Surgery Co-Management Guide

Transcription

GIMBEL EYE CENTRE
LEADERS IN CORRECTIVE
EYE SURGERY SINCE 1964
Last revised April 2013
CALGARY: 403-286-3022 | Toll-free 1-800-661-1138
EDMONTON: 780-452-4111 | Toll-free 1-888-211-4822
gimbel.com
Table of Contents
If you are reading a digital format, you can click on the bolded headings
to jump to that section of the guide.
Introduction..........................................................................................................................................................................4
Meet our Doctors.................................................................................................................................................................5
Meet our Calgary Doctors.................................................................................................................................................5
Meet our Edmonton Doctors.............................................................................................................................................5
Contact Information............................................................................................................................................................6
The Role of the Co-Managing Eyecare Provider............................................................................................................7
Pre-Operative Evaluation...................................................................................................................................................7
Referrals to Gimbel Eye Centre.........................................................................................................................................7
Post-Operative Evaluations...............................................................................................................................................7
Corneal Refractive Surgery Descriptions........................................................................................................................8
IntraLase Laser Assisted In Situ Keratomileusis (IntraLASIK)...........................................................................................8
Photo Refractive Keratectomy (PRK)................................................................................................................................8
Photo Therapeutic Keratectomy (PTK)..............................................................................................................................8
Astigmatic Keratotomy (AK)..............................................................................................................................................8
Laser Technology and Wavefront Treatment.....................................................................................................................8
Corneal Refractive Surgery Patient Selection................................................................................................................9
Eligibility Criteria for Corneal Refractive Surgery...............................................................................................................9
Contraindications for Corneal Refractive Surgery...........................................................................................................10
Corneal Refractive Surgery Post Operative Care........................................................................................................11
Postoperative Medication and Follow Up Regimen........................................................................................................11
PRK Post-Operative Extended Medication Protocol.......................................................................................................12
Corneal Surgery Post Operative Presentation and Activity Restrictions.........................................................................13
Corneal Refractive Surgery Complications and Treatment.............................................................................................14
Phakic IOL Refractive Surgery Descriptions................................................................................................................16
Implantable Collamer Lenses (ICL).................................................................................................................................16
Angle Supported Phakic IOL (Cachet)............................................................................................................................16
gimbel.com | 2
Printed in Canada | 2013
LEADERS IN CORRECTIVE EYE SURGERY SINCE 1964
Phakic IOL Surgery Patient Selection............................................................................................................................17
Eligibility Criteria for Phakic IOL Surgery.........................................................................................................................17
Contraindications for Phakic IOL Surgery.......................................................................................................................17
Phakic IOL Postoperative Care.......................................................................................................................................18
Postoperative Medication and Follow Up Regimen........................................................................................................18
Phakic IOL Post Operative Presentation and Activity Restrictions..................................................................................19
Phakic IOL Postoperative Evaluation Considerations.....................................................................................................20
Phakic IOL Surgery Complications and Treatment.........................................................................................................21
Refractive Lens Exchange/Cataract Extraction Descriptions....................................................................................22
Surgery Description.........................................................................................................................................................22
Alberta Health Care (AHC) Covered Services.................................................................................................................22
Refractive Lens Exchange and Cataract Surgery Patient Selection.........................................................................23
Refractive Lens Exchange/Cataract Surgery Lifestyle Implant Choices.........................................................................24
Refractive Lens Exchange/Cataract Surgery Post Operative Care...........................................................................25
Refractive Lens Exchange and Cataract Surgery Post Operative Medications and Follow up......................................25
Refractive Lens Exchange and Cataract Surgery Post Operative Presentations and Activity Restrictions....................26
Refractive Lens Exchange/Cataract Surgery Complications and Treatment..................................................................27
Collagen Cross Linking Description..............................................................................................................................28
Accelerated Collagen Cross Linking Patient Selection..............................................................................................29
Presbyopia, Monovision and the Role of the Co-managing Doctor.........................................................................30
Special Considerations in Refractive Surgery.............................................................................................................31
Fee Information.................................................................................................................................................................32
Frequently Asked Questions...........................................................................................................................................33
Forms..................................................................................................................................................................................34
Last Revised April 2013
3 | gimbel.com
Introduction
Dear Doctor,
Welcome to our new and updated Co-management guide! Since 1964, Gimbel Eye Centre has been providing
Refractive and Cataract surgical options in a convenient, compassionate, and caring manner to our mutual patients.
As an established ophthalmic surgery practice, we pride ourselves in providing honest, high quality care and realize
that our success lies in the company we keep. We are very aware that the relationship with our co-managing Doctors
is an integral part of our success. As we are committed to reinforcing your role as the Primary Eye Care Provider, we
provide the convenience of collecting your co-management fees at the time of their surgery payment, and then pass
it along to you. This promotes patient compliance, and emphasizes the importance of the patient returning to you for
proper follow up care and beyond. In recognizing that our Associated Eyecare Providers may have different practice
needs, we can deduct from your patient’s surgery fees to enable you to charge your patient directly for follow up care
based on your own fee schedule.
Our goal with this new Co-management guide is to provide a concise, easy-to-reference resource to enable the busy
practitioner to feel confident and up-to-date in our quickly evolving professions. Included are surgery descriptions,
eligibility criteria, post-operative care, complication management, and fee structures. This resource is available in
digital format and hard copy.
In addition to the Co-management guide, Gimbel Eye Centre provides numerous other resources including
YouTube videos with over 100 hours of intraocular surgery footage, our updated Website at www.gimbel.com,
complimentary Continuing Education Seminars regarding a wide range of ophthalmic surgery topics, and periodic
Webinars and Webcasts.
We welcome an open dialogue with our team of surgeons, optometrists, and staff, to support both you and your
patient in this important life experience. We would be pleased to have you visit our Calgary or Edmonton Centre,
and perhaps observe a surgery or two!
Thanks for sharing our vision of providing the best eye care solutions for our mutual patients.
Sincerely,
Gimbel Eye Centre Team
gimbel.com | 4
Meet our Doctors
Meet our Calgary Doctors
H.V. Gimbel, MD, MPH,
FRCSC, AOE, FACS, CABES
Executive Medical Director
Marcella LaBelle BSc OD
Jacinthe Kassab, MD, FRCSC
John van Westenbrugge,
Associate Medical Director,
Clinical Services
MD, FRCSC Associate Medical
Director, Surgical Services
Mona Purba BSc OD
Zenur Khan MSc OD
Leta Theissen BSc OD
Meet our Edmonton Doctors
Geoffrey B Kaye, MB, ChB.
Nohad Teliani BSc OD
FCS(SA), FRCSC Executive
Medical Director, Gimbel Eye
Centre, Edmonton
5 | gimbel.com
Contact Information
Office Addresses
Gimbel Eye Centre
Gimbel Eye Centre
CALGARY
EDMONTON
Market Mall Executive Professional Centre
450, 4935 - 40th Avenue NW
Calgary, Alberta T3A 2N1
Mira Health Centre
140, 11910 - 111th Avenue
Edmonton, Alberta T5G 0E5
Office Telephone Numbers
Office Telephone Numbers
(403) 286-3022
1 (800) 661-1138
(780) 452-4111
1 (888) 211-4822
Office Fax Numbers
Office Fax Numbers
(403) 286-2943
(780) 452-4114
Manager, Operations
Manager, Operations
Lynda Kelly, COMT
Violet Wray, LPN
Your Contact Person
Glenn Gimbel, President
(403) 202-3312
[email protected]
gimbel.com | 6
The Role of the Co-Managing Eyecare Provider
As the Primary Eyecare provider, your role is important in the patient’s Refractive Surgery journey,
from beginning to end.
Pre-Operative Evaluation
A full eye examination including complete ocular and health history, refractive status, and dilated ocular health
evaluation is recommended prior to referring the patient to our Centre. This is advantageous to the patient because
we can pre-screen the referral and handle/discuss any issues prior to the patient’s arrival for Gimbel Eye Centre
assessment. This is advantageous to you because it establishes your participation in the patient’s experience and
encourages the patient to return to you for follow up care and beyond. The data collected in your referral will be carefully
evaluated in conjunction with a complete Gimbel Eye Centre assessment to maximize accuracy and repeatability in
the data used for surgery purposes. There is historical precedence that it is both the Refractive Surgery Centre’s and the
Primary Eyecare Provider’s responsibility to ensure adequate informed consent surrounding the risks and benefits of
refractive surgery, including presbyopia considerations and monovision.
Refractions: For refractive surgery purposes: it is recommended to maximize the cyl and minimize
the sphere component as this increases the odds of achieving emmetropia.
Visual Acuity: For testing standardization, we request measurements up to 20/15.
Referrals to Gimbel Eye Centre
Pre-Operative Surgery Assessment Referral Forms (provided in this guide) can be forwarded via fax or e-mail. Our
Patient Counselor will then contact the patient directly to make arrangements for a Gimbel Eye Centre preoperative
assessment, surgery, and 1-day post-operative follow-up. A few things to be aware of in referring your patients:
For All Surgery Types:
The patient is required to discontinue soft contact lens wear for a minimum of 48 hours prior to testing
at Gimbel Eye Centre, or 2 weeks for RGP contact lenses.
For Potential Phakic IOL candidates:
The patient should be prepared for two days of pre-operative testing at Gimbel Eye Centre and should
make their travel arrangements accordingly.
Post-Operative Evaluations
After the patient’s 1-day follow up visit, we encourage the patient to return to you for their follow up care. A report
will be sent to you indicating type of surgery performed and the patient’s current vision status. Follow up frequency
and testing will be outlined in each section of this guide. A Post-Operative Follow Up Referral form (provided in
this guide) should be sent to Gimbel Eye Centre for review, and a response will be returned if requested. We are
happy to reassess the patient upon your request at no additional fee. Please be advised that due to processing times,
it may be several weeks before you receive co-management fees.
7 | gimbel.com
Corneal Refractive Surgery Descriptions
IntraLase Laser Assisted In Situ Keratomileusis (IntraLASIK).
There are two lasers used in this procedure. The IntraLase Femtosecond Laser creates a flap by introducing focused
energy, which creates a CO2 bubble in between the corneal layers. The laser then creates the laser flap edge by cutting
around the perimeter, leaving a superior hinge. This advanced method of flap creation avoids most of the risks of using
a mechanical microkeratome blade, reducing post-operative complications such as dryness, providing better contrast
sensitivity, and creating an optimal stromal bed surface. Once the flap is lifted, the Nidek Excimer Laser EC5000 CXIII
re-contours the corneal surface by ablating tissue to correct the refractive error and minimizing higher order aberrations.
If IntraLASIK Xtra was chosen, the KXL collagen cross linking procedure is performed (see KXL Collagen Cross
linking section). The surgeon replaces the flap, taking care to ensure good flap position and adherence.
Photo Refractive Keratectomy (PRK)
The surgeon loosens the corneal epithelium with an alcohol-based chemical solution and gently removes the epithelial
cells. The Nidek Excimer Laser EC5000 CXIII re-contours the corneal surface by ablating tissue to correct the
refractive error and minimizing higher order aberrations. If PRK Xtra was chosen, the KXL collagen cross linking
procedure is performed (see KXL Collagen Cross linking section). The surgeon inserts a bandage contact lens.
Photo Therapeutic Keratectomy (PTK)
This procedure is not a refractive surgery in that it is done therapeutically, primarily for corneal conditions such as
scarring, haze, or recurrent corneal erosion. It is similar to PRK as described above, except the surgeon limits the laser
tissue ablation to the pathology or higher order aberrations being treated and stops once sufficient pathological tissue
has been removed. The surgeon then inserts a bandage contact lens and healing will be similar to PRK.
Astigmatic Keratotomy (AK)
This procedure is generally done in conjunction with Intraocular surgery such as cataract surgery, and is done to reduce
minor amounts of corneal astigmatism. The surgeon strategically creates a partial thickness peri-limbal incision. The
length of the incision influences the amount of flattening of the steepest corneal meridian.
Laser Technology and Wavefront Treatment
All patients at Gimbel Eye Centre undergo wavefront analysis, which measures the Higher Order Aberrations of
the entire eye. Factors affecting Higher Order Aberrations include refractive error, corneal abnormalities (such as
scars), and lenticular changes, which can impact the quality of the vision. The standard laser treatment for all Gimbel
Eye Centre patients is an aspheric, wavefront-optimized treatment. In addition, our surgeons use Active Tracker
technology to follow the eye’s movements during laser treatment, and Torsion Error Detection to compensate for
natural rotation of the eye while lying down. Iris recognition technology is used, which takes the OPD scan iris
information to align the cylinder treatment axis at surgery.
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Corneal Refractive Surgery Patient Selection
Eligibility Criteria for Corneal Refractive Surgery*
Type of Surgery
Refractive Range
Healing Time/Time off Work
Other Considerations
PRK
-0.75 to -8.00D
+1.00 to +2.00D
cyl -0.50D to -4.00D
7-10 days healing
1 week off work
3 days discomfort
• adequate pachymetry
• acceptable corneal topography
• may be preferred for certain
occupations (police)
• ease of enhancement
PTK
any
7-10 days healing
1 week off work
3 days discomfort
• reserved for corneal pathologies
such as scars, haze, or recurrent
corneal erosion, higher order
aberrations
IntraLASIK
-0.75 to -8.00D
+1.00 to +2.00D
cyl -0.50D to -4.00D
3-5 days
3 days off work
minimal discomfort
• adequate pachymetry
• consider rare risk of flap
dislodgement
AK
cyl -0.50D to -2.00D
Must have spherical equivalent
of almost plano if this is a
primary surgery orthogonal
cylinder axis.
1-2 days healing
minimal discomfort
• less predictable than other
refractive surgery options
• often done in conjunction with
other procedures, thus post
operative medications are those
of the primary surgery.
* The patient should be at least 18 years of age, not pregnant or nursing, with at least 12 months of stable refractions
(within +/-0.50D).
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Corneal Refractive Surgery Patient Selection
Contraindications for Corneal Refractive Surgery
Category
Condition
Comments
Ocular Pathology
Corneal scar
PRK may be preferred due to risk of flap
complication
Endothelial Dystrophy
PRK may be preferred due to risk of
endothelial cell damage with flap creation
Map Dot Fingerprint Dystrophy and/or Recurrent
Corneal Erosion
PRK may be preferred due to weak
Bowman’s layer
Herpes Simplex/Zoster with history of ocular
involvement
Considered on a case-by-case basis due to
risk of re-activation
Lid Disease i.e. Blepharitis
Must be pre-treated due to risk of infiltrates/
infection
Extreme Dry Eyes
Considered on a case-by-case basis
Phakic IOLs may be preferred
Binocular Dysfunction
If prism required in glasses and/or pt experiences
diplopia/headaches with contact lenses, then
there may be a risk of decompensation after
surgery and may require glasses with prism
after surgery.
Amblyopia (BCVA <20/40)
Pt must understand the risks/implications of
doing surgery when one eye is already weak
Nystagmus
Considered on a case-by-case basis. Consider
challenges in eye stability during the surgical
procedure.
Other i.e. macular degeneration, retinal holes
or tears
Priority will be given to the pathology first.
Consider potential vision loss due to surgery.
Autoimmune Disorders:
– rheumatoid arthritis, Sjogren’s
syndrome, Lupus
Considered on a case-by-case basis due
to risk of corneal melt
Gastrointestinal Disorders:
– Ulcerative Colitis, Crohn’s Disease,
Irritable Bowel Syndrome
Considered on a case-by-case basis due to risk
of inflammatory reaction. Must be in remission.
Diabetes
Must not have any retinopathy, and blood
sugar levels should be controlled. Consider
infection risk.
Immuno-compromised patients:
HIV, AIDS, Hepatitis
Prefer that the patient is on HART therapy and
the virus is not detectable in the blood. Consider
infection risk. For Hep B or C, consider risk of
transmission.
Accutane, Clarus
Must be off this medication for 6 months prior
to surgery due to risk of severe dryness
Systemic Pathology
Medications
gimbel.com | 10
Corneal Refractive Surgery Post Operative Care
Postoperative Medication and Follow Up Regimen
Type of Corneal Surgery
Medication/Treatment Protocol
IntraLASIK
➢
➢
➢
Prednisolone 1.0%
• qid x 7 days
Vigamox 0.5%
• qid x 7 days then stop
Artificial Tears:
• q15-30 minutes during waking hours
x 2 days, then prn
• Celluvisc for first 4 sleeps, then prn
Follow Up Schedule
Day 1,
Week 1,
Month 1
Then yearly eye examinations
Eye Shields:
• First 5-7 nights to protect the eyes/
maintain hydration
➢ PRK/PTK
➢
➢
➢
➢
➢
Vigamox 0.5%
• qid x 7 days then stop
Gabapentin
• 300 mg p.o. tid x 3 days
• okay to use Advil or Tylenol in
conjunction with Gabapentin if needed
FML 0.1%
• qid x 1 month minimum (see Extended
Medication Protocol next page)
Nevanac 0.1%
• qid on day of surgery then prn up to
qid for the first week
Tetracaine 0.5%
• last resort pain eye drop prn, used
sparingly
Day1,
Day 3,
Week 1,
Month 1,
Then monthly until 1 month after
FML is discontinued, then yearly eye
examinations
Artificial tears
• q15-30 minutes-waking hours until
contact lens is removed then prn
• Celluvisc for first 4 sleeps, then prn
Eye Shields:
• First 5-7 nights to protect the eyes/
maintain hydration
Bandage Contact Lens:
• To be removed after re-epithelialization,
with forceps, by Doctor
* Additional visits should be performed as deemed clinically necessary. The post operative co-management fee includes the first
12 months of follow up, not including the yearly eye examination.
11 | gimbel.com
PRK Post-Operative Extended Medication
All patients require FML qid for the first month. Taper regimen is based upon primary preoperative refraction.
For patients having an enhancement, the taper regimen is determined by the initial preoperative refraction prior
to the first surgery; not the current refraction.
Pre-Operative Spherical Equivalent
FML 0.1% Duration Guideline
+2.00D to -3.00D
Qid x 1 month then stop
-3.00D to -6.00D
Qid x 1 month
Tid x 1 month
Bid x 1 month
Qd x 1 month then stop
-6.00D or greater
Qid x 2 months
Tid x 1 month
Bid x 1 month
Bid/qd alternating x 1 month
Qd x 1 month
Qd every 2nd day x 1 month
Then 1 gtt 2 times per week x 1 month
Guidelines in altering FML 1% taper regimens:
1) If the patient has corneal haze, increase the dose and advise UV protection.
2) If the patient shows myopic regression, increase dose and/or maintain current dosage for longer.
3) If the patient has a hyperopic response, consider decreasing the FML dosage faster
Examples of deviation from protocol:
1. Patient’s post op Rx is -0.75D and is currently on FML bid, consider increasing to qid.
2. Patient’s post op Rx is +1.00D and is currently on FML qid, consider decreasing to bid.
3. Patient’s post op Rx is +1.00D and has significant corneal haze: treat aggressively with FML medications i.e.
qid (the need to treat the haze is priority over the hyperopia).
NOTE: Patients who show consistent regression and are more than 6 months post surgery, are unlikely to respond
to an increase in FML and should be monitored for stability in consideration of enhancement.
NOTE: All patients require monthly tonometry measurements while taking FML.
gimbel.com | 12
Corneal Surgery Post Operative Presentation
and Activity Restrictions
The following is a summary of potential symptoms and findings associated with each surgery. For the normal
findings, an expected timeline for the finding to subside is provided.
(H= hours, D= days, W=Weeks, M= Months)
Type of Surgery
Normal (Time to Subside)
Not Normal
Activity Restrictions
IntraLASIK
VA 20/15 to 20/50 (may take 3-5 days
to start improving)
Foreign Body Sensation (48 H)
Tearing/Photophobia (72H)
Dry Eyes (up to 6M)
Sub-conjunctival hemorages (2-3W)
Ghosting/Halos/Glare (2-3M)
Less contrast sensitivity (improves
up to 6M but usually reaches 98%
of original contrast)
Epithelial edema (2-4W)
Pus-like discharge
Dislocated/wrinkled
flap
Unusually high pain
Interface cloudiness
Epithelial Defect
Infiltrate
Epithelial cells under
flap
Foreign body/debris
under flap
Diffuse Lamellar
Keratitis
• No pets in the bed for
2 nights after surgery
VA 20/30 to 20/400 (up to 1W)
Mild to severe pain (48H)
Foreign body sensation (3-5D)
Tearing, Photophobia (3-5D)
Lid edema (3-5D)
Ghost images (2-4W)
Dry eyes (up to 3 M)
Halo/Glare (2-3M)
Drop in VA/diplopia (occurs at day
3-5 and is a result of fusion line
formation)(72H)
Less contrast sensitivity (improves
up to 6M but usually reaches 98%
of original contrast)
Descemet’s Folds (72H)
Epithelial Defect (3-5D)
Presence of Contact Lens (remove
after re-epithelialization)
Pus-like discharge
Infiltrate/infection
Anterior chamber cells
Non-healing epithelial
defect (beyond
5-7 days)
Raised IOP (check
after 3W)
Corneal haze
PRK/PTK
*AK does not have the
same discomfort elements
as PRK and PTK
• No eye make-up
for 7 days
• No swimming,
hot tub, water sports
for 21 days
• No Dusty/smoky
environments for
21 days
• No eye rubbing for
6 weeks
• UV protection for
6 months
• Safety glasses during
appropriate activities
• No heavy lifting x
3-4 days
• No upside-down
positions i.e. yoga
x 3-4 days
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Corneal Refractive Surgery Complications
This list contains the most likely observed complications. If you have any questions please contact us.
Complication
IntraLASIK
PRK/PTK/
AK
Description
Treatment
Dry Eyes
X
X
Common after surgery and usually
improves over time although can be
permanent. If severe diffuse SPK noted,
consider preservative toxicity.
Traditional Dry Eye
Therapy modalities
Inflammation
X
X
May present as whitish distinct or diffuse
infiltrates sometimes in a perilimbal
arcuate pattern. Risk of corneal melt in
rare cases. Look for corneal thinning. May
be associated with systemic autoimmune
conditions.
Refer to GEC for
assessment. Prompt
and aggressive
treatment is needed.
Halos/ Starbursts
X
X
Usually diminish over a few months but
can be permanent and affect night driving.
Patients with large pre-op pupil size should
be advised of this potential risk.
Usually subsides but
can use yellow tinted
glasses, or Alphagan
gtts prn
Epithelial Ingrowth
X
Migration and proliferation of epithelial cells
under the flap. More common after relifting
of a flap i.e. enhancements. May cause
blurry vision, FBS, dryness, tearing.
Monitor, if migrating
more than 1 mm
consider surgical
intervention.
Infection
X
X
Rare but possible. Ulcers, epithelial
defects, haze, decrease in vision, pus-like
discharge, red eye.
Contact GEC for
guidance in treatment
Corneal Haze
X
X
With IntraLASIK can have patchy areas
of haze that are not clinically significant.
With PRK it appears like superficial white
grainy subepithelial cells that don’t stain.
It typically presents within 1 month and
peaks around 2-3 months before subsiding.
For PRK: Advise
UV protection, treat
with steroids. In rare
cases, PTK may be
considered.
Ectasia
X
X
Corneal instability resulting in refractive
error, vision decline with visual distortion.
Usually requires topography to diagnose.
Refer to GEC for
assessment if vision
affected.
Flap Disturbances
X
Mild wrinkles, shifting of flap, striaie
formation. May or may not be visually
significant.
Refer to GEC for
assessment.
More on next page…
gimbel.com | 14
Corneal Refractive Surgery Complications
and Treatment (con’t)
Complication
Intra
LASIK
PRK/PTK/
AK
Description
Treatment
Epithelial Erosion
X
X
May result in loose epithelium, rough
edges or defects especially along flap
margin in IntraLASIK, or ablation zone
in PRK. Foreign body sensation, pain
especially when opening eyes in the
morning, decrease in vision. Increases risk
of DLK and epithelial ingrowth in IntraLASIK
patients. May subside as eye heals further.
Copious nonpreserved lubrication.
Some cases may
require antibiotics and/
or bandage contact
lens. Rarely, PTK may
be considered.
Diffuse Lamellar
Keratitis (Sands
of Sahara)
X
Rapid onset, non-infectious white blood
cells reaction in the interface (looks like fine
white grainy cells). May have pain, blurry
vision, FBS, photophobia and can rapidly
progress if not aggressively treated. In early
stages may be asymptomatic and limited to
the periphery of the flap, and one needs to
rely on clinical diagnosis. More severe cases
can involve the central cornea, and present
with sand-dune-like cell accumulation, hazy
flap, edema and striaie. Usually occurs
within 1-3 days post-operatively but can also
present later in cases of trauma.
Prompt and aggressive
treatment is needed.
Please contact
GEC immediately
so the surgeon
can be involved in
treatment as this has
the potential to have
permanent vision
effects.
Refractive Error
X
May be due to regression (mild keratometry
changes from either epithelial fill-in or prolific
epithelial growth resulting in refractive error).
May settle/resolve over time. May also be
influenced by dry eyes, therefore dry eye
therapy is recommended for all patients
with post-operative refractive error.
Consider enhancement
after 3 months of stable
vision. Coverage is
18 months. Minimum
refractive error is
>0.50D. May enhance
only one eye at a time.
If deemed unsafe, the
surgeon may advise
against further surgery.
X
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Phakic IOL Refractive Surgery Descriptions
Phakic IOLs refer to synthetic implants that are inserted into the eye without removing the natural crystalline lens.
They are considered a “premium” option as they provide superior quality of optics compared to corneal refractive
surgery in all but relatively small refractive errors. They are removable, preserve remaining natural accommodation,
and pose less retinal risk compared to lensectomy surgeries i.e. Refractive Lens Exchange. Please be aware that the
need for special testing, calculations, and lens implant ordering times necessitates a processing time of 1-3 months
from the date of the initial consultation to the actual surgery date. Gimbel Eye Centre currently performs two types
of Phakic IOL surgeries:
Implantable Collamer Lenses (ICL)
Performed at Gimbel Eye Centre since 1997, this implant sits in the posterior chamber, supported by the sulcus
and aqueous humour pressure. Prior to the day of surgery, a prophylactic peripheral iridotomy will be performed
(usually 2 iridotomies between the 10 and 2 o’clock position in the eye). This is done to ensure adequate aqueous flow.
Occasionally, a single Surgical Iridectomy will be chosen instead, if the patient’s irises are very darkly pigmented.
The surgery takes about 15 minutes per eye, involves less than a 3 mm self-sealing clear corneal incision, and usually
no stitches or needles are required. After the incision is made, and the anterior chamber is filled with a viscoelastic
material, the implant is placed initially in the anterior chamber. Then the plate haptics are manipulated to go
behind the iris, so that the implant vaults over the natural crystalline lens. If a Toric Implant is inserted, the surgeon
manipulates the implant to the desired orientation. The viscoelastic material is flushed from the eye and care is taken
to ensure the wound is secure. These implants are not visible to the naked eye.
Angle Supported Phakic IOL (Cachet)
Performed at Gimbel Eye Centre since 2010, this surgery differs from ICL in that the lens (or implant) is placed in
the anterior chamber. It is supported by its flexible haptics nestled in the anterior chamber angle, similar to a shower
curtain rod. The surgery takes about 15 minutes per eye, involves less than a 3 mm self-sealing clear corneal incision,
and usually no stitches or needles are required. After the incision is made, and the anterior chamber is filled with
a viscoelastic material, the implant is placed in front of the iris in the anterior chamber. The flexible haptics are
manipulated into position. The viscoelastic material is flushed from the eye and care is taken to ensure the wound is
secure. These implants can be cosmetically visible at close range with proper lighting, much like the edge of a contact lens.
gimbel.com | 16
Phakic IOL Surgery Patient Selection
Eligibility Criteria for Phakic IOL Surgery
Type of Surgery
Refractive Range
Healing Time/Time off Work
ICL
-2.75D to -20.00D
+2.00D to +14.00D
cyl up to -5.00D (myopic
torics only)
3 days healing
1 week off work (for
numerous appointments)
• Minimum AC depth
2.6/2.75 mm. Younger
patients need more
generous AC depth
• Corneal diameter
10.50 - 13.00 mm
• Bioptics can be considered
Cachet
-6.00D to -16.50D
3 days healing
3-4 days off work (for
numerous appointments)
• Minimum AC depth plus
pachymetry = 3.2 mm
• Must meet minimum age
adjusted endothelial cell count
• Mesopic pupil size <7.00D
• Corneal diameter
10.50 - 13.00 mm
• Bioptics can be considered
* The patient should be at least 18 years of age, not pregnant or nursing, with at least 12 months of stable refractions (within +/-0.50D).
Contraindications for Phakic IOL Surgery
Category
Condition
Comments
Ocular Pathology
Glaucoma
May impede aqueous flow
Pigment Dispersion Syndrome
Implant may interact with weakened iris
layer, worsening the condition
Recurrent Uveitis
Implant may exacerbate the condition
Binocular Dysfunction
If prism required in glasses and/or pt
experiences diplopia/headaches with
contact lenses, then there may be a risk
of decompensation after surgery
Amblyopia
Pt must understand the risks/implications
of doing surgery on an amblyopic system
Other i.e. macular degeneration, retinal
holes/tears
Priority will be given to the pathology first.
Consider potential vision loss.
Diabetes
Must not have any retinopathy, and blood
sugar levels should be controlled. Consider
infection risk.
Immuno-compromised Patients: HIV, AIDS,
Hepatitis
Prefer that the patient is on HART therapy
and the virus is not detectable in the blood.
Consider infection risk. For Hep B or C,
consider risk of transmission.
Systemic Pathology
17 | gimbel.com
Phakic IOL Postoperative Care
Postoperative Medication and Follow Up Regimen
Type of Phakic IOL Surgery
Medications/Treatment Protocol
Follow Up Schedule
ICL
Prednisolone 1.0%:
• qid starting day of surgery until 1 week
post op
• bid x 2 weeks
Day 1,
Week 2,
Month 2,
Month 6,
Month 12,
then yearly eye examinations
Vigamox 0.5%:
• qid starting 1 day pre-op until 1 week
post op
Emergency Medications:
Cyclogel 1.0% bid x 3 days
Phenylephrine 10% bid x 3 days
(to be taken if symptoms of brow ache,
pt to first contact their follow up Doctor)
Artificial tears:
q1h for 1-2 days then prn
Cachet
Prednisolone 1.0%:
• qid starting day of surgery until 1 week
post op
• bid x 2 weeks
Vigamox 0.5%:
• qid starting 1 day pre-op until 1 week
post op
Artificial tears:
• q1h for 1-2 days then prn
Day 1,
Week 2,
Month 2,
Month 6,
Month 12,
then yearly eye examinations
*Pt is required to return to GEC every 6
months for Specular Microscopy for an
indefinite period of time. The patient will
remain with their Primary Eyecare Provider
for all routine eye care. The fee for each
Specular Microscopy visit is $75.
*Please do once yearly gonioscopy testing
to monitor for angle synechiaie
*Additional visits should be performed as deemed clinically necessary. The post operative co-management fee includes the first
12 months of follow up, not including the yearly eye examination.
gimbel.com | 18
Phakic IOL Post Operative Presentation
and Activity Restrictions
Type of Surgery
Not Normal
ICL
VA 20/15 to 20/50
(accommodation may be
affected by pupil dilation)
Dry Eyes (up to 2M)
Ghosting/Halos/Glare (may take
a while for pupil to return to
normal size )(6M)
Edema at the incision side (1W)
Pupil Dilation (48H)
Vault 2-4+ (see next page)
Orientation should be on target
immediately
Mild AC reaction (1-2+ cells,
1+flare)
Pus-like discharge
Wound gaping/leak
Unusually high pain
Epithelial Defect
Elevated IOP
High Vault (see next page)
Low to No Vault
Shallow Angle
Iris to Corneal touch
Iris Transillumination
Non resolving anterior
chamber reaction
Iridotomy not patent
Progressively excessive
deposits on the IOL
Anterior subcapsular lens
changes
ICL is rotated (see next page)
Retinal Detachment
VA 20/15 to 20/50
Dry Eyes (up to 2M)
Ghosting/Halos/Glare 6M)
Edema at the incision site (1W)
Pus-like discharge
Wound gaping/leak
Unusually high pain
Significant corneal haze
Non-resolving Descemet’s folds
Elevated IOP
Progressive pigment on IOL
Implant sits close to the cornea
Pupil irregular
Haptics not located in angle
Anterior Subcapsular lens
changes
Iris Transillumination
Non resolving AC reaction
Cachet
• No pets in the bed for 2 nights
after surgery
• No eye make-up for 7 days
• No swimming, hot tub, water
sports for 14 days
• No Dusty/smoky
environments for 14 days
• No vigorous eye rubbing
19 | gimbel.com
Phakic IOL Postoperative Evaluation Considerations
The Phakic IOLs have special considerations during the follow up care. If you have any questions please contact us.
Type of Surgery
Special
Consideration
Description/Evaluation
Interpretation
ICL
Vaulting
The subjective assessment of how
many central IOL thicknesses could be
placed in the space between the natural
crystalline lens and the implant. This may
be influenced by implant length, thickness,
position in the sulcus, trapped viscoelastic
fluid behind the implant, and PI patency.
Example: 2 IOL thicknesses= 2+ vault
• Vault less than 1+ poses risk
of cataract formation
• Vault more than 4+ poses
risk of pupil block
In both situations, GEC should
be notified.
Orientation
The subjective assessment of the location
of the Toric engraving on the implant
haptic, in relation to a 180 degree scale.
Must be done dilated to see the marking.
Example: 030 degrees
*Note this does NOT equal refractive
error axis
• If orientation does not
match intended orientation,
refractive error will be
impacted
• Consider improper implant
rotation if pt presents with
a significant hyperopic
astigmatic error
Example: +2.50-2.50 x 010
Vaulting
Given the very flexible haptics, the implant
length is much more forgiving in these
implants. In general one would like to see a
small vault over the iris so as not to rub the
iris, but not too high as to risk endothelial
damage.
• A very high vault may risk
endothelial cell damage
over time
Orientation
Although Cachet implants are not available
in astigmatic correction, and therefore
orientation does not impact refractive
error, practitioners are still encouraged to
document the physical orientation of the
implant in relation to a 180 degree scale.
Rotation would indicate too loose a fit or
eye rubbing
• Implant rotation would
risk damage to the
trabecular meshwork
and/or endothelium.
Cachet
gimbel.com | 20
Phakic IOL Surgery Complications and Treatment
Complication
ICL
Cachet
Description
Treatment
Pupil Block
X
X
Pain, brow ache, photophobia, blur, nausea,
elevated IOP. Usually occurs early postoperatively and can be associated with
implant length, trapped viscoelastic fluid,
or PI patency issues.
Contact GEC ASAP for
guidance as the treatment
varies with different causes
of pupil block and amount
of IOP elevation.
Cataract
X
X
Occurs later postoperatively (mean time is 3
years) and is often associated with low vault.
It is important to distinguish implant related lens
changes (anterior subcapsular) versus natural
progression of age-related (nuclear sclerosis
or cortical spoking).
Contact GEC for guidance
in treatment. The risk of
removal and replacement
of the implant has to be
considered (traumatic
cataract).
Infection
X
X
Endophthalmitis is rare. Unilateral red, painful
eye, anterior and/or posterior chamber reaction,
blurry vision, hypopyon, white clumps in vitreous.
Contact GEC immediately
for surgeon guidance as
this is a potentially sight
threatening condition.
Intraocular
Inflammation
X
X
Significant AC reaction.
Aggressive steroidal
treatment, contact GEC.
Corneal Haze/
Decompensation
X
X
Descemets folds, corneal edema, decrease
in vision.
Muro 128 gtts qid, contact
GEC if no improvement
after 72 hours.
Dry Eyes
X
X
Common early post-operatively but longer term
is less risk than corneal refractive surgery and
similar to cataract surgery.
Traditional Dry Eye Therapy
Modalities
Halos/glare
X
X
More common with Cachet as the lens is more
anterior to pupil. Greater risk with large pupils
and high correction. May subside over time.
May subside after 6
months, monitor. Alphagan
gtts prn may be considered.
Refractive Error
X
X
May be associated with temporary corneal
edema. May also be associated with implant
rotation.
Consider etiology and treat
accordingly. Bioptics may
be considered.
Implant Rotation
X
X
Usually obvious by the 2-week check after
surgery. Refractive error and blur are present
if toric ICL. Often a hyperopic astigmatic error.
Contact GEC for surgical
treatment consideration.
Wound Leak
X
X
Very low IOP, ache, blur. Globe soft on palpation.
+/- Seidel sign. Wound may be gaping.
Contact GEC ASAP for
surgical intervention, risk
of endophthalmitis.
X
Cachet: pupil ovalization
Cachet: Angle synechiaie
Monitor, contact GEC if
IOP affected.
Other
21 | gimbel.com
Refractive Lens Exchange/Cataract
Extraction Descriptions
Surgery Description
Refractive Lens Exchange (RLE) and Cataract Extraction (CE) are both intraocular lensectomy procedures that have
been performed at Gimbel Eye Centre for several decades. The surgeon creates a strategically placed incision near
the cornea or at the limbus, usually 2.2 mm in length. The anterior chamber is filled with viscoelastic gel. An anterior
capsular curvilinear capsulorhexis (CCC) is made with forceps and the lens is removed with a phacoemulsification
technique. The synthetic implant is inserted and placed within the natural lens’ capsular bag. If a Toric Implant is
inserted, the surgeon manipulates the implant to the desired orientation. The viscoelastic material is aspirated from
the eye, intra ocular antibiotics are instilled and care is taken to ensure the wound is secure.
Alberta Health Care (AHC) Covered Services
It is an ongoing challenge to the ophthalmological community to manage the aging population’s growing need for
cataract extraction. All cataract surgeons are given a finite number of cataract surgery allotments each year, which
directly influences the length of the waiting lists, and this can change depending on the political environment.
As lens changes are part of aging (as are a few wrinkles and a few grey hairs), patients with early lens changes are
not classified as cataracts. They can be monitored until such time as the changes become significant enough to be
disabling and require a medically necessary cataract operation. Also, choosing the option of uninsured Refractive
Lens Exchange (RLE) for refractive purposes may be considered. We are committed to working within the public
healthcare system, while respecting the needs and desires of the patient.
Implant Choices
Over the years the lensectomy procedure has evolved with improved surgical techniques and implant choices, and
consequently the expectations of the patient has risen. At Gimbel Eye Centre we are constantly evaluating technological
advancements and weighing them against current market demands. It is our position at Gimbel Eye Centre that no
implant choice can provide a total replacement for natural accommodation. However, with careful patient selection, we
can offer the patient a wide selection of implant choices and tailor the treatment plan to the individual’s lifestyle. In the
section titled Refractive Lens Exchange/Cataract Surgery Lifestyle Implant Choices, we will discuss the implant
choices currently offered at Gimbel Eye Centre. The choice of implant is a very personal choice made between the
patient and the surgeon. Any insight you can give us regarding your patient’s lifestyle is immensely helpful in arriving
at the final implant choice.
gimbel.com | 22
Refractive Lens Exchange/Cataract Surgery
Patient Selection
Eligibility Criteria for Refractive Lens Exchange/Cataract Surgery
Type of Surgery
Refractive Range
Healing Time/Time
Off Work
Refractive Lens
Exchange
All ranges of correction
IOL powers available
-10.00D to +40.00D
Astigmatism:
-0.75D to -11.00D
Toric considered if corneal cyl
>=-0.50D
3-5 days healing
3-5 days off work
• careful lifestyle review will influence
implant selection
• pt is responsible for all costs
• pt must understand loss of
accommodation and the limitations
of lifestyle implants
Cataract Surgery
All ranges of correction
IOL powers available
-10.00D to +40.00D
Astigmatism:
-0.75D to -11.00D
Toric considered if corneal cyl
>=-0.50D
3-5 days healing
3-5 days off work
• only a standard spherical implant
is covered under AHC
• for all other implant choices, pt to
pay the difference
• pt must understand loss of
accommodation and the limitations
of lifestyle implants
Contraindications for Refractive Lens Exchange/Cataract Surgery
Category
Condition
Comments
Ocular Pathology
Endothelial dystrophy/poor endothelial
morphology
Rarely, corneal decompensation can occur,
sometimes requiring corneal transplant.
Any acute ocular condition that warrants
priority treatment
Example: uncontrolled glaucoma or wet
macular degeneration or retinal pathology
• Priority treatment is given to the acute ocular
condition before surgery.
• A risk/benefit analysis should be viewed quite
differently between an elective (RLE) and
medically necessary procedure (cataract surgery)
Immuno-compromised Patients:
HIV, AIDS, Hepatitis
Prefer that the patient is on HART therapy and the
virus is not detectable in the blood. Consider infection
risk. For Hep B or C, consider risk of transmission.
Congestive Heart Failure, COPD and other
lung problems
If necessary, the surgery can be performed with the
chest elevated 30-45 degrees.
Flomax
Risk of Floppy Iris Syndrome. GEC would like to be
informed in advance if pt is taking this medication.
Systemic Pathology
Medications
23 | gimbel.com
Lifestyle Implant Choices
Careful screening of patient’s lifestyle should be done prior to implant selection.
Implant Type
Description
Advantages
Disadvantages
Comments
Fixed Focus
(Acrysof, Acrysof
Toric, Rayner T Flex
Toric etc.)
The traditional
treatment using a fixed
focus implant to either
target OU distance,
intermediate, near or
monovision.
Highest quality optics
Only one ideal range
for each eye — the
patient is expected
to be dependent on
glasses for all other
ranges.
Toric considered for
corneal cyl greater
than -0.50D.
Monovision
(same brands as
above)
Using a fixed focus
implant targeting one
eye for near (-1.00D
to -2.50D).
Greater range of
functional vision
Distance vision quality
compromise.
May affect depth
perception.
Recommend trialing
with contact lenses
prior to surgery if
possible. Please
note this will not be
exact demonstration
of surgery due
to presence of
lens changes/
loss of remaining
accommodation.
Accommodative
(Tetraflex)
Implant is designed to
move forward with the
movement of ciliary
body for near work.
Single optics therefore
minimal compromise
in quality of vision.
Higher incidence of
residual refractive
error .
High incidence
of needing YAG
treatment
May have gradual
loss of near benefit as
fibrotic tissue forms.
Pt should be prepared
to do 6 months of near
vision exercises to
“train” how to maximize
lens advantages.
Should try to avoid
reading glasses as
much as possible.
Multifocal
(Restor, Restor
Toric. Rayner M Flex,
Rayner M flex T)
Power is in annular
rings which splits the
images in a refractive
or diffractive pattern.
Functions may be
influenced by changes
in pupil size during
far/near work.
Better refractive
predictability than
Accommodative
implants.
Loss in contrast
sensitivity/distance
vision quality. Potential
halos or rings of lights
around light sources
at night.
Intermediate range is
the weakest.
Neural adaptation
may have symptoms
reduce after 2-6
months.
Sulcoflex
Pseudophakic
supplementary IOL
can provide additional
sphere, toric or
multifocal power to
the eye.
Removable
Predictable outcomes
The multifocal
choice has the same
disadvantages as
noted above but is
easily removable.
A removable option
that can be done
during primary
surgery or as
secondary surgery
gimbel.com | 24
Refractive Lens Exchange/Cataract Surgery Post
Operative Care
Post Operative Medication and Follow Up Regimens
Type of Surgery
Medication/Treatment Protocol
Refractive Lens Exchange
Vigamox 0.5%:
qid starting 1 day pre-op until 1 week
post op
Prednisolone 1.0%:
• qid starting day of surgery until
1 week post op
• bid x 2 weeks
Follow Up Schedule
Day 1, Week 2, Week 8 then yearly
eye examinations
Artificial Tears:
• q1/2 hour x 3 days
• prn afterwards
Glasses:
• Should allow 4-6 weeks for capsular
contraction before prescribing glasses
for any residual refractive error.
Cataract Surgery
Vigamox 0.5%:
qid starting 1 day pre-op until 1 week
post op
Prednisolone 1.0%:
• qid starting day of surgery until
1 week post op
• bid x 2 weeks
Day 1, Week 2, Week 8 then yearly
eye examinations
Artificial Tears:
• q1/2 hour x 3 days
• prn afterwards
Glasses:
• Should allow 4-6 weeks for capsular
contraction before prescribing glasses
for any residual refractive error.
*Additional visits should be performed as deemed clinically necessary. For RLE, the post operative co-management fee includes
the first 12 months of follow up, not including the yearly eye examination. For Cataract Surgery, billing is in compliance with
Alberta Health Care Regulations.
25 | gimbel.com
Refractive Lens Exchange and Cataract Surgery Post
Operative Presentations and Actvity Restrictions
Type of Surgery
Not Normal
Refractive Lens Exchange/
Cataract Surgery
VA 20/15 to 20/50
(consideration should
be given to other ocular
conditions affecting BCVA)
Foreign Body Sensation
(48 H)
Dry Eyes (up to 2M)
Ghosting/Halos/Glare (2-3M)
Edema at the incision site
(1W)
Pupil Dilation (24H)
Reflections/Distortions from
IOL (4W)
Increase in floaters (indefinite)
Mild AC reaction (1-2+ cells,
1+flare)Change in pupil
size/shape
Pus-like discharge
Wound gaping/leak
Unusually high pain
Epithelial Defect
Elevated IOP
Significant anterior chamber
reaction
Fibrous tissue formation
Hypopyon
Lens is rotated (Toric)
Retinal Detachment
Posterior capsular
opacification
Macular Edema
Implant not sitting “in the
capsular bag”
Implant displaced from
central position
Posterior capsular tear
Implant decentration off of
the visual axis (especially
for multifocal implants)
• No pets in the bed for 2
nights after surgery
• No eye make-up for 7 days
• No swimming, hot tub,
water sports for 21 days
• No Dusty/smoky
environments for 14 days
• No eye rubbing
gimbel.com | 26
Complications and Treatment
Complication
Description
Treatment
Infection
Endophthalmitis is rare. Unilateral red,
painful eye, anterior and/or posterior
chamber reaction, blurry vision,
hypopyon, white clumps in vitreous.
Contact GEC immediately for surgeon
guidance as this is a potentially sight
threatening condition. Hours of waiting
can make a big difference.
Elevated IOP
Common early postoperatively, trapped
viscoelastic fluid. May or may not be
symptomatic.
Topical and oral medications. If IOP
> 40 mm Hg consider paracentesis
aqueous drainage by the surgeon.
Intraocular Inflammation
Significant AC reaction. Rarely fibrous
strands across the pupil.
Aggressive steroidal treatment –
Prednisolone 1% q1h, Atropine 1% or
at least Cyclopentolate 1% , contact
GEC.
Corneal Haze/Decompensation
Descemets folds, corneal edema,
decrease in vision.
Muro 128 gtts qid, can also add Pred
Forte 1.0% qid if needed, contact GEC
if no improvement after 72 hours.
Cystoid Macular Edema
Painless decrease in vision usually after
the first few weeks. Elevated macula
with or without hemorrhages.
Contact GEC for further diagnosis
(OCT) and treatment considerations.
Posterior Subcapsular Opacification
Painless decrease in vision usually after
the first few weeks. Posterior capsule
may have white or clear fibrotic cells,
Elschnig pearls, or visually significant
striations.
Non-urgent referral to GEC if visually
significant.
*YAG treatment preferably deferred
until 3 months post op if possible to
minimize risks of treatment.
Retinal Detachment/Hemorrhage
Painless decrease in vision associated
with increase in floaters, flashes, or
curtain to side of vision. May also see
hemorrhages/red blood cells in the
vitreous/retina.
Urgent referral to retinal specialist.
Refractive Error
May be associated with temporary
corneal edema near the incision. May
also be associated with implant rotation.
Consider etiology and treat accordingly.
Consider further refractive surgery, or
glasses, after 6-8 weeks.
Implant Dislocation
Usually a result of trauma with zonular
tears if capsule and IOL are subluxated
by the CCC. May subluxate months or
years after surgery.
Refer to GEC for surgical treatment.
27 | gimbel.com
Collagen Cross Linking Description
Collagen Cross Linking
The concept of collagen cross linking has been prevalent in dentistry for several decades. In ophthalmic practice,
collagen cross linking has been used to treat pathological corneas such as keratoconus for a number of years.
Historically, the Collagen Cross Linking procedure (CXL) required a corneal soak with Riboflavin (vitamin B2)
for about 30 minutes and then exposure to UV light for 30 minutes. Originally it was believed that this process
strengthened the collagen fibrils, but more recent studies suggest it increases the bond strength in between the
collagen. This would be similar to adding more and stronger rungs to a ladder, if the sides of the ladder were the
collagen fibrils. The UV exposure is equivalent to about one day in the sun. The procedure results in a strengthening
of the cornea to almost 4 times its original strength, thus stabilizing the cornea. In addition, Mi et al have reported
that cross linking during the laser procedure increases the flap-to-interface adhesion, thus potentially reducing the
risk of epithelial ingrowth and/or flap dislodgement.1 The cross linking process has evolved, and Gimbel Eye Centre
Calgary location is pleased to provide Accelerated Collagen Cross Linking (KXL) with the Avedro system. The
higher energy allows for a much shorter Riboflavin soak time of 1-5 minutes and UV exposure of 3-5 minutes. The
speed of this new technology allows us to incorporate the procedure more easily into a refractive practice and opens
up the possibilities of routine usage. The total energy absorption remains the same, therefor one can expect equivalent
results to the previous technology, but in a more practical timeframe. There are two types of situations in which KXL
is performed at Gimbel Eye Centre:
Prophylactic Treatment
Patients may opt to have Prophylactic KXL treatment in conjunction with their corneal refractive surgery especially
if there is a pre-operative risk factor for corneal instability. The refractive procedure is performed as usual, and after
the laser ablation, the cornea is soaked with a riboflavin solution. If IntraLASIK, the flap is replaced prior to UV
light KXL treatment. If PRK, the UV light KXL treatment is done prior to bandage contact lens placement. The
healing experience and follow up are the same as regular IntraLASIK or PRK surgery. If a patient opts for this
treatment option, their procedures are called IntraLASIK Xtra or PRK Xtra. Post operative care is equivalent to the
primary corneal surgery undertaken.
Therapeutic Treatment
Patients who have diagnosed pathology on the cornea may undergo KXL treatment to stabilize the corneal
pathology. Examples of potential Therapeutic KXL candidates are people who have frank Keratoconus, Pellucid
Marginal Degeneration, or Iatrogenic Ectasia. In the future, patients who suffer from vision fluctuation as a result
of previous Radial Keratotomy procedures may also be candidates. The treatment approach is carefully evaluated by
our experienced surgeons, and may include some ablation of the tissue (PRK) for some or all of the refractive error.
Currently, therapeutic treatment patients require epithelial debridement to prepare the cornea for the Riboflavin soak,
and therefore the healing time/follow up and medication schedule is the similar to a PRK patient. Performing the
surgery without removing the epithelium is available on a limited, case-by-case basis but may soon be the norm as a
new formulation of riboflavin becomes available. It is recommended that these patients have a regular post operative
topographical analysis of their corneas. Currently this procedure is not an Alberta Health Care insured service.
gimbel.com | 28
Accelerated Collagen Cross Linking (KXL) Patient
Selection
Eligibility and Contraindications for Collagen Cross Linking
Type of Treatment
Clinical Findings
Contraindications
Comments
Prophylactic
Minimum residual corneal
bed depth after laser
ablation of 325 microns
Some eligible risk factors
are:
• Young age
• Thin corneas
• Minor topographical
asymmetry
• Against-the-rule
astigmatism
• Steep Keratometry
Pseudophakia if no IOL UV
protection
Aphakia
Macular Degeneration
Pregnancy
Herpetic keratitis
Rheumatoid disorders
Known riboflavin allergy
Patients who are diagnosed
with corneal pathology and
are not good candidates for
refractive surgery
The minimum corneal
thickness of 325 microns is
to protect the endothelium
and is an improvement over
the previous technology
(minimum was 400 microns)
*Patients must discontinue
vitamin C supplements for 1
week prior and 1 week after
surgery
Therapeutic
Minimum starting
pachymetry of 325 microns
Corneal pathology such
as:
• Keratoconus
• Pellucid Marginal
• Degeneration
• Iatrogenic Ectasia
Pseudophakia if no IOL UV
protection
Aphakics
Macular Degeneration
Pregnancy
Herpetic keratitis
Rheumatoid disorders
Known riboflavin allergy
Currently not insured by
Alberta Health Services
The minimum corneal
thickness of 325 microns is
to protect the endothelium
and is an improvement over
the previous technology
(minimum was 400 microns)
*Patients must discontinue
vitamin C supplements for 1
week prior and 1 week after
surgery
29 | gimbel.com
Presbyopia, Monovision and the Role of the
Co-managing Doctor
The Presbyopic Conundrum
All ophthalmic practitioners are familiar with the longstanding Achilles heal of our industry—the inevitable onset
of Presbyopia. When preparing for Refractive Surgery of any type, careful consideration must be given to the effect
on near vision. For example, presbyopic patients who are used to removing their glasses to read must understand
their current near benefit, and the need for glasses for all tasks arms length and closer after surgery. Refractive Lens
Exchange patients also need to have this emphasized, and told that even a monovision trial with contact lenses isn’t a
true demonstration given the removal of the accommodative lens after surgery.
Monovision
The technique of Monovision has been used in prescribing optical devices and in surgeries for decades. The obvious
advantage is a wider range of functional vision, at the sacrifice of some distance clarity and perhaps some depth
perception. For Refractive Lens Exchange and Cataract patients, it is the ONLY surgical option that uses the highest
quality single fixed focus implant while still giving a wide range of vision. It is important to recognize that although
there are other “premium” options available such as accommodative and multifocal options, they come at a sacrifice of
vision quality. Monovision is the only option where most concerns regarding vision quality can be easily alleviated by
a pair of task-specific glasses. With this in mind, Monovision is the most widely used technique to address the needs
of the presbyope at Gimbel Eye Centre.
The Monovision Trial
Recognizing that not every patient will easily adapt to a monovision system, a monovision trial is required prior to
surgery. Gimbel Eye Centre encourages the patient to work with their Primary Eyecare Provider in fitting, trialing,
and adjusting their own individual monovision system, via contact lenses, to ensure acceptance and adaptation prior
to undergoing surgery. This step is an essential component prior to the surgeon making final decisions/calculations
for surgery. We encourage the patient to trial monovision for a few days to a few weeks in order to experience what
monovision feels like in their own daily environment. The patient should expect to pay the appropriate fees to the
Primary Eyecare Provider for this service. Once the trial is completed, we ask that the Primary Eyecare Provider
send a report detailing the final monovision fit information (see Monovision form included in this guide). Included
in this report we request that you provide a contact lens over-refraction using the final set of contacts that were
deemed ideal for the patient. This is in recognition of vertex differences, tear film qualities and astigmatism masking
in the contact lens.
gimbel.com | 30
Special Consideration in Refractive Surgery
There will always be special circumstances that may arise surrounding Refractive Surgery. Below are a few of these
situations:
Previous RK patients
Radial Keratotomy (RK) was one of the first refractive surgeries performed at Gimbel Eye Centre in the mid 1980’s.
A diamond knife was used to create spoke-like incisions on the cornea to flatten the overall curvature. Although
quite successful considering the choices available at the time, many patients have experienced a moderate to high
hyperopic drift over the years. They may also experience moderate fluctuations in refractive error throughout the
day. Patients with this condition desiring refractive surgery should have multiple refractions performed, at different
times of the day, to carefully evaluate the range of refractive errors. Choices of surgery may include Refractive Lens
Exchange, Phakic IOLs, or PRK surgery depending on the circumstance.
Refractive Surgery for the Unusual or High Refractive Error
Sometimes the patient’s refractive error exceeds any surgical option available. In these cases, a Bioptic procedure can
be considered–where multiple procedures can be combined to achieve the desired result. Usually the primary surgery
will be chosen to address the majority of the prescription. For example, a +12.00-3.00 x 010 patient could consider an
ICL for their hyperopia, then consider corneal refractive surgery for the remainder of the astigmatism. In these cases,
the patient will likely wait 2-4 months in between the procedures to allow for stabilization, and the patient should be
advised of the need of a pair of interim glasses.
Refractive Surgery for Keratoconics
A keratoconic patient is a good example of a potentially difficult refractive error to manage, due to corneal pathology.
Often it is a challenge to work within the traditional methods of optical devices due to the refractive error. Gimbel
Eye Centre has successfully treated many of these patients with Phakic IOLs. More recently, PRK with topography
guided segmental ablation with therapeutic cross linking has been introduced into the practice when the refractive
error is low to moderate. Although it is recognized that the refractive procedure has not halted the underlying
pathological condition after cross linking, it can bring the patient’s refractive error into a more manageable range and
can be used in conjunction with other optical devices. Often the overall optical quality of the vision may improve, by
neutralizing the majority, if not all, of the current refractive error.
Second Opinions
Gimbel Eye Centre welcomes requests for second opinions on patients who have had surgery at another clinic and
desire an assessment of their results/concerns. We are committed to provide an honest, but diplomatic consultation
and make every effort to respect the patient’s needs and fears, as well as our colleague’s need for respectful
consideration.
31 | gimbel.com
Fee Information
All prices are per eye unless otherwise indicated. This is a general range of fees, apply to Alberta residents only,
and are subject to change. Additional fees may apply for special circumstances such as out-of-province patients or
complex intraocular cases. Please contact us for residents outside of Alberta.
Procedure Type
Total Patient Fee
Primary Eyecare Provider
Co-management Fee
(deducted from Fee)
IntraLASIK or PRK
$1800
$225
IntraLASIK Xtra or PRKXtra
(prophylactic cross linking with
refractive laser tx)
$2200
$225
Therapeutic KXL
(may or may not include
therapeutic laser tx)
$2500
$225
AK/LRI (if primary surgery)
$1170
$225
AK/LRI (if done at same time as
another primary surgery)
$250
—
ICL/TICL
$3800/$4150
$225
Cachet
$4200
$225
RLE (fee depends on implant
chosen)
$2500-5350
$225
Cataract with Standard IOL
No fee to patient (AHC covered)
Charge to AHC accordingly
Cataract with Premium IOL (toric,
multifocal, etc.)
$765-3000
Charge to AHC accordingly
Bioptics (add to primary surgery fee)
$1175
—
Second Opinion
$250 (single fee, not per eye)
Secondary Corneal Surgery
(when Primary Surgery was done
elsewhere)
$2525
$225
Secondary Intraocular Surgery (add
fee to regular cost of procedure)
(when Primary Surgery was done
elsewhere)
$1000
$225
gimbel.com | 32
Frequently Asked Questions
Will I be awake for the surgery?
Yes, all of our procedures are done while the patient is awake, and topical anesthesia is used to numb the eye before
surgery. Medication can be given prior to surgery to reduce anxiety.
What if I can’t keep my eye open?
A fine eyelid speculum is used to gently hold the eyelid open during surgery, while the other eye is covered by a
shield. Try not to squeeze your eyes during surgery, and breathe normally.
Will the treatment be permanent?
Consider refractive surgery like resetting the prescription. Once the vision stabilizes after the initial healing period,
only natural and gradual changes that would have otherwise happened may occur. Approximately 5% of patients
return to correct residual refractive error.
What are the success rates for surgery?
For laser surgery, more than 95% of patients enjoy at least 20/40 vision without glasses or contact lenses, which is
clear enough to drive and perform most daily tasks without correction. For Phakic IOL patients, more than 98%
enjoy the same.
Does Gimbel Eye Centre have financing available?
Gimbel Eye Centre refers patients to Medicard, which provides financing options for patients seeking elective
medical procedures. The patient may contact a Gimbel Eye Centre Counselor to discuss financing options or contact
Medicard directly by telephone, toll-free at 1-888-689-9876, or via website, www.medicard.com.
33 | gimbel.com
Refractive Surgery Assessment & Referral Form
PLEASE PRINT or TYPE
Assessment Date (m/d/y):_________________
Patient Name (Dr./Mr./Mrs./Ms./Miss):______________________________ Sex:
M Female
M Male
DOB (m/d/y):________________________________ Address:____________________________________________________
City:_________________________Prov/State:___________________________ Postal/Zip:_____________________________
Telephone (res):_________________Telephone (bus):______________________ Telephone (cell):________________________
Name of Doctor Assessing:_________________________________________________________________________________
Telephone:__________________________________ City:________________________________________________________
Patient History
Ocular History (e.g., Injury, Amblyopia, Previous Eye Surgery Dry Eye, Motivation for surgery, etc.):
______________________________________________________________________________________________________
Medical History:_________________________________________________________________________________________
______________________________________________________________________________________________________
Please Check:
M Diabetes
M Vascular Disease M Ocular Herpes Simplex/Zoster M Pregnancy/Nursing
M Collagen
M Auto Immune M Other (please specify):_____________________________
List Medications, include Imitrex® (migraine), Accutane® (acne), Amiodarone® (cardiac anti-arrhythmic) &/or Flomax® (urinary flow):
Ocular:___________________________________________ Systemic:____________________________________________
_________________________________________________ ____________________________________________________
Current Spectacles Rx
Prism:
M Yes
Current Contact Lens Rx
OD___________________________ OS_____________________________________
M No
Refraction Date:___________________
Vertex Distance:___________________
OD
M Soft
M Manual
Anterior Segment
OS
_______________ 20/_________
___________________________
_______________mm_______ _______________ mm_________
_________________________
___________________________
_________________________
___________________________
M Dilated M Undilated _________________________
___________________________
C/D (Cup-to-disc ratio)_________________________
___________________________
Crystalline Lens
_________________________
Macula
_________________________
Periphery
_________________________
Pachymetry
_________________________
Monovision Discussed
M OS
M Monovision Simulated
_______________20/________ Best Corrected Visual Acuity
M RGP
M Auto_________________________
Pupil Size (Diameter in dim illumination)_
Posterior Segment
M OD
OD___________________________ OS_____________________________________
If contact lenses are worn, indicate:
Keratometry Readings
Eye Dominance:
M Yes
M No
___________________________
___________________________
___________________________
___________________________
Contact Lens Monovision Trial Completed
M Yes
M No
Comments:_____________________________________________________________________________________________
______________________________________________________________________________________________________
_____________________________________________________ Doctor Signature:___________________________________
M Gimbel Eye Centre Calgary Fax: (403) 202-3303
gimbel.com | 34
M Gimbel Eye Centre Edmonton Fax: (780) 452-4114
Primary Eye Care Provider Refractive Surgery Follow
Up Form
Patient Name (Dr./ Mr./Mrs./Ms./ Miss):_____________________________________________________________________
DOB (m/d/y):_______________________________________ Examination Date:_____________________________________
Assessing Doctor:___________________________________________________
Surgery Date: _____________Type:
M LASIK
M PRK
M ICL
M OD
M Cachet M RLE
M MD
M Cross Linking
EXAMINATION
Visual Acuity Without Correction
ODOS
_________________________
___________________________
Manifest Refraction
_________________________
___________________________
Keratomerty
_________________________
___________________________
Intraocular Pressure
__________________ mm Hg
____________________ mm Hg
Ocular Medications:
_________________________
___________________________
Current
LASIK
Interface clear
M Yes
M No
M Yes
M No
Flap smooth
M Yes
M No
M Yes
M No
Flap in good condition
M Yes
M No
M Yes
M No
PRK
Haze Grading (please specify) M Clear
M Clear
M Mild
M Mild
M Marked
M Marked
RLE / ICL Iridotomy/s patent (ICL only)
M Yes
M No
M Yes
M No
IOL/ICL centred
M Yes
M No
M Yes
M No
Crystalline lens grading (ICL only)
M Yes
M No
M Yes
M No
Periphery intact
M Yes
M No
M Yes
M No
Vaulting grading
Toric ICL orientation (in degrees) _______________________ Degrees ________________________ Degrees
______________________ +Vaulting _____________________ +Vaulting
(Visual estimate of space between back surface of ICL and front of crystalline lens, i.e., If space is 2x central ICL thickness, then 2+ vault)
Comments or questions:___________________________________________________________________________________
______________________________________________________________________________________________________
Treatment plan:__________________________________________________________________________________________
______________________________________________________________________________________________________
Is the patient satisfied with the surgical outcome?
M Yes
M No
Comments:_____________________________________________________________________________________________
Assessing Doctor’s Fax:___________________________________ Would you like a reply:_
M Yes
M No
Signature of Assessing Doctor:________________________________________________
FOR GEC OFFICE USE ONLY
Surgeon Comments:______________________________________________________________________________________
35 | gimbel.com
Cataract Surgery Assessment & Referral Form
Patient referred for:
M Cataract Assessment
M Secondary Cataract/YAG laser Tx
M Primary Cataract
M 2nd Opinion on Previous Cataract Sx
Referral Date (m/d/y):__________________________________________
Patient Name (Dr./Mr./Mrs./Ms./Miss):___________________________ Sex:
M Female
M Male
DOB (m/d/y):_________________________________________________Alberta Health Care #:________________________
Address:______________________________________________________E-mail:____________________________________
Telephone (res):_______________________________ (bus):_______________________ (cell):__________________________
City:_______________________________________ Prov/State:___________________ Postal/Zip:______________________
If the Patient may not be reached or would have difficult answering questions, please indicate a contact person below:
Name of Contact Person:_________________________________Relationship to Patient:______________________________
Telephone (res):_______________________________ (bus):_______________________ (cell):___________________________
Assessing Doctor Name:____________________________ Type of doctor:
M OD
M MD
M OPH
Address:_______________________________________________________PRACID #: _______________________________
Telephone:________________________________________ Facsimile:______________________________________________
City:_______________________________________ Prov/State:___________________ Postal/Zip:______________________
Patient Health History
Ocular History (e.g., Injury, Amblyopia, Dry Eye, etc.):__________________________________________________________
______________________________________________________________________________________________________
If Patient has had previous eye surgery, please indicate type of sx:
OD_____________________________________
OS______________________________________
Name of Surgeon:___________________________________________Location:______________________________________
Date of Sx (m/d/y):__________________________________________Was a lens implanted?
M Yes
M No
Please Check:
M Diabetes
M Mobility Problem
M Benign Prostatic Hypertrophy
M Heart
M Asthma
M Auto Immune Disease
M Immune Deficiency
M Language Difficulty
M Hepatitis
M Ocular Herpes Zoster
M Ocular Herpes Simplex
M Hearing Difficulty
M Atopy
M Pregnancy/Nursing
M Collagen Vascular Disease
M Hypertension
M Other health problems or concerns (If yes, please specify):
_______________________________________________________________________________________________
List medications, include Imitrex® (migraine), Accutane® (acne), Amiodarone® (cardiac anti-arrhythmic) &/or Flomax® (urinary flow):
Ocular:___________________________________________ Systemic:_____________________________________________
___________________________________________ ____________________________________________
___________________________________________ ____________________________________________
List allergies to food (include nuts and shellfish) medications, surgical tape, eye drops, iodine &/or latex:
______________________________________________________________________________________________________
__________________________________________________ Specify if allergies are:
M Airborne
M Contact
PLEASE COMPLETE BOTH SIDES OF THIS FORM
gimbel.com | 36
Cataract Surgery Assessment & Referral Form cont’d
Patient Name:___________________________________________________________________________________________
Does Patient have cataracts?
M Yes
M No
If Yes, indicate:
M OD
M OS
Does Patient have glaucoma?
M Yes
M No
If Yes, indicate:
M OD
M OS
Current or last IOP:_________________ OD_______ OS
IOP measured by:
M AT
M NCT
Does Patient have macular degeneration?
M Yes
M No
If Yes, indicate:
M OD
M OS
Any abnormalities of the cornea?
M Yes
M No
If Yes, indicate:
M OD
M OS
If Yes, please explain:______________________________________________________________________________________
______________________________________________________________________________________________________
Any abnormalities of the iris?
M Yes
M No
If Yes, indicate:
M OD
M OS
If Yes, please explain:______________________________________________________________________________________
______________________________________________________________________________________________________
Best Corrected Visual Acuity
OD 20/________________ Current Spectacles Rx
OD____________________ OS_______________________________
Does the patient wear prism(s) in his/her current spectacles?
OS 20/____________________________
M Yes
M No
Would you prefer that our office (Calgary or Edmonton) performed follow-up care?
M Yes
M No
M Other
If Other, please specify: ___________________________________________________________________________________
Does Patient wear contact lenses?
M Yes
M Soft
M No
If Yes, indicate:
M Hard
M Rigid Gas Permeable
M Other, please specify:______________________
M Instructed to leave out contact lenses for _______ days prior to assessment
Comments:_____________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Has Gimbel Eye Centre seen this Patient previously?
M Yes
M No
Signature of Assessing Doctor:___________________________________________
For Office Use Only
Patient ID:_____________________________________________________________________________________________
Appointment Date:_____________________________________Appointment Type:___________________________________
Comments:_____________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
37 | gimbel.com
Primary Eye Care Provider Cataract Surgery
Follow-Up Form
PLEASE TYPE / PRINT
Patient Name (Mr./Mrs./Ms.):_____________________________________________________________________________
DOB (m/d/y):____________________________________ Follow-Up Exam Date (m/d/y):____________________________
City:___________________________________________ Patient’s Telephone:______________________________________
Assessing Dr.:____________________________________ M OD
M MD
City:____________________________________ Surgery Date (m/d/y):___________________________________________
EXAMINATION
ODOS
Visual Acuity Without Correction
_________________________
__________________________
Manifest Refraction
_________________________
__________________________
Keratomerty
_________________________
___________________________
Visual Acuity With Above Refraction
_________________________
__________________________
M AT __________________ mm Hg
___________________ mm Hg
Intraocular Pressure by
M NCT
Slit Lamp
AC clear
M Yes
M No
M Yes
M No
Cornea clear
M Yes
M No
M Yes
M No
IOL centred
M Yes
M No
M Yes
M No
Posterior Capsule clear
M Yes
M No
M Yes
M No
Retina Posterior Pole intact
M Yes
M No
M Yes
M No
Additional Observations, Comments or Questions:____________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Is the patient satisfied with the surgical outcome?
M Yes
M No
If No, please indicate why the patient is dissatisfied.____________________________________________________________
_____________________________________________________________________________________________________
Next visit scheduled (m/d/y):____________________________________ Would you like a reply?
M Yes
M No
Assessing Doctor’s Fax:_____________________________ ____________________________________________________
Signature of Assessing Doctor
FOR GEC OFFICE USE ONLY
Surgeon Comments:_____________________________________________________________________________________
_____________________________________________________________________________________________________
gimbel.com | 38
References
1. MiS, Dooley EP, Albon J, Boulton ME, Meek KM, Kamma-Lorger CS. The adhesion of LASIK-like flaps in the
cornea: effects of cross-linking, stromal fibroblasts and cytokine treatment: Presented in part in British Society for
Matrix Biology annual Meeting 2008, Cadiff, UK, 8-9 September 2008.
39 | gimbel.com
gimbel.com | 40

Surgery Co-Management Guide

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