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IOLMaster - A Practical Operation Guide

1. IOLMaster A Practical Operation Guide MB by Joel H Emerson and Kelly Tompkins Clinical Application Specialists Carl Zeiss Meditec Copyright Carl Zeiss Meditec Inc All rights reserved Trademarks lOLMaster is either a registered trademark or trademark of Carl Zeiss Meditec Inc in the United and or other countries All other trademarks used in this document are the property of their respective owners IOLMaster A Practical Operation Guide Contents i Contents PtrOCUCTION PRRRRREREEEEEREFEFFEEEEEEREEEREEREEREEREEEEEEEFERERRERRREREREERRRRRERRERRRERRERRERREERRERREERERERRRERRRERRRRRRR V 1 The Eye and the IOLMaster ssssssnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn 1 1 PEVOS and Optics 101 1 1 eHow the Lenses of the Eye Work cccccsscscscsesseseeseeseceessesseseesaesaesaeseesassaeseseessessessessessesaes 1 2 2 Entering Surgeon Names and Lenses uunnunnunnunnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn 2 1 e Adding Surgeon Names tenteactasesesiierezecuse tan eseticnretesuictin uevcwasronetsdateaduuapesdiealadsrwuedost atancuaedscemtadeaaatss 2 1 Choosing A Lens Modification Option nursensensennennnsnnennnnnensennennnnennennennennennnnnnnnnnnnnnnn 2 3 AUGING A LenS te ee 2 5 e Downloading and Importing Lenses u u 0420u4004n0nnennnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn 2 7 3 Preparing Your Patient for Testing uuuuuunnonnnnnnnnnn
2. Mustermann E mma 04r 29 1922 0870 Mustermann E va 02 03 1920 08 03 Mustermann E va 08718 1920 08 08 Mustermann Hedwig 1172971922 08 Mustermann Heinz 017 0171911 09 1 Mustermann Helene 02021941 08 Mustermann Helene04 15 1920 08 Mustermann Helga 02 037 1931 08 1 Mustermann Hildegard 05 05 1911 0 Mustermann lle 037 1671927 08 04 Mustermann ngeborg 09 25 1 930 08 Mustermann Johann 07 1 371932 08 Mustermann Kathe 1 0 03 17 914 081 Mustermann Kathi1 1 161 926 08 01 Mustermann Klaus 03 09 1 926 06 01 Mustermann Knut 09 21 1970 08 17 Mustermann Lillemor 03 1 6 1981 OF Mustermann Ludmilla 08 05 1939 07 Mustermann M antfred 17 09 1 929 08 Mustermann M arga 10 25 1 929 07 0 lOLMaster A Practical Operation Guide Repeat steps 5 through 7 for all desired patients implanted with this IOL type Note that you must transfer separately each patients opposite eye A minimum of 10 entries is required for optimization but at least 20 is prefera Once you have selected all the patients for this lens type you will see them listed on the lett side of your screen as shown below You are ready to proceed to the next set of steps Mustermann M aranne d2 15 1915 07 0 Mustermann Mathilde 01 01 71923 08 0 Mustermann ttt 09 061 900 07 06 2000 Optimizing Lenses John O Public 0 0 lene 1 9 select patient pen jse efs eiz m 10 enter IOL power a E 11 enter Post Op refraction
3. How to Perform the Test Keratometer Mode Manual This is the measurement of how steep or flat the cornea is The test moves into Keratometer Mode when you press the space bar while in Axial Length Mode To return to Keratometer Mode from another screen click the Keratometer Moae icon Alternatively you can press the letter K on your keyboard 1 First move the scanner left and right as needed and aber Genes Alan pe rotate the joystick to move the scanner up and down as ne needed to get the spot of light dead center in your target Unlike the axial length test the spot can t be just anywhere in the green circle it must be right in the center 2 Next you ll want to focus the outer six lights Because the cornea is curved the central spot is nearer to the scanner than the outer six spots Therefore you cannot have both the central spot and the outer six spots focused at the same time Z Best Practice In summary while you want to center the central spot you want to focus the peripheral spots Being in focus means having the lights small and sharp When in focus most If not all of the six outer spots will have thin rings or halos around them like a view of Saturn trom above Look for these rings to make sure they are in focus yy Helptul hint on focusing the peripheral spots If you are having trouble getting the outer spots in focus first focus the central spot to be as small and sharp as possible
4. 02 03 1931 08 11 Mustermann Hilda 0172771921 08 15 Mustermann Hilde 02 1 5 1 930 08 04 Mustermann Hildegard 05 05 1 911 oi Mustermann lle 037 1671927 08 044 Mustermann Ingeborg 09 25 1930 0E Mustermann Irmgard 077 217 1923 087 Mustermann Johann 07 1 371932 08 z Mustermann Kathe 1 0 03 1971 4 08 1 7 click lt lt gt Mustermann K thi 11 18 1926 08 01 i Mustermann Klaus 03 09 1926 08701 Mustermann Kr ut 037 2171970 08 71 7 5 Select the patient Make sure that patient s file has measurement data and is not filled with O s zeros Check the data in the fields labeled AL for axial length K for corneal curvature etc If the measurement data is filled with O s it means there was more than one file created for that patient Therefore that patient probably is listed more than once on the right side Select another entry for that patient until you find the one with measurement data in it lOLMaster A Practical Operation Guide Optimizing Lenses Ze 6 Select the surgical eye and select the checkbox labeled keep other side in table This will keep the other eye available in the right hand list for later use 7 Click the left arrow lt lt button at lower left to transfer the data file for the 8 click OK 8 Click OK The next screen looks as shown below selected eye over to the left side of the screen Assign data records Mustermann Antonia 057 1871921 07 AS Mustermann 0 aniela 06 25 1 970 08
5. Ble Max ALM 5 OD Sol amp i Sample If individual axial lengths differ by more than 0 05 mm from their mean the message multiple peaks will appear This does not mean the composite signal is unreliable nor that the composite axial length is incorrect However in such cases we strongly recommend that you closely review the composite signal and the individual axial lengths as you review adhere to the Best Practice described under What to do with double peaks on page 4 8 Signal to Noise Ratio or SNR The SNR or Signal to Noise Ratio helps you evaluate how high your peak is compared to the background static line This number appears in the lower right corner of the screen after each measurement After five or more measurements a traffic light appears along with the SNR value If the SNR is too low less than 1 6 a red stop light will appear above it and the word error will appear in the data column instead of a measurement lOLMaster A Practical Operation Guide Taking Measurements If the SNR is of borderline quality between 1 6 and 2 0 inclusive a yellow caution light will appear above it and a numeric AL value will appear in the data column but it will have an exclamation mark after it If the SNR is high enough above 2 0 a green go light will appear above it and a numeric AL value will appear in the data column as normal Important Note A
6. Cataract Surgery When cataract surgery is performed the cataract is not merely peeled off of the lens remember the cataract and the lens actually are the same thing Instead the lens which has become the cataract is removed from the eye The good news is that more light can get into the eye now since the cataract has been removed The bad news is that without the crystalline lens the eye is left with only the cornea to focus images ot light Though the cornea is powerful about twice as powertul as the crystalline lens typically it is still not powertul enough by itself to focus images properly E onto the retina Thus if the cataract is removed and nothing more is done the patient is lett aphakic literally without a lens In most cases aphakic eyes are farsighted distant images are blurred and nearby images are even worse This is because the eye is shorter than the distance the cornea needs to focus the image by itself Placing a lens in front of the eye either a thick lens in a pair of glasses or a hard contact lens on the corneal surface can help an aphakic eye to focus the image onto the retina Since the 1940 s though there has been the option to implant a small synthetic lens inside the eye itself which provides the patient clear vision with minimal need for glasses or contact lenses Over the past six decades techniques and technologies have improved continuously yielding sater surgeries and be
7. Mustermann Otto 017017 1911 0971 Ea n Mustermann walter 10 22 1791 g 08 0272 Mustermann waltraut 02729 1928 08 02 Mustermann w altraut 1171771921 08 02 Mustermann Werner 09 02 1915 08 07 2 14 click Optimize 14 Click Optimize You will see a blue progress bar going across your screen while the instrument is calculating your new lens constants When it is finished calculating the new lens constant values it will display those new numbers in the New column near the center If there are dashes in any or all of the fields this means you need to add more patients to the optimization then press Optimize again Evaluate the new proposed lens constant numbers and show to the surgeon 15 click lt lt after surgeon approves new val the new values ew values appear 16 click OK to exit 15 If these numbers are acceptable to the surgeon click the lt lt button between the New and the Basis column headings These new values now become your current lens constants It is important that the surgeon is aware of this because IOLMaster A Practical Operation Guide Optimizing Lenses the surgical outcomes will be affected These optimized numbers will be closer to the target retraction and if the surgeon has been using a fudge factor that may no longer be necessary Important Note This transfer of constants is permanent You may want to consider writing down the old Basis numbers on a piece of paper b
8. To delete such erroneous measurements click to highlight the word error and press the Delete key What to do with double peaks Double peaks are caused when it is unclear which retinal layer is providing the brightest reflection Patients with a blond or otherwise pale fundus or with macular pathology or who are fixating slightly off center may have double peaks in their graphs First of all if you suspect that you have a graph with a double peak you can check this by zooming in on the graph To zoom in click the black x axis line directly below the red spike If you still can t tell zoom in further the same way again click the black x axis line directly below the red spike Right click to go back to the Original graph size gt If there s only one peak and the graph looks typical then use this as your anchor and delete all measurements that are not within 0 05 mm of this number It there are two peaks whichever peak is clearly the taller of the two will automatically have the dot above it If the dot is over the top of the right hand peak then you re probably still okay Just pick another graph or two Try to find a graph that has just a single peak with a dot over it and use that as your anchor to know which measurements to delete If there are two peaks and the dot is between the two peaks or the dot is over the left peak then we have a problem See the Best Practice section below for
9. To do this press the lt M gt key the Automatic mode display will disappear Keep in mind you will now lOLMaster A Practical Operation Guide Taking Measurements have to manually ensure correct alignment as described above Press the lt M gt key to re activate the automatic mode The automatic mode will always be switched back on for the other eye and for every new patient Environmental Conditions Avoid any light hitting the IOLMaster or the examined eye directly or trom the side The best results will be obtained when the examination room is slightly dimmed Untavorable room illumination will be indicated by a sun symbol In addition the slit illumination may be flashing on and off In this case additional dark exposures are being taken to improve the measurement results Error Messages If the IOLMaster is not properly aligned the images of the anterior lens and or cornea cannot be evaluated In this case the message Measuring error and a reference to the lacking or unrecognized image feature are displayed In addition the first image that has caused a measuring error is displayed With SHOW SEQUENCE all five images are displayed in succession for error analysis The anterior chamber depth measurement may be repeated as often as desired ACD viewing evaluation X Troubleshooting If you attempt an ACD measurement and a message box appears asking you to manually type in the corneal curvature measurements t
10. rectly Be sure to click on the by the patient s name then click on the date they were in for their exam then click Open Clicking on the patients name and then on New or double clicking on the patients name will provide you with nothing in the way of data These just add another visit date to that patient s file Third don t forget that once you get into a certain patient s file you will be in Overview Mode and you will need to click on one of the measurement modes to view the measurements that were taken that day Fourth if you have done everything described above correctly and there s still nothing there then the data is in fact gone Most likely there has been an interruption in the power supply a flicker a blackout an improper shutdown etc which has caused the computer to essentially have a partial crash Data lost in this way cannot be retrieved but hopefully you still have the hardcopy you printed out at the time of the test You may want to consider the use of an Uninterruptible Power Supply UPS If you are still losing data even with the use of a UPS then the problem may lie within the IOLMaster itself In this case call Customer Service and explain that you are losing patient data even though you are shutting down properly and are using a UPS to prevent power interrup tions Read through Chapter 7 for more details uae Note Occasionally there is a glitch which causes the data to be absent shortly
11. 2 Choose which formula you want in each of the four columns lOLMaster A Practical Operation Guide Lens Calculations 3 Click on IOL Calculation and the Print This is useful tor practices that utilize mainly one type of lens for nearly every patient Using the Multi Formula tab the surgeon can compare what different formulas calculate for that one lens The Haigis L Formula This is a relatively new formula a modified version of the Haigis formula which is usetul for calculating lenses for eyes that have had myopic LASIK surgery Because the Haigis L does not make use of corneal power to predict post operative lens position it is unaffected by the errors that other formulas make in this regard Please research this formula further if you are interested in using it Multiple papers are published on this formula In terms of performing the calculations and printing out the results use this tab just like you would the regular Haigis formula New with version 5 software Haigis L Formula now also for eyes which underwent hyperopic LVC For post retractive surgery patients the system offers the Haigis L formula for eyes that have undergone myopic or hyperopic LVC LASIK PRK LASEK The Phakic IOL Formula Some patients would like to have LASIK to correct their nearsightedness but cannot have the procedure for example because their cornea is too thin Now there is an alternative the Phakic IOL Essentially this procedure impl
12. 97a Please make sure you are following the correct ACD alignment technique as described in the User s Manual e Make sure the fixation point is in focus and inside the green box e The fixation point should be between the images of the cornea and the crystalline lens closer to the lens but not touching It e Avoid any bright reflections on the cornea Cornea Lens 1 Focus fixation spot 2 Place in green box 3 Place near lens section 4 Push joystick button ns gt Important Note Because the ACD adjustment aid improves the quality of alignment you may get ACD readings that differ from readings obtained in manual mode Differences smaller than 0 1mm are within the measurement tolerance and are no reason for concern Generally the ACD adjustment aid will increase the repeatability of your results Adjustment Aid Automatic Mode Arrows will point in the direction the joystick should be moved in order to reach the best measurement position In Automatic mode the measurement can be activated by pressing the joystick button Automatic activated before the optimum measurement position has been reached The measurement is then triggered automatically as soon as the traffic light turns green Important Manual Mode In some cases you may not be able to get the traffic light to turn green In such cases you can temporarily de activate the automatic mode allowing a measurement to be taken even when the light is yellow or red
13. Snellen Database Erase records alter 365 days Patients wal be identified by Mame first name D Number Display Radus i Comeal K s Cytinder Cylinder Den hss Caution K eratomster indices affect comeal power for a gwen Refractive Index 1 3375 T radus of curvature Adjustment aid Keratometer Antenor Chamber Depth M Adjustment aid KER I Automatic KER i Adjustment aid ACD I Automatic ACD Printing IOL Calculation one eye per page both eyes on page I Emmetropy IOL Clinic You will also see a checkbox to select Adjustment aid Selecting Adjustment aid provides you a traffic light symbol that indicates the status of your focus e Red light System out of focus e Yellow light System near best focus e Green light System in best focus position As always be sure the central spot is dead center in the target and that the six peripheral lights are small and sharp preferably with those thin Saturn rings around them Remind the patient to look straight ahead at the light Press the joystick to activate automatic acquisition the system will acquire three measurements in rapid succession as long as the optinum measurement condition green light has been reached Press the M key to switch back to manual mode If an average of the three measurements appears proceed to Part 3 Anterior Chamber Measurement page 4 21 Just press the space bar on your ke
14. focal point and then begin to spread out or diverge once again When these diverging rays reach the retina an image of light is projected there as if on a movie screen at the theater Because the image appears beyond the focal point it is flipped around backwards and upside down But the brain expects this and automatically corrects the image s orientation when it is processing the nerve impulses it receives trom the retina Cataracts There are a number of patients who will come to your office under the impression that a cataract is a film or growth that forms over the cornea It is a myth perpetuated by novels and movies in which blind characters have cloudy white corneas While the cornea can certainly become cloudy over time that is not a cataract A cataract is just another name for the crystalline lens it is what the lens is called after one or more of its layers have become clouded to the point that is affecting the patient s vision or to the point that the doctor can clearly see it A lOLMaster A Practical Operation Guide The Eye and the IOLMaster MEE cataractous lens does not focus images of light as well as a clear crystalline lens would by the time the images pass through the cataract they may have become blurred or faded out Conversely some cataracts may also cause light to become scattered as it passes through the lens causing sources of light to seem overly bright with distracting streaks and glare
15. further information It both peaks are of fairly equal height then the computer will split the difference and put the dot between them Best Practice If you have a graph with two peaks It is probably simplest and best to delete the measurement that goes with the double peak graph and take a few more measurements trying to get more single peak graphs However for some patients espedally patients with blond or pale retina or with macular lOLMaster A Practical Operation Guide Taking Measurements pathologies most of your graphs may end up having double peaks If you were to delete all double peaks then you would not have enough good measurements left So again the right hand peak Is usually the correct one Just save all the measurements that have a dot over the nght hand peak and delete all the measurements with a dot in between or over the left peak Although it is possible fo move the measurement cursor to a different peak by holding down the left mouse button and dragging it to a different peak doing this will change the axial length measurement Therefore we don t recommend that you do this unless you are very experienced with this process Please see the user manual for more detailed information on how to ao this Double peaks from patients with an existing IOL When measuring a patient with a phakic IOL or a patient who is pseudophakic from previous cataract surgery it is possible to get a double peak t
16. high SNR does not necessarily mean you have a good scan A blink for instance often produces a very high SNR because the distance between the highest peak and the bottomed out background Static is quite a lot Another possibility is having a great central spike height and thus a good SNR but retinal pathology causes the peak to be split in two providing the wrong results In short the SNR is relevant only when taken in conjunction with the appearance of the graph Best practice After you have taken 5 measurements if you don t have a green light above the SNR value you should take more measurements until you do have a green light Important Note Because IOLMaster measures with a laser the system will allow you to attempt the measurement up to twenty times Even if you delete some measurements the system still will prevent you from acquiring more than twenty measurements per eye each day Some practices regularly take all twenty measurements instead of taking only the required five Once you have become practiced and efficient at obtaining axial length measurements it only takes a few more seconds to acquire all twenty measurements compared to the required five This increases your likelinood of obtaining a valid reading and also improves your skills in obtaining good scans As you are taking measurements intentionally move the spot of light around in the green circle and take each measurement at a new location D
17. implant e Stable post op refraction And that means stab e at the very least six weeks alter the surgery if not eight or more weeks You will need to have at least 10 such results per lens per doctor The more the better it is recommended to have at least 20 4 You are now ready to fill out the Personalization Data Sheet provided Tor you on the next page Make copies of it so you can use it for each lens that you optimize IOLMaster A Practical Operation Guide 1OLMaster Lens Constant Personalization Data Sheet IOL Make Model IOL Location Sx Eye 3 Patient Name or ID Sx Date RorL IOL Power D Post Op Refraction Notes Each Surgeon and IOL Brand Model must have its own data sheet OL Power must be power listed on IOL packaging label in the chart for this patient eye Patient post operative Visual Acuity must be stable and 20 30 or better Optimizing Lenses Ze Lets Get Started You will need to take all of the data you have gathered put it on your Personalization Data Sheet and be in front of the IOLMaster Follow these step by Step instructions to enter your data into the optimization program New Patient 1 From the New PATIENT screen select User Database trom the Options menu Patient eier EN j Ba click Options gt User Database A dialog titled Please enter password User Database appears vice Je nal Please enter password x Administrator Password Carl Zeiss 2 sel
18. important to understand what this system is testing the human eye So in this chapter we ll discuss the various structures of the eye how they assist in focusing light and how cataracts and cataract surgery affect this ability to focus light Do you need to read this chapter in order to operate the IOLMaster Well technically no you don t You can follow the steps for testing the eye described in Chapter 4 but strongly advise against skipping ahead The human eye is a marvelous and complex organ and understanding how it interacts with light both before and after cataract surgery uwill give you a better perspective and a more intuitive grasp of the IOLMaster Of course if you are a doctor or a technician well experienced in the anterior segment what follows will undoubtedly be old news to you But for those new to the ophthalmic field in general or the anterior segment that is the tront half of the eye in particular believe you will find this chapter very useful Eyes and Optics 101 For the purposes of explaining how the eye works were going to simplity the anatomy and mechanisms of the eye and say that the eye is comprised of three main parts the cornea the crystalline lens and the retina Cornea The crystalline lens is a clear structure about the size and shape of an M amp M which sits just behind the dark pupil of the eye Despite it s name this lens is not made of crystal but is transp
19. lens will be needed for surgery Proceed to IOL Calculation Mode by pressing the letter I on the keyboard or click on the OL Calculation icon See Chapter 5 Lens Calculations for details Please refer to Chapter 5 to learn about lens calculations and how to perform them You ll see that many lens calculation formulas such as the Hoffer Q the Holliday and the SRK T only require the axial length and corneal curvature measurements However there are some more complex formulas such as the Haigis and the Holliday II that require anterior chamber depth and white to white measurements lOLMaster A Practical Operation Guide Lens Calculations 5 1 5 Lens Calculations Now that you have acquired measurements of your patients eyes you can use them to determine what IOL power your patient needs to have the best possible post operative vision cae Important Note This chapter assumes your IOLMaster system has the surgeons names and their favorite lens implants already programmed into the computer If the surgeons and lenses are not yet entered refer to Chapter 2 for instructions to do so Lens Calculation Mode After you have completed measuring both eyes you can activate the IOL Calculation Mode by pressing I on the keyboard or by clicking OL Calculation icon Note that pressing the space bar will not take you to this mode formula tabs OL Zalculakeon Hase SAKE II Haflerdl Holladay SREST M
20. needed and rotate the joystick to move the scanner up and down as needed to get the spot ot light within the green circle The spot of light just needs to be somewhere within the green circle It does not need to be dead center Some 6 amp Se B times in fact intentionally moving the spot around within ALM 0 OD the circle will help you to scan around a dense area of the cataract 2 Next you ll want to focus the spot of light Again if you ve just come here from Overview Mode chances are the spot will be fairly small and sharp already But if not move the scanner forward toward the patient or pull it back away trom the patient as needed to focus the image on the eye You ll know you are in focus when the little spot of light on the pupil becomes very small and sharp Sometimes it s hard to tell if the spot is really as small and sharp as it can be But you can double check your focus by looking at the vertical line of light that extends up and down from the central spot If this line is thin and sharp then you re in focus 3 Now say to the patient Blink a couple times now stop blinking and look straight ahead at the light Push the joystick button The screen flashes for a second and then a number appears in the left or right eye data column If you re testing the right eye the number appears on the left and vice versa This number is the axial length or AL for short which is the length
21. numbers is missing or blurred spots of light Sometimes the computer still has enough information to obtain consistent results and give you an average but sometimes not and you have to work a little harder to get three good measurements Conveniently if the computer notices a blurred or missing spot of light it will warn you of this after you push the joystick button by showing you a small image at the bottom of the screen This image has six small dots like the six spots of light on the cornea One or more of these dots will be flashing to indicate which of the corresponding spots of light the system is having trouble measuring If you have tried all of our suggestions but you are still getting error messages instead of readings you can if all else fails obtain the K s from a different source such as an ATLAS Corneal Topographer or a manual keratometer and manually type these alternative measurements in when performing the lens calculations see Chapter Five for details However using non IOLMaster corneal measurements involves its own set of risks and difficulties so it s best to keep trying to get the K s with the IOLMaster see a more detailed explanation of this in Chapter Five Unlike the Axial Length Mode this part of the testing is not a laser so you can try as many times as you like lOLMaster A Practical Operation Guide Taking Measurements Important Note Regarding K s from other sources you may notice that
22. of each pair are compared to determine corneal curvature and astigmatism as a radial measurement A radial measurement is the radius that is half the diameter of an imaginary circle drawn on the cornea and extending axially into the eye connecting each pair of points This measurement is made as shown below lOLMaster A Practical Operation Guide cornea Taking Measurements Here is a side view of a cornea Notice how it is not perfectly round but more like a bell curve In this representation there are two beams of light shining on the cornea those beams represent two of the six beams that shine onto the cornea to give the six reflective spots of the Corneal Curvature Mode From the positions of the focused spots on the cornea the computer can tell how curved the cornea is at each spot The nearness of the spots to one another indicates how steep or flat the cornea is between those points Flatter corneas cause the spots to be located further from one another whereas steeper corneas cause the spots to be located closer together The computer determines the radius an imaginary line that extends into the eye perpendicular to the corneal surface from the reflection spot These two lines meet at the center of the imaginary circle The corneal surface between the two points of reflection are sections of a circle while the point where the two lines meet is the center of this same circle Thus an imaginary circle is forme
23. of the eye the distance trom the cornea to the retina measured in millimeters mm lOLMaster A Practical Operation Guide Taking Measurements Ze amp Best practice The OlMaster requires you to take at least 5 measurements It Is a good idea to take these five measurements with the white light in different guadrants of the green circle Take the first one in the center and then for each successive measurement rotate the joystick to move the white light and take a measurement in each of the four quadrants of the green circle We also recommend that you take two more measurements one after you pull the joystick back and defocus the light to the size of the green circle and a second after you push the Joystick in towards the patient again This will give you a total of 7 measurements The reason for taking measurements in this way Is to try to get around some of the denser opacities of a patients cataract The image below shows how cataracts have varying opacity in different areas of the lens and you may tind that you get a better signal in areas where the cataract isn t as dense 4 Evaluate your results You can evaluate the quality of your scans in two ways First by evaluating the waveform graph itself and second by the SNR value Evaluating the Waveform Graph The waveform graph is the red spiky line superimposed on the video image after each push of the button A good graph should have one tall spike ending in a
24. of the data is stored nearly indefinitely in the list of patients accessed for the Optimization function Furthermore copies of the measurements should be kept in the patient s record to serve as a backup akin to keeping printouts of ultrasound A scans in the records As described earlier in the Lost Data section see page 7 1 if you need to recalculate the IOL for a patient and for whatever reason the patient data is not on the instrument you can recreate a data record and recalculate the IOL at anytime in the future as long as you have the printout with the measurements on it lOLMaster A Practical Operation Guide Data Management For more in depth information on the export transmit process please read the appropriate section of the user manual and it you need further assistance please contact Carl Zeiss Meditec technical support at 1 800 341 6968 Important Note If your questions involve networking and or computer interface issues you will need to have your company s IT specialist contact technical support directly to insure proper and effective communication IOLMaster A Practical Operation Guide Frequently Asked Questions I 8 Frequently Asked Questions need more help than this guide or the user manual can provide Who do contact If you have a question about the manual operation of your system how to test an eye how to print results how to enter a new lens etc and you can wait about one busines
25. should give you and idea of what s going on In the illustrations above we ve seen two of the six reflected spots of light If every cornea were equally curved all the way around two spots is all we would need But of course that would make things too easy In reality almost every cornea has a detectable amount of astigmatism that is the cornea has irregular curvature For example it may have a steeper curvature along the 90 degree axis and a flatter curvature along the 180 degree axis Because of the possible irregularity multiple areas of the cornea must be tested In the end all of the circles and their radii are combined together into one set of measurements showing the steepest curvature and at what axis the flattest curvature and at what axis and the difference between the two Finally the computer converts these composite radial measurements into the more familiar diopters Whereas radius is a measurement of shape diopter is a measurement of light bending power A lens with one diopter of power can focus parallel rays of light to a point one meter behind the lens A lens with two diopters can focus the light closer to one half of a meter Three diopters focuses to one third of a meter four diopters to one fourth of meter and so on The computer determines the total corneal power from the anterior curvature of the cornea using the keratometer index of 1 3375 lOLMaster A Practical Operation Guide Taking Measurements
26. spot make it as small and sharp as possible 3 Now that the spot is small move the scanner to the right or left as needed without moving forward or back since that would mess up the focus to get the spot positioned between the two arcs of light lens reflection The outer arc the blurrier one that is closer to the patient s temple is the cor neal reflection It will almost always be outside the box which is okay The inner arc the sharper one that seems to be inside the pupil and is closest to the patient s nose is the lens reflection Both the focused solitary spot and the lens reflection arc should be within the box In addition the spot should be close to this arc about one spot s size away but without touching Have the patient blink a time or two then push the joystick button The com puter takes five quick measurements and averages them for you 4 Make a mental note of what the number is get refocused and realigned then try the measurement again to see if you get a similar number You do not have to delete the original set of numbers simply push the joystick button again and it will overwrite what was there before If your new measurement is within 0 10 mm of your original number you re okay to proceed to the next measurement using White to White Mode Just press the space bar to advance to that mode lOLMaster A Practical Operation Guide Taking Measurements If your new measurement is more
27. than 0 10 mm off keep on performing the measurements until you are able to get consistent numbers Important Note This test uses a bright light Be sure to warn the patient of this Remind them to look at the light inside the instrument not at the light coming from the side Also needless to say you ll want to be as quick and efficient at this test as possible to minimize patient discomfort and subsequent lack of cooperation New with version 5 software ACD Measurement Adjustment Aid By clicking on the Video Help button in the upper right corner of the ACD Measurement window you can play a video illustrating the optinum measurement position Note There is no audio to accompany the video presentation A traffic light display helps you find the optimum ACD measurement position Please note the ACD adjustment aid is monitoring the correct instrument alignment Only when the optimum measurement position has been reached the traffic light will change from red to yellow and then trom yellow to green When the traffic light turns green the instrument will allow ACD measurements The traffic light can be activated deactivated under Options gt Program Settings gt Program Max Muster I0LMaster Advanced Technology T Focus fixation spot 2 Place in green box 3 Place near lens section 4 Push joystick button aalus el e aisle a Ready Max Muster ACD OD lOLMaster A Practical Operation Guide Taking Measurements
28. the lOLMaster may provide slightly different corneal curvature measurements than manual keratometry This is for several different reasons e First manual keratometry measures the corneal curvature more peripherally perhaps at 3 0 mm or 3 2 mm depending on your manual system while the OLMaster measures the more relevant central curvature at 2 5 mm Thus on a typical eye OLMaster K s will be slightly steeper than manual K s while on a post retractive eye the IOLMaster K s may be slightly flatter e Second the IOLMaster determines curvature by measuring the relative position of six spots on the cornea rather than the two mires of manual keratometry thus providing more detail e Third if your IOLMaster is set to give curvature results in diopters rather than millimeters radius the original radius is converted into diopters using the keratometer refractive index of 1 3375 as opposed to some other keratometry systems Part 3 Anterior Chamber Measurement Anterior Chamber Depth ACD Mode In ACD mode you measure the distance from the cornea to the front surface of the natural crystalline lens a measurement that certain more advanced calculation formulas require The test moves into this mode when you press the space bar from the Corneal Curvature Mode To return to ACD Mode from another screen click the Anterior Chamber Depth ACD icon at the bottom your screen Alternatively you can press the letter D on your keyboar
29. the cataract can unnaturally alter lOLMaster A Practical Operation Guide Lens Calculations 5 9 refraction results Instead these numbers should come from the refraction that was considered stable after the refractive surgery 2 Now that you ve entered all of your data select the Apply checkbox next to the data you ve just entered 3 Finally click on the formula tab you normally would have used for this patient and print out your results trom there You will notice that the corneal curvature measurements have been altered Contact Lens Method The Contact Lens Method requires putting a rigid gas permeable contact lens on your patient s eye and doing an over retraction with the contact lens on as well as entering other data Very important note If you are doing all of your patient s testing on the same day it is critical that you place the contact lens on the patient s eye only after all of the other testing is performed including performing an uncorrected refraction on the phoropter Otherwise you risk disturbing the corneal surface and or the integrity of the tear film and thus potentially distorting other measurements 1 Manually enter the following data e CL Power This is the diopter strength of the contact lens you are using for this measurement e CL base curve This is the curvature of the contact lens which should be printed on the box it came in e Refr with CL This is the phoropter refract
30. 118 5 pACD 5 72 sf 1 96 A 119 2 A 119 7 49 12 re A 118 9 se al 0 40 pACD 5 68 sf 1 89 A 119 1 A 119 3 135 3 series A 118 4 0921o 01040 PACD 5 82 sf 2 02 A 119 2 A 119 8 14 3 Ai ee a aaa 1 29 al 0 40 A STEN See A eee a a20 A 120 Ni2f14 2 rot As you can see there is a lens constant surgeon factor tor each formula that is used on the IOLMaster Please note that the nominal value is the manufac turer s lens constant You can check Dr Warren Hill s website www doctor hill com for some addi tional optimized lens constants He has some of these posted for you to get started including some A C IOL constants cs Important Note Specific A constants found on the ULIB website and Dr Hill s website are not recommended by Carl Zeiss Meditec You must examine them and determine if they are right for you 2 Side by Side comparison study Measure the axial length on the IOLMaster Then measure the axial length with contact ultrasound A scan You should measure 10 to 20 patients Subtract the ultrasound s average axial length trom the IOLMaster s average axial length This will produce a very small number probably around 0 10 or 0 15 Whatever this small number is multiply it by 3 Then add this new number to your manufacturer s A constant Example Avg axial length on IOLMaster 23 70 mm Avg axial length on contact ultrasound 23 60 mm 23 70 23 60 0 10 0 10 x 3 0 30 lOLMaster A Practical Operation Guide Entering Surgeon N
31. C7 Data Management Proper Shutdown First before you can manage your data you have to make sure your data is not accidentally lost Unfortunately this can happen with the IOLMaster as it can with any computer if there is a sudden fluctuation or interruption in the power supply A common interruption to the power supply results trom improperly shutting down the IOLMaster To exit properly click the Zxificon at lower right of the New PATIENT screen Although exiting from the New PATIENT screen is recommended the Exit icon is also available trom the measurement screen and the IOLMaster can be shut down from that screen too When the system asks if you re sure you want to shut down click Yes When it says it s sate to turn off the power then and only then should you switch off the main power using the on off switch on the side Even then the computer may take its time completing the shutdown process your screen may Stay lit for a few extra seconds even after the switch is turned oft If you simply turn the unit off at the switch or turn off the power strip or unplug the power cord etc without going through the shutdown steps you run the risk of losing patient data The computer has some built in safety mechanisms to help prevent this it automatically attempts a proper shut down even if you turn it off at the switch but why take the chance Worse yet if power is interrupted by switching off a power strip or unplugging
32. Database dialog appears showing the tab for the user you selected Administrator x Administrator Mame Password Confirmation Add e Set Data store Backup Restore Import lOLMaster A Practical Operation Guide Entering Surgeon Names and Lenses A list of surgeons if you have entered any appears on the left To add a new surgeon to the list just type his or her name exactly as you want it to appear on your lens calculation printouts in the Name field at right and click Add ga Important Note At this stage you may choose to assign a password to your administrator or your physician Using passwords has pros and cons ultimately it is the physician s decision whether or not to use them If you do assign a password to the administrator be very careful not to forget it If you forget the administrator s password it is not an easy fix and will require a phone call to Carl Zeiss Meditec technical support As you add new surgeons their names will be listed alphabetically and each will one will have his or her own tab at the top of the screen The tabs also appear alphabetically except that the Administrator tab will always be at the far left 4 Atter you have added a surgeon or surgeons or if they re already there trom before click on their tab at the top of the screen You are now in that surgeon s personal lens file A list of already entered lenses appears on the left and a lot of empty
33. Important Note If you are using the Holladay II formula you will not be calculating your lenses on the IOLMaster therefore there is no need to perform an optimization of your lens constants The optimizing of lenses is discussed in the next chapter What About Sulcus Lenses Sometimes the lens bag simply cannot be used to hold the implant In this case the lens may need to be placed in the ciliary sulcus an area of the eye that is still behind the iris but is about halt a millimeter closer to the front of the eye than the standard implant position Because the implant will be positioned closer to the cornea a change must be made to its power to account for this lOLMaster A Practical Operation Guide Optimizing Lenses I 6 Optimizing Lenses So now you ve had your OLMaster for a few months You ve tested dozens of patients who have then had their eyes operated on and you ve had time to see how their stable post operative retractions are turning out It all has gone well most if not all of your patients refractions will have turned out to be close to the target retraction But chances are while the surgical outcomes will be good they will not be quite as excellent as the IOLMaster has the potential to provide This is because every surgeon has a different surgical technique which in turn will have a different impact on each type of lens The good news is that the IOLMaster has a built in program you can utilize to
34. Praim Upy CeeOn 9114 Potech Folles 460 Faktach Pelvis AG1 4 Select the desired lenses by clicking on them To choose more than one lens at a time hold the Ctrl key while clicking every lens you want to import 5 Select one or more doctors for whom you will import the selected lenses Hold the Ctrl key while clicking to select multiple doctors If each surgeon in your practice uses different lenses you will complete this process separately for each one 6 Click the gt gt button to import the highlighted lenses into the lens database for the selected doctor s You may notice that not every IOL in existence appears on the list you downloaded Recall that only lenses used often enough by the ULIB group to have sufficient data for lens constant optimization make it onto the site A very important note If you have already optimized a certain lens then you do NOT want to import that lens to your lens database on the IOLMaster If you do it will erase your optimized lens numbers and replace it with the website s numbers lOLMaster A Practical Operation Guide Preparing Your Patient for Testing 3 Preparing Your Patient for Testing Now that we ve covered the basics of what you will be testing and you have set up your user database we are ready talk about how you will perform testing The purpose of this chapter is to cover patient preparation and entering new patient data The next chapter will cover actual measuring of axi
35. Your Patient for Testing Fe Selecting an existing patient to test again If you want to re test a patient who is already in the patient list click the patient s name and then click New or just double click the name and the test begins Recalling old test results To find and view a specific test result for a certain patient click the to the left of the patient s name and their test dates will appear To view a result click to highlight the date you want and click Open or just double click on the date Helpful hint When trying to recall old tests avoid double clicking on a patient s name or selecting a name and then clicking New Instead of opening old test results these actions will begin a new test and result in a new test date in the patient s list of tests Deleting unwanted files If you want to delete an entire patient click on a patient s name in the list and press the Delete key on the keyboard You will have to contirm the deletion by clicking Yes u u If you just want to delete a particular visit click the by the patient s name click on the date you want to delete then press Delete on the keyboard Click Yes to contirm your action Note If you delete the only date listed for a patient then all data for that patient is deleted too IOLMaster A Practical Operation Guide Taking Measurements 4 Taking Measurements At this point you are probably anxious to get to the fun stuff taking measure
36. after the scan is acquired but it will be present again when the system is properly shut down and restarted Contact Customer Service if this is the case Why is the A constant that prints out not the same as the manufacturer s A constant Because the IOLMaster measures slightly differently than contact ultrasound and manual keratometry the A constants for the lenses are often adjusted usually a little higher to account for this So if the manufacturer s A constant is 118 4 you may see a 118 7 for your SRK T printout instead Furthermore some of the formulas printouts will not have an A constant at all but instead have an SF for Holladay a pACD for Hoffer Q or a list of a0 al and a2 constants for Haigis Read through Chapter 2 tor more details lOLMaster A Practical Operation Guide Frequently Asked Questions Why are the axial length and corneal curvatures different on the IOLMaster than on ultrasound and manual keratometry Regarding axial length Unlike A scan ultrasound which reflects off the surface of the retina the OLMaster beam passes through the translucent surface of the retina and back further to the more opaque pigment layer The computer corrects for this difference but because everyone has different tissue thick nesses results from the OLMaster and immersion ultrasound may be slightly different In addition the use of contact ultrasound will indent the cornea thus decreas ing the distance b
37. al length corneal curvature anterior depth and white to white External Controls Joystick On Off switch on side Table height control While most of the external controls the up down button of the table the knob to raise and lower the chinrest etc will be familiar to most operators there are a few details that warrant further explanation The mouse touchpad and buttons At the bottom of the keyboard is a touchpad with lett and right mouse buttons If you have a laptop computer you ve probably used these before But if not here s how they work You can move your arrow cursor around on the screen by putting your finger on the touchpad and then sliding your finger in the desired direction When the cursor is over what you want to select push the left mouse button or you can sharply tap the pad with your finger which sends the same signal to the computer as a click A press of the left mouse button or tap on the touchpad is what we mean when we say click in this guide Right click means to press the right mouse button Note You will always be using the left mouse button Try to avoid moving the cursor with short strokes on the touchpad Instead place your finger on the touchpad and move the cursor using long strokes This is lOLMaster A Practical Operation Guide Preparing Your Patient for Testing Fe because short quick strokes can lead to unintentional clicks as you
38. ames and Lenses Pi Zug This is the number you will add to any manufacturer s A constant Now that you have this number proceed to the Adding A Lens section on page 2 5 This method is more customized and takes into account your own practice compression factor 3 Speak to your lens representative explain that you have an IOLMaster and ask what numbers you should use Often lens manufacturers will have a recommended lens constant for use with the OLMaster Write this information down and proceed to the Adding A Lens section on page 2 5 Ultimately whichever method you use you are strongly encouraged to 1 Do a comparison of your old method of measuring and calculating IOL power and the new method using the OLMaster Do not rely solely on calculations from the IOLMaster until you feel comfortable with the expected outcomes using the IOLMaster 2 Perform an optimization of the lens constants once you have enough post operative data to do so Chapter 6 deals with the optimization program on the lOLMaster Adding A Lens Now that you have your lens constants it s time to enter them into the IOLMaster You will need to be in one of the surgeon s files for this 1 First type the name of the lens in the lens Name field at upper right lOLMaster A Practical Operation Guide Entering Surgeon Names and Lenses 2 Then type the appropriate number in the Manufacturer A constant field called A const Manufact locate
39. ands of a skilled operator the IOLMaster can measure and calculate with such precision as to provide the absolute best lens power for each patient The ability to see is one of the greatest gifts we have been given And with the help of this technology you will be instrumental in restoring that gift to your cataract patients So it is our hope that this guide will assist you in your initial and ongoing use of your new IOLMaster system Note This guide is based on version 5 of IOLMaster system software Special Thanks We give special thanks to Mely Medel and Kathy Lewis for making this project possible and as always to our fellow Clinical Application Specialists for their support We also thank those who reviewed the content of this guide and helped with editing including Denny Dugal and Claus Dreher for their technical expertise and Katy Murphy for her clinical expertise In addition Joel offers particular thanks to Tom McMillan who first introduced him to the IOLMaster many years ago Joel H Emerson amp Kelly Tompkins Clinical Application Specialists Carl Zeiss Meditec IOLMaster A Practical Operation Guide The Eye and the IOLMaster Ne C1 The Eye and the lOLMaster Welcome to the first chapter of your IOLMaster s practical operation guide Soon enough you will be reading about your new testing system and how to use it to measure your patients eyes But before we discuss how to go about using the lOLMaster it s first
40. ants a synthetic lens in front of the natural crystalline lens IOLMaster A Practical Operation Guide Lens Calculations 5 7 With this tab you must manually type in the patient s current refraction in the measurements summary area to the lett even if you entered the retraction on the NEW PATIENT screen IOL Calculation Haige a Il Hoflarl Holaday SRREVT Muki Formula Haige L phakic IOL Prot Refrachye Surgen EIRE 01 1311 ce ey Maana Aral Length men 24 10 412 ya Surgeon Or Mustermann Corneal E s fmm 7 0 reas 7 3 Ar Target Aehaction Optica ACh tmm 3 26 350 to Ret sphicy O 4 50 1 75 5 5 4 050 eres Im ft 2 fiz phakl pph pha peph Surgical Eye J OD F os IOL Calculstion Pint IOL Calculabon Data Opktec Arkisar IOLTECH PAL Iinpoitant saat waning IOLE REF D IOL D REF D Please rater to the manufach rers qudelines regarding jem oz eo fa lens ppe and critical dstances ta the endothelin 6 00 010 FAD 0 69 a tis brim 0 16 500 art E all 0 30 pa us em for ss Jana Erm IEL E BA a 00 05 D joa OF Cancel Unlike other formulas your lens choices here are pre set You can choose from Ophtec Artisan AMO Verisyse Staar ICL and IOLTECH PRL Simply enter your current refraction and target refraction pick your lens and calculate like any of the other formulas Prior Refractive Surgery Though the IOLMaster offers the new Haigis L f
41. arent living tissue It is made up of the nucleus which is the core of the lens several cortical layers that surround the nucleus like the layers of an onion and finally an outer capsule or bag that holds everything in place The crystalline lens helps to focus images of light onto the retina and can even change its shape in order to adjust this Tfocus or accommodate when the various objects being viewed are at different distances trom the eye lOLMaster A Practical Operation Guide The Eye and the IOLMaster The cornea is the clear dome on the front of the eye Like the crystalline lens the cornea helps to focus images of light onto the retina Though it does not change shape like the crystalline lens the cornea is the more powerful of the two providing about two thirds of the light bending power of the eye The retina is the tissue at the back of the eye The cornea and crystalline lens together focus images of light onto the retina which then converts those images into nerve impulses for the brain to interpret How the Lenses of the Eye Work Light retlects off an object and comes to the eyes as parallel rays of light The outward curving or convex clear dome of the cornea bends these rays of light inward into the eye These converging rays of light then pass through the crystalline lens of the eye which bends them inward even more sharply These rays cross over each other at a single spot called the
42. asurements of one eye pull the scanner back toward you and then slide it over so it s in front of the other eye The computer will put you back in Overview Mode automatically Simply repeat all the steps you just went through for the other eye When you ve finished with both eyes click on the printer icon at the bottom of your screen This prints out all your measurements to keep in your chart New with version 5 software IOLMaster Advanced Technology Plausibility Checks In this feature the computer checks the plausibility of your results Plausibility checks of OD OS AL and K values provide additional safety especially on problematic eyes Alter axial length and keratometry measurements the system checks the following conditions and gives appropriate warnings e AL lt 22 mm short eye e AL gt 25 mm long eye e R gt 8 4 mm very flat corneal curvature e R lt 7 2 mm very steep corneal curvature e R1 R2 gt 0 5 mm high astigmatism It both eyes are measured the system will check consistency between both eyes e AL difference between OD and OS gt 0 3 mm Axial length of right eye is X mm smaller larger than axial length of left eye check plausibility e R K difference between OD and OS gt 0 2 mm 1dpt Mean corneal radius K of right eye is X smaller larger than mean corneal radius K of left eye check plausibility In all cases the following warning is shown e Examine that no pathologica
43. ault value It remains the same until you change it again It is a good idea to double check whether the target refraction is set where you want it each time you calculate a lens The Lenses At the bottom of the screen you will see four columns each with the name ot a lens implant at the top These fields will be blank the first time you enter the lens calculation screen or the first time you calculate a lens for a specific surgeon When blank click on each down arrow to select 4 lenses that surgeon prefers Note that these columns are not where lenses are added but rather where already entered lenses are selected See Chapter 2 to add lenses for surgeons Formula Calculation Tabs A row of tabs appears at the top of the screen each one with the name of a different lens calculation formula The first five tabs are single formulas that can be used to calculate lenses for patients who have not had prior refractive surgery The last five tabs are Tor multi formula calculations patients who have had prior refractive surgery or patients having phakic IOL surgery All of these will be discussed in more detail later in the chapter How to calculate using one of the first five tabs 1 Click the tab of the formula you wish to use 2 Select the surgeon who will be operating on this patient 3 Check whether the target retraction is what you want it to be If not edit it to the desired target retraction for this patient 4 In the four lens co
44. cae Important Note Carl Zeiss Meditec does not recommend any particular method for dealing with prior refractive surgery patients and their lens calculations This is a medical decision and these methods are merely provided for our customers convenience Clinical History Method The Clinical History Method requires entering patient data trom the patient s records trom both before and after retractive surgery 1 Manually enter the following data e Corneal K s Pre OP This is the average corneal curvature measurement in diopters trom before the refractive procedure e Vertex This is the distance trom the back of the glass lens to the front of the cornea In this case it is the distance trom the phoropter lens to the front of the cornea when the refractions were performed Most phoropters have a mechanism by which an experienced examiner can determine the vertex distance Whoever performed the patient s retraction for the refractive surgery work up should have written the vertex down somewhere in the chart e Refr Pre OP This is the sphere and the cylinder of the distance vision retraction from before the retractive surgery procedure no axis required e Refr Post OP This is the sphere and the cylinder of the distance vision retraction from after the refractive surgery procedure no axis required gs Important Note This post refractive surgery refraction should not be the most recent refraction as the presence of
45. cal equation However the SRK Il is really useful only on medium length eyes the larger or smaller the eye the more modifications have to be made to the A constant and even that does not always help Surgeons who are used to the SRK II may wish to consider the SRK T as an alternative Haigis Formula Now that weve covered some of the other formulas let s discuss the Haigis formula created by Dr Wolfgang Haigis It is the only formula on the IOLMaster except for the Phakic IOL formula that takes into account the ACD measurement The Haigis formula uses the a0 al and a2 constants to take into account various aspects of the eye This makes the Haigis formula potentially the most useful of all the formulas able to correctly calculate for any length eye with varying positions of the crystalline lens However because of the use of multiple constants this tormula should be optimized before it is used The al and a2 constants can only be optimized by Dr Hill or Dr Haigis For detailed instructions to do this please see Chapter 6 Printouts using the Haigis will list the lenses a0 al and a2 constants rather than a lens A constant The Multi Formula Selecting the Multi Formula tab reverses the order of things rather than having four lenses calculated under one formula type you pick one lens and have that lens calculated with up to four separate formulas at the same time 1 Choose the one lens that you want to calculate
46. ck here to begin Complete the copying process onto your CD Importing Files from the CD or Jump Drive into the IOLMaster Now you have a CD or a jump drive with a whole list of lenses that can be download into your IOLMaster Make sure you ve entered all the surgeons on the Administrator tab before proceeding 1 You will want to be back in the Administrator tab for this If you are already in the Surgeon Lens tiles just click on the Administrator tab far lett to return to it If you are back in the New PATIENT screen click Options gt User Database select Administrator in the Name field and click OK to get back to the Administrator tab 2 Install the CD into its drive on the lett side of the system s base when facing the screen or the jump drive into its port on the right side of the base Give the computer a few seconds to recognize the CD or jump drive Pacewerd Confnnalign ade ers lOLMaster A Practical Operation Guide Entering Surgeon Names and Lenses Pi We The import dialog that appears has a list of lenses on the lett and doctors on the right Import of lens constant data Br Lent corstants in the import databace Surgeons of Ihe cumert ucel data base E Dr Schmidt MP 2125 Dr Schmit M5612 en Inner JU Gar nnor XF 55 Hoya are Va BOB Hamani psss TEU Lenstse L 10 D Agua Senza Il Oprter PC265 Oprrec PEEN Oortec REFS 0 Pham Teams 23000 Praim Upy 303C
47. clearly defined single peak like the one shown below next to the Chrysler Building There will be a row of smaller spikes appearing on either side of the primary central lOLMaster A Practical Operation Guide Taking Measurements spike with each of the smaller spikes becoming shorter and shorter until they become a flat line of background static Pe Pe EEN AF ARAAAR ARR Pada eda be 1 i i LI Pe 1 Ei at Tr T sy Fa H an X i A h u me a zy m g E FE T 73 LAETTE PERCE EEoE Pees ae g uz Chrysler Building Ideal Sears Tower Double New York City waveform Chicago u peak A double peak like that shown next to the Sears Tower is not considered a good graph Because there are two peaks the instrument isn t sure where to place the measurement cursor and this can result in erroneous measurements A little later we ll tell you what to do when you get a double peak The more interference with a scan usually from dense cataracts the higher and shakier the background static line will be A blink or eye movement will cause a section of the graph to bottom out to nothing See below some examples of poor Scans flat noise l4 40 mm 14 40 mm Waves 6 movement 14 40 mm 14 40 mm lOLMaster A Practical Operation Guide Taking Measurements Ea With scans like these the word error will appear in the list of axial lengths instead of a number
48. d How Does It Work A slit beam is projected from the side of the scanner it passes through the cornea at an angle and continues on to the crystalline lens It reflects trom the surface of the cornea and from the lens surface The computer measures the distance between the corneal reflection and the lens reflection and along with the corneal curvature obtained in the previous mode computes the distance trom the cornea to the lens lOLMaster A Practical Operation Guide DEMO Mode OL Master Taking Measurements 973 How to Perform the Test When you first come to Anterior Chamber Depth ACD Mode you will see three spots of light two close together off to the side and one by itself near the center of the screen plus two curved arcs of light For the time being ignore the pair of spots and the two arcs and concentrate only on the solitary spot ot light 1 First get your spot of light inside the green box It can be Patient Eunctions AL gettings Options 2 corneal reflection anywhere as long as it stays within the green box If entered this mode directly from Overview Mode the spot of light probably will be in the box already Otherwise move the scanner lett and right as needed and rotate the joystick to move the scanner up and down as needed to get the spot of light within the green box 2 Next move the scanner forward toward the patient or pull it back away trom the patient as needed to focus the
49. d and the lines to center are radii of the circle The size of this imaginary circle is determined by the reflection points points that are closer together will produce smaller circles and smaller radii while points that are further apart will produce larger circles and larger radii lOLMaster A Practical Operation Guide Taking Measurements O Here is the imaginary circle superimposed on the cornea Notice how the circle coincides with the central corneal surface but not necessarily the peripheral surface Since the central area of the cornea is more relevant to vision the spots of light are also fairly central the central 2 5 mm in order to match the circle up with the important central corneal curvature Do you see how the reflection points of the parallel beams of light define radii as they converge at a the circle s center point This is the real key to understanding radii the radii converge at the center ot the circle formed by the central corneal surface just as light rays are focused caused to converge by the cornea A flatter cornea means a larger circle and longer radii which in turn means the focal point is further back in the eye A steeper cornea means a smaller circle and shorter radii which in turn means the focal point is closer to the cornea rs Important Note The circles shown are not to scale with the cornea the circles and their radii will typically be much larger compared to the cornea but this
50. d halt marble side is facing the IOLMaster This should be done for both eyes Just take the calibration eye out of the slit lamp flip it around and measure the other eye If you are using the WTW measurement on the IOLMaster you should check its calibration as well In this case rotate the calibration eye again until the grid is facing the IOLMaster When you select WTW while in test eye mode instruc tions to check this measurement will appear on screen 5 When you have measured axial length and K s it s time to check the results The calibration eyes axial length and corneal curvature is printed on the calibration eye underneath the applicable lens The axial length and K s you obtained on the test should match what is printed under the lens Helpful hint On the calibration eye the corneal curvature K measurements are given as a radius rather than in diopters However if you print out the calibration results it will print the K s in diopters as well as radius It is a good idea to keep a binder or log of some kind to document your calibration checks in case there is any reason to refer to it later Alternatively if you want to change the measurement lOLMaster A Practical Operation Guide Taking Measurements units trom diopters to radius temporarily select Program Settings from the Options menu click Options gt Program Settings and then select the Radius option So What Now Now it s time to calculate which
51. d just below the lens name box This number is based on the method of lens constant modification you have chosen User Manager 273 12 3 Next enter the appropriate lens constant numbers in the fields next to each formula These numbers are based on the method of lens constant moditication you have chosen For option 1 using the ULIB website lens constant information You can enter the information manually in each field from a printout or import it directly into the IOLMaster trom the media you have downloaded it to When entering data manually make sure you enter each number correctly in the field that corresponds to its formula Remember the nominal number is what you put in the manufacturer s box you do not need to enter a manufacturer s ACD To import data directly see the Downloading and Importing Lenses section on page 2 7 For option 2 side by side comparison Just add whatever your result was continuing the example above you would add 0 3 to whatever A constant is printed on the lens box Enter the resulting sum in the Manufact field Select D or D diopter steps and click Add The instrument will automatically calculate and fill in the rest of the formula fields below It is a good idea to go back and change the manufacturer s number to the correct manufacturer s lens constant and then click Set This way you will know at a glance whether the lens constant information was adjusted lOLMaste
52. d lens it is refractive surgery Patients expect good vision alter surgery without having to use glasses or contact lenses One of the things that can interfere with good post operative vision are pre operative measurements made on an unstable cornea Contact lenses warp corneas sometimes just a little sometimes a lot If a patient wears contact lenses make sure he or she leaves them out long enough for the cornea to return to a normal stable shape before measuring The use of refractions and topographies may be needed to ensure the cornea has ceased to change Don t touch the cornea Schedule your IOLMaster testing in such a way that the patient s eye has not been touched that day such as from ultrasound A scans automounter pressure checks gonioscopies etc Any and all of these tests can disrupt the tear film and corneal shape thus throwing off measurements IOLMaster A Practical Operation Guide Preparing Your Patient for Testing New Patient Screen Entering New Patient Information The first screen that appears when you turn the instrument on is a reminder that a daily calibration check of the IOLMaster is very important See Chapter 7 for instructions to perform a calibration check Click the OK button to move to the next screen which is the New PATIENT screen When you are in any of the testing screens and you want to get back to the New PATIENT screen just move your cursor and click on the Wew Patient icon shown at le
53. d optimized IOL constants for the Zeiss OLMaster 4 On the next webpage that appears explanatory paragraphs at the top conclude with the following sentence To proceed with the download click here for the English version Click where indicated on the highlighted word here and you will be taken to a Zeiss disclaimer page 5 Read the page At the bottom select the checkbox next to Yes I ve read the instructions for using the constants When you do a Start download option will appear Click Start download 6 At this point the instructions may vary depending on your browser For Internet Explorer select the Save option A dialog will prompt you to specity where to save the file In the Save in field use the down arrow to locate your IOLMaster A Practical Operation Guide Entering Surgeon Names and Lenses CD burner probably the D drive or the jump drive you have plugged into a free USB port probably the drive with the highest letter maybe E or F or G Click Save If you are using a jump drive the file will probably be downloaded directly into the jump drive If you are using a CD burner depending on the program your computer uses the download may save the file directly onto the CD or it may copy it into a temporary file first If the latter situation obtains a message will probably pop up on your screen saying something like You have files waiting to be copied onto CD Cli
54. d try to move your spot of light away from those darker areas Some patients have cataracts that are simply too dense either overall or just centrally tor the laser to safely penetrate If every measurement is either error has a strange looking graph or produces numbers too inconsistent to know which Ones to keep or delete then you must resort to using your ultrasound unit to measure axial length What About Eyes That Have Already Had Surgery If the eye has had refractive surgery such as LASIK or RK there is no difference in measurement technique neither in Axial Length Mode nor in the Corneal Curvature Mode we will explain later The effects of having had surgery come into play after taking measurements when it s time to calculate for the lens implant If the eye has had previous cataract surgery or some type of retinal surgery take your cursor and click the AL Settings menu at the top of the screen The menu opens showing options for various types of eyes Click an eye type and the axial length measurement will change based on the computer s re analysis of the wave patterns The AL Settings options are DEMO Mode IOLMaster e Phakic This is the default setting Phakic eyes have their natural crystalline Patient Eunchons lens or cataract still in place and have had no other invasive surgery u e Aphakic This means that the natural lens has been removed but no implant SELPODNAKIC SCOT ey has been put
55. different testing screen and wish to return to Overview Mode just move your cursor over the Overview icon and click Alternatively you can press the letter O on the keyboard Note that the Overview Mode is NOT a test It is just your chance to get lined up with the patient s eye So you do not have to spend much time here at all close is good enough 1 First move the scanner left and right as needed and rotate the joystick to move the scanner up and down as needed to get the green cross hairs over the dark pupil of the eye DEHO Mode DOLMaster Petert_dnsicht Funkteren Gotonen 2 2 Next move the scanner forward toward the patient or pull it back away from the patient as needed to focus the image of the eye You will know when you are in focus because the little spots of light reflecting in the pupil will become very small and sharp But remember this is NOT a alealea test so dont stress u wnetner or not the spots are H amo oo perfectly focused you re going to have to re focus anyway in a few seconds VIO La olo Ready Eber O Helpful hint on focusing If you are moving toward the patient and the lights are getting smaller and sharper then you re on the right track But if you are moving toward the patient and the lights are getting larger and fuzzier then you have gone too tar start pulling back toward you until the spots of light get smaller again For practice feel tree to overshoot t
56. ea to the image it s projecting on the other side The steeper the cornea is the shorter the distance is between the cornea and the image it is projecting The flatter the cornea is the longer the distance is between the cornea and the image it is projecting By measuring the length of the eye from the cornea to the retina called the axial length we know what the focal distance should be to get the image projected properly on the retina Typically once the crystalline lens is removed the focal distance of the cornea is longer than the axial length of the eye But by inserting a synthetic lens of the proper light bending power the overly long focal distance can be shortened to match the actual length of the eye IOLMaster A Practical Operation Guide The Eye and the IOLMaster GO implant axial length focal distance shortened So all the surgeon needs to do is insert a lens with enough light bending power to shorten the focal distance to match the patient s axial length Easy right Well as it turns out it s not as easy as that Because the lens implant and the cornea have space between them and because each one sits at different distances from the retina the equation becomes a bit more complex That is why it is essential to obtain accurate measurements of both the axial length and the corneal curvature Before the invention of the IOLMaster analysis of ultrasonic echoes i e an A scan was used to measure
57. ect surgeon F inst Abbe New password Sa Confirmation 2 Click the down arrow by the Name field select the surgeon whose lens you are going to optimize and click OK You should see the tab for the selected surgeon listing the IOLs he or she uses as below User Hanager 3 select lens and click Optimize 3 Select the IOL you are going to optimize then click the Optimize button The selected lens screen appears IOLMaster A Practical Operation Guide Optimizing Lenses John Public O D lens 1 4 click Load 4 Click the Load button You will now see a screen as shown below The right side displays the list of all patients that you have measured on the IOLMaster Assign data records Mustermann Adelheid 01 09 1 923 07 amp Mustermann Anita 097 247 1936 08 04 i Mustermann Antonia 05 18 1921 07 Huztermann Daniela 0625 1 970 087 5 se ect Mustermann Eleonore 127711771924 06 n Mustermann Elisabeth 12 03 1915 08 patient Mustermann E mil 02 01 71934 0607 Mustermann E mma 04729 1922 087 0 Mustermann E mma 1 2 29 17 922 08 0 Mustermann E va 027 0371920 08 03 6 select eye x Mustermann E va 08 18 1920 08 08 and this 20 checkbox Mustermann Harry 07 31 1929 08 11 Mustermann Hedwig 11 22 1913 08 Mustermann Hedwig 1129 1 922 08 Mustermann Heinz 01 407 41911 09 15 Mustermann Helene 02 02 1 941 08 Mustermann Helene 04 15 1920 08 1 Mustermann Helga
58. efore making the transfer 16 Click OK to exit the optimization program Congratulations You ve just optimized your first lens Repeat all of these steps for each lens that has at least ten qualitying eyes but remember we recommend that you have at least twenty qualifying eyes from the same doctor s surgery Remember that optimization isn t a one time event We recommend that you continually add to your optimization database and update the constants Optimizing the Haigis Formula The Haigis formula is unique in that it has three separate constants a0 al and a2 The a0 constant is much like any other formula s constant but the al and a2 constants are different they are tied directly to the measured anterior chamber depth for a1 and axial length for a2 Because of this only the a0 constant will be optimized by means of entering post operative data If you want to use the Haigis formula you will need to contact Dr Hill or Dr Haigis for their assistance in optimizing al and a2 For detailed instructions on collecting this data for submission please refer to Dr Hill s website specifically www doctor hill com physicians download htm Now What Atter your lenses have been optimized back them up That way if something ever happened to your hard drive all that hard work won t have gone to waste Refer to the next chapter for steps on backing up the lenses lOLMaster A Practical Operation Guide Data Management IA
59. epending on the type and density of the cataract some areas may be easier to measure through than others There are two ways to tell if one area of the green circle is better for scanning through than another looking at the waveform graph shape and looking at the SNR number Pictured at left are two simple patterns you could use to acquire multiple measurements through different locations The first is a clockwise pattern starting at the top The second is a zigzag pattern in which you slide to opposite sides of the circle There is no right or wrong order if you even have an order at all but having one can help you remember which location works best for that eye lOLMaster A Practical Operation Guide Taking Measurements Ey As you measure through various sections of the circle make a mental note of which areas of the circle work best that is have both a typical graph and have a higher SNR number After your first ten measurements or so you should know where the hotspot is Return to that spot and finish taking your twenty measurements there O Helpful hint Each time you push the joystick button you will see the pupil light up for just a moment Often you will be able actually to see the dark cataract against the background flash Remember where the cataract was such as a Cortical Spoke coming in toward the center from the five o clock position or a central PSC that seems darker more to the left than the right an
60. er Z Anterior Chamber Depth and White to White Measurement Yalues iV Axial Length l Mean Value List of Values IV Keratometer Active Value List of Values V Anterior Chamber Depth v White To White Active Value C List of Values lOLMaster A Practical Operation Guide Data Management 6 Click on the Export tab and choose the desired options Primarily you will be selecting whether you are exporting to a CD or USB device and what you wish the name of the exported file to be If you are exporting to a specific program on another PC be sure to consult that program s instructions to see it it requires these options to be contigured in a certain way File output Field separator is emicolon Decimal separator Comma X Output path CD AW C USB stick File name esportes O Holladay Il Consultant One common reason customers want to export their measurement data is because they are using the Holladay II Consultant You can export measurement data as a text file from the OLMaster onto the Holladay Il Consultant program via removable media CD or USB device or serial port It is important that you contact Dr Holladay s company in order to set up the Holladay II Consultant program so that it can receive the data from the IOLMaster They are better equipped to handle questions on how to set up their program The Holladay Il Consultant program is a product of Jack T Holladay M D and is not aff
61. etween the cornea and the retina and artificially shortening the axial length measured Because of this axial lengths measured on the IOL Master are almost always longer than those obtained through contact ultra sound ultrasound vs optical biometry Ultrasound A Scan IOLMaster 10MHz sound wave 780nm laser beam averaging across foveal cup reflection at Bruch s membrane Regarding corneal curvature First manual keratometry measures the corneal curvature more peripherally perhaps at 3 0 mm or 3 2 mm depending on your manual system while the IOLMaster measures the more relevant central curvature at 2 5 mm Thus on a typical eye IOLMaster K s will be slightly lOLMaster A Practical Operation Guide Frequently Asked Questions I Ze steeper than manual K s while on a post refractive eye the IOLMaster K s may be slightly flatter IOLMaster K s Manual K s Second the IOLMaster determines curvature by measuring the relative position of six spots on the cornea rather than the two mires of manual keratometry thus providing more detail Third if your IOLMaster is set to give curvature results in diopters rather than radius the original radius is converted into diopters using the keratometry refractive index of 1 3375 which is not the same value as some other keratom etry systems use The joystick controls seem so touchy Is it broken Probably not When you are performing a test your screen is zoomed in very close to
62. fields on the right unless one of the lenses is highlighted as shown below User Manager x Administrator Or Mustermann John Q Public O D Lenses Name flens 1 A Const 11 Manufact ACD m Manufact A Const 118 SRE Il A Const 118 SAK T These boxes are for the modified i ig lens constants az 1 f th pACD 14 96 Hoffert or e various sr iz Holladap formulas you will Power Steps 1 2D 1 4D be using Erase Optimize u ia The fields to the right are empty when no lens is selected In that case they are for entering new lens data These fields are highlighted above lOLMaster A Practical Operation Guide Entering Surgeon Names and Lenses Fir Ze So now you are in the surgeon files and are ready to add a lens At this point you will have to decide what lens constant intormation you will be inputting for each new lens Choosing A Lens Modification Option Each lens comes with a manufacturer s A constant a number which can be used in various lens calculation formulas But traditionally this A constant has been calculated assuming the use of contact ultrasound A scans and manual corneal curvature measurements Because the IOLMaster obtains measurements differently than the lens manufacturer s A constant is designed for modifications to this number need to be made Typically the IOLMaster measures the axial length measurement longer than contact ultrasound The reason for this
63. fora B E a 9 Select a patient 10 Enter diopter power of implanted IOL 11 Enter post operative refraction the dates are optional 12 Repeat steps 9 through 11 until data has been entered for each patient You will notice that as you enter patient data the background color behind the patient names will change trom red to yellow or white The colors have the fol lowing meanings e Red Patient is missing the IOL power and postoperative data e Yellow No ACD values were measured for that patient which means that the a0 constant for the Haigis formula will not be optimized Please see information about optimizing the Haigis formula later in this chapter e White All measurements were done and data is available for optimization 13 Make sure all data has been inputted for each patient on the left side of the screen lOLMaster A Practical Operation Guide Optimizing Lenses I John Public O D lens 1 Mustermann Helene 027027194 08 01 2 Mustermann Helene 04 15 1920 08 04 2 Mustermann Helga 02 03 1931 08 1 6 20 Mustermann Hilda 01 27 1921 08 75 20 Mustermann Hilde 02 15 1930 08 04 201 Mustermann Hildegard 05 05 1911 08 1C Wustermann llse 03 16 1327 08704200C Mustermann ngeborg 09 25 1930 08 1 4 Mustermann ohann OF 13 1932 08 02 2 ae om ao etmann Lillemor 03 18 1981 07 07 2 8 15 2000 note white Te 09 18 2000 background i Mustermann Melitta 0841 5 1 326 0841 arg
64. hat can severely throw off of the axial length measurement The instrument will sometimes pick up a reflection from the IOL creating a false peak and making the axial length erroneously short Best Practice As shown in the image below try to move around taking measurements in different quadrants and thereby avoiding reflections Reflection from IOL This process Is similar to trying to get around the denser portions of a cataract Most importantly use your own judgement if you see an axial length measurement abnormally short as in the case below be aware that something like an existing IOL probably Is causing an erroneous measurement lOLMaster A Practical Operation Guide Taking Measurements ET New Composite Graph This is a new feature introduced in version 5 software After you have taken five axial length measurements a composite graph will appear in blue with an SNR traffic light See Signal to Noise Ratio or SNR on page 4 10 for an explanation of this feature Underneath the original five measurements will appear a single composite value Unlike previous versions this composite value is not an average IOLMaster calculates the composite value by combining the individual signals which significantly increases the signal to noise ratio Carl Zeiss IOLMaster Advanced Technology Patient Functions Al Settings Options If composite signal is unsatisfactory take another 5 AL measurements O e amp
65. hat is keep going forward and the lights will start to get larger and fuzzier because you ve gone too far in that direction This way you will learn how small the lights are supposed to get and you ll know what it looks like when you re in focus 3 Finally without moving the joystick push the button on top of the joystick This will advance you to the next part of the test Axial Length Mode This is the A scan test but performed with lasers instead of ultrasound The test moves into this mode when you push the joystick button at the end of the Overview lOLMaster A Practical Operation Guide DEMO Mode OlMaster Patient Functions AL Setkings Options Sal Ready Ho Eber Taking Measurements Mode However if you are on a different screen and wish to return to Axial Length Mode just move your cursor over the Ax a Length icon and click Alternatively you can press the letter A on your keyboard In Axial Length Mode the eye zooms in very close so the pupil fills most of the screen If you ever get lost and cannot find the center of the pupil just return to Overview Mode by clicking on the magnifying glass icon or by pressing the 0 key on the keyboard 1 First get your spot of light somewhere within the green circle If you ve entered this mode directly from Overview Mode your spot of light will probably already be in the circle Otherwise move the scanner left and right as
66. her one through the Carl Zeiss Meditec Customer Service department Call 800 341 6968 choose the parts department option It is part Z 0000001046387 The cost is approximately 730 00 How do change how the K s are acquired If you want the Adjustment Aid traffic light turned on or off and or you want the Automatic Mode three scans acquired in rapid succession turned on or off select Program Settings from the Options menu click Options gt Pro IOLMaster A Practical Operation Guide Frequently Asked Questions gram Settings at the top of the screen From here you can turn those features on or off To activate automatic three scan acquisition you can also press the M key while in the Corneal Curvature Keratometer Mode Program Expert Network Uzer management Progam Language needs restart MAMEA Display Visual Acuity Decimal f Snellen Database Erase records alter 365 days Patients wall be identified by Mame first name D Number Ferstometer Display Radius i Comeal K s Cylinder Cylinder en hss Caution K eratomster indices affect comeal power for a ven Refractive Index 1 3375 T radius of curvature Adjustment aid Keratometer Antenor Chamber Depth M Adjustment aid KER I Automatic KER M Adjustment aid ACD I Automatic ACD Printing 7 Zn IOL Calculation one eye per page both eyes on page M Emmetropy IOL Clinic What is the Kerat
67. his means that you either somehow skipped measuring the K s or more likely you measured them but did not notice that there was an evaluation instead of an average Go back to the Corneal Curvature Mode and fix the problems retesting the K s if necessary lOLMaster A Practical Operation Guide Taking Measurements EIE Part 4 White to White Measurement White to White Mode This is a measurement of the horizontal width of the visible iris from the white scaler on one side to the white sclera on the other side Certain more advanced lens calculation formulas need this measurement but even if you are not using such formulas this measurement can still be useful during various kinds of cataract surgery If necessary click the White to White icon to get to this mode How Does It Work The computer takes a high contrast photo of the eye then detects the boundary between the paler sclera and the darker iris and traces that boundary with a marker line at either side of the iris Then the computer simply measures the longest distance between the two curved markers How to Perform the Test When you first come to White to White Mode you will see a screen that looks nearly identical to the first test screen Overview Mode 1 First place the central spot of light in the center of the Zam Eule oer 2 green circle target Move the scanner left and right and i 4 rotate the joystick to move the scanner up and down as needed 2 Ne
68. ience and ironically his or her own clarity of vision Now we have the IOLMaster It is quick easy to use and highly accurate It measures the axial length along the eye s visual axis directly to the macula It measures more centralized and thus more relevant corneal curvature Its measurements are highly consistent and repeatable And it has a number of built in safety checks to help catch any mistakes the tester may make Now Tor what you ve been waiting for using the IOLMaster Chapter 2 will deal with setting up your database of doctors and lenses and Chapters 3 through 5 will deal with testing and calculating results lOLMaster A Practical Operation Guide Entering Surgeon Names and Lenses I C2 Entering Surgeon Names and Lenses Okay so you have an IOLMaster and are probably anxious to get started taking measurements That time will come soon enough Before taking any measurements it is a good idea to set up the user database first This chapter deals with that very subject Adding Surgeon Names 1 From the New PATIENT screen select User Database trom the Options menu click Options gt User Database A dialog titled Please enter password appears 2 Click the down arrow by the Name field and select Administrator as shown Please enter password x x Administrator Password Cancel Change password New password Confirmation 3 Leave the password blank and click OK The User
69. iliated with Carl Zeiss Meditec Backing Up Surgeon and Lens Data It is a good idea to backup your surgeon information as well as their lens implant information This is especially important after an optimization has been completed To complete this process follow the next few steps 1 Click on Options then User Database 2 In the Name field click the down arrow and select Administrator You will now be on the Administrator tab and should see a list of surgeon names on the left side lOLMaster A Practical Operation Guide Data Management Vi Zug 3 Click Backup and insert a blank UDF formatted CD RW in the drive or a USB memory stick in a USB port Note Two formatted CD RWs are included in your lOLMaster accessory kit If you dont have these you can format UDF a CD RW on another PC not on the IOLMaster Administ rear Henne as Password 00000 pm Confirmation enc Erate Ha Restore If you have lost the surgeon and lens information for any reason you can simply insert the CD RW or USB with this information on it and select Restore Import The use of the import function is discussed in Chapter 2 Finding All of This a Little Confusing You are not alone It might be helpful to know that most customers don t use the export functions as a way to backup their data mostly because the data is stored in an easily accessible form on the NEw PATIENT screen for up to 365 days and a summary
70. in its place Pseudophakic Pa Pseudophakic Acrylate m e Pseudophakic This means that the natural lens has been removed and en replaced with an implant Note that there are four different types of lens Phakic TOL PMMA 0 2mm materials to choose from Silicone Memory PMMA and Acrylic If you are R arti unsure of the type of lens it is patients often do not keep the lens identification Primary Piggy back Hydrophobic Acrylate cards their surgeon gave them a good guess would be PMMA If you guess lOLMaster A Practical Operation Guide Taking Measurements wrong your new axial length will only be 0 01 mm off target which is such a small amount it won t affect your lens calculations Silicone Filled Eye This means the eye has been filled with silicone oil probably after retinal surgery but still has the natural lens intact Silicone Filled Aphakic This means the eye has been filled with silicone oil and the lens has been removed probably during the same surgery but no implant has been put in its place Silicone Filled Pseudophakic This means the eye has been tilled with silicone oil and there is an implant present Phakic IOL This means the eye has both its natural crystalline lens and a lens implant which was probably inserted as an alternative to LASIK Primary Piggy back This means the eye has two separate lens implants You can choose from Silicone or Acrylate What About Extremel
71. ince those early days the surgical techniques and lens implant designs have continued to improve Modern cataract surgery is typically performed as an outpatient procedure often with no stitches and only anesthetic drops to numb the eye Lens implants are now inserted in a rolled up state and then unfold into their proper shape inside the eye itself While the patient may be at the surgical site Tor a IOLMaster A Practical Operation Guide few hours the actual removal of the cataract and insertion of the lens implant often takes less than ten minutes And yet even with all of the advances in materials and techniques there is always a question of which implanted lens strength to use in order to give the patient the best possible vision after surgery For many years we simply guessed at the implant power needed based on the patients glasses prescription More recently we utilized a combination of ultrasound A scan devices and manual keratometry tools and a simple algebraic equation to estimate the implant power needed While such methods were innovative for their time and certainly a vast improvement over simply guessing there is now available a much better way to acquire the measurements needed and to correctly choose the best lens power The IOLMaster This innovative technology is easy to use provides an unprecedented degree of accuracy and has a number of automatic fail safes to help prevent mistakes and oversights In the h
72. ion for distance vision performed with the contact lens on Remember this measurement should be acquired last e Refr without CL This is the phoropter refraction for distance vision performed before the contact lens is put on e Vertex This is the distance trom the back of the glass lens to the front of the cornea In this case it is the distance trom the phoropter lens to the front of the cornea when the refractions are performed Most phoropters have a mechanism by which an experienced examiner can determine the vertex distance 2 Now that you ve entered all of your data select the Apply checkbox next to the data you ve just entered IOLMaster A Practical Operation Guide Lens Calculations 3 Finally click on the formula tab that you normally would have used for this patient and print out your results trom there You will notice that the corneal curvature measurements have been altered What About the Holladay II The Holladay Il is a newer version of the original Holladay program To use this formula you must purchase it trom Dr Holladay and install it on a separate computer It cannot be installed on the IOLMaster Then you must transfer the measurements by CD data cable or manually Please see Chapter 7 for basic instructions to export calculation data Should you choose to purchase the Holladay II program you will be provided instructions on how best to utilize it trom Dr Holladay s organization
73. is that with contact ultrasound you are compressing the cornea thereby shortening the axial length of the eye but with the OLMaster there is no contact with the eye and no artificial shortening of the axial length This difference if ignored can result in undesired post operative retractions Important Note If you are using immersion ultrasound for your axial length measurement method and have a lens constant that has already been adjusted for immersion measurements there is a good chance that this lens constant will also work well with the IOLMaster You can proceed to the Adding A Lens section on page 2 5 and input these numbers into the lOLMaster lens database Below are a few of the most common options you have for modifying your lens constants The surgeon should decide which method to use 1 Input lens constant information from the ULIB website The ULIB website contains optimized lens constant information for many lenses provided by many surgeons all over the world The ULIB website is maintained by Dr Woligan Haigis PhD You can find this website by doing an internet search for ULIB or by following the link in the IOLMaster page on the Carl Zeiss Meditec website which can be found at www meditec zeiss com iolmaster You can then choose either to print out this list of optimized lens constants and manually enter the information into the IOLMaster or download the information electronically to a CD or USB memory stick and im
74. it from the wall the risk of losing patient data is huge So in short do yourselt a favor and shut down properly O Helpful hint If your electrical infrastructure is prone to interruptions like flickers brown outs and black outs consider getting a UPS Uninterruptible Power Supply It is hardware about the size of a car battery with several plug in sockets for power cords The UPS plugs into the wall to keep its battery charged The IOLMaster plugs into the UPS and draws power through It The UPS maintains a steady energy flow smoothing out partial and temporary interruptions to the wall power and it there is a blackout the UPS battery provides several minutes for you to shut down the OLMaster properly before the UPS battery gives out Lost Data So what happens if the patient data is lost due to an improper shutdown or sudden power interruption You may see that a patient s name remains in the list lOLMaster A Practical Operation Guide Data Management but when you click on the by the name and then open a dated exam file below it contains no measurements What do you do If the data is truly lost you cannot recover it directly you can only retrieve it trom a backup source if you have one However if you need to print out a new lens calculation there is a way 1 First get the printout of the patient s measurements trom their chart 2 Now click on the patient s name in the New PATIENT screen and then c
75. l changes are present lOLMaster A Practical Operation Guide Taking Measurements IT This warning will also be added to the Remark field of the examined patient Part 5 Calibration Check Best Practice It is important to check the calibration of your OlMaster at the beginning of every day you will be using the instrument This confirms that the Ol Master is operating properly and helps ensure that the measurements you take will be accurate 1 Get the calibration eye from its gray carrying case The test eye looks like a small black box sitting on top of metal posts 2 Place the metal pins at either side of the patient s chinrest and insert the metal prongs of the calibration eye into the holes 3 Rotate the black box so that the calibration eye the side that looks like a small spy camera lens is directly facing the IOLMaster lens 4 Test the calibration eye as if it were a real patient There may be a patient of the name Check Device already at the top of your list Check the calibration under this name If not just enter a fake patient name like Check Calibration or something similar Once in testing mode select Test Eye trom the Options menu click Options gt Test Eye This way the instrument knows you are in test eye mode Next measure the axial length and K s as if the spy camera lens of the black box were a real eye To measure ACD you need to rotate the calibration eye so that the roun
76. lick New 3 When the test begins skip doing the measurements and click on the OL Calculation icon or press I 4 Manually type in the patient data trom the printout into the appropriate fields and calculate lenses as you normally would Export or Transfer Data Data can be transferred in one of two ways you can export data to removable media like a CD RW or USB memory device or you can transfer data directly to a networked computer by cable Either method must be executed from the patient measurement screen The Export Icon for CD or USB Export From the measurement screen click the Export icon or press the X key on the keyboard and the current data will be exported in a text Tile to either a CD or a USB memory device The text format will conform to the export settings you select through the Program Settings menu The Send or Transmit Icon for Direct Transfer From the measurement screen click the Send or Transmid icon or press the S key on the keyboard and the current data will be sent in a text file to a networked computer The IOLMaster and the target computer must have been configured to communicate The text format will contorm to the selected export settings Note You must have the Option B software installed on the receiving PC so that it can recognize the data it will be receiving from your IOLMaster Also note that although the IOLMaster has an Ethernet port it does not communicate with Option B s
77. lumns make sure the selected lenses are those you want It not click the down arrow and select the name of the lens you want in that column lOLMaster A Practical Operation Guide Lens Calculations 5 Click IOL Calculation to see the results on screen only click Print IOL Calculation Data to see the results and also print them out Important Note The screen only shows you one eye s results at a time Under the summary data click the OD right eye or OS left eye radio button to see the results for the other eye When you print both eyes results appear on the same sheet of paper Choosing a Formula Choosing a formula is a medical decision Carl Zeiss Meditec cannot recommend a certain formula There is much literature available on selecting a formula and you are encouraged to investigate this before you make this important decision Dr Warren Hill s website has a wealth of information on this subject available for you to research For further details go to www doctor hill com Basic Formulas The SRK T the Holladay and the Hotfer Q formulas are all commonly used and fairly straightforward formulas These formulas require only the axial length and corneal curvature measurements if you measure anterior chamber depth for instance the results will not be incorporated into the results Each of these three formulas allow for up to four different lenses to be calculated and printed out at the same time e SRK T is a for
78. ments This chapter is broken into five parts e Part 1 Axial Length Measurement below e Part 2 Corneal Curvature Mode page 4 14 Part 3 Anterior Chamber Measurement page 4 21 Part 4 White to White Measurement page 4 26 e Part 5 Calibration Check page 4 28 If you are reading this chapter it is assumed you are already familiar with the information provided in the previous chapters You will also notice that in this chapter we include sections called Best Practices These are included to highlight what we consider the best ways to use the IOLMaster We hope this is helpful Important Note As you learn about taking measurements as explained in this chapter it is important that you practice these techniques on a fellow technician not on an actual patient who will have cataract surgery You must be proficient with these measurement techniques before performing them on patients It is also extremely important that you check the calibration of your JOLMaster every day before taking measurements on actual patients Please see Part 5 Calibration Check page 4 26 for detailed instructions to check the calibration Part 1 Axial Length Measurement How Does It Work See the illustration below for a detailed description Basically the IOLMaster uses light to measure the axial length of the eye the distance trom the front surface of the cornea to the retina whereas A scan ultrasound uses sound waves to measure this dista
79. mula sometimes called the Theoretic Formula produced by Donald Sandars M D You may find it useful for both medium axial lengths between 22 5 mm and 26 mm and long eyes axial lengths over 26 mm but not for short eyes axial lengths less than 22 5 mm Printouts using the SRK T formula will list the lenses A constants These A con stants are rarely if ever the same as the manufacturer s A constants Chapter 2 explains more about this Holladay that is Holladay is a formula produced by Jack Holladay M D You may find it useful for both medium axial lengths between 22 5 mm and 26 mm and long eyes axial lengths over 26 mm and it seems to handle short eyes axial lengths below 22 5 mm slightly better than SRKIT Printouts using the Holladay formula will list the lenses SF surgeon factor rather than a lens A constant lOLMaster A Practical Operation Guide Lens Calculations 55 e Hoffer Q is a formula produced by Kenneth Hoffer M D You may find it useful for both short axial lengths less than 22 5 mm and medium eyes axial lengths between 22 5 mm and 26 mm but that it does not handle long eyes axial lengths over 26 mm as well as the Holladay and SRK T Printouts using the Hotter Q will list the lenses pACD personalized ACD con stant rather than a lens A constant But What About SRK II SRK II is an older linear regression formula which uses a lens A constant and a simple mathemati
80. n nun nun nn nn nn nn nn 7 1 PFODELSNULU OWN ee aE A 7 1 sEXpOrtor Iranster Dalaran teen a a aaa aa 7 2 Holaday IkConsultant ee a ie 7 4 e Backing Up Surgeon and Lens Data uuuussunsnsennnnnnennnnennnnnnnnnnnnnnnennnnnnnnnnnnnnnnnnnnnnnnnn 7 4 ORESTOFE Yan nee en een en ee 7 5 AMPO oaan acacia einer nee Belege a dace 7 5 Finding All of This a Little COMPUSING c ceccececseeseeeceeseeceeesesecaesaesaesaesaesaesaeeateesseseatensaeses 7 5 8 Frequently Asked Questions uuunnunnonnunnunnunnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn 8 1 IOLMaster A Practical Operation Guide IOLMaster A Practical Operation Guide Introduction The eye is the light of the body therefore if the eye is good then the whole body will be full of light but if the eye is bad then the whole body will be full of darkness We are visual creatures Our society our technology our entire way of lite is centered around our ability to see And if that ability is taken away from us we will do everything we can to restore our sight One of the most common causes of vision loss is the cataract a clouding of the natural lens that sits behind the pupil Exposure to certain chemicals and medications can cause cataracts to develop Ultraviolet light may speed up the process as well Even poor health is thought to play a part But ultimately anyone who lives long enough will develop a cataract simply from the passing of time The fi
81. nce lOLMaster A Practical Operation Guide Taking Measurements Ze Short Wavelength Optical Partially Coherent Path 2 Optical Infrared Laser reflects at Path 1 Light Source Corneal reflects at 780nm Vertex RPE M OVING Mirror 1 Axial _ Length Constructive interference occurs in this path Fhotodetector detects constructive when two beams interference as peaks I are of equal length gs Important Note Unlike A scan ultrasound which reflects off the wide cupped surface of the macula the IOLMaster beam passes through the translucent surface of the retina and back further to the more opaque pigment layer The computer corrects for this difference ultrasound vs optical biometry Ultrasound A Scan IOLMaster 10MHz sound wave 780nm laser beam averaging across foveal cup reflection at Bruch s membrane In addition the use of contact ultrasound will indent the cornea thus decreasing the distance between the cornea and the retina and artificially lOLMaster A Practical Operation Guide Taking Measurements Shortening the axial length measured Because of this axial lengths measured on the IOLMaster are almost always longer than those obtained through contact ultrasound How to Perform the Test Once you click the New button back on the New PATIENT screen your screen changes into testing mode A video image of the eye appears in the middle of the screen and a row of icons appears along the bottom Em
82. ne of the formulas utilized by the IOLMaster need this measurement x Troubleshooting If the number is missing entirely that means that the test was somehow not done at all or more likely that there was an evaluation instead of an average So what to do First note which measurement is missing and for which eye Second click Cancel at the bottom of the screen Third slide the scanner to the correct eye to your lett for the right eye to your right for the left eye Fourth click on the appropriate icon or press the appropriate key A Axial Length K Cornea D AC Depth Fifth fix the problem delete bad numbers to get the average back or take more measurements Note that the numbers that appear automatically in these fields are those acquired during the IOLMaster testing You can if you choose to override the computer and type in axial length measurements corneal curvature measurements etc from other sources Simply click on the field that contains the numbers you wish to change click at the end of the number to insert the blinking text cursor there backspace over the number and type in the new number Important Note While the computer will let you type in numbers from other sources like axial lengths from contact biometry or K s from manual keratometers this is not the recommended course of action The lens constants you have entered have been modified to take into account the unique measurement capabilities
83. nnnnnnnunnnnnnnnnnnnnnnnnnnnnnnnnn nun 3 1 SEX COD Mall CONOIS dsrs ee teyada trent e A R S 3 1 sPatient Preparation TIDS za ee een nen ae 3 2 e New Patient Screen Entering New Patient Information c cccceccecceescseeseeseeseecseserssreeeeees 3 3 4 Taking Measurements uuununnnnunnnunnunnnnnnnnnnnnnnnn nun nun nn nun nun nun nn nn nn nn nn nn 4 1 Part 1 Axial Lengtn Messurements aiissteneeiii ee 4 1 Part 2 Corneal Curvature Mode sccsninnritoe an R E 4 14 Part 3 Anterior Chamber Measurement uucursenrsenenensonenensnnnnenenonnnnnnennnnnnennnnnsnnnenesnnnnnnen 4 21 e Part 4 White to White Measurement uunusersenenensneenenenennennnennennnnnnnenenennenenannnnnennennennnnnnn 4 26 New with version 5 software IOLMaster Advanced Technology Plausibility Checks 4 27 Pall oe Calibration Chekon aaa a 4 28 50 WNAENOW een 4 29 5 Lens Calculations u au Band anne anne Hua Eu Aaaa aaia 5 1 stens Calculation Mod C sses tigen ernennen kennen erkenne 5 1 eChoosing ai ONIN Ul een a aces a 5 4 6 Optimizing Lenses uuuuunuununnunuuununnnnnnnnnunnnn nn nun nun nun nun nun nun nun nn nn nn nn nn 6 1 PrepariNg TOr OPLUMIZALION stcsstes2stsateascnssntadbateadeadsaaeoutvesapicecsanasitaanhaddacsaehsoinsntocaseaaeimnlacaseen 6 2 stets Geb Starten ce BE een 6 5 Optimizing the Haigis Formula nn 6 10 SNOW VNU ers en ee 6 10 7 Data Management uuuuununnuunnnnnnunnunnnnnnnnnnnnnn nun nun nun nun nun nu
84. of the IOLMaster These are discussed in Chapter 2 If you enter numbers from other sources the calculation formulas will not know that the numbers are from non IOLMaster sources and will calculate the results as if they were This may produce a significant and unexpected surprise outcome in post operative refractions Surgeon Specifications On the right side of the screen you will see a field containing the surgeon s name You can choose different surgeons each of which can be pre set to have different default lenses Each time you power up the instrument this field will be blank you have to select a surgeon s name by clicking on the down arrow lOLMaster A Practical Operation Guide Lens Calculations 5 3 Just under the surgeon s name you will see a Target Refraction field This is the desired post operative retraction you want your patient to have after cataract surgery and lens implantation Typically the target retraction is near 0 00 This will allow the patient to see as well as possible at a distance The instrument calculates 1 00 to 1 00 diopters above and below the target retraction so if you are looking for a result within this margin there is no need to change the target retraction If you desire the target refraction to be outside this margin you will need to change the target refraction number Important Note Please be aware that if you change the target refraction it will not automatically return to any def
85. oftware through the Ethernet port but through the serial port lOLMaster A Practical Operation Guide Data Management Tr Zu Export or Send Transmit Settings It is important to make sure you have all of the export settings correctly set or you may experience problems with the export or send procedure Follow the next few Steps to complete this process 1 To access the export settings on the IOLMaster select Program Settings trom the Options menu then select Export Settings click Options gt Program Settings gt Export Settings Send Datato PMS 2 In the area named Send data to PMS select the radio button for the C old appropriate version of export old or new You will most likely choose the new new with OL calc table option since the old option is primarily for software versions 1 and 2 COM speed 19200 Standard 3 In the Axial Length Measurement area you can select which type of axial length measurement to transfer Asal engi Measuiemeni Disolay Single measurement classic Single measurement advanced identheatnn You ul most likely select Single measurement advanced since more informa 7 eck Nene tion is transferred this way vv First Name 4 Choose what patient into you want transfer with your measurements IV Date of Birth 5 Choose the measurement values you want to transter Unless you have a M Exam Date See specific reason to do otherwise select all four Axial Length Keratomet
86. ometer Refractive Index What should we set it at The keratometer index is the convergent factor that is used to change K s from radius of curvature to diopter K s In the U S the keratometer index on most manual keratometers is 1 3375 Therefore in the U S the IOLMaster will default to that number but it is a good idea to double check it especially after your instrument has been serviced Note the figure above shows the keratome ter index set at a different number This is the number used in some other countries It is not the correct number for the U S See the figure below for a correct retractive index setting Keratometer Display Redius f Consalk s Cylinder C4 Cyinder Caulioy Kerstometer nines afecti comeal power for a owen radius of currcturel Rehactye index 1 3375 w My patient s data is missing First was your patient in over a year ago If so the computer has probably deleted the file to make room for newer exams The IOLMaster computer is not designed tor mass storage so it will delete older tiles to make room for newer ones You can check to see how long your system is set up to keep data click lOLMaster A Practical Operation Guide Frequently Asked Questions Ze Options gt Program Settings and then look at the Erase Records tield It should be set to 365 days the maximum it can be If it s not change it to 365 Second is the data really missing or have you simply tried to access it incor
87. one or both of the top two spots typically results trom the upper eyelid drooping down too low If you see this happening tell the patient to open wide after the blink If that doesn t work you may have to reach around to hold it up yourself or have a colleague help you to do so The numbers you obtain here describe the corneal curvature and Its light bend ing power or simply Ks for short 4 Note and act on what appears just De ow your list of three measurements e If an average of the three measurements appears you re done with that eye e If the word evaluation appears delete one or more of the measurements and try again until an average appears Don t forget to have the patient blink between measurements New with version 5 software Keratometer Mode Automatic If only one measurement is acquired instead of three you are in manual mode Press the M key on the keyboard to switch to automatic mode cae Important Note With the latest version 5 software there will be only one beep after the last of the 3 measurements lOLMaster A Practical Operation Guide Taking Measurements You can have the instrument default to automatic mode by changing a setting in the Program Settings menu Select Options gt Program Settings and select the Automatic checkbox in the Keratometer area Program Expert Network Uses management Program Language needs restart 20E SL Display Visual Acuity Decimal f
88. optimize and personalize surgical outcomes This process involves manually entering your post operative data into the IOLMaster and allowing the optimization program to alter the lens constants so as to take into account each surgeon s technique This in turn will improve outcomes of future surgeries by providing each surgeon with personalized lens constants Below is an illustration that might help explain all of this E m ig 7 i V in 1 4 s r TR er ne 1 x 4 if 4 f V Ena Immersion ultrasound can With un personalized lens Personalized lens constants provide good accuracy constants IOLMaster can provide high precision tight clustered around bull s provide higher precision cluster and high accuracy eye but with low precision tight cluster but may initially centered on bull s eye large spread have lower accuracy clustered away from bull s eye e Important Note To avoid confusion note that the terms optimized and personalized are used interchangeably in this chapter lOLMaster A Practical Operation Guide Optimizing Lenses Sound complicated It really isn t Just follow this step by step process and you will be on your way Preparing for Optimization Take these steps to prepare for optimization 1 Check with the surgeon to make sure he or she wants you to perform the optimization 2 Read the lens personalization section in your user manual 3 Organize yo
89. ormula it is appropriate only for myopic LASIK surgery patients The Prior Refractive Surgery tab provides two other methods for calculating lOLs for prior refractive surgery patients The Clinical History Method and the Contact Lens Method that are discussed in this section are not lens calculation formulas but more of a preparation for lens calculation When this last tab is activated there are two separate sets of data that lOLMaster A Practical Operation Guide Lens Calculations can be entered for each eye tor the Clinical History Method the top set of boxes or for the Contact Lens Method the bottom set of boxes r Mustermann A013 OD ng OS ef i Measurement Values Measurement Values Avial Length 2376 KER 246 7 44 74 Axial Length 23 45 per 55 t Clinical History Method Clinical History Method u Comealk see OP 4200 Vetes 12 Comeal K s 45 00 Vetex 12 Data for clinical Rel preOP ap 20 ion Ref peOP spk 300 cyt 1 50 history method Ref post OP spb 0 00 cl 0 50 Ref post OP sph 0 50 ot 0 00 Comeslk s S35 Radius 844 App Comeatk s TST Radius 782 on Contact Lens Method Contact Lens Method CL power 1 00 Vetex 0 CL power 050 vete Data for contact Chbssecuve 37 CLbsse cuve E50 Retr with CL fooo ol foso Ret wthCL sph oo et foo lens method Rel wihowCL f200 el 200 Riel without CL sph 500 fe Comeati s I Radius 846 Apply IF Comealk s 1 75 Radius 75 Apply Iv
90. ou a list of printers that have been tested to be compatible with your IOLMaster lOLMaster A Practical Operation Guide ul Carl Zeiss Meditec Inc 5160 Hacienda Drive Dublin CA 94568 USA Toll Free 800 341 6968 Phone 925 557 4100 Fax 925 557 4101 info meditec zeiss com www meditec zeiss com EC REP Carl Zeiss Meditec AG Goeschwitzer Strasse 51 52 07745 Jena Germany Phone 49 36 41 2 20 3 33 Fax 49 36 41 2 20 2 82 info meditec zeiss com www meditec zeiss com 50 US C Eo 2660021123648 B 10L 1411 IOLMaster A Practical Operation Guide Specifications subject to change
91. pick up and put down your finger repeatedly So until you are used to the pad you may activate the wrong icon by mistake by using quick finger strokes on the pad or even letting your wrist bump into it while you are typing If after some practice you find you can t get used to moving the cursor with the touchpad you can use a regular mouse instead Just follow the keyboard cord along to where it plugs into the IOLMaster There the cord splits into two plugs a purple one for the keys and a green one for the mouse Pull out the green plug and plug your mouse cord in instead You want to use a normal mouse i e not the wireless or laser operated variety that has a PS2 plug The joystick You can raise or lower the IOLMaster scanning device by rotating the joystick knob Rotating twisting clockwise will raise the device upward toward the patient s forehead while rotating twisting counterclockwise will lower the device toward the patients cheek You can also move the scanning device right and lett and torward and back by moving the joystick in the same direction as you want to go You will have better control over the scanners movements if you use two hands Patient Preparation Tips Before you even begin testing your patient with the IOLMaster there are some preparations you can make to increase the precision and accuracy of your testing e Ensure corneal stability Modern cataract surgery is not simply the removal of a cloude
92. port it directly into the IOLMaster For instructions see the Downloading and Importing Lenses section on page 2 7 This method has proven very useful for many surgeons and is probably the most commonly used method However every surgeon s technique is differ lOLMaster A Practical Operation Guide Entering Surgeon Names and Lenses ent the A constants that work for one doctor may not necessarily work for another You may notice that not every IOL in existence appears on the ULIB list Only lenses used often enough by the ULIB group to have sufficient data for lens constant optimization make it onto the site Below is an example of what the list of lenses on the ULIB website looks like 3 Optimized IOL constants for the ZEISS IOLMaster Microsoft Internet Explorer View Favorites Tools Help Address http fwww augenklinik uni wuerzburg defeulibjconst htm v BE aa OG PP k e N r Links VTS gt Kronos weather Google 8 Gelo Babel Fish Optimized IOL Constants for the ZEISS IOLMaster reported by ULIB members or other sources as of July 19 2005 Please note constants are preliminary especially ifn lt 50 For details how to create your own tentative constants please click here IOL nominal Haigis HofferQ Holl 1 SRKT SRKI n Ref Acri Tec Acri Lyc 44S A 118 0 cake al 0 40 ACD 5 07 sf 1 29 A 118 3 A 118 5 6 Acri Tec Acri Lyc 53N A 118 0 Baer al 0 40 pACD 5 07 sf 1 29 A 118 3 A 118 5 5 Fr aa A
93. pty columns soon to be filled with data appear to the left and right of the video image a SU sad Won Wel Ready Eber left eye OS data column lO hael ole e SS leo I LM 0 OD Have the patient come forward into the chinrest Get the eye lined up with the red marker and make the patient comfortable by raising or lowering the table The patient can hold onto the handle bars at either side of the IOLMaster if needed The instrument knows which eye you are testing by which side the scanner is moved to When you have the scanner in front of the patient s right eye data will appear to the left of the video image When you have the scanner in front of the patient s lett eye data will appear to the right of the video image Tell your patient to always stare straight ahead at the spot of light The spot will change color depending on which part of the test you are performing but it will always be straight ahead Allow the patient to blink normally Tell the patient you will inform them when they need to stop blinking lOLMaster A Practical Operation Guide Taking Measurements U When you first come to this screen or when you ve just switched from one eye to the other you ll notice that the magnitying glass icon at lower left has been selected automatically This indicates you are in Overview Mode Overview Mode Q This is the first screen that appears when you click New to begin testing If you are on a
94. r A Practical Operation Guide Entering Surgeon Names and Lenses 2 Zug e For option 3 getting the information from the lens representative Enter the information you are given in each field including the fields for each formula Select D or D diopter steps and click Add Important Note Adding a new lens to one surgeon s file will not add it to every surgeon s file You must add each surgeon s desired lenses under his or her own tab Congratulations You ve just added a lens This lens will now be available to be placed in one of the lens fields in the LENS CALCULATION screen Downloading and Importing Lenses Downloading ULIB Lens Constant Data onto a CD RW or Jump Drive You will need to use another computer not the OLMaster that is connected to the internet to access the User Group for Laser Interference Biometry ULIB website This computer will need to have a CD burner or a free USB port with a compatible jump drive also called thumb drives memory sticks USB sticks etc 1 Put a blank CD RW into the CD drive or plug in your USB memory stick so that the computer is ready and recognizes the drive 2 Go the ULIB website www augenklinik uni wuerzburg de eulib index htm Links to it can be found on the IOLMaster page of the Carl Zeiss Meditec web site www meditec zeiss com iolmaster and through Dr Warren Hill s website www doctor hill com 3 Near the bottom of the ULIB webpage click the link to Downloa
95. rst known technique to restore vision lost from a cataract has been traced back to India where in the 5th Century B C the surgeon Susruta performed an operation which later came to be called couching This technique involved literally pushing the cataract out of the way with a needle inserted into the eye Though dangerous couching would continue to be used as the primary form of treatment for cataracts for the next two thousand years In the 1740 s a French surgeon named Jacques Daviel performed the first known removal of the cataract trom the eye rather than simply pushing it aside like his predecessors by physically popping the clouded lens out through the pupil in one solid piece While this new technique of cataract extraction was somewhat safer and more effective than couching both operations left the patient severely far sighted distant objects appeared blurry and nearby objects looked even worse The use of thick glasses was required to provide the patient with usable vision after the operation Then in the 1940 s Harold Ridley successfully experimented with replacing the natural lens with a synthetic one in order to provide the patient with functional vision even without glasses after the cataract surgery In the 1960 s Charles Kelman introduced the technique of phacoemulsitication in which an ultrasonic probe is inserted into the eye essentially liquetying the lens and suctioning it out through a tube Ever s
96. rysler Building single peak or Sears Tower antennas double peak especially if the warning multiple peaks is shown Go through the single measurements and try to determine which peak is the correct one especially if the composite peak s shape is like the Sears Tower antennas double peak If possible perform additional measurements It necessary move the measurement cursor circle to the correct peak on the blue composite graph The AL measurement for the other eye may help you decide which is the correct peak Do not delete single measurements because they are identified as outliers AL is printed in RED or have low SNR Error warning The reason is that the software already recognized them as outliers and has printed the AL in RED Even a low SNR signal may contain significant information for the correct AL That is the rationale for using the composite signal cae Important Note With the latest version 5 software the Error warning in single measurements has been replaced by dashes You do not have to delete these measurements if there is a good composite signal and AL value Part 2 Corneal Curvature Mode How Does It Work Six spots of light are projected onto the cornea in a hexagonal pattern with a diameter of about 2 5 mm so the distance of each spot to the visual axis is about 1 3 mm The position of each pair of reflection spots is detected and measured by the computer the relative positions
97. s day for a reply you should contact the Carl Zeiss Meditec trainer who provided your office with instruction If the question involves a problem with your system the screen is frozen It wont turn on it won t network etc or you have an urgent question about anything that simply cannot wait one business day for a reply contact Cus tomer Service at 800 341 6968 and follow the prompts to the Service depart ment at the time of this writing pushing 2 as soon as the automated message begins will get you to Service If your question is clinical in nature you can find a wealth of information on Dr Warren Hill s website www doctor hill com How often should check the calibration of my IOLMaster EVERY DAY Or better stated at the beginning of every day that you use the instrument What if my instrument is out of calibration The first thing to do is clean your test eye Clean by spraying a small amount of lens cleaner on a soft cloth or lens tissue and then wiping the calibration eye Also make sure there is no bright fluorescent light or sunlight shining directly on the instrument Re test the calibration If it is still not within calibration lim its call Customer Service at 1 800 341 6968 to report this You should not test patients if your instrument is out of calibration It may require a visit from your local field service engineer What if lost my calibration test eye Can get another one You can order anot
98. the axial length and lining up and focusing images reflected off the cornea i e manual keratometry was used to measure corneal curvature But with ultrasound it is difficult to tell whether the scan is directed toward the macula that is toward the area of the retina that provides the patient with central vision What s more contact ultrasound requires actually touching the cornea with a probe which presses the cornea in and artiticially shortens the axial length The alternative to contact ultrasound was immersion ultrasound While this method certainly is more accurate than contact ultrasound it requires the patient s lids to be held open while a plastic tube is placed over the eye and filled with saline Not only is this uncomfortable for the patient it still fails to provide certainty that the scan is being directed to the patient s central vision As for manual keratometry this technique was designed for measuring the peripheral cornea for contact lens fittings Peripheral corneal measurements do not necessarily provide the correct central corneal curvature the curvature that most directly impacts the patients vision What s more the measurement requires lOLMaster A Practical Operation Guide The Eye and the IOLMaster looking through a scope and turning various knobs to carefully align a series of shapes reflected trom the patient s cornea The accuracy of these measurements depends greatly on the examiner s skill pat
99. the patient s pupil so even a little movement of the controls has a big impact on the pupil position So be sure to hold the joystick firmly with one hand and the base of the scanner just beside the joystick with the other and move the scanner using both hands together Do do anything different when measuring a pseudophakic patient Yes in two ways 1 When in Axial Length Mode select the appropriate pseudophakic IOL type from the AL Settings menu at the top of the screen This must be done before calculating the IOL for that patient but not before measuring the patient Please see What About Eyes That Have Already Had Surgery page 4 12 tor more details about this 2 Be cautious when measuring axial length on a pseudophakic patient You will sometimes get two tall spikes one unusually short and one at the axial length you would expect for that patient The first unusually short spike is probably the instrument picking up a reflection from the IOL that is in the patient s eye If this spike is equal or taller than the more realistic axial length the lOLMaster A Practical Operation Guide Frequently Asked Questions instrument will probably put the measurement cursor on that spike causing the axial length measurement to be incorrect The easiest and safest thing to do in this case is to delete that measurement and take more measurements You may not be able to get rid of that short spike but you should be able to get eno
100. then pull the scanner back toward you just a hair and the outer spots will come into focus 3 Now say to the patient Blink a couple times now stop blinking and look straight ahead at the light Before you push the joystick button take a quick look at the six spots are they all small and sharp or are one or two of them blurred or have streaks coming out from them Blurred or streaked spots will not be analyzed well In this case have the patient blink a few more times have them blink rapidly tor a few seconds then stop The blurriness and lOLMaster A Practical Operation Guide Taking Measurements E streaks should be gone so now you can push the button Push the joystick button and the system acquires three measurements in rapid succession The measurement values appear in the left or right eye data column as usual Z Best Practice Have the patient blink between EACH PUSH of the button Patients fend to stare during such tests which arys out the cornea Rather than having the patient blink a time or two at the beginning of each testing mode have them blink a time or two between each push of the joystick button A good tear film will helo with all the tests especially the K s Using a light artiticial tear can help smooth the fear film if a patient has extremely ary eyes but do not use a very viscous brand of fears This can add too much of a tear film making the reflective surface irregular and unstable Trouble with
101. tt There are four important things you can do on the NEw PATIENT screen add a new patient to test select an existing patient to test recall old test results and delete unwanted files Patient Options 2 Last Mame lOLMastor First Marne 4 ICHECK DEVICE 01 01 1911 Date of Birth i fields to list of ID Number enter new existing Retraction oo 0 6 fo Y patient patients osmo e 6 information Visual Acuity OD 05 Remark Ce 4 Adding a new patient to test Make sure your blinking cursor bar is in the Last Name field at the upper right of the screen If it s not move your cursor there and click on the field Now you can begin to enter the patient s data Use the Tab or Enter key to move between fields You always must enter data for last name first name and date of birth ID number may also be required depending on the system settings You can enter more information if you wish to or simply begin testing If some fields contain information you don t want to be there such as from the last patient you tested or trom accidentally having clicked on an existing patient s name in the list click on the word IOLMaster at the top of the patient list This will clear all the fields to give you a fresh start Click New at the bottom to begin testing The New button does not mean new patient in this context instead it means new test lOLMaster A Practical Operation Guide Preparing
102. tter implants lens implant remaining lens capsule Today in most cases the front of the crystalline lens capsule is removed along with the clouded contents lOLMaster A Practical Operation Guide The Eye and the IOLMaster of the lens leaving the rest of the clear capsule intact to hold the implanted lens in place Thus the intraocular lens or IOL sits more or less in the same position the natural lens once occupied How Strong Should the Implant Be Now that we can implant a lens into the eye to replace the natural crystalline lens removed during cataract surgery the question arises as to how strong the implanted lens should be If it is too strong the eye will be lett nearsighted only objects near the eye come into focus but if it is not strong enough the eye will be left farsighted with distant objects blurred and nearby objects even more blurred In the past surgeons simply had to guess at the implant strength based on the patient s prescription for glasses or contacts Then along came the notion of measuring the length of the eye and the curvature of the cornea How are those two measurements useful for choosing a lens implant strength Good question By measuring the curvature of the cornea these measurements are often called K s short for keratometry literally corneal measurement we can determine the focal distance of the cornea that is the distance trom the corn
103. ugh readings where that spike is shorter than the actual axial length Can enter manual K s and or other biometer s axial lengths into the lens calculation screen Well technically yes but this is not recommended The reason it is not recom mended is that as Chapter 2 discusses the lens constants you entered for the IOLMaster have been adjusted to account for the difference in how the IOLMaster measures For this reason you would not want to use measurements from these other technologies in the IOLMaster because the IOLMaster will calculate the IOL using the IOLMaster adjusted lens constants which would be incorrect in this case It is best to stick with the same technology the IOLMaster for all measure ments this way you don t have to worry about these issues What do do if my printer stops working Printers are under warranty through Carl Zeiss Meditec for 30 days and for 1 year with the printer company It it is within the 30 day window contact Cus tomer Service at 1 800 341 6968 If it is past the 30 day window but still within the year contact the printer company directly It it is over a year it may be best to purchase another printer However you should not purchase just any printer To find out which printers are approved for use with the IOLMaster call Customer Service or check the Carl Zeiss Meditec website www meditec zeiss com iolmaster If you call they will ask you for your IOLMaster serial and give y
104. ur data so that you are ready to fill out the Lens Constant Personalization Data Sheet You will need to have the post operative data Organized in a particular way Please see the following sections Surgeon and Lens Criteria and Patient Criteria Surgeon and Lens Criteria e Make sure that the results are separated by doctor then by lens e For instance you don t want the results from Dr Jones surgeries to be used when optimizing Dr Smith s lenses and you don t want the results from Dr Smith s surgeries using Lens A to be used when optimizing Dr Smith s Lens B e Therefore you need a list of results that are only for Dr Smith s Lens A patients and another list of results that are only for Dr Smith s Lens B patients and another list of results that are only for Dr Jones s Lens A patients and so on Patient Criteria Include the following types of patients Patients with no prior refractive surgery e Patients with no astigmatic relaxing incisions LRI at the time of their cataract surgery e Patients with no macular pathology Patients with best corrected vision of at least 20 30 Dont include any surprise results For each separate doctor and for each separate doctor s individual lens you will need the following intormation e The patient s name e The eye that was operated on lOLMaster A Practical Operation Guide Optimizing Lenses Ze e The power in diopters of the lens
105. uti Formula Haig phakic Iak Prior Refiactive Surgen Meter 0071 S07 selected surgeon measurements Axial Lenath ramp 23 81 jae Eye Surgeon Dr Mustermann Comealks mmi 721 i713 735 47 33 Taget Renaction oy 05 ta rg et refraction su m ma ry Ophea ACD mm ET oe l Sugea Eye OD C os X Celewetion A Erini IOL Cakuaton Dots 4 columns of Lena 1 Lene a Lena 3 kest gt LA READ OKT RERAD 0 0 RERO GEO AREND preferred lenses ka b b 1 for selected read 1 54 18 0 Bat 125 1 745 125 T5 ms fa m a feo a feo a al h ET 0 23 16 0 123 105 ang 105 0 03 m m feo fom as om p p ERRES b a tademank of CTI Compulathonal Techralogy Inc ok Cancel Summary Data At the lett side of the screen you will see fields containing a summary of measurements for both eyes If any number is grayed out that means the particular formula you selected does not need that number e Axial Length This is the average axial length number that appeared at the bottom of the list of measurements back in Axial Length Mode e K s This is the average steepest and tlattest K that appeared at the bottom of the list of measurements back in Keratometer Mode lOLMaster A Practical Operation Guide Lens Calculations e ACD This is the average anterior chamber depth that appeared at the bottom of the list of measurements back in ACD Mode Note WtW white to white does not appear here since no
106. xt move the scanner back and forth and focus the flecks of the iris 3 Have the patient open their lids wide and push the joystick button The computer takes a snapshot of the eye and superimposes some graphics on it A Take a look at the superimposed graphics The most important graphics are two curved white lines one on each side of the iris at the iris sclera boundary It the white lines are in the correct position click OK below the snapshot It the white lines are not in the right spot too far into the darker iris for instance click Cancel to try again As for the other graphics you may see this image in the center of the pupil The circled cross hair is the optical axis the center point between the two edges of the iris The plain cross hairs is the visual axis where the central dot used to be the path along which the patients sees Note that the visual axis will often be slightly off center in the pupil more toward the patient s nose which is as it should be lOLMaster A Practical Operation Guide Taking Measurements Once you have taken a measurement you like and saved it by clicking OK take two more measurements and see it they all match up within 0 2 mm Important Note Dimming the room lights can help this test by reducing glare from the eye and making the darker iris lighter sclera boundary more visible to the system Moving on to the other eye Now that you ve taken all the desired me
107. y Farsighted or Nearsighted Patients Some patients have prescriptions that are so great that they can barely even see the light in front of them much less fixate on it In such cases you may want to have them wear their glasses but not contact lenses for the axial length measurement Are we done yet If you have a good composite graph with a green light on the SNR stoplight you re probably okay to proceed to the K s But just in case you should do a quick double check Look over your measurements to make sure everything makes sense If all of your measurements are about the same number you re okay to proceed to the corneal curvature measurements If not use the up and down arrows on your keyboard to quickly scroll up and down your list of numbers Use the information you have learned in this chapter to decide which numbers to delete if any Important Note Deleting single measurements merely because they have a low SNR may negatively influence the composite signal The idea behind the composite algorithm is to produce a composite signal with a good SNR from a number of single measurements with varying SNRs New with version 5 software Axial Length Guidelines for Best Practices e A good composite signal has a SNR above 2 0 e A borderline value is between 1 6 and 2 0 IOLMaster A Practical Operation Guide Taking Measurements ET e Below 1 6 no AL is displayed Take a closer look at the composite signal peak s shape Ch
108. yboard to advance to this mode If the word evaluation appears then the largest number steepest curvature and the smallest number flattest curvature are more than a quarter diopter different on average lOLMaster A Practical Operation Guide Taking Measurements OT The computer determines this by averaging each of the three sets of numbers into three invisible average numbers These three separate averages do not appear on the screen the computer simply does the calculations internally If the largest and smallest average are more than a quarter diopter apart the word evaluation will appear at the bottom of the list rather than a number If you are fairly certain which of the three measurements is incorrect for example you saw the patient move or blink during that measurement you saw some debris float through the tear film you were out of focus or off center when you pushed the joystick button etc go ahead and delete that one and see if the average number appears at the bottom of list If it does go ahead and take one more measurement to make a total of three just to be sure If it still says evaluation delete the remaining two and start over fresh Helpful Hint Much like the axial length measurements a traffic light appears to help determine the quality of your image x Troubleshooting The main cause of getting evaluations at the bottom of the list or getting errors instead of

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