Refractive Cataract Surgery and Comanagement Implications

1. Refractive Cataract Surgery and Comanagement Implications Scott O. Sykes, MD Utah Eye Centers Mount Ogden Eye Center

2. Refractive Cataract Surgery • Improving spherical equivalent outcomes • Improving astigmatism outcomes • Addressing Presbyopia • Monovision • Presbyopia IOLs • Post refractive surgery patients • Comanagement • Preoperative issues • Postoperative issues

3. Preoperative Comanagement Issues • Concurrent eye disease • Glaucoma • Pseudoexfoliation • Macular health (ERM, AMD, etc) • Corneal disease • Prior refractive surgery • Amblyopia • Prior monovision (which eye, how myopic?) • Psychological factors

4. Preoperative considerations: Glaucoma and PX • MIGS options: • iStent • Cypass—myopic shift possible • Pupillary miosis: increased operative risk • Zonular laxity: increased operative risk and postoperative decentration

5. Concomitant Cataract & Glaucoma Patients - US Significant Treatment Opportunity One in five Cataracts Eyes on OHT Medication Centers for Medicare and Medicaid Services. 2002 – 2007. Medicare Standard Analytical File. Baltimore, MD. 2007 . CONFIDENTIAL

6. Concurrent eye disease: Macular issues • Modern Cataract Surgery: Preop Macular OCT on every patient • Macular Degeneration • Epiretinal Membrane • Diabetic Retinopathy • Visual potential • Multifocal IOLs • Toric IOLs

7. Macular Issues

8. Concurrent eye disease: corneal disease • Keratoconus • Keratopathy • Dry Eye • ABMD • Nodular Degeneration • Prior Refractive Surgery

9. Keratoconus/PMD • Modern Cataract Surgery: preop topo on every patient, both eyes • Form Fruste Keratoconus surprisingly common with routine preop topography testing • Visual potential • Refractive unpredictability • Multifocal IOLs • RGP tolerance and success • Post operative expectations • Future transplant risk • Case Review (Rounds patient)

10. Case Review: PMD (previously undetected; patient an attorney )

11. Case Review: PMD (previously undetected; patient an attorney ) • Preop extensive discussion of irregular astigmatism • Two months post-op • UCVA: 20/25 +2 OD, 20/20 OS • +0.25 – 0.25 x 069 20/20 OD • +0.25 – 0.25 x 101 20/20 OS

12. Other Corneal Issues: Keratopathy • Keratopathy: DES, ABMD, Scarring • Visual potential • Irregular astigmatism • Refractive unpredictability • Post operative expectations • Preoperative treatments (delaying cataract surgery) • Preoperative corneal surgery • Case Review (ES)

13. Keratopathy: Case Review

14. Keratopathy: Case Review • Keratometry: • Before Rx for DES: 45.11 x 45.58 (45.34) • After Rx for DES: 44.29 x 44.76 (44.52) • Refractive error avoided: 0.82 D hyperopia • Post op UCVA: 20/20 • Delay surgery as long as needed to get the cornea healthy and stable.

15. Preoperative astigmatism • Refractive astigmatism vs. corneal astigmatism • Anterior corneal astigmatism vs. posterior corneal astigmatism • Regular astigmatism vs. irregular astigmatism

16. Preoperative Astigmatism • 52 year old man referred for cataract evaluation • OD -5.50 – 3.00 x 094 20/25 • Mild NS and PSC • OS unable to refract CF • Severe NS and PSC • How should we treat his astigmatism?

17. Refractive astigmatism vs. corneal astigmatism

18. Refractive astigmatism vs. corneal astigmatism • No astigmatism treatment • Result: 20/20 OU UCVA

19. Astigmatism from Pterygium prior to Cataract Surgery

20. Nodular Degeneration or ABMD

22. Improving refractive predictability post refractive surgery • Clinical history method • Advanced IOL formulas/calculators • Intra operative abberometry (ORA)

23. Net corneal power (K) Ks, Kf, axis Axial length (AL) Piol: IOL Implant power Effective lens position (ELP) WTW Rfx: Desired post op refraction Vertex distance (V) IOL Formula: Old and New

27. Net corneal power (K) Ks, Kf, axis Axial length (AL) Piol: IOL Implant power Effective lens position (ELP) WTW Rfx: Desired post op refraction Vertex distance (V) IOL Formula: Old and New

28. All (Excluding Post lvC)

29. All Cases (Excluding Post lvC)

30. Symfony

31. Toric IOLs

32. Toric IOLs

33. Toric IOLs

34. ORA Influenced

35. Post Myopic LVC (All Surgeons)

36. Post Hyperopic LVC (All Surgeons)

37. Post RK (All Surgeons)

38. Intraoperative Aberrometry: Not an independent, stand-alone prediction • ORA recommendation still based on all formula variables • Bad data in = bad data out • Incorrect data (data entry errors, etc.) • Inaccurate data • Post refractive surgery • Poor quality (dry eye, ABMD, etc) • Intraoperative measurement variables (IOP, speculum pressure, fluid, corneal hydration, viscoelastic, etc.) • Outliers are still outliers (AL, K’s, etc) • ORA gives additional benefit of a wavefront-measured aphakic refraction and a proprietary modification of the formula.

39. Does ORA Help? Bottom Line • Outcome within 0.5 D of target • ORA: 85% No ORA:75% • How often do I make a change because of ORA? • 1 of 3.5 patients • How often does the change yield a better outcome? • 3 of 4 patients • What is the magnitude of the change? 0.25 D • Is this worth the cost to the patient or the surgeon? • Patient cost: bundled into premium package ($100) • Surgeon cost: • Preop staff time • Increased operative time • Decreased postoperative chair time • Decreased postoperative enhancement rate

40. Lessons Learned & Next Steps ORA helpful, but still must consider as just one piece of information. Great outcomes analysis tool as well. Post-refractive surgery: ASCRS Post refractive Barrett formula surprisingly good but ORA helps some. Post operative data needs to be more reliable (e.g., tech refractions vs. MD/OD refractions). Upcoming comparison for second eye surgery: ORA vs. first eye outcome • Upcoming comparison of Barrett Formula vs ORA. • IOL Master 500 can’t calculate Barrett

41. Postoperative issues for comanagement • Refractive error • Posterior capsule opacification (PCO) • Anterior capsule phimosis • Communicating results to ophthalmologist

42. Managing postoperative refractive error • Manage based on patient and physician expectations • Was a premium lens used? • Is the patient happy? • Correcting postoperative refractive error • Glasses • LRI • Lasik or PRK • IOL exchange

43. Managing postoperative refractive error • Large spherical surprises: treat early (2-4 weeks) with IOL exchange • Large astigmatic surprises after toric IOL: treat after at least two weeks with Toric IOL repositioning • Mild refractive error • Watch until stable, 3-4 months • Treat with glasses, LRI, or PRK/LASIK

44. Cost of Touch Ups after Premium Technology Use • Usually covered in initial upgrade fee, so no additional fee for LRI or PRK/LASIK

45. Managing Posterior Capsule Opacification • Rule out other causes of reduced vision, especially CME or corneal causes • Treat the patient, not the capsule • Patients must be visually symptomatic • Preferably YAG done after 3-4 months • Don’t YAG if any concern about need for IOL exchange

46. Managing Postoperative Cystoid Macular Edema • Topical Steroid and NSAID • Follow with serial OCT • Retina consult if not resolving

47. Anterior Capsule Phimosis

48. Managing postoperative anterior capsule phimosis • Usually in pseudoexfoliation • May not be evident until late without dilated examination • Causes hyperopic shift usually • Increases risk of zonular weakening and lens decentration • Refer for YAG as soon as recognized • Case Review

49. Communicating postoperative results • Satisfies legal requirements • Leads to better outcomes by providing data for nomograms

50. Thank You