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Optometric Certification Course for the Visian ICL

Optometric Certification Course for the Visian ICL. Offering patients the latest refractive procedure: The Visian Implantable Contact Lens. C. Dan Siapco, MD North Cascade Eye Associates Mount Vernon, WA. Course Objectives . Identify appropriate ICL patients

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Optometric Certification Course for the Visian ICL

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  1. Optometric Certification Course for the Visian ICL Offering patients the latest refractive procedure: The Visian Implantable Contact Lens C. Dan Siapco, MD North Cascade Eye Associates Mount Vernon, WA

  2. Course Objectives • Identify appropriate ICL patients • Identify who does NOT qualify for the ICL • Appropriately manage postoperative ICL patients • Refer ALL ICL patients to our center* *shameless self-promotion

  3. Optometric Certification Course • First of its kind presented in the US • BDP is committed to education and training of surgeons and optometrists in new technology • Surgeons • MD certification course & live surgery • Comanagement of ICL patients needs to occur as numbers of patients increase

  4. ICL in the Public Arena • Today Show • Much more to come • Need to be ready to answer questions and be familiar with the technology • Patients increasingly asking for ICL vs LASIK

  5. Our Experience • FDA Investigators for clinical trials in 1997 • We are the highest volume ICL surgical practice in the world • Hosted surgeons seeking refinement of techniques • Speaker at US and international conferences • Goal is to provide patients a VIP experience

  6. Refractive Surgery • Review of classical approaches

  7. Evolution of Refractive Surgery ICL • The Visian ICL represents a major step in the evolution of refractive surgery LASIK Cataract/ IOL

  8. Background on the ICL • Phakic intraocular lens (PIOL, ICL, etc) • Posterior chamber lens implant—behind iris, anterior to crystalline lens • Collamer material very biocompatible

  9. Background on the ICL • Excellent visual outcomes • Minimal healing time • Minimal postoperative restrictions • Remarkably low risk of complications

  10. Comparison to Verisyze • Invisible in the eye to the patient and observers Verisyse Visian ICL

  11. Identifying the Ideal ICL Candidate

  12. Identifying the Ideal ICL Candidate • Topography • Pachymetry • Higher Rx • Pupil Size • Visual Demands • Medical Conditions

  13. 1) Topography Questionable or suspicious topography (forme fruste keratoconus, etc)

  14. 1) Topography No question topography—Keratoconus

  15. 2) Marginal Corneal Thickness • Thin pachymetry • LASIK tissue ablation must leave a residual untreated bed of 250µ (275 µ at BDPEC) • Consider future enhancements in higher corrections, especially in younger patients

  16. LASIK Plans • 6.5 mm pupil • -7.50 +0.75 x 178 • 519 micron cornea 7.0 mm treatment zone 120µ IntraLase flap 122µ ablation required 519µ - 120µ = 399µ - 122µ = 277µ bed • Much more concerning when the patient is 22 years old and may likely require future enhancements

  17. What about PRK in these patients? • Compared to PRK, the ICL offers •Much quicker visual recovery—1 day vs 1 month •Absence of pain vs up to 1 week of intense pain •No fluctuating vision vs 1 month of back-and forth •Postoperative regimen is EXQUISITELY simple compared to PRK Steroids Antibiotic

  18. What about PRK in these patients? • PRK is a practice killer • PRK patients don’t refer other PRK patients • PRK patients always wonder if they made the right choice • Managing postop PRK can be very difficult

  19. 3) Higher Correction Patients with -6.00 diopters or more have the ICL recommended as a procedure of choice, due to the greater quality of vision this offers

  20. 4) Large Pupils • If the pupil is larger than 7.0 mm , the ICL is recommended as the procedure of choice --Glare & halos inconsequential compared to LASIK

  21. 5) Higher Visual Demands • Patients with higher visual expectations (engineers, professional drivers, etc.) -need quicker visual recovery -expect improved quality of vision -require less halos at night • ICL candidates, even at less than -6.00 correction

  22. 5) Higher Visual Demands • National Geographic photographer • Military sniper trainer • Radiology personnel • FBI agent --all could have LASIK, but opted for ICL for better visual quality

  23. 6) Medical Contraindications Strongly consider the ICL in these patients • Dry eyes • Collagen vascular disease • Fibromyalgia • Cheloid formers • Aborted LASIK flaps • Engineering background

  24. Refractive Considerations • The myopic ICL is approved for -3 to -20 refractive errors, with up to 1.50 diopters of cylinder • ICL patients typically tolerate residual refractive error much betterthan LASIK patients. • Patients with postoperative refractive error may consider LASIK enhancement over the ICL

  25. Patient Outcomes

  26. After ICL After LASIK Quality of Vision • Simulation of quality of vision having equal treatment with the ICL and LASIK based on higher order aberrometry (-7.0D treatment)

  27. High Definition Vision from Edwin J. Sarver, PhD; Donald R. Sanders, MD, PhD; John A. Vukich, MD Comparison of Image Quality for High Myopes Corrected with Laser in situ Keratomileusis and Phakic Intraocular Lens

  28. LASIK vs ICL 1 Day Postop • LASIK Patient “e…v…o…t…z…2, but when is it going to clear up?” • ICL Patient “Oh my gosh, I’ve never seen like this in my life!” Significant “WOW!” factor

  29. Risks of ICL Surgery

  30. Risks—General • Cataract • 1.3% in FDA Study over 8 years • 0.3% in patients younger than 45, less than -13 Rx • Pupillary block glaucoma • Relieves with pupillary dilation • Iridectomy performed as part of ICL procedure

  31. Risks—General • Endothelial cell loss • No cases of clinical significance • Endophthalmitis • Only 1 confirmed case in over 80,000 ICLs • Patient suffered no visual loss

  32. Risks—Sizing of Lens • Four ICL sizes • Based on white-to-white measurement or sulcus-to-sulcus from B-scan • 12.2mm, 12.6mm, 13.2mm, 13.7mm

  33. Risks of ICL Surgery—Sizing of Lens • Sizing too large (excessive vault) • Narrowing of angle, crowding of iris and chamber • IOP elevation • Consider exchanging for shorter ICL

  34. Risks of ICL Surgery—Sizing of Lens • Sizing too short (shallow or absent vault) • Lens rests on anterior capsule • Theoretical risk of cataract formation • Patients with zero vault many years post ICL show no cataract • Consider exchanging for longer ICL

  35. Preoperative Evaluation

  36. Preoperative Screening • Myopia -3.00 to -20.00 • +/- astigmatism • Topography • Anterior chamber depth (ACD) • 3.0mm FDA approval • On A-scan subtract pachymetry from ACD for true ACD

  37. Contraindications • No previous refractive surgery • Progressive refractive error • Corneal/Endothelial pathology • Glaucoma • Narrow AC angle • Cataract or capsular opacification • AC Depth < 3.0mm

  38. Contraindications • History of: • Iritis • Synechiae • Pigment dispersion • Pseudoexfoliation • Low/abnormal endothelial cell count per age range • Keratoconus – Some data to support this may be an excellent alternative • Patients under age 21 (off-label)

  39. Postoperative Evaluation

  40. Postoperative Evaluation • Vision • IOP • Slit Lamp Examination

  41. Slit Lamp Examination • Slit Lamp Examination • Patency of PI • No inflammation, chamber formed • Round Pupil • Vault

  42. Assessing the Vault • Dark or clear space between ICL and crystalline lens • Aqueous space • Measured in percentage of corneal thickness • “Perfect” vault is 100% • Good vault is approximately 50-150%, but can be less or more

  43. Assessing the Vault • ICL is extremely compatible with ocular tissues, even at extremes of vault • Rarely has to be exchanged

  44. Postoperative Instructions • Exquisitely simple! • Pred qid for 1-2 weeks • Vigamox qid for 1-2 weeks • Shield or goggles at bedtime for 3 days

  45. Conclusion • The Visian ICL represents the latest evolution of refractive surgery • Pushes refractive surgery into the realm of phakic intraocular procedures • Bridges the gap for patients who previously were not candidates for any refractive procedures • Raises the bar for improved visual acuity even in patients who are LASIK candidates

  46. A Life-Changing Experience • My highest myope treated with ICL is -18.00 • She was functionally debilitated by myopia • Unable to wear contact lenses due to dry eyes • Is now 20/15 uncorrected • Declares emphatically that the ICL has “changed my life!” • Is busy handing out business cards to anybody who wears glasses, regardless of their Rx

  47. Educating Your Patients • Successful communication of what is best for the patient • High Definition Vision • Use the visianinfo.com website • Use previous ICL patients—best ambassadors for your practice • STAAR marketing & consultation support

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