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Co-Managing Premium Iols: the Optometrist's Role COPE #26507-PO

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Co-Managing Premium Iols: the Optometrist's Role COPE #26507-PO Disclosures Walter O. Whitley, OD, MBA, FAAO has received consulting fees, honorarium or research funding from: Rapid Fire Grand Rounds • Alcon • Science Based Health COPE#52118- PO • Allergan • Shire • Bausch and Lomb • Sun Pharmaceuticals • Biotissue • TearLab Corporation • Beaver-Visitec • Tearscience Walter O. Whitley, OD, MBA, FAAO • Ocusoft Director of Optometric Services Virginia Eye Consultants • Publications Residency Program Supervisor – Advanced Ocular Care – Co-Chief Medical Editor PCO at Salus University – Review of Optometry – Contributing Editor – Optometry Times – Editorial Advisory Board Virginia Eye Consultants Pearls on Optometric Co-management Tertiary Referral Eye Care Since 1963 • John D. Sheppard, MD, MMSc • Walter Whitley, OD, MBA, FAAO • Get to know your surgeon • Stephen V. Scoper, MD • Mark Enochs, OD • David Salib, MD • Chris Kuc, OD, FAAO • Convey patient preferences, observations and • Elizabeth Yeu, MD • Cecelia Koetting, OD, FAAO • Thomas J. Joly, MD, PhD • Leanna Olennikov, OD conditions to your surgeon • Dayna M. Lago, MD • Chris Kruthoff, OD • Constance Okeke, MD, MSCE • Jillian Janes, OD • Inform your patients on your role in perioperative • Esther Chang, MD • Jay Starling, MD care • Samantha Dewundara, MD • Rohit Adyanthaya, MD • Successful co-management is the result of • Albert Cheung, MD continuous communication 1 Today’s Optometrists TODAY’S CATARACT PATIENT • In 2015, people aged 50 and older represented 45% of the US population1 “To be on the cutting edge of • There were approximately 4 million cataract procedures in 2015 and optometry, you need to be on the that number is expected to grow by 3% in 20166 cutting edge of science and Active Outgoing Still Digitally technology.” working savvy 1. Centers for Disease Control and Prevention website. http://www.cdc.gov/healthcommunication/pdf/audience/audienceinsight_boomers.pdf. Accessed December 21, 2016. 2. Hill W. Distribution of corneal astigmatism in normal adult population. Keratometry database: http://www.doctor-hill.com/iol-main/astigmatism_chart.htm. Accessed January 13, 2017. US-ODE-16-E-5238 6 3. AcrySof® IQ Toric IOL Directions for Use. Alcon data on file, 2009. High Patient Expectations in Cataract Why Become Involved? Refractive Surgery • By 2020 the U.S. population over 65 will Cataract Outcomes*** 100% • Patient expectations are at an all- double from current levels – 12.9% of time high for refractive surgery 90% 97% total population • Positive experiences with LASIK 80% have produced high expectations, 70% at a minimum achieving: • CMS allows ODs/MDs to bill for non- 71% 60% – 92.6% of LASIK patients with vision of covered services 20/40 or better* 50% – 95.4% of patients satisfied with their 40% outcome after LASIK surgery** 41% • Tangible vs. Intangible benefits 30% • Cataract surgery outcomes may not be meeting the target of 0.5D 20% ± that is considered the standard 10% 0% ±0.25D ±0.5D ±1.0D *“LASIK Surgery Statistics.” Docshop.com. http://www.docshop.com/education/vision/refractive/lasik/statistics **Solomon, K et al. (2009) “LASIK world literature review: quality of life and patient satisfaction.” Ophthalmology. 16(4):691-701 ***Graph: Data from Dr. Warren Hill & Behndig A, et al. Aiming for emmetropia after cataract surgery: Swedish National Cataract Register study. J Cataract Refract Surg. 2012;38(7):1181-6. 8/13 VRN13066SK 8 2 What Do Our Patients Know About Advanced Technology: Cataracts? The Players • What is a cataract? • When do I need cataract surgery? • How is the surgery done? • Who do I go to? • What are my options? • Will I need glasses? • Will I still see you after the surgery? SYMFONY First Extended Depth of Focus Lens (EDOF) Coupling of two new principles: – Diffractive echelette to elongate the range of focus – Reduction in chromatic aberration to increase contrast sensitivity Different than a MF-IOL: – Rather than splitting incoming light into two focal points, it elongates depth of focus – Not affected by pupil diameter 3 Glare and Halos Tecnis Symfony AcrySof® IQ ReSTOR® IOL1,2,3 +2.5 D Parameter +3.0 D Model • First EDOF IOL approved in the US SV25T0 SN6AD1 number ADD power +2.5 D +3.0 D @ IOL plane • Available in both toric and non-toric ADD power +2.0 D @ Spectacle +2.5 D Plane Central ring • Offers patients extended range of vision 0.94 mm 0.86 mm diameter 7 # rings 9 Apodized 10.2 mm2 • Lower glare/halo side effect profile 8.4 mm2 Diffractive Area Dist: 69% Energy Dist: 59% Near: distribution Near: 18.0% (3 mm) 25.5% RES14040SK-D 16 1. AcrySof® IQ ReSTOR® +2.5 D IOL Directions for Use. Asphericity -0.1µm 2. AcrySof® IQ ReSTOR® +3.0 D IOL Directions for-0.2µm Use. 3. Data on Fil e, Alcon Inc. 4 Defocus Curves1,2 Introducing…..Restor Toric RES14040SK-D 17 1. AcrySof® IQ , AcrySof® IQ ReSTOR® +3.0 D 2. AcrySof® IQ ReSTOR® +2.5 Directions for http://www.alconsurgical.ca/images/CataractIOLs/Calculator_Product_Sp . ec_image3.JPG “The Pipeline”: Future IOLs Setting Expectations • Akkommodative 1CU (Human Optics) • Individual patient perceptions vary • Tetraflex IOL (Lenstec) • Sarfarazi Elliptical IOL (B&L) • Synchrony (Visiogen) • Best vision after bilateral implantation • FlexOptic Lens (Quest Vision Technologies) • NuLens (NuLens) • Glare/Halos • FluidVision IOL (PowerVision) • LiquiLens (Vision Solutions) • Smart IOL (Medenium) • Lighting considerations • Light Adjustable Lens (Calhoun Vision) • Readers • Possibility of refinement 5 Preparation for Ocular Surgery Ocular Pathology • Optimize the Ocular Surface • Normalize the Lids • Prepare the Cornea • Eliminate Intra-ocular Inflammation • Control Glaucoma • Satisfy the Macula • Evaluate the Retinal Periphery • Patient Education Cat Sx and OSD Testing only when Patients Management of Patient Expectations Complain of Dryness is Insufficient • Chair time about source(s) of “BLURRY VISION” • > 40% of people with 70 Do you have FBS? 59% objective evidence of dry 60 eye are asymptomatic1 50 • Cataract surgery can worsen DED for months 40 28% 30 after surgery • Cataract surgery patients 20 13% often complain of 10 0 fluctuating vision rather Most or Some of Never • Refractive cataract surgery: quality of vision may than dryness or FBS2 all the the time time require chronic DED Rx Despite a lack of discomfort, • Cyclosporine ophthalmic emulsion 0.05%, dryness or FBS, >60% of subjects lifetegrast 5%, Topical amniotic membrane drops had significant signs of OSD2 1. Bron AJ, Tomlinson A, Foulks GN, et al. The Ocular Surface 2014; In press. 2. Trattler W, Reilly C, Goldberg D, et al. Prospective Health Assessment of Cataract Patients Ocular Surface Study; Poster, ASCRS 2011. 6 Dry Eye Prevalence in Patients Dry Eye Prevalence in Patients Scheduled for Cataract Surgery Schedule for Cataract Surgery • 80% of Patients had dry eye severity score of Level 2 or • Study Design: Prospective, multicenter, observational, Higher pilot study (N=143) of which 136 met the inclusion criteria at 9 sites across the United States to determine the • Tear Break Up Time: 62.9% with < 5 sec incidence and severity of Dry Eye Disease in consecutive patients 55 and older scheduled for cataract surgery (68 • 76.8% of eyes were positive for Nafl corneal staining male and 68 female patients) • Only 22.1% (30 pts) received a previous Dx of Dry Eye • Primary outcome measure: Incidence of Dry Eye as evaluated by grade on International Task Force (ITF) level • Secondary outcome measures: TBUT, corneal staining with fluorescein, and conjunctival staining with lissamine 1. Trattler WB, et al. Clinical Study Report: Cataract and Dry Eye: prospective health assessment of cataract patients ocular surface study. 2010. Goal of Therapy: Cataract Surgery and Dry Eye Stabilize Interblink Tear Film • Ocular surface must be optimized pre-operatively for accurate keratometry 27 28 Photo accessed from http://i1.ytimg.com/vi/IFRJw1xeVJI/hqdefau lt.jpg on 12/28/15 7 “Hot spots” and “Flat spots” Irregularly Shaped or Smudgy are Abnormal Placido Disk is Abnormal! Take a Closer Look if Average K Values are Different 8 Dry Eye Preparation for Case Example Cataract Sx Measurements • 71 yo WF, physician’s wife, presents for 1. Frequent NPAT use evaluation of blurred vision 2. Topical steroid course • Guillan Barre Syndrome distant past Lag - Fluoromethalone, loteprednol ophthalmos R > L - PF Dexamethasone 0.01% to 0.1% • “Another MD has been treating my dry eye for 3. Upper and/or lower punctal occlusion one year and says I’m still not ready for cataract 4. MGD management: MiboFlo, Lipiflow surgery” 5. Prokera Self-retaining AMT • Meds: clonidine, Crestor, Fentanyl, Cymbalta, 6. Address any other issues, i.e. blepharospasms, Lasix, Dilaudid, Cymbalta, Fioricet lag ophthalmos, filamentary keratitis Case Example • 2+ MGD with telangiectasia • Poor blink rate • Lag OD > OS (1-2mm) • Diffuse 2-3+ stain within central and inferior cornea OD, +KNV with ant stromal scar inferior periphery 9 Management of Patient Expectations Case Example • ACUTE preparation for cataract surgery different • Treatment from chronic management of DED – Fire/Ice Mask bid, Ocusoft Plus lid wipes – Topical steroid drops and/or ointment: First line – Loteprednol ointment qhs x 1 week therapy – PF Dexamethasone 0.1% qid – Aggressive NPAT – Aggressive lubrication – Lipiflow thermal pulsation After 2 weeks, minimal improvement, and Prokera – If imaging unimproved after 3-4 weeks, consider self-retaining AMT placed Prokera AMG Case Example S/P Prokera Self-retaining AMT • Patient returned 1 week later for Prokera removal OD Pre-Prokera • Cataract surgery measurements acquired the day after s/p Prokera (placed for 5 days) 10 Blepharitis Endophthalmitis Vitrectomy Study • 69% of patients with bacterial endophthalmitis were • Lid hygiene culture-positive Gram-negative • BlephEx organisms • ABx/steroid ointment bid 6% • Demodex treatment 24% 70% • Wait 1-2 months before Other cataract sx: ? Bacteria Gram-positive released from lid hygiene organisms Gram-positive coagulase-negative 1. Han DP, Wisniewski SR, Wilson LA, et al. Spectrum and susceptibilities of microbiologic organisms (Staphylococcus isolates in the endophthalmitis vitrectomy study. Am J Ophthalmol 1996;122(1):1-17.
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