Refractive Cataract Surgery and Comanagement Implications Scott O. Sykes, MD Utah Eye Centers Mount Ogden Eye Center

Refractive Cataract Surgery Improving spherical equivalent outcomes Improving astigmatism outcomes Addressing Presbyopia Monovision Presbyopia IOLs Post refractive surgery patients Comanagement Preoperative issues Postoperative issues

Preoperative Comanagement Issues Concurrent eye disease Glaucoma Pseudoexfoliation Macular health (ERM, AMD, etc) Corneal disease Prior refractive surgery Amblyopia Prior monovision (which eye, how myopic?) Psychological factors

Preoperative considerations: Glaucoma and PX MIGS options: iStent Cypass—myopic shift possible Pupillary miosis: increased operative risk Zonular laxity: increased operative risk and postoperative decentration

Concomitant Cataract & Glaucoma Patients - US Significant Treatment Opportunity One in five Cataracts Eyes on OHT Medication Centers for Medicare and Medicaid Services. 2002 – 2007. Medicare Standard Analytical File. Baltimore, MD. 2007 . CONFIDENTIAL

Concurrent eye disease: Macular issues Modern Cataract Surgery: Preop Macular OCT on every patient Macular Degeneration Epiretinal Membrane Diabetic Retinopathy Visual potential Multifocal IOLs Toric IOLs

Macular Issues

Concurrent eye disease: corneal disease Keratoconus Keratopathy Dry Eye ABMD Nodular Degeneration Prior Refractive Surgery

Keratoconus/PMD Modern Cataract Surgery: preop topo on every patient, both eyes Form Fruste Keratoconus surprisingly common with routine preop topography testing Visual potential Refractive unpredictability Multifocal IOLs RGP tolerance and success Post operative expectations Future transplant risk Case Review (Rounds patient)

Case Review: PMD (previously undetected; patient an attorney )

Case Review: PMD (previously undetected; patient an attorney ) Preop extensive discussion of irregular astigmatism Two months post-op UCVA: 20/25 +2 OD, 20/20 OS +0.25 – 0.25 x 069 20/20 OD +0.25 – 0.25 x 101 20/20 OS

Other Corneal Issues: Keratopathy Keratopathy: DES, ABMD, Scarring Visual potential Irregular astigmatism Refractive unpredictability Post operative expectations Preoperative treatments (delaying cataract surgery) Preoperative corneal surgery Case Review (ES)

Keratopathy: Case Review

Keratopathy: Case Review Keratometry: Before Rx for DES: 45.11 x 45.58 (45.34) After Rx for DES: 44.29 x 44.76 (44.52) Refractive error avoided: 0.82 D hyperopia Post op UCVA: 20/20 Delay surgery as long as needed to get the cornea healthy and stable.

Preoperative astigmatism Refractive astigmatism vs. corneal astigmatism Anterior corneal astigmatism vs. posterior corneal astigmatism Regular astigmatism vs. irregular astigmatism

Preoperative Astigmatism 52 year old man referred for cataract evaluation OD -5.50 – 3.00 x 094 20/25 Mild NS and PSC OS unable to refract CF Severe NS and PSC How should we treat his astigmatism?

Refractive astigmatism vs. corneal astigmatism

Refractive astigmatism vs. corneal astigmatism No astigmatism treatment Result: 20/20 OU UCVA

Astigmatism from Pterygium prior to Cataract Surgery

Nodular Degeneration or ABMD

Improving refractive predictability post refractive surgery Clinical history method Advanced IOL formulas/calculators Intra operative abberometry (ORA)

IOL Formula: Old and New Net corneal power (K) Ks, Kf, axis Axial length (AL) Piol: IOL Implant power Effective lens position (ELP) WTW Rfx: Desired post op refraction Vertex distance (V)

IOL Formula: Old and New Net corneal power (K) Ks, Kf, axis Axial length (AL) Piol: IOL Implant power Effective lens position (ELP) WTW Rfx: Desired post op refraction Vertex distance (V)

All (Excluding Post lvC)

All Cases (Excluding Post lvC)

Symfony

Toric IOLs

Toric IOLs

Toric IOLs

ORA Influenced

Post Myopic LVC (All Surgeons)

Post Hyperopic LVC (All Surgeons)

Post RK (All Surgeons)

Intraoperative Aberrometry: Not an independent, stand-alone prediction ORA recommendation still based on all formula variables Bad data in = bad data out Incorrect data (data entry errors, etc.) Inaccurate data Post refractive surgery Poor quality (dry eye, ABMD, etc) Intraoperative measurement variables (IOP, speculum pressure, fluid, corneal hydration, viscoelastic, etc.) Outliers are still outliers (AL, K’s, etc) ORA gives additional benefit of a wavefront-measured aphakic refraction and a proprietary modification of the formula.

Does ORA Help? Bottom Line Outcome within 0.5 D of target ORA: 85% No ORA:75% How often do I make a change because of ORA? 1 of 3.5 patients How often does the change yield a better outcome? 3 of 4 patients What is the magnitude of the change? 0.25 D Is this worth the cost to the patient or the surgeon? Patient cost: bundled into premium package ($100) Surgeon cost: Preop staff time Increased operative time Decreased postoperative chair time Decreased postoperative enhancement rate

Lessons Learned & Next Steps ORA helpful, but still must consider as just one piece of information. Great outcomes analysis tool as well. Post-refractive surgery: ASCRS Post refractive Barrett formula surprisingly good but ORA helps some. Post operative data needs to be more reliable (e.g., tech refractions vs. MD/OD refractions). Upcoming comparison for second eye surgery: ORA vs. first eye outcome Upcoming comparison of Barrett Formula vs ORA. IOL Master 500 can’t calculate Barrett

Postoperative issues for comanagement Refractive error Posterior capsule opacification (PCO) Anterior capsule phimosis Communicating results to ophthalmologist

Managing postoperative refractive error Manage based on patient and physician expectations Was a premium lens used? Is the patient happy? Correcting postoperative refractive error Glasses LRI Lasik or PRK IOL exchange

Managing postoperative refractive error Large spherical surprises: treat early (2-4 weeks) with IOL exchange Large astigmatic surprises after toric IOL: treat after at least two weeks with Toric IOL repositioning Mild refractive error Watch until stable, 3-4 months Treat with glasses, LRI, or PRK/LASIK

Cost of Touch Ups after Premium Technology Use Usually covered in initial upgrade fee, so no additional fee for LRI or PRK/LASIK

Managing Posterior Capsule Opacification Rule out other causes of reduced vision, especially CME or corneal causes Treat the patient, not the capsule Patients must be visually symptomatic Preferably YAG done after 3-4 months Don’t YAG if any concern about need for IOL exchange

Managing Postoperative Cystoid Macular Edema Topical Steroid and NSAID Follow with serial OCT Retina consult if not resolving

Anterior Capsule Phimosis

Managing postoperative anterior capsule phimosis Usually in pseudoexfoliation May not be evident until late without dilated examination Causes hyperopic shift usually Increases risk of zonular weakening and lens decentration Refer for YAG as soon as recognized Case Review

Communicating postoperative results Satisfies legal requirements Leads to better outcomes by providing data for nomograms

Thank You