ACOS 2011 Newsletter

3/7/13 2:56 PM

Email not displaying correctly? View it in your browser

Forward to a Friend

As the weather heats up across the country, this second volume of the ACOS newsletter reviews two hot topics: first, a potential source of axis error in astigmatic correction that Steven Dell, MD, described at the AIRS meeting earlier this year; and second, how to market the laser refractive cataract procedure according to ophthalmic industry advisor Shareef Mahdavi. I hope this newsletter will help get you excited about the exceptional content that will be presented at the Deer Valley meeting at the end of this month. We are proud to host some of the top ophthalmic practitioners and other noted professionals in this meetings lively, interactive format. Click here for a list of faculty and topics for the Deer Valley meeting. I look forward to seeing you there! Stephen G. Slade, MD ACOS President

Optimizing Postoperative Cataract Results

By Steven J. Dell, MD At the Aspen Invitational Refractive Symposium this past February, Steven Dell, MD, of Austin, Texas, gave a presentation on optimizing postoperative cataract results by focusing on astigmatic correction. Although the accuracy of refractive outcomes in cataract surgery continues to improve, with updated IOL formulas enabling surgeons to achieve a standard deviation of the spherical component of 0.25 D or less and femtosecond laser technology refining the effective lens position, Dr. Dell suggested that cataract surgeons must start focusing on unexpected areas of refractive error, such as astigmatism. Laser interferometry axial length determination has become extremely accurate thanks to devices such as the IOLMaster (Carl Zeiss Meditec Inc., Dublin, CA) and the Lenstar LS 900 (Haag-Streit AG, Kniz, Switzerland). As a result, Dr. Dell believes that keratometry has become the weakest link in IOL calculations. With different measuring devices providing different keratometric readings, surgeons need to know what the correct answer is. Even topographers, when used serially on the same eye, can give different answers for the steep meridian. Precise identification of the steep meridian is obviously critical for achieving emmetropia with any IOL, but this is especially true with toric IOLs. Dr. Dell designed a study to determine what the variables may be (eg, head position), and whether these instruments can be standardized for clinical use. He identified patient accommodation during testing of one possible unanticipated variable in correctly identifying the steep meridian. In reviewing the literature, Dr. Dell realized that, rather than there being a near triad, there is in fact a near
http://www.bmcpromotion.com/ACOS/2011-07/ Page 1 of 5

ACOS 2011 Newsletter

3/7/13 2:56 PM

quadrad: accommodation, convergence, miosis, and excyclotorsion.1-4 The excyclotorsion that accompanies accommodation almost never comes up clinically, because surgeons refract patients at a distance. Additionally, with LRI planning, small errors in the steep meridian generally do not matter. This is because the wide arc of an LRI still covers the steep meridian, even if it is slightly misaligned, and the overall relative inaccuracy of LRIs prevents small axis errors from becoming the main source of ammetropia postoperatively. Dr. Dell feels that excyclotorsion during measurement is most problematic when implanting toric IOLs. With toric IOLs, a highly precise correction of astigmatism is possible, and variables like small axis errors suddenly become very important. There are numerous well-known sources of error between determining the eyes axis with topography and then implanting the IOL at that axis. These include misaligned marking of the patient preoperatively and placing the toric IOL slightly off-meridian. Dr. Dell believes that an important unexpected source of error may be the astigmatic source data itself. Dr. Dell devised three hypothesizes: If the accommodative stimulus differs among measuring devices, it will produce a discernable pattern of excyclotorsion differences. The device with the greatest accommodative stimulus will produce the most excyclotorsion. Source data error of the steep axis could be clinically important with toric IOLs. With 49 consecutive eyes that were scheduled for cataract surgery, Dr. Dell calculated their steep axes using the Nidek OPD (Nidek, Inc., Fremont, CA), the Atlas 995 topographer (Carl Zeiss Meditec, Inc.), and the IOLMaster. Then, he ranked each eye according to the device that showed the most excyclotorsion. The Nidek OPD was rarely the most excyclotorted (about 10% of the time), and it was the least excyclotorted device about half the time. The Zeiss Atlas was the oppositeit was the most excyclotorted device about half the time, and the least excyclotorted device about 20% of the time. The IOLMaster was right in the middle (Figure 1). Next, Dr. Dell assigned a mean relative excyclotorsion score for each device, with the Nidek OPD showing the least excyclotorsion, the Atlas showing the most, and the IOLMaster in the middle. Dr. Dell concluded that these outcomes reflected design characteristics of the devices. The two Zeiss devices use a red LED fixation target located within their hardware, and therefore it is difficult to determine the targets distance from the cornea. Dr. Dell approximated that the fixation target was 20 cm from the cornea in both of the Zeiss devices. By contrast, Dr. Dell explained, the Nidek OPD has a nonaccommodative target that is approximately 40 to 45 cm away from the cornea. Likewise, this device produced measurements that were usually the least excyclotorted. Thus, Dr. Dell concluded that excyclotorsion with accommodation may be a source of axis error, and that the Nidek OPD most effectively minimized this error in his study. He suggested that intraoperative wavefront aberrometry, such as with the ORange device (WaveTec Vision, Aliso Viejo, CA), may help prevent this error. Likewise, ophthalmic surgeons may benefit from a device that registers the eyes steep meridian while the patient is upright and then transfers this data to the OR, such as the Surgery Guidance technology by SMI (SensoMotoric Instruments GmbH; Teltow, Germany). Dr. Dell felt that excyclotorsion was an important issue to be aware of and address in refractive cataract surgery. Steven J. Dell, MD, is the medical director of Dell Laser Consultants, and director of refractive and corneal surgery for Texan Eye in Austin. He stated that he holds no financial interest in any product or company discussed herein. Dr. Dell may be reached at (512) 327-7000.
1. Read SA, Buehren T, Collins MJ. Influence of accommodation on the anterior and posterior cornea. J Cataract Refract Surg. 2007;33(11):18771885.

http://www.bmcpromotion.com/ACOS/2011-07/

Page 2 of 5

ACOS 2011 Newsletter

3/7/13 2:56 PM

2. Buehren T, Collins MJ, Loughridge J, et al. Corneal topography and accommodation. Cornea. 2003;22:311316. 3. Allen MJ, Carter JH. The torsion component of the near reflex; a photographic study of the non-moving eye in unilateral convergence. Am J Optom Arch Am Acad Optom. 1967; 44:343349. 4. Bannon RE. Near point binocular problems astigmatism and cyclophoria. Ophthalmic Opt. 1971;11:158168.

Laser Cataract Surgery: the Next New Thing in Ophthalmology

By Shareef Mahdavi This material is adapted from Shareef Mahdavis article Laser Cataract Surgery: the Next New Thing in Ophthalmology, which was published in the March 2011 edition of CRSToday. In 2010, ophthalmologists became aware of the next big revolution in the field: using a femtosecond laser to perform cataract surgery. Those fortunate to be at the Aspen Invitational Refractive Symposium in March of that year sat in awe as Stephen Slade, MD, showed videos of his first cases. These were performed commercially, fully FDA approved, in his Houston-based office. Following is a brief description of where this technology may fit into the practice of ophthalmology. Cataract surgery has a refractive component that the Centers for Medicare & Medicaid Services deemed elective when they began allowing patients to pay separately for the use of specific devices that may improve their refractive outcomes. The promise to make cataract surgery safer and less prone to complications appeals to consumers. With cataract surgery, a very different market dynamic is at work than what occurred with LASIK. Surgeons and industry should focus on market conversion rather than expansion. In the near term, it is about improving the conversion of cataract surgery to premium cataract surgery. In the longer term, laser cataract surgery should become a commonly accepted option for patients. A baseline survey of surgeons expectations regarding patient acceptance of laser cataract surgery was conducted in February 2011. Fiftythree surgeons who collectively perform over 50,000 cataract cases per year projected the percentage of their patients who would pay additional money ($1,000 was the amount used for this survey) in order to use the laser in conjunction with their cataract surgery. The summary results are shown in the figures below:

http://www.bmcpromotion.com/ACOS/2011-07/

Page 3 of 5

ACOS 2011 Newsletter

3/7/13 2:56 PM

According to Los Angeles surgeon Samuel Masket,MD, Many of my patients may not want to pay extra for their cataract surgery, but pretty much all of my patients expect a refractive-like outcome. Dr. Maskets sentiment captures what has been missing from the cataract surgery equation: LASIK-like unaided vision. LASIK trials indicate that 20/20 vision is routinely achieved in 95% of patients, but this benchmark is only achieved by slightly more than half of cataract surgery patients. The potential to raise the percentage of patients who do not require glasses after cataract surgery is of huge interest. The first boomers turned 65 in January 2011, and this large demographic will create growing demand for cataract surgery, improved outcomes, and a more concierge-like experience. Their expectations, which have been well defined over the years, have several key implications for this category. No.1. Do not differentiate based on technology. One of the major mistakes occurred when manufacturers and surgeons attempted to draw distinctions based on the type of laser. The discussion should be based on the benefits to the patient. Consumers and patients simply need to be educated on how laser cataract surgery is different. No. 2. Do not bash current technology.

http://www.bmcpromotion.com/ACOS/2011-07/

Page 4 of 5

ACOS 2011 Newsletter

3/7/13 2:56 PM

Phacoemulsification will continue to exist for the foreseeable future, and it is imperative that surgeons and staff do not degrade a procedure that has been successful. No. 3. Do not call it cataract surgery. The procedure should be renamed laser cataract surgery or lens-based laser surgery. A name will help separate it from traditional cataract surgery. No. 4. Stop using the term cataract. The term cataract no longer accurately describes what is happening inside the eye. Harvey Carter, MD, was the first surgeon I heard use the phrase dysfunctional lens syndrome with his patients. This is an example of effective communication in relevant terms. The femtosecond laser is a big deal. I do believe that it has the potential to transform lens-based surgery in ways that build upon the decades-long successes of the IOL and phacoemulsification. This transformation will take time, but the procedure will complement phacoemulsification, attracting the interest of manufacturers and surgeons alike. Shareef Mahdavi is president of SM2 Strategic and advises numerous ophthalmic companies, including Alcon, Laboratories, Inc., Bausch + Lomb, and WaveTec Vision. He has authored more than 80 articles for Cataract & Refractive Surgery Today and has a regular blog on customer experience, available at www.premiumexperiencenetwork.com. Mr. Mahdavi may be reached at (925)425-9900; shareef@sm2strategic.com.

http://www.bmcpromotion.com/ACOS/2011-07/

Page 5 of 5