11/16/2017 Professional Disclosures • Alcon: Advisory Board, Consultant, Research, Speaker Laser Applications in • Allergan: Advisory Board, Research, Speaker • Bausch & Lomb: Advisory Board, Research, Speaker Clinical Optometry • Beaver Visitec: Consultant COPE ID: 49115-LP • Biotissue: Advisory Board, Speaker Walter O. Whitley, OD, MBA, FAAO • Ocusoft: Advisory Board Director of Optometric Services • Science Based Health: Advisory Board, Speaker Virginia Eye Consultants • Shire: Advisory Board, Speaker Residency Program Supervisor • Sun Pharmaceuticals: Advisory Board PCO at Salus University • TearLab Corporation: Advisory Board • Tearscience: Speaker Virginia Eye Consultants Tertiary Referral Eye Care Since 1963 Today’s Optometrists • John D. Sheppard, MD, MMSc • Walter Whitley, OD, MBA, FAAO • Stephen V. Scoper, MD • Cecelia Koetting, OD, FAAO • David Salib, MD • Chris Kruthoff, OD, FAAO “To be on the cutting edge of optometry, • Elizabeth Yeu, MD • Jessica Schiffbauer, OD you need to be on the cutting edge of • Thomas J. Joly, MD, PhD • Kelsey Butler, OD science and technology” • Dayna M. Lago, MD • Constance Okeke, MD, MSCE • Jay Starling, MD • Samantha Dewundara, MD Basic Laser Principles Anterior Segment Applications • Photodisruption – YAG Laser, Femto • YAG Laser Posterior Capsulotomy • Phototherapeutic Keratectomy • Photoablation – PRK • Corneal Transplantation • Corneal Crosslinking??? • Photocoagulation - PRP • Intense Pulse Light???? 1 11/16/2017 YAG Capsulotomy What Do Patient’s Want to Know? • Indications • What is it? – Decreased visual acuity – Reduced contrast sensitivity • Why did I get it? – Increased glare – Poor view of fundus • How is it treated? – Small anterior capsulorhexis – PAM shows improved acuity • ATIOL Considerations YLC Contraindications Does the BCVA Make Sense? • Corneal scarring /edema that prevents a clear view during the procedure • Placement of a glass intraocular lens during cataract surgery • Presence of iritis • Macular edema • Previous retinal tears or detachments • Early postoperative period • Glaucoma patients YLC Procedure Follow Up • Dilation • 90 day global period • Apraclonidine 1% • Consider medications – inflammation/IOP • Power setting • Check refraction – Mild haze - 0.8 mJoules – Moderate haze – 1.5 mJoules • IOP – Dense haze – 2.2 mJoules • Presence of inflammation • Q-switched vs. mode-locked • Dilation • Focus just deep to the capsule/IOL interface • Anything else? • Create window through posterior capsule 2 11/16/2017 YLC Complications Refractive Surgery Applications • Transient intraocular pressure elevation • LASIK • Iritis • PRK • Retinal tears and detachments • Cataract Surgery • Macular edema • Lenticule Extraction • Corneal edema • Intrastromal Corneal • Intraocular lens dislocation into the vitreous Reshaping • Pitting of the intraocular lens • Corneal inlays • Lens Bleaching High Patient Expectations in Cataract Refractive Surgery The Femto Phaco Market Cataract Outcomes*** • Patient expectations are at an all-time 100% high for refractive surgery 90% 97% • Positive experiences with LASIK have 80% produced high expectations, at a 70% minimum achieving: 71% 60% – 92.6% of LASIK patients with vision of 20/40 or better* 50% – 95.4% of patients satisfied with their 40% outcome after LASIK surgery** 41% 30% • Cataract surgery outcomes may not 20% be meeting the target of ±0.5D 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 16 Limitations of Traditional Traditional Cataract Surgery: Cataract Surgery Common Complications • 10-40% Posterior capsule opacification • 2-12% Transient cystoid macular edema • 4-10% Corneal endothelial cell loss • 1-5% Vitreous prolapse or loss • 1-2% Persistent cystoid macular edema • 0.6-2% Retinal detachment • 0.3% IOL Malposition • 0.3% Consecutive corneal transplantation • 0.1% Endophthalmitis 7 3 11/16/2017 Improved Refractive Quality = Safety Cataract Surgery • Fewer Wound Leaks • Address Major Requirements for Improved Refractive • Lower Endophthalmitis Rates Procedure • Fewer Corneal Abrasions, Less PO Pain • More Predictable PO Astigmatism • LRIs arcuate & without induced Dry Eye IOL Position Corneal Early Wow Factor • Less IOL Decentration & IOL Tilt Predictability Astigmatism • Reduced Phaco • Fewer YAG Capsulotomies • Uniform Shape and • Reproducible Power and Corneal • Less Phaco Time Size Capsulotomy Corneal Entry and Edema Arcuate Incisions • Fewer Ruptured Posterior Capsules Norrby SJ, J Cataract Refract Hill WJ, J Cataract Refract Devgan U, Current Opinions in Surg 2008;34:368–376 Surg 2008;34:364–367 Ophthalmology 2011;18:19–22. • Lower Endothelial Cell Loss 8 Manual Clear Corneal Incisions Laser Corneal Incisions • Dynamics of wound architecture created with hand- held instruments1 – Imprecise tunnel length and geometry – Frequently require stromal hydration to seal – May result in cascading intraoperative difficulties (fluid control, anterior chamber maintenance) – Incisions may be unstable at low IOPs • Recent literature suggests an increased incidence of post-op infection2 Customized wound architecture and placement Self-sealing incisions 1Behrens A, Stark WJ, Pratzer KA, McDonnell PJ. Dynamics of small-incision clear cornea wounds after phacoemulsification surgery using optical coherence tomography in the early postoperative period, J Refract Surg, 2008;24(1):46-9. 2Taban M, Behrens A, Newcomb RL, Nobe MY, Saedi G, Sweet PM, McDonnell PJ. Acute endophthalmitis following cataract surgery: a LSX11513SK systematic review of the literature, Arch Ophthalmol. 2005;123(5):613-20. 12 Effective Lens Position (ELP) Does Capsulotomy Size Impact • “The key to highly accurate IOL power calculation is being able Effective Lens Position? 1 to correctly predict ELP for any given patient and IOL” • ELP is assumed value, from empirical data – A constant and surgeon factor • A significant source of IOL power error and key to post surgery refraction3 • Size of capsulorhexis effects ELP4 1Haigis W, Lege B, Miller N, Schneider B, Comparison of immersion ultrasound biometry and partial coherence interferometry for IOL calculation according to Haigis, Graefes, Arch Clin Exp Ophthalmol, 2000;238:765-773. 2Norrby S, Sources of error in intraocular lens power calculation,J Cataract Refract Surg, 2008;34:368-376. 3Hill WE, Does the Capsulorrhexis Affect Refractive Outcomes? In Chang D, editor: Cataract and Refractive Surgery Today, LSX11513SK 2009:78. 4Cekiç O, Batman C, The relationship between capsulorhexis size and anterior chamber depth relation. Ophthalmic Surg Lasers, 1999;30(3):185-190. Erratum in: Ophthalmic Surg Lasers,1999;30(9):714 13 4 11/16/2017 1 Factors Affecting IOL Predictability Laser Capsulotomy Results If IOL is 0.5 mm posterior to the If IOL is 0.5 mm anterior to the assumed plane, a 21 D lens will assumed plane, a 21 D lens will produce only 20 D of correction produce 22 D of correction Myopic Hyperopic • Perfect centration • Precision diameter: < ± 0.25 mm • No radial tears • Easy and complete removal of capsule • No adverse events • Less PCO formation 1Norrby S, Sources of error in intraocular lens power calculation,J Cataract Refract Surg, 2008;34:368-376. LSX11513SK 14 Laser Fragmentation • Cylinder pattern, utilized for the softer lens, enables removal with I & A only, no phaco power • Chop pattern efficiently fragments the lens for removal with reduced phaco power and time1 Only 20% of manual rhexis achieved diameter accuracy of +/- 0.25mm Astigmatism More Prevalent than Recognized Lane, Stephen, M.D. Toric IOLs Pearls for Success. Cataract & Refractive Surgery Today. August 2009. Pgs. 59-61. 5 11/16/2017 Addressing Astigmatism Basics of Corneal Incisions • Differentiate corneal • Corneal coupling – 1:1 ratio cylinder from refractive cylinder – Corneal • More flattening – Lenticular – Mixed – Larger incisions • Accurate / consistent – Central incisions measurements – Penetrating incisions – Manual keratometry – Corneal topography – Deeper cuts – IOL Master – Paired incisions – Lenstar – Cassini Arcuate Incisions Arcuate Incisions • Manually executed by “tracing” corneal marks with handheld diamond knife • Inconsistent depth control • Unpredictable effect due to imprecise wound architecture • Square edge and depth • Uniform depth (no ripples) • No image-guided surgical • Precise, reproducible planning or visualization – Arc shape – Arc length – Diameter LSX11513SK 20 Steinert RF, Application of the Femtosecond Laser in Cataract Surgery for the Creation of Multi-Planar, Self-Sealing Incisions, ASCRS 2010, Boston 22 Prediction Error Distribution Frequency Distribution (%) of Eyes Hyperopic Myopic 32% More 27%27% 23% Less 18% More Less LenSx… 15% 15% Manual… 12% 9% 9% 0% 0% 0% 5% 4% 0% 4% ≤ -1 -0.75 -0.5 -0.25 0 0.25 0.5 0.75 ≥ 1 LSX11513SK Spherical Equivalent Prediction Error (D) = Pred. Ref. - Actual 1M PostOP Ref. 27 6 11/16/2017 Femtosecond Laser Companies: Value Postoperative Considerations Added Indications • Normal postoperative course • Cataract Surgery: – One day – Anterior & Posterior Capsule Polishing – Posterior Capsulotomy – One week – Paracentesis –