Premium IOL and Cataract Co-management by Dr. J. Alberto Martinez

1. Premium IOL and Cataract Co-Management J. Alberto Martinez, M.D. Visionary Ophthalmology October 3, 2010

2. Testimonial

3. OUTLINE THE MARKET AND THE OPORTUNITY ETHICAL CONCERNS TECHNICAL ASPECTS LEGAL SURGICAL POSTOPERATIVE CARE

4. The Graying of America Another boomer turns 50 years of age every 7 seconds They represent the majority of the US workforce They are the US economic engine 13 trillion in assets ( 50% of US asset base) Average life span of 78.5 men, 82.5 women As they age: glaucoma, diabetic eye disease and cataracts

5. The graying of America Are you prepared to meet boomers health care challenges? Are you current with technological advances? Are you embracing the newest ophthalmic technologies? Their increased expectations regarding outcomes is unprecedented! We can not afford to wait. This wave has come to shore!

6. Ethical Concerns Ethical concerns are absolutely above any considerations Needless to say, the patient’s welfare must remain the top priority of the MD-OD team World class outcomes can not be compromised by transfer of care Team approach must benefit the patient first and MD-OD team second.

7. Legal concerns Co-management more common but still controversial It is critical that any c0-management relationship be ethical and compliant with all legal requirements Professional societies including AOA have guidelines Fundamental: no agreement to refer back. Must be based on patient choice

8. Legal Concerns Patients must understand clearly who can provide post-op care Patients must choose to return to OD and sign a statement Work with a knowledgeable attorney Medicare rules are clear on the amounts paid for surgery and for post-op care OD must receive fair market value for their services

9. Legal Concerns Patient must be informed about the amounts paid to each provider Visionary Ophthalmology will develop a mechanism to allocate appropriate amounts Premium IOLs are most complex c0-management arrangement for it involves covered and non-covered services VO is committed to develop an ethical, legal and fair co-management practice.

10. High Technology IOLs Many IOLs available. Choosing is a complex decision. Surgeons need to take into account: Patient’s desires and epectations Status of the non-operative eye Presence of any comorbidities Potential risks

11. Spherical aberration occurs when light rays are over-refracted at the periphery of a lens system, resulting in a region of defocused light which can decrease image quality. The Problem: Spherical Optics *Smith G, Atchinson D A. The Eye and Visual Optical Instruments. Cambridge University Press, Cambridge, United Kingdom. 1997;667.

12. Aspheric optics align the light rays to compensate for positive corneal spherical aberration, resulting in enhanced image quality. The Solution: Aspheric Optics *Smith G, Atchinson D A. The Eye and Visual Optical Instruments. Cambridge University Press, Cambridge, United Kingdom. 1997;667.

13. Clinical improvements demonstrated over spherical control lens include: Improved functional vision Increased contrast sensitivity Reduction of spherical aberration and total high order aberrations (HOAs) Benefits of Asphericity

14. Why Toric IOL? The AcrySof® IQ Toric IOL offers cataract surgery patients with astigmatism: Reduction of residual refractive cylinder Improved uncorrected distance visual acuity Increased spectacle-independent distance vision

15. Selection criteria for Toric IOL Preoperative regular astigmatism CCC possible Intact capsular bag Precautions in patients with pre-existing ocular disease conditions Careful consideration in the cases of those with prior corneal refractive surgery

16. Designed for a Wide Range of Astigmatic Patients AcrySof® IQ Toric IOL is designed to accommodate a variety of cataract patients with astigmatism A wide range of cylinder powers means more candidates can benefit from AcrySof® IQ Toric IOL

17. Dramatically Reduces Residual Refractive Cylinder 63% of patients achieved ≤0.50 diopters of residual refractive cylinder1 87% of patients achieved ≤1.00 diopters of residual refractive cylinder1

18. The AcrySof® IQ Toric IOL: Builds on a long line of innovation from Alcon Takes the trusted platform for precise astigmatism correction and adds the enhanced image quality of an aspheric lens The Next Step in Toric Technology

19. Presbyopia-correcting IOLs Crystalens: an accomodating IOL. Reversible and unpredictable Rezoom: A refractive mutifocal IOL (AMO) Restor: Difractive IOL (Alcon) Tecnis: Difractive IOL (AMO)

20. US Presbyopia-Correcting IOL Survey Share Source: Market Scope Quarterly Cataract Update * Trademarks are the property of their respective owners.

21. Two Different Add Power Options SN6AD3 Add Power: +4.0 D Spectacle Plane: +3.2 D Range: +10.0 D to +34.0 D A-Constant: 118.9 SN6AD1 Add Power: +3.0 D Spectacle Plane: +2.5 D Range: +6.0 D to +34.0 D A-Constant: 118.9 Source: AcrySof® IQ ReSTOR® IOL Package Insert.

22. AcrySof® IQ ReSTOR® IOL +3.0 D was specifically designed to: Maintain existing optical design characteristics and manufacturing processes Move near vision distance out 6-7 cm Improve intermediate vision without sacrificing distance and near1 True Performance at All Distances Source: AcrySof® IQ ReSTOR® IOL Package Insert. 1.Maxwell A, et al. Functional Outcomes After Bilateral Implantation of ApodizedDiffractive Aspheric Acrylic Intraocular Lenses with a +3.0 or +4.0 Diopter Addition Power. J Cataract Refractive Surg. Vol. 35, December 2009.

23. Patient Education

24. Define Clouding of the natural lens that allows less light to pass through to the retina Symptoms Blurred vision Dull colors Poor night vision Sensitivity to light Treatment ONLY treatment is to have it surgically removed and replaced with an artificial lens Begin with the Problem: Cataracts

25. Take into account: Pathology Lifestyle Astigmatism Preexisting ocular conditions, i.e. dry eye Consider Their Needs

26. Before they leave the office, patients should have: Educational materials on cataracts and the procedures Materials that explain their IOL options A follow-up appointment for their cataract surgical evaluation Keep Them Informed

27. Post Operative Care

28. Measure visual acuity Test all distances if the patient has a presbyopia-correcting IOL Look for a quiet anterior chamber Continue antibiotic, steroidal and NSAID therapy Treat dry eye aggressively What to Expect After Surgery – Day One

29. VO is committed to educating co-management physicians to provide seamless care. Mini-fellowships to include: Day one post-op care at VO Three week post-op visit at VO Pre-op evaluation and choosing the apropriate IOL OR visit at our ASC to learn the technical issues associated with Toric and Multifocal IOL Educational process tailored to individual needs Educational Process for Optometrists

30. Premium IOLs are not only great technology to offer patients but can have a significant financial impact in your practice as well Financial Rewards

31. “To be on the cutting edge of optometry, you need to be on the cutting edge of ophthalmology.” - Richard Van De Velde, O.D. Imhoff Eye Center Brunswick, GA Today’s optometrist provides… Patient care at any age Patient support Patient education for all conditions Today's Optometrist

32. Testimonial