April 2016

 

COVER FEATURE

 

New technology in cataract surgery

New cataract surgery technology


by EyeWorld staff

 
 

ASCRS logo

One advantage of using intracameral injections for dilation over drops is that fewer drops need to be given. When you are in a busy surgical center and a nurse needs to give 3 or 4 sets of drops prior to surgery, eliminating some of those drops could potentially make it easier for the nursing staff. Nick Mamalis, MD

Global Trends in Ophthalmology Copyright 2016 Global Trends in Ophthalmology and the American Society of Cataract & Refractive Surgery. All rights reserved.

 
Diagram of change IOL power

Figure 1: Percent of cases in which ophthalmologists change IOL power when using intraoperative aberrometry

Diagram of laser methods

Figure 2: Ophthalmologists anticipated mix of laser and hand-performed methods for cataract surgery in 10 years

Survey respondents

Figure 3: Survey respondents selected up to 3 presbyopia-correcting technologies that they are most interested in integrating into their practices during the next 5 years Source: ASCRS

ASCRS members weigh in

Several new technologies are being used to improve outcomes in cataract surgery. These include aberrometry, laser-assisted cataract surgery (LACS), multifocal IOLs, and drug delivery systems.

In the 2015 ASCRS Clinical Survey, ASCRS members were surveyed about their experience with these technologies. Here are the results.

Ophthalmologists were asked, In what percentage of cases do you end up changing the IOL power when using intraoperative aberrometry? There was a nearly even split among 1% to 10% (28%), 11% to 30% (33%), and more than 30% (30%). See Figure 1.

I change the spherical power in about 40% of cases, usually by only 0.5 D, said Robert Cionni, MD, the Eye Institute of Utah, Salt Lake City. Larger changes from the original plan are more often seen for post-laser refractive surgery cases. My preoperative calculations are typically based on the LENSTAR [Haag-Streit, Koniz, Switzerland] measurements, the Holladay 2 formula, and the VERION [Alcon, Fort Worth, Texas] toric formulas, which do not currently take the posterior corneal curvature into effect. We have seen better estimates of the toric magnitude and axis recently using the Barrett toric calculator, but our recent analysis still demonstrates superior outcomes using aberrometry.

LACS

When asked what they think their mix of laser versus current hand-performed mechanical methods for cataract surgery will be 10 years from now, 94% of ophthalmologists said they think they will do at least some laser-assisted cataract surgery (LACS) in 10 years. Additionally, 38% think a majority or all will be laser-assisted. Thirty-nine percent of U.S. ophthalmologists and 38% of non-U.S. ophthalmologists think the majority or all will be hand-performed. See Figure 2. In general, surgeons will make a change in practice when new technology clearly demonstrates better outcomes, improved efficiencies, or a significant cost savings, Dr. Cionni said. We are not quite there yet with LACS. It is definitely more expensive, takes a little longer than manual surgery, and outcomes have not yet been shown to be clearly superior to manual techniques when we look at mean outcomes. However, I have yet to see any surgeon produce more consistently precise capsulotomies, corneal incisions, or arcuate incisions as with LACS. LACS is already proving to help us with challenging cases such as in patients with zonular compromise or intumescent cataract. In time, LACS will enable other new technologies as well, much like phaco led us to small incision foldable IOLs. Once this occurs, the uptake of LACS will grow significantly.

Multifocal IOLs

The survey also asked about multifocal IOLs. Ophthalmologists were asked to select up to 3 of the following presbyopia-correcting technologies that they are most interested in integrating into their practices during the next 5 years: extended range of vision multifocal IOLs, light-adjustable IOLs, shape-changing IOLs, corneal inlays, dual optic accommodating IOLs, laser vision correction monovision, presbyopia femtosecond ablations, multifocal laser vision correction ablation, hinge-type accommodating IOLs, and others.

The top 3 were extended range of vision multifocal IOLs (63%), light-adjustable IOLs (35%), and shape-changing IOLs (22%). On average, only 2 options were selected, and the top 3 were the same for U.S. and non-U.S. doctors. See Figure 3.

Dilation

Ophthalmologists were also asked, In the majority of cases, how are you dilating your patients? The majority (70%) are dilating with topical drops, while 26% said they use topical drops and intracameral epinephrine.

I, like the majority of respondents, still rely primarily on topical drops for routine cataract cases and intracameral epinephrine with topical drops for complex cases, in particular those with intraoperative floppy iris syndrome, said Christopher Starr, MD, Weill Cornell Medicine, New York Presbyterian Hospital, New York. While this strategy works well for a majority of cases, there are still many instances in which a steady infusion of epinephrine or phenylephrine along with an NSAID would be advantageous. Now that we have a commercially available product, I would not be surprised to see its use increase in future surveys. With FDA approval of a commercially prepared intracameral broad-spectrum antibiotic, I would expect a similar trend in the context of endophthalmitis prophylaxis. According to Nick Mamalis, MD, John Moran Eye Center, University of Utah, Salt Lake City, there are advantages and disadvantages to drops and intracameral injections for dilation. One advantage of using intracameral injections for dilation over drops is that fewer drops need to be given. When you are in a busy surgical center and a nurse needs to give 3 or 4 sets of drops prior to surgery, eliminating some of those drops could potentially make it easier for the nursing staff. Another potential advantage of eliminating some of the topical drops is eliminating effects on the corneal epithelium. Lastly, when patients come into the operating room and they are widely dilated, when you first turn on the microscope light, they are very sensitive to the light; if you are dilating them with an intracameral injection, the pupil is still smaller when you initially turn on the microscope, and only then do you dilate them, so they will be a little less sensitive to the microscope light. The disadvantage is that the pupil doesnt dilate as widely. Physicians who use this frequently have admitted that it dilates well for the surgery but not quite as well as the drops. Other potential disadvantages include issues involved in the proper mixing of the intracameral injection for dilation and the potential for causing toxic anterior segment syndrome if preserved rather than non-preserved medications are used or if an incorrect dosage of the medication is drawn out, Dr. Mamalis said. There is a commercially available intracameral dilating solution in Europe with phenylephrine and lidocaine that may help with pupillary dilation for cataract surgery and avoid potential problems with custom mixing of intracameral medications.

Editors note: Dr. Cionni has financial interests with Alcon, Ocumetrics (Surrey, British Columbia), and ClarVista Medical (Aliso Viejo, California). Drs. Starr and Mamalis have no financial interests related to their comments.

Contact information

Cionni: 801-266-2283
Starr: cestarr@med.cornell.edu
Mamalis: nick.mamalis@hsc.utah.edu

Related articles:

Cataract surgery and small pupils by Matt Young and Gloria Gamat EyeWorld Contributing Writers

New technological advancements in cataract surgery

Femto in cataract surgery: The state of the technology by Liz Hillman EyeWorld Staff Writer

Managing makeup after surgery by J. E. “Jay” McDonald II, M.D.

The evolution of laser cataract surgery by Lauren Lipuma EyeWorld Staff Writer

Cataract surgery in post-refractive surgery patients by Michelle Dalton EyeWorld Contributing Writer

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