The New Frontier - American Osteopathic College of Ophthalmology

Transcription

Laser Assisted Cataract
S
Surgery:
Th
The N
New F
Frontier
ti
The Joseph H
H. Wyatt DO Lecture
Brian D.
D Ranelle D.O.
DO
T
Texas
Eye
E and
d Laser
L
Center
C
Ft. Worth and Hurst, Texas
Surgery
The New
Frontier
Dr. Brian D. Ranelle Texas Eye & Laser Center
The Joseph
p H. Wyatt
y
Lecture
1957
1972
1962
1958
The Joseph
p H. Wyatt
y
Lecture
1978
1938
2010
The Joseph
p H. Wyatt
y
Lecture
Dr. Joseph Wyatt and
partner Dr. Patrick
p
Murray 1975
The Joseph
p H. Wyatt
y
DO
Lecture




1874 AT Stillll establishes
bl h the
h Osteopathic
h
Profession
1908 A
American
i
College
C ll
off Ophthalmology
O hth l l
and ENT established
1961 First Osteopathic Ophthalmology
residency started by Joseph Wyatt DO in
Detroit,
Detroit Michigan
1995 Separate colleges of
Ophthalmology and ENT established
Dr. Brian D. Ranelle TexasoEye & Laser Center
The Joseph
p H. Wyatt
y
Lecture







Born Feb.
b 20, 1920 in Flora,
l
Illonis
ll
Quarterback and captain of both football
and
d basketball
b k tb ll teams
t
Attended Kirksville College Osteo
Osteo.. Med
Internship 1943 Detroit Osteo
Osteo.. Hosp.
1946--48 EENT residency LA, California
1946
1961 Started first ophthalmology residency
in Detroit, Mich.
Over 100 residents graduated from DOH
Joseph
p H. Wyatt
y
DO
Lecture
“ When you complete your residency
yyou are given
g
the right
g to tend to
patients and treat their eye disease.
However,, Ophthalmology
p
gy is a specialty
p
y
that constantly changes and requires
that you keep up or you fall behind.
behind ”
Laser--Assisted Cataract
Laser
Surgery


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


3 million cataract surgeries in U.S. in 2010
78 million babyy boomers coming
g
10,000 baby boomers turn 65 every day
Patients
at e ts des
desire
e to be g
glasses
asses independent
depe de t
Patient awareness of Lasers is high
Lasik & Intralase are forefore-runners of
Femtosecond Lasers with high acceptance
Surgery: Presbyopia


Baby Boomers
Born 19461946-1964, 78 million
A
Ages
40-65
40Disposable income
Do not want to look or be old
Ophthalmic Needs:
Earlyy cataracts
Refractive errors
Presbyopia
Desire to be glasses free
Surgery



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
Femtosecond Laser Technology
Photodisruption
p
of tissue
tissue--cells
High speed, ultra short pulses that last one
millionth of one billionth of one second
High degree of controlled sculpting
No collateral damage
g to adjacent
j
tissue
Plasma formation with production of OBL/
bubbles
Optical Delivery System

Laser is set to desired
depthd th-LenSx
depth
L S
– Defined distance from
bottom of glass applanation
surface – Patient Interface

Pulses delivered in a
prescribed pattern creating a
horizontal or vertical
cleavage plane in the
cornea,anterior capsule and
lens
Photodisruption
p
Thousands of laser pulses are connected together
in a raster pattern to define a resection plane
Photodisruption
p
Laser pulses can be stacked on each other
to create an angled cleavage plane
Surgery
Femtosecond
Lasers
L S
LenSx
Intralase
LenSx
Dr. Brian D. Ranelle
Texas Eye & Laser Center
Intralase
Laser Assisted Cataract Surgery

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Most important innovation in cataract
surgery since phacoemulsification(1970’s)
phacoemulsification(1970’s)
and lens Implants (late 1960’s)
Technology (LACS) compliments the use of
P b
Presbyopic
i correcting
i IOL’s
IOL’
Advantages of Femtosecond lasers i.e.
accuracy, tissue
ti
friendly,
f i dl reproducible
d ibl etc.
t
Hopes of improving visual out comes
Surgery
Lens Anterior
Capsulotomy
Laser Assisted
Capsulotomy

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
Precise every time, watch for tags
Size shape
Size,
shape, centration ideal
Manual capsulotomy less predictable,
less precise
Capsulotomy diameter variability
laser = 29um
manual =339um
Better IOL centration/
centration/ p
position
Capsulotomy
Laser Assisted Cataract Surgery
Present visual outcomes for Lasik vs.
cataract surgery
g y
Cataract--40
Cataract
40--50% 20/40 or better UCVA
Lasik-- 95% 20/20 or better UCVA
Lasik
Introduction of Femtosecond technology
bi
brings
cataract
t
t surgery tto a visual
i
l
level comparable with Lasik except for
commorbidities
biditi
Surgery
LenSx
Capsulotomy
Surgery
LenSx
Precision
Incision
3Plane
Laser Microincisional
Cataract Surgery
Allows small incisions of
any size
Precise corneal incisions
Incisions can be placed
anywhere on cornea
Can still make manual
incisions
Laser Arcuate Incisions
for Astigmatism

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73% of population has > .50 D of
astigmatism
g
39% has > 1.00D of astigmatism
Treat more ATR astigmatism,
astigmatism less
WTR astigmatism
A id flipping
Avoid
fli i axis
i
Combine arcuates with Toric IOL’s
Refractive Accuracy:
y
Addressing Astigmatism
TORIC IOL
Manual
LRI
TORIC
O C IOL
O
Laser Arcuate Nomogram
LRI’s
LRI s
.50D 1 = 45*
.75D
75D
2 = 30*
1.50D 2 = 60*
3.00D 2 = 90*
LenSx
.50D 1 = 30*
.75D 2 = 20
20*
1.50 D 2 = 40*
3 00D 2 = 60*
3.00D
30% Reduction from LRI
nomogram
Donnenfeld nomogram
Residual Astigmatism is the most common cause of
reduced vision after cataract surgery
Laser Assisted Cataract:
Corneal Incisions

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Primary and secondary incisions more
p
reproducable
Arcuate incisions precise
Arcuates 80
80--85% deep
Arcuates at 8.5
8.5--9mm OZ
Open arcuates at surgery or later
Improved
p
visual outcomes
Surgery: Addressing
Astigmatism
g
Arcuate Incisions
LenSx
Laser Assisted
Fragmentation of Lens




Breaks up, chops nucleus
Easier to remove
Less surgical time
S l t nucleofractious
Select
l f ti
options:
ti
Quadrant
Cylinder
Combination
Surgery
Laser Lens Chop
Lens Fragmentation
Advantages
g of Laser Assisted
Cataract Surgery

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Excellent control of laser treatment
Ability to produce precise and
reproducible incisions
Accurate placement of IOL post
post--op or
Effective Lens Position (ELP)
C
Corrects
t A
Astigmatism
ti
ti
Less refractive and surgical surprises
Surgery: Effective Lens
Position ((ELP))

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Precise capsulotomy (5mm) , no
collateral tissue damage
Ideal IOL placement in capsular bag
Stronger capsulotomy
capsulotomy,, less tears
Goal is Better visual outcomes
Especially important with Premium
IOL’s
IOL s
Surgery: Ultrasound Power




Reduced Ultrasound Power/Time
42% reduction in Phaco
Phaco.. Power
50% reduction in Phaco.
Phaco. time
P
Preservation
ti off endothelial
d th li l cells
ll
Less corneal edema/ corneal thickness
Surgery
Advantages
LenSx
Surgery: Advantages

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
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Uniform size, centered capsulotomy
Reproduceable
p
corneal incisions
Arcuate incisions for astigmatism
Nucleus removal: Less phaco
phaco.. power/
time
Less post
post--op inflammation,
inflammation with better
vision faster
IOL position more predictable
d
bl (ELP)
(
)
Three Big
g Advantages
g of
Laser Cataract Surgery
44% Reduction in Phaco. Power
50% Reduction in Phaco. Time
Reduced endotheliai cell loss
Standared
Phacoemulsification



M t common method
Most
th d off cataract
t
t
surgery
More ultrasound needed as cataract
becomes more dense
Excess ultrasound energy problems:
corneal edema/ endothelial cell loss
wound burns
more time
ti
with
ith potential
t ti l complications
li ti
Standard
Phacoemulsification
Over 50%
increase in
ultrasound power
Extends phaco.
time
Increased
co neal edema
corneal
More post-op
inflamation
Methods To Reduce
Ultrasound Power


Ultrasound modulation of energy
Torsional phaco
Pulse duty cycle
S i l Techniques
Surgical
T h i
to
t reduce
d
power/phaco
power/
phaco.. time
Chopping techniques of lens
Viscoelastics
Disadvantages
g of Laser Assisted
Cataract Surgery

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Post –op subconjunctival hemorrhageshemorrhages-mild
Cost of equipment
q p
high
g
Adds time to routine cataract surgery
Not
ot reimbursed
e bu sed by medicare/
medicare
ed ca e/
e/ insurance
su a ce
Not all patients candiates
candiates-- tight lids, small
pupils,
p
p , glaucoma,
g
, corneal conditions,, ARMD
Not all patients can be docked
Laser Assisted Cataract Surgery:
g y
Other Uses of Laser

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Corneal surgeriessurgeries- Transplants,
Lamellar Sx
Refractive laser/ Intrastromal vision
correction
Collagen crosscross-linking for KC / ectasia
S l l surgery
Scleral
surgery-- Glaucoma
Gl
S
Surgery
Corneal wedge resections etc
Laser Assisted Cataract Surgery:
g y
Goals

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
Increased precision / safety
Makes cataract surgery more
reproducible
Surgeon directed,
directed computer controlled
Achieve true refractive outcomes
comparable
bl to
t Lasik
L ik
Will it become the Standard of Care?
Laser Vision Correction:
Femtosecond Lasers


Laser corneal surgery
Lasik corneal flaps
p
Lameller Sx,
Sx, Wedge resections
Laser
ase ass
assisted
sted cata
cataract
act su
surgery
ge y
Clear lens removal/Refractive lens exchange
Combined with Presbyopic/
Presbyopic/ Toric IOL’s
Beginning Lessons


Good Docking is the Key
Good lid speculum
Proparacaine applied to PI
Proper head position
P e ent P
Prevent
Problems
oblems
Meniscus creep
Air bubbles with dock
Conjunctival obstruction
Lid hitting
g speculum
p
Beginning Lessions
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Learning curve
Re--Dock several times for good suction
Re
Adjust surgical schedule
Laser setset-up: Outside OR ideal
A oid complications
Avoid
Ant./Post. Capsule tears
Capsule block
block--gentle hydrodissection
If docking not good or capsulotomy poor convert to
routine case!
Integration
g
of the Laser
in the ASC

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Space: In ASC between OR’s
Time: Adds 5 minutes/ case
Access: Make it easy for patients/ staff
Money:
M
Costs/
C t / Marketing
M k ti
People: Patients
Patients// Staff
Personal Experience
p
with
LACS

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
Anterior capsule tears
Posterior capsule tears
Reduced phaco.
phaco. time
L
Less
postt-op inflammation
posti fl
ti
Faster visual recovery
Excellent IOL position
Safer than manual technique
Laser assisted cataract surgery raises
tthe
e bar
ba in vision
s o correction
co ect o to a new
e
level. It is customizable, it is more
precise and more reproduceable than
standard cataract surgery. This will
benefit the patient with better visual
outcomes and safety.
safety Our patients
should see the results with this
advanced technology.
Optiwave
p
Refractive
Analysis (ORA) (Orange)





Customizes cataract surgery with
LenSx:: LenSx Plus
LenSx
Enhanced wavefront image used
Improves accuracy of IOL selection
Intraoperative astigmatic correction:
Both LRI
LRI’ss and Toric IOL’s
IOL s
Refines refractive results for better
visual
i
l outcomes
t
Blade-Free Laser Assisted
BladeCataract Surgery

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Technology has given
surgeons choices
Surgeons need to
give patients choices
Ideal for Premium
IOL’s
Achieving greater
value in
Refractive/Cataract
Surgery
The New Frontier: Laser
Assisted
i
d Cataract Surgery
Weapon Grade
Vision“Baby””
Vision“Baby
Laser Assisted Video

The New Frontier - American Osteopathic College of Ophthalmology

Transcription

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