Refractive Lens Surgery - part 1 ppt

With the development of excimer lasers came a very marked change in the at-titude of eye surgeons internationally re-garding the concept of invading “healthy” tissue for refractive purpo

Refractive Lens Surgery

I H Fine

M Packer

R S Hoffman (Eds.)

Editors I Howard Fine

Library of Congress Control Number: 2005924302

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ISBN-10 3-540-22716-4 Springer Berlin Heidelberg New York

ISBN-13 978-3-540-22716-8 Springer Berlin Heidelberg New York

This eBook does not include ancillary media that was packaged with the printed version of the book

The editors respectfully dedicate this book

to the many pioneers of refractive surgery

who had the courage to operate on healthy

eyes in order to enhance the quality of life

of their patients They were right all along

and those of us who were doubters havelearned that lesson and as a result haveenhanced the satisfaction we derive fromour own careers

V

Dedication for Refractive Lens Surgery

The first recorded time a human lens was

removed for the purpose of addressing a

refractive error was by an ophthalmologist

named Fukala in 1890 We do not know

what type of criticism he experienced, but

we know that today he is a forgotten man in

ophthalmology The introduction of this as

a concept in the late 1980s by both Drs Paul

Koch and Robert Osher’s manuscripts,

re-sulted in considerable disdain and some

condemnation by some of their colleagues

and peers At the time, refractive surgery in

the United States was limited to radial

ker-atotomy With the development of excimer

lasers came a very marked change in the

at-titude of eye surgeons internationally

re-garding the concept of invading “healthy”

tissue for refractive purposes and within a

relatively short period of time, LASIK was a

firmly established procedure as were other

modalities of corneal refractive surgery

However, we have come to recognize that

corneal refractive surgery, and especially

LASIK, has limitations We have also

learned much in the recent past about

functional vision through the use of

con-trast sensitivity and an analysis of higher

order optical aberrations We have also

learned that the cornea has constant

spher-ical aberration but the lens has changing

spherical aberrations In the young, the

hu-man lens compensates for the cornea’s

pos-itive spherical aberration, but as we age the

changing spherical aberration within the

lens exacerbates corneal spherical

aberra-tion Because of the changing sphericalaberration in the lens, no matter what isdone to the cornea as a refractive surgerymodality, including the most sophisticatedcustom corneal shaping, functional vision

is going to be degraded by changing ical aberration in the lens over time.This coupled with the fact that highermyopes and hyperopes, patients with earlycataracts, and presbyopes are not necessar-ily good candidates for LASIK has resulted

spher-in a fresh look at lens-based refractive gery We have seen recent improvements inphakic IOL technology and utilization and

sur-we ourselves have been increasingly vated to work with lens related refractivesurgery modalities

moti-Our own work with power modulations,the IOL Master, and wavefront technologyIOLs has convinced us that lens-related re-fractive surgery can give superior results.Stephen Klyce, MD, the developer ofcorneal topography has demonstrated,using topographical and wavefront analysismethods, that IOL intraocular optics are far superior to the optics of the most so-phisticated, customized wavefront treatedcornea We have also seen the development

of new lens technologies including proved multifocal IOLs, improved accom-modative IOLs, light adjustable IOLs, in-jectable IOLs, and a variety of otherinvestigational IOL technologies that sug-gest unimaginable possibilities Our ownresults with the Array and Crystalens have

im-VII

Preface

been very encouraging as has our work

with bimanual micro-incision

phacoemul-sification, which I believe has allowed us to

develop a refractive lens exchange

tech-nique that sets a new standard for safety

and efficacy It is our belief that refractive

lens exchange is indeed not only the future

of refractive surgery, but in many ways the

procedure that will become a mainstay of

ophthalmology within the coming decades

A major task for any editor is delegation,

and this book represents the ultimate in

delegation My reliance on my two partners

is evident throughout the book in the thorship of the chapters we have produced

au-It is my belief that just as refractive lensexchange represents the future of refractivesurgery that my partners, Drs Richard S.Hoffman and Mark Packer, represent thenew generation of leadership in anteriorsegment ophthalmic surgery

I Howard Fine

The Tecnis Multifocal IOL 145

Mark Packer, I Howard Fine,

The Light–Adjustable Lens 161

Richard S Hoffman, I Howard Fine,

The Vision Membrane 187

Lee Nordan, Mike Morris

Jorge L Alio, Ahmed Galal,

Jose-Luis Rodriguez Prats,

Mohamed Ramzy

Chapter 22

The Infiniti Vision System 209

Mark Packer, Richard S Hoffman,

The Staar Sonic Wave 221

Richard S Hoffman, I Howard Fine,Mark Packer

Chapter 25

AMO Sovereign with WhiteStar Technology 227

Richard S Hoffman, I Howard Fine,Mark Packer

Conclusion: The Future

of Refractive Lens Surgery 237

Mark Packer, I Howard Fine,Richard S Hoffman

Subject Index 239

Chapter 1

The Crystalline Lens as a Target

for Refractive Surgery 1

Mark Packer, I Howard Fine,

Richard S Hoffman

Chapter 2

Refractive Lens Exchange

as a Refractive Surgery Modality 3

Richard S Hoffman, I Howard Fine,

Mark Packer

Chapter 3

Biometry for Refractive Lens Surgery 11

Mark Packer, I Howard Fine,

Correction of Keratometric Astigmatism:

AcrySof Toric IOL 71

Nhung X Nguyen,Achim Langenbucher,Berthold Seitz, M Küchle

1550 Oak St Suite 5 Eugene, Oregon 97401, USAJack Holladay, MD

5108 Braeburn DriveBellaire, TX 77401-4902, USAJohn Hunkeler, MDHunkeler Eye Institute, P.A

4321 Washington, Suite 6000Kansas City, MO 64111-5905, USADouglas Koch, MD

Cullen Eye Institute

6565 Fannin, Suite NC205Houston, TX 77030, USAThomas Kohnen, MDJohann Wolfgang Goethe-University Department of OphthalmologyTheodor-Stern Kai 7

60590 Frankfurt, GermanyStephen S Lane, MDAssociated Eye Care, Ltd

232 North Main StreetStillwater, MN 55082, USARichard L Lindstrom, MDMinnesota Eye Consultants, P.A

710 E 24th Street, Suite 106Minneapolis, MN 55404, USA

Contributors

XI

Ocala Eye Surgeons

1500 S Magnolia Ext Ste 106

9728 NX GroningenThe Netherlands

Mark Packer, MD, FACS Department of OphthalmologyOregon Health & Science University

1550 Oak St Suite 5 Eugene, Oregon 97401, USAFaezeh Mona Sarfarazi, MD, FICSPresident, Shenasa Medical LLC

7461 Mermaid Lane Carlsbad, CA 92009, USA Evdoxia Terzi, MDJohann Wolfgang Goethe-UniversityDepartment of OphthalmologyTheodor-Stern Kai 7

60590 Frankfurt, Germany

1.1 Introduction

Refractive surgeons have historically offered

procedures for clients or patients desiring

spectacle and contact lens independence

With the availability of new technology,

how-ever, surgeons are now finding a competitive

advantage among their increasingly

well-ed-ucated clientele by offering improved

func-tional vision as well [1] Measured by

techniques such as wavefront aberrometry,

contrast sensitivity, night driving simulation,

reading speed and quality of life

question-naires, functional vision represents not only

the optical and neural capability to see to

drive at night or walk safely down a poorly

il-luminated flight of stairs, but also the ability

to read a restaurant menu by candle light or

navigate a web page without reliance on

glasses Our goal as refractive surgeons has

become crisp, clear and colorful naked vision

at all distances under all conditions of

lumi-nance and glare, much like the vision enjoyed

by young emmetropes

In large part because of the immense

pop-ularity of laser-assisted in-situ

keratomileu-sis (LASIK), refractive surgeons have focused

on the cornea as the tissue of choice for

re-fractive correction Excimer laser ablations,

with wavefront guidance or prolate

optimiza-tion, can achieve excellent results with great

accuracy and permanency [2] However,

while the corrected cornea remains stable, the

human lens changes.All young candidates for

corneal refractive surgery must be advised

that they will eventually succumb to

pres-byopia and the need for reading glasses due

to changes occurring primarily in the talline lens [3] In a more subtle but neverthe-less significant change, lenticular sphericalaberration dramatically reverses from nega-tive to positive as we age and causes substan-tial loss of image quality [4] Therefore, anyrefractive correction of spherical aberration

crys-in the cornea will be overwhelmed by agcrys-ingchanges in the lens Finally, and in ever-increasing numbers, those who have hadcorneal refractive surgery will requirecataract extraction and intraocular lens im-plantation So far, the accuracy of intraocularlens power calculation for these patients hasremained troubling [5]

Presbyopia, increasing spherical tion and the development of cataracts repre-sent three factors that should prompt the re-fractive surgeon to look behind the cornea tothe lens Most commonly, however, the reason

aberra-to consider refractive lens surgery remainsthe physical and biological limits of LASIK Inyounger patients, with intact accommoda-tion, the insertion of a phakic refractive lensoffers a compelling alternative Beyond theage of 45, any refractive surgical modalitythat does not address presbyopia offers onlyhalf a loaf to the most demanding andwealthiest generation ever to grace this plan-

et, the venerable baby boomers [6]

Science and industry are responding to thedemographic changes in society with the de-velopment of improved technology for biom-etry, intraocular lens power calculation andlens extraction, as well as a wide array of in-

The Crystalline Lens

as a Target for Refractive Surgery

Mark Packer, I Howard Fine, Richard S Hoffman

1

novative pseudophakic intraocular lens

de-signs The goal of Refractive Lens Surgery is to

provide a snapshot of developments in this

rapidly changing field The time lags inherent

in writing, editing and publishing mean that

we will inevitably omit nascent yet

potential-ly significant technological advances

The future of refractive surgery, in our

opinion, lies in the lens Candidates for

sur-gery can enjoy a predictable refractive

proce-dure with rapid recovery that addresses all

re-fractive errors, including presbyopia, and

never develop cataracts; surgeons can offer

these procedures without the intrusion of

third-party payers and re-establish an

undis-rupted physician–patient relationship; and

society as a whole can enjoy the decreased

taxation burden from the declining expense

of cataract surgery for the growing ranks of

baby boomers who opt for refractive lens

sur-gery and ultimately reach the age of

govern-ment health coverage as pseudophakes This

combination of benefits represents an

irre-sistible driving force that will keep refractive

lens procedures at the forefront of

oph-thalmic medical technology

Schroe-3 Gilmartin B (1995) The aetiology of opia: a summary of the role of lenticular and extralenticular structures Ophthalmic Physiol Opt 15:431–437

presby-4 Artal P, Guirao A, Berrio E, Piers P, Norrby S (2003) Optical aberrations and the aging eye Int Ophthalmol Clin 43:63–77

5 Packer M, Brown LK, Fine IH, Hoffman RS (2004) Intraocular lens power calculation after incisional and thermal keratorefractive sur- gery J Cataract Refract Surg 30:1430–1434

6 Jeffrey NA (2003) The bionic boomer Wall Street J Online 22 Aug 2003

2 M Packer · I H Fine, R S Hoffman

Advances in small incision surgery have

en-abled cataract surgery to evolve from a

proce-dure concerned primarily with the safe

re-moval of the cataractous lens to a procedure

refined to yield the best possible

postopera-tive refracpostopera-tive result As the outcomes of

cataract surgery have improved, the use of

lens surgery as a refractive modality in

pa-tients without cataracts has increased in

pop-ularity

Removal of the crystalline lens for

refrac-tive purposes or refracrefrac-tive lens exchange

(RLE) offers many advantages over corneal

refractive surgery Patients with high degrees

of myopia, hyperopia, and astigmatism are

poor candidates for excimer laser surgery In

addition, presbyopia can only be addressed

currently with monovision or reading

glass-es RLE with multifocal or accommodatingintraocular lenses (IOLs) in combinationwith corneal astigmatic procedures couldtheoretically address all refractive errors in-cluding presbyopia, while simultaneouslyeliminating the need for cataract surgery inthe future

Current attempts to enhance refractive sults and improve functional vision with cus-tomized corneal ablations with the excimerlaser expose another advantage of RLE Theoverall spherical aberration of the human eyetends to increase with increasing age [1–4].This is not the result of significant changes incorneal spherical aberration but rather in-creasing lenticular spherical aberration [5–7]

re-Refractive Lens Exchange

as a Refractive Surgery Modality

Richard S Hoffman, I Howard Fine, Mark Packer

2 Ultimately, refractive lens exchange will be performed through twomicroincisions as future lens technologies become available

2 Attention to detail with regard to proper patient selection, ative measurements, intraoperative technique, and postoperativemanagement has resulted in excellent outcomes and improvedpatient acceptance of this effective technique

preoper-2

This implies that attempts to enhance visual

function by addressing higher-order optical

aberrations with corneal refractive surgery

will be sabotaged at a later date by lenticular

changes Addressing both lower-order and

higher-order aberrations with lenticular

sur-gery would theoretically create a more stable

ideal optical system that could not be altered

by lenticular changes, since the crystalline

lens would be removed and exchanged with a

stable pseudophakic lens

The availability of new IOL and lens

ex-traction technology should hopefully allow

RLEs to be performed with added safety and

increased patient satisfaction

2.1 Intraocular Lens

Technology 2.1.1 Multifocal IOLs

Perhaps the greatest catalyst for the

resur-gence of RLE has been the development of

multifocal lens technology High hyperopes,

presbyopes, and patients with borderline

cataracts who have presented for refractive

surgery have been ideal candidates for this

new technology

Historically, multifocal IOLs have been

de-veloped and investigated for decades Newer

multifocal IOLs are currently under

investi-gation within the USA The 3M diffractive

multifocal IOL (3M, St Paul, Minnesota), has

been acquired, redesigned, and formatted for

the three-piece foldable Acrysof acrylic IOL

(Alcon Laboratories, Dallas, Texas)

Pharma-cia previously designed a diffractive

multifo-cal IOL, the CeeOn 811 E (AMO, Groningen,

The Netherlands), which has been combined

with the wavefront-adjusted optics of the

Tec-nis Z9000 with the expectation of improved

quality of vision [8] in addition to multifocal

optics

The only multifocal IOL currently

ap-proved for general use in the USA is the Array

(AMO, Advanced Medical Optics; Santa Ana,

California) The Array is a zonal progressiveIOL with five concentric zones on the anteri-

or surface Zones 1, 3, and 5 are dominant zones, while zones 2 and 4 are neardominant The lens has an aspheric designand each zone repeats the entire refractive se-quence corresponding to distance, intermedi-ate, and near foci This results in vision over arange of distances [9]

distance-A small recent study reviewed the clinicalresults of bilaterally implanted Array multifo-cal lens implants in RLE patients [10] A total

of 68 eyes were evaluated, comprising 32 lateral and four unilateral Array implanta-tions One hundred per cent of patients un-dergoing bilateral RLE achieved binocularvisual acuity of 20/40 and J5 or better, meas-ured 1–3 months postoperatively Over 90%achieved uncorrected binocular visual acuity

bi-of 20/30 and J4 or better, and nearly 60%achieved uncorrected binocular visual acuity

of 20/25 and J3 or better This study includedpatients with preoperative spherical equiva-lents between 7 D of myopia and 7 D of hyper-opia, with the majority of patients havingpreoperative spherical equivalents betweenplano and +2.50 Excellent lens power deter-minations and refractive results wereachieved

Another recent study by Dick et al

evaluat-ed the safety, efficacy, prevaluat-edictability, stability,complications, and patient satisfaction afterbilateral RLE with the Array IOL [11] In theirstudy, all patients achieved uncorrectedbinocular visual acuity of 20/30 and J4 or bet-ter High patient satisfaction and no intraop-erative or postoperative complications in thisgroup of 25 patients confirmed the excellentresults that can be achieved with this proce-dure

The potential for utilizing a monofocal IOLwith accommodative ability may allow forRLEs without the potential photic phenome-

4 R S Hoffman · I H Fine · M Packer