ArtemisArtemistmtm II VHF Ultrasound II VHF Ultrasound for Sizing the Visian ICLfor Sizing the Visian ICL

ASCRS 2008ASCRS 2008

Philip C. Roholt, MDPhilip C. Roholt, MD

N. Canton, Ohio, USAN. Canton, Ohio, USA

The author has no proprietary interest inThe author has no proprietary interest in

products discussed in this paper.products discussed in this paper.

ArtemisArtemistmtm II II

VHF (50K) Ultrasonic BiometryVHF (50K) Ultrasonic Biometry High-resolution B-scan imagingHigh-resolution B-scan imaging Integral immersion water bath systemIntegral immersion water bath system Single-sweep 3D arc-scan for full sulcus-to-Single-sweep 3D arc-scan for full sulcus-to-

sulcus (SS) measurementssulcus (SS) measurements Infra-red video monitoring of pt eye positionInfra-red video monitoring of pt eye position Patented design, unique fixation devicePatented design, unique fixation device

In-line fixation opticsIn-line fixation optics Reproducible visual axis centered scanReproducible visual axis centered scan

VisianVisiantmtm ICL Sizing ICL Sizing External limbal white-to-white (WTW) is usedExternal limbal white-to-white (WTW) is used Poor correlation of WTW to sulcus-to-sulcus (STS) measurementsPoor correlation of WTW to sulcus-to-sulcus (STS) measurements

Cadaveric eyesCadaveric eyes11

11stst generation UBM generation UBM2 2

No correlation of WTW to STSNo correlation of WTW to STS33. “One size fits all would work better . “One size fits all would work better than using WTW.” Myopia Rthan using WTW.” Myopia R22=0.0165, Hyperopia R=0.0165, Hyperopia R22=0.204=0.204

Angle-to-angle (ATA) is also not predictive of STSAngle-to-angle (ATA) is also not predictive of STS33

Multivariate regression analysis:Multivariate regression analysis: age, sphere, cylinder, SEQ, WTW, ACD, avg K, pachymetry, ATAage, sphere, cylinder, SEQ, WTW, ACD, avg K, pachymetry, ATA

Only Only ATAATA & & ACDACD statistically significant statistically significant But, 95% confidence interval of predicting STS with this equation is But, 95% confidence interval of predicting STS with this equation is

±0.91 mm±0.91 mm ie the error of estimating STS would be more than 0.91 mm in 5% ie the error of estimating STS would be more than 0.91 mm in 5%

casescases

1.Werner, L et.al. 1.Werner, L et.al. Correlation between different measurements within the eye relative to phakic Correlation between different measurements within the eye relative to phakic intraocular lens implantation. intraocular lens implantation. JCRS. 2004;30:1982JCRS. 2004;30:1982

2.Pop, M et.al. 2.Pop, M et.al. Predicting sulcus size using ocular measurements. Predicting sulcus size using ocular measurements. JCRS. 2001;27,1033.JCRS. 2001;27,1033.

3. Reinstein, D. Personal communication, Sept, 2007.3. Reinstein, D. Personal communication, Sept, 2007.

Artemis UBM forArtemis UBM forSTS MeasurementSTS Measurement

Artemis has been shown to be accurate, Artemis has been shown to be accurate, repeatable, and reproducible for SS repeatable, and reproducible for SS measurementsmeasurementsReinstein, DZ. Reinstein, DZ. Accuracy, repeatability, and reproducibility of Artemis very Accuracy, repeatability, and reproducibility of Artemis very

high-frequency digital ultrasound arc-scan lateral dimension high-frequency digital ultrasound arc-scan lateral dimension measurements. measurements. JRS. 2006;32:1799.JRS. 2006;32:1799.

Artemis ICL StudyArtemis ICL Study

45 pts, 85 eyes examined with Artemis 45 pts, 85 eyes examined with Artemis as part of complete pre-op workupas part of complete pre-op workup

Artemis measurements included STS at Artemis measurements included STS at the Theoretical Sulcus (TS) and ciliary the Theoretical Sulcus (TS) and ciliary processes (CP)processes (CP)

Post-op Measurements on 15 patients Post-op Measurements on 15 patients (28 eyes) with minimum 3 mo f/u.(28 eyes) with minimum 3 mo f/u.

Artemis ICL Study - Artemis ICL Study - ResultsResults

PRE-OPPRE-OP MR -9.75 D +/- 1.85 DMR -9.75 D +/- 1.85 D SE -6.0 to -14.5 DSE -6.0 to -14.5 D ACA: m 35.19ACA: m 35.19oo

Lens Radius m 10.11mm Lens Radius m 10.11mm +/- 1.01mm+/- 1.01mm

STS-TS: 11.081 mm sd STS-TS: 11.081 mm sd 0.504 0.504

STS-CP: 10.462mm sd STS-CP: 10.462mm sd 0.476 mm0.476 mm

POST-OPPOST-OP MR -0.35 +/- 0.64 DMR -0.35 +/- 0.64 D >>20/20 83.2% 20/20 83.2% >>20/40 100%20/40 100% Gain Gain >> 1 line 28.2% 1 line 28.2% Vault: m 282u +/-106u Vault: m 282u +/-106u

(range 0 to 524u)(range 0 to 524u) ACA: m 26.43ACA: m 26.43oo

No loss BCVANo loss BCVA No ICL explantationNo ICL explantation

ICL Position as Imaged by ICL Position as Imaged by ArtemisArtemis

ICL haptic rests in the posterior ciliary ICL haptic rests in the posterior ciliary sulcus, abutting against the ciliary sulcus, abutting against the ciliary processesprocesses

The ICL does not rest in the “Theoretical The ICL does not rest in the “Theoretical Sulcus.” (Usually reported as the STS)Sulcus.” (Usually reported as the STS)

CB acts as a “shock absorber” and is CB acts as a “shock absorber” and is compressed by the pliable ICL haptic.compressed by the pliable ICL haptic.

STS MeasurementsSTS Measurements

Published UBM STS MeasurementsPublished UBM STS Measurements 35 MHz Optikon Hiscan UBM35 MHz Optikon Hiscan UBM11: STS-TS 11.32 +/- : STS-TS 11.32 +/-

0.72mm0.72mm 50 MHz Artemis I50 MHz Artemis I22: STS-TS 12.32 +/- 0.10mm: STS-TS 12.32 +/- 0.10mm

Current Study (ArtemisCurrent Study (Artemistmtm II) II) STS-TS: 11.08 +/- 0.504mmSTS-TS: 11.08 +/- 0.504mm STS-CP: 10.462 +/- 0.476STS-CP: 10.462 +/- 0.476 Measured STS is less in the current studyMeasured STS is less in the current study

1. Oh J, Shin H, Kim J, et al. Direct measurement of the ciliary sulcus diameter by 35-Megahertz ultrasound biomicroscopy. Ophthalmology, 2007;114:1685-8

2. Rondeau MJ, Barcsay G, Silverman, R, et al. Very high frequency ultrasound biometry of the anterior and posterior chamber diameter. J Refract Surg 2004;20:454-64.

PreOp: OS STS 10.98

LRadius 8.08 OS

Theoretical STS is longer than STS at ciliary process

Pre-op VHF UBM for sizing the ICL

OS Vault 66u

ICL 12.6 OS

Note position of ICL haptics against ciliary process (arrows), not in “Theoretical Sulcus”

Post-op VHF UBM with ICL

Anterior ICL

Posterior ICL

Accommodation and ICLAccommodation and ICL

Recent reports of impairment of Recent reports of impairment of accomodationaccomodation Tanzer DJ. Tanzer DJ. US FDA clinical trial of the toric US FDA clinical trial of the toric

implantable collamer lens for moderate to implantable collamer lens for moderate to high myopic astigmatism. high myopic astigmatism. Paper presented Paper presented at the AAO Annual Meeting. November 10, at the AAO Annual Meeting. November 10, 2006, Las Vegas, NV.2006, Las Vegas, NV.

ConclusionsConclusions Theoretical sulcus measurements in this study Theoretical sulcus measurements in this study

differed from other reportsdiffered from other reports STS is measured at the ciliary process for ICL STS is measured at the ciliary process for ICL

estimation because of the actual haptic estimation because of the actual haptic positioningpositioning

Ciliary body and processes act as a “shock Ciliary body and processes act as a “shock absorber” and is compressed by the pliable ICL absorber” and is compressed by the pliable ICL haptic. ICL may influence accommodationhaptic. ICL may influence accommodation

Artemis is useful in imaging of anterior Artemis is useful in imaging of anterior segment and specifically the ciliary sulcus and segment and specifically the ciliary sulcus and anterior lens, to aid in Visian ICL selection.anterior lens, to aid in Visian ICL selection.