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The Bionic Patient: Intraocular LensesMultifocal OptionsSandra Lora Cremers, MD, FACS
Visionary Ophthalmology
Eyedoc2020.blogspot.com
November 10, 2013
Sandra Lora Cremers, MD, FACS
Cell/Text 443-535-2268
DOES IT SEE
THROUGH WALLS?
You Are Confusing Us With The iphone BionicEye App
JUST RELEASED BY GOOGLE GLASS YEAR 2020 UNDER DR. CREMERS’S TEAM AT VISIONARY OPHTHALMOLOGY
PATIENT
PATIENT
Why Should I Pay Attention?
1. Great all around care to your patients
2. For friends, family members, for yourself
3. Co-management
Objectives:1. History & Types of Multifocal IOLs
2. Indications, Goals, & Contraindications
3. Managing the unhappy IOL patient
4. Future
History & Types
Timeline of Eye Surgery:
Timeline of Intraocular Lenses 2012 2013 2014 2015 2016
AT LISA TRILAL Calhoun
Synchrony Dual Optic Tetraflex 1CU Akkommodative
Fluidvision
Timeline of Refractive Cataract Surgery IOLs:
IOL Materials:PMMA->Silicone->Hydrophilic Acrylic->Hydrophobic Acrylic->Nanotubes-
Macromolecules; Liquid Crystal
IOL Design:
Plate Haptic 3-piece 1-piece Foldable Injectable
IOL Optic:
UV Filter Aspheric Multifocal Accommodating Toric
Market Share
Rate of Baby Boomers Turning 65 yrs in US:
• 2.7 million per year
• 7,584 per day
Silent Generation (born between 1925-1942): hard working, economically conscience, and trusting of the government. They were
very optimistic about the future and held a strong set of moral obligations.
Baby Boom Generation (1943-1960): strong set of ideals and traditions, and are regarded as being very family-oriented. They are
fearful of the future, relatively active and liberal socially but conservative politically.
Generation X (1961-1981) or (1965-1976): Live in the present, likes to experiment, and expects immediate results. Xers are selfish
and cynical, and depend a lot on their parents. They question authority and feel they carry the burden of the previous generations.
Generation Y (1979-1994) (1977-1994) (1989-1993) & Millennials (1982-) materialistic, selfish, disrespectful; but also
very aware of the world and very technologically literate. They are trying to grow-up too quickly, and have no good role models to look towards.
Types of Multifocal IOLS
2 Key Types of MIOLsDIFFRACTIVE IOL
Closely spaced stepped rings (ring no. & height varies) spit incoming light (diffract) into multiple beams: add together in phase
at predetermined near point; overall curvature gives distance VA
REFRACTIVE IOLZones of different optical powers,
commonly in alternating rings of Near & Far foci juxtaposed achieve
multifocality
-Pupil dependent: if distance central zone, loose near in bright light;ARRAY
REZOOM-a refractive, distance-dominant multifocal optic
ReSTOR-refraction, diffraction, & apodization
TECNIS-Pupil independent
Multifocal Optic
AcrySof ReSTOR SA60D3
Foldable acrylic apodized diffractive IOL
6.0 mm optic
Add power of 3.00 or 4.00 D
Hybrid diffractive–refractive optic
3.6 mm center of concentric diffractive steps
Identical periphery to monofocal acrylic IOL.
DIFFRACTIVE IOL
REFRACTIVE IOL
ReSTOR TECNIS REZOOM
The Tecnis Multifocal
Foldable acrylic diffractive IOL
6.0 mm optic
Combines diffractive optic technology with an aspheric modified prolate anterior surface designed to reduce spherical aberrations
Dffraction pattern creates 2 major focal points that are 4.00 D apart
ReSTOR 3.0 Tecnis MTF
ReSTOR
Chromatic Aberration:• Occurs when light is separated into its
separate components
• These wavelengths refract differently,
creating multiple focal points
ReSTOR 3.0 Tecnis MTF
Indications
Goals of Refractive Cataract Surgery:
1. 20/20 Distance, Intermediate, Near
2. No pain
3. Immediate return of vision
4. 100% safe, 0% complications
5. No long term issues: i.e. PCO
Extra Attention Prior to Cataract Surgery:
1. Contact Lens: hold till stable refraction: Min: Soft 2wk; Hard 1 mo
2. Dry eyes, MGD must be assessed & treated
3. Angles-Gonio, Pentacam; Lens Type; Macula OCT; Nerve HVF
4. Triple check A’s & K’s, Belin-Ambrosio Enhanced Ectasia
Display
5. Check Eye Dominance
6. Check for Angle Kappa
7. Cataract Questionnaire
Pre-Operative OCT
1. Gold standard for detecting (3-4% incidence in
routine surgery)
1. ERM (Epiretinal Membranes)
2. Lamellar Holes
2. Macular Thickness >230 microns before surgery
correlates with worse visual acuity after surgery
ANGLE KAPPAThe Angle between the Visual Axis and the Pupillary Axis
Phaco Monofocal TORIC LRILenSx LASER Multifocal
CHOICES FOR CATARACT SURGERY by Sandra Lora Cremers, MD, FACSOld Standard or
Government Option
New Standard for “Forever Young” Option*High-tech implants are designed to give you a greater better ability to
drive, see your phone, and read without glasses, though they do not guarantee a life without any glasses.
DRIVING VISION OPTION:Astigmatism Correction:
Toric, Limbal Relaxing Incision (LRI)
CRYSTALENS REZOOMRESTOR
-Lower energy needed; Less endothelial cell loss; less complication-not covered by insurance
-Traditional-More energy needed-More loss of corneal cells;
Alternatives: No surgery/Observe: this can increase risk of surgery in future (increases energy needed & following risks); Risks: less than 1%: risk of infection: loss of vision, loss of eye; second surgery (due to infection, residual refractive error, IOL displacement; retinal problem from vitreous loss, residual lens material; intolerable haloes, glare); 10-30% risk (over 3yrs) of Posterior Capsule Opacification needing short laser procedure (covered by insurance); 5% risk of IOL exchange due to halo/glare from Multifocal IOL; Information presented above do not guarantee results.*
-Eliminate need for full time glasses use in 97%; Best for good Distance Vision-Function comfortably without glasses (20/40 or better); 99% distance; 90% intermediate; 74% reading (20/25 or better); Risk: halos/glare (5%)(usually go away but can be permanent); Loss of contrast sensitivity possible. Not good if pupil>2.5-May still need glasses for small print.-Easier IOL to remove if unhappy
-Only gives one range of vision; (ie, will need reading glasses); Risk of halo/glare (1%, 2%); Covered by insurance
-Good for distance & computer, night vision;can take up to one year to fully improve;-Good Contrast Sensitivity-Less halos/glare vs other MIOL; harder to exchange-May need reading glasses especially for smaller print.
-Better for Computer distance; Moderate reading range vision (if pupil <2.5mm, not as good for reading); Not as good for night vision -May have halos or glare (usually go away but can be permanent)-Easier IOL to remove if unhappy
Pupil independent; Best for Reading; Comfortably without glasses: 96.9 % near, 89.7% intermediate, 95.5% distance; 88% no dependence on glasses at 6mo; Risks: 3.7% surgical reintervention; 2.6% macular edema; 0.3% hypopyon, eye infection, persistent high eye pressure requiring drops
TECNIS
AccommodatingOption to have chance to be free from reading glasses; Avoid if pilot, full time night driver, h/o macular degeneration, severe dry eye, severe glaucoma, type A+
-Less Halos, glare risk; better contrast sensitivity-Best choice if:-history of LASIK-glaucoma-macular issues.
-implant that only corrects astigmatism, not reading-no reported increase in halos, glare
-incisions on cornea to decrease astigmatism; can be combined with implant
Contraindications
Complications
Complications with MIOL: the Usual...
And… 1/20 desire IOL exchange to due haloes/glare
Managing the Unhappy Patient
-Post Multifocal IOL
Main Cause of Complaints:(Glare, Haloes, Contrast Sensitivity Loss)
Why do Multifocal Intraocular Lenses Cause
Glare, Haloes?
6 Causes of Complaints:(Glare, Haloes, Contrast Sensitivity Loss)
1. Cylinder, residual astigmatism, refractive error
2. Corneal disease (i.e., Dry Eye, MGD, OSD)
3. CME
4. Capsular opacification (i.e., PCO, phimosis)
5. Centered issue: (i.e., decentration, angle kappa)
6. Crazy (i.e., your surgeon …to use an MIOL on patient)
Dry Eye: Various Treatments
Treating Positive Angle Kappa Patient if Unhappy:
Future
Future ATIOLs...to USAFINEVISIONLentis MPlusAT LISA 65/35TECNIS MIOL TORIC
What do you need to tell
patients?
Key Questions:
1. Do you mind using glasses to see both distance &
near?
2. Do you mind wearing glasses for reading?
3. What do you want & expect from your vision?
4. What activity will you be using your eyes the most?
5. If you could see well without glasses, but had haloes
& glare around lights, would that bother you?
Summary:
1. MIOLs work well for selected patients
2. No guarantees with any IOL
3. Haloes and/or glare around lights possible
4. Small risk will not be happy with first IOL
5. Majority are happy with MIOLs
Co-Management
Carolina Clavijo
Office Manager
Cell & Text: 240-676-7267
Thank you for your attention.
Acknowledgements:
Alberto Martinez, MD
Eric Donnenfeld, MD, FACS
Jason Wang, MD
