“Future-Proof” Your Cataract Surgery Suite

You’ll need to find new efficiencies in the ASC — sooner than you might think

“Future-Proof” Your Cataract Surgery Suite

You'll need to find new efficiencies in the ASC — sooner than you might think. Here's a look a several new ideas.


The future is clear: the baby boomers are coming. All the latest projections show that ophthalmology is going to experience a surge in cataract surgery volume as a consequence of this sizable group now reaching cataract age and also a decline in the number of practicing ophthalmologists.

On first glance this should come as good news for cataract surgeons, as one would expect a financial boon would follow. Unfortunately for us, Medicare is being defunded under Obamacare and will not be able to reimburse surgeons at todays rates, which are already severely discounted from prior levels. This essentially means that we are going to have to work harder for less revenue. So what else is new? This has been going on since the 1980s.

This will force ophthalmologists to confront radical change. Some will either decide to retire early or become medical ophthalmologists, leaving those who continue to perform surgery with an even greater caseload. To remain financially viable in a cataract surgery practice of the future — the very near future — high surgical volume and ASC ownership are paramount. Having a vested interest in an ASC allows one to reap the benefits of an efficiently run OR.

People in technology circles talk of “future-proofing” computers and other vital systems. That means avoiding obsolescence by investing in devices that can perform many tasks and that have a long usable life, especially those with upgrade paths that will allow you to benefit from future enhancements without having to replace the entire system.

If you think about it, the most important system to future-proof is your ASC as a whole. Below are several new technologies that are allowing cataract surgeons to do just that.

Built for Speed

To succeed as high-volume surgeons, we need to be able to make the most of our limited time, which will be in ever-shorter supply. Cataract surgery is no longer the 30-minute ordeal it used to be, but it can no longer be even a 15-minute procedure. Many surgeons have been able to lower their procedure times to under five minutes by sheer skill. The benefit of advancing technology is that it makes good surgeons great ones, and thus provides for better patient outcomes.

One would expect that this new technology would be cost prohibitive to implement. While some items do indeed come with high price tags, industry is responding to the limited financial resources available in this economy, providing upgrade options to existing surgical device platforms that are already in your ASC.

Some of the most significant benefits can be seen in the latest technology available on the different phaco machines.

Alcon's Infiniti system has been a solid and robust platform, with many options and upgrades introduced over the last several years. One that all Infiniti users should consider investing in is the combination of the Ozil hand-piece and IP software. Many surgeons have held back on purchasing the hand-piece, as it requires a bent phaco needle for optimal performance. The bent needle, while unique, allows the torsional movement of the Ozil hand-piece to be magnified, resulting in more efficient cataract removal. The amount of energy and time spent in the eye can be greatly reduced with this system.

Upgrading to the Infiniti's IP soft ware allows for better fluidics in the eye. It detects occlusion while the Ozil hand-piece is in use and compensates with a short pulse of longitudinal phaco energy to push the nuclear fragment off the tip and allow it to be re-engaged. This minimizes the surgical manipulation needed inside the eye. The two technologies of Ozil and IP software combined allow for a smoother and more predictable case.

Abbott Medical Optics has been allowing for upgrades to its Signature phaco platform as well. The system had always been endowed with AMO's Whitestar technology that more efficiently uses phaco energy by breaking down the phaco waveform into micropulses to deliver the same effective power with a fraction of the energy used and heat produced. This platform also was introduced with a dual-pump setup. The user can choose on the fly between a peristaltic pump (vacuum builds) or a Venturi pump (immediate vacuum). This allows the surgeon to select the most comfortable and efficient method of cataract removal based on the circumstances. Most surgeons prefer a peristaltic pump for grooving and a Venturi pump for efficient quadrant removal, and then back to a peristaltic pump for controlled cortex removal. The flexibility of this platform allows for the best of both worlds.

A recent upgrade to the Signature platform was that of Ellips technology, which allows for an elliptical movement of the phaco needle, combining both longitudinal and horizontal phaco energy simultaneously. Initially, the effect was not as robust as one would hope but the recent release of the new Ellips FX hand-pieces along with the upgraded accompanying software has turned this platform into a real powerhouse. The Signature's software allows for extremely stable fluidics by using a very high sampling frequency and quick-reacting pumps. This allows the surgeon to run the system at higher and more efficient fluidics without the trampolining effect seen in the past.

The Ellips FX hand-piece provides for efficient cataract removal by maintaining contact between the cataract and the tip of the phaco needle and directing the phaco energy into the cataract with less energy loss. This can be accomplished with either a straight or bent phaco needle, allowing for surgeon preference and comfort.

Upgrading either the Alcon or the AMO phaco systems with new hand-pieces and software comes at a moderate cost but with a significant gain in surgical efficiency and decrease in surgeon stress. The performance gains can easily deliver a 10% to 25% reduction in case times. This might not seem like much at first but it can easily start saving hours on your surgical day as your volumes mount.

And though I don't have first-hand experience with Bausch+Lomb's Stellaris, the system has been lauded for the safety profile of its low-energy phaco, dual-pump technology analogous to that of AMO's Signature, and its suitability for micro-incisional surgery. (Editor's note: For more information, see the article on Phaco Technology of this month.)

Bright Ideas

Having a muscle car doesn't mean much if you can't see the road. So it is with our surgical microscopes — they are probably the most underrated piece of surgical equipment that we use. In the past, most of us have felt that what we get from our microscopes is “good enough.” But over the last several years, new lighting technologies have started to show us what we've been missing. The reality is that the majority of surgeons could not justify the high cost of total microscope replacement when they already liked their current optics. All they wanted was a way to upgrade their light sources.

Enter Endure Medical, a manufacturer of surgical microscopes out of Atlanta. In addition to making its own line of scopes, the company also services and upgrades other brands of surgical microscopes, including Leica, Wild and Zeiss. Its latest upgrade for microscopes is the Illumni illumination head, which can be mounted to almost any brand of surgical microscope at a fraction of the cost of a new microscope.

The Illumni head features three separate light sources to illuminate the eye during surgery. This allows for a considerable increase in the contrast and detail seen in the eye. This is most impressive when performing the capsulorhexis because eye position does not affect the red reflex. The extra detail that is visible can be overwhelming at first, as the amount of visual cues are multiplied. This quickly becomes an added tool as your depth perception is increased, giving you more confidence in the relative distances within the eye. This situational awareness and detail truly has made cataract surgery “high definition” for the surgeon.

In addition to the scopes themselves, Endure also manufactures a line of surgical microscope replacement stands. The beauty of these is that all control functions are solidstate and digital, unlike most stands that rely upon analog controls that wear out with use. The Endure digital controls come on a removable panel that can be replaced by the user, allowing for a quick repair if necessary by overnight shipping of a new panel to be swapped out by the OR staff. This can save considerable time and money, negating the need for technician time and travel expenses to evaluate and repair your stand. As it is a digital system, it is also programmable for multiple surgeons and foot-pedal button functions, which helps with case turnover.

Sterilization Without Procrastination

Decreases in case times are all well and good, but only if you can turn over the rooms and the instruments rapidly. Medium-to-large steam autoclaves always do a fine job with sterilization but can be cumbersome with their peculiarities. Warm-up time can take several minutes just to get the autoclave up to temperature before it can run a sterilization cycle. This may force you to have either extra instrument trays or more autoclaves to run at a pace of six or more surgeries an hour.

To overcome these limitations, it helps to see what our dental colleagues are using for sterilization. They need to sterilize instruments very quickly over and over all day long. SciCan has developed a series of autoclaves originally for the dental market that work extremely well for our purposes as well. Its Statim 5000 model is ideal for an ophthalmic ASC. It only heats the water necessary for a sterilization cycle instead of the full reservoir, thus reducing start up time. To sterilize instruments and phaco hand-pieces only takes nine minutes. This quick turnover time allows for fewer trays of instruments and possibly less autoclaves.

Outsourcing Cataract Services to Treat Patients Close to Home


As a solo practitioner who operates out of a large surgery center as well as two rural satellite offices, my patients are spread across a broad geographic range. In the tri-state area of South Dakota, Iowa and Nebraska in which I practice, many patients expect to have to travel long distances to reach medical facilities with the capabilities they need, as their smaller local facilities simply cannot invest in the equipment to provide services such as cataract surgery. Additionally, as many of us have seen, even the larger facilities face challenges in keeping their equipment up-to-date.
    However, for the past 15 years, I have used an outsourcing service to bring cataract surgery equipment to my surgical facilities, and have found it is an outstanding way for all parties involved to benefit. Sightpath Medical works with with me and the facilities in which I operate to ensure smooth surgery days from start to finish. The facilities contract with Sightpath and make no capital investment, but rather pay for the service on a per-case basis. In turn, I am able to select from my choice of state-of-the-art equipment, instruments, supplies and IOLs, which Sightpath's technicians set up in my facilities.
    The ability to offer treatment close to patients' homes with the most current technology has been an excellent benefit to my practice. Additionally, the technicians provided by Sightpath Medical are an exceptional help. Specializing in ophthalmology and certified by the National Board of Surgical Technology and Surgical Assisting, they know the instrumentation and machines inside and out. If necessary, they are able to troubleshoot most problems onsite immediately, preventing delays in surgery. Having someone onsite who is able to provide everything I need for surgery and ensure all equipment is working properly has been a great help. The technicians can scrub in during the procedure, and they even helped me when I needed to hire and train a fulltime scrub technician.
    Using these services, I am able to provide quality care to patients at three sites with the latest equipment, while still keeping costs down. It has helped me be a better surgeon, and I have been impressed with how Sightpath Medical has gone above and beyond to help facilitate my cataract surgery process.

Beth Bruening, MD, is trained and board-certified in general ophthalmology, with 16 years experience in comprehensive medical and surgical eye care, with cataract, refractive, cosmetic, glaucoma and motility disorders.

Get it Right the First Time

To take an ASC to next level of efficiency, one might want to investigate WaveTec's new ORange intraoperative aberrometer. This device allows for intraoperative IOL power and cylinder calculations, toric IOL rotation optimization and LRI on-the-table verification. These capabilities give surgeons greater intraoperative precision by allowing us to apply the old carpenter's rule: “measure twice, cut once.”

At first, one would assume correctly that using an ORange system is going to add more time per case in the operating room. What becomes apparent later is the savings you accrue by being more accurate in the OR and reducing your enhancement procedures. The cost to the practice of just one enhancement includes not merely the repeat surgical encounter but also the staff and physician time that is “wasted” on repeat appointments (verification, check in/out, tech time, doctor time, billing adjustments), loss of available time slots and word of mouth.

The Future is Now

All these advances and upgrades make a tangible improvement in your OR efficiency but require a staff that is ready to step up to the next level. This usually requires a gradual change in the OR environment with administration and surgeons leading the way. Most staff members understand that the future is going to involve change and are grateful to have stable employment.

This is an opportunity to generate excitement in your ASC while preparing your practice to shoulder the increased cataract caseload that is already materializing in ophthalmic practices across the country. OM

Farrell C. Tyson, MD, FACS, is a refractive cataract/glaucoma eye surgeon at the Cape Coral Eye Center in Florida. He may be reached at