The introduction of computers into the continuum of care has had just as big an impact as advancements in IOLs, surgical techniques and precision instruments. Today, digitally controlled surgical tools in the OR allow visual outcomes for cataract patients that could not have been imagined a few short decades ago.
Equipment integration featuring suites of interlinked machines allow computer-controlled measuring, marking and surgical devices to communicate, therefore directly transferring outcome-critical data. What is now done instantaneously was in the very recent past done by manually marking patients’ eyes and moving patients’ surgical plan information from one machine to another — with inherent risk of input error every time.
Cataract surgeons who have kept pace with fast, precise and efficient technologies in the OR have benefitted their practices and their patients by doing so.
In the cataract suite market, Zeiss, Alcon and LENSAR provide groups of integrated digital tools that can enhance a surgeon’s ability to see, measure and precisely remove an opacified natural lens and replace it with the correctly chosen and positioned IOL, with consistently on-target refractive results. The measuring, visualizing, marking and data-transfer capabilities of a cataract suite work irrespective of a surgeon’s cutting tool preference, whether femtosecond laser, trusty scalpel or something yet to come.
Here’s a look at what these companies offer.
Piece by piece
Zeiss introduced the first optical biometer 20 years ago and was one of the first to introduce optical coherence tomography (OCT) for ophthalmic use. The manufacturer recently integrated swept-source OCT technology into biometry to create its first swept-source biometry device.
The company’s CALLISTO eye OR management system was designed to integrate seamlessly into the surgeon’s existing OR setup, no matter the layout, and function closely with the Zeiss OPMI LUMERA 700 surgical microscope. The company notes that the devices “will have the capability to communicate with other devices in the future,” further integrating the cataract treatment workplace for better efficiency and convenience.
The computer-assisted cataract surgery system creates overlays for the surgical microscope using data retrieved from the data management system. That means the data surgeons need is injected into the eyepiece of surgical microscopes. Zeiss’ IOLMaster 700 provides a full-length OCT image showing anatomical details on a longitudinal cut through the entire eye, allowing surgeons to see unusual eye geometries such as tilt or decentration of the crystalline lens.
With one click, the company’s FORUM data management system receives the biometry data and reference image in DICOM format for later import into the computer-assisted cataract surgery system CALLISTO eye.
Serving the surgeon
“Often, astigmatic correction can vary depending on how we mark the eye, how we implant the lens and how we leave the eye,” notes Inder Paul Singh, MD, president of The Eye Centers of Racine and Kenosha, Racine, Wis. “In our practice, the Zeiss cataract suite lets us obtain high-quality, predictable, reproducible preoperative measurements and incorporate those measurements easily and efficiently intraoperatively. We can more confidently align lenses just where they should be.”
Dr. Singh is keen on the IOLMaster 700’s new features, as well. “It achieves our measurements, our A-scan or axial length with swept-source OCT, which is really next level. It is a cross-sectional, B-scan view of the entire eye, so we can visualize the fovea and confirm the center of the visual axis when measuring axial length.”
Swept-source OCT’s total keratometry shows anterior chamber depth along with the posterior cornea, which provides reliable and accurate lens thickness measurements. “Also, for planning astigmatic correction, whether that’s arcuate incisions, LRIs or toric lenses, with the rule, against the rule, surgeons can be much more predictable now, in my opinion, by having total keratometry,” he says. In addition, this can all be done without manually marking the patient since the IOLMaster 700 captures a reference image that is then transferred into the OR via the CALLISTO system.
Dr. Singh finds that, ultimately, these devices are less operator dependent and more predictable. “This is beneficial to flow, more seamless for the technician and less time is needed for training,” he notes. “Because the information we have is so accurate and detailed, the results are outstanding — even in patients with previous refractive surgeries.”
With Zeiss’ VERACITY software to integrate all of diagnostic tools, surgeons can go a step further, even ordering the lens needed and sending information to the ASC or hospital. Along with FORUM, which integrates other Zeiss technologies like the visual fields and OCTs, into one software platform, “I can really integrate all technologies into one area and help plan better,” Dr. Singh says.
Piece by piece
Alcon’s suite of cataract offerings is comprised of the ORA System with VerifEye+ and the VERION Image Guided System, which act to streamine the process of taking patient measurements from clinic to the OR. These components integrate with the manufacturer’s LenSx Laser, LuxOR LX3 ophthalmic microscope and the CENTURION vision system.
Stephen Slade, MD, of Houston’s Slade and Baker Vision says that the integration of our microscope, phaco, laser and diagnostic information is a new frontier and one that will pay off for our patients. “Planning phaco settings based on lens density from diagnostics, better lens power selection, capsular integrity and more all will add greatly to our results.”
Alcon notes that the ORA System intraoperative wavefront aberrometer provides real-time information on IOL spherical and cylinder power calculations through aphakic measurements and axis orientation through pseudophakic measurements. More importantly, during the aphakic phase, the ORA is able to measure the total refractive astigmatism, which accounts for both anterior and posterior curvatures of the cornea.
Given that the cornea contributes 66% of the eye’s refractive power, this measurement is very important in eyes that have been planned for toric IOL implantation, as well as eyes that have a history of keratorefractive procedures.
Serving the surgeon
Surgeons can rely on ORA to validate data used in preoperative IOL calculations through intraoperative, real-time, aphakic measurements. Also, the device verifies both the spherical and cylindrical power of the toric IOL needed. Using ORA, surgeons can achieve predictable postoperative refractive outcomes for their individual visual needs
“In my surgeries, I have found the ORA helpful as an adjuvant to preoperative measurements and IOL calculations in verification of the correct IOL power, both sphere and cylinder, that needs to be implanted to achieve the planned postoperative visual outcome for patients — especially ones who are post-refractive or have high magnitude of astigmatism,” says Zaina Al-Mohstaseb, MD, associate professor and associate residency director, department of ophthalmology, Baylor College of Medicine in Houston.
The VERION Digital Marker transfers measurement data, patient information, reference image and surgical plan to the LenSx Laser and most surgical microscopes via USB stick. Then, during the procedure, the VERION Image Guided System positions all incision locations and assists with lens alignment in real time while accounting for the variable impact of cyclorotation and patient eye movement.
Because the precisely formed capsulorhexis is essential when implanting advanced technology IOLs, Alcon says its system provides a digital template for making a manual rhexis. The goal of the system is to help streamline surgical planning and data transfer so the surgeon can provide consistent refractive patient outcomes.
Put simply, the VERION Image Guided System can help:
- Minimize data transcription errors
- Improve clinical efficiency
- Increase toric and multifocal IOL confidence
- Ensure surgical consistency
- Optimize visual outcomes
Piece by piece
LENSAR’s Cataract Laser with Augmented Reality technology incorporates a 3-D imaging system. The system has precise guidance for astigmatism treatment planning, helping surgeons deliver LASIK-like outcomes for arcuate incision and toric IOL patients. The company says the system is streamlined and simplified with pre-programmable surgeon preferences, an optimized graphical user interface, wireless integration with preoperative diagnostic data, cataract density imaging and automatic customized fragmentation patterns and arcuate incision planning at the laser.
Most recently, the manufacturer released its Streamline IV upgrade featuring biomechanically stable, permanent capsular marks on the steep axis for guidance. Key to the system is that the preoperative diagnostic data can be transferred wirelessly from Pentacam and the Cassini Corneal Shape Analyzer to the LENSAR Laser System (USB integration is also available with Nidek OPD-Scan III and Topcon’s Aladdin).
Serving the surgeon
“I’m a big believer in refractive cataract surgery, and the latest premium IOL developments are upping the ante in terms of what patients expect,” says Mark Lobanoff, MD, director of refractive surgery at North Suburban Eye Specialists in Minneapolis, Minn., who uses the LENSAR femtosecond laser. “They don’t want any ‘buts’ or trade-offs. So, I am a big fan of femtosecond laser cataract surgery — I do think it offers better results. Certainly, it’s being debated, but in my hands, I find it’s the best way to get the most premium results from patients.”
“The beauty of the LENSAR is, I can use the Pentacam image to obtain iris registration and determine the amount of astigmatism, and that data is sent wirelessly to the LENSAR laser,” Dr. Lobanoff notes. “So, it goes directly from our clinic right into the laser. I don’t have to touch anything. My technicians send the data, seamlessly. LENSAR will now can recognize the patient’s iris, recognize any cyclotorsion and perfectly align where the incisions are going to go.” That is the benefit of interconnectivity, he says.
Dr. Lobanoff appreciates the IntelliAxis feature of LENSAR, which cuts the capsulorhexis by making two small nubs in the steep axis of the eye. This eases the match up of toricity marks on a toric lens. “You can match them to where that small nub is on the capsulorhexis, so you know that toric IOL is in the correct axis. The other advantage is now all the postop visits, whether it’s the surgeon or an optometrist, can determine if that IOL has rotated with 100% certainty.” This offers assurance with regard to lens position.
When your tools have connectivity and you have a streamlined approach, the process is seamless, Dr. Lobanoff adds.
Interconnected, communicating devices make the surgeon’s job easier and allow for ultimate accuracy and speed workflow. Maybe the OR of tomorrow will be nearly unrecognizable to today’s surgeons. But, technological advances in OCT, biometry and surgical calculations are available today to doctors who appreciate their benefits and to patients who need them. OM
Dr. Singh is a consultant for Carl Zeiss Meditec; Dr. Slade is a consultant for Alcon; Dr. Al-Mohtaseb is a consultant for Alcon; Dr. Lobanoff is a consultant for LENSAR.