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Refractive Surgery September 22, 2012

Refractive Surgery September 22, 2012. Matthew Carnahan, MD. Refractive Surgical Modalities. RK PRK, LASEK, epi-LASIK LASIK Wavefront LASIK IntraLASIK Conductive Keratoplasty. Phakic IOL Presbyopic IOL multifocal pseudo-accommodating Refractive Lens Exchange (monofocal, multifocal)

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Refractive Surgery September 22, 2012

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  1. Refractive SurgerySeptember 22, 2012 Matthew Carnahan, MD

  2. Refractive Surgical Modalities • RK • PRK, LASEK, epi-LASIK • LASIK • Wavefront LASIK • IntraLASIK • Conductive Keratoplasty • Phakic IOL • Presbyopic IOL • multifocal • pseudo-accommodating • Refractive Lens Exchange (monofocal, multifocal) • Toric IOL

  3. Radial Keratotomy http://www.youtube.com/watch?v=FzcKFvZuIqs&feature=related http://www.youtube.com/watch?v=i1AoFonNLwc

  4. PRK or LASEK http://www.youtube.com/watch?v=QRNzDC5xlc8 http://www.youtube.com/watch?v=gjnN481Fvks

  5. LASIK with microkeratome http://www.youtube.com/watch?v=Yel9QlQr56o

  6. IntraLASIK • Femtosecond laser • With gas bubbles, bluntly dissect between corneal collagen lamellae • create a plane which becomes the flap for LASIK without a blade http://www.youtube.com/watch?v=3-ry8mLaY8M

  7. Conductive Keratoplasty (CK) FDA Approved for presbyopia Induces myopia in an emmetropic eye, achieving monovision http://www.youtube.com/watch?v=u39XvfOvhxA http://www.youtube.com/watch?v=89W4z08ZrdA

  8. Phakic IOLs for High Myopes http://www.youtube.com/watch?v=LIsZz5y7QOY http://www.youtube.com/watch?v=wzzAhcthhKo • Sulcus - Visian • Iris - Verisyse/Artisan

  9. Refractive Lens Exchange (RLE) • Natural Lens Replacement • Monofocal IOL (+/- monovision) • Accommodating IOL – Crystalens • Multifocal IOL • ReSTOR • Tecnis • Valuable for patients with thin corneas or high refractive errors (hyperopia / astigmatism)

  10. Presbyopia correcting IOLs • Multifocal IOL • Tecnis • ReSTOR • Pseudo-accomodating IOL • Crystalens http://www.youtube.com/watch?v=T1w1qEUPZPI&feature=related

  11. Crystalens pseudo-accommodation • Distance • Near http://www.youtube.com/watch?v=xmP5FlQBmcM

  12. Multifocal IOL – ReSTOR® • The AcrySof® ReSTOR® IOL incorporates an apodized diffractive optic with refraction to achieve a range of quality vision. http://www.youtube.com/watch?v=7hcHO_1PF30&feature=related http://www.youtube.com/watch?v=mJgofz7NMbs&feature=related

  13. Tecnis MFIOL • Diffractive, 1 or 3 piece, silicone or acrylic, aspheric • Less pupil dependent, 4+add on posterior surface http://www.youtube.com/watch?v=AJ5_glCYVYo&feature=related

  14. Contraindications to MFIOLs: Patient Considerations • Subjective Exclusion Criteria • Hypercritical patients • Patients with unrealistic expectations • Those who want to wear glasses • Occupational night drivers • Individuals with a monofocal lens

  15. Contraindications to MFIOLs: medical exclusion criteria • Pre-existing ocular pathology • Significant dry eye • Corneal scarring, cornea guttata • Glaucoma • Macular disease • Previous refractive surgery (not an absolute) • Pupil size <2.5 mm • Monofocal implant in first eye • >1.0 D of corneal astigmatism (may need added LVC, maybe toric instead) • Unstable capsular support

  16. Managing the Total Condition • Physical • Controlling astigmatism • Enhancing distance vision • Enhancing near vision • Managing common patient concerns • Psychological • Concerns with halos • Adapting to a new visual system

  17. Who is your MFIOL patient? • Motivated to reduce dependency on glasses • Candidate for bilateral implantation • Cataract patients who want to retain the ability to see objects near and distant with reduced dependency on glasses • (50+ who are considering LASIK: frustrated presbyopes)

  18. Toric IOL • Design • AcrySof Single-Piece platform • Open loop, modified-L haptics • Posterior toricity • Toric axis marks • Dimensions • Overall length: 13.0 mm • Optic diameter: 6.0 mm

  19. Synchrony accommodating IOL • Single piece dual optic silicone accommodating lens, movement via ciliary body • 5.5mm +32D anterior optic • 6.0mm minus power post. optic • FDA phase 3 • 2 year f/u – 90%+ 20/20 UCVA • Better than ReSTOR at 60cm & 80cm distance corrected http://www.youtube.com/watch?v=dll3rXrr9CY

  20. Acri.LISA • German single piece aspheric acrylic multifocal lens with toric option • Can go through a 1.8mm incision • L: light intensity (65% refractive/distance & 35 diffractive/near) • I: independence from pupillary size • S: smooth refractive/diffractie surface profile • A: aspheric surface

  21. MPlus • “Sector-shaped near-vision section offering HD-Vision-natural contrast sensitivity and best-corrected distance and near visual acuity.” • One piece aspheric, multifocal toric acrylic

  22. M-Flex Multifocal IOL (& T-flex toric) • Acrylic, 6.25mm multizone (4 or 5 depending on base power) aspheric optic • Distance dominant with +3.0 or +4.0D add = +2.25 or +3.0D at spectacle plane • Made for 2mm incision

  23. Rayner Sulcoflex • Acrylic injectable IOL with undulating haptics and posterior haptic angulation for secondary suclus placement in pseudophakic eyes • Multifocal and toric versions are available

  24. Multifocal laser ablation (presbyLASIK) • Different power zones for varying distances • Epstein in Chicago: distance center, near periphery – similar to PAC (Pseudo-Accommodative Cornea) by Telandro in France (>10K cases done since ’04) • Alioi in Spain: center of cornea shaped for near vision, peripheral zone for distance (believe to reduce aberrations and allows for stronger near correction)

  25. Laser Cataract Surgery • Femtosecond laser creating • Capsulorhexis • Lens pre-dicing • Main incision • Paracentesis • Corneal relaxing incisions http://www.youtube.com/watch?v=osegmN1E8JE&feature=related

  26. Thank You • http://www.youtube.com/watch?v=U3X_zVvRTn0&feature=related

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