHITECTURE

AND DEPTH

• NO IMAGE-GUIDED SURGICAL

PLANNING OR VISUALIZATION

LASER ARCUATE INCISION• Square edge

• Uniform depth (no ripples)

• Precise, reproducible

– Arc shape

– Arc length

– Diameter

DESIGNED FOR A WIDE RANGE OF ASTIGMATIC PATIENTS

ACRYSOF® IQ TORIC IOL IS

DESIGNED TO ACCOMMODATE

A VARIETY OF CATARACT

PATIENTS WITH ASTIGMATISM

1. Data on file, Alcon Inc.

STAAR™ TORIC IOL

• TWO MODELS

1.50 D AND 2.25D

SILICONE, ONE PIECE DESIGN

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TECNIS® TORIC IOL: SPECIFICATIONS

• WAVEFRONT-DESIGNED TORIC ASPHERIC SURFACE

• +5.0 D TO +34.0 D IN 0.5 D INCREMENTS

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Lens Model ZCT150 ZCT225 ZCT300 ZCT400

Cylinder Powers 1.50 D 2.25 D 3.00 D 4.00 D

Corneal Plane1 1.03 D 1.55 D 2.06 D 2.74 D

Correction Range (Based on combined Corneal Astigmatism)2

0.75–1.50 D 1.50–2.00 D 2.00–2.75 D 2.75–3.62 D

2013.03.05-ME6511

1. Based on average pseudophakic human eye.2. Preoperative Keratometric cylinder plus surgically-induced astigmatism

TRULIGN™ TORIC IOL KEY PROPERTIES

• 5.0-MM OPTIC BODY

• BICONVEX SHAPE

• RECTANGULAR HINGED HAPTICS

• APPROVED DIOPTRIC POWER RANGE FROM +4.00 TO +33.00 D

• CYLINDER POWERS 1.25, 2.00, AND 2.75 D

• ROUND-TO-THE-RIGHT ASYMMETRIC POLYIMIDE LOOPS

x

o

o

SPECIFICATIONS

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Model

The Bausch + Lomb TRULIGN Toric posterior chamber IOL is a modified plate haptic lens with hinges across the plates adjacent to the optic. Axis marks on the anterior surface denote the flat meridian of the lens.

*A-constant and ACD are estimates only. It is recommended that each surgeon develop his or her own values.

ModelRecommended

Starting A-constant

Recommended Starting ACD

Overall Diameter

Available Now Diopter Power

TRULIGN™Toric IOL

BL1UT 119.1* 5.61 mm* 11.5 mm17.0 to 25.0 D in

0.50 D steps

Cylinder powers–IOL plane 1.25, 2.00, 2.75 DCylinder powers–corneal plane 0.83, 1.33, 1.83 DOptic body diameter 5.0 mmAnterior surface Aspheric with axis marksPosterior surface Aspheric toric (cyl at 1.25, 2.00, 2.75 D)Material–body and plates Silicone with enhanced UV protection; 10% UV cutoff at 400 nmMaterial–loop (haptics) PolyimideRefractive index at 35o C 1.43Edge design 360º posterior square edgeDelivery system Crystalsert® IOL Delivery System

THE TRULIGN™ TORIC IOL PROVIDES A BROADER RANGE OF VISION

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TRULIGN ToricStandard Toric

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TORIC IOL’S

• MAIN CONCERN WITH TORIC IOL’S IS MISALIGNMENT

• 3 DEGREES OFF = LOSS OF 10% OF TORIC POWER

• 10 DEGREES OFF = LOSS OF 33% OF TORIC POWER

• 20 DEGREES OFF = LOSS OF 66% OF TORIC POWER

LENSX® LASER ARCUATE INCISIONSIMAGE-GUIDED SURGICAL PLANNING WITH 3D

VISUALIZATION

• REAL TIME CORNEAL THICKNESS• COMPUTER PROGRAMMED INCISIONS

- % DEPTH

- INCISION LENGTH AND POSITION

- 3D VISUALIZATION OF INCISION PLACEMENT

• PREDICTABLE INCISION WIDTH, TUNNEL LENGTH

• TITRATABLE INCISIONS- ADJUSTABLE DURING SURGICAL PROCEDURE

- ADJUSTABLE POST-OP AT SLIT LAMP

ORA SYSTEM™(OPTIWAVE™ REFRACTIVE ANALYSIS)

• PROVIDES INTRA-OPERATIVE REFRACTIVE INFORMATION

• ATTACHES TO MOST SURGICAL MICROSCOPES FOR ON-DEMAND INTRAOPERATIVE MEASUREMENTS OF SPHERE, CYLINDER AND AXIS

• ENABLES REAL-TIME SURGICAL COURSE CORRECTION

• “GET IT RIGHT – RIGHT ON THE TABLE” THE FIRST TIME

• EVERY ORA SYSTEM CONNECTS LIVE TO WAVETEC SERVERS TO CAPTURE EVERY PROCEDURE AND PUSH SOFTWARE UPGRADES

SURGERY

• AFTER LONG DISCUSSION PT CHOSE RLE

• OD: B+L TRULIGN WITH LENSX AND LRI

• OS: B+L TRULIGN WITH LENSX AND LRI

• GOAL: OD: PL

OS: -0.50

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3 MONTH POST-OP

• UCVA: OD: 20/15, J3

OS: 20/30, J1

FEELS VISION IS GREAT

GOLF GAME IS GREAT!

PATIENT DEMOGRAPHICS

• 39 YO MALE

• NO TOBACCO/ALCOHOL

• NO GLASSES

• OHX

• POKED IN OS BY CHILD 2010 WITH SUBSEQUENT CORNEAL INFILTRATE. RESOLVED WELL

• NO MED/SURG

• ORIENTED TO TIME, PLACE AND PERSON

EXAMINATION

• EOM’S

• FULL RANGE OF MOTION OU

• PUPILS

• PERRLA –APD

• VISUAL FIELD

• FULL TO FINGER COUNT

• FACIAL AMSLER – NORMAL OD AND OS

EXAMINATION

• CC: COMP EXAM AND DECREASING VA OD BUT VERY GRADUAL

• VASC: OD 20/30 OS 20/20

• K’S

• OD 42/42.75 @ 001

• OS 42.25/42.75 @ 168

• MANIFEST

• OD +0.75 -1.00 094 20/20

• OS +0.50 -1.25 068 20/20

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EXAMINATION (CONT)

• IOP - GOLDMANN

• OD 15.0

• OS 15.0

• SLIT LAMP EXAM

• ADNEXA, LIDS AND LASHES,CONJUNCTIVA, IRIS, LENS ALL CLEAR OU

• CORNEA: EBMD OD>OS

• VITREOUS, MACULAE AND PERIPHERAL RETINA: CLEAR OU

• OPTIC DISC

• OD 0.4/0.4

• OS 0.5/0.55

DIAGNOSTIC TESTING

• OCT OPTIC NERVE AND MACUALE OU

• FUNDUS PHOTOS OU

• PENTACAM – SPECIFICALLY FOR PACHYMETRY

• OD 573 UM

• OS 585 UM

• RNFL - NONGLAUCOMATOUS

• 96 UM

• 100 UM

RNFL AND ONH OPTIC DISC CUBE PENTACAM TO CHECK PACHYMETRY

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PENTACAM TO CHECK PACHYMETRY WHATS THE DIAGNOSIS?????

• TOTAL DUMB LUCK

INCIDENCE OF KERATOCONUS

• REPORTED IN LITERATURE BETWEEN ~1:500 TO ~1:2000

• INCREASED FREQUENCY AFTER 1995??

COLLAGEN CROSS LINKING

• VITAMIN B2 AND UV-A LIGHT

• RECENT LETTER TO AVEDRO ABOUT POSSIBLE APPROVAL

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“WHY DON’T MY CONTACTS WORK ANYMORE”

• 67 Y/O FEMALE

• SUCCESSFUL ACUVUE BIFOCAL CL WEARER

• WORE MONOVISION PRIOR TO BIFOCAL

• NO MEDICAL HISTORY, NO FAMILY HISTORY

• TRENDS TOWARD “EASY GOING” ON DELL SURVEY

• CURRENT COMPLAINT – CONTACTS NOT COMFORTABLE

• NO VISION COMPLAINTS

EXAM

MANIFEST OD -3.00 SPHERE 20/40

OS -5.50-1.00X105 20/30-

SLE TBUT 4-6 SECOND

CORNEAL STAIN WITH FL 2+ OU

EROSION ALONG LID MARGIN

NUCLEAR SCLEROSIS 1+ OU BRUNES 2+ OU

FUNDUS OLD CR SCARS AWAY FROM MACULA

TREATMENT

• DISCONTINUE CLS

• HOT COMPRESS BID

• AT QID

• RTO 2 WEEKS

“PT VERY UPSET ABOUT BEING OUT OF CLS 2 WEEKS”

2 WEEK VISIT

BCVA OD 20/40 OS 20/30

SLE TBUT – 4-6 SECONDS

NO CHANGE IN STAINING

NO CHANGE WITH LIDS

PATIENT ADMITS WEARING CONTACTS “SOME”

ADD RESTASIS BID RTO 2 WEEKS

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VISITS

BETTER AT 2 WEEK VISIT

EYES MORE COMFORTABLE “OKAY” NOT WEARING CL’S

1 MONTH AFTER RESTASIS

TBUT 6-8 SECONDS

CORNEA CLEAR

BCVA OD 20/40 OS 20/30

DISCUSSED CE WITH IOL

LENS OPTIONS

• SINGLE VISION IOL – LOSES NEAR VISION FROM CL’S

• MONOVISION IOL- GREATER “DISPARITY” THAN WHEN SUCCESSFUL

WITH MONO

• MULTIFOCAL IOL – SIMILAR TO CURRENT CLS

• ACCOMMODATIVE IOL – NEED GLASSES FOR NEAR

TREATMENT

RESTOR 3.0 IOL OU

UCVA OD 20/25 OS 20/25 J2OU

MANIFEST OD PLANO -0.25X180 20/25+

OS PLANO -0.25X100 20/25+

PT VERY HAPPY WITH VISION

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BINOCULAR DEFOCUS CURVE

Refraction (D)

IQ ReSTOR® IOL +3.0 D [N=117] IQ ReSTOR® IOL +4.0 D [N=114]

∞

20/25

20/32

20/40

20/50

20/63

20/80

20/100

20/20

+1.00 +0.50 0.00 -0.50 -1.00 -1.50 -2.00 -2.50 -3.00 -3.50 -4.00

Snel

len

Source: AcrySof® IQ ReSTOR® IOL Package Insert

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HISTORY

• 50 Y/O WHITE FEMALE (MARRIED)

• RN FOR BLOOD BANK

• NO MEDICINES OR MEDICAL ALLERGIES

• MEDICAL HISTORY NEGATIVE

• OCULAR HISTORY NEGATIVE

• FAMILY HISTORY NEGATIVE

CLINICAL FINDINGS

• UCVA• OD 20/30• OS 20/30-

• MANIFEST• OD +1.00-1.00X104 20/20

• OS +0.75-2.00X078 20/20

• CYCLOPLEGIC• OD +1.00-1.00X106 20/20

• OS +1.00-2.00X80 20/20

CLINICAL FINDINGS

• SLE – WNL• FUNDUS – WNL• PACHYMETRY

• OD 524• OS 533

• TBUT > 15 SECONDS• K’S

• OD 43.6@65 43.3@155• OS 43.9@156 43.4@66

• DISCUSSED NEED FOR READING GLASSES AT LENGTH

PRE-OP WAVESCANS

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POST-OP VISITS

• DAY 1• UCVA OD 20/20-1

OS 20/25• SLE – TRACE EDEMA OU• RTO 1 WEEK

• DAY 7 • UCVA OD 20/20

OS 20/20-• SLE – FLAP WELL POSITIONED • RTO 3 WEEKS

POST-OP VISITS

• DAY 12• PATIENT REPORTS VERY POOR NEAR VISION• UCVA OD 20/20-

OS 20/20-• SLE TBUT 8 SECONDS OU

TRACE SPK OU

• MANIFEST • OD +0.50 SPH 20/20• OS +1.00 SPH 20/20

• CHANGED AT TO SYSTANE FREE

• 1 MONTH POST-OP

• NEAR VISION BETTER BUT STILL CAUSES NAUSEA AND DIFFICULTY AT WORK• UCVA

• OD 20/20

• OS 20/20

• SLE – TBUT 10 SEC OU

TRACE SPK OD

• MANIFEST

• OD +0.25 SPH 20/20

• OS +0.50-0.50X90 20/20

POST-OP WAVESCANS

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• 2 MONTH POST-OP• STILL HAS NAUSEA WHEN READING• UCVA

• OD 20/20• OS 20/20-

• SLE – TBUT 8-10 SECONDSNO SPK

• MANIFEST• OD +0.25 SPH 20/20• OS +0.50 SPH 20/20

• ADD GENTEAL GEL AT NIGHT

• 3 MONTH POST-OP

• NEAR COMPLAINTS LESS OKAY WITH +1.00 READERS

• UCVA • OD 20/20

• OS 20/20

• SLE – TBUT 10-12 SECONDS

• MANIFEST• OD +0.25 SPHERE

• OS +0.50 SPHERE

• 5 MONTH VISIT• VA AT NEAR WORSE• UCVA

• OD 20/25• OS 20/20

• SLE – WNL• MANIFEST

• OD +0.50 SPHERE 20/20• OS +0.50 SPHERE 20/20

• TRIAL +0.50 CONTACT LENS OU

• PATIENT REPORTS GREATLY IMPROVED VA AT NEAR, NO NAUSUA, CAN

READ CHARTS WITHOUT CORRECTION

• CYCLO

• OD +0.50 SPHERE

• OS +0.50 SPHERE

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ENHANCEMENT SURGERY

• TREAT BOTH EYES FULL WAVESCAN TREATMENT

• OD +0.85-0.23X116

• OS +0.97-0.18X86

DAY 1

• OD 20/20

• OS 20/20

• VA SEEMS VERY GOOD AT NEAR

• DAY 7 POST – ENHANCEMENT

• AWOKE WITH VA IN OD BLURRY

• OD 20/70

• OS 20/20

• SLE – VERTICAL STRAIE OD / DISLODGED FLAP

STRIAE

• FLOURESCEIN MAKES IT EASIER TO SEE AS VALLEYS AND MOUNTAINS DIFFERENTIATE WITH NEGATIVE STAINING

STRAIE TREATMENT

• FLAP LIFT WITH EPITHELIAL DEBRIDEMENT/ HYPOTONIC SALINE

• DAY 1 – FLAP WELL POSITIONED / BANDAGE CONTACT LENS IN

PLACE

• DAY 2 – UCVA 20/60 / BANDAGE IN PLACE

• DAY 4 – UCVA 20/50 / BANDAGE CL REMOVED / CELLS AT EDGE OF

FLAP?

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• DAY 10

• UCVA 20/25-

• EPITHELIAL INGROWTH

• ADDED MURO 128 QID

PRE EPISCRAPE PHOTO

• 1 MONTH POST FLAP STRETCH

• UCVA 20/30+

• MANIFEST OD +0.50-1.25X165 20/20

• TBUT 4-6 SEC

• NO CHANGE IN INGROWTH

• MEDS • RESTASIS BID

• MURO 128 QID

• AT QID

• 2 MONTH POST FLAP STRETCH

• UCVA 20/60

• MANIFEST +1.25-1.50X158 20/20-

• TBUT 10-12 SECS

• NO CHANGE IN INGROWTH

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PRE EPISCRAPE PHOTO• INSERT PICTURE

POST EPISCRAPE

• DAY 1• UCVA 20/30• CELLS GONE

• TBUT 4-6 SECONDS

• 1 MONTH VISIT• UCVA 20/40

• CELLS RETURNING• ADD MURO 128

• MANIFEST OD +1.00-1.00X165 20/20

• 2 MONTHS POST EPI-SCRAPE• UCVA 20/30-• MANIFEST +1.75-1.50X160 20/20• CELLS STABLE• TBUT 9-10 SECONDS

• 3 MONTHS POST EPI-SCRAPE• UCVA 20/30-• MANIFEST +1.50.0.75X165 20/30• CELLS STABLE• CONSIDER PRK ENHANCEMENT

• 4 MONTH• MANIFEST +1.50-1.25X168• CYCLO +1.50-1.25X165

PRE PRK WAVESCAN

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PRE-PRK TOPOGRAPHY PRE PRK TREATMENT PLAN

PRK POST-OP

• DAY 1• 20/60 BCL IN PLACE

• DAY 4 • 20/70 BCL REMOVED / RE-EPITHELIALIZED

• DAY 15• 20/20-• CELLS NO CHANGE• PATIENT HAPPY WITH NEAR AND FAR VISION

• 3 MONTH VISIT• 20/20• NO CHANGE WITH CELLS MOVING TO ENGLAND

KERATOCONIC PATIENT

• BS

• WHITE MALE

• DOB 9/17/47

• LONG HISTORY OF KERATOCONUS

• FIRST SEEN 5/21/07

• WEARING RGP’S

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KERATOCONUS

• KERATOCONUS IS A PRIMARY EYE DISEASE THAT RESULTS IN A DEFORMATION OF THE CORNEA AND LOSS OF VISION.

• THE CORNEA THINS AND BECOMES CONE SHAPED

• THERE IS USUALLY (ALWAYS??) A GENETIC BASIS.

• LOTS OF THEORIES ABOUT MECHANISM:• TISSUE JUST WEAKER THAN NORMAL, UNDERGOES

STRUCTURAL FAILURE, WHICH TRIGGERS MANY THINGS• THERE IS AN INABILITY TO HANDLE

OXIDATIVE STRESS IN THE CORNEA, DUE TO CONGENITALLY ABNORMALLY ENZYMES, WHICH CAUSES OXIDATIVE DAMAGE, APOPTOSIS, AND SO ON

ECTASIA

• ECTASIA IS A CLINICAL STATE THAT HAS THE PROPERTIES AND COURSE OF KERATOCONUS, BUT OCCURS AFTER REFRACTIVE SURGERY

• MOST COMMONLY, POST LASIK• HAS OCCURRED WITH PRK AND PTK• MANY THEORIES:

• SOME CORNEAS ARE WEAKER THAN OTHERS• SOME ARE DESTINED TO HAVE KC• SOME ARE DUE TO MECHANICAL INACCURACY (FLAP TOO THICK)• SURGERY SETS UP AN OXIDATIVE STRESS CASCADE, THAT IN TURN

TRIGGERS KC.• POST PRK KERATOCYTE APOPTOSIS CAN BE BLOCKED BY

ANTIOXIDANTS.

ECTASIA—ANATOMICAL BASIS

• MICHAEL SMOLEK, PH.D. OF NEW ORLEANS HAS DETERMINED THE STRUCTURE OF THE CORNEA MAY EXPLAIN WHY ECTASIA IS MORE LIKELY AFTER LASIK

• ANTERIOR STROMA IS CROSS-LINKED• POSTERIOR STROMA IS NOT

HISTORY

• CHRONIC ALLERGIES- EYE RUBBING

• FAMILY HX- TRANSPLANT, KC

• REFRACTIVE STABILITY

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EXAM

• DECREASED BSCVA• REFRACTION- MYOPIA >8D• US CORNEAL PACHYMETRY• RETINOSCOPY• MANUAL K’S- IRREG, >47• WAVEFRONT- INCREASED COMA• ORBSCAN/PENTACAM- POST FLOAT, THICKNESS GRADIENT• ASSYMETRY BETWEEN EYES• ENHANCEMENTS

ECTASIA--SCREENING• OTHER THINGS

• STEEP K: K>47 (RABINOWITZ)• I/S RATIO AT 3.0 MM >1.4

• ADD PARACENTRAL K INFERIORLY AND SUPERIORLY

• DIVIDE THE INFERIOR TOTAL BY SUPERIOR TOTAL

• DIFFERENCE IN K FROM RIGHT TO LEFT

• HIGH MYOPIA• <-9.0?

• <-8.0?

ECTASIA--SCREENING• TOPOGRAPHY—THE PRIMARY TOOL

• ASYMMETRICAL ASTIGMATISM

• AKA FFKC

• “SMILEY FACE”

PELLUCID MD

TOPOGRAPHY—A COMMENT

• NOT EVERY CASE OF ASYMMETRICAL ASTIGMATISMRELATES TO KC OR ECTASIA.

• OTHER CAUSES INCLUDEDISPLACED CORNEAL APEXOR OTHER FORMS OF MISSHAPEDCORNEA.

• AT LEAST 50% ARE PROBABLY BENIGN. YOU JUST DON’T ALWAYS KNOW WHICH 50%.

• HOWEVER, THE MORE THE CYLINDER, THE HIGHER THE SUSPICION.

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TOPOGRAPHY—A COMMENT• QUESTION: WHICH PATIENT SHOWS TYPICAL

ASYMMETRIC ASTIGMATISM?

They are all the same topo of the same person,Just printed with different Scales:A: Automatic AdjustmentB: Standard, w/ 0.25D stepsC: Standard, w/ 0.50D steps

SUMMARY OF ASYMMETRIC BOWTIE Good

Bad

Dangerous

SIGNS AND SYMPTOMS

• PT REPORTS DISCOMFORT WITH CURRENT RGP’S

• REPORTS HALO AND GLARE AT NIGHT

• CURRENT RGP’S OD: 20/40-2

• OS: 20/70-1

• ADD +2.00 20/25

• SLIT LAMP: GRADE 2 3-9 STAINING, GRADE 2- GPC

• MINOR THINNING OD, MODERATE OS, VOGTS STRAIE

INITIAL TREATMENT

• MR: OD: -7.50 – 1.00 X 123, 20/25-

• OS: -10.50 – 0.50 X 125, 20/80

• REFIT INTO NEW RGP’S

• KERATOCONIC DESIGN WITH ACUITY: OD: 20/20-, OS 20/25

• PUT ON RESTASIS BID AND BLINK QID OU

• MUCH BETTER VISION AND IMPROVED COMFORT

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3 YEARS LATER

• VISION HAS DECREASED IN OD TO 20/60

• PT SAYS EVERYTHING FEELS LIKE LOOKING THRU A “FILM”

• GRADE 2+ NS WITH OIL DROPLETS IN OD

• GRADE 1+ NS IN OS

• CORNEA RELATIVELY STABLE

HOW TO PROCEED?

• WHAT IOL TO SELECT?

• MONOFOCAL

• TORIC

• ACCOMMODATIVE

• MULTIFOCAL

SELECTION

• WE PERFORMED SURGERY

• OD 8/17/10, IMPLANTED CRYSTALENS 50, 4.0

• OS 11/16/11, IMPLANTED CRYSTALENS AO 400

• LIMBAL INCISIONS MADE TO MINIMIZE ASTIGMATISM

• HERE IS THE TOPOGRAPHY AFTER 1 MONTH OF NO CL WEAR

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POST OP RESULTS

• 1 YEAR AFTER SECOND EYE

• MR: OD: -0.25 -1.50 X 53. 20/25

• OS: +2.00 -3.25 X 127, 20/30 –

• ADD: +2.00, 20/20 NEAR

• PT VERY HAPPY WITH JUST WEARING SPECTACLES AND HAS DECIDED

TO DISCONTINUE RGP WEAR

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