Delivering on the promise: AcrySof IQ ReSTOR IOL
Transcription
Delivering on the promise: AcrySof IQ ReSTOR IOL
www.eyeworld.org What role does advanced technology play in your practice? This Show Daily supplement is sponsored by Alcon. 2012 ASCRS•ASOA Chicago Show Daily Supplement Delivering on the promise: AcrySof IQ ReSTOR IOL by John Davidson, M.D., and Cathleen McCabe, M.D. Why using this multifocal lens can increase patient satisfaction and referrals ost ophthalmologists agree that patient selection will always be a major factor in patient satisfaction— and that’s true in our experiences as well. As two ophthalmologists practicing on either coast, we’ve found that while our patient populations may differ in demographics, they both demand excellent post-cataract surgery vision. Patients are usually happy simply because you’ve removed their cataract, but of all the happy patients, patients with multifocal lenses are thrilled with their M new vision. It’s this type of patient satisfaction that leads to more wordof-mouth referrals and a higher volume practice. Patients may not know the name of a particular IOL, but they know their neighbors, colleagues, or family friends don’t need to use spectacles nearly as often as some of their other acquaintances— and those are the lenses patients want. Our results have mimicked those of the FDA study data (see Figure 1). In clinical studies, the distance peak of the defocus curve demonstrated that the AcrySof IQ ReSTOR +3.0 IOL (Alcon, Fort Worth, Texas) patients achieved a mean distance visual acuity of 20/20 or better, with a clear range for near vision from –2.0 D to –4.5 D (see Figure 2). In 6-month post-op data of patient satisfaction with the SN6AD1 (ReSTOR +3) John Davidson, M.D., and Cathleen McCabe, M.D. Overall Baseline 0.5 Day vision Baseline 0.7 Night vision Bilateral Bilateral Baseline Bilateral Scale: 0-4 (0=not at all satisfied; 4=completely satisfied) 3.3 3.3 0.6 3.1 Figure 1. Patient satisfaction This supplement was produced by EyeWorld and sponsored by Alcon. The doctors featured in this supplement received compensation from Alcon for their contributions to this supplement. Michelle Dalton, EyeWorld contributing editor based in Reading, Pa., assisted in writing this supplement. Copyright 2012 ASCRS Ophthalmic Corporation. All rights reserved. The views expressed here do not necessarily reflect those of the editor, editorial board, or the publisher, and in no way imply endorsement by EyeWorld or ASCRS. Figure 2. Mean defocus curves of the AcrySof IQ ReSTOR +4 IOL vs. an AcrySof IQ ReSTOR +3 IOL addition, the mean intermediate visual acuity of 20/25 or better is an improvement of 1.5 lines in visual acuity for patients implanted with an IQ ReSTOR +3.0 IOL vs. an IQ ReSTOR +4.0 IOL (AcrySof IQ ReSTOR 6-month directions for use). Here, we offer some of our pearls for ensuring success with the IQ ReSTOR IOL. Why choose the ReSTOR IOL Dr. Davidson: The IQ ReSTOR IOL gives me confidence that I can meet or exceed patient expectations for unaided near vision without compromising far vision. In my practice, I have found refractive results and patient satisfaction ratings with the IQ ReSTOR IOL to be highly predictable. The IQ ReSTOR +3 IOL delivers near vision consistently. I have not explanted any of the 1,000 IQ ReSTOR +3 IOLs (SN6AD1) that I have implanted. The IQ ReSTOR +3 IOL is a significant improvement over previous ReSTOR IOL generations, possessing an expanded range of focus. I describe the first generation lens as having a near “sweet spot” and the IQ ReSTOR +3 IOL as having a near “sweet zone.” Dr. McCabe: After implanting more than 2,000 advanced technology lenses, I have learned that a detailed conversation with the patient and careful examination of the eye are critical to success. As long as the cornea and the rest of the eye are healthy, I explain to my patients the range of options available and that we offer all of the advanced technology lenses. I have found the IQ ReSTOR IOL will most reliably provide excellent unaided vision at all distances, and it is my preferred advanced technology lens choice. Two important exceptions to that rule are those patients with any amount of early corneal disease or those with significant dry eye that cannot be managed. Dr. Davidson: I recommend the IQ ReSTOR IOL to cataract patients with healthy eyes who desire high quality full-range vision, who are willing to tolerate a temporary halo Please refer to page 12 for important safety information about the Alcon surgical products described in this supplement. continued on page 2 2 EW Chicago 2012 Sunday, April 22, 2012 My practice is booming— baby booming, that is by Dan Grossman, M.D. very day, 10,000 baby boomers turn 65, and the number of Americans over age 65 is expected to double within 7 years.1 As baby boomers approach the age of cataract onset, the rate of cataract surgery will increase dramatically. Even if the number of ophthalmology residents were to double tomorrow, there would still not be enough surgeons to serve this growing need. As the demand for cataract surgery continues to surpass the available workforce of surgeons, I believe laser refractive cataract surgery will become the norm. Technologies such as the LenSx Laser (Alcon, Fort Worth, Texas) combined with advanced technol- E Dan Grossman, M.D. is perfect, “ Nobutlensusing the IQ ReSTOR IOL has required less chair time, fewer post-op issues to address, and yields significantly more patients who leave our offices happy ” ogy IOLs will play a prominent role in cataract treatment. The baby boomer population presents a unique demographic of cataract surgery patients—they are educated, technologically savvy, and demanding when it comes to their health. To provide the best treatment for this patient population, I think options such as the AcrySof IQ ReSTOR IOL (Alcon) and LenSx Laser technology are a must heading into the future. A rapid shift At the Eye Center of Southern Indiana, we adopted the IQ ReSTOR IOL in September 2010. Prior to this, we used an accommodative lens technology as our primary premium lens. Unfortunately, about 20% of our accommodative lens patients were dissatisfied, which necessitated additional chair time and doing whatever we could to make the patients happy and to give them the best possible vision. Since adopting the IQ ReSTOR IOL technology, I’ve implanted more than 215 lenses. The swing toward the IQ ReSTOR has been swift. There is less patient dissatisfaction post-op along with outcomes that usually give patients independence from glasses—more than 90% of my patients are doing well and are satisfied at about 6 weeks post-op. No lens is perfect, but using the IQ ReSTOR IOL has required less chair time, fewer post-op issues to address, and yields significantly Davidson/McCabe continued from page 1 effect at night, and who are candidates for excimer laser enhancement, including select chronic monovision and low myopic patients. In my practice, residual refractive error and posterior capsule opacity are the leading causes of dissatisfaction post-op. I offer LASIK or PRK to patients who would benefit from such enhancements, as soon as the refractive error stabilizes, no sooner than 3 months post-op, and after YAG posterior capsulotomy has been performed if also indicated. Word of mouth is finally becoming a prominent factor to the point where I’m now seeing patients on nearly a daily basis who are asking for the lens by name. Dr. McCabe: One other patient group that is somewhat difficult to manage is low myopes. With a monofocal lens, patients will lose the ability to read but will gain distance vision. The loss of unaided reading vision is a difficult concept for these patients to understand; I believe this patient group is usually much better suited for a multifocal lens like the IQ ReSTOR IOL. Dr. Davidson: While showing a near card to patients, I point to the 20/200 line, and tell them that’s the unaided near vision they can expect with a basic lens. Then I show them the J1-3 lines and tell them that’s the improved vision they should expect with the IQ ReSTOR IOL. Implantation pearls Dr. McCabe: Ensuring you’ve made an appropriately sized, shaped, and centered capsulorhexis will help provide for the long-term stability of the IQ ReSTOR IOL. Centration can sometimes be difficult to assess in a dilated pupil. However, the Purkinje images of the microscope light from the lens surface and cornea can easily be superimposed on the center ring of the lens. I’ve found that making sure the two images are right in the center of the lens allows for perfect alignment on the first post-op day. I spend additional time in surgery confirming that the lens is centered correctly. Mastel (Rapid City, S.D.) recently introduced a rim light that attaches to the microscope and allows the patient and surgeon to see a fixation light that is helpful in aligning the lens correctly. Dr. Davidson: I also like to center the central ring of the IQ ReSTOR IOL on the first Purkinje image (the brighter, smaller reflection of the microscope light). I find that by at first orienting the haptics along the 6/12 o’clock meridian, the lens is more likely to remain centered if nudging nasally is required for centration. Small, astigmatically neutral corneal wounds are important in achieving predictable outcomes because surgeons need to avoid inducing astigmatism as much as possible. Do not be surprised if minor residual refractive errors affect patient satisfaction. I’ve had rare patients who are 20/25, J2 unaided, and desire enhancement for –0.25+0.50X180, 20/15, J1+, and others who are 20/20, J1 with nearly a diopter of residual refractive astigmatism. A general rule of thumb is to leave the residual refractive error within 0.50 D of myopia, hyperopia, and astigmatism. Both surgeons agree no lens can promise perfection. No patient can be promised 100% spectacle freedom 100% of the time for 100% of the patient’s chosen activities, but so far the IQ ReSTOR IOL comes closest to achieving those results. Dr. Davidson is medical director, NVISION Laser Eye Center, Camarillo, Calif., assistant clinical professor of ophthalmology, Jules Stein Eye Center, Los Angeles, and in practice at Miramar Eye Specialists, Ventura, Calif. Dr. McCabe is medical director and partner, The Eye Associates, Sarasota, Fla. Contact information Davidson: [email protected] McCabe: [email protected] Please refer to page 12 for important safety information about the Alcon surgical products described in this supplement. What role does advanced technology play in your practice? EW Chicago 2012 3 more patients who leave our offices happy. That leads to increased patient referrals. Counseling the patient We’ve found that the name of the IQ ReSTOR IOL product lends itself to patient education, particularly with baby boomers. The concept of being returned to their more vital and functional days truly resonates with this active, young-at-heart population. When we offer this advanced technology IOL, we begin by explaining the concept of presbyopia. Later in the discussion, we introduce the idea of advanced technology IOLs, their advantages, and their impact. We can’t guarantee perfect vision, but this is the best approach to spectacle independence. Immediately following surgery, patients often complain about seeing the rings on the lens itself or about seeing rings of light when looking at a light source directly. For this reason, patient expectations must be managed post-op as well. There is a period of time during which neural adaptation takes place. Over time patients generally adapt to the new optical system, and this effect usually fades. By creating proper patient expectations and offering continued encouragement during the first few weeks of adaptation, we can achieve an excellent success rate. Lens centration and emmetropic outcome One of the keys to patient success is an emmetropic outcome, along with a well-centered IOL. We spend a lot of time making sure that the lens is centered before doing final hydration of the wound and exiting the wound. For this reason I perform these surgeries using the LenSx Laser.2 The LenSx Laser creates a predictable rhexis, which has given us more predictable centration and effective lens position.3 In my experience, the LenSx Laser and the IQ ReSTOR IOL products offer predictable options for my cataract surgery patients. Patient awareness strategies Baby boomers are particularly interested in maintaining their active lifestyles, and we try to market to that idea—we also make an effort to educate our optometry network on the newest technologies and options. While our patients are technology savvy, they don’t necessarily understand the nuances of cataract surgery or the different IOLs available to them. In our patient population, that’s best accomplished by face-to-face time in the office. We’ve recently redesigned our website to include a great deal of content explaining the technology, as well as multimedia such as videos and testimonials. This type of material is a beneficial educational tool for patients who are technologically savvy. We are also trying to become more involved in social media. In general, we’ve found that the personality trait that causes baby boomers to require more extensive pre-op counseling—their discriminating nature—is the very same trait that makes them ideal candidates for the IQ ReSTOR IOL. Baby boomers want the best technology available, and no sales tactics or gimmicks will convince them unless it is a quality product. We stand behind the technology the IQ ReSTOR IOL offers, along with our strong reputation for excellence. References 1. Love J. AARP Research and Strategic Analysis, December 2010. 2. Nagy Z, Takacs A, Filkorn T, Sarayba M. Initial Clinical Evaluation of an Intraocular Femtosecond Laser in Cataract Surgery, Journal of Refractive Surgery, 2009;25:10531060. 3. Cionni, R. et al. “Comparison of Effective Lens Position and Refractive Outcome: Femtosecond Laser vs. Manual Capsulotomy.” Presented at the 2011 International Society of Refractive Surgery meeting (American Academy of Ophthalmology). Oct. 21-22, Orlando, Fla. Dr. Grossman is founder of The Eye Center of Southern Indiana, Bloomington, Ind. Contact information Grossman: [email protected] EW Chicago 2012 4 Sunday, April 22, 2012 Should toric IOLs become the standard of care? by Brad Black, M.D. oric IOLs offer an efficient and consistent method of correcting pre-existing corneal astigmatism in cataract patients. A 2010 study published in the Journal of Cataract & Refractive Surgery1 found that toric IOL implantation was more predictable and effective than limbal relaxing incisions (LRIs) in correcting refractive astigmatism, resulting in greater spectacle independence. The AcrySof IQ Toric IOL (Alcon, Fort Worth, Texas) offers an excellent range of visual correction that gives us the capability to correct 0.75 D to 4.0 D of pre-existing corneal astigmatism. In addition to these advantages, toric IOLs obviate the need for the additional incisions required with LRIs. In light of these advantages and the excellent visual outcomes achieved, I think the AcrySof IQ Toric IOL is quickly emerging as the new standard of care for patients with cataracts and pre-existing corneal astigmatism. T Brad Black, M.D. The reason that “ torics are preferred by many surgeons in patients with 0.75 D of pre-existing corneal astigmatism or greater is because the toric IOL is more predictable and consistent than LRIs ” Corneal astigmatism: When to treat? When treating with a monofocal IOL, residual astigmatism of even 0.75 D should be considered visually significant and all of these patients considered as potential candidates for the AcrySof IQ Toric IOL. Physicians know that 0.5 D of astigmatism creates a considerable amount of visual aberration for a patient and can cause vision to drop to the 20/30 to 20/40 ranges. In monofocal lens patients who are predicted to have residual astigmatism of 0.8 D or 0.9 D, I will consider implanting a lower power of the AcrySof IQ Toric IOL, the T3, which will leave them with 0.1 or 0.2 in the opposite direction to achieve the best possible visual outcome. Regarding the higher levels of astigmatism, we are now able to address a greater range of refractive error. However, I always recommend surgeons perform topography in these patients to rule out ectasia or any type of progressive irregular astigmatism. Incisional LRIs versus toric IOLs The reason that torics are preferred by many surgeons in patients with 0.75 D of pre-existing corneal astigmatism or greater is because the toric IOL is more predictable and consistent than LRIs2; there is no risk of regression later on. Larger LRIs may also induce significant peripheral aberration, which certainly runs counter to our goal of minimizing, not creating, aberrations. Surgical pearls If surgeons have not yet implanted a toric lens, the AcrySof IQ Toric IOL is an excellent way to get started. Surgical technique doesn’t vary much from monofocal IOL implantation. One small adjustment you must make is marking the 3, 6, and 9 o’clock axes pre-op before the patient lays down to avoid misplacement of the IOL due to ocular cyclorotation in the supine position. Once you have mastered marking the desired axis intraoperatively, it’s just a matter of rotating the IOL clockwise after insertion to those marks. Post-op issues A question that often arises is, “What if the toric lens is off by 5 degrees?” In my opinion, when you check the patient on that first postop day and the vision is good and the patient is happy, where the lens ended up is not nearly as important as you might think. The intended axis is merely an approximation based on pre-op K readings. It cannot provide full knowledge of where the lens should be placed as we know there are other factors that may influence post-op refractive cylinder. If the patient is happy, there’s no need to bring him/her back into the OR. Leave the lens alone. Conversely, if a patient is not happy with his/her vision post-op or comes in with 20/40 vision, which rarely happens, and thinks he/she is happy, the surgeon must dilate that patient to verify the axis position. If the lens is misaligned, even by as little as 10 or 15 degrees, I take the patient back to the OR and rotate the lens to the intended axis determined pre-op. Remember, the patient will not complain of tilted images, etc.—just blurry vision as one loses 3% of the cylinder power for each degree of misalignment. You can make these patients happier. Patient education Educating the patient about astigmatism and what a toric lens actually does is equally important. Although many patients know that they have astigmatism, their understanding of it may be very limited. We like to use visuals when explaining astigmatism to a patient, likening the shape of their eye to a football rather than a basketball, or a teaspoon rather than a soup spoon. We explain that this irregular shape interferes with their vision and that the AcrySof IQ Toric IOL will figuratively correct the shape of their eye. We then explain to patients that without correcting this problem, their vision without glasses will not be as clear, i.e., it will cause halos around lights and/or less distinct vision and reduced contrast. Providing detailed patient education allows patients to make an informed decision. It is not uncommon for patients to say, “I don’t mind wearing glasses,” whereupon I will explain that it’s not simply about spectacle freedom. It is about quality of vision. People understand that it’s optically superior to correct astigmatism inside their eye as opposed to wearing glasses. Also, I will often ask patients, especially the high astigmats, how often their glasses had to be remade in the past when their astigmatism wasn’t properly corrected. Then I tell them that with a toric lens, those days are over. References 1. Mingo-Botin, D. et al., Comparison of toric intraocular lenses and peripheral corneal relaxing incisions to treat astigmatism during cataract surgery, J Cataract Refract Surg 2010; 36:1700-1708. 2. Data on file, Novartis AG. Dr. Black is founder of Dr. Brad Black’s Eye Associates in Jeffersonville, Ind. Contact information Black: [email protected] Please refer to page 12 for important safety information about the Alcon surgical products described in this supplement. What role does advanced technology play in your practice? EW Chicago 2012 5 What impact does SIA have on treating preexisting corneal astigmatism with a toric lens? by Paul Ernest, M.D. ith about 65% of older patients presenting with corneal astigmatism between 0.25 D and 1.25 D, the need to offer a solution to these patients will continue to grow. In my patient population, 35% of patients have astigmatism of 0.75 D and above, and I implant an AcrySof IQ Toric IOL (Alcon, Fort Worth, Texas) in a significant number of these patients. Most ophthalmologists agree that 0.5 D of astigmatism translates to about 0.25 D of spherical error and can negatively impact high contrast visual acuity. With that in mind, any reduction in post-op astigmatism of more than 0.5 D will impact visual acuity. The AcrySof Toric IOLs have been on the U.S. market since 2005, with the lowest IOL cylinder power of 1.50 D, and I think these lenses should be W the primary treatment consideration for patients with pre-existing corneal astigmatism and corneal cylinder as low as 0.75 D. I think it’s equally crucial that we know what degree of surgically induced astigmatism (SIA) we’re introducing during the procedure. A personal interest of mine has always been methods to reduce SIA. Wound geometry and location certainly play a role—surgeons will have lower SIA levels if the wound geometry is square and placed at the posterior limbus. My SIA for a square wound originating at the posterior limbus is 0.25 D with a standard deviation (SD) of 0.14 D. Clear corneal incisions have a higher SIA and wider SDs. We have recently shown that 2.2 mm square posterior limbal incisions induced significantly less SIA relative to similar-sized clear corneal incisions.1 More importantly, that same study showed the SIA was significantly less variable as well. Furthermore, for patients with lower levels of astigmatism (i.e., 0.75 D), the wound architecture and location play the most significant role. It is my opinion that it is difficult to treat 0.75 D if you fall into the category of having an SIA of 0.6 D with an SD of 0.4 D. For a high level of astigmatism —3.5 D or 4.0 D—SIA is not a relevant factor. I think there’s a tendency for surgeons who use clear corneal incisions to avoid using the AcrySof T3 Toric lens because their outcomes are less predictable. They may be unaware that it could be the incision that’s causing the inconsistent outcomes and not the lens itself. I was involved in a study evaluating the refractive results of the AcrySof T3 Toric and AcrySof IQ continued on page 6 Paul Ernest, M.D. These lenses “should be the primary treatment consideration for patients with pre-existing corneal astigmatism and corneal cylinder as low as 0.75 D ” Figure 1. Distribution of post-op refractive astigmatism by IOL type 6 EW Chicago 2012 Sunday, April 22, 2012 AcrySof platform provides confidence, con monofocals and advanced technology lens by Jason Jones, M.D. Years of experience have convinced me this is the best family of lenses for the majority of patients have been a long-time user of the AcrySof (Alcon, Fort Worth, Texas) family of lenses, ever since my residency. In my hands, the AcrySof IOL continues to be a very comfortable and convenient product to use. One of the benefits of choosing this family of lenses—from the IQ to the IQ Toric to the IQ ReSTOR IOL—is just that: It’s a family of products all built on the same platform. And that platform has shown time and time again to provide patients with phenomenal visual outcomes. That, in turn, means I inherently know how the lens is going to perform as it’s unfolding, as it’s being inserted, and as I’m positioning it, regardless of which variation of the lens I’m using. There are numerous aspects of the AcrySof IOL line I appreciate: It has excellent centration, and it’s constructed out of optimal material I Jason Jones, M.D. Because the “ AcrySof is a family of products, the newer user can gain a lot of experience with monofocal lenses and have more confidence when beginning to use the advanced technology platforms ” for a thin profile and easy delivery. All of the AcrySof lenses are very forgiving during the implantation through a cartridge and into the capsular bag. One of the more endearing properties of the platform’s ability is that the lenses are gentle to the ocular structures and have the flexibility to tolerate the implantation through a very small incision in a reliable fashion. This allows me to reduce my wound size, while still using a reliable portfolio of advanced technology IOLs. As I mentioned earlier, this is a family of products that goes from an aspheric monofocal to an aspheric toric to an aspheric multifo- AcrySof IQ IOL Ernest continued from page 5 spherical monofocal IOLs. Correcting relatively small amounts of corneal astigmatism with the lowpowered T3 reduced the post-op astigmatism by about 0.75 D more than the spherical lens (bearing in mind these patients had 0.75 D to 1.38 D of pre-op astigmatism).2 Given the small amount of SIA we noticed in these patients, the residual effects were basically non-existent (see Figure 1). It’s been my experience that calculating SIAs is not difficult. Warren Hill, M.D., has created a website that allows surgeons to calculate their SIAs as well as their SD. The program can be downloaded off doctorhill.com/physicians/ download.htm. According to Dr. Hill, the SIA Calculator has been designed to calculate, by means of vector analysis, the amount of SIA created during the cataract surgical procedure. To gain the most benefit, I suggest that surgeons use the same instrument for both pre-op and post-op K measurements. If the SDs can be minimized, using an IOL calculator will give you great success with toric IOLs. If the SDs are variable, however, it’s likely surgeons will be disappointed with their initial outcomes. For those who are not consistently calculating their SIAs, I recommend taking about 30-50 eyes, measuring the preop and post-op Ks, running a simple vector analysis, and calculating not only the SIA but the SDs. After the first 50 cases or so, I recommend surgeons revisit wound construction and architecture. Once the SIAs are lower and surgeons start seeing more consistent outcomes, it becomes much easier to approach the T3 lens with a high degree of certainty about visual outcomes. Like the cataract procedure itself, every step builds on the one before it. If surgeons know their SIAs, they can look at their SDs and work on getting those deviations as narrow as possible. Keeping tight SDs has given me the confidence to know I can easily treat lower levels of astigmatism very effectively with a lens-based procedure. References 1. Ernest P, Hill W, Potvin R. Minimizing surgically induced astigmatism at the time of cataract surgery using a square posterior limbal incision. J Ophthalmol 2011; 2011:243170. 2. Ernest P, Potvin R. Effects of preoperative corneal astigmatism orientation on results with a low-cylinder-power toric intraocular lens. J Cataract Refract Surg 2011;37(4): 727-32. Dr. Ernest is in private practice, TLC Michigan. Contact information Ernest: [email protected] Please refer to page 12 for important safety information about the Alcon surgical products described in this supplement. What role does advanced technology play in your practice? EW Chicago 2012 7 nsistency in ses cal. This is a proven platform that has seen advances, and we can likely expect more in the future. The breadth of the family of lenses is an attractive element because as surgeons use them on a routine basis, they become more accustomed to the handling properties, and they have a greater ability to have surgical expectations that are met and understand how the products will perform. The familiarity with the lens family can be helpful when surgeons step into a position where a patient has difficult anatomy or if they’re using an advanced technology IOL for the first time. Knowing a new lens has consistent, proven properties, they have a greater confidence in their ability to deliver the desired outcome. It’s a nice element of the AcrySof—to have a family of lenses that goes from a very low diopter to a very high AcrySof IQ ReSTOR IOL diopter power in a single-piece acrylic. Material advantages Being a hydrophobic acrylic lens, all of the AcrySof lenses are stable, both short and long term. This platform has no reported issues with calcification. The acrylic nature gives this lens a high index of refraction. The inherent flexibility of the lens allows it to be implanted through a small incision. The mechanical properties allow the material to be soft and pliable at body temperature, which makes the lens gentle on ocular structures as it is being implanted. Additionally, the element of material flexibility allows a surgeon who knows where the visual axis is to slightly nudge the lens into place a little more readily than he/she might be able to with other platforms. In my hands, I’ve found lenses with stiff haptics tend to center on the capsular bag, which may not coincide with the visual axis. In many routine cases, visual axis centration may not make a large difference, but in the cases that do benefit from this ability, the individualized centration can have a big impact (particularly with the IQ Toric and IQ ReSTOR lenses). AcrySof IQ Toric IOL Because the AcrySof is a family of products, the newer user—either in residency or a trained surgeon—can gain a lot of experience with monofocal lenses and have more confidence when beginning to use the advanced technology platforms. The AcrySof IQ, a monofocal lens, is a single-piece lens that feels more resilient in my hands during implantation. There’s little risk of damaged haptics, and it decreases the potential for intraocular damage —there’s no appendage that can get caught or possibly break off during the implantation procedure. I prefer the one-piece because of the additional stability. The one-piece design of the AcrySof platform gives me that extra element of control. It’s nice to take that for granted. I’ve worked with all the iterations of various IOLs, and there can be some issues—as I tell my patients, these products are all made by human beings and as such they are not perfect. No matter which lens you’re implanting, I find it helpful to communicate that a successful surgery will deliver excellent vision, but it may not give the patient every single aspect he or she desires. My advice to other surgeons is to perform meticulous surgery, analyze your results, and pay strict attention to lens power calculations. I regularly look at multiple formulas to help me decide which power lens to implant. From my perspective, a real benefit of the AcrySof family is that it gives surgeons an IOL platform across a range of advanced technology that shares the consistency I look for in a lens. Dr. Jones is president and medical director, Jones Eye Clinic, Sioux City, Iowa and Sioux Falls, S.D. Contact information Jones: [email protected] 8 EW Chicago 2012 Sunday, April 22, 2012 Femtosecond laser arcuate incisions: Delivering accuracy and reproducibility by Eric D. Donnenfeld, M.D. here are many steps within the cataract procedure, when performed manually, that contain an inherent level of variability. These steps include capsulotomy, making the primary and secondary incisions, and making arcuate incisions in the cornea. Many surgeons have avoided performing similar types of incisions like manual arcuate incisions during cataract surgery. Manual arcuate incisions require significant expertise and produce some degree of unpredictability. As a result, manual arcuate incisions are largely avoided by the great majority of cataract surgeons due to concerns about accuracy. The LenSx Laser (Alcon, Fort Worth, Texas) utilizes image-guided surgical planning with 3D visualization for the surgeon. This enables surgeons to plan and execute the necessary corneal incisions to address the needs of the patient at the time of cataract surgery with computer-controlled arcuate incisions of precise depth, length, and position. The integrated imaging system ensures incisions of accurate width and tunnel length and geometric shape. My early experiences with the femtosecond laser for refractive cataract surgery demonstrate that the femtosecond laser will provide another layer of precision by creating reproducible arcuate incisions at the desired optical zone. Incorporating femtosecond laser arcuate incisions into my armamentarium has given me the confidence to know I’m offering the most advanced technologies on the market today to my patients. T Eric Donnenfeld, M.D. My early “ experiences with the femtosecond laser for refractive cataract surgery demonstrate that the femtosecond laser will provide another layer of precision by creating reproducible arcuate incisions at the desired optical zone ” Adjust arcuate incisions The surgeon’s ability to adjust surgical parameters and thereby titrate the amount of residual tissue attachments in the incision enables another distinct advantage. Utilizing this feature, the surgeon can adjust the arcuate incision width by using a blunt manual instrument. These kinds of incisions also could be likened to a LASIK flap. The surgeon must lift the flap by hand to make use of the incision. Likewise, until the cataract femtosecond incisions are opened manually, the The LenSx Laser Source: Alcon fenestrations the surgeon has made with the laser have not been realized. A great majority of ophthalmologists aren’t doing any type of manual arcuate incision during cataract surgery due to fear of cutting deeply into the cornea and risking perforation. Using the femtosecond laser allows any ophthalmologist to perform a quality arcuate incision. Surgeons can be assured that this is being done with the accuracy and precision of a laser that is as good as any surgeon, even one with years of experience. rate and reproducible way of doing cataract surgery. If I can incorporate that technology into my cataract surgery, I will do so at any opportunity. I’m getting better reproducibility with my femtosecond incisions than I ever got with my manual incisions. Using the femtosecond laser to create those incisions is more reproducible, gives me adjustable incisions, and provides a level of accuracy that I cannot consistently achieve manually. Accuracy and reproducibility Contact information My personal belief is that femtosecond cataract surgery is a more accu- Donnenfeld: [email protected] Dr. Donnenfeld is a partner at Ophthalmic Consultants of Long Island. Please refer to page 12 for important safety information about the Alcon surgical products described in this supplement. What role does advanced technology play in your practice? EW Chicago 2012 9 Optimized outcomes with advanced optical biometry by Joseph Sokol, M.D. ataract surgery has advanced to the point where accurate measurements are essential to achieving the best visual outcomes. I have found that the LENSTAR LS 900 optical biometer (Haag-Streit USA, Mason, Ohio) gives me the most comprehensive set of information with reliable and accurate measurements for planning cataract surgery with advanced technology IOLs. C The need for optical biometry In my opinion, if you are performing state-of-the-art cataract surgery, you should be committed to achieving emmetropia in as many patients as possible regardless of the lens you are implanting. It therefore follows that having reliable and accurate measurements of the eye pre-operatively is essential. For many years applanation ultrasound was the method by which physicians gained information to calculate lens powers. Immersion ultrasound was a big step forward but was not uniformly adopted due to the difficulty in performing the procedure as well as the inconvenience to the patient. Optical biometry has made immersion ultrasound quality measurements available to surgeons and patients alike in an easier format. Crucial measurements Within optical biometry, both the IOLMaster (Carl Zeiss Meditec, Dublin, Calif.) and the LENSTAR LS 900 optical biometer deliver excellent results. Like many surgeons, I began to try to improve my outcomes by using a version 5 IOLMaster. While this did much to reduce refractive surprises and speed up the acquisition of data, I still struggled with certain cases. A particular source of frustration was the accuracy of the axis of astigmatism that the IOLMaster found in patients as compared to manual or automated keratometry. When implanting toric lenses, this was a concern. Once I started using the LENSTAR LS 900 optical biometer, I began to have consistent, predictable results. I found that the axial length measured between optical biometers was very consistent, but the keratometry as determined by the LENSTAR optical biometer was improved based upon the additional points of measurement. Each LENSTAR optical biometer scan measures the anterior corneal curvature at 32 discrete points divided between two different zones—one at 2.3 mm and the other offset at 1.65 mm. That means that when the instrument acquires five scans, you have sampled over 600 measurements on the cornea per eye. I believe that the additional measure- ments on the cornea provided better outcomes for my toric IOL patients or for multifocal or accommodating lens patients in whom I needed to do limbal relaxing incisions. In fact, a recently published study using simulated outcomes suggested that overall results for a group of patients whose toric IOL surgery planning was performed with the LENSTAR optical biometer was equivalent to manual Ks, but with a reduced siteto-site variability.1 With the IOLMaster, the black box was in play. You got a set of numbers but without confidence values and without the ability to see examples of the actual scans. If a surgeon’s K readings produce high standard deviations, either in the values or the axis, it is often unwise to proceed with surgery until the cause can be determined. It may be that the patient’s ocular surface needs to be improved or that the tear film needs to be addressed. My advice is to correct those issues as best you can and then to repeat the K readings. One can also get a sense of the problem by looking at the Placido disc images. Distorted mires, ectatic areas, or poor images are all warning signs that should be heeded. Quantity plus quality equals greater efficiency While the difference between ultrasound and optical biometry is huge, the difference between the LENSTAR optical biometer and the IOLMaster is smaller but meaningful. We all love to be efficient in what we do. In one scan, the LENSTAR optical biometer measures lens thickness, pachymetry, pupillometry, keratometry, axial length, anterior chamber depth, and the white-to-white limbal distance. The LENSTAR optical biometer provides additional parameters—such as the lens thickness— that are often included in newer fourth-generation formulas and provide a measured, rather than a calculated, anterior chamber depth. This increased data along with the use of the newer, more sophisticated formulas should eliminate some of the surgeon’s reliance on estimations. Additionally, the LENSTAR optical continued on page 10 Joseph Sokol, M.D. The keratometry “ as determined by the LENSTAR optical biometer was improved based upon the additional points of measurement ” 10 EW Chicago 2012 Sunday, April 22, 2012 Latest advancements in cataract surgery for achieving precise outcomes by Robert J. Cionni, M.D. ecently my cataract clinic has begun to resemble a refractive clinic—the patients want to know whether or not they will still need their glasses after surgery. The nice thing is if we use the best technologies, the chance of obtaining the best results is more likely. In my opinion, that means advanced technology lenses, optical biometers, femtosecond lasers, and intraoperative aberrometry. Fortunately, numerous emerging technologies hold the promise of optimizing cataract surgery during all phases of the procedure. These innovations have the potential to provide uniformly superior results in the hands of any surgeon. R Robert J. Cionni, M.D. “ Numerous emerging technologies hold the promise of optimizing cataract surgery during all phases of the procedure ” The LENSTAR LS 900 optical biometer I recommend measuring keratometric cylinder using multiple methods, including the LENSTAR LS 900 optical biometer (Haag-Streit USA, Mason, Ohio), which gives us various readings other technologies are not able to provide. The LENSTAR biometer basically does what we previously asked the IOLMaster 500 (Carl Zeiss Meditec, Sokol continued from page 9 biometer, similar to ultrasound, allows the surgeon to see what exactly is being measured. This ability to see the tracing to confirm the accuracy of the reading is reassuring. If the operator feels that the machine has mistakenly located the anterior or posterior lens surface or the retinal spike, for example, the calipers on the scan in question can be manually moved and realigned to increase the accuracy of the result. From a clinician’s standpoint, the joystick on the LENSTAR optical biometer is similar to what we’ve used on a slit lamp. The LENSTAR optical biometer has been programmed to only capture data on the visual axis—ensuring that if the patient has problems maintaining fixation, the LENSTAR optical biometer will pause the scanning portion until the patient fixates again. One last feature I have found helpful—the LENSTAR optical biometer almost obviates the possibility of technician error as data does not have to be transcribed. Instead, the LENSTAR optical biometer automatically inputs the data it captures into the Holladay II program. There is a short learning curve to utilizing this instrument. As the biometer is being integrated into the practice, technicians and surgeons may find the images a bit tricky to obtain at first. Training from the Haag-Streit/Alcon team and confidence and experience from repetitive use conquered this problem in a relatively short time. Measurements equal results Since I’ve been using the LENSTAR optical biometer in my practice, I feel more comfortable that I’m getting accurate information for predictable outcomes. This instrument gives me peace of mind. I firmly believe to meet out patients’ growing expectations, we are obligated to provide excellent results. One way that we can continue to achieve those results is to use the best instrumentation available on the market today. I have come to appreciate that the LENSTAR optical biometer occupies that top spot. Dr. Sokol is founder and owner, CT Eye Specialists LLC, Shelton, Conn. Reference 1. Hill W, Osher R, Cooke D, et al. Simulation of toric intraocular lens results: Manual keratometry versus dual-zone automated keratometry from an integrated biometer. J Cataract Refract Surg. 2011;37:2181-2187. Contact information Sokol: [email protected] LENSTAR is a registered trademark of Haag-Streit. Please refer to page 12 for important safety information about the Alcon surgical products described in this supplement. What role does advanced technology play in your practice? Dublin, Calif.) to do. While they both provide good axial length readings, the LENSTAR biometer will take a little longer to produce those simply because it’s taking so many more readings and providing more information. In my opinion, the LENSTAR biometer provides the most reliable keratometry readings, which include accurate axis and magnitude of corneal cylinder. In the past, we relied on a topographer to determine the axis and on manual keratometry readings for the magnitude. Now, we can rely on the LENSTAR instrument to give us not only the axial length, but also keratometry and lens thickness, and then input that data into the LenSx Laser (Alcon, Fort Worth, Texas). The lens thickness reading is also important in the newer genera- EW Chicago 2012 11 tion formulas in order to get the best implant power. Our group is working with Lenstar and Alcon to incorporate the LENSTAR testing into such innovations as patient identification in the operating room. We’re using the LENSTAR biometer to take a picture and identify sentinel vessels, iris markers such as nevi, and similar landmarks. The LENSTAR can use those phenomena to align the images in order to identify the patient’s steep axis once the patient is in the OR. If there is cyclotorsion after a patient is in the reclining position, the LENSTAR biometer realigns the images so the surgeon can be assured of acting on the true astigmatic axis. In the future, I predict we’ll be using biometers like the LENSTAR biometer in conjunction with phaco machines to ensure the bar code scanned into the phaco machine matches what the LENSTAR biometer found as an appropriate lens. It’ll act as another layer to ensure surgeons are implanting the proper lens power. To further test the accuracy of the LenSx Laser over manual methods, we implanted an additional 23 patients with the IQ ReSTOR IOL (Alcon) and 28 patients with the AcrySof IQ Toric IOL (Alcon). In the IQ ReSTOR IOL group, 12 underwent capsulotomy with the LenSx Laser and 11 via manual procedures. The toric group was split equally. In all cases, the accuracy to within 0.25 D of the target was significantly better with the LenSx Laser. In my hands, the worst outcomes were in the toric group with manual methods, where 21% were within 0.25 D. At 1 month post-op, 100% of the patients implanted with the IQ ReSTOR IOL/LenSx Laser had 20/25 or better, compared to 36% with the manual procedure. Likewise, 82% of the SN60WF/LenSx Laser and 71% of the AcrySof IQ Toric IOL/LenSx Laser patients reached 20/25 or better at month 1 post-op compared to 54% and 36%, respectively, in the manual keratometry group. The LenSx Laser As the cataract surgery market continues to grow, new technologies are being developed to meet this need. Devices such as the LENSTAR optical biometer, the LenSx Laser, and the Wavetec ORA (WaveTec Vision, Aliso Viejo, Calif.)—as well as the advanced implants and phaco machines we already have—enable us to confidently tell patients that they are more likely to end up with the results they are demanding we provide. We’ve been incredibly lucky to be among the first groups to incorporate the LenSx Laser for refractive cataract surgery. In a study I presented at the 2011 International Society of Refractive Surgery (ISRS) meeting,1 I compared the femtosecond laser with manual capsulotomy in terms of effective lens position (ELP) and refractive outcomes. In the study, I looked at 26 patients who underwent surgery with manual capsulotomy and 22 patients who had surgery with femtosecond incisions (both groups implanted with the SN60WF lens [Alcon]). The two study groups were comparable in terms of demographics and axial lengths, keratometry, and anterior chamber depth. We didn’t perform any astigmatic limbal relaxing incisions; we were looking only at the spherical outcome. We found that 59% more of those in the femtosecond group reached 20/20 uncorrected vision. Advanced technologies, predictable results Reference 1. Cionni, R. et al. Comparison of Effective Lens Position and Refractive Outcome: Femtosecond Laser vs. Manual Capsulotomy. Presented at the 2011 International Society of Refractive Surgery meeting (American Academy of Ophthalmology). Oct. 21-22, Orlando, Fla. Dr. Cionni is medical director, The Eye Institute of Utah, Salt Lake City. Contact information Cionni: [email protected] Lenstar is a registered trademark of Haag-Streit. 12 EW Chicago 2012 Sunday, April 22, 2012 Important safety information AcrySof IQ intraocular lenses Caution: Federal (U.S.) law restricts this device to sale by or on the order of a physician. Indications: The AcrySof IQ posterior chamber intraocular lens is intended for the replacement of the human lens to achieve visual correction of aphakia in adult patients following cataract surgery. This lens is intended for placement in the capsular bag. Warning/precaution: Careful pre-operative evaluation and sound clinical judgment should be used by the surgeon to decide the risk/benefit ratio before implanting a lens in a patient with any of the conditions described in the Directions for Use labeling. Caution should be used prior to lens encapsulation to avoid lens decentrations or dislocations. Studies have shown that color vision discrimination is not adversely affected in individuals with the AcrySof Natural IOL and normal color vision. The effect on vision of the AcrySof Natural IOL in subjects with hereditary color vision defects and acquired color vision defects secondary to ocular disease (e.g., glaucoma, diabetic retinopathy, chronic uveitis, and other retinal or optic nerve diseases) has not been studied. Do not resterilize; do not store over 45 degrees C; use only sterile irrigating solutions such as BSS or BSS PLUS Sterile Intraocular Irrigating Solutions. Attention: Reference the Directions for Use labeling for a complete listing of indications, warnings, and precautions. AcrySof IQ ReSTOR intraocular lenses Caution: Federal (U.S.) law restricts this device to sale by or on the order of a physician. Indications: The AcrySof IQ ReSTOR posterior chamber intraocular lens (IOL) is intended for primary implantation for the visual correction of aphakia secondary to removal of a cataractous lens in adult patients with and without presbyopia, who desire near, intermediate, and distance vision with increased spectacle independence. The lens is intended to be placed in the capsular bag. Warning/precaution: Careful pre-op evaluation and sound clinical judgment should be used by the surgeon to decide the risk/benefit ratio before implanting a lens in a patient with any of the conditions described in the Directions for Use labeling. Physicians should target emmetropia and ensure that IOL centration is achieved. Care should be taken to remove viscoelastic from the eye at the close of surgery. Some patients may experience visual disturbances and/or discomfort due to multifocality, especially under dim light conditions. Clinical studies with the AcrySof ReSTOR lens indicated that posterior capsule opacification (PCO), when present, developed earlier into clinically significant PCO. Prior to surgery, physicians should provide prospective patients with a copy of the Patient Information Brochure available from Alcon for this product informing them of possible risks and benefits associated with the AcrySof IQ ReSTOR IOLs. Studies have shown that color vision discrimination is not adversely affected in individuals with the AcrySof Natural IOL and normal color vision. The effect on vision of the AcrySof Natural IOL in subjects with hereditary color vision defects and acquired color vision defects secondary to ocular disease (e.g., glaucoma, diabetic retinopathy, chronic uveitis, and other retinal or optic nerve diseases) has not been studied. Do not resterilize; do not store over 45 degrees C; use only sterile irrigating solutions such as BSS or BSS PLUS Sterile Intraocular Irrigating Solutions. Attention: Reference the Directions for Use labeling for a complete listing of indications, warnings, and precautions. AcrySof IQ Toric intraocular lenses Caution: Federal (U.S.) law restricts this device to sale by or on the order of a physician. Indications: The AcrySof IQ Toric posterior chamber intraocular lens is intended for primary implantation in the capsular bag of the eye for visual correction of aphakia and pre-existing corneal astigmatism secondary to removal of a cataractous lens in adult patients with or without presbyopia, who desire improved uncorrected distance vision, reduction of residual refractive cylinder, and increased spectacle independence for distance vision. Warning/precaution: Careful pre-operative evaluation and sound clinical judgment should be used by the surgeon to decide the risk/benefit ratio before implanting a lens in a patient with any of the conditions described in the Directions for Use labeling. Toric IOLs should not be implanted if the posterior capsule is ruptured, if the zonules are damaged, or if a primary posterior capsulotomy is planned. Rotation can reduce astigmatic correction; if necessary, lens repositioning should occur as early as possible prior to lens encapsulation. All viscoelastics should be removed from both the anterior and posterior sides of the lens; residual viscoelastics may allow the lens to rotate. Optical theory suggests that high astigmatic patients (i.e. >2.5 D) may experience spatial distortions. Possible toric IOL related factors may include residual cylindrical error or axis misalignments. Prior to surgery, physicians should provide prospective patients with a copy of the Patient Information Brochure available from Alcon for this product informing them of possible risks and benefits associated with the AcrySof IQ Toric Cylinder Power IOLs. Studies have shown that color vision discrimination is not adversely affected in individuals with the AcrySof Natural IOL and normal color vision. The effect on vision of the AcrySof Natural IOL in subjects with hereditary color vision defects and acquired color vision defects secondary to ocular disease (e.g., glaucoma, diabetic retinopathy, chronic uveitis, and other retinal or optic nerve diseases) has not been studied. Do not resterilize; do not store over 45 degrees C; use only sterile irrigating solutions such as BSS or BSS PLUS Sterile Intraocular Irrigating Solutions. Attention: Reference the Directions for Use labeling for a complete listing of indications, warnings, and precautions. LENSTAR LS 900 Optical Biometer The LENSTAR LS 900 Optical Biometer is a non-invasive, non-contact OLCR (optical low-coherence reflectometry) biometer used for obtaining ocular measurements and performing calculations to assist in the determination of the appropriate power and type of IOL for implantation after removal of the natural crystalline lens following cataract removal. The LENSTAR LS 900 Optical Biometer measures: • Axial eye length • Corneal thickness • Anterior chamber depth • Lens thickness • Radii of curvature of flat and steep meridian • Axis of the flat meridian • White to white distance • Pupil diameter LenSx Laser Caution: Federal (U.S.) law restricts this device to sale by or on the order of a physician. Indication: The LenSx Laser is indicated for use in patients undergoing cataract surgery for removal of the crystalline lens. Intended uses in cataract surgery include anterior capsulotomy, phacofragmentation, and the creation of single-plane and multi-plane arc cuts/incisions in the cornea, each of which may be performed either individually or consecutively during the same procedure. Restrictions: • Patients must be able to lie flat and motionless in a supine position. • Patient must be able to understand and give an informed consent. • Patients must be able to tolerate local or topical anesthesia. • Patients with elevated IOP should use topical steroids only under close medical supervision. Contraindications: • Corneal disease that precludes applanation of the cornea or transmission of laser light at 1030 nm wavelength • Descemetocele with impending corneal rupture • Presence of blood or other material in the anterior chamber • Poorly dilating pupil, such that the iris is not peripheral to the intended diameter for the capsulotomy • Conditions that would cause inadequate clearance between the intended capsulotomy depth and the endothelium (applicable to capsulotomy only) • Previous corneal incisions that might provide a potential space into which the gas produced by the procedure can escape • Corneal thickness requirements that are beyond the range of the system • Corneal opacity that would interfere with the laser beam • Hypotony, glaucoma, or the presence of a corneal implant • Residual, recurrent, active ocular or eyelid disease, including any corneal abnormality (for example, recurrent corneal erosion, severe basement membrane disease) • This device is not intended for use in pediatric surgery • A history of lens with zonular instability • Any contraindication to cataract or keratoplasty surgery Attention: Reference the Directions for Use labeling for a complete listing of indications, warnings, and precautions. Warnings: The LenSx Laser system should only be operated by a physician trained in its use. The LenSx Laser delivery system employs one sterile disposable LenSx Laser Patient Interface consisting of an applanation lens and suction ring. The Patient Interface is intended for single use only. The disposables used in conjunction with Alcon instrument products constitute a complete surgical system. Use of disposables other than those manufactured by Alcon may affect system performance and create potential hazards. The physician should base patient selection criteria on professional experience, published literature, and educational courses. Adult patients should be scheduled to undergo cataract extraction. Precautions: • Do not use cell phones or pagers of any kind in the same room as the LenSx Laser. • Discard used Patient Interfaces as medical waste. AEs/Complications: • Capsulotomy, phacofragmentation, or cut or incision decentration • Incomplete or interrupted capsulotomy, fragmentation, or corneal incision procedure • Capsular tear • Corneal abrasion or defect • Pain • Infection • Bleeding • Damage to intraocular structures • Anterior chamber fluid leakage, anterior chamber collapse • Elevated pressure to the eye MIX12044SOV
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