“new options in anterior surgery ” steven b. siepser, md january 12, 2009
TRANSCRIPT
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“New Options in Anterior Surgery”
Steven B. Siepser, MD
January 12, 2009
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OUTLINE
I. DSALK for keratoconus
II. DSAEK for Fuch’s dystrophy
III. ECP for glaucoma
IV. Trabectome
V. ICL for high myopia
VI. CK for Presbyopia
VII. Crystalens No Glasses Cataract
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Keratoconus overview
• Bulging of the central cornea• First appears in teens-20’s; both eyes• Progressive loss of vision
– Severe irregular astigmatism• Management:
glasses RGP contacts corneal transplant
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Keratoconus Analogy
BROOKLYN BRIDGE RINGLETS
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Munson’s Sign Apical Scarring
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Penetrating Keratoplasty
Transplant procedure Removal of full thickness corneal button Donor cornea and recipient Transfer to a recipient eye
PKP
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PKP Video
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Disadvantages of PKP
• “Open Sky” – Eye is open during the surgery
• Expulsive hemorrhage– Contents of eye are forced out by hemorrhage
• Increased infection rate• Long recuperation period• Astigmatism and suture adjustment
needed• Graft failure and rejection (5 %)
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Deep Stromal Automated Lamellar Keratoplasty (DSALK)
AKA “Superficial Lamellar Keratoplasty”
Corneal overlay
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Old Management
– Hold off surgery– Significant loss of best corrected vision– Severe corneal scarring or thinning– Imminent Descemetocele– Contact Lens intolerance– Progressive change
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New Management
• <20/30 best corrected vision• Need for optimal visual acuity• Difficult contact lens fitting• Variable visual acuity
Early intervention is best…
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Advantages of Earlier Surgery
• Thicker cornea• Faster rehabilitation• No new astigmatism• Can have LASIK / PRK later on• Less chance of perforation
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DSALK FOR KERATOCONUS
DSALK AUTOMATED KERATOMEKERATOCONUS
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DSALK
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DSALK Post-Op Photo
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DSALK VIDEO
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Fuch’s Dystrophy
• Malfunction of corneal endothelium • Dehydration system to maintain a clear
cornea• Usually females, 50’s, both eyes• Guttatae
– corneal swelling, folds• Decreased vision, foreign body sensation,
pain in morning• Management:
“salt” drops bandage contact lens surgery
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Fuch’s Dystrophy
GUTTATA
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Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK)
AKA “Endothelial Resurfacing”
or Posterior Lamellar Keratoplasty
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DSAEK Surgical Procedure
• Prepare endothelial graft from donor cornea
• Strip and peel off Descemet’s membrane of the patient
• Introduce graft into eye• Flatten, place air bubble to allow
adherence to back surface of cornea• Patient should stay on back until next day
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DSAEK
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Advantages over Full-thickness Corneal Transplant
• Faster healing• No stitches, therefore more predictable• Safer – small incision like cataract surgery• Vision clears more quickly
– 1-3 months vs 1-2 years for standard PKP• 90% of patient’s own cornea is left
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Video
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SUMMARY OF NEW TRANSPLANT PROCEDURES
• Full thickness PKP is on it’s way out…• Newer transplant procedures
– transplanting the diseased portion of the cornea
• DSALK: anterior cornea, i.e.keratoconus• DSAEK: endothelium, i.e. Fuch’s• Both use a microkeratome (“automated”)
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Glaucoma summary
• Fluid inside the eye is produced by a structure called the ciliary body
• Fluid is drained by the trabecular meshwork
• Pressure inside the eye is too high• Damage occurs to the optic nerve• Causes a slow loss of side vision
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Treating Glaucoma
• DROPS– slow down the production of fluid – increase the drainage of fluid
• LASER– SLT: Improves Outflow– ECP: Decreases production of acqueous
• SURGERY– Trabeculectomy: Older opening method– Trabectome: Directly addresses outflow
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Glaucoma-Eyemaginations
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Endoscopic Cyclophotocoagulation (ECP)
• Ciliary body is cauterized with a laser to decrease production of fluid
• Camera inside the eye• Instrument used:
– Camera + light source + laser– Tiny optical fibres view, illuminate and treat
the ciliary body• Usually ~60 laser applications
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ECP
• Often performed at the time of cataract extraction
• Can be performed after ALT, SLT or filtering bleb surgery
• A majority of patients have their pressure reduced, leading many to eliminate drops
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ECP
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ECP Video
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Trabecutome Video
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Myopic Refractive Surgery
Total US Population = 301,362,263Myopic 75,340,000 25%
Mild (<-2.00 D) 48,217,600 64% Moderate (-2.00 to -6.00 D) 24,108,800 32% High (>-6.00 D) 3,013,600 4%
Surgeons are becoming progressively less willing to attempt LASIK in high myopes (12 D)
(U.S. Bureau of Census, International Database/Archives of Ophthalmology)
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LASIK / PRK FOR HIGH MYOPIA
• Central corneal thickness < 500 um is considered thin
• Calculations can be performed to determine residual corneal thickness after treatment
• Convention is to leave >300 um “untouched”
• Many patients have been “turned away”
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See What You’ve Been Missing
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Implantable Collamer Lens (ICL)
FDA Approval December 22, 2005
Dr. Siepser’s first caseJuly 14, 2006
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ICL Design
• Sits behind the patients iris (colored part)
• YAG PI done one week in advance– Iridectomy in the iris
• Foldable– Injected through a 3mm corneal incision
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< 100 um
< 50 microns
500-600 um
ICL is Very Thin
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Indications For Use
STAAR Visian ICL is indicated for placement in the posterior chamber of the phakic eye for:
Correction of myopia -3.00 D to -15.00 D
Reduction of myopia -15.00 D to -20.00 D
< 2.50 D of astigmatism (toric ICL under FDA review)
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VIDEO
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Immediate Post-Op
• High “WOW factor”• Not uncommon to see 20/40 or better
vision at the early postop check• A 2-4 hour postop check is required to
check pressure
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Accommodation – The Missing Element
• Cataract & refractive surgery focused on ‘Perfect’ distance vision without glasses, However…..
Unable to effectively deal with loss of accommodation• Patients still dependent on glasses• Cataract patients want to see the same as the
“young” LASIK patient and do not understand their limitation!
• Presbyopes – Once again are told
they need to continue to wear glasses in order
to see up-close (the same story 20 years later!)
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FD04-011 rev 00
source: 1997 Baltimore Eye Study
Refractive Distribution for Patients over 40 years
13.4
5.8
3.21.71.3
2.4 1.92.1
4.0
8.7
14.5
20.320.5
0
5
10
15
20
25
<-6 -5 -4 -3 -2 -1 0 1 2 3 4 5 >6
Spherical equivalent (D)
Pa
tie
nts
ov
er
40
ye
ars
(%
)
40.8%
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CK for Presbyopia
• First time reading needs• Freedom from reading glasses
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FD04-011 rev 00
Conductive Keratoplasty® (CK®)
• Controlled radiofrequency
• Stroma heats
Tip = 7-O suture or human hair
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The IOL PortfolioIOL’s come in many sizes, shapes & materials.Each has unique characteristics & capabilities
Single Power Lenses
Accommodating Lens
• Corrects only distance vision
• Does not accommodate in eye
• Glasses required
• Single focal point• Full range of
distance, intermediate & near vision
• Uses eye’s natural focusing mechanism
• Rapid visual recovery
Multifocal/Defractive Lenses
• Multiple, fixed focal points
• Does not accommodate in eye
• Must find appropriate focal point
• Extensive neurological adaptation
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Crystalens HD™
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Video of Crystalens
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Crystalens HD™
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THANK YOU FOR COMING!
• Any questions?