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«assoCiate editors steven J. dell, Md dell laser ConsUltants texan eye aUstin, texas Warren e. hill, Md east valley oPhthalMology Mesa, arizona ...»

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Mastering refractive iOLs:

the art and science

Chief editor

david f. Chang, Md

CliniCal Professor, University of California

san franCisCo, Ca

assoCiate editors

steven J. dell, Md

dell laser ConsUltants

texan eye

aUstin, texas

Warren e. hill, Md

east valley oPhthalMology

Mesa, arizona

riChard l. lindstroM, Md

Minnesota eye ConsUltants

BlooMington, Mn

Kevin l. Waltz, od, Md

eye sUrgeons of indiana

indianaPolis, in

Delivering the best in health care information and education worldwide www.slackbooks.com ISBN: 978-1-55642-859-3 Copyright © 2008 by SLACK Incorporated All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publisher, except for brief quotations embodied in critical articles and reviews.

The procedures and practices described in this book should be implemented in a manner consistent with the professional standards set for the circumstances that apply in each specific situation. Every effort has been made to confirm the accuracy of the information presented and to correctly relate generally accepted practices. The authors, editor, and publisher cannot accept responsibility for errors or exclusions or for the outcome of the material presented herein. There is no expressed or implied warranty of this book or information imparted by it. Care has been taken to ensure that drug selection and dosages are in accordance with currently accepted/recommended practice. Due to continuing research, changes in government policy and regulations, and various effects of drug reactions and interactions, it is recommended that the reader carefully review all materials and literature provided for each drug, especially those that are new or not frequently used. Any review or mention of specific companies or products is not intended as an endorsement by the author or publisher.

SLACK Incorporated uses a review process to evaluate submitted material. Prior to publication, educators or clinicians provide important feedback on the content that we publish. We welcome feedback on this work.

Contact SLACK Incorporated for more information about other books in this field or about the availability of our books from distributors outside the United States.

Published by: SLACK Incorporated 6900 Grove Road Thorofare, NJ 08086 USA Telephone: 856-848-1000 Fax: 856-853-5991 www.slackbooks.com Library of Congress Cataloging-in-Publication Data Mastering refractive IOLs : the art and science / chief editor, David F. Chang.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-1-55642-859-3 (alk. paper)

1. Intraocular lenses. I. Chang, David F., 1954DNLM: 1. Lens Implantation, Intraocular--methods. WW 358 M423 2008] RE988.M37 2008 617.7’1--dc22 For permission to reprint material in another publication, contact SLACK Incorporated. Authorization to photocopy items for internal, personal, or academic use is granted by SLACK Incorporated provided that the appropriate fee is paid directly to Copyright Clearance Center.

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–  –  –

This textbook highlights the latest advances in refractive IOL technology and surgery. No longer satisfied with simply treating cataracts, our efforts are now focused on reversing lens aging through the pseudophakic correction of presbyopia. Amidst such exciting advances, it is easy to forget that the greatest challenge in the field of cataract and IOL surgery continues to be the staggering and increasing backlog of cataract blindness in developing countries.

Modern phacoemulsification machines are expensive to purchase and maintain, incur relatively high disposable costs, and require extensive surgical training. Furthermore, for the more advanced and mature cataracts typical of underserved populations, performing phacoemulsification becomes more difficult and complication prone. What is needed is a high-volume, cost-effective, “low tech” procedure that can treat the most advanced of cataracts with a low complication rate in the shortest amount of time.

This very goal is being achieved in a handful of international programs that are providing a hopeful paradigm for overcoming cataract blindness worldwide. I have had the privilege of visiting and collaborating with doctors at both the Aravind Eye Hospital network in Southern India, and the Tilganga Eye Center in Kathmandu, Nepal. Observing first-hand how these 2 systems provide low-cost, high-volume and quality cataract surgery is an awe-inspiring experience for any visiting ophthalmologist.

Founded in 1976 by the legendary Dr. G. Venkataswamy, Aravind Eye Hospital has grown into a network of 5 regional eye hospitals providing high-level ophthalmic care to the poor population of Southern India. Private paying patients comprise approximately 30% of their patient base. This revenue funds the 70% of Aravind’s services that are provided at no cost to the indigent via a financially self-sustaining program that receives minimal government reimbursement. In terms of cataract surgery, this means that of the approximately 200,000 procedures performed annually in the Aravind system, 70% are provided for free.

While private cataract patients at Aravind may pay anywhere from $200 to $300 to undergo phacoemulsification with foldable IOLs imported from the United States, the nonpaying cataract patients are treated for less than $15 per case, including the IOL. This is accomplished by performing a manual, sutureless, small incision extracapsular procedure with reusable equipment and supplies. Their IOL manufacturing facility, Aurolab, produces PMMA IOLs for less than $5 per lens. Following a retrobulbar block, the nucleus is expressed through a capsulorrhexis and a temporal, self-sealing 6.0- to 6.5-mm scleral pocket incision.

Manual cortical cleanup precedes capsular bag implantation of a square edge PMMA IOL. The technique is commonly abbreviated as manual SICS (small incision cataract surgery).

While the procedure itself seems straightforward, it is the stunning speed, skill, and efficiency with which it is performed that must literally be seen to be believed. By alternating between 2 parallel operating room tables, a single surgeon is able to perform over 15 cases per hour by consistently completing sub-5-minute procedures on the densest of cataracts with no intervening turnover time. To ensure efficiency across different surgical teams, every aspect of the procedure is standardized, from preoperative patient and instrument preparation to the surgical steps themselves. Having been screened in outlying rural eye camps, as many as 300 to 400 cataract patients will be bused to a regional Aravind eye hospital where they will all undergo their surgery on one single day. After several days of in-house follow-up, they are transported back to their rural villages where a local postoperative visit and refraction are performed 1 month later by the Aravind staff.

Founded in 1994 by Dr. Sanduk Ruit, the Tilganga Eye Center is a shining example of an efficient eye care delivery system on a smaller scale. Dr. Ruit has developed his own variation of the manual, sutureless SICS. Our prospective randomized trial comparing phaco and manual, sutureless SICS in a camp population showed that the latter method produces excellent results at iv ivDedication a fraction of the cost.1 Tilganga Eye Center is also financially self-sustaining wherein private care subsidizes charity care. They also have their own IOL manufacturing facility, which, like that at Aravind, is able to supply low-cost IOLs to other developing countries. Because the rural population in Nepal is so widely scattered amongst mountain villages that are accessible only by foot, the Tilganga system strives to deliver portable cataract care by transporting the necessary staff and equipment to remote eye camps. Using a single portable operating table, the Tilganga surgeons can also perform more than 10 cataract surgeries per hour. As at Aravind, the high-volume, cost-effective Tilganga surgical techniques and protocols are standardized across their surgical teams. Since 1994 when Dr. Ruit and Dr. Geoff Tabin co-founded the Himalayan Cataract Project, Tilganga ophthalmologists and staff have provided mobile cataract surgical care and physician training in numerous developing countries across mountainous Asia.

Though of a different scale and serving different types of communities, Aravind and Tilganga are complimentary models of how best to address the world’s backlog of cataract blindness. They demonstrate that the solution requires not only a costeffective surgical technique, but also an entire system of efficient and financially self-sustaining cataract care delivery. Beyond the impressive productivity of these 2 institutions, equally important has been their mission to train surgical teams from other developing countries in their methods of cataract surgery. An efficient, high-volume system utilizing low cost, sub-5-minute procedures to tackle advanced cataracts with minimal complications is clearly the best way to leverage the scarcest and most precious asset of the system—the cataract surgeon.

I consider this work to be the most inspiring and impressive accomplishment in our field of cataract surgery and it is with great respect and admiration that I dedicate this textbook to my friends at the Aravind and Tilganga Eye Hospitals. They are the unsung but true heroes in our field, and as we struggle to meet the high refractive expectations of our premium IOL patients, we must remember and salute our colleagues in developing countries that are on the frontlines of the most important surgical battlefield.


1. Ruit S, Tabin G, Chang DF, et al. A prospective randomized clinical trial of phacoemulsification vs manual sutureless small incision extracapsular cataract surgery in Nepal. Am J Ophthalmol. 2007;143:32-38.

In addition to his AMO, Alcon, and Visiogen consulting fees, Dr. Chang will also donate any royalties from this book to the Himalayan Cataract Project.




About the Chief Editor

About the Associate Editors

Contributing Authors

Foreword by Spencer P. Thornton, MD, FACS


Section I Why Offer Premium IOLs?

Chapter 1 The Birth of the Premium IOL Channel

Jim Denning, BS Chapter 2 Refractive IOLs—Economic Demographics

David Harmon Chapter 3 Refractive IOLs—Economic Demographics

Geoff Charlton Chapter 4 Refractive Surgery and IOLs—Future Trends

I. Howard Fine, MD Chapter 5 Refractive Surgery and IOLs—Future Trends

Richard L. Lindstrom, MD Chapter 6 Refractive surgery and IOLs—Future Trends

Lee T. Nordan, MD Chapter 7 What Is a Premium IOL Worth?

J. Andy Corley Chapter 8 What Is a Premium IOL Worth?

Kay Coulson, MBA

–  –  –

Chapter 10 Premium IOLs—Re-Engineering Your Practice

Darrell E. White, MD Chapter 11 The Refractive IOL Patient’s Journey

Stephen S. Lane, MD Chapter 12 Premium IOLs—External Marketing

Michael W. Malley, BA Chapter 13 Premium IOLs—External Marketing

Shareef Mahdavi, BA

–  –  –

Chapter 15 Lessons learned From Marketing Cosmetic Surgery

Marie Czenko Kuechel, MA vi viContents Chapter 16 Premium IOLs and the Role of Your Staff

R. Bruce Wallace, III, MD, FACS Chapter 17 Premium IOLs and the Role of Your Staff

Kevin L. Waltz, OD, MD Chapter 18 ASCRS Presbyopia Education Task Force—Challenge Ahead

John Ciccone Section II Transitioning to Presbyopia-Correcting IOLs

Chapter 19 Lessons Learned From Keratorefractive Surgery

Louis Probst, MD and John Lehr, OD Chapter 20 Transitioning From Cataract to Refractive IOL Surgery

Kevin Denny, MD Chapter 21 Transitioning From Cataract to Refractive IOL Surgery

Sandra Yeh, MD Chapter 22 Transitioning From Cataract to Refractive IOL Surgery

Timothy B. Cavanaugh, MD Chapter 23 Transitioning From Keratorefractive to Refractive IOL Surgery

Jay Bansal, MD Chapter 24 Transitioning From Keratorefractive to Refractive IOL Surgery

Marguerite B. McDonald, MD, FACS Chapter 25 Transitioning From Keratorefractive to Refractive IOL Surgery

Jose L. Güell, MD; Merce Morral, MD; Oscar Gris, MD; and Felicidad Manero, MD Chapter 26 Refractive IOLs in a Residency Program—Can It Work?

Thomas A. Oetting, MD; Jeffrey J. Caspar, MD; Bonnie An Henderson, MD; and Terry Kim, MD Chapter 27 Refractive IOLs in a Managed Care Setting

William Jerry Chang, MD Chapter 28 Refractive IOLs in a Comanaged Optometric Network

Paul Ernest, MD Section III Transitioning to Presbyopia-Correcting IOLs: Quick Start Guides............... 87 Chapter 29 How Do I Get Started With the ReZoom?

George Beiko, BM, BCh, FRCS(C) Chapter 30 How Do I Get Started With the ReSTOR?

Richard Tipperman, MD Chapter 31 How Do I Get Started With the Tecnis Multifocal?

Julian D. Stevens, MRCP, FRCS, FRCOphth Chapter 32 How Do I Get Started With the Crystalens?

D. Michael Colvard, MD, FACS

–  –  –

Chapter 34 AMO ReZoom Multifocal—Clinical Pearls

Farrell Tyson, MD, FACS Chapter 35 AMO ReZoom Multifocal—Clinical Pearls

Rosa Braga-Mele, MD, MEd, FRCSC Chapter 36 Alcon ReSTOR Multifocal—Clinical Pearls

Robert J. Cionni, MD Chapter 37 Alcon ReSTOR Multifocal—Clinical Pearls

David Allen, BSc, FRCS, FRCOphth Chapter 38 Alcon ReSTOR Multifocal—Clinical Pearls

Samuel Masket, MD Chapter 39 Aspheric ReSTOR—What Is Different?

Paul Ernest, MD Chapter 40 Aspheric ReSTOR—What Is Different?

Robert P. Lehmann, MD, FACS Chapter 41 ReSTOR Designs—Past, Present, Future

Satish Modi, MD, FRCS(C), CPI Chapter 42 Diffractive Multifocal IOL—How Does It Work?

James A. Davison, MD, FACS Chapter 43 AMO Tecnis Multifocal—Clinical Pearls

Pietro Giardini, MD and Nicola Hauranieh, MD Chapter 44 AMO Tecnis Multifocal—Clinical Pearls

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