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The IOL Handbook 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 lenses, 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 lens 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 Optometry 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.
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