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Refractive SurgerySeptember 22, 2012
Matthew Carnahan, MD
Refractive Surgical Modalities
• RK• PRK, LASEK, epi-LASIK• LASIK• Wavefront LASIK• IntraLASIK• Conductive Keratoplasty
• Phakic IOL• Presbyopic IOL
– multifocal– pseudo-accommodating
• Refractive Lens Exchange (monofocal, multifocal)
• Toric IOL
•
Radial Keratotomy
http://www.youtube.com/watch?v=FzcKFvZuIqs&feature=related
http://www.youtube.com/watch?v=i1AoFonNLwc
PRK or LASEK
http://www.youtube.com/watch?v=QRNzDC5xlc8
http://www.youtube.com/watch?v=gjnN481Fvks
LASIK with microkeratome
http://www.youtube.com/watch?v=Yel9QlQr56o
IntraLASIK
Femtosecond laser• With gas bubbles, bluntly dissect
between corneal collagen lamellae• create a plane which becomes the
flap for LASIK without a blade http://www.youtube.com/watch?v=3-ry8mLaY8M
Conductive Keratoplasty (CK)
FDA Approved for presbyopia FDA Approved for presbyopia Induces myopia in an emmetropic eye, Induces myopia in an emmetropic eye, achieving monovisionachieving monovision
http://www.youtube.com/watch?v=u39XvfOvhxA
http://www.youtube.com/watch?v=89W4z08ZrdA
Phakic IOLs for High Myopes
• Sulcus - Visian • Iris - Verisyse/Artisanhttp://www.youtube.com/watch?v=LIsZz5y7QOY
http://www.youtube.com/watch?v=wzzAhcthhKo
Refractive Lens Exchange (RLE)
• Natural Lens Replacement– Monofocal IOL (+/- monovision)– Accommodating IOL – Crystalens– Multifocal IOL
• ReSTOR• Tecnis
• Valuable for patients with thin corneas or high refractive errors (hyperopia / astigmatism)
Presbyopia correcting IOLs
• Multifocal IOL– Tecnis– ReSTOR
• Pseudo-accomodating IOL– Crystalens
http://www.youtube.com/
watch?v=T1w1qEUPZPI&featur
e=related
Crystalens
• Distance • Nearpseudo-accommodationpseudo-accommodation
http://www.youtube.com/watch?
v=xmP5FlQBmcM
Multifocal IOL – ReSTOR®
• The AcrySof® ReSTOR® IOL incorporates an apodized diffractive optic with refraction to achieve a range of quality vision.
http://www.youtube.com/watch?
v=7hcHO_1PF30&feature=related
http://www.youtube.com/watch?
v=mJgofz7NMbs&feature=related
Tecnis MFIOL
• Diffractive, 1 or 3 piece, silicone or acrylic, aspheric• Less pupil dependent, 4+add on posterior surface
http://www.youtube.com/watch?v=AJ5_glCYVYo&feature=related
Contraindications to MFIOLs: Patient Considerations
• Subjective Exclusion Criteria– Hypercritical patients– Patients with unrealistic expectations– Those who want to wear glasses– Occupational night drivers– Individuals with a monofocal lens
Contraindications to MFIOLs: medical exclusion criteria
• Pre-existing ocular pathology • Significant dry eye• Corneal scarring, cornea guttata• Glaucoma• Macular disease
• Previous refractive surgery (not an absolute)• Pupil size <2.5 mm• Monofocal implant in first eye• >1.0 D of corneal astigmatism (may need added LVC, maybe toric
instead)• Unstable capsular support
Managing the Total Condition
• Physical– Controlling astigmatism– Enhancing distance vision– Enhancing near vision– Managing common patient concerns
• Psychological– Concerns with halos– Adapting to a new visual system
Who is your MFIOL patient?
• Motivated to reduce dependency on glasses
• Candidate for bilateral implantation
• Cataract patients who want to retain the ability to see objects near
and distant with reduced dependency on glasses
• (50+ who are considering LASIK: frustrated presbyopes)
• Design– AcrySof Single-Piece platform– Open loop, modified-L haptics– Posterior toricity – Toric axis marks
• Dimensions– Overall length: 13.0 mm– Optic diameter: 6.0 mm
Toric IOL
Synchrony accommodating IOL
• Single piece dual optic silicone accommodating lens, movement via ciliary body
• 5.5mm +32D anterior optic• 6.0mm minus power post. optic• FDA phase 3• 2 year f/u – 90%+ 20/20 UCVA• Better than ReSTOR at 60cm& 80cm distance corrected
http://www.youtube.com/watch?v=dll3rXrr9CY
Acri.LISA
• German single piece aspheric acrylic multifocal lens with toric option
• Can go through a 1.8mm incision• L: light intensity (65% refractive/distance & 35
diffractive/near)• I: independence from pupillary size• S: smooth refractive/diffractie surface profile• A: aspheric surface
MPlus
• “Sector-shaped near-vision section offering HD-Vision-natural contrast sensitivity and best-corrected distance and near visual acuity.”
• One piece aspheric, multifocal toric acrylic
M-Flex Multifocal IOL (& T-flex toric)
• Acrylic, 6.25mm multizone (4 or 5 depending on base power) aspheric optic
• Distance dominant with +3.0 or +4.0D add = +2.25 or +3.0D at spectacle plane• Made for 2mm incision
Rayner Sulcoflex
• Acrylic injectable IOL withundulating haptics andposterior haptic angulationfor secondary suclus placement in pseudophakiceyes• Multifocal and toric versions are available
Multifocal laser ablation (presbyLASIK)
• Different power zones for varying distances• Epstein in Chicago: distance center, near periphery –
similar to PAC (Pseudo-Accommodative Cornea) by Telandro in France (>10K cases done since ’04)
• Alioi in Spain: center of cornea shaped for near vision, peripheral zone for distance (believe to reduce aberrations and allows for stronger near correction)
Laser Cataract Surgery
• Femtosecond laser creating- Capsulorhexis- Lens pre-dicing- Main incision- Paracentesis- Corneal relaxing incisions
http://www.youtube.com/watch?v=osegmN1E8JE&feature
=related
Thank You
• http://www.youtube.com/watch?v=U3X_zVvRTn0&feature=related