APACRS 2021 Daily News (Sunday, 1 August 2021)

CSCRS: Progress to Perfection At this year’s Combined Symposium of Cataract and Re- fractive Societies (CSCRS), the APACRS invited colleagues from the American Society of Cataract and Refractive Surgery (ASCRS) and the European Society of Cataract and Refractive Surgeons (ESCRS) to take a critical look at whether cataract and refractive surgery technology has advanced enough to supercede the importance of manual techniques. The symposium followed the broad structure of cataract surgery itself, discussing “low-tech” manual techniques and “high-tech” equipment and instrumentation first in creating a continuous curvilinear capsulorhexis (CCC), then through nucleus dissection and removal, and ending with techniques and technologies informing refractive out- comes. Tasked with making the case for the “low tech” side of CCC creation, Filomena Ribeiro, MD, PhD, FEBO, Portu- gal, said “only a few scenarios” from European Registry of Quality Outcomes for Cataract and Refractive Surgery (EU- REQUO) publications showed any benefit to creating CCCs using a femtosecond laser over manual techniques—this despite the fact that near perfect lens centration is “man- datory for maximal optical benefits with modern cataract surgery.” Beyond the data, however, Dr. Ribeiro made an appeal to doctors’ more artistic sensibilities. “The cap- sulorhexis is an important part of your signature that you leave in every eye,” she said. “Even decades after your surgery, a fellow doctor will be able to examine that eye and see the results of your handiwork.” On the opposite side of the CCC debate, Richard Tipper- man, MD, USA, agreed that while automated capsulorhex- is has “a number of theoretical advantages compared to manual capsulotomy, absent a large multicenter study no conclusive statement can be made of its benefit.” Howev- er, recalling the history of phacoemulsification, which only gained popularity after 30 years when foldable IOLs were introduced, Tipperman said that FLACS and automated capsulorhexis may only be waiting for a similar enabling technology that would leverage the procedures’ benefits. For dealing with the nucleus, Takayuki Akahoshi, MD, Ja- pan, made the case for using manual prechop. In 2020, he performed a total of 8,263 cases, about 60 cases per day without stress, all performed using phaco prechop through sub-2-mm incisions. In terms of complications, he had only 13 cases of posterior capsule rupture (0.16%) and no en- dophthalmitis. In phaco prechop, he said, the most import- ant point is complete separation of the nucleus; by laser, only a limited area of the nucleus can be prechopped, the posterior plate and periphery of the nucleus are not sepa- rated completely. Thomas Kohnen, FEBO, Germany, in making the case for the “automated” side of nucleus management, said that laser-assisted lens extraction allows optimal IOL centering, reduced energy, endothelial cell protection, and individual positioning of incisions. Furthermore, combining femtosec- ond laser with ultrasound reduced endothelial cell death compared with ultrasound alone, and though long-term studies are needed, the technology continues to develop. For his routine phaco surgery, Graham Barrett, MD, Aus- tralia, detailed his preference for “low tech,” saying he preferred manual control to automated technologies. He preferred the vertical chop using a phaco axe; manual control of both vacuum and ultrasound with a responsive Venturi-based vacuum system; and continuous ultrasound delivered via MicroFlow Phaco Needle, which he invented and licensed to Bausch + Lomb. He said that having direct surgeon control is like driving a car with manual transmis- sion. “An automatic may seem easier to drive, but there is no doubt about which method provides optimal control, particularly in challenging circumstances,” he said. Arguing for the use of high-tech instruments and tools to achieve precision outcomes, Elizabeth Yeu, MD, USA, said that the process for planning cataract surgery has become longer and more tedious. Surgeons have to check and recheck various devices and instruments that are often un- connected, perform data evaluation that is analogue-driven and prone to transcription errors. Moreover, the process is time consuming and, when performed manually, potentially inaccurate. However, the refractive cataract surgical process can be made more efficient using tools such as the Zeiss veracity suite, which automatically populates data from EMR and diagnostics equipment in organized sections, eliminates Asia-Pacific Association of Cataract & Refractive Surgeons Sunday, 1 August 2021 EWAP Daily News - 3