Eyeworld

EW FEATURE 38 by Faith A. Hayden EyeWorld Staff Writer Implantable telescope gives hope to end-stage AMD patients Device, part of a first-ever treatment plan, approved by FDA, and Medicare applies I magine being told by one es- teemed ophthalmologist after the next that there's no hope— that the end-stage AMD wreak- ing havoc on your eyes, your vision, and your entire life, is irre- versible. Imagine being told that you'll never see the faces of your grandchildren, you'll never again read a book or a newspaper, and you'll always need assistance pour- ing coffee. For most end-stage AMD pa- tients, this is the prognosis. But now, thanks to an implantable miniature telescope approved by the FDA and reimbursed by Medicare, it doesn't always have to be. Developed by VisionCare Ophthalmic Technologies (Saratoga, Calif.), the mini telescope is inserted into one eye by a cornea specialist. The implant enlarges images by ap- proximately 2.2 or 2.7 times their normal size and projects them into healthier areas of the retina instead of the macula alone. This reduces the blind spot and allows the patient to better view objects that were pre- viously unrecognizable. "There can be complications, which is why the device is restricted to cornea-trained surgeons," said Kathryn A. Colby, M.D., Massachu- setts Eye and Ear Infirmary, Boston. The procedure is complex, requiring proper wound construction, anterior chamber management, and device insertion after phacoemulsification for a successful surgery. Complica- tions include surgical trauma to the corneal endothelium. "It's critical that surgeons not view this first-of-a-kind device sim- ply as a larger IOL," stated an article written by Dr. Colby in the Archives of Ophthalmology (2007; 125(8):1118- 1121). "One must create an ade- quately large incision at the limbus, use an appropriately steep down- ward entry angle to avoid corneal touch, and make a large-diameter (>7-mm) capsulorhexis to accommo- date the stiff haptics of the carrier plate with minimal intraoperative manipulation. Meticulous attention should be paid to surgical detail to avoid iris prolapse and a flat anterior chamber." The surgery, though, is just the beginning. Like a knee or hip re- placement, the patient has to go through months of physical, or in this case visual, rehabilitation to learn how to use this new vision in everyday activities "The brain isn't used to seeing one large image and one regular-size image," said Susan A. Primo, O.D., M.P.H., F.A.A.O., director, Vision and Optical Services, Emory Eye Center, Atlanta. "Patients are not really using two eyes at the same time, they're using one eye for detail and specific activities, that's the tele- scope eye, and the fellow eye, which is the non-implanted eye, for walk- ing around and other activities like going up and down stairs." This rehab process, called the CentraSight treatment program, in- volves a comprehensive team of doc- tors including a retina surgeon, cornea surgeon, low-vision special- ist, and occupational therapist, and four distinct steps: diagnosis, candi- date screening, implantation, and rehabilitation. Candidate screening is critical, and doctors interviewed estimate that only 25% of those screened will continue on to implan- tation. "There's many things in the an- terior segment of the eye that would eliminate them as candidates," said February 2011 What's ahead in 2012 December 2011 T he Monthly Pulse Survey for Decem- ber clearly underscores the interest ophthalmic surgeons have in new technology. Not surprisingly, cost is the overriding concern for introducing femto cataract surgery into our practices. IOLs continue to evolve, and premium lenses that are only available outside of the U.S. are a continuing source of frustration for American surgeons and our patients alike. In our survey, limbal relaxing incisions are used by only 11% of surgeons, demonstrating the overwhelming accept- ance of toric IOLs for patients with astig- matism. The jury is still out on corneal inlays for presbyopia, but we look forward to learning more about this option as the international experience continues to accumulate. – John A. Vukich, M.D., international editor T he Monthly Pulse Survey has covered some very interesting topics, and there are a lot of take-home messages from it. When we look at femto cataract surgery, the reality is the cost. The issue is not only of buying costly equipment but also of the cost per case that will hit the doctor and the patient. This comes out very clearly in the survey. Another issue is whether the technology has gotten to a level where it can replace phaco. The an- swer to that is obviously no. As far as IOL technology, every ophthalmologist would like to have the latest and most useful IOLs in his armamentarium. In India we have access to all these IOLs like the toric phakic and multifocal IOLs, and they are a real boon to the patients. Coming to the third question on toric IOLs, once again, they have definitely made a huge impact on our results. They are also easier to im- plant, and it is very clear in the survey that doctors want this technology. In the final question of corneal inlays, the re- sponse is clear that one needs more time with corneal inlays to make a final call. All in all, this survey tells us the direction high-tech ophthalmology is moving in and helps us keep pace with it. –Amar Agarwal, M.S., F.R.C.S., F.R.C.Ophth. T he femto cataract surgery hype is cre- ating a lot of buzz at international congresses. But the big question is, who is going to pay for this exciting tech- nology? The future will tell us how suc- cessful this new technology will be. The second question concerning IOLs not available in the U.S. raises some interest- ing thoughts. All of these lenses have ter- rific indications and have proved their efficacy and safety for patients and broaden the range for surgeons to correct higher degrees of astigmatism. Toric IOLs, if properly positioned in the eye, correct astigmatism effectively and are not sub- ject to loss of correction over time, like LRIs. Last but not least is presbyopia cor- rection, the holy grail of ophthalmology. We can partially get rid of reading glasses with corneal inlays, but we need to pro- vide patients with adequate expectations about this technology. The big advantage is its reversibility. It's obvious that many surgeons are still not familiar enough with this technology. –Erik L. Mertens, M.D. Monthly Pulse Keeping a Pulse on Ophthalmology The implantable miniature telescope and vision treatment program can help some end-stage AMD patients Source: VisionCare Ophthalmic Technologies AT A GLANCE • The implantable miniature telescope can help some end- stage AMD patients regain functional vision • The telescope is not for everyone and includes many contraindica- tions • The telescope has been approved for use in the U.S. by the FDA, and Medicare applies

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