New Technology:

Cornea and

Cataract Surgery

Darcy H. Wolsey, MD

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CorneaDMEK

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Endothelial KeratoplastyTreats Endothelial dysfunction

Fuch’s Corneal Dystrophy

PPMD

ICE syndrome

Failed corneal transplant

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Surgical trauma

Pseudophakic/aphakic corneal edema

Advanced cataract

Ahmed Valve

Retained Fragment

Endothelial Transplants: Advantages over PKP• Faster visual recovery• Minimal topographic changes (reduction of astigmatism)

• Smaller incision

• Small and predictable hyperopic shift

• Tectonically resistant globe

• No suture-related complications

• Lower incidence of allograft rejection

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DSAEK Success

Why change something that is working?

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Good vision

Mild shift in vision

Quick recovery (weeks)

Minimal discomfort

Moderately Technical

DSAEK

Donor Button

Stripped Descemet’s and Endothelium

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DSAEK: Good

Good vision Majority get 20/40 Small percentage 20/20

Mild shift in vision Ave hyperopic shift +1.25 Astigmatism change

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Can it be better? DSAEK: Can it be better? Ultra-thin DSAEK

DSAEK grafts Up to 160 microns

Ultra-thin DSAEK Less than 100 microns

Nano-thin 50 microns

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DMEK: Descemet Membrane Endothelial Keratoplasty

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Donor Cornea: only Descemet and Endothelium

Stripped Descemet’s and Endothelium

DSAEK vs. DMEKDSAEK Removal of Descemet’s membrane

Replace with thinly cut cornea including stroma AND Descemet’s with healthy endothelial cells

Air used

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DMEK Removal of Descemet’s membrane

Replace with ONLY Descemet’s with endothelial cells

PI placed inferior

Gas used

Benefits of DMEKQuicker visual recovery Weeks to glasses

Smaller incision: 2.4 mm vs 4.0mm with DSAEK

Minimal visual shift

Can be used in patients with refractive IOLs

Better quality of vision

More patients with 20/20 vision

Less rejection

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DMEK downsideTechnically more difficult

Higher dislocation rate

Higher graft failure rate (learning curve)

Need more “normal” eye Cannot do in abnormal anterior segment

Previous vitrectomy

Poor visualization

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Post OpDSAEK

Lay supine 24 hours Limited activity 2 wk Low risk for rebubble Vision clears in 4 wk

Glasses 2-3 mo Pred taper for 6 mo

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DMEK

Lay supine 48 hrs Limited activity 2 wk High risk for rebubble Vision clears in 1-2wk

Glasses 6 weeks Pred taper for 6 mo

Cataract: New

TechnologyRx Sight Light

Adjustable Lens (LAL)

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Current IOLs: Good but not Great• 20/20 rates

• 70% - 80%

• Post Refractive patients - more unpredictable

• Previous management for post op refractive error:

• Lasik/PRK

• IOL Exchange or reposition

• Glasses

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Light Adjustable Lens• IOL is reshaped after surgery to

account for mild refractive error

• Particles (monomers) migrate within the lens when exposed to UV light

• Lens looks like standard 3 piece IOL

• Photosensitizing silicone lens

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Light Adjustable Lens• Treats

• +2.00 to -2.00 D sphere

• +0.75 astigmatism

• Treatments occur 2-3 weeks after surgery • Can have up to 3 treatments to adjust for residual

correction

• 1-2 “Lock In” treatments

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Light Adjustable Lens• HOWEVER….

• Patient must wear UV protective glasses inside and outdoors until several days after “lock in” treatment

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Light Adjustable Lens●Pros:●Outcomes extremely predictable and certain●Excellent with post-LASIK/PRK/RK●Cons:●UV Blocking glasses required for 3-5 weeks●More work for us (numerous visits)●Most expensive option for patient●No MFIOL option (Mild EDOF)

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Cataract: New

TechnologyPanOptix

Trifocal IOL

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Presbyopia-correcting-IOLs Options

● Available for well over a decade

● LOW ADOPTION - Only 7% of current cataract surgeries as assessed by the ASCRS 2017 survey

● REASON - Tedious and very specific pre-op process, no coverage of entire range of vision, cost

● Unpredictable outcomes

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PanOptics “Bends” the Rules● Based on quadrifocal which follows the law:●Too little light at the distance focus

● The 120cm light is redirected to distance to attain 88% light utilized:●50% at distance●25% at 60cm●25% at 40cm

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PanOptics - Improvements

●Not pupil dependent●Better reading in dimmer light●Larger central distance zone

●Less rings●Less halos

Study Results Phenomenal!Continuous 20/25 from near to far (no dead spots)

● More forgiving with slightly missed refractive target

● Still glare/halos but better tolerated

● Happier patients!

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