Making Cataract Surgery

Refractive Surgery
Eric E. Schmidt, O.D.
Bladen Eye Center
Elizabethtown, NC
Cataract Surgery
It is considered to be the most successful
surgery in the world! SO..

Why do we want to mess with success?
Whats all the fuss about?
What do we really want to achieve?
Goals Of Surgery
Visual improvement maximum
achievable visual acuity
20/20 w/out eyeglasses!
No anisometropia

Remember though; 20/20 may not always
be possible
Plano may not always be the best desired
end point
Uncorrected 20/20 begins with you
Choosing the right surgeon
Counseling your patient
Keep abreast of new stuff
Guide your surgeon to become proficient at
new stuff
Keep your staff up-to-date on the new stuff
Identify patients who would benefit from new
stuff
You need to understand that cataract surgery
should be considered refractive surgery
Why Bother With Co-Management?
Enhance px success
Continuity of care
Logistic concerns
They are your patients
Builds practice image

It is certainly not a monetary issue!!!
Pre-operative procedures
Set realistic goals for each individual patient
Perform detailed binocular refraction
Determine desired endpoint for the patients visual
system
Choose the best procedure to achieve this
Perform all the necessary pre-op tests
A-Scan
PAM
BAT
DFE
Retinal imaging
Wavefront testing
Pre-operative management
Px counseling
Describe the procedure, anesthesia
Describe the post-op course
Choose the surgeon
Schedule the appt
Pre-op regimen
Prescribe the pre-op meds
Discuss case w/ surgeon

A-Scan
Biometry- this is the key to choosing the
correct IOL power.
IOL chosen based on desired endpoint
refraction, axial length and keratometry
A-Scan ultrasound very easy to perform
CPT code 76516
76519
Should this be done by the referring OD?
IOL MASTER
Zeiss
Not ultrasonography
High resolution partial coherence
interferometry
Easy to perform (<1minute, non-contact)
Yields extremely precise axial length
(0.02mm), white-to-white, AC depth (+/-
0.1mm) and keratometry
Costs more, same reimbursement, but
allows us to pinpoint endpoint refractive
error.
IOL MASTER
Traditional SRK and Holladay Formulas,
but ..
Haigis formula
Surgeon specific
IOL specific
Allows a new level of mathematical flexibility
in calculating IOL power
Greatly increases accuracy and precision
as compared to A-scan

IOL Master
This renders a 5-fold increase in accuracy
Solves some A-scan issues
Posterior staphyloma
Long eyes (>24.5mm)
Short eyes (<22mm)
Silicone oil
Asteroid hyalosis

Cataract Surgery- Weve Come A
Long Way Baby!
ICCE
ECCE
Phacoemulsification
No-stitch, no patch
Surgical Incisions
Is one type really better than another?

Scleral tunnel
Clear cornea
Micro-incision (1mm)
Phacoemulsification
No new advances in this ; until now!
2 new instruments
Less energy, less heat
No need for irrigation
Sleeveless allows for micro-incisions

Capsulorhexis technique is very important
Current Phaco Energy Sources
Ultrasound
Efficiently emulsifies cataracts of any hardness
Rapid motion of phaco tip creates friction/heat
Laser
Efficiently emulsifies only +1 or +2 cataracts
Rests between laser bursts allow cooling
Sonic
Efficiently emulsifies only +1 or +2 cataracts
Less tip motion and friction/heat than ultrasound
Micro-incisions need micro IOL!!!
Super thin IOL
Injectable IOL
Liquid IOL
Lens refilling procedure
Post-operative regimen
Not much new to talk about EXCEPT
The incidence rate of endophthalmitis is
tripling
0.66% in clear cornea
0.25% in scleral tunnel


Can we prevent this?
Why is this happening?

Post-operative regimen

Antibiotic 4
th
generation fluoroquinolone
QID
Steroid prednisolone acetate 1% QID (or
more)
NSAID
Intraocular steroid Dex DSS
Post-op visits
1 day
1 week
3-4 weeks (DFE)
Clear Corneal Incisions Dont
Leak
They Suck!!!!
Endophthalmitis
Increase due to natural endogenous flora
from lids
75-90% gram positives
Staph. Epidermidis (42%)
Staph. Aureus,Enterococcus
Pay close attention to the lids pre- and
post-operatively
To reduce endophthalmitis
incidence
Fluoroquinolone QID 4 days prior to
surgery
Lid scrubs if needed
Artificial tears
Betadine prep peri-operatively
May need to leave px on topical antibiotics
longer post-operatively
Orals ??
Post-op concerns
Glare and haloes
Internal reflections
Anisometropia
2
nd
eye management
Post. Capsule opacification
What About Astigmatism?
Toric IOL


Astigmatic Keratotomy

Who are candidates?
Are there refractive limitations?
What can the patient (and us ) realistically
expect?
Toric IOL
STAAR Surgical silicone plate lens
Corrects 1.4 2.3 D of cyl at the spectacle
plane
Corrects the astigmatism at the nodal
point
Lessens distortion
Better qualitative visual acuity
Improved contrast sensitivity
There are some axis considerations
Toric IOL Success
Depends upon:
Surgical skill the surgery must be
astigmatically neutral
Proper IOL positioning
IOL maintaining a stable position in the bag
Aggressive post-operative monitoring
Toric IOL
Post-op considerations
Must be able to detect IOL rotation
If this occurs it must be corrected by 3 weeks
IOL may have to be rotated by surgeon
Patient must be dilated at 2 weeks to detect
this
Astigmatic keratotomy
Relaxing incision made nasally
Shallow (<150 microns)
Useful for pre-operative WTR cylinder
-1.00 to -2.50 cylinder

How effective is it?

Astigmatic Keratotomy
When should you recommend it?
Plano in other eye
Px does not like to wear specs
CL wearer
Those picky patients
WTR cylinder (170 010)
High cylinder pxs

Post-op considerations
Astigmatic keratotomy
What are the drawbacks?
Poor predictability

Limited range of correction

Post-operative FB sensation


So an optometrists walks into an
exam room to see a post-op px
O.D.- Howre those eyes doing Mr. Jones?
Px Not so great.
O.D. Whaddaya mean , not so great?
Youre seeing 20/20 in each eye without
glasses!
Px Yeah, but I cant see my newspaper!
What to do about presbyopia?
Monovision IOL

Presbyopic Lens Exchange (PRELEX)

Multifocal IOL

Accommodating IOL
Multifocal IOL options
Monovision

Refractive

Diffractive

Accommodative
The Ideal Multifocal IOL Patient
Baby Boomer
50s to the mid 60s
Cataract starting to compromise quality of
vision
Active lifestyle
Concerned about their appearance &
quality of life
Do not want to get old
Spending billions on lifestyle enhancing
procedures
Realistic Expectations
Motivated
Asks lots of questions

Whos A Candidate? / Clinical
Hyperopic
Loss of accommodation
Cataract
Unilateral traumatic cataract
Congenital cataract
Astigmatism (can be corrected)
High myopes (surgeon preference)
Whos A Candidate? /
Motivation
Wants to be less dependent on glasses
Understands the limitations of the Array
visual system
Willing to accept several months to adapt
to their new visual system
Whos Not A Candidate?
Significant dry eyes
Corneal scarring
Mild to moderate myopia
Pupil size < 2.5 mm
Monofocal implant in first eye
Uncorrected post-op astigmatism > 0.5 D
Unstable capsular support
Someone who demands perfect vision
ReZoom Multifocal IOL (AMO)
Refractive lens
2
nd
generation acrylic IOL
Delivers good near, distance and
intermediate vision
Is The ReZoom Perfect?
The most common concerns
Distance blur
Monocular diplopia
Object glow
Ghosting
Halos at night
These are the biggest post-op challenges




Acrysof ReStor IOL (Alcon)
Diffractive technology

Silicone material

Uses apodization to soften blur and sharpen
vision

Provides excellent VA at near, distance and
intermediate ranges
Strengths of the AcrySof

ReSTOR

IOL
High quality uncorrected near and
distance vision with 20/40 or better
intermediate vision without movement of
the IOL
80% Overall Spectacle Freedom
Nearly 94% of patients would have the
lens again
Aspheric Multifocal IOL Technology

Do We currently have any aspheric
multifocal IOLs?
Tecnis multifocal (AMO)

Sofport AO (Bausch & Lomb)
Explain the WOW! Factor
(or lack thereof)
Haloes and glaare at night are common-
these diminish with time
Longer adaptation period may take
weeks or months for pxs to accept their
new visual system
Near vision may be fuzzy to myopes
May need reading specs for prolonged
nearpoint work
Accomodative IOL
Crystalens- eyeonics
Silicone IOL with hinged optics
IOL moves forward or back depending on
ciliary muscle tone
Implanted using phaco technique
Capsulorhexis is critical
Pre-op biometry crucial
Enter: Accommodating Lens
The first accommodating lens technology
approved as safe & effective by the Food &
Drug Administration
Manufactured by eyeonics
A USA company
The lens uses the natural focusing
ability of the eye to provide a
single focal point throughout a full
range of vision from far, through
intermediate to near seamlessly
A New Paradigm In Vision Correction
(In contrast with multifocal IOLs which use a
dual simultaneous focus or monovision where
one eye is
set for distance & one eye for near)
eyeonics crystalens
The Ideal Crystalens Patient
Baby Boomer
50s to the mid 60s
Cataract starting to compromise quality of
vision
Active lifestyle
Concerned about their appearance & quality
of life
Do not want to get old
Spending billions on lifestyle enhancing
procedures
Realistic Expectations
Motivated
Asks lots of questions

Crystalens Post-Op Considerations
1% Atropine day of surgery & 1 day PO
Otherwise standard post-op regimen
Distance vision stable 1 week
Near vision begins to return @ 2 weeks
No significant glare or halos after 10 days
Must follow more often
Crystalens Post-op
Post-op: 10-14 days post-op
Keratometry
Uncorrected distance and near visual acuity
Controlled maximum plus refraction
Distance and near visual acuity through
distance correction
Gradual Plus Build-up to J1 to determine
add.
Verify refractive findings with cycloplegic
refraction


Spectacle Use Survey
Bilateral Implanted Subjects
Wearing Spectacles n/n (%)
I do not wear spectacles 33/128 (25.8%)
Almost none of the time 61/128 (47.7%)
26% to 50% of the time 20/128 (15.6%)
51% to 75% of the time 8/128 (6.3%)
76% to 100% of the time 6/128 (4.7%)
Night Spectacles n/n (%)
No 110/128 (84.6%)
Yes 20/130 (15.4%)
73.5% }
Is There A WOW Factor?
Cataract Surgery-
Whats on the horizon?
Adjustable IOL-
Material is fixed w/ laser to -0.75
Take to phoropter, refract to plano
Fix that w/ longer laser light
ICL
Clear Lens Extraction
Impeller extraction technique
Lens filling system