A slideshow presentation reviewing the features of multi-focal implants. Pertinent information is presented to help eye care providers to help them guide their patients, on the selection of multi-focal implant. Co-management pearls are provided regarding the post operative care of these patients.

1. Dr. M. Ronan Conlon
Midwest Eye Care Institute
Saskatoon
February 2nd, 2012 – Saskatoon Club

2.  Share my experience with multi-focal
implants
 Patient video – highlighting many of
features of multi-focal implants
 Patient selection/Education
 C0-Management
 Managing the Unhappy Patient

3.  Population trends in
3.0
Canada predict a
2.5 significant increase in
2.0
patients requiring
cataract surgery in the
Millions
2010
1.5
2021 next 15 years
1.0
2031
 Advanced technologies
are now available to
0.5
these patients to
0.0 enhance their visual
70 to 74
>100
85 to 89
60 to 64
65 to 69
75 to 79
90 to 94
80 to 84
95 to 99
function
Age Group
Projected population by age group and sex according to three projection scenarios for
2010, 2011, 2016, 2021, 2026,2031 and 2036, at July 1. Statistics Canada.

4.  Advanced Technology Lenses (Part 1) –
Toric implants – presented September
15th, 2011

6. 50.0
Moderate
1.0 – 2.0D
25%
% of Patients
40.0
30.0 Severe
>2.0 D
20.0 10%
10.0
0.0
<.5 <1 <1.5 Cylinder D
<2 <2.5 ( < ) <3 <3.5 >3.5
N = 10,411

7. AcrySof® IQ TORIC IOL:
Astigmatism Correction
7

8.  81.1% of patients were
≤5º of intended axis
 97.1% of patients were
≤10º of intended axis
 less than 4º average
rotation 6 months
after implantation

9. Cylinder Powers
Estimated Percent of Cataract Patients
with Astigmatism
0.5D 4D+
*Based on average pseudophakic human eye. 9

10. 2010 – 805 Cataract Cases 2011 - 850 Cataract Cases
47
11 (6%)
94 73
(1.0%) Aspheric
(12%) Aspheric (9%)
Toric Toric
ReSTOR 546 ReSTOR
700 (65%)
(87%) ReSTOR 166
ReSTOR
Toric (20%)
Toric

11.  Toric Implant at axis 90
degrees

12. Key points for patients to understand
• Toric lenses are designed to work with
the shape of your cornea to focus light
to a single point at the back of your
eye to improve your quality of vision.
• By doing this, Toric lenses will make
you less dependant on your glasses for
distance vision
• Toric lenses only correct astigmatism
and do not correct presbyopia
• You will have to wear reading glasses
after cataract surgery

13. Key points for patients to understand
• Toric lenses have become the standard
of care for astigmatic cataract patients
in my practice
• Patients see better if they have a toric
implant – it’s that simple
• These lenses work extremely well

14. Multifocal IOLs
The Goal: To make patients less dependant on
their glasses for all distances

15.  Diffractive
 ReSTOR +3.0
 Technis
 AcriLisa (Europe)
 Zonal Refractive
 ReZoom
 Accommodating
 Crystalens
 Synchrony

16.  It’s a light
management
system
 Microscopic steps
sends light where
you need it, when
you need it

18. 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
18

19. IOL Model Cylinder Power Cylinder Power Recommended
@ IOL Plane @ Corneal Plane* Corneal Astigmatism
Correction Range
(Online Calculator Limits)
SND1T2 1.00 0.68 0.50 to 0.89 D
SND1T3 1.50 1.03 0.90 to 1.28 D
SND1T4 2.25 1.55 1.29 to 1.80 D
SND1T5 3.00 2.06 1.81 to 2.32 D
*Based on an average pseudophakic human eye
19

20. Binocular Defocus Curve
∞
20/20
20/25
20/32
20/40
20/50
20/63
20/80
20/100
+1.00 +0.50 0.00 -0.50 -1.00 -1.50 -2.00 -2.50 -3.00 -3.50 -4.00
Refraction (D)
AcrySof® IQ ReSTOR® IOL +3.0 D [N=116]
Mean Defocus Curve for AcrySof® IQ +3.0 D ReSTOR® IOL
Binocular, Best Case, 6 Months Postoperative
Source: AcrySof® IQ ReSTOR® IOL Package Insert
20

21.  55 bilateral ReSTOR 2011 - 850 Cataract Cases
implantations so far 47
(6%)
73
 30 have completed 6 (9%)
Aspheric
month Late Outcome Toric
Assessments –
measuring ReSTOR
546
(65%)
UCDVA, UCNVA, BCDV 166 ReSTOR
(20%)
A, BCNVA, refraction Toric
and survey of visual
activities and function

22.  98% would have same implants again
 Mean UCDVA 20/25 (range 20/20+ to 20/30-
, UCNVA 20/25 (range 20/20+ to 20/40)
 All of the patients with UCVA worse than
20/25 are due to uncorrected astigmatism
>0.75 D; all correct to 20/20 near and distance
with this cylinder corrected

23. Richard L. Lindstrom – August 2009 OSN
Perspective
• Careful patient selection
• Reducing patient expectations
• Achieving the desired refractive result

24. 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

25. 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.

26. 40,000 premium
lens implants
 60% (24,000) eyes left
with > 0.75D untreated
residual K astigmatism
 Minimum goal less than
0.50
 Correction of cylinder is
extremely important

27.  What can you do?
 Optometry has a key role in the education
and counsel of patients seeking guidance in
new implant technology

28.  Acceptance and Embracement of a change in
practice model
 From medicare model – “treatment for
pathology”
▪ High volume, efficient, low cost care
 Patient orientated model – “treatment for Quality
of Life”
▪ High quality, personalized to patients
needs, expectations, and desires, patient pay

29.  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

30. 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

31. 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.

32. Take into account:
▪ Lifestyle
▪ Astigmatism
▪ Preexisting ocular conditions, i.e. dry eye
▪ Pathology – rule out retinal pathology

33. Astigmatism No Astigmatism
Basic IOL Basic IOL
• regular
astigmatism
Toric IOL • healthy eye? ReSTOR
ReSTORToric Shared Decision
Making!

34. Key points for patients to understand
• ReSTOR is a multifocal lens which make you less
dependant on glasses after cataract surgery at
all distances
• Although 20/20 vision is not guaranteed, 80% of
patients report not needing glasses after
surgery
• 20% of patients report needing glasses for
specific activities such as working on a computer
or reading in dim light
• Glare and halo around lights at night may be
reported after surgery, most patients adapt
within a few weeks
• Adequate light is recommended for ideal
reading vision

36.  Expansion of patient variety and opportunity for
practice growth
 With the development of toric, multi-focal, and
multi-focal toricIOL’s cataract surgery has
evolved into “refractive cataract surgery”
 Shared practice experience and opportunity for
higher degrees of patient satisfaction
 Optometrists play an integral role in selecting
and recommending IOL technologies
 Saskatchewan has a larger geographical area
and travel is a significant issue for patients

37.  Patient should discontinue contact lens wear
two weeks prior to axial length and
keratometry measurements – more accurate
IOL measurements
 Discuss with your patient the various IOL
options – regular, toric, multi-focal, and
multi-focal toric
 Advise your surgeon and what you think
would work best – make a recommendation

38.  Manage Ocular Surface
Disease
 Treat Dry Eye
 Manage Eyelid Margin
Disease

39. • Many cataract surgeons now perform same day post
evaluations, and patient go home same day
• Examination
• Vision is usually 20/40 or better
• Anterior segment – cornea generally clear to mild edema, AC
inflammation minimal +1, eye should be comfortable, AC
deep, wound sealed
• Lens centered
• IOP – 10 to 25 (contact surgeon if outside these parameters)
• Post Medications – Vigamox TID x 1 week, Maxidex TID x 4
weeks, Nevanac TID x 4 weeks
• Follow visit in 3-4 weeks, and sooner if concerns

40.  IOP spike
 25 – 30 mmHg – Alphagan P BID x 1 week
 > 30 mmHg – contact surgeon
 Bullouskeratopathy
 Lubricated surface, consider Muro 128 qhs
 Usually related to increased IOP, endothelial comprise
 Tilted IOL
 Not an emergency, but contact surgeon
 Peaked Pupil
 Not an emergency, but contact surgeon, check IOP and wound leak
 Retain lens fragment
 Increased steroid 6X/day, and contact surgeon
 Retinal detachment
 Urgent – contact surgeon

41. • Conduct a dilated fundus exam to check for
cystoid macular edema (CME)
• Discontinue drops
• Prescribe spectacles, if necessary
• 20% of multi-focal toric implant patients require
spectacles for some activities
• Decreased Vision
• Check for ocular surface disease – dry eye, MGD, EBMD
• IOP
• Fundus - CME

42.  Lens tilted
 Inferior lens out of bag
 May or may not require
adjustment
 Persistent
BullousKeratopathy
 Control IOP
 Muro 128 gtts/ung

43. • Patient should have bilateral lenses
• Check visual acuities at appropriate distances
• Survey the patient for their satisfaction

44.  Posterior capsular opacification (PCO)
• Treated with a Nd:YAG laser
 Persistent tear film abnormalities unless you
are comfortable managing it
 Residual refractive error if the patient is
interested in a surgical solution

45.  Cylinder and Residual
Refractive Error
 Cornea and OSN
 Capsule
 CME
 Centered

46.  Optimizing the ocular
surface very important
 Options
 Artificial tears
 Restasis
 Serum based tears
 Punctal plugs
 Nutritional supplements
– omega 3’s

47.  Lid hyperthermia
 Hot compresses or lid
scrubs
 Nutritional supplements
 Topical azithromycin bid
2 days then qd for 1
month
 Tobradex
 Severe cases
 Oral doxycycline 50 mg PO
daily

48.  Consider Yag laser
 Avoid Yag laser if
explantation still a
consideration!

49.  NSAID’s mandatory
 Significant reduction
post operative CME