Devgan Crystalens Lessons

Lens-Based Refractive Surgery
Cataract Surgery
Uday Devgan MD
Los Angeles, CA
OSN NY 2013
Panel Members:

Doug Koch, MD
 Houston,

TX
Dick Lindstrom, MD
 Minneapolis,

Eric Donnenfeld, MD
 Long

MN
Island, NY
Thomas John, MD
 Chicago,
IL
Uday Devgan, MD
Current Disclosures:





Royalty: Accutome
Consultant: Aaren Scientific; Alcon Laboratories, Inc.;
Bausch + Lomb; Omeros
Fees for Non-CME Services: Alcon Laboratories, Inc.;
Bausch + Lomb
Ownership Interest: LensGen; Specialty Surgical
Advisor: Gerson Lehman Group
My presentation may include OFF-LABEL use of devices and/or medications.
This talk represents my personal opinion as a surgeon.
Doug Koch, MD
Consultant: Abbott Medical Optics;
Revision Optics
 Ownership Interest: Optimedica
 Contracted Research: Ziemer

Dick Lindstrom, MD




Consultant: Abbott Medical Optics; Acufocus; Advanced Refractive Technologies; Adoptics, Alcon
Laboratories, Inc.; AqueSys; Bausch + Lomb; Bio Syntrx; Calhoun Vision, Inc.; Clarity
Ophthalmics; Clear Sight; CoDa Therapeutics; EBV Partners; EGG Basket Ventures; ELENZA;
Encore; Evision Photography; Eyemaginations, Inc.; Foresight Venture Fund #3; ForSight;
Glaukos Corporation; High Performance Optics; Hoya Surgical Optics; Improve Your Vision; ISTA
Pharmaceuticals; LensAR; LenSx; Lifeguard Health; Lumineyes, Inc.; Minnesota Eye Consultants,
P.A.; NuLens; OCULAR SURGERY NEWS; Ocular Optics; Ocular Therapeutix; Omega Eye
Health; Omeros Corporation; Pixel Optics; Quest; Refractec; Revital Vision; Schroder Life Science
Venture Fund; Seros Medical, LLC; Sight Path; SLACK Inc. SRxA; Strathspey Crown;
Surgijet/Visijet; 3D Vision Systems; TLC Vision; TearLab; Tracey Technologies; Transcend
Medical, Inc.; TruVision; Versant; Vision Solutions Technologies
Investor: Abbott Medical Optics; Acufocus; AqueSys; Bausch + Lomb; Bio Syntrx; Calhoun Vision,
Inc.; Clarity Ophthalmics; Clear Sight; CoDa Therapeutics; Confluence Acquisition Partners I, Inc.;
Curveright, LLC.; CXL Ophthalmics, LLC.; EBV Partners; EGG Basket Ventures; Encore; Evision
Photography; Evision Medical Laser; Eyemaginations, Inc.; Foresight Venture Fund #3; Fziomed;
Glaukos Corporation; HEAVEN Fund; Healthcare Transaction Services; High Performance Optics;
Improve Your Vision; LensAR; LenSx; Lifeguard Health; Minnesota Eye Consultants, P.A.; Nisco;
NuLens; Ocular Optics; Ocular Therapeutix; Omega Eye Health; OnPoint; One Focus Ventures;
Pixel Optics; Quest; Rainwater Healthcare; Refractec; Revision Optics; Revital Vision; SarboxNP;
SARcode Corporation; Schroder Life Science Venture Fund; SightPath; Solbeam; Strathspey
Crown; Surgijet/Visijet; 3D Vision Systems; TLC Vision; TearLab.; Tracey Technologies;
Transcend Medical, Inc; TriPrima; TruVision; Viradax; Vision Solutions Technologies; Wavetec
Vision
Royalty: Acufocus; Bausch + Lomb; Quest
Medical Director: Refractec; Sight Path; TLC Vision
Eric Donnenfeld, MD
Consultant: Abbott Medical Optics;
Acufocus; Allergan; Alcon Laboratories,
Inc.; Aquesys; Bausch + Lomb; Better
Vision Network; CRST; Elenza; Glaukos;
Lacripen; LenSx; Merck; Novabay;
Odyssey; Pfizer; PRN; QLT; Sarcode;
TearLab; TLC Laser Centers; TrueVision;
Wavetec
 Ownership Interest: Lacripen

Thomas John, MD
Consultant: Allergan; Bausch + Lomb; BioTissue; iScience Surgical Corp.
 Royalty: ASICO Inc.; Jaypee – Highlights
Medical Publishers Inc.
 Speakers’ Bureau: Allergan; Bausch +
Lomb; iScience Surgical Corp.

Part #1:
Femtosecond Laser
Cataract Surgery
Our Surgery Center
First femtosecond laser x 2 years
Second femtosecond laser x 6 months
Many partners and associate surgeons.
Varying use of FS laser depending on MD.
I have chosen to be very selective and cautious.
The current use of FS lasers
The Future Uses ?
Nucleus Softening with FemtoSecond Laser
2 femtos in laser room, then 3 ORs
Alcon LenSx femto laser
OptiMedica Catalys femto laser
Image shown for educational purposes only
Potential Benefits of Femto Phaco






Novice / Beginners
Perfect rhexis, good
incision, lens already
chopped, less U/S
Speeds up surgery
Refractive accuracy?
Safety? Imaging?
Gives a novice the
results of a more
experienced surgeon






Experienced Surgeon
Already have a great
rhexis, incision, and
phaco chopper
May slow things down
Refractive accuracy?
Safety? Imaging?
Perhaps a less
pronounced benefit…
for now
Refractive Accuracy
Increased? Or not?
Does rhexis morphology matter?
Very good manual rhexis
Perfect femto-laser rhexis
Both overlap the optic edge 360°
Refractive Outcomes w FS laser

Cionni, ASCRS 2011


Knorz paper 2012:



slight advantage to femto
FS laser spread: 0.38 D +/- 0.28 D
Manual spread: 0.50 D +/- 0.38 D
Lawless, JRS Dec 2012:


FS laser prediction error: 0.26 D +/- 0.25 D
Manual prediction error: 0.23 D +/- 0.16 D
Jim Davidson MD, ASCRS 2011
2000 eyes w same monofocal IOL
Group 1: 360° capsule overlap
Group 2: lacking full 360° overlap
No significant difference in refractive outcomes between groups.
Manual LRI
• Harder to account for
differences in corneal
pachymetry
vs
•
•
Femto LRI
OCT guided to exact depth
Titrate effect by opening
incision later
Precision of Arcuate Incisions
Arc length & diameter
80% of measured pachy
Survey of Panelists
Which
nomogram do you
use for LRIs / AKs?
Different
for femto vs
diamond?
Complications
of Femto Phaco
Current potential complications:

Mild:
Partial rhexis / tags
 Incomplete lens fragmentation
 Subconj hemorrhage


Moderate:
Anterior capsular tear
 Misplaced incisions


Severe:
Posterior capsule tears
 Posterior lens dislocation

A tilted eye => misaligned energy

Iris must be centered & parallel to the floor
A tilted eye => misaligned energy

Iris must be centered & parallel to the floor
Partially Cut Capsulorrhexis
Complete it with the forceps.
Complete it with the forceps.
2 out of first 50 cases = dropped nucleus
Air Bubbles:
Large pockets of gas between cataract and posterior capsule
Do rhexis before lens fragmentation to limit intra-bag pressure increase from gas.
Same Aussie Group: First 200 eyes
Ant. capsule tear
4.0%
Post. capsule tear
3.5%
Posterior lens
dislocation
2.0%
Ant. capsule tags
10.5%
Induced miosis
9.5%
1 out of 2 patients need re-docking
# docking tries
1.50
Docking the eye to the laser

Iris must be centered & parallel to the floor
Same Aussie Group: Next 1300 eyes
Ant. capsule tear
0.3%
Post. capsule tear
0.3%
Posterior lens
dislocation
0%
Ant. capsule tags
1.6%
Induced miosis
1.2%
1 out of 20 patients need re-docking
# docking tries
1.05
Vision Eye Institute, Chatswood, Australia
FS Laser Learning Curve
First 200 cases Next 1300 cases
Ant. capsule tear
4.0%
0.3%
Post. capsule tear
3.5%
0.3%
Posterior lens
dislocation
2.0%
0%
Ant. capsule tags
10.5%
1.6%
Induced miosis
9.5%
1.2%
# docking tries
1.50
1.05
About 10x more complications in first 200 cases!
Learning Curve
Every new technology and technique has a unique learning curve.
ECCE surgery:
No risk of wound burn
Uday Devgan MD
phaco surgery:
New risk of wound burn
New complication unique to phaco ultrasound energy.
Keratome corneal incision learning curve
Beginning resident corneal incision
Experienced surgeon corneal incision
My learning curve with FS incison
My goal: barely nick limbal vessels
FS rhexis learning curve is certainly easier
than learning to do it with forceps.
Future of Femto Phaco?
New design accommodating IOLs?
Micro-rhexis and lens polymer injection?
High intra-bag pressure causing
rhexis run-out
Pic courtesy of
Jamison Engle MD
Argentinian Flag Sign
Femto Rhexis in < 2 seconds
Pic courtesy of
Jamison Engle MD
Marfan Syn
Femto Rhexis
Brandon Ayers MD – Wills Eye
Intra-stromal Toric IOL marking
with Femto-second laser
From 30%
to 50% depth
Case Presentation
Pre-op OCT imaging in a truly brunescent cataract.
88 yo w brunescent cataract
OD: - dense cataract
- no view of post seg
OS: - difficult phaco case
- dropped nucleus
- PPV&L / sulcus IOL
FS Laser can’t figure out the
posterior capsule contour
Pre-existing posterior capsule
defect (posterior polar)
Dense rock, 88 yo patient, and
defect of the posterior capsule!
STRESS !
Perfect 5mm rhexis & nucleus
softening done with FS laser
Lots of OVD behind nucleus:
cataract removed & PC hole evident
No Vitreous loss, haptics in sulcus,
optic buttonholed through rhexis
Evolution of Technology
1 GB in 1991
1 GB in 2006
1 GB in 2013
.
We’ve come a long way
 How
will cataract surgery evolve
in the next 10 years?
Only time will tell…
Part #2:
IOL calculations in
short vs. long eyes
IOL calc formulae generations

1st generation:


do not use
Just a simple linear regression, IOL = A – 0.9K - 2.5L
2nd generation:

SRK
SRK-II
do not use
Same as SRK but adds a fudge factor for big/small eyes
SRK-T, Holladay 1, Hoffer Q
 Use only K and Axial length to determine ELP
use this

3rd generation:

4th generation:
Holladay 2, Haigis, Olsen
 Better ELP prediction w additional data
use this
Main Source of Error in IOL calcs
for Hyperopic Eyes
Normal Eye
Hyperopic
Eye
• K values
• Axial Length
• ELP
• Effective
• Lens
• Position
• With a high powered IOL (+30), a small
change in ELP gives a big Rx change
Small, hyperopic eyes:
Shallow AC depth (<3mm)
AC depth of 1 mm
Small, hyperopic eyes:
short axial lengths (<22 mm)
Small, hyperopic eyes:
ELP: Effective Lens Position
Blue arrow indicates
the Effective Lens
Position (ELP)
A more anterior ELP
= a lower IOL power
required for same Rx
A more posterior ELP
= a higher IOL power
required for same Rx
Small, hyperopic eyes:
anterior segment size?
Data Needed for IOL Calcs

Hoffer, Holladay1, SRK/T
 Holladay

K
Axial Length








2
K
Axial Length
White-to-White
ACD
Lens Thickness
Refraction
Age
IOL calcs in a
very small eye
(+6.50 hyperope)
Another case: Small, hyperopic eyes:
Case #1: IOL calcs in small, hyperopic eyes
Uday Devgan MD
Another case: Small, hyperopic eyes:
Case #1: IOL calcs in small, hyperopic eyes
Uday Devgan MD
Another case: Small, hyperopic eyes:
Case #1: IOL calcs in small, hyperopic eyes
Uday Devgan MD
Another case: Small, hyperopic eyes:
IOL Calcs in small, hyperopic Eyes
th
use 4 gen formulae
(Holladay 2, Haigis)
IOL calcs in a
very long eye
(-20.0 D myope)
Main Source of Error in IOL calcs
for Myopic Eyes
Normal Eye
• K values
• Axial Length
• ELP
Myopic
Eye
Staphyloma?
• With a low powered IOL (+5), a change
in ELP gives about the same Rx post-op
Long, myopic eyes: IOL calcs
Adjusted AL = 33.32 mm
Adjusted AL = 32.82
Normal Ks OU (44ish)
Myopic IOL Calcs (AL > 25 mm):
Make it easy

Stick with Holladay 1 equation

may also work well with Holladay 2, but not tested
the officially published formula for IOLM & Holladay 1:

Adjusted AL = 0.8289 x AL + 4.2663
An easier version of the formula for IOLM & Holladay 1:

Adjusted AL = 0.83 x AL + 4.27
Myopic IOL Calcs (AL > 25 mm):
Adjusted AL = 0.83 x AL + 4.27
=0.8289xAL+4.2663
Axial Length
25
24.99
25.5
25.40
26
25.82
26.5
26.23
27
26.65
27.5
27.06
28
27.48
28.5
27.89
29
28.30
29.5
28.72
30
29.13
30.5
29.55
31
29.96
31.5
30.38
32
30.79
32.5
31.21
33
31.62
33.5
32.03
34
32.45
34.5
32.86
35
33.28
=0.83xAL+4.27
difference
25.02
0.12%
25.44
0.12%
25.85
0.13%
26.27
0.13%
26.68
0.13%
27.10
0.13%
27.51
0.13%
27.93
0.13%
28.34
0.13%
28.76
0.13%
29.17
0.13%
29.59
0.13%
30.00
0.13%
30.42
0.13%
30.83
0.13%
31.25
0.13%
31.66
0.13%
32.08
0.13%
32.49
0.13%
32.91
0.13%
33.32
0.13%
Simplified formula is accurate to within 0.13% = less than 0.1 D difference in IOL power
Long, myopic eyes:
IOL calcs

Do NOT use
these calcs!

Instead use
the WangKoch AL
adjustment,
then re-calc
Long, myopic eyes:
re-calc’ed with AL adjustment
Long, myopic eyes:
Post-Op Refraction

Goal of -1.00

IOLM: -10.0 IOL SRK/T
(would’ve been hyperopic)

Wang-Koch adjustment
said -6.0 D IOL
Patient ended up -0.75 D SE
IOL Calcs in long, myopic Eyes
use Wang-Koch Axial
Length Adjustment
measured
AL = 0.83×AL + 4.27
Then plug it into Holladay 1
Part #3:
Epi-Retinal Membranes
& Cataract Surgery
Epi-Retinal Membranes
About 7% of patients age 55+
 About 20% of patients age 75+
 More common in DM, prior RD repair


Gass Classification System

High risk of CME post-cataract surgery
Gass JDM. Macular dysfunction caused by epiretinal membrane contraction.
In: Stereoscopic Atlas of Macular Diseases: Diagnosis and Treatment.
Vol 2, 4th ed. St Louis, Mo: Mosby; 1997:938-50.
Cystoid Macular Edema after CEIOL

What are risk factors for CME?
Capsule Break / Vitreous Loss / Vitreous traction
 ERM
 Diabetic (Especially with prior CSME)
 Uveitis
 Retinal Vein Occlusion
 CME in other eye (50% risk!)


When does CME usually present post-op?
Henderson BA. Clinical pseudophakic cystoid macular edema. Risk factors for development
and duration after treatment. J Cataract Refract Surg. 2007 Sep;33(9):1550-8.
Mild ERM + cataract
Mild ERM + cataract
Enhanced Pic
Mild ERM + cataract
Pre-Op BCVA = 20/50
Corresponds to level of cataract
Mild ERM + cataract

Gass Classification 0:
“Cellophane Maculopathy”
 Minimal surface wrinkling
 No vascular distortion

Rx: prolonged NSAIDs post-op
 Likely to recover good visual acuity after
cataract surgery

Mild ERM + cataract

OCT = normal (other than mild ERM)
Go
ahead with cataract surgery
NSAID / steroid regimen
Many studies show benefit of NSAIDs
& steroids for CME (off label)
1.
Rosetti L, Bujtar E, CastoldiD, Torrazza C, Orzalesi N. Effectiveness of diclofenac eye drops in reducing inflammation and the incidence of cystoid macular edema
after cataract surgery. J Cataract Refract Surg 1996;22 (Suppl l):794-99.
2.
McColgin AZ, Raizman MB. Efficacy of topical Voltaren in reducing the incidence of post operative cystoid macular edema. Invest Ophthmol Vis Sci. 1999;40:S289.
3.
Miyake, K. Masuda and S. Shirato et al., Comparison of diclofenac and fluorometholone in preventing cystoid macular edema after small incision cataract surgery: a
multicentered prospective trial. Jpn J Ophthalmol. 2000 Jan-Feb;44(1):58-67.
4.
Italian Diclofenac Study Group: Efficacy of diclofenac eyedrops in preventing postoperative inflammation and long-term cystoid macular edema. J Cataract Refract
Surg 1997;23:1183-89.
5.
Donnenfeld ED, et al. Preoperative ketorolac tromethamine 0.4% in phacoemulsification outcomes: pharmacokinetic-response curve. J Cataract Refract Surg. 2006
Sep;32(9):1474-82.
6.
Tauber S, Gessler J, Scott W, Peterson, C, HamletP. The effect of topical Ketorolac 0.4% on cystoid macular edema following routine cataract surgery. Proceedings
of the Association for Research in Vision and Ophthalmology (ARVO) Meeting, Fort Lauderdale, Florida, April 30-May 4, 2006. 683.
7.
Fry EL, Fry LL. Nepafenac versus Ketorolac tromethamine in the prevention of postoperative cystoid macular edema. Proceedings of the American Society of Cataract
& Refractive Surgery (ARCRS) Meeting, San Diego, CA, April 27 – May 2, 2007. R26B.
8.
Henderson, BA, et al. Clinical pseudophakic cystoid macular edema. Risk factors for development and duration after treatment. J Cataract Refract Surg. 2007
Sep;33(9):1550-8.
9.
Wolf EJ, Braunstein A, Shih C, Braunstein RE. Incidence of visually significant pseudophakic macular edema after uneventful phacoemulsification in patients treated
with nepafenac. J Cataract Refract Surg. 2007 Sep;33(9):1546-9.
10. Shimura M, Nakazawa T, Yasuda K, Nishida K. Diclofenac prevents an early event of macular thickening after cataract surgery in patients with diabetes. J Ocul
Pharmacol Ther. 2007 Jun;23(3):284-91.
11. Miyake K, et al. The effect of topical diclofenac on choroidal blood flow in early postoperative pseudophakias with regard to cystoid macular edema formation. Invest
Ophthalmol Vis Sci. 2007 Dec;48(12):5647-52.
12. Wittpenn. Relationship of retinal thickening and contrast sensitivity in low-risk cataract patients. Proceedings of the American Academy of Ophthalmology, New
Orleans, LA, November 10-13, 2007. PO010.
13. Yung CW, et al. The effect of topical ketorolac tromethamine 0.5% on macular thickness in diabetic patients after cataract surgery. Proceedings of the American
Academy of Ophthalmology, New Orleans, LA, November 10-13, 2007. PO257.
14. Asano S, et al. Reducing angiographic cystoid macular edema and blood-aqueous barrier disruption after small-incision phacoemulsification and foldable intraocular
lens implantation: multicenter prospective randomized comparison of topical diclofenac 0.1% and betamethasone 0.1%. J Cataract Refract Surg. 2008 Jan;34(1):57-63.
15. Heier JS, Topping TM, Baumann W, Dirks MS, Chern S. Ketorolac versus prednisolone versus combination therapy in the treatment of acute pseudophakic cystoid
macular edema. Ophthalmology. 2000 Nov;107(11):2034-8;discussion 2039.
16. Rossetti L, Autelitano A. Cystoid macular edema following cataract surgery. Curr Opin Ophthamol. 2000 Feb;11(1):65-72
17. Ray S, D'Amico DJ. Pseudophakic cystoid macular edema. Semin Ophthalmol. 2002 Sep-Dec;17(3-4):167-80.
18. Shalnus R. Topical nonsteroidal anti-inflammatory therapy in ophthalmology. Ophthalmologica. 2003 Mar-Apr;217(2):89-98.
19. O’Brien TP. Emerging guidelines for use of NSAID therapy to optimize cataract surgery patient care. Curr Med Res Opin. 2005 Jul;21(7):1131-7.
20. Gulkilik G et al: Cystoid macular edema after phacoemulsification: Risk factors and effect on visual acuity. Can J Ophthalmol. 2006 Apr;41:699.
21. Kim SJ, Equi R, Bressler NM. Analysis of macular edema after cataract surgery in patients with diabetes using optical coherence tomography. Ophthalmology. 2007
May; 114(5):881-9.
Moderate ERM + cataract
Moderate ERM + cataract
Pre-Op BCVA = 20/160
Doesn’t correspond well to
2+NS cataract (20/50ish)
Enhanced Pic
Moderate ERM + cataract
Pre-Op macular
edema on OCT
Moderate ERM + cataract

Gass Classification 1:
“Crinkled Cellophane Maculopathy”
 Retinal surface wrinkling
 Vessels pulled / twisted

May have pre-existing macular edema
 Unlikely to recover good visual acuity after
cataract surgery


Higher CME risk with cataract surgery
Moderate ERM + cataract
Retinal
consultation and
possible vitrectomy and
membrane peeling prior to
cataract surgery
If dense cataract, may warrant
combined procedure
NSAID / steroid regimen
Severe ERM + cataract
Severe ERM + cataract
Enhanced Pic
Severe ERM + cataract
Pre-Op BCVA = 20/400
Doesn’t correspond well to
2+NS cataract (20/50ish)
Severe ERM + cataract

Gass Classification 2:
“Macular Pucker”
 Thick membrane (even a cataract surgeon can see it)
 Extensive retinal surface wrinkling
 Vessels pulled / twisted into the pucker

Has a pucker and maybe even macular hole
 Definitely need PPV & membrane peeling to
recover max vision from cataract surgery
 Higher CME risk even after PPV & MP

Severe ERM + cataract
If
possible, first do vitrectomy
and membrane peeling.
Plan later cataract surgery or
combined with PPV
NSAID / steroid regimen
Case Presentation
91 yo w cataract & ERM

2-3+ NS, BCVA 20/50
91 yo cataract + ERM
Significant
ERM with
retinal
surface
wrinkling
noted pre-op
 pucker

91 yo cataract + ERM

Significant
macular
thickening &
ERM seen
on OCT OD
So I sent her to the retina doc
And he says to do the phaco first!
Post-op she achieves 20/30-2

Patient happy!

Still with ERM

Keeping her on
the NSAIDs

Follow-up with
retina doc
Epi-Retinal Membranes & CME
carefully evaluate retina pre-op
benefit of NSAIDs / follow OCT
Part #4:
Dr Koch’s Cases:
Toric IOL Calcs &
Posterior Corneal
Astigmatism
What would you do?
A little astigmatism. . .

71 yo female for cataract surgery OS

Corneal astigmatism:
Atlas:
0.95 D @169°
1.34 D @176°
1.64 D @173°
IOLMaster:
Lenstar:

Which toric would you choose. . .
T3
T4
T5
T6
A little astigmatism. . .


71 yo female for cataract surgery OS
Pre-op


MR: -5.75 + 2.50 x 176 = 20/40
Corneal astigmatism:
 Atlas:
0.95 D @169°
 IOLMaster: 1.34 D @176°
 Lenstar:
1.64 D @173°

Any change in which toric you would
choose? T3 T4 T5 T6
And the outcome was. . .
Atlas:
IOLMaster:
Lenstar:

Alcon SN6AT4@175° implanted for near


0.95 D @169°
1.34 D @176°
1.64 D @173°
Correct ~1.5 D corneal astig
Post-op one month


UCVA: 20/60
MR: -2.25 + 1.00 x 165 =20/20
 Astigmatism
undercorrected by 1 D
Total Corneal Power astig: 2.5D@2
Posterior corneal astig: -0.27D@157
Recommendation #1:
To account for the ATR shift with
age, we need a new target for
postop astigmatism*:
Up to 0.4D of WTR astigmatism
For most eyes the anticipated
amount is much lower
Recommendation #2:
Account for posterior corneal
astigmatism
Estimated mean values:
 0.5 D in with-the-rule corneas
 0.3 D in against-the-rule corneas
Recommendation #3

Consider use of the Holladay II
 Account
for the impact on effective IOL
toricity of IOL power and ACD

Factor in your surgically induced
astigmatism
Recommendation #4:
When feasible, should we
measure. . .
 ?? Preoperative posterior corneal
astigmatism
 ?? Intraoperatively
Baylor Toric IOL Nomogram

Values in the table are the vector sum
of:
 Anterior
corneal astigmatism
 Surgically induced astigmatism (SIA)
0.7 D
Toric IOL
WTR (D)
ATR (D)
0
≤ 1.69 (PCRI if >1.00)
< 0.39
T3 (1.03)
1.70 – 2.19
0.40*– 0.79
T4 (1.55)
2.20 – 2.69
0.80 – 1.29
T5 (2.06)
2.70 – 3.19
1.30 – 1.79
T6 (2.57)
3.20 – 3.69
1.80 – 2.29
T7 (3.08)
3.70 – 4.19
2.30 – 2.79
T8 (3.60)
4.20 – 4.69
2.80 – 3.29
T9 (4.11)
4.70 – 5.19
3.30 – 3.79
*Especially if specs have more ATR
0.7 D
Toric IOL
WTR (D)
ATR (D)
0
≤ 1.69 (PCRI if >1.00)
< 0.39
0.7 D ZCT150 (1.03)
1.70 – 2.19
0.40*– 0.79
ZCT225 (1.55)
2.20 – 2.69
0.80 – 1.29
ZCT300 (2.06)
2.70 – 3.24
1.30 – 1.79 0.7 D
ZCT400 (2.74)
3.25 – 4.00
1.80 – 2.50
*Especially if specs have more ATR
Example 1
Cornea:
 SIA:
 Use:

3.70 D WTR
0.20 D WTR
3.90 D for IOL toricity
Toric IOL
WTR (D)
ATR (D)
T6 (2.57)
3.20 – 3.69
1.80 – 2.29
T7 (3.08)
3.70 – 4.19
2.30 – 2.79
T8 (3.60)
4.20 – 4.69
2.80 – 3.29
Not a T8!!
Example 2
Cornea:
 SIA:
 Use:

1.90 D ATR
0.20 D WTR
1.70 D for IOL toricity
Toric IOL
WTR (D)
ATR (D)
ZCT225 (1.55)
2.20 – 2.69
0.80 – 1.29
ZCT300 (2.06)
2.70 – 3.24
1.30 – 1.79
ZCT400 (2.74)
3.25 – 4.00
1.80 – 2.50
Not a ZCT225!!
Conclusion

Needs more work
 Data
 Accuracy
 Role

of refraction as predictive factor
Promising role of:
 Preoperative
measurements
 Intraoperative aberrometry
RK case

68 yo female with prior RK
#

of incisions: 16
Target for intermediate
Toric: Yes
or
No ??
ASCRS IOL
calculator
Target:
-0.25 -0.5 -0.75
-1.00 more minus?
IOL for -1.00?
21 21.5 22 22.5
23 23.5 24
aa
ASCRS IOL
calculator
Target: -1.0 D
22.5 D SN60WF used
5 weeks postop:
MR: -3.75 + 0.75 x 176
SE = -3.38 D
IOL exchange
22.5
SE = -3.38 D
IOL exchange
22.5
SE = -3.38 D
Target: -1.0 D
20.5 D SN60WF
Post-op 3 weeks
MR: pl + 0.25 x 180
SE = +0.13
Keratoconus
64 yrs male with KC
 Pre-op MR OD: -14.25 + 3.25 x 119 = 20/40

-14.25 + 3.25 x 119 = 20/40
Toric: Yes
or
No ??
IOL Master with Holladay 1
What IOL power?
5.0 5.5 6.0 6.5 7.0
What toricity?
T3 T4 T5 T6
T7 T8 T9
IOL Master with Holladay 1
SN6AT5
7.0 D
-1.09 D target
POM #3 MR
Plano + 2.25 x 103 = 20/20
SE = +1.13 D
Needed T9 to get all cyl
Hyperope (formerly +2)


78 yrs male
Current MR OS


Plano + 1.0 x 163
Target -0.25
Lenstar with Holladay 1
Lenstar: -0.26 D
Holladay 2: -0.47 D
IOLMaster: -0.73 D
24.5 D ZCB00
-0.26 D
POW #3 MR:
-1.75 + 1.0 x 170 = 20/20
SE = -1.25 D
Phakic IOL and Cataract
Pre CE/IOL Exam for OS
Auto Ks:
IOL Master Ks:
Manual Ks:
39.25/39.50@115
39.38/39.66 @109
39.50/40.00 @ 99
Biometry (AL):
27.64
What do you do with the incision?
Any issues in calculating IOL power?
Phakic IOL case
1.
2.
3.
Look for site of wound of prior
surgery—AVOID!
Use the optimized AL (Holladay 1) =
27.18 mm
Use a temporal anterior scleral
tunnel to minimize surgically induced
astigmatism
S
Uday Devgan MD
Uday Devgan MD
Toric IOL calcs & Post K Astig
post-op target 0.4 D WTR
Average post K Astig is
0.5 D for WTR corneas
0.3 D for ATR corneas
Holladay 2 factors ACD and IOL
power on Toric power
If possible: measure post K & use intraoperative aberrometry
Part #5:
Decentered &
Dislocated IOLs
Decentered MF IOL
64 yo CE IOL OD done 3 months ago
 Computer executive

UCVA 20/40- OD
 -0.50+0.50x180 = 20/30
OS mild cataract
 -2.50 sph = 20/20

Decentered MF IOL – is this ok?

How much decentration is tolerable?

Pt c/o ghosting of vision.

Is this explained
by the IOL shift?
Hmm, looks more involved that I thought

Capsular bag partially
open with some
vitreous prolapse

Some posterior
capsular wrinkles
right in the middle
Normal OCT – no CME
Decentered MF IOL - ghosting

A fundus photo shows the
ghosting of vessels as
camera takes pic through
decentered MF IOL
Higher Risk Surgery – educate pts

Additional
documentation of
extensive patient
discussion for
more complicated
cases.

Helps set realistic
expectations
Decentered IOL with open posterior
capsule, vitreous prolapse
Plan:
• Anterior Vitrectomy
• Remove MF IOL
• Replace w monofocal IOL
Cut IOL 80% down the middle
Anterior Vitrectomy & IOL Exchange

Implant a threepiece silicone IOL

Sulcus placement

Monofocal, aspheric
Nice result post-op
Reasons for an
IOL exchange
Defective IOL
(cracked, calcified)
Subluxed IOL
Subluxed IOL
Really Subluxed IOL
Subluxed single piece IOL
Severely Dislocated IOL
Severe capsule contraction & phimosis
Poorly Tolerated AC IOL
Really Poorly Tolerated AC IOL
Wrong IOL Power
Hyperopic Surprise in a post-RK eye
Wrong IOL Type for Location
(Single-Piece Acrylic IOL in Sulcus)
Never place a single piece acrylic IOL in the sulcus!!
Iris trans-illumination
defects from haptics
Sunset of IOL
Induced UGH syndrome
Plenty of Time to do the Surgery
IOL Exchange Technique

Cut old IOL in half in AC


Insert new IOL first to protect an intact posterior capsule
Fold old IOL in half in AC

Use IOL folding forceps with spatula to assist

Cut old IOL partially & rotate it out of eye

IOL twist in AC to roll it

Then simply pull it out of the eye
IOL exchange due to refractive surprise
You can also twist / fold the IOL
Done by my senior resident Ehsan Rahimy MD. Idea from Jack Chapman MD.
IOL fixation to iris
& iris defect repair
Sometimes it is straightforward
Subluxed IOL &
functionally aphakic

Check position of
IOL at different
angles
Use red reflex for more details

Direct view

Retro-illumination
Get a sufficient bite of iris tissue
Place sutures towards iris periphery
Siepser Knot to Suture IOL to Iris
An ovoid pupil can be avoided by pulling iris
centrally prior to cinching down knots.
Round Pupil with Siepser Knots
Iris-sutured IOL power = in-the-bag IOL power
Thanks to Ike Ahmed MD for this technique.
Can also adjust iris at end of case
Done by my senior resident David Reed MD. Idea from Ike Ahmed MD.
For post-PPV eyes, use an AC
maintainer! (25g angiocath works too)
Minor trauma is easy to fix
IOL Exchange & Iris Repair
IOL exchange + iris repair
iris defect after ruptured globe
Combined surgery: (1) R+R for strabismus,
(2) pupilloplasty, and (3) scleral fixation of IOL
Good result after 6 weeks of healing
Iris defect in a young phakic pt




Traumatic airbag injury
Any iris repair may nick capsular bag!
Wait until cataract develops
Use cosmetic contact for now
Large iris defects cannot be sutured
But lid ptosis can help!
Scleral fixated IOL implanted. No iris repair.

Patients must appreciate that IOL Exchange:
is higher risk than cataract surgery
 is less predictable
 is stressful for the surgeon too

“I’ll do it as a favor to you, but understand that it will take a week off my life!”
Part #6:
New astigmatism after
cataract surgery
6 months post-op
Cataract Surgery
Post-Op Month 6 after CE IOL



Slow decline in vision x 1 month
POM #1: +0.25 -0.50 x100 = 20/20
POM #6: -0.50 -2.00 x100 = 20/50

Refractive cyl
increased by 1.50 D

Spherical equivalent
more myopic by 1.5 D
Clean topography – not much K cyl
Clean topography – not much K cyl
Therefore the
new astigmatism
must be coming
from the IOL.
IOL tilted and forward shifted
Capsule Issues causing IOL Shift
Posterior Capsule Fibrotic Bands
Myopic shift and induced cylinder
YAG laser capsulotomy as well as to break
fibrous bands and adjust IOL position
Another patient
history of mild K cyl
Pre-Op Ks: 42.75 / 43.50 OD
0.75 D of K cyl
 Moderate cataracts
 Otherwise normal exam

Post-Op Ks: 41.75 / 44.00 OD

POW#1 = 20/20 & plano
routine CEIOL
POM#1
 2.25 D of K cyl
 -1.25+2.50x71

= 20/20- vision
What happened?
EBMD causing K irregularity
Epithelial Basement Membrane Dys
Dry Eye may limit visual results
Poor Tear Film = Poor Vision
 New
astigmatism after CE IOL:
 Look
for Corneal Causes
Ocular
 Look
Tilt
surface
for IOL Causes
/ shift of IOL
Part #7:
An interesting lens
calculation challenge…
60 yo c/o poor vision OD x 1 yr
3+ NS cataract
 Central opalescence
 4-RK cuts + 1 AK

Prior-RK IOL calcs
Fudge factor method
add this much to IOL power
2-cut RK = add +0.5 D
4-cut RK = add +1.0 D
8-cut RK = add +2.0 D
12-cut RK = add +3.0 D
16-cut RK = add +4.0 D
32-cut RK = ???
There must be a better way !?!?!
60 yo c/o poor vision OD x 1 yr

He wants cataract surgery soon, before
his vacation to Europe
He has old records! Lucky me.

“Hey doc, that means that you can get my
vision back to perfect, right?”
Records Review
1992: 4-cut RK + AK
 2010: LASIK done for
hyperopic shift
 2011: aborted LASIK
enhancement
 2011: PRK enhance
for more hyperopia
 2012: PRK enhance
again but now for
myopic shift from NS

IOL Calcs




Straight calcs:
Avg K power:
Atlas Topo:
IOLM/Lenstar:
+21.0 Holladay = -0.32
+23.5
+22.0
+22.0
Intra-Op
Aberrometry
My calcs said +22.0
 Aberrometry says
+20.0 for plano

Hmm, let’s just add
a pinch more power
 Use +20.5 D IOL

Make sure post-op Ks go back
to baseline before evaluating Rx
 Pre-Op
K
Ks & Rx
avg = 38.50
 Post-Op
K
Ks & Rx
avg = 38.00
I anticipate that the Rx will get about 0.5 D more myopic with time
Prior-RK IOL calcs
RK incisions swell during phaco
Wait until the post-op K values
return back to the pre-op K
values before you judge the Rx
Pre-op K value = 38.50
Post-op D#1 K = 36.50
Post-op W#2 K = 38.00
Post-op M#2 K = 38.50
Rx +1.50
Rx 0.00
Rx -0.50
 Post-RK
 Still
/ Post-LASIK / Post-PRK
no magic method
Stick
with iol.ascrs.org and aim myopic
 Intra-Op
Though
aberrometry is looking better
some corneas aren’t easily read
Femto Phaco

May help in tough cases
 white

Arcuate incisions
 More

predictable than diamonds but toric IOLs best
Learning Curve
 Low

cataracts, weak zonules, real-time imaging
complication rate with experience
Refractive accuracy?
 Femto
vs. manual rhexis – not sure, time will tell
Short vs Long Eye IOL Calcs

Use only theoretical formulae
 3rd
gen (SRK-T, Holladay 1, Hoffer Q) or 4th gen
 Never use SRK-I or SRK-II

Short, hyperopic eyes
 Use

4th gen formulae (Holladay 2, Haigis)
Long, myopic eyes
 Use
Wang Koch adjustment: AL = 0.83×AL
+ 4.27
measured
then plug into Holladay 1
Epi-Retinal Membranes & CME

About 20% of patients age 75+
 About

7% of patients age 55+
Gass Classification
 0=mild,

Correlate Cataract to degree of poor vision
 If

1=crinkled, 2=pucker
mild cataract and severe vision decrease, beware!
Benefit of NSAIDs
 Prolonged
treatment and serial OCTs
Toric IOL calcs & post K Astig

Post-op target = up to 0.4 D WTR

What is Average Posterior K Astigmatism?
 0.5

Holladay 2 helps accuracy
 It

D for WTR corneas / 0.3 D for ATR corneas
factors in ACD and IOL power on toric power
Consider newer technology to help
 measure
posterior cornea / intra-op aberrometry
Decentered / Dislocated IOLs

Decentered MFIOLs may induce ghosting
 Ghosting

IOL exchange is a reasonable choice
 Higher

seen on fundus photos
risk than cataract surgery
Iris suturing is time consuming
 But
not that technically challenging
New Astigmatism after CEIOL

Corneal sources of astigmatism
 Ocular

surface disease, EBMD, dry eye, etc
IOL sources of astigmatism
 Tilted
/ shifted IOL, PCO
IOL Calcs after RK, LASIK, PRK

No easy answers
 iol.ascrs.org

and aim for post-op myopia
Consider newer technology to help
 intra-op
aberrometry – new future devices
If you remember
just ONE thing…
This slide is © Uday Devgan, MD
Learn from your mistakes!
Hang in there!
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