Part 3 of 3

February 15, 2010

Sponsored By

0210_Alcon IoLHandbookjc.indd 1 1/25/10 9:55 AM Esteemed Panel of Authors

David Geffen, O.D., F.A.A.O., is currently director of optometric and refractive services at the Gordon & Weiss Vision Institute in San Diego, California. He has lectured and written extensively on contact , surgery procedures and intraocular lenses. He is the current treasurer for the Optometric Council on Refractive Technology. He is currently serving as the Chair for the Optowest Advisory Panel for the California Optometric Association. Dr. Geffen has conducted dozens of contact related studies for many manufacturers and has served as an industry consultant for several companies over the years.

Jim Owen, O.D., M.B.A., F.A.A.O., is a graduate of the Illinois College of and received his MBA from San Diego State University. He is a Fellow of the American Academy of Optometry and is currently the Immediate Past President of the Optometric Council for Refractive Technology. He has a private practice in Encinitas, California. He participates is clinical research for laser vision correction, dry eye and contact lenses.

Chris Quinn, O.D., F.A.A.O., is President Omni Eye Service, Iselin, New Jersey. He is the principal author of the American Optomet- ric Association’s Clinical Guideline on Care of the Patient with Conjunctivitis. He is currently a contributing editor to the Review of Optometry. He is a recognized authority and sought after to lecture nationally and internationally on the treatment of eye disease and co-management.

Bernard C. Tekiele, III, O.D., is Director of Refractive Surgery at the Michigan Eye Institute. Dr. Tekiele specializes in refractive surgery and comprehensive medical eye care. Dr. Tekiele earned his undergraduate degree from the University of Michigan and his Optom- etry degree from the Illinois College of Optometry in Chicago, IL. Following a hospital-based internship at the Cleveland Veteran’s Affairs Medical Center in Cleveland, OH, Dr. Tekiele completed a residency in Family Practice Optometry at the University of Alabama at Birmingham/The Medical Center. Dr. Tekiele furthermore underwent specialized post-residency training in the areas of therapeutic laser therapy for the anterior segment and excimer laser vision correction at Northeastern University in Oklahoma City, OK. A Historical Perspective on Cataracts SO OFTEN IN SCIENCE, IT TAKES making it cloudy. Surgical procedures on available. time before clinical discovery becomes the lens of the eye were fi rst described During World War II, Gordon Cleav- accepted practice. Just as it took de- around the 5th Century in a technique er, a Royal Air Force Flight Lieutenant cades for Galileo to get acceptance that called “couching”. This procedure con- had been shot down. The impact blind- light objects fall as fast as heavy objects, sisted of taking a sharp instrument and ed his right eye and left his left eye badly many of the advances in cataract surgery pushing the opaque lens out of the line damaged from the cockpit windshield. have been met with strong resistance. of sight and into the vitreous. This tech- It was Harold Ridley, M.D., who Nevertheless, improved patient care has nique increased the amount of light get- observed the plastic material from the prevailed, and the procedure continues ting to the retina, but pre-dated the use cockpit windshield in Cleaver’s left eye, to advance. of any type of ophthalmic lens to correct but had not caused any further damage. The word “cataract” comes from the the resulting refractive error. This tech- Dr. Ridley had long thought about in- Greek “cataracta,” meaning waterfall. It nique continued through the Middle was believed that fl uids fi lled the lens, Ages in Africa, Europe, the Middle East and Asia. Two of the all-time great Growing Demographics composers, Johann Sebastian Bach and of IOL Candidates Georg Frederic Handel, were rendered blind by the couching procedure at the There are over 1.8 million cataract surger- hands of the same “surgeon.” In the ies performed each year at an estimated cost mid-18th Century, John Taylor, toured of over $3.4 billion dollars according to the National Eye Institute (NEI). As Baby Boomers Europe performing couching opera- continue to advance to the cataract age, the tions before vast public audiences, but demand for cataract surgery will increase as then left town before complications will the expectations for a higher quality of vi- arose. sion after the surgery. This market for cataract In 1748, Jacques Daniel is credited patients continues to grow today and in the with developing the fi rst extracapus- foreseeable future. lar cataract procedure. Interestingly, The number of Americans over 60-years-old grows at approximately 3.4 percent per year Daniel’s technique is very similar to and will be almost 15 percent of the total popu- Some type of cataract surgery has the extracapular technique that lasted lation by 2020. It is estimated that 15 percent been explored for thousands of years, until the development of phacoemulsi- of those 60-64 year-olds have lens changes from the 5th Century until todayʼs latest fi cation. Unfortunately, it took over 100 necessitating cataract surgery. That figure technology. years before this innovation became

2 REVIEW OF OPTOMETRY FEBRUARY 15, 2010

0210_Alcon IoLHandbookjc.indd 2 1/25/10 9:56 AM serting an intraocular lens (IOL) in the eye prior to examining Mr. Cleaver. So, Lens Platforms Mr. Cleaver became his “Phase 1” trial. Dr. Ridley went on to develop implant- WHEN SIR CHARLES RIDLEY port. Three-piece designs are gener- able lenses for cataract surgery—but implanted the first IOL in 1949, he ally less compact, however, and often not without a fi ght. Another ophthalmic could have never imagined the in- require a larger incision size to place legend of the day, Sir Stewart Duke- dustry that his bold invention would the lens properly. Elder, would refute Dr. Ridley’s work as spawn. Since that time, IOLs have un- “beyond reproach” and would not even dergone a dramatic evolution in both Edge design- There has been a examine Dr. Ridley’s patients. In fact, it design and functionality. Today, IOLs lot of interest in the design of the wasn’t until the 1970’s when the intra- are made from a variety of materials, IOL optic edge. Variations in the ocular lens became acceptable and not and represent a variety of designs, edge design of the lens can reduce referred to as a “foreign body”. all to increase biocompatibility, re- the incidence of posterior capsular Another milestone in the history of duce complications such as PCO and fibrosis (PCO). A square edge on the cataracts occurred during a visit to the dysphotopsias, and to ease insertion posterior surface of the lens, which dentist. Dr. Charles Kelman came to through increasingly small incisions. is in direct apposition to the poste- the conclusion that the same ultrasound rior capsule, can act a barrier to the “method” that was being used to clean his Here is a brief summary of lens de- migration of residual lens epithelial teeth could be used to break up a catarac- sign characteristics and a summary tous lens without disturbing the rest of the of the most popular lens platforms eye. This new method changed cataract in use in the United States today. surgery from a hospital stay to an outpa- tient procedure, from a very large incision Materials- IOLs are typically to a small incision, and from a procedure defined by the material that the that merely cleared a clouded lens to a optic of the lens is made from. refractive procedure. Like his colleagues Early IOLs were made from before him, Dr. Kelman’s technique was PMMA. PMMA lenses offered not widely accepted. Opponents tried excellent optical clarity and were to rescind his operating privileges and extremely biocompatible. Bio- deeming the procedure experimental and compatibility is essential to pre- not reimbursable. Today it is the standard vent inflammation and reduce for cataract procedures. deposits on the lens surface. To- While some type of cataract surgery day, IOLs are made from three basic The basic Alcon lens platform is based has been around for more than 3,000 materials: Polymethyl methacrylate on the AcrySof® IQ lens design, which years, advances in cataract surgery con- (PMMA), silicone, and acrylic. Acryl- is a one piece acrylic lens. tinue to improve and will continue to do ic lenses are further subdivided into so in the future. Our challenge will be hydrophilic and hydrophobic materi- cells responsible for PCO. In addi- to identify those breakthroughs that pro- als. Silicone and acrylic lenses domi- tion, careful design of the lens edge vide improved patient care versus those nate the U.S. market today because can reduce the incidence of IOL re- that do not. ★ the material is flexible, which allows lated dysphotopsias by reducing un- the lens to be folded, and therefore, wanted reflections from the lens. grows to 75 percent of those over 80-years- inserted through a smaller incision. old. Silicone lenses have been associated Haptic design- Most haptics today By 2020, the number of Americans affected with a higher incidence of posterior are open loop design in a variety of by cataracts is expected to grow to 30.1 mil- capsular opacification (PCO). styles. Haptics in three-piece lenses lion. The incidence does not appear to differ are made from a variety of materials from males to females with Hispanics show- Design- IOLs are either one-piece including PMMA and polypropolene ing a slight increased in incidence from other races. or three-piece designs. Plate haptic or polyamide. The number of elective IOLs has grown to lenses are a form of one piece design. Lens angulation, the planar rela- over ten percent of the total number of lenses In the one piece design, the optic is tionship between the optic and hap- implanted in 2009, up from approximately two integral with the haptics, while in tics of an IOL, will determine the percent in 2004. This percentage is expected three piece designs, the haptics are a angulation of the lens as it positions to grow as the Baby Boomers are in need of different material and are attached to itself in the capsular bag. A small de- cataract surgery. Key factors in the growth the optic. Three-piece design lenses gree of posterior vault of the optic of elective lenses include the ability of these lenses to be implanted in the eye safely, the can be more rigid than one-piece de- will prevent pupillary capture and ability of these lenses to give patients freedom signs, which can be an advantage in help ensure contact with the poste- from and the satisfaction these lenses centration of the lens. Three-piece rior capsule. However, if the lens is give patients, which allows for positive word- design lenses can also be placed in inserted backward, it can result in a of-mouth referrals. ★ the ciliary sulcus, a useful feature mild undesirable change in refrac- in patients with loss of capsular sup- tive outcome.

REVIEW OF OPTOMETRY FEBRUARY 15, 2010 3

0210_Alcon IoLHandbookjc.indd 3 1/25/10 9:56 AM of the major manufacturers has built Abbott Medical Optics (formerly Delivery System- Each lens a line of products to support their American Medical Optics) (AMO) has platform has a “delivery system” lenses and this has become known as developed a lens platform around the designed to implant the lens. their “platform.” Lens platforms are Tecnics lens, the first aspheric IOL ap- Variously know as “shooters” often used in conjunction with the proved in the United States. The Tec- or injectors, these devices have manufacturers phaco machine and nis lens is made from a hydrophobic become the most common way viscoelastic material. acrylic material and is available in both that IOLs are delivered into the eye Alcon has the largest market share one piece and three piece designs. The following removal of a cataract. of IOLs in the United States. The lens is also available in silicone materi- In the early age of phacoemulsifi- basic Alcon lens platform is based al. The lens is an aspheric biconvex lens cation, the advantage of smaller inci- on the AcrySof® IQ lens design. The with negative spherical aberration de- sion size was mitigated by the need to one piece design lens is made from signed to neutralize the positive spheri- enlarge the incision to accommodate a hydrophobic acrylic material, is bi- cal aberration of the cornea. The lens the implantation of PMMA lenses. convex in shape, and is aspheric with is lathe cut with open loop “C” shaped The incision generally needed to be negative spherical aberration to neu- haptics made from PMMA. The edge enlarged to about 6.0 mm to accom- tralize the natural positive spherical is square at the posterior surface of the modate the diameter of the optic of aberration of the cornea. The lens is lens and is vaulted five degrees poste- the IOL. With the advent of acrylic compression molded and contains a riorly. The lens has UV absorbers in- and silicone material lenses, the flex- blue light absorbing chromophore corporated but no chromophores that ibility of these materials allowed the which absorbs light in the 400-475 absorb light in the visible spectrum. lens to be folded prior to insertion in the eye. This allowed the surgeon to implant the lens through the small Alcon has the largest market share of IOLs in the United phaco incision without having to en- large the incision to accommodate the States. The basic Alcon lens platform is based on the AcrySof lens. The smaller incision also allowed the incision to be “self sealing,” thus IQ lens design. eliminating the need for closure of the wound with sutures. nm wavelength range (FDA Submis- The Tecnis lens is also produced as a Early on, the IOL would be folded sion Data: AcrySof IQ lens, Alcon multifocal lens with an aspheric front with forceps and delivered into the Surgical). The lens has a square edge surface and a diffractive posterior sur- eye. This resulted in an uncontrolled design and an open loop “L” shaped face for pupil size independent near unfolding of the lens, creating the haptic with no vault. In addition to vision (Tecnis multifocal). The delivery potential for problems. Lens delivery the monofocal aspheric IOL, the system for the Tecnis lens requires an devices were developed to easily in- AcrySof lens is available in a toric de- incision size of approximately 2.6mm sert the lens into the eye in the folded sign as well. (FDA Submission Data: Tecnis Lens, configuration, control the placement The AcrySof IQ Toric lens is identical AMO). The Tecnis platform does not of the haptics in the capsular bag, and to the AcrySof IQ monofocal IOL with include a toric lens design. allow the lens to unfold in a controlled the addition of 3 different toric powers Bausch & Lomb (B&L) produces fashion. with correction of approximately 1.0, the Sofport lens platform. The Sofport 1.5 and 2.0 diopters of at is a three-piece silicone lens. The lens Optic enhancers- All IOLs today the spectacle plane. The haptic design is a biconvex aspheric design and has contain Ultraviolet (UV) absorbers to of the AcrySof IQ lens provides excel- no spherical aberration. The lens has a prevent excessive retinal exposure to lent stability and centration of the lens. square edge with open loop “C” shaped UV light. In addition, various manu- Rotation of the lens is less than 4%, a haptics made from PMMA. The lens facturers have added chromphores particularly important feature of the has a five degree posterior vault and to the lens to increase absorption of toric lens (FDA Submission Data: Ac- also has incorporated their “Violet potentially harmful visible light in the rysof IQ Toric Lens, Alcon Surgical). Shield Technology” to absorb visible violet and blue spectrum to simulate The AcrySof IQ ReSTOR IOL adds light in the violet spectrum which may the characteristics of the natural lens. multifocality to the other design fea- potentially damage retinal cells (FDA tures of the lens platform. The AcrySof Submission Data: Sofport lens, Bausch Fabrication- Current IOLs are ei- IQ ReSTOR lens has an apodized opti- & Lomb). Bausch & Lomb has also de- ther lathe cut or compression molded. cal system on the front surface of the veloped the Akreos lens platform. The lens and provides an add power of +3.0 Akreos is a one-piece hydrophilic acryl- Lens platforms- The IOL mar- D or +4.0 D at the spectacle plane. The ic material with an aspheric design. ket in the United States has evolved delivery system of the AcrySof IOL al- Like the Sofport, the lens is designed to include three major players and a lows placement of the lens through an to have no spherical aberration. The host of other manufacturers. Each incision size as small as 2.2 mm. lens is lathe cut and comes in varying

4 REVIEW OF OPTOMETRY FEBRUARY 15, 2010

0210_Alcon IoLHandbookjc.indd 4 1/25/10 9:56 AM total diameters depending on lens power for improved cen- Our patients today have a wide range of options in IOL tration. The lens has a posterior square edge and has a novel design each with its own set of advantages and potential dis- four haptic design for increased centration and stability. The advantages. Technology in the development of these lenses delivery system for B&L lenses requires an incision size of will continue to march forward with the ultimate goal to com- approximately 2.6mm (FDA Submission Data: Akreos Lens, pletely correct the patient’s refractive error, restore accommo- Bausch & Lomb). dation, and to minimize the risk of unwanted side effects. ★

The Essentials of IOL Optics ONE OF THE BIGGEST REVOLU- and decreased spherical aberration oc- ers. I believe that if a patient decides tions in eyecare was the acceptance of curs. This causes light scatter and re- to use a single vision IOL, it should be IOLs in the 1970’s. Prior to that, elderly sults in sub-optimized vision. With the an . You need to discuss people were at the mercy of thick, visu- implantation of a spherical IOL, we will with your surgeon which lenses they ally disturbing glasses or high-powered clear the vision of the patient due to the use and why. contact lenses. Without their correction, opacification of the lens, but we are not these people had limited function. The correcting for spherical aberration to Toric IOLs introduction of IOLs gave these people neutralize the corneal spherical aber- Aspheric IOLs, while providing ex- freedom and the ability to function ration. Functional vision was not opti- cellent optics, still do not address two without the crutch of their corrections. mized with spherical lenses, and we still of the major concerns in correcting our However, it was soon realized that these found patients not feeling that their vi- patients’ vision: astigmatism and pres- lenses had their own limitations, too. sion was “crisp.” In 2004, aspheric IOLs byopia. Today, toric IOLs are now avail- Early cataract surgery often produced were introduced. We now have three able to address patients’ astigmatism. large amounts of residual astigmatism as approved lenses: Bausch & Lomb’s First, we need to analyze the patient’s well as spherical errors and did not cor- Softport, AMO’s Tecnis and Alcon’s prescription and determine the amount rect near vision. Therefore, the patient AcrySof IQ IOL. These three lenses of residual astigmatism we expect to was still very dependent on glasses or correct for slightly differing amounts of find. Preoperative keratometry read- contact lenses. As surgical procedures spherical aberration. By measuring cor- ings are important to take. Once the improved and wound size grew smaller, neal spherical aberration preoperatively, crystalline lens is replaced, the lenticu- the predictability of the endpoint refrac- the surgeon can select the appropriate lar astigmatism present at pre-op will tive error was greatly enhanced. By the IOL for the individual. The Bausch & be gone. If there appears to be greater late 1990’s, most patients were getting Lomb lens adds no spherical aberration, than three quarters of a diopter of cor- results that provided excellent distant the Alcon adds 0.20 microns of spherical neal astigmatism, it is time to start the vision or the ability to have monovision. aberration and the Tecnis adds 0.27 mi- discussion with the patient about possi- crons of negative spherical aberration. ble solutions. In our office, I have found Aspheric IOLs Aspheric IOLs need to be centered the discussion of deluxe lens options In the late 1990’s, we began to look well to have the optimal effect. And, the to be quite straightforward. Patients at more than just simple refractive er- higher the negative spherical aberration understand astigmatism will decrease ror. We obtained the technology to mea- added, the more important centration their acuity. Patients also understand sure higher order aberrations. This led becomes. If the lenses which induce that they are not able to read without us to discover that the average human negative spherical aberration should the help of some near correction. While eye changes in aberrations over time. decenter, they will induce the multifocal option involves lengthy The vision deteriorates more aberrations, especially discussions and education, I have found over time as we age. The coma. Surgeon skill is be- our astigmatic patients embrace the idea eyes of a young person coming more important in of toric IOLs. This is similar to our soft have little if any spheri- cataract surgery as it is re- lens patients with moderate amounts of cal aberration, and 19 ally a refractive procedure cylinder; they readily accept toric soft years of age seems to be today. Research has shown lenses. The patient readily understands optimal. That is the time that aspheric IOL’s increase that the more sophisticated design has of best contrast sensi- contrast sensitivity, and an additional cost associated with it. tivity as well as optical this will help your patients There are currently two toric lenses quality. The cornea has improve their functional available to our patients, the STAAR To- positive spherical aberra- vision. Studies done at driv- ric (STAAR Surgical) and the AcrySof tion, which is neutralized ing simulators have shown IQ Toric (Alcon) IOL. The STAAR by the negative spherical correcting higher Toric comes in two models, correcting aberration of the lens. AcrySof IQ Toric IOL is one of order aberrations 1.50D or 2.25D of astigmatism. The With age, the lens hard- two approved astigmatism cor- can increase the re- early model of the STARR lens, the TF, ens and changes shape recting IOLs on the market. action time of driv- was plagued by rotation stability prob-

REVIEW OF OPTOMETRY FEBRUARY 15, 2010 5

0210_Alcon IoLHandbookjc.indd 5 1/25/10 9:56 AM lems. The latest model, the TL, seems to have improved the stability of the lens. The STAAR material is silicone and is a one-piece design. The AcrySof IQ Toric currently comes in three models, cor- recting approximately 1.0, 1.5 and 2.0 diopters of astigmatism at the spectacle plane. The high quality optics obtained by the AcrySof Toric can be attributed to the aspheric optics as well as the unique design to create rotational stability. The Alcon acrylic material has a “tacky” sur- face quality that promotes short-term stability and generates fibronectin and other natural tissue adhesives that stabi- lizes the implant to the capsule bag over the long term. The design of the haptics Six-month data reported from U.S. clinical trials on the IQ ReSTOR® IOL +3.0 D also helps to stabilize the lens. The hap- (Alcon Laboratories, Inc.) showed patients experienced an improvement in intermedi- tics are open-loop modified L-haptics ate vision. with three reference dots on each side that mark the axis of the cylinder on its haptics that allow the lens to move for- which cause some stray light. The Tecnis posterior surface. Chang reported the ward. The amount of movement will multifocal from AMO uses a full-aper- mean rotation for the AcrySof IQ Toric determine the level of accommodation ture diffractive design to achieve the two IOL was less than four degrees from ini- the patient achieves. Since it is a single focal points. With a 5mm aperture, the tial alignment 12 months postoperative- vision lens and now comes in an aspheric Tecnis IOL splits light energy to 41% to ly.1 The silicone surface of the STAAR button on the center of the optic, patients near and 41% to distance. The anterior lens is much more slippery, and there- will achieve distance vision similar to the surface is aspheric while the posterior fore tends to rotate more. Lens place- other single vision aspheric lenses on the has the diffractive surface. The diffrac- ment is critical for the optics to perform market. The lens is clear and does not tive surface creates 4 diopters of power properly. For every three degrees of have a UV blocker. which is about 3.6 diopters of effective rotation, you lose approximately 10% of There are two theories to achieve an add. Since the posterior surface is dif- the astigmatic effect. We have found in accommodative affect. The first is the fractive across the full surface, it is pupil our practice correcting the astigmatism lens will move forward with contraction independent. The FDA clinical trials at the nodal point of the eye yields bet- of the cilliary body, and thereby putting showed distance vision with 100% at ter results than toric LASIK. pressure on the vitreous to push on the 20/40 and 86% at 20/25 or better. Near posterior surface of the lens. The sec- results were over 99% at 20/40 or bet- Presbyopia-Correcting IOLs ondary theory is arching the lens where ter with 77% at 20/25 or better. More The golden ring for our cataract pa- the pressure seems to flex the lens to than 93% of patients were comfortable tients is the correction of presbyopia. achieve a change in power and aberra- at near, intermediate and distance. The Our goal is to provide the vision of the tions to allow for near acuity. The amount lens blocks UV radiation from 430nm eye with full accommodation and no of accommodation seems to vary and has and below. potential for glare and halos—although been reported from 1.0 to 2.50 diopters The AcrySof IQ ReSTOR IOL has we are not there yet! However, we have in some cases. In our practice, we typi- two models. The first is the SN6AD1, three very good options approved in the cally aim for the dominant eye to be be- the newest model, with a +3.0 D add U.S. at this time with two or three new tween 0-0.25 D and the non-dominant and + 2.5 D at the spectacle plane. The designs nearing approval. eye to be between 0.5-0.75 D. We second is the SN6AD3 which has a +4.0 Let’s start by discussing the accom- achieve good intermediate and often ad- D add and +3.2 D at the spectacle plane. modative lens. Bausch & Lomb’s lens equate near with this recipe. We also find The lens has a central 3.6mm apodized is the Crystalens. This lens has gone the Crystalens to be an excellent choice diffractive surface with distance optical through several design changes from the for previous refractive surgery patients. zones. The lens is built on the AcrySof early models to the 5.0 and the currently Especially for our RK patients, it helps apheric platform to enhance overall vi- used HD design. The newest change is with the diurnal fluctuation many have. sion. The problem with the earlier ver- the introduction of the AO which uses sion (+4.0 D) was the intermediate dis- aspheric optics to enhance overall vision. Multifocal IOLs tance. The newer version (+3.0 D) has The lens has excellent distance optics, as Multifocal IOLs simultaneously pro- gained much better patient acceptance. it is a single vision lens that has hinged duce near and far images on the retina The new version has very good near vi-

6 REVIEW OF OPTOMETRY FEBRUARY 15, 2010

0210_Alcon IoLHandbookjc.indd 6 1/25/10 9:56 AM sion and provides better intermediate vision than its predeces- Optics of IOLs are advancing rapidly. There are several sor. The lens also has a yellow chromophore to filter both UV exciting new designs in clinical trials. We are in a unique time and short end blue light to protect the macula. Our patients for eyecare where we will be able to create new and more have adapted to this new lens very well. Six-month data re- effective optical systems for the eye. Through cataract and ported from U.S. clinical trials on the IQ ReSTOR IOL +3.0 refractive surgery, our patients will be able to see at the high- D showed patients experienced an improvement in interme- est level possible. ★ diate vision. 1.Chang, DF. J Cataract Refract Surg. 2008 Nov;34(11):1842-7. CLs vs. Presbyopia-Correcting IOLs: Tap into the Expanding Presbyopic Market

TO PUT IT SIMPLY, PRESBYOPIA is the new frontier for eyecare. Just consider, 10,000 Baby Boomers will turn 50 each day until 2014. This group is more demanding, they are better educated on new technolo- gies, and they can afford them. The Boomers are more in tune with their looks, and they don’t want to look their age. They are willing to spend money on Botox, designer clothes and refractive procedures. Demands for near vision have never been higher. These new Presbyopia correction presents a growing market for your practice, as 10,000 Baby Boomers are spending more of their Boomers will be turning 50 each day until 2014 and will seek precise near vision time utilizing high tech devices such correction. as Blackberrys™, Iphones™, and the latest in computer technologies. we often hear about previous failure In fact, it is estimated that 43% of Today, less than 10% of peo- with contact lenses. The patient may the 79 million adults over 50 cur- have tried a multifocal lens years ago rently use the Internet 11-30 hours ple ages 50-64 wear contact or tried monovision with little suc- per week. lenses, compared to 33% of cess. The mention of a presbyopia- Manufacturers have provided people ages 35-49 who wear correcting lens sends bad memories great advances in all aspects of to their heads. Even if the patient presbyopic correction. As a result, contact lenses. had never tried contacts, they always we have many new advanced pro- know someone who was “unhappy.” gressive spectacles, multifocal con- This presents an extra challenge to tact lenses, presbyopic laser tech- show growth. Multifocal fits have us in our discussion of presbyopia- niques and IOLs for our presbyopic been rising rapidly while monovi- correcting IOLs. We need to make patients. sion has declined. It is important the patient understand that contact to point out that the 40-55-year-old lenses are not the best indicator of Contact Lenses for Presbyopes female controls recommendations success with presbyopia-correcting Today, less than 10% of people for health care for their children, IOLs. The reverse is not true. Pa- ages 50-64 wear contact lenses, com- spouses as well as their parents. Fit- tients who have had good success pared to 33% of people ages 35-49 ting this group in multifocal lenses with a multifocal un- who wear contact lenses. This rep- helps keep these patients returning derstand the limitations and benefits resents a wonderful opportunity for to your office more frequently. Keep these IOLs represent. I have found our practices to educate our patients in mind that the average contact lens that our patients have done extreme- about this exciting technology. The patient returns every 1.5 years, while ly well adjusting to presbyopia-cor- success rates for these lenses have spectacle patients return at a rate of recting IOLs with previous multifo- risen rapidly, and the patients who every 3.5 years. cal contact lens wear. wear multifocal lenses are very loyal We do not recommend trial fit- and refer their friends. Compar- Presbyopia-Correcting IOLs ting patients with multifocal contact ing years 2007 to 2008, multifo- When talking to our patients about lenses to test for acceptance of a cals were the only lens modality to multifocal or accommodative IOLs, presbyopia-correcting IOL. ★

REVIEW OF OPTOMETRY FEBRUARY 15, 2010 7

0210_Alcon IoLHandbookjc.indd 7 1/25/10 9:57 AM Preoperative Patient Discussion

IN CONSIDERING THE develops a cataract, education should Modern IOLs have revolutionized visual needs of our patients, no begin long before the patient gets to cataract surgery by eliminating the one is as qualified and expe- the ophthalmic surgeon. This educa- need for aphakic spectacles or contact rienced in understanding and com- tion should include the potential need lenses. Patients today have a bewilder- municating these needs to patients for surgical intervention and how ing choice of refractive options when than their optometrist. Therefore, the that will impact their visual needs. contemplating cataract surgery, and preoperative patient visit is an excel- Although there is an increasing rec- every optometrist should help guide lent opportunity for you to share in- ognition among surgeons of the im- their patients in understanding those formation not only on cataracts, but portance of the refractive outcome of options and making recommendations also on the many exciting elective IOL cataract surgery, too often, there is an based on your experience and the options that are available to your pa- emphasis on achieving good anatomi- needs of your patients. Remember tients. cal results free of post-surgical com- that the preoperative patient discus- With this in mind, when a patient plications. sion is an opportunity not only to edu-

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0210_Alcon IoLHandbookjc.indd 8 1/25/10 9:57 AM cate your patients, but also an exciting time to explain that primary cataract opportunity for your practice. surgery today is performed with ultra- sound and not with a laser. Discuss the Educate Patients on extraordinarily high rate of success, Treatment Options but also discuss the small but im- When patients are faced with a di- portant risk of complications. agnosis of cataract, there can be sig- nificant fear and apprehension. Patient Discuss IOL Options education can alleviate this anxiety. Just as important as the dis- Not all patients will require surgical cussion of potential compli- intervention, but all patients deserve to cations is a discussion of the be fully educated about the condition patient’s options for their post and their treatment options. For many surgical refractive outcome. patients, an updated spectacle pre- You should be aware of the visu- scription and reassurance are all that is al needs of the individual patient, needed, since their visual demands do and to never prejudge a patient be- not exceed their visual performance. In fore presenting their options. Patients determining if the patient is a surgical should have a good understanding of the candidate, it all comes down to a very role the IOL plays in their post-surgical simple question. If the patient would outcome. like to see better and feels impaired by The standard option is a mono- The preop visit should include in depth their current level of visual function, focal IOL, we use an aspheric lens discussion on the potential need for surgical then cataract extraction is the best op- as our primary lens in all patients. intervention and how it will impact their visual tion. We no longer wait for the cataract We then begin a careful discus- needs. to “ripen” or mature, since the risk of sion of alternative lens options. complications from surgery are small. Perhaps the easiest discussion is when glare and decreased contrast sensitivity, We intervene when the patient is suffi- patients are good candidates for a toric but over a period of three-six months, ciently symptomatic, and the small risk IOL. In this case, the recommendation they adapt very well and are extremely is less than the potential benefit. is easy since the results are predictable satisfied. and the side effect profile of toric IOLs Multifocal lenses provide an excellent Education Methods and Topics is very favorable. We then discuss the op- balance between outstanding distance If the patient is indeed a surgical can- tions for correction of presbyopia. This vision and useful near vision. We also didate, each patient should be fully in- is a more detailed explanation, since ex- carefully explain to patients that bilater- formed of the risks, benefits and alterna- plaining accommodation and multifocal al implantation of the lens will ease the tives to surgical cataract extraction. You lenses is not completely intuitive to most transition and hasten any adaptation that can use an anatomical model or figure, patients. We need to make sure patients occurs. We do not use a presbyopia cor- which often provides the patient with understand the benefits and limitations recting lens in patients with unilateral the basic understanding of a cataract of presbyopia-correcting lenses. We cataract. and how it is to be removed. Video and want to make sure the patient has ex- After the discussion of the various lens animations for this discussion can also cellent ocular health and does not have options with the patient and making an prove very useful in helping the patient glaucoma, ARMD or retinal disease that IOL recommendation, we then discuss understand what will happen should would diminish the potential for an ex- the additional cost associated with these they elect to undergo surgery. cellent outcome. We also assess the new technologically advanced lenses. Most effective discussions begin with patients’ personality to determine if they We are careful to point out not only the an explanation of exactly what is a cata- are highly critical visually or seem more extra cost of the lens, but also the in- ract, since many misconceptions con- tolerant of change and imperfection. creased time and complexity associated tinue. In each case, we carefully explain Such judgments are difficult in a short with both the pre-operative assessment that a cataract is simply causing less than time, but knowing the patient over the and post-operative care. The discussion perfect vision, but that it is not damaging course of several years gives the O.D. an of these options with the patient can the eye or affecting the fellow eye. Cata- excellent opportunity to get a feel for the take considerably more time for patients ract surgery is an elective procedure chances of success and the patient’s tol- who are interested in having a presby- and there are few medical indications to erance for an extended period of adapta- opia correcting lens implanted, since remove the cataract. Reassure patients tion. If the patient is an acceptable can- there are often more questions and con- that deferring surgery will not increase didate physically, ocular health wise and sideration to the patient’s individual situ- the risk of surgical complications or with an accepting personality, then we ation and visual needs. Considering the make the procedure more difficult un- discuss the specific lens options includ- extra time involved counseling patients, less the cataract is very advanced. You ing multifocal IOLs and/or accommo- the extra cost of the lens, and the extra should carefully explain to the patient dating IOLs. Based on our experience, time and commitment during the post- the methods used to remove a cataract. most patients will do quite well with a operative period, the extra charge for Keep in mind that you will need extra multifocal IOL. They will have some these lenses are well earned. ★

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0210_Alcon IoLHandbookjc.indd 9 1/25/10 9:57 AM Diagnostic Equipment for Your Elective IOL Practice

THE PRIMARY EYE CARE PHYSICIAN IS VERY familiar with cataract evaluation. Oftentimes, the optom- etrist, acting as the “gatekeeper” provider, will be first to Keys for Successful diagnose cataract and recommend treatment when ap- propriate. It is perfectly germane to the role of optometric Postoperative medical eye care to diagnose cataract, recommend surgical consultation when necessary and discuss intraocular lens options, which have become myriad with advanced “life- Management Elective style” implant technology. IOL Practice Early Education is Key The patient interview is one of the most important as- MANAGEMENT OF CATARACT OUTCOMES IS AN pects of the cataract consultation and subsequent IOL important aspect of routine optometric care. There is selection. We provide all prospective cataract surgery pa- great satisfaction in witnessing first hand the “miracu- tients with a packet of information explaining cataract sur- lous” changes that occur when a patient’s vision has gery and introducing advanced lifestyle IOL options at the been restored and his or her color perception enhanced. time of cataract diagnosis. Adding to this already positive experience, patients will When the patient returns also enjoy the many benefits of advanced, lifestyle intra- Key Points to the office for biometry, ocular lenses, which render many without the need for 1. Educate patients early. they then have a strong spectacles postoperatively. 2. Perform a thorough patient substrate knowledge base Optometry plays an integral role in patient selection, interview and consider using a allowing them to feel IOL recommendation and postoperative management preoperative questionnaire. confident with their IOL of refractive cataract patients. It is important for optom- 3. Pay close attention to slit lamp choice. etrists to immerse themselves in elective IOL knowl- and dilated fundus findings. I avoid use of terms edge and be able to astutely manage patient expecta- a. Tear film considerations. such as “always” and “nev- tions and outcomes. b. The cornea must be clear. er,” which could foster Cataract care management has become an increasingly c. Vitreous opacities. unrealistic expectations exciting aspect of practice. The diagnosis of cataract is d. Macular pathology. for our patients. We want no longer a diagnosis of “doom and gloom” for the pa- 4. Make a specific IOL to share patients’ experi- tient. Rather, it is an opportunity of hope. Patients have recommendation. ences to help prospec- options that were just a dream years ago. Indeed, their tive cataract patients gain older peers and family members were not able to have a full understanding of the privilege of making IOL choices. The consultation what to expect. Moreover, early education is critical to the has become patient-centric, and the eye care provider growth of elective IOL volume in the eye care provider’s has the task of guiding the patient through myriad IOL practice. choices that best suit the patient’s visual goals. Once that patient has selected an appropriate lifestyle Todayʼs Cataract Patient IOL and undergone successful surgery, it is now the Cataract is a disease of senescence. As such, optometrists responsibility of the co-managing physician to provide expect to find lenticular changes as their patients approach a “soft landing” for the patient. I will discuss each as- retirement age and beyond. Certainly, one would expect pect of postoperative care and highlight specific areas activity of daily living (ADL) attenuation secondary to clini- of concentration to assure optimal outcomes. It is also cally significant cataract in a patient aged 75 years. What important for us to keep our clinical senses on high alert one may not necessarily expect is ADL to affect lenticular for occult processes that may confound a perfect surgi- changes in say, a 55-year-old. However, this is precisely the cal outcome. population — the Baby Boomers — where our attention should now be affixed. Day One Visit Over the next two decades, the pool of potential cata- The day one visit is a critical one. There is some con- ract surgery candidates will swell by tens of millions. This troversy questioning the need of this day one visit, and “wave” of patients will be comprised of seniors leading very whether it can be performed on the same day of surgery active lives who are concerned about getting older and

10 REVIEW OF OPTOMETRY FEBRUARY 15, 2010

0210_Alcon IoLHandbookjc.indd 10 1/25/10 9:57 AM looking older. Because glasses and bifocals have a social sider the 55-year-old active individual with symptoms of stigma associated with the aged, lifestyle intraocular lens glare around headlights while driving at night. Your clinical acceptance will soar among this population. The prudent senses should be immediately heightened to think “possible eye care practitioner should begin planting seeds of knowl- lenticular changes,” and your clinical examination may re- edge in their patients now to reap a harvest of elective IOL veal early, +1, say, nuclear sclerotic cataract. This is hardly candidates in the future. a “diamond” in the eye, especially when you consider this Diagnosis of cataract is clinical, and a patient’s symp- patient may refract to 20/20. toms may not correlate with our clinical findings. Con- A conundrum. Do you: or a week after surgery. Especially with advanced life- A. Refer to an ophthalmologist for a cataract evaluation? style IOL patients, this visit serves as a nidus to galva- Or nize the patient’s confidence that the choice of implant B. Prescribe your with antireflective coating was the correct one. and reevaluate in six-12 months? Although the basic examination during the day one vis- Both actions are appropriate. In the former, the patient it is performed the same way irrespective of IOL choice, is referred to a sub-specialist for evaluation and treatment these specific observations must be made between mul- of a disease process affecting quality of life. The surgeon tifocal and toric IOLs. may or may not recommend surgery at the time of exami- nation, but the impetus for flow of information regarding Visual Acuity: intraocular lens options has begun. In the latter, the patient • Standard and Toric IOLs will be educated regarding options for cataract surgery and Measure uncorrected distance visual acuity in the op- appropriately “primed” for future discussion regarding im- erated eye. Measure pinhole visual acuity for unexpect- plant surgery. What is common to the two scenarios, ir- ed uncorrected results. respective of when surgery is actually scheduled, is early dissemination of information. Early education is critical to • Multifocal IOLs the eventual success, or failure, of a practice to assimilate I recommend testing at distance, intermediate and into elective IOLs and increase conversion. near visual acuity at this visit. If you demonstrate im- proved near visual acuity at this early stage, it builds Advanced Diagnostic Practices excitement and anticipation for the second eye surgery. Equipment important for use in determining severity of Capitalize on the results patients are sharing with you. cataract and gauging an appropriate referral window for routine general medical eye examinations include: • Cornea • Snellen visual acuity chart The cornea should be clear. Pay special attention to • Slit lamp, topography the presence of microcystic edema, as this is almost al- • Binocular indirect ophthalmoscope ways an indicator of increased intraocular pressure. If (BIO). IOP is high, manage with drops and/or oral agents in the usual manner, and discharge the patient when stable. If More advanced diagnostic patients present with significant stromal edema and De- equipment include: cemet’s folds, increase the frequency of postop steroid • Optical coherence tomography drops as frequently as every one-two hours while awake (OCT) depending upon severity to facilitate visual recovery. • Colvard pupilometer • IOL Master or LENSTAR™ Anterior Chamber The anterior chamber should be relatively quiet. It is Slit Lamp Evaluation Pearls not unusual to observe rare cells. Significant cells and The importance of careful examination of the patient is flare in the absence of corneal edema should be man- self-evident. Several key areas of concentration will eluci- aged by increased topical steroid frequency. If the ante- date an appropriate candidate for advanced IOLs versus rior chamber reaction is severe as if looking into a snow- one who should be excluded from candidacy. storm and is associated with central corneal edema, a Working anteriorly to posteriorly, the following areas re- relatively quiet eye (no significant injection), consider quire careful discernment: toxic anterior segment syndrome (T.A.S.S.). The sur- geon should be notified and a retinal consultation may • Adnexa: Even trace amounts of lid disease, namely be indicated. blepharitis, can have a profound and deleterious effect on subjective outcomes. Since lid disease can stifle appropri- IOL ate tear production, lid disease should be managed aggres- • Standard sively prior to cataract surgery. I recommend use of all The optic should be centered and clear. tools in our arsenal to manage blepharitis, such as warm Continued on Page 12 soaks, sterile lid cleansing pads, antibiotics and steroids.

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0210_Alcon IoLHandbookjc.indd 11 1/25/10 10:22 AM • Tear film: The multilayer, biologic tear film is the principle refractive surface of the eye. If • Multifocal this surface is challenged from adnexal disease Obvious concentric rings can be seen on the mul- causing insufficiency in any of its components— tifocal IOL and is the signature of a multifocal IOL. oily, aqueous or mucin— a patient will perceive The central zones enhance near visual acuity and their vision as “fluctuating,” “waxy,” “blurry,” or more peripheral zones assist with intermediate and they will experience “glare and halos.” The astute clinician distance visual acuity. manages tear film insufficiencies aggressively with all ele- ments in his armamentarium to create a uniform refractive • Toric surface to enhance subjective visual acuity postoperatively. For patients receiving a toric IOL, I recommend di- Use of supportive products, such as preservative-free tears, lating the operated eye on day one to ensure proper long-lasting non-preserved artificial tears, ophthalmic gels, axis alignment. Three dots will be found at the pe- prescription agents such as Restasis (Allergan) and punctal riphery of the optic 180 degrees apart from one an- plugs can be used in varying combinations to ameliorate other. The alignment of the peripheral dots on the dry eye symptoms. optic should match the planned corrected axis of astigmatism. A good indication of whether the axis • Cornea: Early in my career, I worked with an ophthal- if properly aligned is uncorrected visual acuity. If the mologist who was fellowship trained in cornea. He taught visual acuity is found to be within acceptable range me an important rule about corneal tissue: The cornea (>20/30) at this visit, that is strong empirical evidence should be clear. If we keep this rule on the tip of a neu- that alignment was achieved. ron while examining patients, we may avoid pitfalls such as After careful evaluation of the day one surgical pa- recommending advanced IOLs to the wrong patients and tient, the patient will be discharged with instructions elucidate etiology of to use postoperative medications as directed, sleep amorphous postopera- with an eye shield over the operated eye and limit Steps Toward a tive complaints. physical activity. My typical postoperative medical Successful regimen is: Elective IOL Practice: • Topography or 1. Communicate your belief in elective Pentacam corneal Antibiotic: analysis can also prove • Vigamox (Alcon) t.i.d. x one week IOLs. 2. Assume all cataract patients are invaluable to decipher Steroid: potential elective IOL candidates until and correlate conflict- • Omnipred (Alcon) (or equivalent) t.i.d. x one week proven otherwise. ing information during then b.i.d. x four weeks* 3. Describe elective IOLs to patients as preoperative evalua- Non-steroidal: an investment that never depreciates. tion. Special consider- •Nevanac (Alcon) t.i.d. x one week then b.i.d. x four 4. Set reasonable expectations. ation must be given to weeks* 5. Educate patients early. corneal astigmatism. 6. Involve family members in cataract The presence or ab- * I typically extend use of the steroid and non-ste- consultations. sence of corneal cyl- roidal drops to six weeks postop for elective IOL pa- inder can influence tients. proper IOL recom- mendation. Attention must also be given to the pattern of astigmatism. Asymmetric, non-orthogonal, irregular or in fact, erroneously believe cataract surgery will eliminate apical astigmatism may confound candidacy for advanced floaters. It is important to inform patients that floaters IOL technology altogether. will not disappear after cataract surgery. Moreover, pa- tients with symptomatic floaters may not be appropriate • Lens: The type of cataract diagnosed: nuclear sclerotic, candidates for multifocal IOL technology. cortical, posterior subcapsular, anterior subcapsular, etc., should not preclude one patient versus another for con- • Macula: We perform preoperative OCT on all pro- sideration of advanced IOL technology. Careful attention spective elective IOL candidates to rule out presence should be noted, however, to other subtle findings such as of occult epiretinal membranes and macular thicken- pseudoexfoliation, phacodonesis and whether the cataract’s ing. Subtle macular pathology— even fine pigment mot- genesis is traumatic. tling— can negatively affect elective IOL outcomes, espe- cially multifocal IOLs. Careful observation and thorough • Vitreous: Vitreous opacities and posterior vitreous de- preoperative testing can prevent most cases of recom- tachment may influence a patient’s subjective evaluation mending an elective IOL to the wrong surgical candidate of outcome and should be taken into consideration when and thus save countless minutes— which can seem like recommending certain lifestyle implants. Many patients, hours— in the examination lane. A potential acuity meter

12 REVIEW OF OPTOMETRY FEBRUARY 15, 2010

0210_Alcon IoLHandbookjc.indd 12 1/25/10 10:23 AM Week One Visit By now, the patient should be more accustomed to the improved visual acuity and anticipate surgery on the fellow eye if it has not yet had surgery. At this visit, offer re- assurance, be sure the patient un- derstands how to continue medica- tions and offer explanation for any questions they have about their experience. I discontinue antibiotic drops at this visit and continue both steroi- dal and non-steroidal drops b.i.d. Visual acuity should be crisp and measured in the same fashion as day one. Also, slit lamp evaluation is performed in the same manner as day one. Any corneal edema or folds noted at day one should be cleared at this visit and the ante- rior chamber should be deep and quiet. If corneal edema and folds persist and/or an anterior chamber reac- tion persists, I recommend per- forming gonioscopy to search for a retained lens material in the angle. Once a patientʼs vision is restored, careful postoperative management is critical. Retained lens material in the eye can induce chronic inflammation and may be cause for patients to retained lens material finding, con- clear” and manage tear film issues return to the O.R. for irrigation. sult the surgeon. aggressively. If the angle is clear, I recommend dilating the eye to search for re- Subtle corneal changes can great- Month One Visit tained lens material. Most in- ly influence a patient’s experience At one month, the fellow eye may stances of retained lens fragments with their surgical eye. Become or may not have been operated on are benign, and the remnants will a keen observer of subtleties and slowly resorb over time. With any remember “the cornea should be Continued on Page 14

(PAM) may also be used preopera- tests necessary to deliver a desirable rotation of the implant for optimal acu- tively if visual outcome is question- outcome. The surgeon will generally ity (www.acrysoftoriccalculator.com). able. perform a second dilated fundus ex- Together, the optometrist and oph- amination, perform an OCT and to- thalmologist must educate prospec- Recommend a Specific IOL pography. Colvard pupilometry may tive surgical candidates regarding Once a careful preoperative exami- be obtained to determine mesopic intraocular lens technology available nation has been performed, I recom- pupil size, and IOL Master™ testing today. Because cataract surgery is mend making a specific IOL rec- will be performed to determine proper deemed “refractive” surgery, emme- ommendation, whether a standard, IOL power. Some optometric prac- tropia is an expected outcome for a toric or multifocal IOL. The clinician tices perform IOL Master™ testing, large proportion of our healthy sur- should be comfortable enough with which is perfectly acceptable utilizing gical patients. Utilizing today’s most his findings and know the patient well a well-trained technician who delivers sophisticated implant technology and enough to be confident to refer to an consistent data. For patients who are exacting clinical acumen, patients ophthalmologist for a formal cataract candidates for a toric IOL, a computer benefit from near-perfect outcomes consultation. generated Toric Calculator is used to and have options their parents did The M.D. will perform several other determine the precise planned axis of not have. ★

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0210_Alcon IoLHandbookjc.indd 13 1/25/10 10:27 AM yet. I recommend performing a • Fluctuating vision tion for treatment of astigmatism in dilated fundus examination at this • Blurry vision a multifocal IOL. Unplanned re- visit after careful visual acuity as- • Missed expectations sidual refractive error is typically the sessment and slit lamp evaluation. result of corneal astigmatism or am- It is at this point during the post- Etiology for qualitative issues are metropia due to planned lens power. operative experience that cystoid generally quickly discovered af- Unplanned residual refractive error macular edema (CME) may mani- ter a careful clinical examination. can be managed with laser vision fest. Be alerted to this entity with They are typically related to: correction, piggyback IOLs, spec- any drop in best-corrected visual • Posterior capsular opacification tacle or contact lens use. acuity. A cystic appearance to the (PCO) Elective IOL patients typically macula will be evident, and your • Tear film abnormalities have little tolerance for any postop- diagnosis can be solidified with • Residual refractive error erative outcome that is less than sat- OCT. isfactory. It is important to deal with Once the patient is bilaterally implanted, adaptation should oc- cur in a stepwise pattern. For pa- As the cataract patient population swells and patients tients who elected to proceed with seek youthful options for their visual experiences, we standard or toric IOLs, the one month visit is the time when a fi- have an opportunity to significantly alter a patient’s life nal spectacle prescription is given in a positive way. and medications discontinued. To- ric patients generally require only reading glasses postoperatively. PCO their complaints professionally and For multifocal IOL patients, neu- With improved intraocular lens diplomatically. Irrespective of how roadaptation will continue and the designs and materials, PCO is less careful the clinician was to not over- patient should be enjoying glasses- common. Especially with mul- state potential visual outcome, the free vision at all distances. Medi- tifocal IOLs, faint PCO can pro- patient expects near perfection. We cations are continued an additional duce dramatic symptoms of glare. have tools at our disposal to assist two weeks. I recommend intervening early them and eliminate their concerns. with the earliest signs of PCO to Do not hesitate to bring the surgeon Month Three address the patient’s complaint. back into the management of an un- You should consider sending a PCO is treated in an office setting happy patient. survey to your elective IOL pa- with Nd:YAG laser capsulotomy. Insertion of elective IOL candi- tients at this point. Ask about their dates and patients into your practice spectacle-free experience, how the Tear Film Abnormalities is an especially gratifying experience. implant has changed their outlook, As discussed earlier, the tear film As the cataract patient population whether they would recommend is the principle refractive surface of swells and patients seek youthful op- the same technology to a friend the eye. The astute clinician man- tions for their visual experiences, we or family member, etc. These are ages tear film insufficiencies ag- have an opportunity to significantly good data to continue practice gressively with all elements in his alter a patient’s life in a positive way. growth and share with staff mem- armamentarium to create a uniform Lifestyle intraocular lenses have bers to maintain excitement about refractive surface to enhance subjec- completely altered the perception elective IOL technology. tive visual acuity postoperatively. of cataract surgery, changed the way You can use supportive products, surgeons perform phacoemulsifica- Month Six and Twelve such as preservative-free tears, long- tion and have left an indelible mark I recommend that patients should lasting non-preserved artificial tears, on all eye care provider practices. return six months after their pro- ophthalmic gels, prescription agents It is only the beginning. Technol- cedure for a full medical eye exam- such as Restasis (Allergan) and punc- ogy will continue to evolve. Patients ination. It is at this visit patients tal plugs, in varying combinations to will soon start the conversation can discuss their results with the ameliorate dry eye symptoms. about lifestyle IOLs because they clinician and express concern over have heard of them on television, any issues they may have experi- Residual Refractive Error the Internet, reading a magazine or enced. There are two types of residual re- speaking with a friend or relative. Common issues dealt with at this fractive error: 1) Planned and 2) Un- The time to prepare your practice visit are generally qualitative issues planned. Planned residual refractive for this exciting journey is now. It such as: error generally occurs because of will be an incredible experience for • Halos and glare planned postop laser vision correc- both the clinician and staff. ★

14 REVIEW OF OPTOMETRY FEBRUARY 15, 2010

0210_Alcon IoLHandbookjc.indd 14 1/25/10 9:58 AM IOL Technology on the Horizon THE ULTIMATE GOAL OF anterior curvature of the lens dur- Arturo Chayet, M.D. et al, re- lens surgery is to restore accom- ing accommodation. This sulcus fix- ported in Ophthalmology that 92.9% modation to an amplitude similar ated lens uses a dynamic diaphragm of patients were within 0.25D after to that of a 25-year-old. There are to force a silicone gel (index 1.40) “correction” with the light adjusted many intraocular lenses, in vari- through a small hole in an anterior lens, and they were able to treat up ous stages of development, which diaphragm when the ciliary muscle to 1.5 diopters of refractive error. It are designed to provide a level of contracts. The pressurized gel is anticipated that wavefront correc- accommodation beyond any lens bulges forward through the hole, tions and presbyopic treatments may available today. These lenses use creating an increasingly more posi- be able to be performed on this lens. various optical and structural meth- tive refracting surface. This is a sim- Time will tell which, if any, of ods to achieve accommodation. ilar mechanism used by waterfowl these lenses will achieve the lofty The AcrySof IQ ReSTOR Mul- when making underwater dives. Ac- goal of truly restoring accommoda- tifocal Toric IOL is designed to pro- commodation has been measured at tion. History has shown us not every- vide presbyopia correction as well 8D on average. one will recognize the best lens as it as astigmatism correction. The Ac- Smart IOL (Medennium, Irvine emerges. The pursuits of providing rySof IQ ReSTOR Multifocal Toric CA) is a flexible thermoplastic gel improved patient care will eventu- IOL has a +3.0 D add power with that can be produced to specific size ally yield the holy grail of eye care, different diopter of astigmastism shapes and powers. It is a thin rod at a lens as remarkable as the human correction. room temperature that expands to crystalline lens. ★ Synchrony IOL (AMO, Santa fill the capsular bag when inserted Ana, CA) is a single-piece, silicone, within the eye. The material is flex- dual optic and foldable lens. The ible enough to change during the lens uses a high power (30-35D) constriction of the ciliary muscle. The anterior optic and a negative pow- lens has been inserted into cadaver er posterior lens which are con- eyes and is awaiting further develop- nected by a spring like haptic. A ment before being inserted into hu- small amount of anterior displace- man eyes. The Optometric Council on Refractive Tech- ment of the anterior lens results in Light Adjustable Lens (Calhoun nology (OCRT) is optometry’s home for those increased near vision. The lens is Vision, Pasadena, CA) is a photosensi- involved in refractive surgery and the advanced in its “compressed” state when in- tive adjustable foldable 3-piece IOL. technologies available for analysis and correc- serted into the capsular bag. When Macromers are embedded into the tion of patients’ vision. Our mission is to ad- the ciliary body contracts, relaxing matrix of the lens. Focal UV light is vance the art and science of refractive technol- the zonules, the anterior lens moves delivered to the lens, which causes a ogy for optometrists. forward, resulting in near vision. polymerization of the macromers and Membership in the OCRT is open to optom- In a pilot evaluation of the lens, it allows them to migrate to the desired etrists, vision scientists, optometric residents showed a mean accommodation of location (for example, to the center of and students. If you would like to receive a membership application or have questions 3.22 diopters (0.88 D STD). the lens for increased plus). A final about membership in OCRT, please contact The NuLens Accommodat- irradiation can lock in the final power OCRT Membership Chairs, Dr. J. Christopher ing IOL (NuLens, Ltd., Herzliya of the lens. Therefore, the power of Freeman at [email protected] or Dr. An- Pituah, Israel) uses a unique design the lens can be altered after insertion, drew Morgenstern at andrewmorgenstern@ to obtain near vision. The structure allowing for treatment of myopia, hy- gmail.com. For more information on the OCRT, of this lens allows it to change the peropia or astigmatism. please visit http://www.ocrt.org/

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0210_Alcon IoLHandbookjc.indd 15 1/25/10 9:58 AM