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3/18/2017Cataract Surgery ‐ Goal “Pushed” from a purely medical procedure to one ofrefractive surgery”Richard A. Erdey, MDErdey Searcy Eye GroupMarch 19, 2017 Optimize outcomes – Post‐op refraction within /‐0.5D sphere and cylinder Reduce risk – “dropless cataract surgery”Prevalence of AstigmatismAstigmatism: Surgical Options35%30% 31%30%0.5 D to 5.0 D 70%25%19%20% Astigmatic Keratometry: Diamond knife or Femto Clear Cornea Incision on steep axis (single or paired) Limbal relaxing incision Scleral Recession15%10%10%5%5%2%0%00.511.522.51% 1% 0%0% 0%33.544.55CORNEAL CYLINDER (D)Astigmatism correction:varies with clear corneal incision placement :Paired Clear Corneal incisionon steep axis 1.0 cylinder1
3/18/2017Astigmatic Keratotomy: ClearCornea incision single vs pairedFemtosecond ‐ intrastromalAstigmatism:Limbal Relaxing Incisions (LRI’s) 1.5D cylinderFemtosecond – 7mm OZ ‐ Intrastromal131 eyes @ 3 mos ‐ SchallhornScleral recession (modified scleraltunnel)for with the rule astigmatism1.0D or greater2
3/18/2017Pre‐op vs post‐op residual astigmatism(n 24 eyes) 2mos ‐3 yrs f/u6.00LASIK or PRK (lamellar)with Cataract Surgery5.00Indications:pre‐op: astigmatism 1.5 diopterspost–op: undesirable ametropia4.003.00Flap creation:preferably make it pre‐oppost‐op: wait three months2.001.00CustomVue treatment:wait at least one month post cataract/ICL surgery0.000.001.002.003.004.005.006.00Attempted Astigmatism correction (D)Wavefront guided LASIKWavelight (Alcon) vs Custom Vue (VISX)Hitting your target with Toric IOL’s 1 Diopter AMO/Alcon 1‐4d cylinder magnitudeTORIC IOL’sAMOCylinder PowersAMO Toric and Alcon AcrySof Toric SN6ATSpherical Powers : 6.0 – 30.0 DModelCylinder Power @IOL PlaneCylinder Power @Corneal 004.02.743
3/18/2017Cylinder PowersAMO Toric and Alcon AcrySof Toric SN6ATSpherical Powers : 6.0 – 30.0 DModelCylinder Power @IOL Plane (D)Cylinder Power @Corneal Plane ating IOLTrulign Toric – Crystalens Cylinder:0.83‐1.83DTrulign ToricTrulign Toricaddresses TWO unmet clinical needs of cataract patientsin one procedure:(1) reducing the visual impact of residual uncorrectedastigmatism(2) uncorrected distance, intermediate vision andfunctional near vision.Mean Distance‐corrected visionat various vergencesSymfony Toric Extended depth of focus4
3/18/2017EXCELLENT DISTANCE AND INTERMEDIATE, GOOD NEARSymfony Toric – 97% satisfactionUncorrected visual acuity at all distances Extended depth of focus 1‐2.6 D cylinder (cornea plane) Monocular Distance Corrected vision with TECNIS Symfony IOL improved 2.4lines for intermediate vision and 2.2 lines for near vision compared to themonofocal control.Multifocal IOL’s AMO25PP2016CT0928Intraoperative Keratometer2.0, 2.37, 3.0 D Adds ALCON 2.0, 2.5 D Adds ALCON Toric option available April 2017 Target: must be near plano, no cylinder.Intraoperative KeratometerHow do we select “correct” powerIOL?5
3/18/2017IOL Formulas1977: Refraction basedIOL Formulas1979: Refraction based add 19.0D to pre‐cataract refraction Emmetropic: 21.0D Myopic: 15D Hyperopic: 25D Large lens power errors commonplaceIOL Formulas1980’s: Regression FormulasIOL Formulas: Keratometry and UltrasoundBiometry (solid probe and immersion)1980’s: Theoretical Formulas Empiric formulas generated by retrospective analysisand averaging data from large number of patients aftercataract surgery Improved refractive prediction Lens power errors were commonplace:Manual KeretometryIOL Formulas (Ultrasound Biometrysolid probe and immersion)Late 80’s: Theoretical Formulas SRK T, Holladay 1, Hoffer‐Q Axial Length and K’s All require an estimation of the effective lens (IOL)position Refractive errors still occur Within /‐ 1.00D of target sphere6
3/18/2017Optical Biometry ‐ IOL Master ‐2000 –partialcoherence interferometry:non contact – axial length 5x more accurate vs USIOL Formulas (Optical Biometry)2013 “Benchmark Standard” /‐ 0.5D 70% /‐ 1.00D 90%IOL Formulas (Optical Biometry)2017: Theoretical Formulas Holliday 2, Haigis, Barret Universal II, Olsen Axial Length, K’s, Lens thickness, W‐W, AC depth, All require an estimation of the effective lens (IOL)position Refractive errors still occurMeasuring Points:32 (lenstar) vs 6 (IOL Master 500/700)Barret Toric Calculator:calculates estimated net corneal astigmatism(Anterior/Posterior Cornea)Posterior corneal surface is a minus lens: if steepvertically, creates power @ 180 deg2. Estimates amount of posterior corneal astigmatism1.7
3/18/2017Hill‐RBF CalculatorHill‐RBF Calculator Selects IOL power using artificial intelligence‐drivenpattern recognition Does not depend on effective lens positionEnhancement options: INFORMIN ADVANCE OF CATARACT SURGERY!Cornea 2017 What’s New? Glasses/Contact lenses IOL Exchange Astigmatic Keratotomy – Limbal Relaxing incision Laser Vision Correction “mini” RK (one/two incisions)AstigmatismIrregular vs Regular100 yrs : So what’s wrong withPenetrating Keratoplasty (PK)?8
3/18/201720 y/o PK 7.5mm – keratoconussuture in 1 yr after surgeryCornea Donor StudyPK’s don’t always last a lifetime PK’s – ScourgesCornea Graft RejectionPK’s – ScourgesCornea Graft RejectionCase report (ASCRS listserv)Deep Anterior LamellarKeratoplasty (DALK) Challenge:Ophthalmology 2008 ‐ Cornea Donor Study Investigator Group 17 yo severe keratoconus, atopic dermatitis PK x 3 Graft rejection/failure each time Immune suppression: cytoxan? Regraft? Keratoprothesis?9
3/18/2017Severe Keratoconus with scarhx of cornea hydrops – age 19Intraoperative KeratometerDALK/PK – after suture adjustment:improves early optical rehabilitation31 yo severe keratoconus/scarIntraoperative KeratometerDALK/PK – before suture adjustmentSevere Keratoconus with scar20 yo 15 mos aft DALK suture out‐ 5.0 0.5 x 20 20/20VERY Early visual rehabilitationLarge Diameter DALK (10mm dia)‐9.0 20/308 days post‐op10
3/18/201737 yo male Severe Reis BucklersCornea Dystrophy37 yo male Severe Reis Bucklers Cornea Dystrophy 1wk s/p DALK 9.5mm diameter20/20 UNCORRECTEDDALK vs PK ‐ 2015USA DALK vs PK 2011‐20151200Are we conserving recipient endothelial cellsduring surgery and what is long term 5000020112012201320142015Fuchs’ Corneal Dystrophy ‐ 39% TransplantsREGRAFTSPKPDALK0Cornea transplantsDSEK:it’s so good, why change?It’s all about vision quality!If 80% BSCVA 20/40 Only 30% achieve 20/2011
3/18/2017Fuchs’ Corneal Dystrophy ‐ 39% TransplantsDMEK:Visual outcome @ 6mos (n 221)BSCVA: 20/40 98% 20/25 79% 20/20 46% 20/18 14%Negligible refractive shiftContact Lens & Anterior Eye ‐ MellesVolume 36, Issue 1 , Pages 13‐21, February 2013Graft Rejection after 2 yrs:DMEK (400 eyes) vs DSEK vs PKGraft RejectionDMEK 2400 eyes 3‐4yrs aft surgery DMEK 20x less than PK. DMEK 15x less than DSEK DMEK 1%Price et al. DMEK Risk of Immunologic RejectionOphthalmology 2016Ophthalmology 2012;119:536–540 Anshu, Price12
3/18/2017Cornea Transplantation USA 2015Total Corneas 79,304 48,792 (vs 35,300 in 1995) 30,512 exported internationally 3.8 million cataract proceduresCornea Transplantation ‐ World2012742 Eye Banks reporting 184,576 transplantsPerformed in 116 countriesCorneas procured in 82 countries53% of worlds population have NO ACCESS tocornea transplantation! 12.7 million waiting for cornea transplantationJAMA Ophth 2016:134(2) 167‐173One Donor Two Recipients!!One Donor Two Recipients!!Review of the First 100Consecutive Patients Reduce cornea donor tissue shortage! Reduce costAm J Ophthalmol 2011;152:523–532 Heindl et alCornea Regenerative Medicine Cultivation of Human Cornea Endothelial CellCultures Transfer to the anterior chamber of the eye Restore endothelial cell counts13
DMEK (400 eyes) vs DSEK vs PK DMEK 20x less than PK. DMEK 15x less than DSEK Ophthalmology 2012;119:536–540 Anshu, Price Graft Rejection DMEK 2400 eyes 3‐4yrs aft surgery DMEK 1% Price et
