0210 IOL Handbook
0210 IOL Handbook
0210 IOL Handbook
Sponsored By
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Jim Owen, O.D., M.B.A., F.A.A.O., is a graduate of the Illinois College of Optometry and received his MBA from San Diego State
University. He is a Fellow of the American Academy of Optometry and is currently the Immediate Past President of the Optometric
Council for Refractive Technology. He has a private practice in Encinitas, California. He participates is clinical research for laser
vision correction, dry eye and contact lenses.
Chris Quinn, O.D., F.A.A.O., is President Omni Eye Service, Iselin, New Jersey. He is the principal author of the American Optometric Associations Clinical Guideline on Care of the Patient with Conjunctivitis. He is currently a contributing editor to the Review of
Optometry. He is a recognized authority and sought after to lecture nationally and internationally on the treatment of eye disease and
co-management.
Bernard C. Tekiele, III, O.D., is Director of Refractive Surgery at the Michigan Eye Institute. Dr. Tekiele specializes in refractive surgery
and comprehensive medical eye care. Dr. Tekiele earned his undergraduate degree from the University of Michigan and his Optometry degree from the Illinois College of Optometry in Chicago, IL. Following a hospital-based internship at the Cleveland Veterans
Affairs Medical Center in Cleveland, OH, Dr. Tekiele completed a residency in Family Practice Optometry at the University of Alabama
at Birmingham/The Medical Center. Dr. Tekiele furthermore underwent specialized post-residency training in the areas of therapeutic
laser therapy for the anterior segment and excimer laser vision correction at Northeastern University in Oklahoma City, OK.
accepted practice. Just as it took decades for Galileo to get acceptance that
light objects fall as fast as heavy objects,
many of the advances in cataract surgery
have been met with strong resistance.
Nevertheless, improved patient care has
prevailed, and the procedure continues
to advance.
The word cataract comes from the
Greek cataracta, meaning waterfall. It
was believed that fluids filled the lens,
available.
During World War II, Gordon Cleaver, a Royal Air Force Flight Lieutenant
had been shot down. The impact blinded his right eye and left his left eye badly
damaged from the cockpit windshield.
It was Harold Ridley, M.D., who
observed the plastic material from the
cockpit windshield in Cleavers left eye,
but had not caused any further damage.
Dr. Ridley had long thought about in-
Growing Demographics
of IOL Candidates
There are over 1.8 million cataract surgeries performed each year at an estimated cost
of over $3.4 billion dollars according to the
National Eye Institute (NEI). As Baby Boomers
continue to advance to the cataract age, the
demand for cataract surgery will increase as
will the expectations for a higher quality of vision after the surgery. This market for cataract
patients continues to grow today and in the
foreseeable future.
The number of Americans over 60-years-old
grows at approximately 3.4 percent per year
and will be almost 15 percent of the total population by 2020. It is estimated that 15 percent
of those 60-64 year-olds have lens changes
necessitating cataract surgery. That figure
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Lens Platforms
WHEN SIR CHARLES RIDLEY
port. Three-piece designs are generally less compact, however, and often
require a larger incision size to place
the lens properly.
Edge design- There has been a
lot of interest in the design of the
IOL optic edge. Variations in the
edge design of the lens can reduce
the incidence of posterior capsular
fibrosis (PCO). A square edge on the
posterior surface of the lens, which
is in direct apposition to the posterior capsule, can act a barrier to the
migration of residual lens epithelial
cells responsible for PCO. In addition, careful design of the lens edge
can reduce the incidence of IOL related dysphotopsias by reducing unwanted reflections from the lens.
Haptic design- Most haptics today
are open loop design in a variety of
styles. Haptics in three-piece lenses
are made from a variety of materials
including PMMA and polypropolene
or polyamide.
Lens angulation, the planar relationship between the optic and haptics of an IOL, will determine the
angulation of the lens as it positions
itself in the capsular bag. A small degree of posterior vault of the optic
will prevent pupillary capture and
help ensure contact with the posterior capsule. However, if the lens is
inserted backward, it can result in a
mild undesirable change in refractive outcome.
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total diameters depending on lens power for improved centration. The lens has a posterior square edge and has a novel
four haptic design for increased centration and stability. The
delivery system for B&L lenses requires an incision size of
approximately 2.6mm (FDA Submission Data: Akreos Lens,
Bausch & Lomb).
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Six-month data reported from U.S. clinical trials on the IQ ReSTOR IOL +3.0 D
(Alcon Laboratories, Inc.) showed patients experienced an improvement in intermediate vision.
haptics that allow the lens to move forward. The amount of movement will
determine the level of accommodation
the patient achieves. Since it is a single
vision lens and now comes in an aspheric
button on the center of the optic, patients
will achieve distance vision similar to the
other single vision aspheric lenses on the
market. The lens is clear and does not
have a UV blocker.
There are two theories to achieve an
accommodative affect. The first is the
lens will move forward with contraction
of the cilliary body, and thereby putting
pressure on the vitreous to push on the
posterior surface of the lens. The secondary theory is arching the lens where
the pressure seems to flex the lens to
achieve a change in power and aberrations to allow for near acuity. The amount
of accommodation seems to vary and has
been reported from 1.0 to 2.50 diopters
in some cases. In our practice, we typically aim for the dominant eye to be between 0-0.25 D and the non-dominant
eye to be between 0.5-0.75 D. We
achieve good intermediate and often adequate near with this recipe. We also find
the Crystalens to be an excellent choice
for previous refractive surgery patients.
Especially for our RK patients, it helps
with the diurnal fluctuation many have.
Multifocal IOLs
Multifocal IOLs simultaneously produce near and far images on the retina
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sion and provides better intermediate vision than its predecessor. The lens also has a yellow chromophore to filter both UV
and short end blue light to protect the macula. Our patients
have adapted to this new lens very well. Six-month data reported from U.S. clinical trials on the IQ ReSTOR IOL +3.0
D showed patients experienced an improvement in intermediate vision.
Presbyopia correction presents a growing market for your practice, as 10,000 Baby
Boomers will be turning 50 each day until 2014 and will seek precise near vision
correction.
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familiar with cataract evaluation. Oftentimes, the optometrist, acting as the gatekeeper provider, will be first to
diagnose cataract and recommend treatment when appropriate. It is perfectly germane to the role of optometric
medical eye care to diagnose cataract, recommend surgical
consultation when necessary and discuss intraocular lens
options, which have become myriad with advanced lifestyle implant technology.
Early Education is Key
The patient interview is one of the most important aspects of the cataract consultation and subsequent IOL
selection. We provide all prospective cataract surgery patients with a packet of information explaining cataract surgery and introducing advanced lifestyle IOL options at the
time of cataract diagnosis.
When the patient returns
Key Points
to the office for biometry,
they then have a strong
1. Educate patients early.
substrate knowledge base
2. Perform a thorough patient
allowing them to feel
interview and consider using a
confident with their IOL
preoperative questionnaire.
choice.
3. Pay close attention to slit lamp
I avoid use of terms
and dilated fundus findings.
such as always and neva. Tear film considerations.
er, which could foster
b. The cornea must be clear.
unrealistic expectations
c. Vitreous opacities.
for our patients. We want
d. Macular pathology.
to share patients experi4. Make a specific IOL
ences to help prospecrecommendation.
tive cataract patients gain
a full understanding of
what to expect. Moreover, early education is critical to the
growth of elective IOL volume in the eye care providers
practice.
Todays Cataract Patient
Cataract is a disease of senescence. As such, optometrists
expect to find lenticular changes as their patients approach
retirement age and beyond. Certainly, one would expect
activity of daily living (ADL) attenuation secondary to clinically significant cataract in a patient aged 75 years. What
one may not necessarily expect is ADL to affect lenticular
changes in say, a 55-year-old. However, this is precisely the
population the Baby Boomers where our attention
should now be affixed.
Over the next two decades, the pool of potential cataract surgery candidates will swell by tens of millions. This
wave of patients will be comprised of seniors leading very
active lives who are concerned about getting older and
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or a week after surgery. Especially with advanced lifestyle IOL patients, this visit serves as a nidus to galvanize the patients confidence that the choice of implant
was the correct one.
Although the basic examination during the day one visit is performed the same way irrespective of IOL choice,
these specific observations must be made between multifocal and toric IOLs.
Visual Acuity:
Standard and Toric IOLs
Measure uncorrected distance visual acuity in the operated eye. Measure pinhole visual acuity for unexpected uncorrected results.
Multifocal IOLs
I recommend testing at distance, intermediate and
near visual acuity at this visit. If you demonstrate improved near visual acuity at this early stage, it builds
excitement and anticipation for the second eye surgery.
Capitalize on the results patients are sharing with you.
Cornea
The cornea should be clear. Pay special attention to
the presence of microcystic edema, as this is almost always an indicator of increased intraocular pressure. If
IOP is high, manage with drops and/or oral agents in the
usual manner, and discharge the patient when stable. If
patients present with significant stromal edema and Decemets folds, increase the frequency of postop steroid
drops as frequently as every one-two hours while awake
depending upon severity to facilitate visual recovery.
Anterior Chamber
The anterior chamber should be relatively quiet. It is
not unusual to observe rare cells. Significant cells and
flare in the absence of corneal edema should be managed by increased topical steroid frequency. If the anterior chamber reaction is severe as if looking into a snowstorm and is associated with central corneal edema, a
relatively quiet eye (no significant injection), consider
toxic anterior segment syndrome (T.A.S.S.). The surgeon should be notified and a retinal consultation may
be indicated.
IOL
Standard
The optic should be centered and clear.
Continued on Page 12
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Successful
Elective IOL Practice:
Topography or
Pentacam
corneal
1. Communicate your belief in elective
analysis can also prove
IOLs.
invaluable to decipher
2. Assume all cataract patients are
and correlate conflictpotential elective IOL candidates until
ing information during
proven otherwise.
preoperative
evalua3. Describe elective IOLs to patients as
tion. Special consideran investment that never depreciates.
4. Set reasonable expectations.
ation must be given to
5. Educate patients early.
corneal
astigmatism.
6. Involve family members in cataract
The presence or abconsultations.
sence of corneal cylinder can influence
proper IOL recommendation. Attention must also be given to the pattern
of astigmatism. Asymmetric, non-orthogonal, irregular or
apical astigmatism may confound candidacy for advanced
IOL technology altogether.
Lens: The type of cataract diagnosed: nuclear sclerotic,
cortical, posterior subcapsular, anterior subcapsular, etc.,
should not preclude one patient versus another for consideration of advanced IOL technology. Careful attention
should be noted, however, to other subtle findings such as
pseudoexfoliation, phacodonesis and whether the cataracts
genesis is traumatic.
Vitreous: Vitreous opacities and posterior vitreous detachment may influence a patients subjective evaluation
of outcome and should be taken into consideration when
recommending certain lifestyle implants. Many patients,
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Multifocal
Obvious concentric rings can be seen on the multifocal IOL and is the signature of a multifocal IOL.
The central zones enhance near visual acuity and
more peripheral zones assist with intermediate and
distance visual acuity.
Toric
For patients receiving a toric IOL, I recommend dilating the operated eye on day one to ensure proper
axis alignment. Three dots will be found at the periphery of the optic 180 degrees apart from one another. The alignment of the peripheral dots on the
optic should match the planned corrected axis of
astigmatism. A good indication of whether the axis
if properly aligned is uncorrected visual acuity. If the
visual acuity is found to be within acceptable range
(>20/30) at this visit, that is strong empirical evidence
that alignment was achieved.
After careful evaluation of the day one surgical patient, the patient will be discharged with instructions
to use postoperative medications as directed, sleep
with an eye shield over the operated eye and limit
physical activity. My typical postoperative medical
regimen is:
Antibiotic:
Vigamox (Alcon) t.i.d. x one week
Steroid:
Omnipred (Alcon) (or equivalent) t.i.d. x one week
then b.i.d. x four weeks*
Non-steroidal:
Nevanac (Alcon) t.i.d. x one week then b.i.d. x four
weeks*
* I typically extend use of the steroid and non-steroidal drops to six weeks postop for elective IOL patients.
in fact, erroneously believe cataract surgery will eliminate
floaters. It is important to inform patients that floaters
will not disappear after cataract surgery. Moreover, patients with symptomatic floaters may not be appropriate
candidates for multifocal IOL technology.
Macula: We perform preoperative OCT on all prospective elective IOL candidates to rule out presence
of occult epiretinal membranes and macular thickening. Subtle macular pathology even fine pigment mottling can negatively affect elective IOL outcomes, especially multifocal IOLs. Careful observation and thorough
preoperative testing can prevent most cases of recommending an elective IOL to the wrong surgical candidate
and thus save countless minutes which can seem like
hours in the examination lane. A potential acuity meter
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Month Three
You should consider sending a
survey to your elective IOL patients at this point. Ask about their
spectacle-free experience, how the
implant has changed their outlook,
whether they would recommend
the same technology to a friend
or family member, etc. These are
good data to continue practice
growth and share with staff members to maintain excitement about
elective IOL technology.
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Fluctuating vision
Blurry vision
Missed expectations
Etiology for qualitative issues are
generally quickly discovered after a careful clinical examination.
They are typically related to:
Posterior capsular opacification
(PCO)
Tear film abnormalities
Residual refractive error
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anterior curvature of the lens during accommodation. This sulcus fixated lens uses a dynamic diaphragm
to force a silicone gel (index 1.40)
through a small hole in an anterior
diaphragm when the ciliary muscle
contracts.
The pressurized gel
bulges forward through the hole,
creating an increasingly more positive refracting surface. This is a similar mechanism used by waterfowl
when making underwater dives. Accommodation has been measured at
8D on average.
Smart IOL (Medennium, Irvine
CA) is a flexible thermoplastic gel
that can be produced to specific size
shapes and powers. It is a thin rod at
room temperature that expands to
fill the capsular bag when inserted
within the eye. The material is flexible enough to change during the
constriction of the ciliary muscle. The
lens has been inserted into cadaver
eyes and is awaiting further development before being inserted into human eyes.
Light Adjustable Lens (Calhoun
Vision, Pasadena, CA) is a photosensitive adjustable foldable 3-piece IOL.
Macromers are embedded into the
matrix of the lens. Focal UV light is
delivered to the lens, which causes a
polymerization of the macromers and
allows them to migrate to the desired
location (for example, to the center of
the lens for increased plus). A final
irradiation can lock in the final power
of the lens. Therefore, the power of
the lens can be altered after insertion,
allowing for treatment of myopia, hyperopia or astigmatism.
The Optometric Council on Refractive Technology (OCRT) is optometrys home for those
involved in refractive surgery and the advanced
technologies available for analysis and correction of patients vision. Our mission is to advance the art and science of refractive technology for optometrists.
Membership in the OCRT is open to optometrists, vision scientists, optometric residents
and students. If you would like to receive a
membership application or have questions
about membership in OCRT, please contact
OCRT Membership Chairs, Dr. J. Christopher
Freeman at [email protected] or Dr. Andrew Morgenstern at andrewmorgenstern@
gmail.com. For more information on the OCRT,
please visit http://www.ocrt.org/
REVIEW OF OPTOMETRY FEBRUARY 15, 2010
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