Transcript LVC OD Seminar - Engineers and Scientists of California

Refractive Surgery
September 22, 2012
Matthew Carnahan, MD
Refractive Surgical Modalities
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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
Radial Keratotomy
•
http://www.youtube.com/watch?v
=FzcKFvZuIqs&feature=related
http://www.youtube.com/watch?v
=i1AoFonNLwc
PRK or LASEK
http://www.youtube.com/watch?v=QRNzDC
5xlc8
http://www.youtube.com/watch?v=gjnN481F
vks
LASIK with microkeratome
http://www.youtube.com/watch?v=Yel9QlQr56o
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
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
Phakic IOLs for High Myopes
• Sulcus - Visian
http://www.
youtube.co
m/watch?v
=LIsZz5y7
QOY
http://www.
youtube.co
m/watch?v
=wzzAhcth
hKo
• Iris - Verisyse/Artisan
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)
Presbyopia correcting IOLs
• Multifocal IOL
– Tecnis
– ReSTOR
• Pseudo-accomodating IOL
– Crystalens
http://www.youtube.com/
watch?v=T1w1qEUPZPI
&feature=related
Crystalens
• Distance
pseudo-accommodation
• Near
http://www.youtube.com/
watch?v=xmP5FlQBmcM
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=rel
ated
http://www.youtube.com/watch
?v=mJgofz7NMbs&feature=rel
ated
Tecnis MFIOL
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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
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
Contraindications to MFIOLs:
medical exclusion criteria
• Pre-existing ocular pathology
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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
Managing the Total Condition
• Physical
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Controlling astigmatism
Enhancing distance vision
Enhancing near vision
Managing common patient concerns
• Psychological
– Concerns with halos
– Adapting to a new visual system
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)
Toric IOL
• Design
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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
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=d
ll3rXrr9CY
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
MPlus
• “Sector-shaped near-vision section offering HD-Visionnatural contrast sensitivity and best-corrected distance
and near visual acuity.”
• One piece aspheric,
multifocal toric acrylic
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
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
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)
Laser Cataract Surgery
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Femtosecond laser creating
Capsulorhexis
Lens pre-dicing
Main incision
Paracentesis
Corneal relaxing incisions
http://www.youtube.com/
watch?v=osegmN1E8JE&
feature=related
Thank You
• http://www.youtube.com/watch?v=U3X_zVvRTn0&featu
re=related