Since the 1980s, the push for efficiency and personalization in patient care has led to the proliferation of ASCs.

ASCs offer a range of advantages for many surgical procedures — those that do not require the capabilities of a fully equipped modern hospital but also are more complicated than an office-based procedure. Some ASCs are general surgical facilities that address a wide range of operations, while others focus exclusively on ophthalmic procedures — most commonly cataract surgery.

For decades, large surgical equipment manufacturers have been refining their offerings to fit within the framework of ophthalmic ASCs. As such, the technologies available to surgeons are tailored to the surgical setting and are more powerful, efficient and effective than ever before.

ALCON

Phacoemulsification

The Active Fluidics technology in Alcon’s Centurion Vision System can detect flow rate, irrigation pressure and vacuum, and the system continuously monitors and adjusts to changes in the eye, further enhancing the surgeon’s ability to regulate IOP.^1-3 The company’s Active Sentry Handpiece also relies on Active Fluidics technology, incorporating an integrated pressure sensor to measure IOP very close to the tip, eliminating delays due to adjustment.

Introduced at the 2019 ASCRS annual meeting, Active Sentry Handpiece and Intrepid Hybrid Tip were designed to improve safety, consistency and control. An advance over the company’s previous phaco unit, Centurion speeds cataract removal with its Energy Delivery platform, which reduces repulsion and enhances torsional efficiency.⁴ Heat transfer to the eye is minimized through fluidics and OZil technology, and the polymer Intrepid Balanced Tip delivers a lower temperature increase than traditional or ultrasound techniques.⁵

“Using the new Centurion with Active Sentry, I am getting exceedingly stable chambers,” says Farrell “Toby” Tyson, MD, medical director of Cape Coral Eye Center, Fla. “Even if the capsular bag was to break or tear, I find that the pressure is so well controlled that the hyaloid face stays intact, allowing for a controlled recovery of a bad situation.”

Speaking on the Intrepid Hybrid Tip, Dr. Tyson says “its rounded polymer edge provides heightened safety and confidence while being almost as efficient as a typical angled sharp phaco needle. That allows the surgeon to have more confidence while maneuvering in the eye because, first, the Active Fluidics ensure the eye is stable and, second, the tip is capsule friendly even in the event of unintended engagement.”

Femtosecond laser

The LenSx Laser has been shown to produce precise and reliably consistent capsulotomies and self-sealing cataract incisions.^6-16 The latest enhancements, cleared in 2018, allowed for the creation of tunnels for intracorneal rings and pockets for presbyopia-correcting inlays. In addition, software updates were implemented to support the new indications and improve graphical user interface functionality.

Planning and biometry

Alcon’s intraoperative aberrometer is the ORA system with AnalyzOR technology, which provides real-time confirmation during surgery. It continuously assesses the eye’s condition, facilitating customized surgical planning. The AnalyzOR tracks, stores and analyzes results to identify personal and worldwide trends. This helps surgeons maximize their approach based on the real outcomes they achieve, customizing their personal lens A-constants. In conjunction with the company’s Argos biometer with Image Guidance, the ORA system can help surgeons plan procedures better.

Surgical microscope

The LuxOR Revalia ophthalmic microscope has a more stable red reflex compared with other microscopes in one study and enhanced depth of field, offering six times larger visualization.^17-19 When used with the suite of Alcon technologies, the LuxOR Revalia can be paired with the company’s Ngenuity 3-D Visualization System, producing a fully integrated suite of machines.

3-D visualization

Alcon’s Ngenuity 3-D Visualization System, the latest version of which was released last year, provides a customizable, digitally enhanced, immersive surgical view. Updated features for cataract surgeons include simultaneous viewing of the Centurion Vision System surgical parameters for real-time surgical feedback, and ORA VerifEye+ cart data and aberrometer reticle displayed on Ngenuity.

BAUSCH + LOMB

Phacoemulsification

During phaco surgery, the Stellaris Elite System reacts automatically to changing procedural factors to maintain stability and surgeon control. As a result, primary focus can remain on the patient instead of the phaco machine. Designed for use in both anterior and posterior segment surgeries, the system can assist in a variety of surgical applications beyond phacoemulsification, including coaxial and bimanual irrigation/aspiration, bipolar coagulation, vitrectomy and viscous fluid and air exchange operations. Paired with its laser module, Stellaris is capable of retinal photocoagulation and laser trabeculoplasty.

The Attune Energy Management System allows for cataract removal with less energy, and the Attune Handpiece delivers optimized, consistent power with increased stroke length.

Femtosecond laser

Bausch + Lomb’s Victus Femtosecond Laser unit can help perform fragmentation, capsulotomies, arcuate incisions, corneal incisions and LASIK flaps. Its key features include the RealEyez swept-source OCT, which delivers continuous high-resolution, real-time visualization.

The Victus’ 3.3 software package was designed to make the platform more user-friendly. The software features a new option for capsulotomy and lens fragmentation centration, providing more choices for location as well as automatic pupil centration for the creation of corneal flaps. In addition to this software, Victus features a new S60 bed, which swings out farther away from the laser.

To capitalize on what she saw as efficiencies, Sharon Richens, MD, founder and owner of Richens Eye Center, St. George, Utah, chose Bausch + Lomb to outfit her newly purchased ASC. “Bausch + Lomb equipment’s combined functionality for an integrated OR has been an excellent investment,” she says.

A key feature that sold her was space savings. “I like the fact that the femtosecond laser offers both LASIK and cataract surgery functionality and just one unit that performs both cataract surgery and vitrectomy. Not only does this save space and money, but by not having so many boxes on wheels in the OR it also means fewer extended warranties to deal with,” Dr. Richens adds.

JOHNSON & JOHNSON VISION

Phacoemulsification

In 2021, Johnson & Johnson Vision anticipates FDA approval of Veritas, the company’s next-generation phacoemulsification vision system. At the AAO virtual meeting last year, Warren Foust, worldwide president for Johnson & Johnson Vision’s surgical business, placed the new device in context of the company’s current action plan.

“For 2021, we’re unleashing momentum built up over the year with an unprecedented pipeline,” he said. “On the equipment side, we are also making strides forward with our Veritas Vision System — our next generation phaco machine featuring innovations in fluidics management and ergonomics for usability.”

Femtosecond laser

Finalized in December 2020, the Catalys Precision Laser System’s cOS 6.0 software update increases the unit’s efficiency and simplifies astigmatism management workflow. The direct input of preoperative keratometry and steep axis data reduces transcription and data entry errors. The need for intraoperative aberrometry to align toric IOLs is also reduced through automated corneal laser marking, which increases accuracy over ink pen manual marking.¹⁹

The cOS 6.0 software update was produced through a product-development and marketing collaboration with Cassini Technologies. It includes advanced visualization with full-volume, 3-D, high-resolution and streaming OCT imaging and enables full compatibility with Ambient, Cassini’s new corneal topography imaging device.

“The Catalys software upgrade with Cassini Connect allows surgeons to digitally bridge diagnostic refractive data from the clinic to the operating room for increased OR efficiency and, in my hands, better results,” says Tal Raviv, MD, associate clinical professor of ophthalmology, New York Eye and Ear Infirmary of Mount Sinai and Icahn School of Medicine at Mount Sinai and Founder and Medical Director of Eye Center of New York, PLLC, in New York City. “I have found this to be particularly powerful for toric IOL alignment. The Catalys can now place corneal intrastromal radial marks at the desired steep axis, using iris registration to account for any cyclotorsion or even topography acquisition artifacts. The Catalys seamlessly matches the preop non-dilated Cassini iris image with the intraop dilated image to ensure toric IOL marks or arcuate corneal incisions can be placed precisely. I have seen 12° corrections routinely picked up and corrected by the iris registration.”

LENSAR

Femtosecond laser

The most recent iteration of the LENSAR Laser System is Streamline IV, the fourth system upgrade in 2 years, and the company claims the system is the only femtosecond laser developed specifically for refractive cataract surgery. The latest platform upgrade allows for micro-radial incisions and supports presbyopia inlay procedures.

“Since integrating the LENSAR Laser System in our surgery center, we have not dropped a step in terms of efficiency — the learning curve for me and my staff has been extremely smooth,” says James Lehmann, MD, of Focal Point Vision, San Antonio, Texas. “The laser is easy to use due to a simple docking process, minimal suction, automatic iris registration, 3-D imaging of the cataract and quick laser delivery. We used to perform 23 cases on average before implementing LENSAR, and we are still able to perform 23 cases. The LENSAR has been integrated seamlessly into our OR rhythm. The time it takes to do the laser allows our staff time to turn over the room and prep the patient, and the laser’s precision saves me steps under the microscope by eliminating the need for LRIs [limbal relaxing incisions], manual capsulorhexis and even extensive hydrodissection.”

ZEISS

Integration

At last year’s virtual AAO meeting, Zeiss presented its cataract workflow using Veracity Surgical to integrate all Zeiss devices. The company says that workflow integration with Zeiss Veracity Surgical boosts productivity so surgeons can deliver care to more patients in less time.

With the latest Zeiss IOLMaster 700 software, surgeons can send their biometry data and scleral reference images via Zeiss EQ Mobile to Callisto eye from Zeiss for computer assisted surgery, streamlining the cataract workflow.

The Zeiss IOLMaster 700 software update features the new Barrett True K with TK formula with up to 12% more post-myopic LASIK patients within ±0.5D compared to the classic K calculation formula.²⁰

Douglas D. Koch, MD, uses the IOLMaster 700 when seeing patients at the Baylor College of Medicine, in Houston, Texas, where he is an ophthalmology professor. “We love the speed and ease of use of the IOLMaster 700 and find its robustness in penetrating dense cataracts and new corneal data — such as total keratometry and central topography — to be very helpful,” he says.

Surgical microscope, 3-D visualization

The Artevo 800 is the first 3-D-capable digital ophthalmic microscope and uses novel DigitalOptics technology to produce high resolution optics and provide better light transmission than traditional optical microscopes, according to the company. These features allow surgery to be performed using lower illumination levels, which translates to greater patient comfort during surgery.

CONCLUSION

According to a study published in JAMA Ophthalmology in 2018, the number of cataract surgeries performed in ASCs increased from 43.6% in 2001 to 73% in 2014.²¹ Utilization of ASCs is likely to grow as new technology continues to be developed for use in these facilities. OM

Farrell “Toby” Tyson, MD, is a consultant to Alcon; Sharon Richens, MD, is a consultant to Bausch + Lomb; Tal Raviv, MD, is a consultant to Johnson & Johnson Vision; Douglas D. Koch, MD, is a consultant for Zeiss.

REFERENCES

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