Paul J. Dougherty, MD - Dougherty Laser Vision

Paul J. Dougherty, MD
Dougherty Laser Vision
Westlake Village, California
Beverly Hills, California
Camarillo, California
Jules Stein Eye Institute
Los Angeles, California
Advances in
Cataract/Pre
mium IOL
Technology
iStent
• iStent® rails are seated against scleral wall of Schlemm’s canal
• iStent® Snorkel sits parallel to the iris plane
3
Dropless Cataract Surgery
-TriMoxiVanco (Steroid + 2 antibiotics)
-Injected into the vitreous through the zonules
-Advantages
No drops for most patients
 Decreases infection rate by >200%
 Lowers CME risk twofold
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-Disadvantages
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5% require supplemental topical steroids
May get floaters for 1-2 weeks
Diabetes and ERM still require NSAID (Prolensa)
Capsular bag must be perfect to use
Intracameral and Intravitreal D
rugs for Dropless Cataract
Surgery
Intraocular
Medications & Proactive Control:
Combination Antibiotic and Steroid into one injection
 TriMoxi and TriMoxiVanc by Imprimis
Pharmaceuticals
– Highly efficient delivery into the vitreous
– Inexpensive compared to pharmacy drugs (SDV)
– Produced by Compounding Pharmacy
 FDA Manufacturing Protocols
 Highly Regulated: High Safety with Accreditation Facility
 Reimburseable by Medicare and Commercial Insurance
 Nationally available 2Q2014: Marketing campaign starting
Cataract Vision
Correction Packages
Standard IOL
 Economy Package
 Premium Package
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Standard IOL
Package
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Basic government-issue IOL
No diagnosis or management of refractive error,
astigmatism, Spherical Aberration
Glasses for every distance
No charge to patient
Co-management fee – 20% only ($154Medicare)
Economy Vision
Correction Package
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Diagnosis and management of refractive error,
astigmatism, Spherical Aberration
Aspheric IOL, LRI for cylinder, $750 LVC
$995/eye to patient ($1495 if previous
LASIK/PRK/RK)
Co-management fee – $250/eye plus 20%
(does not include LVC post-op fee)
Premium Vision
Correction Package
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Diagnosis and management of refractive error,
astigmatism, Spherical Aberration
LVC at no charge. LRI if necessary
Toric or Presbyopic IOL
$2950/eye to patient ($3,450 if previous
LASIK/PRK/RK)
Co-management fee – $500/eye plus 20%
Presyopic IOL’s
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Distance, intermediate, near vision
Accommodative IOL’s
– Softec HD, (Crystalens)
– Work by the eye muscle shifting the lens and
increasing HOA’s
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Multi-focal IOL’s
– Tecnis +2.75/+4.00, (Restor)
– Work by spitting light into distance, near
components
Which Presbyopic IOL?
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First question is does the patient want out of
reading glasses?
If no, recommend Softec HD accomodating IOL
with bilateral distance to get distance and
intermediate, but wear readers
If yes, first choice is Softec HDwith some
monovision (minimum -0.75 D)
– Patients favor monovision IOLs over MF IOLs
– Monovision versus multifocal intraocular lens implantation.Georgios Labiris, MD, PhD,
Athanassios Giarmoukakis, MD, Maria Patsiamanidi, MD, Zois Papadopoulos, MD, Vassilios P.
Kozobolis, MD, PhD. J Cat Refract Surg. 41;1, 53-67. 2015
Which Presbyopic IOL?
Patient wants no glasses
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Ask about history of monovision tolerance
or interest in mono
If possible, trial with glasses or CTL
If unable or unwilling to do mono – then
recommend Multi-focal if willing to tolerate
night halo
The choice is vision quality (Softec HD)
vs. no reading glasses (Tecnis)
Accomodative IOL’s
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B+L Crystalens
Lenstec Softec HD
Mechanism of action: lens movement,
increased depth of field, induction of HOA
Great distance and intermediate
Rarely get reading without some monovision
Primary Mechanism
Optic Movement
UBM
Relaxed
Increased
Pressure
Constricted
Accommodating Lenses
Distance and Intermediate
Arms Length
Distance
Do not underestimate the importance of good
intermediate vision
Crystalens
Properties
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Modified silicone platestyle implant with a 5.0
mm optic
Hinges at haptic/optic
junction
0.75 to 1.0 D of clinical
accommodation
I have abandoned this
IOL
Crystalens
Problems
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Hinges create unreliable effective lens position
– refractive outcomes are less predictable –
high rate of LASIK/PRK enhancement
Small optic (5.0 mm) can lead to edge glare,
night glare especially with large pupil
Hinge leads to z-syndrome (buckled lens with
induced astigmatism, loss of BCVA)
Softec HD
Properties
*Large 5.75 mm optic
*Double aspheric optic with 0 SA
*Flexible hydrophylic acrylic:
enhanced near vision – no hinges
*Spontaneous near vision: FDA
Study
*3 published studies showing
enhanced near vision
*0.75 to 1.00 D of accommodation
Primary Mechanism
Optic Movement
UBM
Relaxed
Increased
Pressure
Constricted
Summary Of Wavefront Findings
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Power Change
– Greater in the center
– Less in the peripheral
– Generally greater than the change in SE
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Aberration
– Increase in negative spherical aberration
– Increase in coma
Summary
Accommodating IOLs
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Good distance and intermediate
May need readers if unable to tolerate
monovision
Single point of focus/normal contrast –
good for picky patients or those with
previous refractive surgery or retina issues
Softec HD is lens of choice
Multi-Focal IOL’s
-When patients want to eliminate dependence on
reading glasses but will tolerate night glare
-Tecnis +2.75, +3.25, +4.00 - better reading in all
lighting conditions
-Restor +3.00, +4.00: decreased reading in low light,
variable reading outcome, “waxy” vision
TECNIS Multifocal
Family of IOLs
NEW
A full range of
outstanding vision…
for patients favoring a close
working distance for
activities such as close
reading or knitting.
A full range of
outstanding vision…
for patients favoring
activities at longer reading
distance
NEW
A full range of
outstanding vision…
for patients favoring
intermediate vision activities
such as golfing or grocery
shopping, computer
A full range of outstanding vision;
personalized to each patient’s lifestyle
TECNIS Multifocal IOLs | PP2014CT0439
25
TECNIS® Multifocal
Family of IOLs
Defocus Curve at 6 Months
Data: DFU, TECNIS® Multifocal 1-Piece IOL, Models ZKB00 and ZLB00, and DFU, TECNIS Multifocal 1-Piece IOL, Model ZMB00.
TECNIS Multifocal IOLs | PP2014CT0439
26

TECNIS
Multifocal Family
of IOLs
Clinical Outcomes
Ability to Function Comfortably Without Glasses at 6 Months Bilateral Subjects –
ZKB00, ZLB00 and ZM900*
>80%
Percent
of patients reported an
ability to function
comfortably without
glasses at all distances
ZKB +2.75D N= 142
ZLB +3.25D
N= 149
ZM900 +4.0D N= 292
Data: DFU, TECNIS® Multifocal 1-Piece IOL, Models ZKB00 and ZLB00, and DFU, TECNIS Multifocal 1-Piece IOL, Model ZMB00.
TECNIS Multifocal IOLs | PP2014CT0439
27
Tecnis Tecnique
 Nail
technician/close reading: use
+4.00 OU
 Otherwise: +2.75 in dominant
eye, then show +0.50 trial over to
decide if +3.25 vs.+2.75 in other
eye
Contraindications
Multi-focals
 Any
eye condition associated
with loss of contrast
– dry eye, RK, LASIK
 Retina – Membranes, ARMD, CSR
 Cornea
 Occupations
driving
that require night
Tecnis Pearls
 Avoid
picky patients
 Aggressively avoid/treat dry eye
 Patience with halos – neuroadaptation
 Early YAG capsulotomy
 Aggressive treatment of
Refractive Error with LVC
Summary
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The emerging standard of care in cataract
surgery is offering patients premium IOL’s
Softec HD – Range of vision, mono to
avoid readers, best vision quality
Multifocal (Tecnis +2.75/+3.25/+4.00) –
Monovision intolerant who don’t want to
wear readers, ok with halos
Summary
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Standard IOL
– Glasses for everything
– No charge to the patient
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Economy Vision Correction Package
– Aspheric IOL, LRI, monovision, $750 LVC
– $995 to patient, $250 to OD
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Premium Vision Correction Package
– Premium IOL, LRI, Free LVC
– $2950 to patient, $500 to OD
Thank You