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American Society of Cataractand Refractive Surgery06-10 May, 2016New Orleans, LouisianaErnest N. Morial Convention CenterCourse 10-105Room 228-230“Best of the Best : Advanced New TechnologiesCataract Surgery”Senior Instructor:Richard L Lindstrom MDInstructor:Eric Donnenfeld MDJack Holladay MD MSEEStephen S Lane MDMatteo Piovella MDSteven C Schallhorn MDTuesday, May 10, 20168.30 AM – 9.30 AM1
INDEXFemto Laser Assisted cataract Surgery: Virtuosity orFrontier?Matteo Piovella MDPag. 3Multifocal Accommodative and Toric IOL Implantation inAdvanced cataract Surgery: 8 Years Up to dateMatteo Piovella MDPag. 8What’s New in Multifocal IOLsEric Donnenfeld MDPag. 19Delivering Improved Outcomes for Today's Cataract PatientStephen S LanePag. 25Preliminary Results of Intrastromal FemtosecondAstigmatism keratotomySteve C. Schallhorn MDPag. 31The Promise of No Glasses or Contact Lenses!Jack T Holladay MD, MSEE, FACSPag. 34ADDRESSESPag. 432
“Femto Laser Assisted cataract Surgery: Virtuosity or Frontier?”Matteo Piovella MD3
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“Multifocal Accommodative and Toric IOL Implantation in Advancedcataract Surgery: 9 Years Up to date”Matteo Piovella MD8
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“What’s New in Multifocal IOLs”Eric D. Donnenfeld MD19
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“Delivering Improved Outcomes for Today's Cataract Patient”Stephen S Lane MDDISCLOSURE Delivering Improved Outcomes forToday's Cataract PatientStephen Lane, MDAlconClarVistaBausch and LombIvantisi-VeenaKalaLifecoreMatiOcular Therapeutics onCareWaveTec1Cataract Surgery Outcomes***Cataract Surgery Outcomes100%90%80%70%60%50%40%30%20%10%0%97% Patient expectations are at an all-timehigh for refractive surgery Positive experiences with LASIK haveproduced high expectations–55%–41% 0.25D 0.5D 1.0D92.6% of LASIK patients achieve vision of20/40 or better*95.4% of patients were satisfied with theiroutcome after LASIK surgery**Cataract surgery outcomes may not bemeeting the target of 0.5D that isconsidered the standard*“LASIK Surgery Statistics.” Docshop.com. /lasik/statistics**Solomon, K et al. (2009) “LASIK world literature review: quality of life and patient satisfaction.” Ophthalmology. 16(4):691-7011 Data fromCRS15001SK***Graph:Dr. Warren Hill & Behndig A, et al. Aiming for emmetropia after cataract surgery: Swedish National Cataract Register study. J Cataract Refract Surg. 2012;38(7):1181-6.What are the issues that affect hittingthe refractive target?Pre-operativeIntra and Post Operative Rhexis shape and size? Posterior cornealastigmatism Alignment, centration A-constant optimizationBiometryManaging astigmatismTranscription errorsCyclorotationManual marking4Manual Toric MarkingCataract Refractive DiagnosticsImage Guidance5625
Removing Ink From the Entire ProcessThe Verion Image Guided SystemDesigned to help you consistently achieve your refractive target.The VERION Image Guided System is designed to add greater accuracy andefficiency during surgical planning and execution. Consisting of the VERION Reference Unit and the VERION Digital Marker, it is designed to help youperform cataract surgery.Courtesy of Michael Jones, MD87Introducing the VERION Image GuidanceCapturing the Reference ImageIMAGE. PLAN. GUIDE.VERION Reference UnitVERION Microscope Integrated Display9ComprehensiveAstigmatism Planner1110Closing the Loop: Optimization1226
Digital Marker GuidanceRegistration Process at the LenSx Laser- Digital Marker LVERION DIGITAL MARKER1314MICROSCOPE INTEGRATED DISPLAYImage Guided System and CentrationVisual Axis CenterLocation of Incisions MarkerRhexis MarkerCentration MarkerToric Alignment MarkerLimbus Center1615Verion Digital Marker MIntraoperative SurgicalAberrometry171827
Outcomes in Modern Cataract SurgeryLiterature“Yardstick” to measure Cataract SurgerySuccess Narvaez / Stulting JCRS Dec. 2006 Driven by LASIK outcomes– 46 % within 0.50 D of formula predicted target– Mean prediction error: 0.52 D /- 0.44 D– Refractive component and Visual Acuity component 95% of outcomes within 0.50 D of nomogrampredicted refractive target 90% of eyes achieving UDVA of 20/20 or better 3% enhancement rates expected Gale et al, Eye Aug. 2007– 55 % of eyes within 0.50 D of formula predicted target– 85% of eyes within 1.00 D of formula predicted target Findings considered the benchmark for the NHS in the UK– Enhancement Rates on Premium IOL cases (Presbyopicand Toric IOLs) Range from 10% to 35%* Intraoperative aberrometry may help refractive cataract surgery reach the next level by Richard L. Lindstrom, MD, Ocular Surgery News U.S. Edition, December 25, 2010Conventional IOL Power DeterminationApproachOutcomes in Modern Cataract SurgeryRecent Literature Andrs Behndig, M.D., Ph.D.,et al, JCataract Refract Surg. (July) 2012 (SwedishNational Cataract Registry.)–17,056 procedures–Emmetropia (spherical equivalent 0.5 to 0.5D and 1.0 D astigmatism) achieved in55% of eyes planned for emmetropia. Various characteristics of the eye are measured preoperatively Axial Length Corneal Power Other measurements that may be used (formulae dependent)– Anterior Chamber Depth– Lens Thickness– White to White– Formula appliedORA System by WaveTec(Optiwave Refractive Analysis) Provides intraoperative refractiveinformation Attaches to most surgical microscopes foron-demand intraoperative measurements ofsphere, cylinder and axis Enables real-time surgical coursecorrection “Get it right – right on the table” the firsttime Every ORA System connects live toWaveTec servers to capture everyprocedure and push software upgradesThe ORA System with VerifEye 2428
Improve astigmatic outcomes for your patientswith real-time intraoperative Validation1Overview The ORA System uses wavefront aberrometry data in themeasurement and analysis of the refractive power of the eye (i.e.sphere, cylinder, and axis measurements) to support cataract surgicalprocedures.Accounts for contribution of anterior and posterior corneal astigmatismin its measurementsReal-time, intraoperative refractometer plus a working algorithmsupported by a large clinical database (100k cases), and a platformfor additional enhancements. 25 Provides streaming refractive information todetermine power, cylindrical magnitude and axis,even for post-refractive-procedure eyes. Accounts for contribution of anterior and posteriorcorneal astigmatism in its measurements. Reduces risk of residual postoperative ,231,43.9 0.250* 95% CI: 61.8 - 80.1% 0.50* 0.75 1.00 1.00DioptersPercent Patients100908070605040302010088.4%fromtarget91,4 90,292,496,181Anticipated ResidualCylinder based uponPreoperativeCalculation71,653,339,231,416,7 3,90 0.25 0.50 0.75 1.00 1.00DioptersSecondary Efficacy ResultPostoperative MRSE Accuracy at 3 Months1009080706050403020100Primary Efficacy ResultResidual Refractive Cylinder at 3 MonthsPercent PatientsPercent PatientsPrimary Efficacy ResultResidual Refractive Cylinder at 3 Months87,391,2 0.75 1.00Improved astigmatic outcomes with VerifEye This carefully controlled clinical study confirms that the ORASystem with VerifEye provides better astigmatic outcomes incataract surgery.69,640,2007,8 0.25 0.50*Diopters* 95% CI: 59.7 – 78.3% 1.00Percent of Patients Within 0.50 D of Intended Target at One Month; n 111 patients, p .0062. Standard of Care: Conventional biometry measurement of the pre-op corneal astigmatism and toric calculator determination of IOL cylinder power.303. Results are statistically significant based on McNemar’s test (p 0.006).29
Synergism of Guidance withAberrometry and FemtosecondCataract SurgeryImproved astigmatic outcomes with VerifEye 53.8% fewer patients were outside the intended target. Paired with the VERION Image Guided Systemaberrometry provides the opportunity to addresspotential sources of error at each procedural stepimaging, planning, guidance and verification. Aberrometry gives you the confidence to effectivelytreat astigmatism for toric IOL patients.*Based on seeing 100 post-op patients per month3231How I use the systems togetherRefractive Cataract Suite Toric case– Establish initial plan with Verion guidance K’s will help establish initial cylinder power and axis – registration will help identifythis axis during surgery Pre-op will supply preliminary spherical power for the toric lens– Obtain consistent VerifEye aberrometry aphakic measurementsintraoperatively Will provide the actual spherical power of the lens, cylinder power and the targetaxis of placement– Use Verion guidance to locate axis obtained during pre-op– Place lens and use VerifEye’s toric pseudophakic aberrometryapplication to refine axis of placement by rotating as directed33Conclusions Aberrometry and Guidance are complimentary Using both together results in refined IOL powerselection and astigmatic treatment3530
“ Preliminary Results of Intrastromal Femtosecond Astigmatism keratotomy”Steve C. Schallhorn MD31
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“ The Promise of No Glasses or Contact Lenses!”Jack T. Holladay MD, MSEE, FACS34
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ADDRESSESRICHARD L LINDSTROM MDMinnesota Eye Consultants,PASte 200 9801 Dupont Ave SBloomington MN 55431-3200Ph.: 952-567-6051Fax: 952-567-6182e-mail: rllindstrom@mneye.comJACK T HOLLADAY MD MSEEFACS5108 Braeburn DR,BALLAIRE TX 77401-4902Ph.: (713) 668 7337Fax: (713) 669 9153e-mail: holladay@docholladay.comMATTEO PIOVELLA MDC. M. A.Centro MicrochirurgiaAmbulatorialeVia Donizetti, 24 - 20900Monza- ItalyPh.: 39 039389498Fax: 39 0392300964e-mail: piovella@piovella.comERIC DONNENFELD MDOphthalmic Consultants ofLong IslandGarden City, New YorkClinical Professor of Ophthalmology NYUTrustee Dartmouth Medical SchoolPh.: 516-766-2519e-mail:ericdonnenfeld@gmail.comSTEPHEN S LANE MDAdjunct Clinical Professor,University of MinnesotaMinnesotaUSAe-mail: sslane@associatedeyecare.comSTEVEN C.SCHALLHORN MD5 Deerdykes RoadWestfield Industrial EstateCumbernauldGlasgow G68 9HFPh.: 01236 795 010e-mail: scschallhorn@yahoo.com43
Positive experiences with LASIK have produced high expectations 92.6% of LASIK patients achieve vision of 20/40 or better* 95.4% of patients were satisfied with their outcome after LASIK surgery* * Cataract surgery outcomes may not be meeting the target of F0.5D that is considered the s
