“New Options in Anterior Surgery”

Steven B. Siepser, MDJanuary 12, 2009

OUTLINE

I. DSALK for keratoconusII. DSAEK for Fuch’s dystrophyIII. ECP for glaucomaIV. TrabectomeV. ICL for high myopiaVI. CK for PresbyopiaVII. Crystalens No Glasses Cataract

Keratoconus overview

• Bulging of the central cornea• First appears in teens-20’s; both eyes• Progressive loss of vision

– Severe irregular astigmatism• Management:

glasses RGP contacts corneal transplant

Keratoconus Analogy

BROOKLYN BRIDGE RINGLETS

Munson’s Sign Apical Scarring

Penetrating Keratoplasty

Transplant procedure Removal of full thickness corneal button Donor cornea and recipient Transfer to a recipient eye

PKP

PKP Video

Disadvantages of PKP• “Open Sky”

– Eye is open during the surgery• Expulsive hemorrhage

– Contents of eye are forced out by hemorrhage• Increased infection rate• Long recuperation period• Astigmatism and suture adjustment

needed• Graft failure and rejection (5 %)

Deep Stromal Automated Lamellar Keratoplasty (DSALK)

AKA “Superficial Lamellar Keratoplasty”

Corneal overlay

Old Management

– Hold off surgery– Significant loss of best corrected vision– Severe corneal scarring or thinning– Imminent Descemetocele– Contact Lens intolerance– Progressive change

New Management

• <20/30 best corrected vision• Need for optimal visual acuity• Difficult contact lens fitting• Variable visual acuity

Early intervention is best…

Advantages of Earlier Surgery

• Thicker cornea• Faster rehabilitation• No new astigmatism• Can have LASIK / PRK later on• Less chance of perforation

DSALK FOR KERATOCONUS

DSALK AUTOMATED KERATOMEKERATOCONUS

DSALK

DSALK Post-Op Photo

DSALK VIDEO

Fuch’s Dystrophy• Malfunction of corneal endothelium • Dehydration system to maintain a clear

cornea• Usually females, 50’s, both eyes• Guttatae

– corneal swelling, folds• Decreased vision, foreign body sensation,

pain in morning• Management:

“salt” drops bandage contact lens surgery

Fuch’s Dystrophy

GUTTATA

Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK)

AKA “Endothelial Resurfacing” or Posterior Lamellar Keratoplasty

DSAEK Surgical Procedure

• Prepare endothelial graft from donor cornea

• Strip and peel off Descemet’s membrane of the patient

• Introduce graft into eye• Flatten, place air bubble to allow

adherence to back surface of cornea• Patient should stay on back until next day

DSAEK

Advantages over Full-thickness Corneal Transplant

• Faster healing• No stitches, therefore more predictable• Safer – small incision like cataract surgery• Vision clears more quickly

– 1-3 months vs 1-2 years for standard PKP• 90% of patient’s own cornea is left

Video

SUMMARY OF NEW TRANSPLANT PROCEDURES

• Full thickness PKP is on it’s way out…• Newer transplant procedures

– transplanting the diseased portion of the cornea

• DSALK: anterior cornea, i.e.keratoconus• DSAEK: endothelium, i.e. Fuch’s• Both use a microkeratome (“automated”)

Glaucoma summary

• Fluid inside the eye is produced by a structure called the ciliary body

• Fluid is drained by the trabecular meshwork

• Pressure inside the eye is too high• Damage occurs to the optic nerve• Causes a slow loss of side vision

Treating Glaucoma

• DROPS– slow down the production of fluid – increase the drainage of fluid

• LASER– SLT: Improves Outflow– ECP: Decreases production of acqueous

• SURGERY– Trabeculectomy: Older opening method– Trabectome: Directly addresses outflow

Glaucoma-Eyemaginations

Endoscopic Cyclophotocoagulation (ECP)

• Ciliary body is cauterized with a laser to decrease production of fluid

• Camera inside the eye• Instrument used:

– Camera + light source + laser– Tiny optical fibres view, illuminate and treat

the ciliary body• Usually ~60 laser applications

ECP

• Often performed at the time of cataract extraction

• Can be performed after ALT, SLT or filtering bleb surgery

• A majority of patients have their pressure reduced, leading many to eliminate drops

ECP

ECP Video

Trabecutome Video

Myopic Refractive Surgery

Total US Population = 301,362,263Myopic 75,340,000 25%

Mild (<-2.00 D) 48,217,600 64% Moderate (-2.00 to -6.00 D) 24,108,800 32% High (>-6.00 D) 3,013,600 4%

Surgeons are becoming progressively less willing to attempt LASIK in high myopes ( 12 D)

(U.S. Bureau of Census, International Database/Archives of Ophthalmology)

LASIK / PRK FOR HIGH MYOPIA

• Central corneal thickness < 500 um is considered thin

• Calculations can be performed to determine residual corneal thickness after treatment

• Convention is to leave >300 um “untouched”

• Many patients have been “turned away”

See What You’ve Been Missing

Implantable Collamer Lens (ICL)

FDA Approval December 22, 2005

Dr. Siepser’s first caseJuly 14, 2006

ICL Design

• Sits behind the patients iris (colored part)

• YAG PI done one week in advance– Iridectomy in the iris

• Foldable– Injected through a 3mm corneal incision

< 100 um

< 50 microns

500-600 um

ICL is Very Thin

Indications For Use

STAAR Visian ICL is indicated for placement in the posterior chamber of the phakic eye for:

Correction of myopia -3.00 D to -15.00 DReduction of myopia -15.00 D to -20.00 D< 2.50 D of astigmatism (toric ICL under FDA

review)

VIDEO

Immediate Post-Op

• High “WOW factor”• Not uncommon to see 20/40 or better

vision at the early postop check• A 2-4 hour postop check is required to

check pressure

Accommodation – The Missing Element

• Cataract & refractive surgery focused on ‘Perfect’ distance vision without glasses, However…..

Unable to effectively deal with loss of accommodation• Patients still dependent on glasses• Cataract patients want to see the same as the

“young” LASIK patient and do not understand their limitation!

• Presbyopes – Once again are told they need to continue to wear glasses in order to see up-close (the same story 20 years later!)

FD04-011 rev 00

source: 1997 Baltimore Eye Study

Refractive Distribution for Patients over 40 years

13.4

5.8

3.21.71.3

2.4 1.92.14.0

8.7

14.5

20.320.5

0

5

10

15

20

25

<-6 -5 -4 -3 -2 -1 0 1 2 3 4 5 >6

Spherical equivalent (D)

Patie

nts

over

40

year

s (%

)

40.8%

CK for Presbyopia

• First time reading needs• Freedom from reading glasses

FD04-011 rev 00

Conductive Keratoplasty® (CK®)

• Controlled radiofrequency

• Stroma heats

Tip = 7-O suture or human hair

The IOL PortfolioIOL’s come in many sizes, shapes & materials.Each has unique characteristics & capabilities

Single Power Lenses

Accommodating Lens

• Corrects only distance vision

• Does not accommodate in eye

• Glasses required

• Single focal point• Full range of

distance, intermediate & near vision

• Uses eye’s natural focusing mechanism

• Rapid visual recovery

Multifocal/Defractive Lenses

• Multiple, fixed focal points

• Does not accommodate in eye

• Must find appropriate focal point

• Extensive neurological adaptation

Crystalens HD™

Video of Crystalens

Crystalens HD™

THANK YOU FOR COMING!

• Any questions?