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7/8/2021
1
Cutting Edge Cataract Care
Paul C. Ajamian, O.D.
Board Certified, American Board of Optometry
Omni Eye Services of Atlanta
The most important factor that determines if a patient is ready for cataract surgery in the eyes of CMS is:
A. Visual acuity
B. Glare testing
C. Lifestyle complaint
D. Density of cataract
History: important but often unreliable
OD: Hand Motion
72 M with history
of GPVAL OD x 1
month only, with
problems driving
and reading out of that eye
OS: 20/20 NO APD!
And just this afternoon….
“My eye was fine
until that optometrist put
“those drops” in, and two days later
I couldn’t see”
Before you refer:
Send a letter
No not this letter!
Before you refer: Send a letter
Ahhhh Much better!
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Vision and Refraction
Visual Acuity (D & N)
Pinhole should be part of vision
Monocular diplopia or glare alleviated?
Glare testing or BAT (medium setting), or
“Ambient Light” (room lights on)
for any patient who is 20/40 or better
If that doesn’t work, try this………………….
Ocular Health
Slit Lamp
Dilated Fundus Exam
BEFORE YOU REFER: STOP AND THINK!
What can affect the results of
cataract surgery and premium IOL’s?
Surface disease/MGD
Chalazia
Pterygia
Corneal dystrophies and degenerations
Undetected pre-op retinal conditions
You wouldn’t send
this…..
So why send this? Could this be a problem?
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Clean Up Crew
Bumpy Corneas could mean Bumpy Post-Op Refraction 55 y/o F c/o months of
monocular f.b. sensation,
contact lens intolerance,
tearing, and mild decrease
in vision
BEFORE AND AFTER:
BCL in placeNSAID and antibiotic
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MILKY NS
Where are We?
Cataract Surgery is now refractive
Patients deserve to know about the newest technologies
Doctors of Optometry should be the authority, not just the referrer
Has surgery changed that much?
NOT REALLY….UNTIL 2012 WHEN THE
LASER CAME ALONG TO BUMP AHEAD
OF PHACO
AND A GLIMPSE INTO THE FUTURE……
3D SURGERY!
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The Changing Face of Cataract Surgery
Large, rapidly growing demographic
Educated, financially secure
Increased life expectancy
Longer working careers
Demand high quality vision (reading,
distance, night vision)
New requirement for near vision (computers)
Unwilling to compromise active lifestyles
The Baby Boomer Generation: 10,000/day reaching 65
LSX11513SK
Femtosecond
Laser Assisted
Cataract
Surgery (FLACS)
“Are you going to do the surgery with the laser?”
The future of cataract surgery available now…ALTHOUGH MANY SURGEONS DON’T THINK THEY NEED IT!
OCT Guided Refractive Cataract Surgery
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Reproducible Primary and Secondary Incisions
Computer programmed
incisions
• % depth
• Length & position
• Visualization of placement
Real time Corneal thickness
Customizable “planed”
incisions (up to 3)
Laser Arcuate Incisions: For Best
Unaided Distance vision
• Square edge
• Uniform depth (no ripples)
• Precise, reproducible
– Arc shape
– Arc length
– Diameter
Steinert RF, Application of the Femtosecond Laser in Cataract Surgery for the Creation of Multi-Planar, Self-Sealing Incisions, ASCRS 2010, Boston
Manual Arcuate Incisions
Manually executed by “tracing” corneal marks with handheld diamond knife
Inconsistent depth control
Unpredictable effect due to imprecise wound architecture and depth
MANY STILL DOING THIS FOR THE $$$$$
LSX11513SK
Laser Corneal Incisions- Astigmatism Management
Precise incisions made in the O.R.
Ability to titrate amount of correction
May be opened intraoperatively
May be opened postoperatively
Opening an Incision In-Office
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Laser Capsulotomy
Precise and reproducible
• Geometrically superior circle (vs. Manual
Capsulorhexis)
Automatic Centration and Size
• Based on limbus and (dilated / undilated) pupil
Capsular Edges
• Closest to manual capsulorhexis in terms of edge
uniformity*
* Bala C, Meades K. SEM of femtosecond laser capsulotomy edge: An inter-platform
comparison. Accepted for publication in Journal of Cataract and Refractive Surgery
Why Is Capsulotomy Size
Important?
▪ Effective lens position (ELP) more predictable
▪ Refractive outcome more predictable
▪ Less frequent PCO
▪ Less chance for anterior capsule phimosis
Impact of ELP on IOL Predictability
If IOL is 0.5 mm posterior to the
assumed plane, a 21 D lens will
produce only 20 D of correction
If IOL is 0.5 mm anterior to the
assumed plane, a 21 D lens
will produce 22 D of correction
Hyperopic Myopic
1Norrby S, Sources of error in intraocular lens power calculation,J Cataract Refract Surg, 2008;34:368-376.
Additional Lens Fragmentation for Versatility
Customizable Lens Fragmentation based on lens characteristics or surgeon preference
Cylinder Chop Hybrid Frag
Benefits of Lowering CDE(Cumulative Dispensed Energy)
Less ultrasound energy (CDE)
Short term
* decreased k edema 1 day post-op
* faster visual recovery
* decreases complications intra-op
Long term
* decreased rate of endothelial cell loss
* pseudophakic bullous keratopathy less likely
LSX13070SK 42
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FLACS Video FLACS Video- Narrow Angle
Ring Around the RosieFLACS Video-OR
How to Present to Patients?
Laser makes more precise, accurate incisions
3D OCT Image guided surgery vs manual procedure
Customized for the patient’s eye
Less energy/less inflammation
Manage low to moderate astigmatism
Potentially safer
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Laser Cataract Surgery:
Who is a candidate?
Premium lens patients
Astigmatism less than 1 diopter
Guttata/Fuch’s /Mature/Traumatic cataracts
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Important to Explain
What’s covered
❑ Cataract removal❑ Monofocal lens
resulting in good
distance vision if no astigmatism
❑ Will need readers
What’s not covered
❑Astigmatism Tx with laser
❑Toric lenses❑Multifocal lenses
❑Additional testing❑ Interoperative
Aberrometry
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And to Make Something Good Even Better….The Cataract
Refractive Suite
Minimize opportunities for error
Multiple technology integration
1. A scan
2. Topography
3. Femtosecond cataract laser
4. Operating microscope
Preoperative and intraoperative
Better multifocal centration/toric alignment
Improve outcomes
Cataract Refractive Suites
Verion (Alcon)
1. Only fully integrated system available (LenSx)
2. Intraoperative aberrometry (Ora) soon
Callisto (Zeiss)
1. No FSL compatibility, (?Optimedica in future)
2. No intraoperative aberrometry
Cassini/TrueVision 3D
1. Collaboration with LensAR
2. Not commercially available
Cirle 3-D/ Spectria
1. Collaboration with Victus (B&L)
2. Not commercially available
The Verion™ Image Guided System
Designed to help consistently achieve the
cataract refractive target.
VERION™ Image Guided System
GUIDE
VERION™ DIGITAL
MARKER
VERION™ REFERENCE
UNIT
VERION™ Image Guided SystemACQUIRE IMAGE
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VERION™ Image Guided SystemTRANSFER TO PLANNER
Image Guided Technology
OR Video- Toric Alignment Verion- Multifocal Centration
The Argos™ Image Guided System
Designed to help consistently achieve the
cataract refractive target.ARGOS®
Swept Source-OCT Biometer
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Superior Acquisition Rate Even in Dense Cataract
• In the dense cataract cases, acquisition rates with ARGOS are 26% higher compared to
IOLMaster 700, thereby reducing the need for Ultrasound biometry by 72% (Figure 2)
Sources: 1. Tamaoki A et al. Ophthalmic Res. 2019 Mar 19:1-13.
2. Mylonas G et al. Acta Ophthalmol. 2011 May;89(3):e237-41.
Figure 2. Acquisition rates comparison between ARGOS and IOLMaster 700 in ≥Grade IV cataract
patients#
#The acquisition rates were sourced from a large, retrospective, single-center study conducted in six hundred and twenty-two eyes of 622 Japanese
patients, who had undergone biometry (before cataract surgery) with ARGOS, IOLMaster 700 and OA-2000 biometers2
Tamaoki
20191
(N = 99 eyes)
Tamaoki
20191
(N = 99 eyes)
89.9%
63.6%
26 %
More
36.4%
P<0.0001*
*Cochran Q test ARGOS
ARGOSARGOS IOLMaster
700
IOLMaster
700
IOLMaster 700
Ac
qu
isit
ion
Su
cc
es
s R
ate
s
Acq
uis
itio
n f
ailu
re
rate
s
72 %
Lower
10.1%
Leave it free for chapter bar menuOutline Cataract Optical Biometry SummaryComparative EvidenceBiometers
Argos Specialty Lens Planning
The ORA System® with VerifEye®:
• The ORA™ System uses wavefrontaberrometry data in the measurement and analysis of the refractive power of
the eye (i.e. sphere, cylinder, and axis measurements)
• Real-time, intraoperative refractometer
• Measures anterior and posterior corneal astigmatism
• Minimizes post-op refractive surprises
The ORA™ System with VerifEye®
Technology
The ORA System® with VerifEye®: Real-time, streaming feedback and guidance
Streaming data to select proper IOL, position toric IOLs within 1° and decide if a toric is necessary
In your ocular On your monitor
©2016 Novartis 05/16 US-ORA-16-E-1963
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62 WF….”may need Toric” OD .5 OS: .7
Who wins? Topography vs
Biometry K’s
SISTER:I WOULD HAVE PLANNED FOR LENSX OD AND TORIC OS
What did ORA SAY?:
TORIC OD
NO TORIC OS
3 wks P/O:
Unaided VA
OD: 20/20OS : 20/20
OD’s Role IS Crucial in IOL Decision
Be involved in decision
making PREOP
It all starts with patient
goals and topography
?Monovision
?Eliminate distance Rx
?Eliminate Rx totally
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Patients Want YOUR advice
Easier conversion ,
better experience
Embarrassing if they
hear it for first time from surgeon
Prepare them regarding out-of-
pocket costs
Acrysof Toric- Extended Power Range
SN6AT3- 1.03D corneal plane
SN6AT4- 1.55D
SN6AT5- 2.06D
SN6AT6- 2.57D
SN6AT7- 3.08D
SN6AT8- 3.60D
SN6AT9- 4.11D
Technis Symfony lens The first toric presbyopiclens: up to 2.75 cylinder
Avoid this lens with:
Myopes with large pupils
Anyone who does a lot of night driving/activities at night
Problems with lens?
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Technis Symfony Plus (J & J Vision) in the pipeline
Stronger near power for reading
Reduced dysphotopsias
Violet light blocker
PanOptix Trifocal IOL Approved on August 27, 2019:ReStor taken off market soon after
THE FIRST AND ONLY TRIFOCAL IOL IN THE U.S.
AcrySof® IQ PanOptix® and AcrySof® IQ PanOptix® Toric IOLs are innovative trifocal lenses that offer you the thrill of delivering a level of refractive performance that breaks free from tradition.
• 20/20 near, intermediate and distance vision
is now possible*,†,1
Proprietary ENLIGHTEN® Optical Technology
99.2% of patients would have had the same
lens implanted again**,2
Available in toric for astigmatism correction
•
•
•
*Based on mean value of binocular defocus curve at near, intermediate and
distance at 6 months (n=127).†Snellen VA was converted from logMAR VA. A Snellen notation of 20/20-2 or better indicates a logMAR VA of 0.04 or better, which means 3 or more of the
5 ETDRS chart letters in the line were identified correctly.
**Response to the following question on IOLSAT questionnaire (Ver. 1.0, Dec. 20,
2018) at 6 months post-op: “Given your vision today, if you had to do it all over,
would you have the same lenses implanted again?”
© 2019 Alcon Inc. 8/19 US-ACP-1900019
UNDENIABLE PATIENT SATISFACTION2
Data collected 6 months post-op:
99.2%of patients would have had the
same lens implanted again.‡,§,2
‡ n=127§Response to the following question on IOLSAT questionnaire (Ver. 1.0, Dec. 20, 2018) at 6 months post-op: “Given your vision today, if you had to do it all over, would you have the same lenses implanted
again?”
© 2019 Alcon Inc. 8/19 US-ACP-1900019
PanOptix candidates
Are candidates for bilateral implantationHave not undergone refractive surgery
Do not have glaucoma or retinal pathology
Have a healthy cornea
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THE GOOD:
72 F PhD R.N. understands nothing perfect in healthcare, plays Bridge constantly, doesn’t want to wear glasses and IS A VERY RELAXED PERSONALITY
THE BAD:
54 F PhD in Physics, spent 50 minutes with her on surgery day answering questions, IS NOT AT ALL RELAXED, tried talking her out of lens, she demanded it and when we checked BP 240/125
THE UGLY:
61 M that the OD referred
without a letter, knew that he was demanding and rejects every CL and Spectacle Rx change, but doesn’t tell us….and we do a ReStor on
patient which he hates
OUR PATIENTOUTCOMES SO FAR..300 pts
.~..a..o
..w
. . . . . . . 00
,.
"
...-·
AlconAlcon
•
© 2019 Alcon Inc. 8/19 US-ACP-1900019
VIVITY
READY FOR LAUNCH
MEDIA RELEASE – THURSDAY, MARCH 12, 2020
Alcon Announces European Launch of Vivity, the Only Presbyopia-correcting Intraocular Lens With X-WAVE
Technology
US LAUNCH OCTOBER 1: OMNI LAUNCH SEPTEMBER 9
LENS AVAILABLE TO MOST SURGEONS AT THE START OF ‘21
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55 YO white male
Moderate drusen in both eyes, Mom lost central vision to wet AMD
at age 60, on AREDS formula for 3 years
Really wants the PanOptix, has a friend who got it and is thrilled, has
been waiting his whole life to get rid of glasses
Devastated at June visit to hear he was not a candidate…..so he
postponed the surgery until September, the day after Vivity
approved!
1 day post op
No glare
20/25 (drusen and pigment changes explain that) and J2 at near
with decent range
Visual disturbance profile similar to a monofocal
He knows he will need “light reading glasses” at times
BOTTOM LINE: YOU CAN USE THIS LENS ON ANYONE YOU WOULD PUT
A MONOFOCAL LENS IN
Light Adjustable Lens Drawbacks
Corrects only small amount of cylinder
The month after surgery is labor intensive for doctor and patient
NO UV EXPOSURE
3 POST OP VISITS
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Light Adjustable Lenses: So What’s the Point?
Designed for surgeons who won’t use technology like ORA and FEMTO
But they are probably the last who will take on this project
Its not a multifocal
It does nothing more than a regular IOL
SO…Why not use technology and get the Rx right initially
IN THE
PIPELINE:
FineVision Triumf (PhysIOL) Trifocal
IC-8 IOL (AcuFocus)
LENSES FOR THE FUTURE
Juvene (LensGen) Curvature changing
fluid optic IOL
enVista Trifocal (B & L)
Eyhance and Eyhance Toric (J and J)
Eyhance: not approved as a premium lens, but is it?
Johnson & Johnson Vision Receives FDA Approval For Next Generation Monofocal Intraocular Lens - TECNIS Eyhance™ And TECNIS Eyhance™ Toric II IOLs - For The
Treatment Of Cataract Patients
First innovation in monofocal technology in 20 years is designed to slightly extend the depth of focus[1]
Pricing at $195 compared to an average monofocalprice of $60 to $100, but you cannot bill the difference
Lens chosen…….time to refer
Selecting The Right Surgeon
Closest not always the best
Very skilled/consistent results
Communicates well with patient & OD
Understands comanagement/history of
supporting optometry/makes you look good
Welcomes OR observation
Organized/efficient practice
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Post-Op Care
Don’t abdicate it to someone else
Post-Op management of premium IOL’s
and LACS fairly straightforward
Be positive on Day 1: its early, results
won’t always be perfect
Why not do post op care?
I’m not on Medicare
“I’m not set up for it”
Takes too much time for the $120 I get from Medicare
Just not interested in doing this, let the
surgeon do it even though patient lives 10 minutes from you and an hour from MD
Once you drill it down….
Medications are the
real time drain on post-op care!
CASE IN POINT: 68 YO
No Trimoxi due to Levaquin allergy
Seen 6.18.20 for her
second eye surgery
s/p PCIOL OD 6.1.20
with good result until Saturday 6.13.20
when she noted significant light sensitivity
Review of drops:
Tobramycin
Pred Forte
Bromsite
Confused on use of drops…so….”may I see them?” I didn’t bring Review of drops:
Tobramycin: used as directed, sort of (still using)
Pred Forte: is in the Bromsite box, using BID
Bromsite: is in the Pred box, using QID but ran out
2+ cell and flare Other options? Less Drops
CatarActiv3
Designer Drugs
Chattanooga
888-935-2930
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Imprimis Dropless Therapy™
The modality of “Dropless” therapy involves the injection of an eye-compatible compound at the end of the cataract case as prophylaxis against inflammation and infection.
Currently, there are 2 combinations available only from Imprimis:
Tri-Moxi: triamcinolone acetonide and moxifloxacin hydrochloride
Tri-Moxi-Vanc: triamcinolone acetonide, moxifloxacin hydrochloride and vancomycin
Imprimis Dropless Therapy™
The modality of “Dropless” therapy involves the injection of an eye-
compatible compound at the end of the cataract case as
prophylaxis against inflammation and infection.
Currently, there are 2 combinations available only from Imprimis:
Tri-Moxi: triamcinolone acetonide and moxifloxacin
hydrochloride
Tri-Moxi-Vanc: triamcinolone acetonide, moxifloxacin
hydrochloride and vancomycin
Case in Point
88 YO FEMALE presents for surgery on her
second eye
Where did you get your first eye done?
Rome, GA
Arthritis prevented her from using drops, daughter had to drive 50 miles each way
several times a day to get at least two
doses of drops in, often spending the day to do all 4 sets
Refused to have second eye done
OPTOMETRIST: WHY?
PATIENT: I can’t deal with the drops and will not burden my daughter again
OPTOMETRIST: I KNOW A PRACTICE IN
ATLANTA THAT DOES DROPLESS SURGERY
PATIENT: GREAT! SIGN ME UP!
Dropless Therapy™ Patient Benefits
Physically/mentally challenged patients
Eliminate compliance challenges of drops
Lift burden from family members/caregivers
Put patients with “Eye Drop Phobia” at ease
Avoid pharmacy issues: refills, generics
Help patients in nursing facilities
Aid patients without insurance, money or
access to sample drops
➢ Osteoarthritis
➢ Rheumatoid Arthritis
➢ Scoliosis
➢ Parkinson’s
➢ Kyphosis
➢ Alzheimer’s
➢ Dementia
➢ Drop Therapy with branded medications can cost over $400
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Just hanging around!
FOR COAG PATIENTS WITH CATARACTS…….
MIGS
Too many options!
Istent G1
Istent Inject
Hydrus Microstent
Kahook Dual Blade Goniotomy
OMNI Procedure
Xen Stent (bleb forming)
MIGS characteristics:
Ab-interno
Clear cornea
No stitches
Recovery is quick
Safety is excellent
Esp compared to Tubes/Trabs
Purpose is to help control IOP and reduce drop burden
I-Stent
Bypass of trabecular meshwork
G1
Modest pressure reduction, decreased dependence of meds
G2 = I-stent Inject
Smaller stents with different design
Injector preloaded with two Istent inject stents
Two stents better than one!
iStent coming attractions!
iStent INFINITE 3 iStents instead of 2 , covering 8 clock hours instead of 5…….. coming 2021
iStent SA for STAND ALONE……..can be done without cataract surgery….coming 2023
iStent W …for wide flange….available this year
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Istent Inject Hydrus Microstent
8mm long
Nitinol material (Nickel Titanium alloy)
Wider device = creates a scaffold of schlemm’s canal
SCAFFOLD
Schlemm’s Canal in Natural State
Schlemm’s Canal with Hydrus
Hydrus (Ivantis): 78% of pts medication-free after 3 yearsPATIENT DOES NOT NEED TO BE ON ANY MEDICATION (0-4 MEDS) FOR APPROVAL OF THIS DEVICE
Kahook Dual Blade (KDB) Goniotomy
Performs an
excisional goniotomy
Strip of trabecular
meshwork excised
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OMNI Procedure
OMNI is a device that performs two
distinct procedures
1. Viscocanaloplasty
2. Trabeculotomy
Reimbursement Realities of MIGS
Medicare YES
Commercial insurance…VARIABLE
but often NO
Important to know if its covered
before you promise it to patients
Take Home Points
Work with leading surgeons who are on cutting edge of technology
Go visit their office and ASC and see for yourself what patients will see
Be involved in post op care: we earned it
Compliance with glaucoma and post op meds a nightmare…now we have some answers!
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