How to be Fabulously Successful with Premium IOL’s Randy J. Epstein, MD “Cataract” Surgery vs. Refractive Lens Exchange “R.L.E.” Professor, Dept. of Ophthalmology Rush University Med Med. Center Center, Chicago IL CEO, Chicago Cornea Consultants, Ltd. Chicago/Highland Pk./Hoff. Est., IL Similarities: Surgical procedure IOL s IOL’s Differences: Indication for surgery Who is paying The Key Elements of Success “Up-charging” for enhanced services: “UPGRADES” Your entire practice must have a “refractive mindset” in order to be successful with refractive IOL’s for BOTH groups, (even ( if you JUST do d cataracts), including: 1) Enhanced “customer” orientation 2) Receptive population 3) EASY availability of financing • Now a well established Medicare paradigm • “Concierge” internal medicine practices have solidified the concept, concept which is growing (you get what you PAY for) • Patients are more accustomed to paying “out of pocket” for more of their healthcare needs (“fee for service”) Refractive IOL’s approved by the FDA in active use in USA Good candidates for Multi-focal IOL’s Multi-focals: – Alcon ReSTOR – AMO Technis – B&L Crystalens Torics: – STAAR AA4203TL – Alcon Acrysof SN60T* series • Patient is interested in decreasing dependence on reading glasses- (Steinert, ‘08: “The patient has to care”) • Young cataract patients • Most refractive lens exchange (RLE) patients (especially hyperopes) • Willing to accept possible halos 1 Multi-focal IOL’s: Best for Hyperopic Presbyopes • Easiest to please as they have TWO optical problems • Greatest margin for error • Low risk of RD RLE: My Preferred Refractive Procedure in “Older” Presbyopes (over 60) • Azar study, 2008: LASIK is “OK” • RLE with a multi-focal IOL addresses both distance and near issues most effectivelyy • Treats lens-induced HOA’s and avoids postLASIK disappointment • Eliminates “post-LASIK” IOL calculation hassle for cataract surgery • (Retinal consults for high myopes) Subjective Exclusion Criteria for Bad candidates for Multi-focal IOL’s • Astigmats (>1.5D of corneal astigmatism) • Macular pathology (ERM’s, drusen) • Abnormal corneas – Keratoconus, prior refractive or corneal surgery – Ocular surface disease (EBMD, dry eyes) Multi-focal IOL’s • • • • Hypercritical patients Patients with unrealistic expectations Occupational night drivers ? Pilots • Mono-focal IOL in the other eye? • Glasses-wearing low myopes (they like to read ‘sc’ and IOL’s never exceed this) Relative Contraindications for Toric IOL’s- NOT MANY! • Fewer ocular issues- (OK to use with GLC, ARMD, post-ops, etc.). KC +/- now… • Ocular surface disease (EBMD (EBMD, dry eyes) • ? High residual astigmatism in other eye (unless you are prepared to deal with it) • Surgical complications Multi-focal IOL’s: Pre-op considerations • 1) Pre-op topography is essential • 2) ? Match IOL color in contra-lateral y ((chromophore/clear) p ) ?? multifocal eye • 3) Plan/discuss need for N/C post-op PRK/LASIK “touch-ups” in advance. • (This is factored into the “up-charge”). 2 Refractive IOL’s: Pre-op considerations: Our patient education routine Our Patient Education Carrels: Patient Education Concepts, Inc. • All patients watch Patient Education Concepts p ((P.E.C.)) DVD or computer p program, and take the quiz (for documentation) while they are dilating • Brochures, etc. • Detailed, written informed consent • Finance plans (CareCredit, etc.) Computer version Alcon “ReSTOR” +4.00D add Multifocal IOL FDA Approval: April, 2005 • “Pseudo-accommodative” • Reading center weighted • Light Li ht energy is i equally ll divided di id d between b t distance di t and near for small pupils • Becomes distance-dominant for large pupils • Aspheric optics • Near point TOO CLOSE for many patients AcrySof® ReSTOR® Aspheric IOL Design AcrySof® IQ ReSTOR® +3.0D add IOL The AcrySof® ReSTOR® Aspheric IOL is designed with negative spherical aberration. SN6AD3 SN6AD1 Add Power: +4.0 D Spectacle Plane: +3.2 D Range: +10.0 D to +34.0 D A-Constant: 118.9 Add Power: +3.0 D Spectacle Plane: +2.5 D Range: +6.0 D to +34.0 D A-Constant: 118.9 18 3 Aspheric Optics with AcrySof® ReSTOR® Aspheric “Deliberate use of unequal adds with ReSTOR” • Osher JCRS 35:1646, 2009 • Patient #1: ReSTOR +4, had computer problems • Patient #2: ReSTOR +3, and unable to read fine print • Both patients “20/Happy” after getting other IOL in second eye Aspheric IOL Aspheric optics align the light rays to compensate for positive corneal spherical aberration, with enhanced image quality. SN6AD1 Design Characteristics Apodization • “Cutting off the feet” (Greek) • Small pupils: Equal distribution of near and distance Rx • Large pupils: Distance dominant • Utilizes existing IQ ReSTOR® IOL +4.0 D platform with identical asphericity, energy distribution profile, and shape factor • Add power modified to +3.0 D – 9 diffractive steps vs. 12 diffractive steps – Slightly wider step spacing to modify the add power 22 Uncorrected Intermediate Photopic VAs Average Near Best Distance 100 90 80 70 60 50 40 30 20 10 0 38 Centim meters (cm) % off Subjects All Implanted, 3 month postoperative, 50 cm 36 34 32 30 28 26 20/25 or better 20/32 or better 20/40 or better Uncorrected IQ ReSTOR® IOL +3.0 D [N=138] IQ ReSTOR® IOL +3.0 D [N=138] IQ ReSTOR® IOL +4.0 D [N=131] IQ ReSTOR® IOL +4.0 D [N=131] Provides a one line or more improvement in binocular intermediate VA. Source: AcrySof® IQ ReSTOR® IOL Package Insert Source: AcrySof® IQ ReSTOR® IOL Package Insert 4 Over 95% of ReSTOR® IOL +3.0 D Patients Would Have the Same Implant Again Binocular Defocus Curve Percent off Subjects ∞ 20/20 20/25 Snellen 20/32 20/40 20/50 20/63 20/80 20/100 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% IQ ReSTOR® IOL +3.0 D [N=138] IQ ReSTOR® IOL +4.0 D [N=131] No +1.00 +0.50 0.00 -0.50 -1.00 -1.50 -2.00 -2.50 -3.00 -3.50 IQ ReSTOR® IOL +3.0 D [N=117] Yes -4.00 Would you have the same implant again? Refraction (D) IQ ReSTOR® IOL +4.0 D [N=114] 25 Source: AcrySof® IQ ReSTOR® IOL Package Insert 26 Source: AcrySof® IQ ReSTOR® IOL Package Insert AcrySof ® IQ ReSTOR® IOL Conclusions Refractive IOL’s: Surgical Considerations True performance at near, intermediate, and distance • 1 – 1.5 line(s) improvement in intermediate VA in favor of SN6AD1 vs SN6AD3 • Best near distance approximately 7 cm (3 in) out for IQ ReSTOR® IOL +3.0 D • Contrast sensitivity measured between SN6AD1 and SN6AD3 demonstrated clinical equivalence • No clinically relevant increase in visual disturbances between SN6AD1 and SN6AD3 • High rate of patient satisfaction and spectacle independence • Mark steep axis on eyeball with patient sitting up (before sedation/block) • Incision placement: I always prefer STEEP AXIS SURGERY when possible • LRI’s 27 Multifocal IOL’s: Surgical Considerations If STEEP AXIS incision placement is NOT possible, must do LRI if patient has preexisting g with-the-rule cylinder y to avoid post-op astigmatic surprises! Refractive IOL Complications • Power errors • Mis-communications (mono-vision, etc.) • Surgical complications – Back-up IOL’s need to be available (on axis surgery especially critical for astigmats as there IS no backup for toric IOL) – Alcon MN60D3= 3 piece multifocal • Post-op complications 5 Long-Term ReSTOR- JCRS 9/08: 80% spectacle independent at 3 yrs. Multifocal IOL’s: Post-op issues • Have Alcon’s minus Rx glasses handy for patients to use for demonstration • Use topography to illustrate residual astigmatism, which is usually the issue • Low threshold for offering NO CHARGE PRK/LASIK touch-ups (included with ‘up-charge’) When to fix astigmatism? Always takes precedence over presbyopia “You have three problems, we can only fix two” (in the following order): – 1) Cataract – 2) Astigmatism – 3) Presbyopia Common “Astigmatism Trap”: Refractive- ATR, K-WTR Common “Astigmatism Trap” Example • • • • MR= +1.00 + 1.00 x 180 OU WITH the-rule astigmatism on topography WITH the rule astigmatism on IOLMaster = “Lenticular Astigmatism”! Lenticular Astigmatism: Solution • Incision made in steep (90 degree) axis(Superior scleral tunnel) • Outcome: Spherical cornea, cornea happy patient 6 Toric IOL’s: Pre-op considerations • LRI’s: online calculators AcrySof® IQ Toric IOL Calculator Makes precise surgical planning easy! – ASCRS calculator: (www.ascrs.org) • Surgical planning • Incision placement (S.I.A.) • Alcon’s online toric IOL calculator takes into account YOUR surgically induced astigmatism (“S.I.A.”) • (www.acrysoftoriccalculator.com) Alcon Acrysof Toric IOL Model #SN60t* • No rotation problems • +10 to +30D of spherical refractive error • 1.0D 1 0D (t3) (t3), 11.5 5 (t4) (t4), or 22.0(t5) 0(t5) D of corneal astigmatism • Must factor in lenticular astigmatism (i.e., IGNORE it)! • Higher powers available in near future Acrysof Toric IOL: Axis marks at haptic insertion points Intuitive input › Patient data › Keratometry › IOL spherical power › Surgically induced astigmatism › Incision location Powerful output › Recommended IOL model and spherical equivalent power › Optimal axis placement › Magnitude and axis of anticipated residual astigmatism AcrySof® IQ Toric IOL Newest monofocal IOL builds on long line of innovation from Alcon Takes the trusted platform for precise astigmatism correction and adds the enhanced image quality of an aspheric lens Bring topography to O.R. 7 Put axis marks ON the eye freehand, using topography as a guide When to fix astigmatism? Case in point • High pre-existing astigmatism (>5.0D OU) • Cataract surgery OD elsewhere, adding to that astigmatism • Presents with cataract OS OD: post-op OS: pre-op OS Phaco, toric IOL, LRI Surgery OS: Toric IOL, LRI, under-correction of myopia Post-op Rx=1.8D corneal cyl. OD= -3.25+6.00x20 OS= -1.25 sph. Patient tolerating Rx in glasses 8 55 year old requested LASIK 8 years agoWears glasses, mild c/o halo/glare OU Myopic Astig. with mild cataracts, with-the rule cylinder: Pre-op – MR: • OD -5.75 + 1.50 x 103=20/20 • OS: -6.00 + 2.25 x 85=20/25 – TMS: • OD: + 1.57 x 103, OS: +2.1 X 90 – Mild ant. stellate cortical cat noted OS > OD – BAT (Med.): 20/40 OD, 20200 OS – Cataract surgery “medically indicated” Surgical plan: Clear corneal temporal incisions OU Post-op: 20/20 sc OU and plano “Never saw better in my life” • Left eye operated on first, with – SN60 t5 (+3.0D cyl. at IOL plane) • Right eye operated on next, next with – = SN60t4 (+2.25 cyl. at IOL plane) Recent long-term post-op TORIC outcomes: JCRS 9-08: 90% >20/40 Toric IOL’s: Surgical Considerations – Don’t evacuate visco till done positioning – Leave 45 degrees short of endpoint for final ‘spin’ when visco is removed - Additive with LRI’s 9 Dr. Laurie Sullivan’s spreadsheet: “[email protected]” (Dotted red= IOL + cyl. axis, green=residual + cyl.) Refractive IOL’s: Economic Considerations • “Upgrade” must include ALL post-op ‘touch-ups’- LRI’s, PRK, LASIK, etc. Thanks for your attention! e-mail: “[email protected]” 10