Advantages of the Latest Technology in Lens Replacement

Surgery

Richard B. Meister M.D.Medical Director

NVISION Sacramento

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Lens Replacement Surgery

• Includes:– Cataract Surgery

– Refractive Lens Exchange

– Dysfunctional Lens Syndrome

• Types:– Manual Basic Cataract Surgery (Insurance Covered)

– Advanced Technology (Patient-Shared Costs)

Advanced Technology

• Lifestyle IOL’s -Toric,Multifocals, Accommodating, Europe- Bifocals, Trifocals

• Interferometers for Axial Length IOL M, LenStar

• Topography

• Corneal OCT

• Sensorimotor Alignment Devices

• FLACS- Femto Laser Assisted Cataract Surgery

• Intraoperative Wavefront Aberrometry

Lifestyle Implant

+Laser Assisted Cataract Surgery

+Intra-operative Aberrometry

+ Refractive Cataract Surgery

A Renaissancein my cataract practice

Lifestyle Lenses

• Multifocal – ReStor, Technis, ReZoom

• Accomodating – Crystalens

• Toric – Acrysof, Technis, Starr

• Accomodating/Toric – Crystalens Trulign

Near Future IOL’s

• ReStor Toric • Calhoun – Light Adjustable IOL

Interferometers for Axial Length Measurement & Keratometry

• IOL Master • LenStar

Topography/Tomography

• Placido Image Based -Topography

• Scheimpflug Based – Tomography

• Axis and Magnitude is Key for Astigmatism correction

Anterior Segment OCT

• Measures Posterior Corneal Astigmatism in addition to CT

• Corneal Epithelial Mapping pending FDA approval

New SMI Alignment Guidance Technology

• SensoMotoricInstruments(SMI)

• Alcon VerionSystem

• Zeiss Cataract Suite

• TrueVision3Dsystem

• Refining the Astigmatism axis location

VERION™ Digital Marker

• The VERION™ Digital Marker can be used with the LenSx® Laser as well as most surgical microscopes.

VRN13066SK

Image. Plan. Guide.

With LenSx® Laser: With OR Microscope:

118/13

Femtosecond Laser Assisted Cataract Surgery- FLACS

• 5 Systems on the Market

• LenSx (Alcon)

• Catalys (AMO)

• Victus (B&L)

• LenSAR

• Z-8 (Ziemer)

FLACS Advantages

• Decreased risk of Capsular rent or rupture

• Continuous smooth precise Capsulotomy

• More consistent Effective Lens Position

• More consistent lens centration

• Consistent Cylinder reduction

• Consistent SIA from Laser created Incisions

• More precise alignment of Arc T’s and Incision

• Less Phaco required from Laser Fragmentation

• Well constructed self sealing incisions

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LenSx (Alcon)

• Industry leader

• Way out front

• Huge jump start

• “Softfit”

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LenSx PI – “Softfit”

• Applanating

• 1 piece

• Rare Corneal Striae

• Clear OCT images

• Higher energies

• Lower IOP with Softfit

• Easy docking for LASIK surgeons

• Complete Capsulotomies

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Imaging - OCT vs. Scheimpflug

LenSx Video

ORA - (OptiWave Refractive Analysis)

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• ORA - one of the most Important technological advances in cataract surgery

• “Real time” Streaming Aphakic refraction on the OR table

• VERY HELPFUL - calculating IOL powers patients prior Myopic and Hyperopic LASIK

ORA - (OptiWave Refractive Analysis)

Case History

• 63 y/o WF c/o decreased Va last 2 yrs Worse last 6 months, Difficulty driving & c/o glare POH 16 cut RK OU 1984,PRK OD 2003, Pterygium Removal OD 2010, 5.93D astig preop, 2.03D post op

• BCVA 20/50 MR +2.50 -1.75 x 122

• IOL Master K’s 34.26@105/38.05@015^ 3.79D

• LenSx K’s 34.18@115/37.51@025 ^ 3.33D

• Atlas Topo 37.11@114/39.41@024 ^ 2.30D

Case History Cont.

• SLE 16 incision RK, very little scarring post Pterygium removal/trace haze nasally

• Lens 2+ NS

• DFE WNL

• Plan ECCE with Phaco & ORA, Toric IOL, possible Scleral Tunnel to avoid RK incisions

Case History Cont.

• Calculated IOL SN6AT8 20.0 D @ 16 degrees, Incision 180

• Ora predicted 22.5D SN6AT9@ 011

• Pseudophakic residual reading -2.37-0.40 x 011

Prior to Pterygium Surgery

After Pterygium Surgery

Pre Op Cataract

AcrySof® IQ Toric IOL

Case History Cont.

• PO Day 1 at Affiliate OD’s office UCVA 20/25 MR = pl

• PO 1 wk UCVA 20/25+3 , MR 20/20 pl

• PO 2 Mos UCVA 20/30 MR 20/20 pl-1.00 x 075

• Pt and Drs Very Happy

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Case 2

• 54 yo WF, hx Myopic PRK 6 years ago, very blurred VA OS

• MRX OS -2.50+0.50x180 20/80

• 3+PSC, 2+ ASC

• Plan:1. Toric/ORA or

2. Basic PCIOL with LRI/ORA

• Pt opted for #2

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Case 2

• IOL Master predicted +17.0 D IOL OS for plano

• Given Hx of Myopic PRK/LASIK:UNDER-predict IOL power

• ORA should predict PCIOL power that more than 17.0 D

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Case 2

• 1.0 D of WTR Astig.

• LRI performed:

• 2 cuts at 90 deg

• ORA should measure no more astigmatism left over

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Aphakic ORA

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PCIOL ORA

Closing the Accuracy GapGetting LASIK-like Results

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Non post refractive patients only** Anders Behndig, M.D., Ph.D., et al, Swedish National Cataract Registry. J Cataract Refract Surg. (July) 2012*** Indicates AcrySof platform results

% of Patients within .50 D

ORA***n=598

ReSTORn=171

87%92%

Literature**

60%

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Lens Replacement Surgery

• Includes:– Cataract Surgery

– Refractive Lens Exchange

– Dysfunctional Lens Syndrome

• Types:– Manual Basic (Insurance Covered)

– Advanced Technology (Patient-Shared Cost)

Lens Replacement Surgery• The State of the Art with Lens Replacement Surgery has

reached new levels of perfection and safety justifying earlier & more elective surgery

• CMS Guidelines have also changed to reflect outcomes

• We have almost all the Advanced Technology we need to achieve LASIK like results.

• Many of our patients with higher expectations have been Raving Fans of LASIK and now have Dysfunctional Lens Syndrome or Cataracts

• We have the opportunity to again create Raving Fans of these patients as Lens Replacement patients

From: Economic Evaluation of Toric Intraocular Lens: A Short- and Long-term Decision Analytic Model

Decision analysis tree and probabilities of treatment pathways. Uncorrected visual acuity levels are presented in Snellen decimal values. AK indicates

astigmatic keratotomy; CK, conductive keratoplasty; ICS, incision corneal surgery; IOL, intraocular lens; IRC, intraoperative refractive correction; LRI, limbal

relaxing incision; LVC, laser vision correction; and PCRI, peripheral corneal relaxing incision.

Figure Legend:

Decision Analysis Tree