Deepinder Dhaliwal, MD, L.Ac, and Kevin Miller, MD, chaired the ASCRS virtual session “Advanced Cataract Surgery: Achieving 20/Happy in 2020” on May 16. Seven ophthalmologists gave presentations, covering cataract surgery topics for during and after the COVID era. 

How do I analyze astigmatism using double-angle polar plots? 

For clearly and accurately displaying astigmatism, Douglas D. Koch, MD, ABO, of Baylor College of Medicine, Houston, Texas, said he found using a double-angle plot to be more effective than a single-angle plot diagram.
“I believe double-angle plots are highly informative, both visually and numerically. They’re easy to understand once you grasp the concept of the doubled angle, the ‘with-the-rule eyes’ to the left, the ‘against-the-rule eyes’ to the right. I believe this is the optimal way to display astigmatic data.”
The “astigmatism double angle plot tool” Excel spreadsheet is available for download at the ASCRS website ( as is a 2018 Journal of Cataract and Refractive Surgery guest editorial co-authored by Dr. Koch that recommended the use of double-angle plots over single-angle. 

I know the words I use are important. What should I say? What should I not say? 

In this presentation, Robert H. Osher, MD, of the Cincinnati Eye Institute, recounted his last cataract case before the COVID-19 quarantine began. While the case was a routine cataract extraction and IOL placement, the OR was in chaos due to people worrying about the effects of COVID-19, said Dr. Osher.

After the operation, the patient complained she could not see. Later, they discovered that, in the confusion of the day, the wrong IOL had been inserted. It was the first time such a thing had happened in my career, remarked Dr. Osher. 

He reassured the patient that the problem would be fixed quickly, took full responsibility and said that there would be no additional charge. Ultimately, Dr. Osher and his team removed the IOL through the original incisions and placed the correct one without incident. 

The lesson, he said, is chaos leads to mistakes. Everyone needs to be on the same page in the OR; if something does go wrong, be sure to be honest, take responsibility and apologize. After the surgery, make sure to take extra care when following up with such patients — let them know you are their partner in this journey and that you will do everything needed to bet the intended result.

What do I need to know about intraoperative refractive guidance? 

When even 1° rotation off an axis target creates a 3.3% loss of efficiency, intraoperative refractive guidance is important for both patients and doctors, said Kendall E. Donaldson, MD, of the Bascom Palmer Eye Institute in Plantation, Fla. 

Dr. Donaldson reviewed Alcon’s ORA System, Alcon’s Verion System, Zeiss’ Callisto Toric Alignment and LENSAR’s Intelliaxis. 

She shared two cases from her practice that made use of intraoperative aberrometry (IA). In the first, a 68-year-old male patient presented with a myopic shift in the right eye consistent with a large cataract and significant astigmatism in both eyes. Using a lens power recommended by IA, the patient ended up seeing at 20/20 with monofocal distance lenses. 

Her second case was a 62-year-old male patient who wanted a LASIK evaluation and presbyopia correction. The man had approximately 1.5 D of against-the-rule astigmatism in both eyes.

Again using a lens recommended by IA, the patient ended up seeing extremely well at both distance and near. 
“Technology can make our decisions easier, especially in complex cases, and with premium cataract surgery it demands premium results,” she said. 

How do I implement a program of bilateral same-day cataract surgery?

Bilateral same-day surgery can be a boon for practices in the COVID era due to its reduction of PPE burn, reduction of staff, surgeon and patient exposure and its fewer required postoperative and pharmacy visits, said Huck A. Holz, MD, of Kaiser Permeante, in Santa Clara, Calif.
Same-day bilateral surgery results in an approximate 31% time savings, largely seen in turnover times, said Dr. Holz. In addition, patients at Kaiser Permeante, which performs more than 7,000 such surgeries yearly, see an average cost savings of $203, which includes copay and parking fees.
Studies, such as “Immediate Sequential vs. Delayed Sequential Bilateral Cataract Surgery: Retrospective Comparison of Postoperative Visual Outcomes,” by Herrington LJ et al, have shown that same-day bilateral surgery has no greater risk or less efficacy than waiting between surgeries, said Dr. Holz.
To lower the risk of endophthalmitis, Dr. Holz and his staff treat each eye surgery as a separate event complete with changes in instrument, gloves, gowns, drapes and separate lots of pharmaceuticals.
For patient selection, Dr. Holz recommends avoiding patients with extreme axial lengths, prior refractive surgery, pathology (ie, DME, Fuchs, iritis, epiretinal membranes) and those with higher risk of endophthalmitis (ie, poor hygiene, severe blepharitis, age of 90-plus). 

When should I offer monovision? When should I offer multifocality?

Sometimes a big initial hurdle for talking to patients about vision options is the language used, said Mitchell A. Jackson, MD, ABO, founder of Jacksoneye in Lake Villa, Ill. Expectations are not always realistic when using unfamililar terms like “monovision” and “micro/mini-monovision.”
His clinic prefers to use the terms “blended vision” instead of monovision and “natural vision” instead of multifocality. 

Ideal blended vision patients are those with jobs or activities that frequently change viewing distances; examples of this would be teachers, performers or people who work in sales. It’s less favorable for those who focus on near or distance vision for a prolonged time, such as surgeons or commercial drivers. 

One of the most important parts of successful blended vision is determining eye dominance. About 75% to 80% of patients prefer using their dominant eye for distance vision, said Dr. Jackson, with the rest preferring using the dominant eye for near. It’s crucial to learn each patient’s preference before proceeding.
For patients looking for “natural vision,” you “need a perfect candidate” for successful outcomes and preoperative due diligence is critical, said Dr. Jackson. Factors for successful outcomes include a patient with “pristine” ocular surface, no macular pathologies and realistic expectations. On the surgeon’s end, you need a plan to correct corneal astigmatism and the ability to treat refractive error postoperatively.

What are the 5 pearls for managing the very small eye?

In eyes with relative anterior microphthalmos (RAM), Abhay R. Vasavada, FRCS, MS, of Raghudeep Eye Hospital, in Jaipur and Ahmedabad, India, recommended the following pearls:

  1. Preoperative assessment.The defining features of RAM are a short axial length, scleral thickening and increased lens volume. It is important, as well, to always look for glaucoma in patients with RAM and examine the health of the cornea.  

  2. Counselling. “It is very important to counsel the patient and the family regarding the challenging nature of the surgery,” said Dr. Vasavada, including the possibilities for uveal inflammation, glaucoma, corneal edema, choroidal effusion and even the remote chance of losing the eye. 

  3. Intraoperative. “Paying attention to intraoperative details remains very crucial,” said Dr. Vasavada. He has found using the “slow-motion” technique of cataract lens removal, developed by Dr. Osher, to be very helpful, as has the use of femtosecond laser-assisted cataract surgery.

  4. IOL Implantation. “IOL implantation remains always a challenge,” said Dr. Vasavada. He prefers to implant a high-powered IOL in a patient’s eye and then correct any residual ametropia postoperatively. Customized IOLs and add-on (“piggy bagging”) IOLs “remain very valuable options,” he said. 

  5. Postoperative. During the postoperative phase, it’s important to monitor for glaucoma, as well as corneal endothelial health, refractive error and retinal evaluation. 


What are the 5 pearls for managing the very large eye?

Large and long eyes have very different anatomies from other eyes, said Sumitra S. Khandelwal, MD, ABO, of Baylor College of Medicine, Cullen Eye Institute, in Houston, Texas. These include larger axial lengths, larger sulcus spaces and larger white-to-white ratios. Her 5 pearls for surgeons: 

  1. Complete preop exam. “Our peripheral exam is not always that detailed, but for these patients it becomes very important,” she said, as the weight of retinal attachment is higher. A careful preoperative retina exam is important, as is counseling about their risks. 

  2. Discuss the target … again and again. Some patients don’t realize they can lose their near vision, said Dr. Khandelwal. That’s why she finds it helpful to have a lifestyle questionnaire that a patient can use determine what vision range is most important to them.

  3. Carefully decide on lens power. Due to higher axial length in these patients, measurements will overstate axial length and therefore underestimate lens power, which can result in a hyperopic surprise. Axial length modifications can be done on IOL formulas. A 2011 paper by Wang L et al, “Optimizing intraocular lens power calculations in eyes with axial length above 25.0 mm,” gives details on how, Dr. Khandelwal said.

  4. Anticipate intraoperative surprises. Patients with deeper anterior chambers can change the phacodynamics of surgery, said Dr. Khandelwal. For instance, in cases with reverse pupillary blocks, she recommended using a lower amount of irrigation, even changing these settings to be more like ones used to treat floppy iris syndrome, as standard irrigation could be uncomfortable for these patients. 

  5. Have a plan for “no man’s land.”Referring to the anisometropia between the two eyes, Dr. Khandelwal recommended performing cataract surgeries 2 weeks apart for each eye, as opposed to 3 weeks apart. Options for patients during that “no man’s land” time between operations include contact lenses, myopic specs or “a great chauffer.” 


What new technologies are on the horizon?

Sumit “Sam” Garg, MD, ABO spoke on upcoming lens technologies, including:

  • TECNIS Eyhance (Johnson & Johnson Vision). Provides one line improvement in intermediate vision by increasing the power of the central optic 

  • Vivity (Alcon). Allows for the wavefront to be stretched and shifted 

  • IC-8 (AcuFocus). Utilizes a small aperture to extend the depth of focus

  • TECNIS Synergy (Johnson & Johnson Vision). Combines capabilities of extended depth of focus lenses and multifocals to deliver vision across a large range

  • EnVista trifocal (Bausch + Lomb). This trifocal lens is currently in FDA trials

  • Gemini refractive capsule (Omega Ophthalmics). A modular system implanted into the capsular bag that allows for delivery of IOLs, drugs and sensors

  • Harmoni (ClaraVista Medical). A modular IOL that allows for exchanges and upgrades

  • PowerVision (Alcon). An IOL with fluid-filled “pontoons” on each side, which can inflate or deflate to adjust between near vision and far visions

  • Atia Vision Modular Presbyopia Correction IOL (Atia Vision). A modular lens system with an exchangeable central front optic, and a shape-changing, accommodative base

  • Opira AIOL (ForSight). A shape-changing IOL that is haptic-fixated in the capsulorhexis, but the optic is located within the sulcus

  • Juvene IOL (LensGen). A modular lens with a base that fits in the capsular bag. Within the base, a fluid-filled lens allows for a shape-changing optic to provide continuous vision from distance to near. OM