Download Limbal Relaxing Incisions - American Academy of Optometry

Technological Advancements in Intra-Ocular Lenses
The Optometric Role
COPE #17470-PO
Douglas K. Devries, O.D.
Eye Care Associates of Nevada
January 24, 2007
Financial Challenges Facing Optometry
 Complex Small Business
 Decreased Reimbursement
 Product & Services
 Increasing Operating Costs
 Explore Alternative Means to Increase Revenue Streams
Today
 Technological Advances in IOL’s
 Multi-Focal & Accommodating IOL’s
 Toric IOL’s
 Wavefront IOL’s
 Role of Primary Care Optometry
Opportunities
 78 Million Americans (babyboomers) will begin Enrolling in Medicare Beginning in 2011
 Technology Adopters
 Care is Provided in Your Practice
 Our Role to Educate and Guide
Refractive Cataract Surgery
 Technological Generation
 Expectation is Plano Sphere
 Distance and Near Desired
Why Become Involved?
 2.7 Million Cataract Surgeries Each Year
 HCFA Allowing Surgeons to Bill for Non-Covered Services
 Progressive vs Bifocal
 Increased Fees Possible for Co-Management
 Intellectual Integrity
IOL Technology
 Wavefront
 Accommodating
 Multi-Focal
 Toric
 Phakic
What’s In The Developmental Pipeline?
Accommodating IOLs in Trial
 Smart IOL (Medennium)
 Quest Vision IOL (Tiburon)
 Synchrony (Visiogen)
 Sarfaraze Elliptical IOL (B&L)
 Kellan Tetraflex
Developmental IOL’s
 Injectable Micro Incision
 Light Adjustable Sph/Cyl/HOA
 Vision Membrane
What is 20/20?
 All of the following represent 20/20 vision
Challenges Facing the Older Driver
Young Lens
Aging Lens
Tecnis IOL
Toric IOLs
Correction of Astigmatism During Cataract Surgery
 Toric IOL
 Limbal Relaxing Incisions
AcrySof® Toric
Limbal Relaxing Incisions
 Similar to Astigmatic Keratotomy
 600 microns deep
 Up to 6mm in length
 Can be paired for larger amounts of Cyl
 Up to 3.00 Diopters of Cyl
Limbal Relaxing Incisions
 Less Stable and Less Predictable then Toric IOL
 Can Be Used In Combination With Toric IOL In Higher Cylinder Amounts
Combination Approach
 Toric IOL
 Limbal Relaxing Incision
 Non-Covered Fee
 Toric Package
Currently Available Accommodating IOL
 Crystalens
Crystalens Model AT-45
FDA device description. “The
crystalens is a modified plate
haptic lens with hinges across the
plates adjacent to the optic.”
How is Accommodation Achieved?
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Ciliary muscle contraction
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Ciliary body shifts forward
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Pressure change in vitreous
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Displaces posterior capsule
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Crystalens moves forward
IOL Power and Accommodation
 Journal of Cataract and Refractive Surgery. Vol. 29, #11 p. 2069-2072
Z-Syndrome / CCS
Monocular UCDVA
Monocular UCNVA
Multi-Focal IOL’s
 AMO Array (first generation)
 AMO ReZoom
 Alcon ReSTOR
ReZoom™ IOL Product Design
Balanced View Optics™ Technology
ReZoom™ IOL vs. ReSTOR™ IOL
ReZoom
ReSTOR
ReSTOR Apodized Diffractive Optic
 Precise reduction in diffractive step heights from center to periphery of 3.6 mm
diameter diffractive region
 Steps reduce from 1.3 microns to 0.2 microns
 larger steps direct more light to near at center
 smaller steps direct more light to distance at edge
 gradual energy blend between powers
Apodized Diffractive Optic
 Apodized diffractive structure blends into peripheral refractive region
 Gradually emphasizes energy going to distance vision with larger pupil sizes

Nighttime visual disturbances minimized by directing more light to distance
when pupils are larger
ReZoom™ IOL vs. ReSTOR™ IOL (SA60D3)
Distance Vision
ReZoom™ IOL vs. ReSTOR™ IOL (SA60D3) Near Vision
Bother from Halos ReZoom vs. ReSTOR
Multi-Focal IOLs
Patient Selection
Patient Selection
Pre-operative Considerations
 Patients who no longer desire to wear glasses
 Ocular pathology
 Corneal scarring
 Injuries
 Herpetic
 IK
Patient Selection
Pre-operative Considerations
 Ocular pathology
 Keratectasia
 Previous refractive surgery > 3.0 D
 Macular disease
 ARMD
 Diabetic retinopathy
Patient Selection
Pre-operative Considerations
 Ocular pathology
 Optic nerve disease
 Ischemic optic neuropathy
 Optic neuritis
 Amblyopia
Patient Selection
Pre-operative Considerations
 Astigmatism considerations
 Pre-op cylinder < 0.75 D ideal
 Cylinder  0.75
 Intra-op AK/LRI
 Post-op excimer Tx
Patient Selection
Pre-operative Considerations
 Patients’ visual demands
 Occupational needs
 Realistic expectations
 Avoid in hypercritical patients
Patient Selection
Pre-operative Considerations
 Monocular implantation
 IOL in fellow eye
 Unilateral cataract
 Possible piggyback plano ReSTOR in future
 Combined ReZoom/ReSTOR
 Combined Multifocal/Accommodative
 Monovision patients
Patient Selection
Pre-operative Considerations
 Limitations of multifocal IOLs
 Reduced contrast sensitivity
 Halos/Glare
 More light needed for reading
 Visual confusion in rare cases
 Explantation/IOL Exchange
Avoid the temptation to tell patients they will not need glasses after surgery
Multifocal IOLs
Pre-Operative Evaluation
 Manifest Refraction
 Corneal Topography
 Complete Ocular Evaluation
Multifocal IOLs
Pre-Operative Discussion
 Physics of Multifocal IOLs
 Benefit – CONVENIENCE
 Limitations
 Glare/Haloes
 Reduced Contrast Sensitivity
Multifocal IOLs
Pre-Operative Discussion
 Alternatives
 Distance OU
 Near OU
 Intermediate
 Monovision Possibilities
Multifocal IOLs
Pre-Operative Discussion
 IOL Removal
 Small Percentage of Patients
Can Be Exchanged for Monofocal IOL at a Later Date
 Multifocal IOLs Cannot Be Implanted Later

Selecting the IOL best for the Patient
 Identify Patient Visual Needs
 Ask “ Where is your world?”
 Near, Intermediate, Distance
 If Combo, which are most important?
 Occupation
 Hobbies
 Dominant / Non-Dominant Eye
 Pupil Size and lighting for Tasks
Recording Intermediate Vision
 No patient feedback
 No FDA clinical data
 No clinical standards
- focal distance?
- object size?
- light intensity?
“Intermediate Vision”
 Meal time (serving, eating)
 Computer use
 Wrist watch
 Dashboard gauges
 Cell phone (caller ID, dialing)
ReZoom / ReSTOR
Mix-Matching
How well is this working?
Combination Approach
 ReZoom Dominant Eye
 ReSTOR Non-Dominant Eye
Patient Satisfaction with Distance Vision
 What is your level of satisfaction with your new distance vision (both eyes together)?
Patient Satisfaction with Near Vision
 What is your level of satisfaction with your new near vision (both eyes together)?
Co-Management Opportunities
 Can Optometrist Receive Payment for Increase in Lens Fee?
 Can Non-Covered Services Be Co-Managed?
 How is Fee Determined?
Non-Covered Services
 Refraction
Contact Lens Trial
Wavefront Testing
Topography
Pachymetry
Routine Care
Ketatoplasty for Enhancement
IOL Exchange
Non-Covered Services Payment
 Not a 80/20 Split
 Must Bill Portion Provided
 Standard Post Op Fees
 Non-Covered Services
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Non-Covered Services Payment
 If Surgeon Collects Full Payment it Must be in 3 Separate Checks
 A SC
 Surgeon
 Optometrist
Non-Covered Services Payment
 Notice of Exclusion from Medicare Benefit (NEMB)
 Both Surgeon and Optometrist Should Obtain
Non-Covered Services Payment
 Determine What You Will Provide
 Avoid Direct Payment From Surgeon
Non-Covered Services Payment
 Toric Packages
 LRI
 Toric IOL
Phakic IOLs
The Verisyse™ Phakic IOL
 Verisyse™ (Artisan® in Europe)
 Design introduced in 1991
after 5-year trial
 Concave- Convex
configuration (low profile)
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Decreased risk of
endothelial damage
Twice the effective
power range
Incisions
 5 to 6 mm incision
 Consider astigmatism
The Enclavation Process
 After aligning lens, peripheral iris tissue is drawn into the split lens haptics

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Stable anchor – minimal tissue trauma
Reversible
Post-Surgical Protocol
 Standard post-intraocular surgery meds

Antibiotic, steroid, NSAID
 Eye shield for 1 week
 Return 1 day post-op to surgeon to check:

IOP, lens position & pupil, visual acuity
 Return to referring OD for routine F/U and visual rehabilitation
Posterior Chamber Implant
 Benefits
Invisible to the patient and the observer
Distant from the corneal endothelium
Beneath the iris
Desirable equivalent optical zone at the corneal plane
Steep but short learning curve
 Result
 Reduced complications
 Predictable refractive outcome
 Better visual outcome and patient satisfaction
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Future is Unfolding Fast
 The Market Demands are Great
 Disposable Income
 Patients are in Our Practice Now
Thank You
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