ANTERIOR SEGMENT/CATARACT SURGERY
From the 6th Annual Downeast Ophthalmology Symposium, presented by the Maine Society of Eye Physicians and
Surgeons, Manchester, ME
Paul N. Arnold, MD, Springfield, MO
| PRESBYOPIA-CORRECTING INTRAOCULAR LENSES (PC-IOLs)
|
| Definition: IOL that, in addition to maintaining bilateral emmetropia (resulting in good uncorrected distance visual acuity
[DVA]), allows patient to see well at near or intermediate distances without correction; excludes postoperative myopia
and monofocal monovision
|
| Centers for Medicare & Medicaid Services (CMS) ruling (May 2005): allows cataract surgeon to bill Medicare patient
for additional noncovered refractive services (ie, preoperative presbyopia examination); also allows ambulatory surgical
center (ASC) or hospital outpatient department (HOPD) to charge patient directly for special PC-IOLs; ruling revolutionary
for cataract and IOL surgeons caring for Medicare patients (introduced concept of patient-shared billing); caveats—
additional charge for presbyopia examination must be reasonable; speaker strongly recommends that patient sign Notice
of Exclusion from Medicare Benefits; refractive services never covered by Medicare (with exception of astigmatic keratotomy
[AK] or wedge resection for postsurgical astigmatism)
|
| New PC-IOLs: accommodating—Crystalens (Eyeonics); multifocal—ReSTOR (Alcon); ReZoom (Advanced Medical Optics)
|
| Crystalens: only accommodating PC-IOL currently available in United States; mechanism of action—when ciliary body
contracts and zonular apparatus loosens, positive vitreous pressure believed to result, which may actually move optic forward;
recent evidence also suggests possibility of some anterior arching of optic during accommodation; changes in improved
model (AT50SE, ie, “Five-O”)—optic diameter 5.0 mm; haptic flange more rectangular; haptic footplates
broader; pros—provides good DVA and intermediate visual acuity (IVA; best IVA of IOLs being compared); best contrast
sensitivity, especially in mesopic conditions; best subjective quality of vision; cons—weakest near visual acuity
(NVA); subject to optic tilt (Z syndrome); very capsule-dependent (important that anterior capsule not cover anterior surface
of optic); unpredictable optic movement
|
| ReZoom multifocal lens: refractive optic; central 3.0 mm for DVA, next ring for NVA; IVA achieved via aspheric blends
between distance and near rings; very pupil-dependent (patient needs >3.5-mm pupil to achieve near focus); pros—
achieves good DVA and better IVA than ReSTOR lens; cons—weaker NVA than ReSTOR; pupil-dependent; greater
incidence of night-vision rings and halos than with ReSTOR; probably lower percentage of true spectacle independence,
and worse modulation transfer function score (as pupillary aperture increases) than with ReSTOR or Crystalens
|
| TECNIS multifocal lens: not yet available in United States (available in Europe where results good); diffractive optic; diffractive
rings present out to periphery; aspheric acrylic platform
|
| ReSTOR multifocal lens: diffractive optic; currently most commonly implanted PC-IOL in United States; standard single-
piece acrylic with or without “natural” yellow chromophore (also available as 3-piece); apodized diffractive portion of
optic in central 3.6 mm; refractive optic in periphery for DVA; now available as aspheric; pros—good DVA and NVA;
probably yields greatest true spectacle independence; choice of 4 formats; cons—weaker IVA; 5% of patients complain
of night rings and halos; waxy or smudgy vision in certain lighting conditions; sensitive to residual refractive error
|
| Mixing vs matching PC-IOLs: mixing—those who advocate mixing lenses speak of synergistic complementarity; 2 independent
studies comparing mixing and matching lenses concluded that best visual acuities “across the board,” and greatest
patient satisfaction achieved by mixing ReSTOR and ReZoom lenses (especially true for patients who do not have
cataracts, ie, those undergoing refractive lens exchange [RLE]); recent multicenter study found best overall results
achieved by mixing Crystalens with ReSTOR; study by Kezirian (mixed and matched all available PC-IOLs) found no
statistically significant difference in binocular DVA, IVA, and NVA in any patient group (only statistically significant
difference percentage of spectacle independence; ReZoom/ReZoom group had approximately one-half true spectacle independence
of all other groups); currently, probably better to consider mixing IOLs if dealing with younger RLE population;
however, if dealing with older refractive cataract surgery patients, probably better to match technologies;
matching—those who advocate matching speak of strengthening weakness of each IOL; for Crystalens, consider mini-
monovision (ie, leaving nondominant eye -0.5 or -0.75 to help improve NVA); for ReSTOR, some have suggested employing
mini-monovision to pull distance focus in somewhat to improve IVA; other school of thought to make nondominant
eye more hyperopic, to push near focal point out and improve IVA; for ReZoom, consider laser iridoplasty to open
up pupil in nondominant eye, allowing near rings to improve NVA
|
| Keys to success with PC-IOLs: patient selection; tempering patient’s expectations (do not overpromise); extremely accurate
biometry (use IOL Master); compulsive optimization of formulae; elimination of residual astigmatism
|
 | Patient selection: use staff to help select appropriate patients (technician should begin asking questions); rule out perfectionists,
patients with obsessive-compulsive disorder, and “constant complainers”
|
| Presbyopia examination: unique refractive “noncovered” examination that must involve additional testing; expect to repeat
evaluation before addressing second eye; be prepared to advise patients who, after undergoing examination, determined
not good candidates for PC-IOL; at speaker’s facility—1-hr examination after initial evaluation; repetition of
certain steps (automatic refraction and manifest refraction if necessary; speaker discusses expected change in patient’s
refraction); detailed questionnaire to determine patient’s visual priorities; pupillometry (photopic and scotopic testing);
ocular dominance testing; stereopsis testing; interocular defocus testing (especially if considering monovision); computerized
video keratography (manual keratometry readings if necessary); pachymetry and macular optical coherence
tomography when necessary; repeat IOL Master (first used when patient dilated during initial evaluation); discussion
with patient
|
| Surgery with PC-IOLs: operate on second eye within 1 to 2 wk (bilateral summation required); speaker strongly recommends
preoperative nonsteroidal anti-inflammatory drugs (NSAIDs), fourth-generation flouroquinolone, and topical
corticosteroid for every patient; continue NSAID and steroid for at least 6 to 8 wk after surgery (patients more affected
by subtle cystoid macular edema); minimize astigmatism with AK (be conservative; possible to extend AK postoperatively
if necessary)
|
| Speaker’s experience: most commonly matches single-piece ReSTOR (finds this lens yields best NVA, which in speaker’s
experience is reason why most patients interested in PC-IOL); makes sure patient’s pupils ≤4 mm; aims for +0.25 postoperative
refraction (to ensure near point not too close); after implantation, tries to align IOL vertically and push it nasally
(to achieve better postoperative centration); be prepared to do whatever necessary to enhance eyes afterwards (eg, AK,
piggyback lens, laser vision correction)
|
| Billing considerations: physician being paid additionally for presbyopia examination; if patient not good candidate for PC-
IOL after examination, some surgeons charge full fee for first eye (at speaker’s clinic, those patients charged 60% of
cost); financial explanation sheets recommended (detail Medicare coverage vs patient’s responsibility; also clarify that
additional charges of physician/surgeon are distinct from additional charges of medical facility); make it easy for patient
to pay before surgery (eg, credit cards, medical credit, payment plans, cash discounts)
|
| STRATEGIES FOR ENHANCING PRODUCTIVITY IN THE ASC
|
| Before day of surgery: experienced team assembled and in position; all paperwork completed (history and physical examination;
preoperative orders; discharge instructions; for standard cataract patients, surgical note completed in advance);
on day of surgery, simply check and initial or sign paperwork and charts (any deviation from normal procedure noted at
that time)
|
| Master list: typed on index card and kept in surgeon’s pocket; list duplicated and placed everywhere in ASC (eg, posted on
equipment, on nurses’ and surgeon’s desks); lists patient information (name; check-in time; procedure; type of anesthesia;
style and power of IOL being implanted)
|
| In ASC reception room: patient signs consent form during check-in; operative eye marked with red dot over brow; dilation
drops initiated (more comfortable for patients to sit with family during this process; dilation becomes “indelible
mark” for site of surgery); always make sure patient goes to bathroom before being escorted to preoperative room
|
| Preoperative preparation: patient placed comfortably on gurney; foot sheet with all relevant patient information
prominently displayed; all monitors for procedure mounted on platform at foot of bed, so that they move with patient
(nothing has to be disconnected or reconnected); knee pillow (takes pressure off patient’s back); warm blankets;
lopsided pillow for patients undergoing temporal procedure
|
| Foot sheet information: includes patient name, procedure, physician’s name, whether there will be viewing of case, allergies,
and important systemic conditions
|
| Anesthesia: speaker uses topical anesthesia with intracameral lidocaine and intravenous (IV) sedation in >90% of patients;
propofol titration as needed in 1–mL doses (typically gives 1 mL in preoperative room and another dose once patient
moved to operating room [OR]); reserves midazolam for highly anxious and younger patients (avoids in elderly patients
because longer acting and more likely to induce somnolence); advocates use of “deep topical” (holding eyelid open while
applying 3-4 drops of tetracaine [eg, TetraVisc] to eye; hold lid open for 1-2 min so solution has time to “really soak into”
conjunctiva; once this has taken effect, put topical 5% povidone iodine [Betadine] on eye and urge patient to rest with
eyes closed); speaker uses peribulbar blocks in 10% of patients (indicated for “movers and shakers” and complicated
cases); usually gives 4-mL IV push of propofol; follows with 2% lidocaine without epinephrine or with bupivacaine (eg,
Marcaine), but with hyaluronidase; usually injects 6 to 7 mL while palpating orbit (single site/single injection method
very effective for obtaining good block); speaker uses tape to keep eye closed and instructs patient to remove tape carefully
4 hr after discharge
|
| In OR: place bed diagonally (maximizes amount of space and circulation around head of patient); “time out” occurs while
scrubbing and preparing patient’s eye (circulating nurse, surgeon, and scrub technician visually and verbally confirm eye
and IOL being implanted); use space-saving devices as much as possible (eg, large flat-panel monitor in corner of room,
small table-top sterilizers, in-wall cupboards with glass faces and clearly labeled drawers); prepare all syringes before
first case brought into OR (speaker splits 2% hydroxypropyl methylcellulose [Ocucoat] and sodium hyaluronate/chondroitin
sulfate [Viscoat] into separate syringes to create “poor man’s DuoVisc”; also prepares 0.50 mL of preservative-
free 1% lidocaine); keep syringes in sterile metal covered tray; never use hot phacoemulsification handpiece (after sterilization,
handpieces placed in sterile metal covered tray for later use)
|
| Family viewing room: use camera setup to visually bring family into OR with patient (reassuring to patient and family;
generates positive perception of procedure); achievable by direct viewing through window from adjacent room or via
cameras and monitors in distant room; consider having patient-family liaison present with family during surgery; audio
contact with surgeon helpful; in speaker’s facility, room camera, microscope camera, and video monitors used throughout
(ie, in OR, viewing room, and preoperative room); video input/output controlled by computer central processing unit
|
| Surgical pearls: use 0.8-mm blunt-sided diamond knife to create paracentesis and to fixate eye when making keratome incision;
attach cystotome to end of viscoelastic (VE) syringe (allows surgeon to go into eye and simultaneously instill VE
material, and then simply rotate syringe and begin capsulorrhexis with cystotome)
|
| Practical tip for increasing OR efficiency: if OR has one scrub technician and one circulating registered nurse, throughput
can be doubled by adding one more technician (machine technician); technicians can trade off on alternate cases (using
this technique, speaker able to do 6 cases/hr in 2 ORs with 2 operating crews or 5 cases/hr in one OR with one crew);
many benefits to having 2 surgical technicians in OR
|
| Postoperative patient-family counseling room: time-saving for nurse in postoperative area; family joins patient for counseling
(minimizes time patient separated from family before and after surgery; also, family hears postoperative instructions
along with patient); opportune time for snack and coffee (to ensure patient feeling well before leaving facility);
excellent private area for surgeon’s discussion with patient and family in complicated cases
|
| New payment regulations from CMS: begin January 2008; will be phased in over 4 yr; rate of reimbursement for ASC to
be linked to rate for HOPDs (ASCs will be paid 65% of HOPD rate for same procedures); annual cost-of-living adjustments
to ASC rates to begin in 2010; procedure list now eliminated for ASCs
|
| Speaker’s tips on building and selling an ASC: prepare for worst case scenario; be sure of case volume before building
facility; larger ORs better (more circulation space); consider building 2 ORs (even if one not finished; ceiling-mounted
microscopes good for practice but hamper resale; consider installing piping for oxygen
|
| Concluding advice: constantly reevaluate procedures (consider what can be done better for patients, staff, and surgeons;
remember that faster not synonymous with better); join and attend meetings of Outpatient Ophthalmic Surgery Society
(OOSS); enlist advice of staff in each area; adopt philosophy of constant quality improvement
|
Suggested Reading
Alfonso JF et al: Correlation of pupil size with visual acuity and contrast sensitivity after implantation of an apodized diffractive
intraocular lens. J Cataract Refract Surg 33:430, 2007; Alfonso JF et al: Prospective visual evaluation of apodized
diffractive intraocular lenses. J Cataract Refract Surg 33:1235, 2007; Alió JL et al: Near vision restoration with refractive
lens exchange and pseudoaccommodating and multifocal refractive and diffractive intraocular lenses: comparative clinical
study. J Cataract Refract Surg 30:2494, 2004; Bellucci R: Multifocal intraocular lenses. Curr Opin Ophthalmol 16:33,
2005; Blaylock JF et al: Visual and refractive status at different focal distances after implantation of the ReSTOR multifocal
intraocular lens. J Cataract Refract Surg 32:1464, 2006; Chiam PJ et al: ReSTOR intraocular lens implantation in cataract
surgery: quality of vision. J Cataract Refract Surg 32:1459, 2006; Cumming JS: Performance of the crystalens. J
Refract Surg 22:633, 2006; Cumming JS et al: Clinical evaluation of the Crystalens AT-45 accommodating intraocular
lens: results of the U.S. Food and Drug Administration clinical trial. J Cataract Refract Surg 32:812, 2006; Dick HB: Accommodative
intraocular lenses: current status. Curr Opin Ophthalmol 16:8, 2005; Dick HB, Dell S: Single optic accommodative
intraocular lenses. Ophthalmol Clin North Am 19:107, 2006; Doane JF, Stechschulte SU: Accommodating
intraocular lenses--a solution for presbyopia. Mo Med 102:59, 2005; Hütz WW et al: Reading ability with 3 multifocal intraocular
lens models. J Cataract Refract Surg 32:2015, 2006; Lane SS et al: Multifocal intraocular lenses. Ophthalmol
Clin North Am 19:89, 2006; Macsai MS et al: Visual outcomes after accommodating intraocular lens implantation. J Cataract
Refract Surg 32:628, 2006; Mamalis N: Additional payments for presbyopia-correcting intraocular lenses. J Cataract
Refract Surg 31:1467, 2005; Olson RJ et al: New intraocular lens technology. Am J Ophthalmol 140:709, 2005; Pepose JS
et al: Visual performance of patients with bilateral vs combination Crystalens, ReZoom, and ReSTOR intraocular lens implants.
Am J Ophthalmol 144:347, 2007; Pineda-Fernández A et al: Refractive outcomes after bilateral multifocal intraocular
lens implantation. J Cataract Refract Surg 30:685, 2004; Souza CE et al: Visual performance of AcrySof ReSTOR
apodized diffractive IOL: a prospective comparative trial. Am J Ophthalmol 141:827, 2006; Steinert RF: Visual outcomes
with multifocal intraocular lenses. Curr Opin Ophthalmol 11:12, 2000; Toto L et al: Visual performance and biocompatibility
of 2 multifocal diffractive IOLs: six-month comparative study. J Cataract Refract Surg 33:1419, 2007; Versteeg FF:
Multifocal IOLs for presbyopia. J Cataract Refract Surg 31:1266, 2005.
Educational Objectives
| The goal of this program is to improve management of anterior segment/cataract surgery (through greater understanding of
presbyopia-correcting intraocular lenses [PC-IOLs]), and to improve efficiency at ophthalmic ambulatory surgical centers
(ASCs). After hearing and assimilating this program, the clinician will be better able to:
|
| 1. Precisely define PC-IOL.
|
| 2. Describe advantages and disadvantages of currently available PC-IOLs.
|
| 3. Decide whether to mix or match IOLs to achieve the best results and greatest and patient satisfaction.
|
| 4. Perform an extensive presbyopia examination to determine whether the patient is a good candidate for PC-IOLs.
|
| 5. Improve efficiency at his or her ASC before, during, and after surgery
|
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and planning committee
members to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of
interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and
not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to
disclose.
Acknowledgements
Dr. Arnold was recorded at the 6th Annual Downeast Ophthalmology Symposium, held September 28-30, 2007, in Bar Harbor,
ME, and sponsored by the Maine Society of Eye Physicians and Surgeons. The Audio-Digest Foundation thanks Dr. Arnold
and the Maine Society of Eye Physicians and Surgeons for their cooperation in the production of this program.
|
