Cataracts and Surgery - Amazon S3IOL calculations Optimized (Wang / Koch) greater than 26mm Axial L. ULIB –Lenstar/ Iolmaster (User group for laser interference biometry)

Course #

737Cataracts and Surgery

1

Cataracts and SurgeryCataracts and Surgery

Dennis Cioni RN/BS/COT

Over a period of 65 years we have gone from sandbags to femtosecond lasers.

Couching

To

Large incisions

to

Phaco and femto

Approximately 2 million people have cataract surgery every year in the United States.

What does the future have in store!

Does anything deterThe formation of

cataracts?

Protect from ultraviolet light

Antioxidants / Free Radicals

Vitamins.

Wellness Survey When should I have cataract surgery?

2

Is cataract surgery being done sooner than in the past?

Why do physician philosophies vary?Nuclear vs Subcapsular

Types of cataractsNuclear

Generalized discoloration of the human lens

Nuclear sclerosisSlow growing

Types of cataractsSubcapsular

Posterior subcapsular(PSC) / Anterior subcapsular(ASC)Faster growing

Types of cataractsCortical

Cortical spokingAnother form of faster growing subcapsular cataract

Implant options keep changing.

Monofocal

Toric Mono

Multifocal

Accomodating/Toric

Toric

The individual qualities of each lens.

The broad stroke of the brush.

3

Nearsighted and farsighted correction.

Hi h lit l ti

Monofocal IOL

High quality resolution.

Dependent on glasses post op for astigmatismcorrection and reading vision.

Nearsighted,farsighted and astigmatism correction.

High quality optics

Toric IOL

High quality optics

Must wear reading glasses or monovision .

Accomodating IOL

Nearsighted and far sighted correction.

B+L Trulign toric Crystalens for astigmatism correction.

Corrects for about +1 50 add (intermed )Corrects for about +1.50 add (intermed.)

Require readers for fine print.

Computer distance is good.

Distance vision is good.

Multifocal IOL

Nearsighted and farsighted correction.

No astigmatism correction.

Corrects distance,intermediate and near vision.

Divides light rays between vision ranges.

Decreased contrast sensitivity.(diffractive optics)

Simultaneous vision / depth perception improved.

Halos

Using this information you will educate your patient.Remember!

You are helping the patient to understand the options,The doctor and patient together will make the final decision.

Is the person interested in decreased dependence on glasses?We are legally required to present all options.

You and the doctor will discuss your options today.

There are a few other topics you want to start discussing.

4

This is a time to introduce education

materials to the patientpatient.

Try to keep it basic.

This is when I start talking about out of pocket expense generally / non specific.

There are many uses and combinations.

Restore Multifocal Technis Multifocal Crystalens AccomadatingBest range of vision Best near va Good distanceHalos @ night Reduced Halos Good IntermediateSmaller Pupils Larger Pupils ok Glasses to ReadAvoid Type As Mini mono

Astig correctionAstig. correction

Toric both distance Toric iol / LRI / MonoExcellent Distance Good range of visionDependant on readers readers for fine print

Legally SpeakingWhat if a patient says

No one told me about the ATIOL option.Are you covered with your current documentation?

What documentation is

necessary.

Reviewed ATIOL options‐Pt ok with glasses post op.

There should be clear evidence of

a standard practice habit

such as brochures.

let’s review the necessary paperwork required to qualify for reimbursement for any type of cataract surgery.

Documentation is very specific for cataract surgery.

Unable to drive at night due to glare.

OUX 6 monthsGlasses no helpModerate severity

Jones,Thomas12/15/1953

10/6/14 59

Dr. J Smith OD

Would problems with glare be adequate?

There is no reason to not have everything in place.

DiabetesHypertensionAll other systems negative

Tears ‐ prn

DC

glare be adequate?

ManifestR +1.00‐.75x90 20/50L +1.50‐.50x95 20/70

50100

70400

5

The second eye is no different than the first eye.

Jones,Thomas12/15/14

10/30/14 59

TV is Blurry

OSX 8 monthsGradual onset Moderate severity

Dr.J.Smith OD

Now things are blurry with my left eye.

(Is this adequate?)

You still have to meet the same requirements.

DC

Diabetes HypertensionAll other systems negative

Tears prn

ManifestL +1.50‐.50x95 20/70

50100

50400

Personal issues:

HobbiesNight driving

Past history ie contact lens with monovision

How do you leave things with the patient to consider?Information sheet with basic pricing.

Possible options.Reminder that the doctor will make the final recommendations.

How does the decision making happen?

#1.Does the patient want reduced dependence on glasses.?#2.Does the patient have significant astigmatism?#3.What are the personality traits, work leisure?#4.Past ocular history,ie monovision with contact lens. Failure with mono.#5 Cost issues Toric half the cost of multifocal LRIs cost#5.Cost issues, Toric half the cost of multifocal, LRIs cost.#6.Halos related to multifocal IOLs.#7.Preferrence of sharper distance,intermediate or near.

If the doctor has all the information and the patient is educated on the options the rest is their call. You have done your job.

Current issues in cataract surgery.Mini mono

Current issues in cataract surgery.Mini monoMultifocal in one eye

Current issues in cataract surgery.Mini monoMultifocal in one eyeNeuro adaptation vs. resignation

6

Current issues in cataract surgery.Mini monoMultifocal in one eyeNeuro adaptation vs. resignationWavefront aberrometry

d t (hi h d b ti )preop and post op (higher order aberrations)


d t (hi h d b ti )pre op and post op(higher order aberrations)OCT

pre op and post op


pre op and post op(higher order aberrations)OCTOCT

pre op and post opIOL calculations

This has become a separate category.

Current issues in cataract surgery.

IOL calculations

Optimized (Wang / Koch) greater than 26mm Axial L.

ULIB – Lenstar / Iolmaster(User group for laser interference biometry)

Post lasik / RK IOL patients ASCRS formula

My vision is only 20/25 in my left eye.My right eye is 20/20.

Settingexpectations

Patients need to understand

Are patients expectations too high?

expectationsthe limitations.

In the beginningThe measurements were pretty basic.

BiometryCorneal measurements

Macular OCT

7

How does the biometry look.

About .75 cyl ouWith average axial length.

Tomey

Topography supports biometry astigmatism measurements.R‐ cyl .77 L‐ cyl .65

Manual K readings

R‐ cyl .25 L‐ cyl .25

Consistency was paramount.

Common macular problems that may limit the success of an ATIOL.

VMT ERM Macular hole

OCT testing is very critical

Normal macula

Post op results

Finally!Restore multifocal was selected.

Unfortunately this criteria Left us with a

small audience for ATIOLs.

What are we doing differently in 2015?

We are more likely to offer ATIOL s to patients with more complicated anatomy and specific personal needs.

What will the doctor need to help guide the patient to achieve desired outcomes.

It’s all about setting the patients expectations.

Does your office have a road map for more complex ATIOL candidates?

8

First topics to consider;Personality traits:Type AMyopes who remove glasses


Lifestyle issues:Competetive ShootersCompetetive ShootersPilotsFrequent night driving


Lifestyle issues:Competetive ShootersCompetetive ShootersPilotsFrequent night driving

Past ocular historyProblems with bifocal CLHappy with mono CLProblems with Progressives

Moderately complex ATIOL patientLenstar Iol Master

Measurements should be consistent.

How do corneal maps affect decision making?What do the variables mean?

Tomey Wavefront / Right Wavefront / Left

R – 44.10 L – 44.41 43.30 44.00

Lets’s look at aberrometry.

Abberometry may include the utilization of the ray tracing principle in measuring the total refractive power of the eye,and all abberations from lower to higher order.

This can be a different perspective.

9

Aberrometry can be quite useful.Zernicke Polynomials

Higher order aberrations in wavefront analysis.

Aberrometry os The Tracey aberrometer has 5 main sections.Section 1.

Internal optics.

Aberrometry ‐ Setion2.Cornea

Aberrometry Section 3.Total Optics combined.

10

Angle kappa / alpha ‐ Another aspect of aberrometry

Angle Alpha‐Visual axis

Angle Kappa‐Center of pupil

< 50 microns differential recommended

.15mm diff.

Angle Alpha/Kappa

.22 mm differentialAngle kappa / alpha

What if it was .65 mm?

Center of corneaOptical axis

Center of implant

Aberrometry Section 4.Corneal Map

Aberrometry Section 5.Numeric Breakdown

Note pupil size and associated refractive changes.

Numeric Breakdown

Testing pupil size

Aberrometry Sidelight Pupilometer

Pupil size is a critical measurement / consider reducing the variables.What is your procedure?

Restore Technis

Power is affected by pupil size.There are many different ways to test pupil size.

This variable can affect outcomes.

11

Final decision making.

Heavy computer use as a secretary.

Good distance vision is a priority.

Patient is OK with glasses for fine print.

Decision to go with Crystalens. (Accomodating IOL)

Let’s look at the final outcome.

Post opresults.

Ideal outcome;‐.50 osHelps with intermediateVision.

Patient will use readers occasionally.

Remember where this all started.

The doctor needs the full picture.

If you are serious about ATIOLs

Postoperative managementNeuro adaptation takes time.

Postoperative managementNeuro adaptation takes time.Everything in focus all the time.

Postoperative managementNeuro adaptation takes time.Everything in focus all the time.Be positive and encouraging while they adjust.

12

Postoperative managementNeuro adaptation takes time.Everything in focus all the time.Be positive and encouraging while they adjust.Remind them they are healing.

Postoperative managementNeuro adaptation takes time.Everything in focus all the time.Be positive and encouraging while they adjust.Remind them they are healing.Binocular vision is the key.

Postoperative managementNeuro adaptation takes time.Everything in focus all the time.Be positive and encouraging while they adjust.Remind them they are healing.Binocular vision is the key.I always start with binocular VA Distance and Near.

Postoperative managementNeuro adaptation takes time.Everything in focus all the time.Be positive and encouraging while they adjust.Remind them they are healing.Binocular vision is the key.I always start with binocular VA Distance and Near.Are there post op options?

Post op management issues

Positive dysphotopsia (glare)

Negative Dysphotopsia (shadows)Negative Dysphotopsia (shadows)

Possible LRI / Lasik touch up

Advanced technology lenses are important to a practice!

Some patients want this product.

A positive attitude is essential.

There has to be a team approach.

The product has to be seamless for patient confidence.

The patients expectations are high.

The team is always there for the patient emotionally.

13

Thank you for attending.

Cataracts and Surgeryg y

Dennis Cioni RN/BS/COT

Case study #3 How does the doctor see the information?

How much info is enough to make the best decision?

What happens when the ophthalmic assistant is not thorough?

Macular OCT

Is the maculaNormal?

Is this enough information for the doctor to make a recommendation?

Astigmatism

Axial lengthCalculation formula

Target outcome

IOL power

Note: IOL power differences

Does ½ D. matter?

I am concerned about the axial length difference.The .50 D difference is a concern.I would try another way to compare axial length.

Case study #3Adding Axial length specific Biometry calculations

Micromanaging Is essential in working with ATIOLs. A half diopter is a big deal.

SRKT formula R 19.5 / L 20.0 Hoffer Q R 19.0 / 19.5

Does .50 D matter?

Case study #3

Corneal map one eye only.

Biometry astigmatismMeasurement ‐ 1.29 D.

1.33 astigmatism

d fThe assistant chose to map only the right eye.

How is the decision making affected if both eyes are not measured?

K readings from iolmaster showed approx. .50 D os.

14

Case study #3Corneal maps of both eyes and manual Ks.

No manual K readings – why not?

Digital KsRight – 1.33DLeft ‐ 1.11 D

Right – 1.25 D.Left – 0.75 D Dominant eye

The complete decision always includes both eyes. There are many options.

IolmasterRight ‐1.29Left ‐ .56

Case study #3Don’t stop now,when does the doctor have enough information?

PentacamAstigmatism – 1.6 D Astigmatism – 1.2D. LRI vs Toric iolLRI vs Toric iol

Case study #3Are we done yet,what if you were the doctor?

AbberometryAstigmatism – 1.19D

.54 mm difference

Case study #3Are we done yet,what if you were the doctor?

AbberometryAstigmatism ‐ .70 DAngle kappa

Practice Issues

The surgeon benefits by getting these patients back to the OD

Helps to develop a network with optometrists.

Otherwise in 5 years the doctor will have no place for new patients.

Also the surgeon will be booked out 3 months with routine exams.

All surgeons want a lively surgical practice.

Enhance your OD / MD network.

Good OD/MD relationships benefit everyone.

Establish prompt post surgical communication.

Establish an expectation early on the tech helps with thisEstablish an expectation early on,the tech helps with this.

From beginning mention getting the patient back to the OD.

Remind the patient the surgeon is there as needed.

15

Critical OD / MD issues

#1. Release date from MDThis is a billing issue.Very important to OD.



#2. Has to be scheduled as “comanaged OD referral”Otherwise coding will not support billingOtherwise coding will not support billing.




#3. There needs to be a contact person at both ends.Since billing can’t wait there probably needs to be aback up person for vacations etc.

Macular OCT

Good foveal contours ou

No apparent retinal issues.




#3. There needs to be a contact person at both ends.Since billing can’t wait there probably needs to be aback up person for vacations etc.

#4. Stay on top of changes. There are always updates in the plan.

Visual tools are important to help the patient understand the importance of their decision.

1. Demonstrate to near sighted people they will no longer be able to read without their glasses if their myopia is corrected.

2 Many people will notice an increased dependence on readers after2. Many people will notice an increased dependence on readers aftercataract surgery.

3. Try to utilize tools that will help to visually demonstrate the issuesthe patient may encounter.

i.e. http://vision.abbottmedicaloptics.com

Documents

Cataracts and Surgery - Amazon S3IOL calculations Optimized (Wang / Koch) greater than 26mm Axial L. ULIB –Lenstar/ Iolmaster (User group for laser interference biometry)