Download - Dysfunctional Lens Syndrome. The Future of Premium Cataract Surgery · Dysfunctional Lens Syndrome. The Future of Premium Cataract Surgery Needs of Baby Boomers. 6/22/2015 2 Needs

6/22/2015

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Dr. Joaquín Fernández

@joaquinfernandezoft

aboutme/drjoaquinfernandez

Dysfunctional Lens Syndrome. The Future of Premium Cataract Surgery

Needs of Baby Boomers

6/22/2015

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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), 313–322.

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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), 313–322.

Future exclusion criteria

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DLSExpectations

Vision CompromiseMIOLs

Vision Compromise of MIOLs

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Vision Compromise of MIOLs


DLSExpectations


Visual Performance Assessment

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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


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Standardization is required

Optical Quality vs Visual Performance

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x x x x x x x x

Visual Acuity (logMAR)

Co

ntr

ast

(lo

g u

nit

s)


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


DLSExpectations



ObjectiveClassification

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Objective Classification. Based on Scattering

Artal, P., Benito, A., Pérez, G. M., Alcón, E., de Casas, Á., Pujol, J., & Marín, J. M. (2011). An objective scatter indexbased on double-pass retinal images of a point source to classify cataracts. PLoS ONE, 6(2), 1–7.


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), 241–247.e2. doi:10.1016/j.ajo.2014.10.025

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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, 93070R–93070R.


DLSExpectations




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, 197–204.

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: 39:481–482

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 isn´t 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), 1442–1444.

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




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