Advanced Technology IOLs

Multi-focal Implants (Part 2)

Dr. M. Ronan Conlon

Midwest Eye Care Institute
Saskatoon
February 2nd, 2012 Saskatoon
Club

Objectives
Share

my experience with multifocal implants

Patient video highlighting many
of features of multi-focal implants
Patient selection/Education
C0-Management
Managing the Unhappy Patient

Canadian Projected Population by Age

Group
2010 to 2031

3000.0

2500.0

2000.0

1500.0

Millions
1000.0

500.0

0.0

Population trends in
Canada predict a
significant increase
in patients requiring
cataract surgery in
the next 15 years
Advanced
technologies are now
available to these
patients to enhance
Age Group
their visual function

2010
2021
2031

Projected population by age group and sex according to three projection scenarios for
2010, 2011, 2016, 2021, 2026,2031 and 2036, at July 1. Statistics Canada.

A brief review
Advanced

Technology Lenses
(Part 1) Toric implants
presented September 15th, 2011

It is estimated that 35% of the

population has clinically significant
astigmatism

% of Patients

Cylinder Distribution
Modera
te
1.0
2.0D
25%

Severe
>2.0 D
10%

Cylinder D ( < )
N = 10,411

AcrySof IQ TORIC
IOL:
Astigmatism
Correction

Rotational Stability

81.1% of patients
were 5 of
intended axis

97.1% of patients
were 10 of
intended axis

less than 4 average

rotation 6 months
after implantation

Cylinder Powers
Estimated Percent of Cataract
Patients with Astigmatism

0.5D

*Based on average pseudophakic human eye.

4D+

Toric Implants My
Practice
2010 805 Cataract Cases

94 1%

Aspheri
c
Toric
ReSTOR

700

ReSTOR
Toric

2011 - 850 Cataract Cases

73

47

166
546

Aspheric
Toric
ReSTOR
ReSTOR
Toric

Dilated exam post Toric Implantation

Toric Implant at
axis 90 degrees

Key points for patients to

understand
Toric lenses are designed to
work with the shape of your
cornea to focus light to a single
point at the back of your eye to
improve your quality of vision.
By doing this, Toric lenses will
make you less dependant on
your glasses for distance vision
Toric lenses only correct
astigmatism and do not correct
presbyopia
You will have to wear reading
glasses after cataract surgery

Key points for patients to

understand
Toric lenses have become the
standard of care for astigmatic
cataract patients in my practice
Patients see better if they have
a toric implant its that simple
These lenses work extremely
well

Multifocal IOLs

The Goal: To make patients less

dependant
on their glasses for all
distances

Multifocal Implants
Diffractive
ReSTOR +3.0
Technis
AcriLisa (Europe)

Zonal

Refractive

ReZoom

Accommodating
Crystalens
Synchrony

What is Apodization how does it work?

Its

a light
management
system

Microscopic

steps

sends light
where you need
it, when you
need it

Apodization

Anterior Apodized Diffractive Aspheric

Surface
9 apodized diffractive steps for +3.0D
add power and balanced light energy
management
Negative 0.1 micron spherical aberration
factor corrects for the positive spherical
aberration of the cornea
Posterior Toric Lens Surface
Posterior toric surface with axis
marks
Allows the lens to correct preexisting corneal
astigmatism

18

Correction Ranges Detail

IOL Model

Cylinder Power
@ IOL Plane

Cylinder Power
@ Corneal Plane*

Recommended
Corneal Astigmatism
Correction Range
(Online Calculator Limits)

SND1T2

1.00

0.68

0.50 to 0.89 D

SND1T3

1.50

1.03

0.90 to 1.28 D

SND1T4

2.25

1.55

1.29 to 1.80 D

SND1T5

3.00

2.06

1.81 to 2.32 D

*Based on an average pseudophakic human

19

Binocular Defocus Curve

cm
cm 0 cm 3 cm
0
0
7
3
5
4

20/20
20/25
20/32
20/40
20/50
20/63
20/80
20/100
+1.00 +0.50 0.00 -0.50 -1.00 -1.50 -2.00 -2.50 -3.00 -3.50 -4.00

Refraction (D)
AcrySof IQ ReSTOR IOL +3.0 D [N=116]
Mean Defocus Curve for AcrySof IQ +3.0 D ReSTOR IOL
Binocular, Best Case, 6 Months Postoperative
Source: AcrySof IQ ReSTOR IOL Package Insert

20

Premium Implants My
Practice

55 bilateral ReSTOR
implantations so far

30 have completed 6
month Late Outcome
Assessments
measuring UCDVA,
UCNVA, BCDVA,
BCNVA, refraction
and survey of visual
activities and
function

2011 - 850 Cataract Cases

73

Aspher
ic

47

Toric

166
546

ReSTO
R
ReSTO
R Toric

Premium Implants Results

98%

would have same implants again

Mean UCDVA 20/25 (range 20/20+ to
20/30-, UCNVA 20/25 (range 20/20+ to
20/40)
All

of the patients with UCVA worse

than 20/25 are due to uncorrected
astigmatism >0.75 D; all correct to
20/20 near and distance with this
cylinder corrected

Success with Premium IOLs

Richard L. Lindstrom August 2009
OSN
Perspective
Careful patient selection
Reducing patient expectations
Achieving the desired refractive
result

Success with Premium IOLs

Richard L. Lindstrom August 2009 OSN
My conclusion after 25 year of

studying the premium IOL field, is that

the level of patient satisfaction is NOT
dependent of careful patient selections
I do NOT believe that patient
satisfaction is really significantly
influenced by extensive efforts to
reduce patient expectations
Patient selection is LESS IMPORTANT
THAN SURGEON PERFORMANCE if
spectacle independence is the desired
outcome

Success with Premium IOLs

Richard L. Lindstrom August 2009
OSN
Every refractive cataract

surgeon must appreciate that it is

the REFRACTIVE OUTCOME THEY
GENERATE, NOT THE PATIENT or
EVEN THE TECHNOLOGY they
select, that is the primary
determinant of patient
satisfaction and word of mouth
referrals.

Surgivision/Datalink
40,000 premium
lens implants
60% (24,000) eyes left

with > 0.75D untreated

residual K astigmatism
Minimum goal less than
0.50
Correction of cylinder is
extremely important

Patient Education

What

can you do?

Optometry

has a key role in the

education and counsel of patients
seeking guidance in new implant
technology

Change in Mindset

Acceptance

and Embracement of a
change in practice model
From medicare model treatment for

pathology
High volume, efficient, low cost care

Patient orientated model treatment

for Quality of Life

High quality, personalized to patients needs,
expectations, and desires, patient pay

Mindset of the Presbyopic Refractive Patient

Patients

are interested in lifestyle,

not pathology and are happy to pay
for the enhanced quality of life
Old paradigm: Patient want to see
better than they did with their
cataracts
New paradigm: Patients want to see
better than they did before they
developed cataracts

Patient Education
Define

Clouding of the natural

lens that allows less light

to pass through to the
retina

Symptoms

Blurred vision
Dull colors
Poor night vision
Sensitivity to light

Treatment

ONLY treatment is to have

it surgically removed and

replaced with an artificial
lens

Explain Their IOL Options

Multi-focal Implant
Designed to correct vision
near, far, and in-between,
for the best chance at
freedom from glasses.
Toric Implants
Designed to correct both
cataracts and astigmatism
at the time of surgery.
Glasses will likely be
needed for near vision.
Multifocal Toric Implants
Provides clear distance
vision. Glasses will likely be
needed for near vision and
possibly for distance vision.

Consider Their Needs

Take into account:

Lifestyle
Astigmatism
Preexisting ocular conditions, i.e. dry eye
Pathology rule out retinal pathology

Astigmatism

No Astigmatism

Basic IOL

Toric IOL

<2.5D of
cy pre-op

ReSTOR
Toric

Basic IOL

regular
astigmatism
healthy eye?

ReSTOR

Shared Decision
Making!

Key points for patients to

understand
ReSTOR is a multifocal lens which
make you less dependant on
glasses after cataract surgery at all
distances
Although 20/20 vision is not
guaranteed, 80% of patients report not
needing glasses after surgery
20% of patients report needing glasses
for specific activities such as working
on a computer or reading in dim light
Glare and halo around lights at night
may be reported after surgery, most
patients adapt within a few weeks
Adequate light is recommended for

C0-Management Pre
and Post Operative
Care

C0-Management OD/MD
Expansion

of patient variety and opportunity

for practice growth
With the development of toric, multi-focal,
and multi-focal toric IOLs cataract surgery
has evolved into refractive cataract surgery
Shared practice experience and opportunity
for higher degrees of patient satisfaction
Optometrists play an integral role in selecting
and recommending IOL technologies
Saskatchewan has a larger geographical area
and travel is a significant issue for patients

Before referring your

patient
Patient

should discontinue contact

lens wear two weeks prior to axial
length and keratometry
measurements more accurate IOL
measurements
Discuss with your patient the various
IOL options regular, toric, multifocal, and multi-focal toric
Advise your surgeon and what you
think would work best make a

Before referring your

patient
Manage Ocular
Surface Disease
Treat Dry Eye
Manage Eyelid
Margin Disease

What to Expect After Surgery

One Day Post Op
Many cataract surgeons now perform same day post

evaluations, and patient go home same day

Examination
Vision is usually 20/40 or better
Anterior segment cornea generally clear to mild edema,
AC inflammation minimal +1, eye should be comfortable, AC
deep, wound sealed
Lens centered
IOP 10 to 25 (contact surgeon if outside these parameters)
Post Medications Vigamox TID x 1 week, Maxidex TID x 4
weeks, Nevanac TID x 4 weeks
Follow visit in 3-4 weeks, and sooner if concerns

Complications Day 1
visit
IOP

spike

25 30 mmHg Alphagan P BID x 1 week

> 30 mmHg contact surgeon

Bullous

keratopathy

Lubricated surface, consider Muro 128 qhs

Usually related to increased IOP, endothelial comprise

Tilted

IOL

Not an emergency, but contact surgeon

Peaked

Pupil

Not an emergency, but contact surgeon, check IOP and wound leak

Retain

lens fragment

Increased steroid 6X/day, and contact surgeon

Retinal

detachment

Urgent contact surgeon

What to Expect After Surgery

One Month
Conduct a dilated fundus exam to check for

cystoid macular edema (CME)

Discontinue drops
Prescribe spectacles, if necessary
20% of multi-focal toric implant patients require
spectacles for some activities

Decreased Vision
Check for ocular surface disease dry eye, MGD,
EBMD
IOP
Fundus - CME

What to Expect After Surgery

One Month Potential Problems

Lens tilted
Inferior lens out of

bag
May or may not
require adjustment

Persistent Bullous
Keratopathy
Control IOP
Muro 128 gtts/ung

What to Expect After Surgery

Three Months

Patient should have bilateral lenses

Check visual acuities at appropriate

distances

Survey the patient for their

satisfaction

When to Refer to the

Ophthalmologist
Posterior

capsular opacification

(PCO)
Treated with a Nd:YAG laser

Persistent

tear film abnormalities

unless you are comfortable
managing it

Residual

refractive error if the

patient is interested in a surgical

The Unhappy Patient!

Cylinder and
Residual Refractive
Error
Cornea and OSN
Capsule
CME
Centered

Ocular Surface Disease

Optimizing the
ocular surface very
important
Options

Artificial tears
Restasis
Serum based tears
Punctal plugs
Nutritional

supplements
omega 3s

Eyelid Disease

Lid hyperthermia
Hot compresses or lid

scrubs

Nutritional
supplements
Topical azithromycin
bid 2 days then qd
for 1 month
Tobradex
Severe cases

Oral doxycycline 50

mg PO daily

Capsule Opacification
Consider Yag laser
Avoid Yag laser if
explantation still a
consideration!

Cystoid macular edema

NSAIDs
mandatory
Significant
reduction post
operative CME

Thank You