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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)
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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
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Lifestyle Implant
+Laser Assisted Cataract Surgery
+Intra-operative Aberrometry
+ Refractive Cataract Surgery
A Renaissancein my cataract practice
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Lifestyle Lenses
• Multifocal – ReStor, Technis, ReZoom
• Accomodating – Crystalens
• Toric – Acrysof, Technis, Starr
• Accomodating/Toric – Crystalens Trulign
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Near Future IOL’s
• ReStor Toric • Calhoun – Light Adjustable IOL
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Interferometers for Axial Length Measurement & Keratometry
• IOL Master • LenStar
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Topography/Tomography
• Placido Image Based -Topography
• Scheimpflug Based – Tomography
• Axis and Magnitude is Key for Astigmatism correction
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Anterior Segment OCT
• Measures Posterior Corneal Astigmatism in addition to CT
• Corneal Epithelial Mapping pending FDA approval
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New SMI Alignment Guidance Technology
• SensoMotoricInstruments(SMI)
• Alcon VerionSystem
• Zeiss Cataract Suite
• TrueVision3Dsystem
• Refining the Astigmatism axis location
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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
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Femtosecond Laser Assisted Cataract Surgery- FLACS
• 5 Systems on the Market
• LenSx (Alcon)
• Catalys (AMO)
• Victus (B&L)
• LenSAR
• Z-8 (Ziemer)
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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
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LenSx Video
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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)
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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
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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
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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
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Prior to Pterygium Surgery
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After Pterygium Surgery
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Pre Op Cataract
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AcrySof® IQ Toric IOL
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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
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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)
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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
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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