1. 1 Uday Devgan MD Los Angeles You can download my slides for free at www.UdayDevgan.com

2. 2 Abbott Medical Optics: consultant, research Accutome Inc: speaker Alcon Laboratories: stockholder Allergan: consultant, speaker, research funding Bausch & Lomb: consultant, research funding Gerson Lehman Group: consultant Haag-Streit: speaker Hoya Surgical Optics: consultant, speaker Inspire Pharma: stockholder (former), consultant Ista Pharma: consultant, speaker, stockholder iTherapeutix: research funding, travel support Optos Inc: speaker Renaissance Surgical: stockholder Sirion Therapeutics: consultant Specialty Surgical: stockholder Staar Surgical: consultant (former) Zeiss / Carl Zeiss Meditec: speaker This presentation represents the speaker’s professional experience. Uday Devgan MD disclosures

3. 3 Astigmatism Must Be Addressed

4. 4 How close do I have to be for excellent visual results with the Crystalens? 1.plano +/- 0.50 D< 0.50 D cyl 2.plano +/- 1.00 D< 1.00 D cyl 3.my patients have such dense cataracts they are happy even if I leave them aphakic. Question #1

5. 5 Confirmed with SurgiVision Data

6. 6 Binocular: 20/20 dist, 20/18 int, 20/25 near if there is minimal cylinder

7. 7 Perfect Plano Quick, where’s my camera?

8. 8 1D Residual Astigmatism (Far)

9. 9 1D Residual Astigmatism (Near)

10. 10 Nailing +/- 0.50 D for Both Sphere and Cylinder Is Important

11. 11 Sphere

12. 12 Effective Lens Position is Critical The A-constant assumes a proper posterior vault of the Crystalens

13. 13 Incisions Must be 100% Sealed

14. 14 Cylinder

15. 15 The Difference Between Sad & Happy +1.00 – 2.00 x 090 SE = Plano +0.25 – 0.50 x 090 SE = Plano

16. 16 0 +0.50 cyl-0.50 cyl Crystalens HD Crystalens AO Is the AO More Forgiving than the HD?

17. 17 Measure & Treat the Astigmatism

18. 18 How do you determine the amount of pre-op astigmatism that needs to be fixed? 1.IOL Master / Lenstar 2.corneal topography 3.manual keratometry 4.manifest refraction Question #2

19. 19 Pre-Op Corneal Cylinder Ignore the refraction cylinder Look at the Corneal cylinder

20. 20 Topography to Check Symmetry

21. 21 Weed-out Inappropriate Patients

22. 22 Address the Astigmatism Topography Effect of your incisions? LRI: Limbal Relaxing Incisions

23. 23 What’s the effect of your incision? Most clear K incisions = Flattening of about 0.50 D 44.25 43.75 Pre-op K: 44.50 x 030 43.50 x 120

24. 24 LRIs can reduce/eliminate K cyl BEFORE AFTER Thank you to Kevin Miller MD for this slide.

25. 25 Factor in your Phaco Incision: Figure 1 © 2009 Uday Devgan MD

26. 26 BEFORE SURGERY 44.75 x 90 44.25 x 180 © 2009 Uday Devgan MD

27. 27 AFTER PHACO INCISION (0.5 D of flattening at 180) 45.00 x 90 44.00 x 180 © 2009 Uday Devgan MD

28. 28 WITH LRI DONE FOR 1 DIOPTER AT 90 44.50 x 90 44.50 x 180 © 2009 Uday Devgan MD

29. 29 LRIs are placed in the peripheral clear cornea by tracing along the fixation ring. © 2009 Uday Devgan MD

30. 30 Post-Op Astigmatism

31. 31 What are the causes of post-op astigmatism? 1.irregular ocular surface 2.residual corneal astigmatism 3.IOL tilt or shift from capsular bag contraction / fibrosis 4.all of the above Question #3

32. 32 Irregular Corneas (uncommon)

33. 33 Residual Refraction (common) Not Enough Effect From Your LRI

34. 34 Capsule Issues Causing IOL Shift

35. 35 Small Rhexis / Phimosis Hyperopic Shift and Induced Cylinder

36. 36 Posterior Capsule Fibrotic Bands Myopic Shift and Induced Cylinder

37. 37 After YAG of Capsular Striae

38. 38 Poor Rhexis = Poor Result All 4 footplates must be at the capsular bag equator One arm in the sulcus will cause IOL tilt

39. 39 If you remember just ONE thing…

40. 40 NAIL PLANO Sphere & Cylinder within 0.50 D of plano