Alcon hayderabad premium slide show

1. Quality vision after cataract surgery-III Success with Premium IOLs Dr. Zia.ul.Mazhry FRCS(Edin), FRCS(Glasgow), FCPS(Pak), CICOphth- (UK) Life Member OSP Member American Academy of Ophthalmology Member European Society of cataract & Refractive surgery Associate Professor & HOD Department of Ophthalmology Central Park medical college WAPDA Teaching Hospital Complex Lahore Pakistan

2. Financial Interest • Live surgery was followed by discussion on premium IOLs • Activity Sponsored by ALCON Pakistan • Material taken from different internet resources • For education purpose only

3. Objective: • On completing this lecture, the ophthalmologist should be able to: 1. Understand the role of premium IOLs in phaco cataract refractive surgery. 2. To address and discuss the main issues related to premium IOL practice. a) Relevant preoperative diagnostic evaluations, b) patient selection criteria, c) counselling, and d) managing expectations 3. Explain the applications, advantages, and disadvantages of multifocal and toric IOLs

4. Discussion Plan • Pre test • Ideal intraocular lens • Overview of Premium IOLs • Patient selection – Understand your patient’s needs – Make the patient understand your limitations • Special preoperative and Operative considerations • Multifocal Iols • Toric IOLs • Summary and the Message

5. 1. Which of the following statements is true regarding multifocal IOLs? Correct Choice a The Sulcoflex multifocal is implanted in-the-bag during routine cataract surgery b In-the-bag multifocal IOLs may be easily removed in cases of non-tolerance c Multifocal IOLs work on the principle of simultaneous vision d All current multifocal IOL designs are rotationally symmetric

6. 2. Which of the following would not be appropriate advice for a patient prior to undergoing cataract with premium MF IOL surgery? Correct Choice a Reading glasses are likely to be needed after the operation b Vision is expected to be good for all distances in most of the cases c Surgery is typically performed under topical/local anesthesia as a day case d As vision will be improved with surgery, there will be no compromise at all.

7. 3. If a +20 D single optic AIOL shifts anteriorly by 0.33mm, the approximate power change would be Correct Choice a 0.01 D b 0.50 D c 1.50 D d 3.33 D

8. 4. The best method for corneal power calculation is: Correct Choice a Manual Keratometer b Corneal Topographer c Autorefractokeratometer d Optical Biometer

9. 5. A patient presents to your practice having undergone MFIOL implantation in her right eye four days ago. During history and symptoms, she report mild halos. What would be the MOST appropriate course of action? Correct Choice a Tell the patient that these are likely to get worse overtime and they should seek medical advice b Advise the patient that halos are a common side effect of MFIOLs, and they are likely to reduce in severity over the next few weeks c Tell the patient to stop driving, immediately d Ignore the symptom and see the patient in two years

10. 7. Multifocal or accommodating IOLs use the following methods to reduce spectacle dependence except: Correct Choice a Having a diffractive grating on the IOL surface to create separate images on the retina b Having zones of different refraction to create separate images on the retina c Being able to move slightly forwards within the eye when focussing at near d Altering the retinal and optic nerve processing of the images that reach the retina

11. 8. Concerns that ophthalmologists and optometrists have with multifocal IOLs include all of the following except: Correct Choice a they are associated with haloes and glare. b they may reduce contrast sensitivity as compared with a monofocal IOL c they increase the risk of postoperative dry eye d they are sometimes associated with "waxy" or "foggy" vision

12. 9. The main advantage of a Apodized diffractive refractive multifocal IOL over the traditional bifocal multifocal is: Correct Choice a this IOL comes in a choice of colours b this IOL provides better intermediate vision for tasks such a working on the computer c This IOL produces x-ray vision for looking through solid objects d with this IOL inside the eye one does not need the special glasses to watch 3-D movies

13. 10. Toric IOL is meant to correct: Correct Choice a Lenticular astigmatism b Corneal astigmatism c Corneal and lenticular astigmatism d Irregular astigmatism

14. Ideal Intraocular Lens – Smaller Incisions – Surgeon friendly implantation • Durable and flexible • Compatible delivery system – Centration & Fixation in Capsular Bag – Excellent visual out come with out aberrations – No loss of contrast sensitivity – No dysphotopsia – No Inflammatory response – No PCO – Spectacle Independence/seamless accommodation – No loss of function with time

15. Cataract Surgery- Refractive Surgery • Refractive IOLs involve the same skills set as that of cataract surgery • Multifocal and accommodating lenses are dramatically changing the way all eye doctors practice refractive surgery

16. Understand Your Patient’s Expectations • Assess vision function goals: – Distance – Intermediate – Near • Determine frequency and importance of – Dim and bright light activities • Talk with the patient! • Pre-operative Exclusion Criteria – Hypercritical patients – Patients with unrealistic expectations – Occupational night drivers • Medical Exclusion – >1.0 D of corneal astigmatism – Pre-existing ocular pathology – Previous refractive surgery patients?

17. Mindset of the Presbyopic Refractive Patient • Patients are interested in lifestyle, not pathology and are happy to pay for the enhanced quality of life • Old paradigm: Patient want to see better than they did with their cataracts • New paradigm: Patients want to see better than they did before they developed cataracts

18. Spectacle Independence? The Goal: To make patients less dependent on their glasses for all distances

19. Explain Their IOL Options Multi-focal Implant • Designed to correct vision near, far, and in-between, for the best chance at freedom from glasses. Toric Implants • Designed to correct both cataracts and astigmatism at the time of surgery. Glasses will likely be needed for near vision. Multifocal Toric Implants • Provides clear distance vision. Glasses will likely be needed for near vision and possibly for distance vision.

20. < 1.0 D =/> 1.0 D Regular ? Non-regular ? AcrySof® IQ (w/spectacles) CATARACT - Diagnosed Corneal Astigmatism ? IOL Decision Process • Spectacle Independence ? • Lifestyle Needs ? Yes No AcrySof® IQ ReSTOR® +3 AcrySof® IQ AcrySof® Toric

21. Success with Premium IOLs Richard L. Lindstrom – August 2009 OSN Perspective • Careful patient selection • Reducing patient expectations • Achieving the desired refractive result

22. Success with Premium IOLs Richard L. Lindstrom – August 2009 OSN – My conclusion after 25 year of studying the premium IOL field, is that the level of patient satisfaction is NOT dependent of careful patient selections – I do NOT believe that patient satisfaction is really significantly influenced by extensive efforts to reduce patient expectations – Patient selection is LESS IMPORTANT THAN SURGEON PERFORMANCE if spectacle independence is the desired outcome

23. Success with Premium IOLs Richard L. Lindstrom – August 2009 OSN – Every refractive cataract surgeon must appreciate that it is the REFRACTIVE OUTCOME THEY GENERATE, NOT THE PATIENT or EVEN THE TECHNOLOGY they select, that is the primary determinant of patient satisfaction and word of mouth referrals.

25. Quality vision after cataract surgery Minimizing Surgeon induced errors

26. Introduction minimizing Surgeon introduced errors • One of the goals of cataract surgery is to achieve emmetropia or balance with the fellow eye. • The spherical component is achieved with the proper IOL power calculation – Careful Biometry – IOL Master – Water bath ultrasound • The astigmatic component can be controlled by: – size and location of the cataract wound – Toric IOLs – intraoperative relaxing incisions – or post-operative • astigmatic keratotomy, • wound revision or • LASIK

27. Biometery • Repeated As and Ks • Always have a tangential look while applying A Scan Probe • Always Compare Two Eyes • Do have finalized Refraction with you if already operated • Do document Keratometric axis and Plan your Incision on steeper axis

28. Placement of Incisions • Clear corneal incisions according to the preoperative steep meridian determined by keratometery • The following scheme can be used to determine the location of clear corneal incision: – Superior, Temporal, Nasal, SuperoTemporal or SuperoNasal S ST SN T N

29. Surgeon Induced Astigmatism • The studies indicate that performing the incision on steeper according to the preoperative axis in eyes with significant astigmatism results in an acceptable outcome

30. Role of Non Dominant Hand

31. ESCRS London 2014

32. The Message-SIEs • One needs to be vigilant if not able to correct preexisting errors, at least do not induce it. We believe it plays a very vital role in improvement of quality of vision after cataract surgery.

33. Place the IOL in fetal position and expect a normal safe delivery

34. What is Apodization … how does it work? • It’s a light management system • Microscopic steps sends light where you need it, when you need it

35. Apodization

36. Anterior Apodized Diffractive Aspheric Surface  9 apodized diffractive steps for +3.0D add power and balanced light energy management  Negative 0.1 micron spherical aberration factor corrects for the positive spherical aberration of the cornea Posterior Toric Lens Surface  Posterior toric surface with axis marks  Allows the lens to correct pre-existing corneal astigmatism 36

37. AcrySof Single Piece Platform AcrySof Restore • Improve quality of distance vision while maintaining near and intermediate vision Apodized diffraction

39. AcrySof® Toric Axis Indicator Marks Toric IOL alignment with the corneal steep axis adds the corrective cylinder power to the corneal flat axis. This will ‘neutralize’ the astigmatic cornea.

40. Toric effect

41. Marking of the Eye • Reference Marks (pre-op) – placed at limbus in two locations 180 degrees apart (3 o’clock and 9 o’clock) – patient in upright position (cyclorotation) • Axis Marks (intra-op) – Axis marks are placed on the eye using pre-op reference marks for alignment – Dell Astigmatism Marker used to mark the steep axis of cornea with which the IOL is to be aligned

46. Reference Marking

47. Axis marking

48. Toric IOL Implantation

49. Astigmatism Management Other Options

50. Surgeon Targeting: “How are you addressing pre-operative corneal astigmatism with your patients?

51. How Limbal Relaxing Incisions (LRI) Work “Coupling” - The amount of corneal flattening induced by the incision is equal to the amount of steepening that occurs 90 degrees away • With this, the spherical equivalent required for the patient remains the same, and the surgeon does not have to adjust the IOL power

52. Relaxing Incisions

53. Calculator input screen Surgeon/Patient Data Keratometry Data 1. SE power 2. SIA factor 3. Incision location Internal Use Only – For Sales Training Purposes

54. Calculator output screen Calculation Provides: • Appropriate SN6ATT IOL model • Optimal axis location of the IOL • Anticipated residual astigmatism Note: Surgeons should print copies of final output for reference in the O.R. and patient chart. Internal Use Only – For

55. 1. Online Calculator 2. Mark cornea (pre / intra-op) 3. Standar d Phaco Procedu re 4. IOL Delivery in the bag Monarch® 7. Final alignment IOL 5. Gross Align IOL 6. OVD Removal I/A Pre-op & Intra-op Tasks Internal Use Only – For Sales Training Purposes

60. 5. A patient presents to your practice having undergone MIOL implantation in her right eye four days ago. During history and symptoms, she report mild halos. What would be the MOST appropriate course of action? Correct Choice a Tell the patient that these are likely to get worse overtime and they shouldseek medical advice b Advise the patient that halos are a common side effect of MIOLs, and they are likely to reduce in severity over the next few weeks c Tell the patient to stop driving, immediately d Ignore the symptom and see the patient in two years

61. 6. You examine a patient who has been implanted, bilaterally with AIOLs two months ago. You refract the patient and find that his distance prescription is plano in both eyes and he has no sign of any other lenticular anomaly. During history and symptoms, however, the patient complains that he can no longer read his paper diary. What would be the MOST appropriate course of action? Correct Choice a Tell the patient that the IOLs need to be removed by the ophthalmologist b Refer the patient for wavefront-guided keratorefractive surgery to correct his spherical aberration c Explain that there is little that can be done and that he will have to get used to it d Advise the patient that AIOLs do not always restore near vision, and that he should be prescribed a near addition

70. 5. A patient presents to your practice having undergone MIOL implantation in her right eye four days ago. During history and symptoms, she report mild halos. What would be the MOST appropriate course of action? Correct Choice a Tell the patient that these are likely to get worse overtime and they shouldseek medical advice b Advise the patient that halos are a common side effect of MIOLs, and they are likely to reduce in severity over the next few weeks c Tell the patient to stop driving, immediately d Ignore the symptom and see the patient in two years

71. 6. You examine a patient who has been implanted, bilaterally with AIOLs two months ago. You refract the patient and find that his distance prescription is plano in both eyes and he has no sign of any other lenticular anomaly. During history and symptoms, however, the patient complains that he can no longer read his paper diary. What would be the MOST appropriate course of action? Correct Choice a Tell the patient that the IOLs need to be removed by the ophthalmologist b Refer the patient for wavefront-guided keratorefractive surgery to correct his spherical aberration c Explain that there is little that can be done and that he will have to get used to it d Advise the patient that AIOLs do not always restore near vision, and that he should be prescribed a near addition

76. What a Surgeon needs for the patient to attain quality vision after Cataract surgery? – Enhance Two Handed Skills – Try to manage patient expectations – Minimize Complications – Select IOL based on objective data – Avoid small errors to add up into a big surprise • Repeated As and Ks – minimize SIA • Incision Placement at steeper meridian, wound size – Aim at Thorough Cortical clearance& – In the Bag Implantation with sub optical Rhexis

77. Remember that you are now a refractive surgeon Under promise Over achieve Celebrate success

78. • Contact – mazhry@yahoo.com – mazhry@facebook.com • Website – www.EyeAcuity.com • Internet access I/D “mazhry” – http:// www.YouTube.com – http:// www.Eyetube.net – http:// www.surgytec.com – http://www.slideshare.net Thank you!

Alcon hayderabad premium slide show

Alcon hayderabad premium slide show

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Alcon hayderabad premium slide show