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