I.
Current State and Future of the Cataract and IOL Marketplace
A. Demographic studies
B. The future of intraocular lens surgery and primary care optometry’s role
II.
Improved Outcomes with Instruments, Techniques, IOL Materials
and Designs
A. Instruments and Techniques
1. Small incision surgery
a) What does size matter and how small will incisions go?
2. Improved crystalline lens removal-what this means for your patients
a) Improved phacoemulsification and fluidics
(1) Cold or low-power phacoemulsification
(2) Bi-manual phacoemulsification
* Surgical video presentation
(3) Aqualase
b) Nd: Yag laser phacoemulsification
c) Catarhex/Optex phaco w/ injection of flexible IOL material
B. New IOL materials can make the difference
1. PMMA
a) Large incision required however excellent optics
2. Silicone
a) Foldable, however high energy unfolding and multiple
designs possible
Acrylic
a) Less energy unfolding however reflections and glare
4. Hydrophylic acrylic
a) Low energy for control, biocompatible but can produce
coating/calcification
5. Collamer
a) Good control with low energy. Collagen/HEMA produces
protein rejection, low inflammation, low glare and many designs
possible with lathe manufacturing
* Surgical video presentation
3.
C. Results of study comparing four different IOL materials and post-operative
induced higher order aberrations-R. Gale Martin, M.D.
D. IOL designs/systems can solve post-operative refractive problems of the past
1. Monofocal IOL-IOL exchange
2. Photosensitive IOL-adjustable power after lens is in the eye
Plus, minus or cylinder power can be added one time after initial IOL
implantation
3.
Multifocal
a) Array (AMO)-solutions and problems involves appropriate
patient selection
b) ReStor (Alcon)-new multifocal IOL with design
enhancements
Accomodative
a) CrystaLens 45-hinged optic/haptic to allow for movement
and pseudo-accommodation
(1) Akkommodative 1CU-4 haptic lens with similar
mechanism of action as the CrystaLens 45
b) Dualflex-uses two IOLs with power allocated 2/3 in IOL in
the bag and 1/3 in sulcus fixated IOL
c) Smart IOL-inserted into the capsular bag as a 1mm diameter
rod, swells to a flexible replacement for crystalline lens nucleus
* Surgical video presentation
5. Toric IOL
a) Demographics and applications to correct 1.4D and 2.3D in
IOL
b) Post-operative management and rotation issues
* Surgical video presentation
6. Foldable Low-power IOL
a) Fine tune the post-op Rx for high myopia
b) Correct post-operative anisometropia with piggyback
application wit low-power IOP in ciliary sulus
* Surgical video presentation
4.
III.
Cornea Refractive Surgery and Post-cataract RX
A. When RK, PRK, Lasik and Lasek patients require cataract surgery, the
calculation used with A-scan and corneal curvature measurements is yielding
post-IOL implant refractions averaging 2-4D greater hyperopia than planned
1. The difficulty in obtaining accurate post-surgical refractive outcomes
deals with many factors:
2. Patients today are mobile and move frequently not thinking to obtain
pre-refractive surgery records
3. Statute of limitations is 7-years and many refractive surgery patients
will not require cataract surgery for 20-30 years following the refractive
procedure
4. The current software programs incorporated in the A-scan
instruments do not account for the cornea changes occurring in the
refractive procedures
5. The solution:
a) The best option currently is to provide the patient with a
copy of their pre-surgery findings:
(1) Spectacle Rx
(2) Topography or Keratometry measurements
(3) Pachymetry readings
(4) IOP
6. Improved software formulas to account for the different flattening
modes of the various corneal refractive procedures.
IV.
Managing Your Cataract Patients as Technology Changes
A. Pre-operative guidance and testing
1. Counseling and direction for the optimal outcomes
2. Your patients expect and deserve your knowledge and opinion as to
the best course of treatment, which includes:
(1) Surgeon
(2) Surgical procedure
(3) IOL material
(4) IOL design
3. A-scan in the optometric practice
4. Valuable for determining the post-operative refraction target
5. Useful as a tool to determine candidates for procedures that have
minimum ACD requirements
6. Keeps you in early control of your cataract patients in the patient’s
perception as well as the surgeon’s.
B. Post-operative management
1. Clinical pearls to relieve stress and resolve complications efficiently
2. Inflammation
3. Refractive surprises
4. IOP spikes
V.
Practical Aspects and Practice Economics of Cataract Surgery
A. Coding and billing
1. Time as a factor in visits to determine surgery
2. Pre-operative visits and decision for surgery
3. A-scan
4. Post-operative care
a) Avoid the time traps by having all the correct information
B. Effective co-management with your cataract surgeon
1. Developing the relationship and establishing expectations
2. Patient informed consent
3. Forms and paperwork
4. Communication
a) Professionals
b) Staff
c) Data and timing