Eyeworld

EW FEATURE 106 Refractive options March 2015 Centers, Kansas City, Mo., however, there are no attributes of the inlays that make him prefer them over monovision. "A pinhole will create increased depth of focus. Certain levels of asphericity and spherical aberration can also increase the range of usable vision. With the latter 2 there can and will always be a trade-off in the quality of the image," he said. "Quality of vision and contrast sen- sitivity will be negatively affected. Conversely, one can maintain quali- ty of vision by utilizing monovision or setting one eye for near focus, i.e., a –2 D residual refractive error." With monovision, the trade-off is that for some patients, fusion is disrupted and some brains will not tolerate this, he said. "Probably close to 30% of patients cannot accept monovision," he said. "For the 70% that do, best distance vision will be reduced [to] a certain degree." Finally, there may be scotopic, unwanted imagery so bothersome that spectacles may be necessary— thereby depleting the advantages of surgery in the first place, he said. Dr. Thompson said he rarely has a patient who wants to have the inlay removed, certainly fewer than those with monovision who want the effect reversed. "The main reason is because in- lays give not only good near and in- termediate effect, but they preserve distance better. You're not dealing with such distance blur, so there's high patient satisfaction," he said. The "whole basis of corneal inlays is to be able to have 20/20 distance vision, but still have a read- ing eye," Dr. Thompson said. "Like a multifocal implant after surgery, that gives you 20/20 distance and good near." Monovision in a 55-year-old often means targeting –1.5 D to –2 D, Dr. Thompson said. Inlays do not require blurring distance nearly as much as this level of monovision does. Inlays provide good binocular distance vision, as they do not inter- fere with distance, and "very good reading vision," Dr. Whitman said. For him, the biggest drawback is that any of the known potential com- plications with making LASIK flaps exist for the inlays, as the KAMRA is placed in a pocket under a flap, and the Raindrop is placed directly under the LASIK flap. The Flexivue comes in different powers, which Dr. Whitman thinks may be a disadvantage. "As people age, our power needs change," he said. "So what happens 5 years after the Flexivue is implanted? A lens exchange? I don't think that's the best platform. The KAMRA and the Raindrop do not depend on a power to work." Dr. Doane said the ease of re- moval, exchange, and repositioning are all welcome features in an inlay, but unacceptable vision or actual biologic incompatibility "may not be noticed in the first 6 months. It is important to assess biological compatibility 12–24 months after implantation," he said. Some patients are simply going to develop an inflammatory reaction, Dr. Whitman said. "We can try to treat that with steroids, but for some patients, inflammation will persist." Dr. Doane said: "These products run a 24/7/365 risk of acute inter- vention. Corneal surgeons need to become corneal internists—always ready with medicines to calm down the eye." Not every patient will have such a dire reaction, "but it is a certain percentage, and every doctor will, in time, find his or her number." Surgeons need to remember that "the inlay is still an implant," Dr. Thompson said. "Watch the patient for any dry eye symptoms because inlays do their best when tear film is healthy," he said. Even with all the potential negatives, Dr. Whitman said "there's no comparison in terms of binocular vision improvement. It's a dramatic leap forward versus monovision." Anterior segment specialists have had "the exact same argument at every meeting. What's better: multifocal vision or monovision or modified monovision? It turns out that all 3 can work well. There isn't a right answer. You just need to understand the differences," Dr. Lindstrom said. EW Editors' note: Drs. Lindstrom and Thompson have financial interests with AcuFocus. Dr. Doane has no financial interests related to his comments. Dr. Whitman has financial interests with ReVision Optics. Contact information Doane: jdoane@discovervision.com Lindstrom: rllindstrom@mneye.com Thompson: vance.thompson@vancethompsonvision.com Whitman: whitman@keywhitman.com increases the [circumlental space], thus tightening the zonules that hold the lens in place. With proper tension on the zonules, the ciliary muscles can once again manipulate and change the shape of the lens to focus on near objects." Pros and cons For John Doane, MD, FACS, in private practice at Discover Vision Correcting presbyopia continued from page 104 VERION ™ REFERENCE UNIT AND VERION ™ DIGITAL MARKER IMPORTANT PRODUCT INFORMATION CAUTION: Federal (USA) law restricts this device to sale by, or on the order of, a physician. INTENDED USES: The VERION ™ Reference Unit is a preoperative measurement device that captures and utilizes a high-resolution reference image of a patient's eye in order to determine the radii and corneal curvature of steep and flat axes, limbal position and diameter, pupil position and diameter, and corneal reflex position. In addition, the VERION ™ Reference Unit provides preoperative surgical planning functions that utilize the reference image and preoperative measurements to assist with planning cataract surgical procedures, including the number and location of incisions and the appropriate intraocular lens using existing formulas. The VERION ™ Reference Unit also supports the export of the high-resolution reference image, preoperative measurement data, and surgical plans for use with the VERION ™ Digital Marker and other compatible devices through the use of a USB memory stick. The VERION ™ Digital Marker links to compatible surgical microscopes to display concurrently the reference and microscope images, allowing the surgeon to account for lateral and rotational eye movements. In addition, the planned capsulorhexis position and radius, IOL positioning, and implantation axis from the VERION ™ Reference Unit surgical plan can be overlaid on a computer screen or the physician's microscope view. CONTRAINDICATIONS: The following conditions may affect the accuracy of surgical plans prepared with the VERION ™ Reference Unit: a pseudophakic eye, eye fixation problems, a non-intact cornea, or an irregular cornea. In addition, patients should refrain from wearing contact lenses during the reference measurement as this may interfere with the accuracy of the measurements. Only trained personnel familiar with the process of IOL power calculation and astigmatism correction planning should use the VERION ™ Reference Unit. Poor quality or inadequate biometer measurements will affect the accuracy of surgical plans prepared with the VERION ™ Reference Unit. The following contraindications may affect the proper functioning of the VERION ™ Digital Marker: changes in a patient's eye between preoperative measurement and surgery, an irregular elliptic limbus (e.g., due to eye fixation during surgery, and bleeding or bloated conjunctiva due to anesthesia). In addition, the use of eye drops that constrict sclera vessels before or during surgery should be avoided. WARNINGS: Only properly trained personnel should operate the VERION ™ Reference Unit and VERION ™ Digital Marker. Only use the provided medical power supplies and data communication cable. The power supplies for the VERION ™ Reference Unit and the VERION ™ Digital Marker must be uninterruptible. Do not use these devices in combination with an extension cord. Do not cover any of the component devices while turned on. Only use a VERION ™ USB stick to transfer data. The VERION ™ USB stick should only be connected to the VERION ™ Reference Unit, the VERION ™ Digital Marker, and other compatible devices. Do not disconnect the VERION ™ USB stick from the VERION ™ Reference Unit during shutdown of the system. The VERION ™ Reference Unit uses infrared light. Unless necessary, medical personnel and patients should avoid direct eye exposure to the emitted or reflected beam. PRECAUTIONS: To ensure the accuracy of VERION ™ Reference Unit measurements, device calibration and the reference measurement should be conducted in dimmed ambient light conditions. Only use the VERION ™ Digital Marker in conjunction with compatible surgical microscopes. ATTENTION: Refer to the user manuals for the VERION ™ Reference Unit and the VERION ™ Digital Marker for a complete description of proper use and maintenance of these devices, as well as a complete list of contraindications, warnings and precautions. ORA ™ SYSTEM IMPORTANT PRODUCT INFORMATION CAUTION: Federal (USA) law restricts this device to sale by, or on the order of, a physician. INTENDED USE: The ORA ™ System uses wavefront aberrometry data in the measurement and analysis of the refractive power of the eye (i.e. sphere, cylinder, and axis measurements) to support cataract surgical procedures. CONTRAINDICATIONS: The ORA ™ System is contraindicated for patients: • who have progressive retinal pathology such as diabetic retinopathy, macular degeneration, or any other pathology that the physician deems would interfere with patient fixation; • who have corneal pathology such as Fuchs', EBMD, keratoconus, advanced pterygiumim pairing the cornea, or any other pathology that the physician deems would interfere with the measurement process; • whose preoperative regimen includes residual viscous substances left on the corneal surface such as lidocaine gel or viscoelastics; • with visually significant media opacity (such as prominent floaters or asteroid hyalosis) what will either limit or prohibit the measurement process; or • who have received retro or peribulbar block or any other treatment that impairs their ability to visualize the fixation light. In addition, utilization of iris hooks during an ORA ™ System image capture is contraindicated, because the use of iris hooks will yield inaccurate measurements. WARNINGS AND PRECAUTIONS: • Significant central corneal irregularities resulting in higher order aberrations might yield inaccurate refractive measurements. • Post refractive keratectomy eyes might yield inaccurate refractive measurement. • The safety and effectiveness of using the data from the ORA ™ System have not been established for determining treatments involving higher order aberrations of the eye such as coma and spherical aberrations. • The ORA ™ System is intended for use by qualified health personnel only. • Improper use of this device may result in exposure to dangerous voltage or hazardous laser-like radiation exposure. • Do not operate the ORA ™ System in the presence of flammable anesthetics or volatile solvents such as alcohol or benzene, or in locations that present an explosion hazard. ATTENTION: Refer to the ORA ™ System Operator's Manual for a complete description of proper use and maintenance of the ORA ™ System, as well as a complete list of contraindications, warnings and precautions. © 2014 Novartis 12/14 ORA14059JAD-A

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