Dominic McHugh Royal Society of Medicine 2010

ARMD

 Leading cause of blindness (“SVL”) in the Western World  2.7 million in the UK have some loss.

 54% increase in >75s over the next 25 yrs.

ARMD

Quality of Life

With ARMD Without ARMD

Home Care Falls

23% 16% 5% 8.3%

Falls With Fractures

3.5% 1.5%

Healthcare Costs

€12,579 €1,300 (£8,521) (£885)

LVA Possibilities

Surgical Rehabilitation for ARMD

• Hanita Ben-Sira implant Galileian telescope 2x IOL+spectacle • Intraocular Miniature Telescope Galileian telescope 2.2- 3.5x intra (Lipshitz) • Difficulty maintaining coaxial alignment Monovision VF 20° 11 mm incision

IOL-VIP System BCC IOL in the capsular bag = telescope ocular BCX IOL in AC= telescope objective

IOL-VIP System

PC IOL AC IOL -66D +55D

IOL CHARACTERISTICS

ANTERIOR CHAMBER IOL (BCX) PC IOL (BCC)

Optic Optic Material Diameter Thickness PMMA with UV filter 5.0

1.5mm

Material Diameter Thickness PMMA with UV filter 5.0

1.5mm

Haptics Haptics Loop shape Material Angle Z PMMA-1P 10° Loop shape Material Angle C PMMA-1P 7° IOL power IOL power +55.00 D -66.00 D

Inclusion criteria for IOL-VIP surgery • Bilateral stable macular degeneration/macular hole • VA 6/18-6/60 • Adequate endothelial cell count • Adequate AC depth • Good peripheral field • Predicted benefit by IOL-VIP simulator

Exclusion criteria for IOL-VIP Surgery • Active exudative macular degeneration • Glaucoma • PAS • Cornea guttata • Endothelial cell count < 1600 cell/mm2 • Shallow anterior chamber with depth < 3 mm • Corneal diameter < 11 mm

IOL-VIP Proposed mechanism of action Prismatic deviation of Image to PRL.

Image magnificiation ~1.3

Image shift to PRL (MP)

Pre-op Post-op RE preop BCVA : 0.25

postop BCVA: 0.5

(Fasciani et al, 2008) LE preop BCVA : 0.3

postop BCVA: 0.7

IOL-VIP Simulator Prism

IOL-VIP Preoperative assessment

Best VA without and with simulator prism, rotated to achieve PRL

IOL-VIP System Optimal simulator orientation determines relative IOL position Right Eye Left Eye 12 12 9 3 9 3 12 9 6 6 3 12 6 9 6 3

9 9 8-7 IOL-VIP System Optimal simulator orientation determines relative IOL position Right Eye Left Eye 12 12 1-2 1-2 3 9 3 8-7 6 1-2 6 1-2 12 3 8-7 8-7 6

• Corneal tunnel (superior/temporal depending on IOL orientation • Large (6-7 mm) CCC • Phacoemulsification if phakic • Enlarge corneal incision to 7 mm • PC IOL: bag if phakic, sulcus if pseudophakic • PI+miochol • A/C IOL • Corneal sutures

IOL-VIP

Surgery

IOL-VIP Visual Outcome Orzalesi et al 2007

IOL-VIP Postoperative findings

•

Low surgical complication rate

•

Endothelial cell loss 7%

•

PCO 18%

•

High hyperopia in emmetropes; better if myopic

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Recent availability of “bespoke” implants

Advantages • Improves reading/distance vision in suitable cases (6/18 6/60 pre op; small-moderate central scotoma) • Patients comment favourably on scotoma shifting away from centre Disadvantages • Careful selection required: pathology; psychology; costs • Lengthy (6 week) postoperative rehabilitation training • Suture removal • Refractive error : hyperopia and astigmatism (reduced with new implants