Oph the Record 2011

OPH the RECORD Pu b l i s h e d b y O p ht e c BV | E SC RS Edition 2011 | #7

14 RingJect Best CTR now ready-to-use

9 AXTC Barcelona First Summer Course at IMO in Barcelona

In this issue: Interview: Huang Wei Jen, MD, Taiwan Interview: Sing Jun Lee, MD, South Korea VacuFix: experiences in Italy & South Africa Intraocular lenses: overview QuadrimaX: 1.8 mm incision New Ophtec offices: Germany & Asia/Pacific Artisan 205: indications

6 VacuFix™

Enclavation made easy

3 PIOLs 25th anniversary!

Ophtec’s President & CEO Erik-Jan Worst on the ARTISAN® & ARTIFLEX® concept

ESCRS in Vienna

Meet us at booth #B313, Congress Centre Vienna, 17-21 September

www.ophtec.com

Vienna: Hundertwasserhaus

Agenda 2011 / 2012 September

17-21

ESCRS

Vienna

September

22-25

SEO

Oviedo

October

13-16

APACRS-KSCRS

Seoul

October

22-25

AAO

Orlando

November

23-25

OB

Brussels

December

9-10

ARTISAN速/ARTIFLEX速 training course (AXTC)

Groningen

January

20-21

ASETCIRC

Madrid

February

2-4

FACOELCHE

Elche

February

3-5

WESCRS

Prague

February

16-20

WOC2012

Abu Dhabi

March

22-25

OSSA

Johannesburg

March

28-30

NOG

Groningen

April

13-16

APAO

Busan

April

20-24

ASCRS

Chicago

April

27-30

SFO

Paris

May

23-26

SECOIR

Sevilla

June

14-16

DOC

Nuremberg

June

22-23

ARTISAN速/ARTIFLEX速 training course (AXTC)

Groningen

September

8-12

ESCRS

Milan

Welcome to Vienna Dear colleague, reader, September 2011. The ESCRS is being held in Vienna, a city with a long and rich history and a superb location to celebrate the anniversary of our Artisan myopia

ARTISAN & ARTIFLEX

lens, a lens that has a long history too. This first Artisan PIOL was implanted for the first time 25 years ago, in November 1986 to be precise. A 25th anniversary for a PIOL: that can safely be called a milestone!

When the iris-fixated lens had already been implanted in aphakic eyes for almost

CONTENT

10 years, Paul U. Fechner of Hannover was the first surgeon to venture to insert the iris-fixated lens in a phakic eye. You all know about the success story that followed. The Artisan and Artiflex lenses have been implanted in large numbers for many years, all over the world. Many refractive lenses have come and gone since that time, but the Artisan lens is still with us, and together with the other Artisan and Artiflex lenses that have seen the light of day since, is still as large as life and up-to-the-minute.

4. Huang Wei Jen, MD

6. VacuFix™

During these 25 years a lot of stories concerning this lens reached me. These are stories not only from happy patients, but also from doctors who describe case histories. This edition of our OphtheRecord contains just such a story. Dr Sung Jin Lee of Seoul describes how he took the courageous step of implanting an Artisan lens in the eye of a woman who had undergone a Scleral Buckling treatment

highest volume Ophtec phakic IOL in Taiwan

experiences from Italy and South Africa

9. Ophtec News 10 ARTISAN® after Retinal detachment

for her retinal detachment, despite a contraindication.

Dr Huang, who works at the Ray Guard Eye Center in Tapei and is the leading

13. Intraocular Lenses Overview

surgeon for Artisan and Artiflex PIOLs in Taiwan, also implants Artisan to treat

Sung Jin Lee, MD, South Korea

retina problems. Dr Huang tells us about Refractive surgery in his country and

14. The RingJect™

about his experiences with Artisan and Artiflex.

This edition also contains news about the Ophtec Capsular Tension Ring. It was

15. Introducing

tested as best by Dr Erik Mertens in the previous edition of OTR and is now available

in a Pre-Loaded disposable injector. I will be introducing you to our RingJect. It seems to me that there is now nothing to stop you from trying out this sublime piece of Ophtec technology.

Finally, we once again place the spotlight on our VacuFix in this edition. Fellow-surgeons will be telling you about this unique Vacuum Enclavation technique. Please feel free to contact us should you have any questions or comments after reading the articles.

best CTR now ready-to-use

Ophtec Germany and Ophtec Asia Pacific

16. ARTISAN® Aphakia Indications 17. QuadrimaX™ 1.8 mm incision

interview with Bernard Trigaux, MD

18. ARTISAN® & ARTIFLEX® in patients with Keratoconus Colophon OphTheRecord is published by Ophtec BV

We hope that you’ll enjoy reading this edition.

Interviews: Mathijs Deen, Tekst & training Amsterdam / Marij Thiecke, Concept & Copy Haren / Laurent Pironnet Editorial: Roelien den Besten; Anna Biltra, Erwin Bouwman, Jérôme Fissiaux, Gitty Geertsma, Walter Nazaire E-mail: r.den.besten@ophtec.com Artwork: www.mennoschreuder.nl Photography page 2: Tim Opsteeg Print: Scholma Druk, Bedum All rights reserved. ©Ophtec BV 2011 | PO Box 398 | 9700 AJ | Groningen

Erik-Jan Worst,

T: +31 50 525 1944 | F: +31 50 525 4386 | www.ophtec.com

Ophtec President and CEO OPH THE RECORD 3

Word-of-mouth is the best kind of advertisement Dr Huang Wei Jen, Ray Guard Eye Center in Taipei, Taiwan

By Mathijs Deen

4 OPH THE RECORD

I

n Taiwan, as in the rest of Asia, myopia is widespread. According to Dr Huang, refractive surgeon at Ray Guard Eye Center in the capital city Taipei: ‘It is currently estimated that around 90% of our college and university students have myopia. Around 10% have diopters of -6 or higher, and about 5% above -8. So, there is a lot of work for refractive surgeons in Taiwan. Their most common solution by far is cornea laser vision correction, which totals about 20,000 corrections per year. In comparison, the number of Phakic IOLs is still low, totalling only 300 per year.’

Dr Huang is Taiwan’s leading surgeon for Artisan and Artiflex, Phakic IOLs. Since he started implanting PIOLs 4 years ago, he has implanted about 250 iris fixated lenses.

He says, ‘I may have done the most PIOLs, but I surely wasn´t the first surgeon in Taiwan to start implanting them. I am a rather conservative person, you see. With new technologies and procedures I always wait at least one year before adopting them myself, because I want to know what the mid to long term results are for patients. I study the data, I check all the ins and outs, and I check them again before I proceed.

But once I trusted that the results were very good, I jumped at the opportunity of using Artisan and, about a year ago, Artiflex.’

Even though Dr Huang himself is convinced of the advantages of Artisan and Artiflex, he still has to make an effort to win over patients. Dr. Huang says, ‘Patients always ask for the laser, because it is much better known and the fee is very low. In Taiwan, refractive surgery is not covered by medical insurance, not even for high diopters. So, unfamiliarity with implanted lenses and the relatively high cost, make patients reluctant to choose this option.’

‘But I can be very convincing. When patients are unfit for LASIK, especially with high diopters, I make it very clear why Artisan and Artiflex are their best options. With these lenses, recovery is fast and guaranteed, visual quality is much better, and there are no problems with night vision.’ ‘And, the procedure is reversible. For anxious patients, knowing that the implanted lens can be taken out if necessary is reassuring.

However, in practice, lens removal occurs only in extremely rare cases.’

Dr Huang has clear-cut criteria for choosing between PIOL and laser: below -8 he suggests LASIK for a normal cornea, but PIOL for a thin or abnormal cornea; above -10, he always opts for PIOL. Increasingly, Dr Huang notices that Artisan and Artiflex are beginning to speak for themselves: ‘Many former patients refer their family, friends and colleagues to me, because they are so happy with these lenses. Word-of-mouth is the best kind of advertisement, of course.’

‘I jumped at the opportunity of using ARTISAN® and, about a year ago, ARTIFLEX®’ His patients are pleasantly surprised by the absence of discomfort with the PIOL procedure. Instead of general anaesthesia, he uses a subconjunctival injection, plus intracameral 0.2% xylocaine for Artisan, and topical anaesthesia plus intracameral 0.2% xylocaine for Artiflex. This way, the patient hardly feels the enclavation; apart from making the patient uncomfortable, pain would cause the patient to squeeze, the eye-ball to move, and could thus cause surgical trauma. Dr Huang stresses that the concentration of xylocaine must not be higher than 0.2%, because this would dilate the pupil and increase the risk of touching the anterior capsule of the crystalline lens – ‘especially with Artisan, where the incision wound is bigger and anterior chamber depth is harder to maintain.’

Almost as a side-note Dr Huang says that he has noticed that some of his colleagues, who begin implanting Artisan, lose confidence after they have done two or three operations, because they find it difficult to maintain the correct anterior chamber depth. Some even drop the procedure altogether after their first attempts. He says, ‘I always suggest to beginners that they should start with Artiflex, as this lens makes it much easier to maintain the correct anterior chamber depth because of the smaller incision. Once they are confident, they can also try Artisan.’

Dr Huang averages 10 PIOL cases per month, which are easily outnumbered by 100 cases of cataract with premium lens and 100 cornea laser vision corrections.

At the Ray Guard Eye Center in Taipei, Dr. Huang works in a team that consists of two anterior segment surgeons, one plastic surgeon, and one retina specialist.

He finds it very useful to collaborate with both anterior and posterior surgeons.

For example, he has referred some of his highly myopic patients with retina tear to his retina colleague for laser treatment to prevent further progression. After a recovery period of three months, he successfully implanted Artiflex in these patients.

Although the majority of cases aren’t particularly novel and exciting, Dr Huang does not tire of his field of work. He says, ‘Even as a small child, I paid a lot of attention to detail and enjoyed disassembling small devices and putting them back together again. I always knew I wanted to become a surgeon. I was attracted to eye surgery, and it turned out to be the right choice for me. It is one of the most dynamic fields of surgery, increasingly developing new technologies and procedures.’ Twenty years ago the procedure of choice was Radial keratotomy, later Photorefractive keratectomy, 15 years ago he started using LASIK and 4 years ago he began implanting Phakic IOLs and applying the Prelex procedure.

Next to PIOL, another special interest of Dr Huang is presbyopia correction procedure.

‘The last frontier’, he calls it , as everybody who is over 45 or 50 years old, will sooner or later develop difficulties with reading.

Like many countries, Taiwan has an ageing population and therefore, more people will benefit longer from a durable solution to this problem.

Over the past 4 years, Dr Huang has implanted about 1000 multifocal IOLs. ‘But why remove the lens and exchange it for an artificial one if the patient doesn’t have cataract? For Ophtec, this is also the way to go: with multifocal lenses, it is very important to keep the lens centrated.

Clinical observation shows that some patients with Artisan or Artiflex develop mild lens decentration over time after implantation. It would be wonderful if Ophtec could solve this problem and develop a multifocal Artisan or Artiflex.’

OPH THE RECORD 5

VacuFix Enclavation made easy ™

Dr. Chris van Niekerk Johannesburg Eye Hospital, South Africa ‘I have never felt comfortable implanting the Artisan IOL. The enclavations never looked or felt just right. Too many times I had to repeat the process. Most times the amount of iris tissue enclavated looked either too much or too little.

Often the IOL would decentrate during the process of enclavation. I used both enclavation needles and forceps without even feeling comfortable.

The VacuFix uses a predetermined amount of vacuum provided by the phaco machine.

The amount of iris picked up therefore is the same every time. A simple upward movement enclavates the iris picked up.

Afterwards the amount of tissue enclavated is just the right amount and looks symmetric.

I also find it easier to keep the IOL stable during the process of enclavation. The VacuFix has greatly simplified implantation of the Artisan or Artiflex IOL.’

Dr. Marissa Willemse Pretoria Eye Institute and Ophthalmologist in private practise, South Africa ‘Made easy? Some would say it is not for the faint hearted. The enclavation of the Artisan / Artiflex lenses has always been a cumbersome procedure. It is a procedure that has had a long learning curve to many, and where ambidextrous persons will surely have an added advantage.

it also has a short learning curve compared to the old enclavation method. The VacuFix system is less invasive and less traumatic to the iris.

A reproducible amount of iris is enclavated every time. The patients experience a faster recovery time.

OPHTEC has launched a new VacuFix enclavation system for the Artisan / Artiflex lenses. The vacuum created by a phaco machine is used to allow the VacuFix to aspirate a fold of iris tissue in a controlled manner. The handles fit to the tubings of the phaco machine. The VacuFix can be used to both the peristaltic and venturi pump systems.

The procedure entails selecting the irrigation and aspiration setting on your phaco machine.

Set the vacuum on 200 mmHg and the aspiration flow on 40cc per minute Fill the tubing’s with balanced salt solution. Block the irrigation tube with the irrigation plug delivered with your instrument. Connect the correct hand piece onto the aspiration tube.

The VacuFix consists of two disposable handles (left and right) with a blunt aspiration cannula. The curved tip carries an aspiration hole which is placed on the iris surface just underneath the slot of the claw. The VacuFix allows the formation of a nice ‘iris bridge’ and enclavates the iris tissue into the slot of the claw of the Artisan/ Artiflex lenses.

Fill the handle with balanced salt solution and make sure that the air is removed from the handle. Introduce the cannula through the sideport and place it underneath the slot of the claw. Hold the lens with the Implantation Forceps (different for Artisan and Artiflex lens as illustrated in the diagram). Place the cannula flat onto the iris surface and depress the footswitch to the maximum aspiration level. Gently lift the VacuFix with the iris fold through the superior part of the claw. (follow the enclavation procedure as illustrated in the diagrams).

Then release the footswitch.

The VacuFix enclavation system is an easy and fast procedure, which improves the precision placement, especially of toric (P)IOLs. Not only is this procedure safe but

6 OPH THE RECORD

VacuFix™ Procedure Although this is an easy procedure, there are a few things to keep in mind: I have realised that positioning the side ports correctly is very important. I introduce the IOL into the anterior chamber and position it pointing to the centre of the pupil. Only then do I make my first side port, after which I enclavate the first side of the lens.

Once the lens is firmly attached to one side of the iris, I do my second side port. This gives me direct access to the claw.

The angle of the side port is also very important. It needs to be in the plane of the iris so that the tip of the VacuFix will be easily introduced behind the slot of the claw.

It will allow for good suction and make a proper ‘iris bridge’ to facilitate the enclavation of the iris tissue into the claws of the Artisan/Artiflex lenses.

The VacuFix tip is placed flat onto the iris surface underneath the slot of the claw

It is also very useful to use the aspiration tips of the VacuFix for creating a peripheral iridotomy. This makes for a precise and functional iridotomy.

An added benefit to the system is that you can enclavate through an iris that has scars in the periphery. Seeing that these lenses are commonly used for trauma patients and that corneal scarring is frequently seen in them. I have used it even in patients with post corneal grafting, and enclavated using the VacuFix system. It is reproducible even through the corneal scars.

Gently lift the VacuFix with the iris fold through the free part of the claw

Using the VacuFix for Toric Artisan/Artiflex lenses the implantation has definitely become more precise and accurate. Once your axis markings are done correctly, enclavating the iris tissue into the claw will lead to excellent results.

My greatest reward is the post-op results.

Patients definitely experience a faster recovery time. They are generally more satisfied, seeing that their (day 1) post operative visual acuity is excellent.

The given results should encourage and maybe entice the anterior surgeon to convert to the VacuFix system.

It has made ‘Artisan/Artiflex Easy’.’

Verify the amount of tissue between the claws and remove the VacuFix from the eye

OPH THE RECORD 7

By Marij Thiecke

Revolution To quote Dr. lori, ‘In 1998, I first became acquainted with iris claw lenses. I will be honest. It was hard getting used to them.

Because I did not perform many procedures and because of the inflexibility of the PMMA, the learning curve was, well, somewhat less steep than it could have been. Currently, I perform some 1,500 procedures at the hospital and 200 at my own clinic each year. In my opinion, the Artiflex, with an incision of 2.8 mm (no more, no less), was and is a true revolution in eye surgery. Not only for the doctor but especially for the patient, who doesn’t need general anaesthesia and who is, of course, less susceptible to complications.’

Setting a new standard in predictability in the process of creating a perfect iris bridge has recently become commonplace for Artisan adepts. With the introduction of the VacuFix enclavation device instead of an enclavation needle, centration and positioning with a fixed and reproducible amount of iris tissue has become easier than ever. Dr. Maurizio Iori is one of its first users and said, ‘There is no learning curve. If you were thinking about one more good reason to switch to the Artisan family, here’s your convincing argument.’

Next step The VacuFix is the next step towards perfection. With the VacuFix, the overall effect is even more predictable. Moreover, the implantation routine has become much easier. With the help of an instruction movie and a personal instruction by OPHTEC, the technique is easily absorbed into a new or existing surgical routine. The preformed curves of the Vacufix tip make it easy to reach the enclavation site. The procedure time itself is not shortened; the strength lies in the increased quality.

Maurizio Iori, MD Medical Director; Ophthalmology Department; Crema Hospital, Crema, Italy

Do try this at home VacuFix makes positioning and centration in the blink of an eye the new standard

‘The VacuFix™ is the next step towards perfection’ Dr. Maurizo Iori has been an eye surgeon for many years. He works from the Crema General Hospital and from his private eye clinic, also located in Crema, Northern Italy. According to Dr. lori, ‘Generally speaking, in Italy a hospital is no breeding ground for a medical revolution. Much patience is needed if you want a new medical instrument or technique implemented at a regular hospital. This is one of the reasons why I decided to set up my own clinic. When I see an improvement or an innovation, I want to be in. Naturally, the more challenging eye surgeries I perform at the Crema Hospital, but straightforward refractive and laser procedures are managed all the better at my small and efficient cutting edge private facility.

And so, almost every working day, the mornings are reserved for the Crema Hospital, and after lunch I go to my own practice. Yes, I think I can consider myself lucky. Career wise, I have the best of both worlds.’

8 OPH THE RECORD

Choices My mother was a pediatrician, my father a radiologist. A medical career seemed obvious.

Yet my medical focus on the eye was not ‘obvious’. I thought about it long and hard.

Eye surgery is all about using your talent and experience on a very small scale and that is still what attracts me about my profession. In Italy, especially the north, the standard and medical level is very good and comparable to that of Spain and Germany. In eye surgery, there is always something to look forward to. A multifocal Artiflex for instance, or a lens with an optic of 6.5 mm, would be fantastic. I think about the possibilities of an Artiflex that could accommodate up to 20-25 dioptre!

Ophtec updates me on a regular basis, and the service level at OPHTEC is so high, that when one of these lenses would become available, I would happily accommodate them.’

> Surgery with VacuFix™ A

D

B

E

C

F

ARTIFLEX® Enclavation

ARTISAN® Enclavation

•

Insert the Implantation Forceps through the main incision

•

Insert the VacuFix through the paracentesis

•

Hold the Artisan/Artiflex lens with the Implantation Forceps (A,B,C for Artiflex D,E,F for Artisan)

•

Place the aspiration hole of the VacuFix cannula flat onto the iris surface underneath the slot of the claw (A / D)

•

Make sure the VacuFix tip stays in contact with the iris surface until the vacuum has reached the maximum level by depressing the footswitch of the phaco

•

Gently lift the VacuFix with the iris fold through the free part of the claw with described movement(s) (B,C for Artiflex; E,F for Artisan)

•

Release the vacuum by releasing the footswitch

• •

Remove the VacuFix from the eye

•

Perform the same procedure on the other side

Verify the amount of iris tissue the centration and positioning of the (P)IOL

Ophtec N E WS

AXTC Summer Course IMO Barcelona

New Ophtec Booth

Ophtec will join this years ESCRS congress with a brand new booth design. This booth is designed to be multifunctional. We are able to create a speakers corner or a wet lab section. A coffee bar area is included. In addition there is the possibility to change graphics easily, so that we will be able to change the themes of the booth during the congress. Please visit our new booth and give us your opinion.

Participants of the Barcelona Artisan & Artfilex Training Course, together with Dr Güell, Erik-Jan Worst (Ophtec president & CEO) and Yvonne Hernandez (General Manager Ophtec España) The First Spanish International Artisan / Artiflex Training Course was conducted last June and was well attended. 17 participants were trained about the pearls of (T)PIOLs of Artisan family. Erik Jan Worst, president & CEO and Dr. J.L.Güell, President ESCRS, offered their best advice about the Phakic IOLs during theoretical and practical sessions. The course was held in the beautiful building of Instituto de Microcirurgía (IMO) in Barcelona.

Dr. Salah Mahjoub (Tunis) Honored with Artisan Ambassador Award during ESCRS PARIS 2010

Meet Ophtec’s Management and Sales team

left to right: Dr. Budo, Dr. Marinho, Dr. Güell, Dr. Mahjoub, Erik-Jan Worst President & CEO Ophtec

Left to right: Erik-Jan Worst (President & CEO Ophtec BV), Laurent Pironnet (Sales Manager Belgium), Arno Lindstädt (General Manager Ophtec GmbH), Jérôme Fissiaux (Director Sales), Fred Wassenburg, (Director Technology & Operations), Hiromasa Yamada (General Manager Ophtec Japan), Willy Smeyers (Sales Manager Belgium), Rick McCarley (President & CEO Ophtec USA), Walter Nazaire (Export Manager), Alexander van Leijenhorst (Account Manager), Alex Lee (Director Sales & Marketing Ophtec Asia Pacific), Rik Engels (Director Finance), Yvonne Hernandez (General Manager Ophtec España), Geke Hoekstra (Director Human Resource), Anneke Worst (Management Consultant), Deon van Wyk (General Manager Ophtec South Africa), Susanne Bouwmeester (Executive Secretary), Jan van Oort (Account Manager).

ARTISAN & ARTIFLEX OPH THE RECORD 9

Sung Jin, Lee Associate Professor, Retina, Dept of Ophthalmology, SCH University Hospital Seoul

10 OPH THE RECORD

ARTISAN® after retinal detachment

‘I am a 3D person’ Dr Sung Jin Lee, MD Soon Chun Hyang University Hospital, Seoul, South Korea

By Mathijs Deen

J

ust a couple of months ago, Dr Lee contacted Médicins Sans Frontières (Doctors Without Borders), to offer his expertise and service to this secular, humanitarian-aid organization.

Their leading principle ‘that the needs of people outweigh respect for borders’, seems to fit him perfectly. Somewhat to his disappointment, they told him that - being over forty - he was too old to start working as a Doctor without Borders.

Dr Lee is a retina surgeon at Soon Chun Hyang University Hospital, in Seoul, Korea.

He has the looks and attitude of a confident young man, and he likes to think ‘outside of the box’. Although the physical boundary between the chambers of the eye is very small, there is a clear divide between anterior surgery and posterior surgery, which few surgeons dare to cross. Dr Lee is one of them.

At heart, he is a doctor without borders.

surgery on a young lady with retinal detachment in one eye, using scleral buckling.

This patient had high myopia and wanted to become spectacle and contact lens independent. Half a year later, she received LASIK on one eye, but no refractive doctor dared to operate on the eye that had a buckle.’

LASIK can be problematic in these cases, because the refractive status may alter if the buckle is removed or displaced for any reason. Moreover, with LASIK, the cornea of the highly myopic eye is cut thin, which appears to add to the changes in eye shape caused by encircling the eye with a buckle.

One of the alternatives, clear lens extraction, may increase the risk of retinal detachment and may result in the loss of accommodation.

So, the eye of the young woman was left as it was. Even though the patient did not need glasses any longer, she practically became a one-eyed person, which is very tiring and unpleasant. In the midst of searching for a He has pioneered with Artisan Phakic solution, Dr Lee heard about Artisan, which Intraocular Lens (PIOL) Implantation after retinal detachment surgery. These patients does not touch the cornea. So he joined 6 had all undergone scleral buckling procedures Korean doctors to visit Ophtec in The Netherlands in 2002. He commented, ‘After to treat retinal detachment, which is the trip, I was convinced that it could work commonly considered a contra-indication and that I myself could perform the surgery, for PIOL implantation, but not necessarily for Dr Lee. He fondly describes his first case. but it took a long time to persuade the patient, because she knew about the contraindication.’

In 2000, he finished his 39-month-duty as a military doctor and became a fellow for Dr Lee was not daunted by the prospect specializing in retinal surgery at YONSEI University Severance Hospital. Then he moved of implanting his first Artisan. His major concern was what he would do if the retina to Soon Chun Hyang University Hospital, his alma mater, working as a retinal surgeon. would become detached once more, due to the refractive surgery.

He said, ‘As a rookie doctor, I performed

As a retina specialist, he knew that the retina was very stable after he had treated the hole with a laser and strengthened it with scleral buckling. He said, ‘I checked the retina again and again to be absolutely sure’. Implanting the Artisan was the easy part. I do not mean to sound conceited, but compared to most posterior surgery, it is very easy and it was successful.’

In 2006, Dr Lee, together with two colleagues, published the first article describing three cases of Artisan PIOL implantation after retinal detachment surgery, all with satisfactory results.* Over the past years, he himself has performed nine such treatments.

All patients gained stable refraction with uncorrected vision. On average he keeps patients under observation for 3 to 6 years and has found no recurrence of retinal detachment. He speculates that the success is due to the specific character of the Artisan, which differs from other PIOLs in that its only contact with the iris surface is the midperipheral portion of the iris.

Dr Lee explains why a myopic error is quite common in patients who develop retinal detachment. Myopia means that the eyes are enlarged. The retina is paved in the eye like thin wallpaper, and stretches as the eye enlarges. Therefore, with high myopia, the retina is very thin and can easily rip or have a hole. If vitreous liquid percolates through a hole in the retina, the back of the retina is filled with water causing the retina to float. You simply can’t see with OPH THE RECORD 11

Left: Dr. Lee visits Prof. J.G.F. Worst and Ophtec in Groningen, 2002; Right: SCH University Hospital Seoul

a floating retina. So, it is not the Artisan lens, but severe myopia that causes the greatest risk of retinal detachment, according to Dr Lee. ‘This is one of the reasons why it is useful for refractive surgeons who use PIOLs, to collaborate with retinal specialists who are familiar with PIOL surgery and, of course, to minimize risk of retinal detachment, these patients need regular retinal examinations,’ he said.

Dr Lee sticks to the following criteria for the Artisan after retinal detachment surgery.

He does not perform Artisan surgery on patients with uveitis or retinal detachment that is related to a macular hole, as the risks are higher than the benefits. Patients older than 50 years have a high prevalence rate of cataract, so they should consider Clear Lens Extraction, which makes them unfit for the Artisan. In the young age group, the Artisan is limited to re-conglutinated retina with scleral buckling only. The Artisan can be performed when the shape of the eye does not change for at least 6 months after retinal detachment surgery.

The retina must be risk free, or preventive Laser photocoagulation must be applied to the retinal hole or tear.

‘I’m not in it for the money’ exchange can make the anterior chamber shallow and cause damage to the corneal endothelium.

At first, some of Dr Lee’s posterior colleagues were suspicious of his outings to anterior surgery. He remembers that a friend called him a ´bat´, which is not exactly a compliment in Korean. Forgivingly, he explains that posterior surgery is both notoriously difficult and badly paid in Korea compared with anterior surgery. ‘He thought that I was secretively trying to go over to the anterior world, where there is more money to be earned in private clinics. But, one day, he called me and said that he had a retinal detachment patient who had a strange lens in his anterior chamber that I might know.

Could I come over and remove it for him?’

It sometimes happens, that patients develop He laughs heartily and says, ‘By now, they know that I´m not in it for the money. Do retinal detachment after refractive PIOL you want to know what the attraction is? I am surgery. If retinal detachment occurs, a 3D person…three d’s: stuff that is Dirty, Dr Lee tries to apply segmental buckling Dangerous and Difficult. Maybe it has instead of vitrectomy to save the PIOL. He something to do with the fact that my father says that even when vitrectomy is needed was a church minister, and he wanted his and if the Artisan doesn’t interfere with son to become a missionary in Africa. That’s vitrectomy, the iris-attached lens can be left where it is, depending on the situation. pretty 3D.’ Working for Médicins Sans Frontières ‘But, if you are handling gas for a long time would have been close to that ideal. But, in his current job, he can also try to cross some while sealing the tear and attaching the borders while trying to resolve difficult retina, you must take out the implanted problems and doing complicated surgery. lens,’ he said. The reason is that air gas 12 OPH THE RECORD

Such a new challenge is, for instance, a patient who has blurred vision and sees flashes. Dr Lee suspects it is caused by the iridectomy site. The patient underwent corneal tattooing, which has slightly decreased the lightning sensation, but has not solved the problem satisfactorily.

Dr Lee thinks that cosmetically, corneal tattooing isn’t the best option and he would like to use a specially designed artificial iris lens to cover the iridectomy site. He has asked Ophtec to discuss this case and to design the lens for this patient.

Dr Lee clearly enjoys his work. And what he enjoys, he wants to share. He enjoys playing the saxophone, so he also plays the saxophone for his patients. And he writes short stories about the retina for them. Actually, he writes them for anyone who is interested. Since 2004 he has contributed articles about the retina to the weekly medical newspaper, Whosaeng.Shinbo, which is the oldest medical newspaper in Korea He said, ‘It started with an attempt to explain to my daughters what kind of work I do. To make this information understandable and interesting, I turned my explanations into short stories which resembled fairy tales or parables. I wrote over 250 of these short articles and placed them on my website www.retina.co.kr, so any Korean with questions about the retina has access to them.’

More information: “Artisan Phakic Intraocular Lens Implantation after Retinal Detachment Surgery” J.K. Chung, MD; Jae Bum Lee, MD; Sung Jin Lee, MD Journal of Refractive Surgery Volume 22, October 2006

Intraocular Lenses overview Phakic IOLs

ARTIFLEX® Toric PIOL

P iris fixation P small incision P no rotation post op P large optical zone

Aphakic IOLs

Optic:

6.0 mm

Haptics:

Iris Fix®

Overall diameter: 8.5 mm Dioptric range:

-1.0 D to -13.5 D in combination with a cylinder of -1.0 D to -5.0 D

ARTISAN® Aphakia | Model 205

P iris fixation P iris claw® design P long clinical experience P predictable, stable, reliable

Aniridia Lenses

5.0 mm

Haptics:

Iris Fix®

Overall diameter: 8.5 mm Dioptric range:

2.0 D to 30.0 D (1.0 D increments)

14.5 D to 24.5 D (0.5 D increments)

Optic:

4.0 mm

Haptics:

C-loop

Aniridia | Model 311

P iris reconstruction and optic correction P sclera, sulcus and capsular bag fixation P safe, stable, reliable

Cataract IOLs

Optic:

Overall diameter: 9.0 mm Dioptric range:

0.0 D and 1.0 D to 30.0 D

(0.5 D increments)

QuadrimaX™ | Aspheric Hydrophilic Acrylic | Model 545

P micro incision: 1.8 mm P aspherical edge

Optic:

5.7 - 6.0 mm | biconvex aspherical surface | straight edge 360º

Haptics:

4 closed loops | 8˚angulation

Overall diameter: 10.5 - 11.0 mm Dioptric range:

More Ophtec (P)IOLs on www.ophtec.com

10.0 D to 30.0 D (1.0 D increments) 14.5 D to 25.5 D (0.5 D increments)

OPH THE RECORD 13

Best Capsular Tension Ring (CTR) now ready for use

RingJect

™

NEW

The RingJect adds the advantages of a preloaded disposable system to the implantation procedure of a Capsular Tension Ring that already has proven to be one of the best, due to its compression moulded PMMA (strength) and unique pre-circular expansion. The action/ retraction mechanism of the injector makes it possible to insert the CTR in a controlled movement in either a clockwise or counter clockwise direction.

Pre loaded Capsular Tension Ring in disposable injector

The Ringject consists of an Ophtec pre loaded Capsular Tension Ring in a single use injector. The CTR is hooked in the Injector and will be automatically loaded after unlocking by pushing the plunger in the Injector. Ophtec’s Capsular Tension Ring is a high precision medical device for insertion in the capsular bag. It consists of a highly flexible compression moulded polymethylmethacrylate (PMMA). A clockwise or counterclockwise insertion is possible. The injector is packed in a transparent blister in which it is ready for use.

The PMMA Capsular Tension Rings are indicated for the stabilization of weakened, broken or missing zonulae preventing IOL decentration after capsular shrinking or to enhance the outcome of a premium IOL.

Advantages & Benefits Pre loaded:

• Automatic load, single packaging a valuable addition to your standard cataract surgery equipment.

Injector:

• Easy to handle, one handed technique • Total control includes action/retraction mechanism

RingJect PC375 | CTR Model 275 12/10

• Implantation in two directions indicators on injector • long small tip especially convenient in cases of deep set eyes

Compression: From 12 mm to 10 mm Material: Available in: Overall Ø:

PMMA | Flexible Ring Clear PMMA 12 mm

RingJect PC376 | CTR Model 276 13/11 Compression: From 13 mm to 11 mm Material: Available in: Overall Ø:

14 OPH THE RECORD

PMMA | Flexible Ring Clear PMMA 13 mm

• 1.9 mm incision.

Capsular Tension Ring:

• Circular expansion and stabilization of the capsular bag • Safe IOL centration in eyes with Zonular dehiscence • Prevents IOL decentation after capsular shrinking • Stabilized conditions during Phaco emulsification surgery • Reduced risk of capsular fibrosis • Improves visual acuity when implanted along with premium IOL.

OPHTEC continues to expand New offices in Germany and the Far East Ophtec Germany

OPHTEC Asia Pacific

The official announcement that Ophtec BV is opening direct sales operations in Germany was made in May 2011 at the DOC in Nürnberg - the most important congress for cataract and refractive surgery in Germany.

Next to the Office in Japan Ophtec has opened a second site in the Far Eeast; Ophtec Asia Pacific, located in Hong Kong. This office is manned by Alex Lee (Director sales and marketing) and Kelly Bok (Clinical applications consultant). Both are committed to offer patients and surgeons in the Far East the same Ophtec service as elsewhere in the world.

Arno G. Lindstädt, General Manager

The response from German ophthalmic surgeons was very positive and encouraging. Upon hearing the announcement, many surgeons expressed that they are looking forward to working directly with Ophtec’s experienced sales representatives and technical experts.

Ophtec has chosen Arno G. Lindstädt as the General Manager for the new satellite office. Arno is well known by surgeons and brings with him a long history of work in the German (domestic) and International ophthalmic markets. The first priority is to assemble the right sales and sales support team to provide the high standard of service Ophtec has become known for throughout the world.

‘My introduction into the ophthalmic industry was in the late 1980’s, working for CooperVision – at that time, a world leader of ophthalmic products.’, Arno explains. ‘From the beginning, I was fascinated by the complexity of the human eye and the multiplicity of surgical techniques. I therefore chose to dedicate my professional career to ophthalmology.’ said Arno. In addition to CooperVision, Arno’s career has included time spent with Allergan, AMO, Carl Zeiss Meditec and AAREN Scientific. ‘What I enjoy most about this industry is the fast pace of product development and the integration of new technology in the creation of new and significant products that assist surgeons in the treatment of their patients.’

‘My first exposure to Ophtec was during my time at Allergan / AMO when I became aware of the famous Artisan Phakic Lens brand. Several years later during the October 2010 DOC, I was excited to meet with Erik-Jan Worst to discuss the potential expansion of Ophtec direct sales in the German market. I immediately sensed a compatible relationship and we agreed to pursue a business plan. After several subsequent meetings, Ophtec Germany was born.’ said Arno.

Arno stated, ‘I was, and continue to be enthusiastic about joining the Ophtec team and contributing to the positive Ophtec culture. I look forward to working with the sales and technical experts within the company to provide superior products and customer service that is Ophtec’s trademark.

Establishing a successful Ophtec Germany is a huge challenge, one that I am ready and willing to accept. I hope to rely on the entire worldwide Ophtec team to help me in this endeavour.’

Arno G. Lindstädt, General Manager of Ophtec Germany a.lindstaedt@de.ophtec.com

Kelly Bok, Clinical Applications Consultant

‘Ophtec develops, manufactures and markets intraocular lenses to enhance patient’s quality of life with better vision. This is not a typical packaged goods company, where the end users simply open the box and experience the product benefits In this case, the end user is a surgical patient and experiences the full benefit of the Ophtec intraocular lens after its implantation by a skilled eye surgeon.’

‘Therefore Ophtec conducts trainings courses for surgeons and guides them in the operating rooms. Ophtec also collects post–operative follow-up information to be able to provide the surgeons with fact based information and the latest know-how to maximize the potential of the products. As a result the surgeons are happy because the patients are satisfied with their vision.

Ophtec is committed to the company motto: “Focus on Perfection” by putting the patient’s vision first.’

‘In pursuit of the company motto outside Europe, especially into the Far East, the distance has presented a great challenge: how to replicate the same clinical service level in the Far East markets? Ophtec has painstakingly selected the distributors and certified surgeons in the same fashion as in Europe.

However, being so far away from the markets, it is difficult to gauge both the surgeons’ and patients’ satisfaction level and take the necessary corrective actions.’

‘Ophtec management is now addressing this issue with a Clinical Applications Consultant for the Far East. This consultant shall establish a network with key surgeons from the Far East to learn the best practices from these experts and disseminate the know-how through communication channels such as surgeon seminars, distributor work-shops and clinical bulletins.

I am new to this game; having joined the Ophtec Asia Pacific team in February this year. The surgeons that I visited seem to like the program and share with me many of their original ideas.’

Kelly Bok Alex Lee, Director Sale & Marketing Ophtec Asia Pacific Alex@Ophtec-ap.com Kelly Bok, Clinical Applications Consultant of OPHTEC Asia Pacific Kelly@ophtec-ap.com

OPH THE RECORD 15

ARTISAN® Aphakia IOL Indications

By Erwin Bouwman

The iris-fixated Artisan Aphakia is an often used back-up lens for cataract surgery. We present an overview of cases in which an Artisan Aphakia can also be considered:

Trauma In case of traumatic cataract and loss of capsular support, an Artisan Aphakia IOL can be effective. Good results are achieved in trauma eyes, also in combination with: • cornea transplantation (Nuijts et al. 2004) • vitrectomy (Riazi et al. 2008)

Weill-Marchesani Secondary pathologies, for instance: Marfan’s Syndrome Marfan’s syndrome is a genetic disorder of the connective tissue.

Subluxated lenses occur in 60 to 80% of the cases. These might be candidates for an Artisan Aphakia (Aspiotis et al. 2006).

• Like Marfan’s, Weill-Marchesani is a genetic connective tissue disorder, often related with subluxated lenses (Por et al. 2005).

Homocystinuria • Homocystinuria represents a group of hereditary metabolic disorders. In the eye, lens subluxation due to abnormal zonulae with broken or fragmented area’s can be observed (Por et al. 2005).

Pseudoexfoliation Syndrome • PEX is a widespread and common disease, characterized by the presence of a fibrillar like substance. PEX patients often have weakened zonulae, making them less suitable for an in-the- bag IOL (Por et al. 2005).

Nuijts RM, Abhilak Missier KA, Nabar VA, Japing WJ. Artisan toric lens implantation for correction of postkeratoplasty astigmatism. Ophthalmology 2004; 111(6):1086-94.

Congenital cataract • Bilateral congenital cataracts are often associated with other diseases. In combination with insufficient capsular support, the Artisan Aphakia is an option that also provides reversibility in these young eyes with changing morphology – the Artisan can easily be exchanged for a lens with a different power.

Especially in these small eyes, regular follow-up (monitoring of the endothelium) is important.

Riazi M; Moghimi S; Najmi Z; Ghaffari R. Secondary Artisan-Verisyse intraocular lens implantation for aphakic correction in post-traumatic vitrectomized eye.

Eye 2008 Nov;22(11):1419-24.

Aspiotis M, Asproudis I, Stefaniotou M, Gorezis S, Psilas K Artisan aphakic intraocular lens implantation in cases of subluxated crystalline lenses due to Marfan syndrome J Refract Surg. 2006; 22(1):99-101.

Y.M. Por, M.J. Lavin Techniques of Intraocular Lens Suspension in the Absence of Capsular/ Zonular Support Survey of Ophthalmology 2005; 50:429-62.

IOL Constants IOL Master IOL

A Scan a-constant

SRK T a-constant

SRK II a-constant

Haigis aO a1 a2

Hoffer-Q pACD

Holladay 1

ARTISAN® Aphakia 205

115.0

115.7

115.7

-0.160

0.400

0.100

3.62

-0.08

ARTISAN® Aphakia 205 (retropupillar)*

116.8

116.9

116.8

-0.250

0.400

0.100

4.34

0.54

Orange Series™ PC 440

118.0

118.2

118.5

0.860

0.400

0.100

5.08

1.32

ErgomaX™ PC 525*

118.0

118.2

118.3

0.930

0.400

0.100

5.13

1.32

TrimaX™ PC 530*

117.8

QuadrimaX™ PC 545

118.0

118.8

119.2

1.320

0.400

0.100

5.50

1.71

118.5

118.5

1.589

0.400

0.100

5.26

1.51

MonomaX™ PC 550*

118.0

118.8

119.4

1.290

0.400

0.100

5.44

1.69

Luna™ PC 620*

119.0

119.6

120.0

1.710

0.400

0.100

5.91

2.13

Aniridia Model 311

118.5

119.0

119.0

1.902

0.400

0.100

5.55

1.79

* Also see www.augenklinik.uni-wuerzburg.de/ulib/c1.htm Version: July 5, 2011 PLEASE NOTE: The above values are estimates. All constants will have to be optimized / personalized by the surgeon. The approximate a-constants have been determined by the manufacturer. The other constants have been determined with the conversion tool on the ULIB website (User group for Laser Interference Biometry; www.augenklinik-uni-wuerzburg.de). The constants for the lens models marked with an asterisk (*) have been optimized based on clinical data of at least 50 implantations.

16 OPH THE RECORD

QuadrimaX

™

Interview with Bernard Trigaux, MD

By Laurent Pironnet

Dr Trigaux has been working with Ophtec for the past five years and performs his surgeries at the Centre Hospitalier Régional (CHR) based in Huy. Huy is about seventy kilometers away from Brussels and is located between the cities of Namur and Liège.

How many cataracts surgeries do you perform in Huy each year?

Dr Trigaux: ‘Three eye surgeons work in the CHR and we perform around seven hundred cataracts procedures per year.’

What Ophtec products did you use during these five years?

‘We started in 2007 with the Ergomax IOL and the viscoelastics solutions ArtiVisc and ArtiVisc Plus. I’ve been using the Quadrimax for over a year.’

Why did you change the Ergomax for the Quadrimax?

‘There are several reasons. The Quadrimax is more rigid than an Ergomax but the IOL can be inserted very easily with the Viscoject 1.8mm injector. I also believe the four haptics of this model offer better stability in the capsular bag. Moreover, the vaulting pushes the lens backward in a more posterior position which should improve the problem of early PCO. Last but not least, I feel more secure with the Quadrimax concerning a potential phimosis.’

After more than a year could you tell us your conclusion concerning the post-op refractive results?

‘Ophtec advises to use an A constant of 118 (contact) and 118,5 (Iolmaster). At first my patients had a slightly myopic postop result so I changed some parameters. Otherwise the results are very good and now I believe I get less PCO with the Quadrimax than with other hydrophilic lenses using the same incisions and the same surgical techniques.’

1.8 mm Micro Incision Surgery

QuadrimaX™ Hydrophilic Acrylic IOL PC545 Lens type:

One piece IOL | In the bag fixation Biconvex | asferical surface | Square edge 360˚

Total diameter:

10.50 to 11.0 mm*

Optic diameter:

5.7 / 6.0 mm*

Lens material:

Hydrophilic Acrylic

Haptieken:

4 closed loops

Angulation:

8˚

Refractive index:

1.46

AC depth:

4.96 mm

A-constant:

118.0 (ultrasound) 118.5 (laser interference)

Dioptre range:

+10.0 D to +30.0 D (1.0 D increments) +14.5 D to +25.5 D (0.5 D increments)

* Depends on dioptre

Do you use other Ophtec products?

‘We successfully implanted our first two Artisan Aphakia IOLs We don’t expect to use many of these but it is a great comfort to have a small stock of these lenses in the OR in case of secondary implantation.’

What do you expect from Ophtec in the future?

‘First of all we expect Ophtec to continue to deliver unique and reliable products. But also the service must stay very good too.

The surgeons must rely on prompt and accurate answers and information. The proactivity and the knowledge of the representative are crucial.’

Nano Cartridge

OPH THE RECORD 17

ArtiVisc & ArtiViscPlus ®

®

ArtiVisc® & ArtiViscPlus® (sodium hyaloronic acid), combine high viscosity and high elasticity with high molecular weight.

They provide protection of endothelial cells and allow tissue manoeuvres whenever this is needed in cataract and refractive surgery.

Successful use in patients with

By Anna Bilstra We notice an increase in the use of Artisan and Artiflex PIOLs in patients with keratoconus, especially with the toric models.

Although results cannot be expected to be the same as in patients without cornea deviations, satisfying results have been reported.

We performed a search in literature for general precautions and clinical results.

Advantages Advantages of PIOL implantations include high power coverage, astigmatism correction (up to 7.5 D with Artisan Toric), reversibility, increased image size and reduced image distortion (table 1).

Table 1: Advantages of PIOL implantation in patients with keratoconus

Reversibility

Progression of keratoconus can lead to change in refraction. In that case Artisan / Artiflex iris fixated lenses can easily be exchanged In case of a cornea transplantation or cataract surgery, iris fixated lenses can easily be removed

The position of a PIOL compared to spectacles or contact lenses has advantages

Image size: the closer the corrective lens to the retina, the larger the magnification of the image Image distortion: the position of the corrective lens behind the irregular cornea provides better optical image in the macula

Patient selection • Patients who have exhausted non surgical options, like contact lenses • Transparent cornea • BSCVA 20/50 (0.40) or better pre-op • No change in refraction or topography for 1 year

Contraindications

P high viscosity P high elasticity P non inflammatory P outstanding optical clarity P no airbubble formation

www.ophtec.com 18 OPH THE RECORD

• Unstable refraction. This leads to unpredictable outcome and possibly necessity for PIOL exchange • Irregular astigmatism. The toric PIOL cannot be aligned with irregular corneal astigmatism. The outcome is unpredictable and possibly the quality of vision will be disappointing

Improve results • Crosslinking before PIOL implantation: stabilization of cornea to increase predictability and stability • Intra Corneal Ring Segments (ICRS / Intacs): reshape cornea to reduce irregular astigmatism

of ARTISAN® and ARTIFLEX® Keratoconus Corneal Thinning

Examples of clinical results: Izquierdo et al. 2011: Crosslinking (CXL) followed by Artiflex Myopia after 6 months • Prospective, 11 eyes with 6 months follow-up Results • UCVA: figure 1. Gain of 5 or more lines in 100% • EC count after CXL: 2739 ± 157 cells/mm2 • EC count after Artiflex: 2669 ± 133 cells/mm2

Normal Eye Source: National Eye Institute

Keratoconus

Source: NEI / Elio Spinello MPH, EdD

1,4

UCVA (logMAR)

1,2 1,0 Pre-op

0,8 Before ARTIFLEX

0,6

After ARTIFLEX

0,4 0,2 0,0

Figure 1: Uncorrected visual acuity (UCVA) in LogMAR. Based on Izquierdo et al, 2011.

Note: Low logMAR values means good visual acuity.

Conclusions • The use of Artisan / Artiflex Phakic IOLs in patients with stable keratoconus for correction of astigmatism and myopia is safe, predictable and effective with minimal complications, also in combination with Crosslinking or intracorneal rings.

• Post-op vision may not be perfect, it is important to manage expectations. The goal for PIOL implantation in patients with keratoconus is an attempt to postpone a possible corneal graft for a long time. Patients need to be informed that progression of keratoconus can lead to change in refraction. This may necessitate cross linking and PIOL exchange, contact lens or glasses.

Venter. 2009: Artisan Phakic Intraocular Lens in patients with keratoconus Artisan / Artiflex and Keratoconus patients in literature

• Retrospective • 18 eyes (12 Artisan Toric, 6 Artisan Myopia) • Follow-up 6 to 12 months

Artiflex after CXL Izquierdo L Jr, Henriquez MA, McCarthy M. Artiflex Phakic Intraocular Lens Implantation After Corneal Collagen Cross-linking in Keratoconic Eyes; J Refract Surg. 2011; 27(7):482-7.

Results BCVA: figure 2

Artisan/Artiflex after Intracorneal ring segments

100%

Cakir H, Utine CA. Combined Kerarings and Artisan/Artiflex IOLs in Keratectasia; J Refract Surg. 2010; April epub.

Eyes (% )

80%

Pre-op Post-op

60%

Artisan (Toric)

40%

Sedaghat M, Ansari-Astaneh MR, Zarei-Ghanavati M, Davis SW, Sikder S. Artisan Iris-supported Phakic IOL Implantation in Patients With Keratoconus: A Review of Sixteen Eyes; J Refract Surg. 2011; Jul;27(7):489-93.

20% 0%

Kamburoglu G, Ertan A, Bahadir M. Implantation of Artisan toric phakic intraocular lens following Intacs in a patient with Keratoconus; J Cataract Refract Surgery 2007; 33(3):528-530.

Venter J. Artisan Phakic Intraocular Lens in Patients with Keratoconus; J Refract Surg. 2009; 25(9):759-64.

1.25

1.0

0.8

0.63

≤0.5

Figure 2: Cumulative best corrected visual acuity (BCVA) in Snellen Decimals before and after Artisan PIOL implantation. Based on Venter, 2009.

Budo C, Bartels MC, van Rij G Implantation of Artisan phakic toric intraocular lenses for the correction of astigmatism and spherical errors in patients with Keratoconus; J Refract Surg. 2005; 21(3): 218-22.

OPH THE RECORD 19

The Jump to Perfection in Refractive Surgery

Artiflex TORIC PIOL OPHTEC | Refractive Surgery

VacuFix™

Vacuum system for a perfect enclavation of all ARTISAN® / ARTIFLEX® (Toric) (P)IOLs

PRECISION

• Best positioning and centration of the (Toric) (P)IOL • Fixed reproducible amount of iris tissue

ONE SYSTEM FIXATES ALL

• Myopia, Hyperopia, Aphakia and Toric IOLs

www.ophtec.com