We often talk about decreasing reimbursements and the pressure to perform surgery in less time. Although we would never diminish the quality of patient outcomes or compromise patient safety, we have to acknowledge that the success of our business is based on our productivity. Thus, we are always driven to improve efficiency.
At the same time, we’re seeing an increased demand for better outcomes. Cataract surgery is now a refractive procedure. I’ve seen patients who are 20/40 on the first day postoperatively, and they’re in tears because they think something went wrong with their surgery. Those are high expectations, and they only seem to get higher.
How can we achieve better outcomes with efficient surgery? First, we need very precise preoperative measurements. Excellent outcomes aren’t possible without accurate measurements. This effort goes beyond our choice of diagnostic tools to include how we capture these measurements and transfer them to the OR. Our systems should integrate our formulas (Barrett, Barrett UII, Barrett TK UII, Barrett Toric, Barrett TK Toric, Barrett True K, Barrett TK True K, Holladay 1 and 2, and Haigis-L). Measurement times must be fast — not only to save time but, more importantly, to keep patients engaged and focused so we can capture good data. Methods should be minimally invasive for the same reasons.
During surgery, visualization is key in achieving better outcomes while maintaining efficiency. We’re trying to make a well-centered capsulotomy and get the best effective lens position, particularly for premium IOLs. In my practice, our choice of microscope has helped us to visualize things we might have missed in the past by offering better visibility during surgery.
IMPROVING VISIBILITY WITH MICROSCOPE TECHNOLOGY
We’ve all had cataract surgery patients who thought their vision wasn’t so bad until they had surgery and found their vision improved dramatically. That’s how I view newer microscope features. We didn’t realize what we were missing until we switched from our older scopes, and suddenly we could see things we’d never seen before. That’s the next-level visualization that elevates efficiency and outcomes.
Stereo coaxial illumination with brilliant red reflex is changing surgery with our new scope (Lumera 700, Zeiss). Now we can have a red reflex that is bright, homogenous, rich in contrast, and excellent with dark eyes, small pupils, rolling eyes, and mature cataracts (Figure 1). Xenon illumination is another advantage. It is very bright and natural, but not jarring to patients, so they feel very comfortable under the scope — unlike with halogen scopes, which were so bright they often startled patients.
This combination provides excellent visualization and detail recognition. In fact, I’ll never forget the first time I saw all the lens epithelial cells on the inside of the capsule after the cataract was removed. I had never experienced this level of visualization before, and it helped me clean up the lens epithelial cells more completely to help prevent posterior capsule opacification and improve the overall stability of the lens. We know that leaving viscoelastic in the capsule can shift a toric lens, and we don’t want that to happen as a result of poor visualization.
Better visualization allows us to customize the capsulotomy very easily, and it leads to less use of trypan blue because the contrast is already outstanding.
Excellent visualization is also essential for surgeons who are using premium lenses in a high percentage of cases. When I’m placing a multi-focal toric lens, I want perfect visualization and alignment to ensure that lens is where I want it to be. Better visualization also helps us take on challenging cases with greater efficiency, improving, for example, our ability to visualize the capsule for a white cataract (Figure 2).
ADDED EFFICIENCIES FOR BUSY SURGERY CENTERS
In addition to better visualization, recent advances in microscope technology can provide practical efficiencies for a busy surgery center. New and enhanced features save time by boosting ergonomics, automation, and customization.
More comfortable lighting: We don’t talk about surgeon fatigue enough, but it’s very important because it affects our satisfaction and our productivity. Just as Xenon illumination is very gentle on the patient’s eyes, it is also gentle on the surgeon’s eyes. Even by the 15th or 20th case of the day, my eyes don’t feel fatigued from the light bouncing back into them as they felt when I was using a microscope with halogen illumination. So I know fatigue isn’t slowing me down.
Programmable push-button settings: Our new scope has fully customizable, programmable hand grips. Even if 10 other surgeons have used the scope before me, I can walk into the OR, hit “Davidson,” and everything is set for me. We also handle a number of combination cases with retina surgeons, so it’s beneficial that we can switch between anterior and posterior segment visualization with the push of a button — without consuming a lot of time or compromising clarity.
Easy eye switching: Another push-button switch is between the right and left eyes. It instantly flips, making it very efficient for high-volume patient flow. It’s a long way from the old days of dismantling the scope and switching the oculars, when we were forced to schedule all right and left eyes sequentially to avoid disruption.
Outstanding assistant scope: For those who work with residents or fellows, outstanding stereopsis from the assistant scope is very important. With our new scope, we rarely have to change seats. The assistant has fully customizable zoom and focus, so if a resident is accommodating significantly, we don’t have to accommodate, too. In this crowded setting, the scope’s wireless foot pedal is a smart feature as well, and the system has fully integrated 1080p video, which makes it seamless to record for teaching purposes.
BETTER VISUALIZATION DELIVERS ON OUTCOMES AND EFFICIENCY
Together, enhanced visualization and these welcome efficiencies remove some of the stress from complex cases. Refractive cataract surgery requires meticulous attention to detail to optimize predictability, reproducibility, and overall outcomes, and it all begins with excellent visualization. ■