EyeWorld Asia-Pacific September 2015 Issue

20 September 2015 EWAP FEATURE Views from Asia-Paci c Michael LAWLESS, MD Clinical Associate Professor University of Sydney 4/270 Victoria Ave., Chatswood, NSW, Australia Tel. no. +61-2-94249999 michael.lawless@visioneyeinstitute.com.au D rs. Donaldson and Hoffman are to be congratulated on summarizing some of the new things available for surgeons in the operating room in 2015. Some are particular to the United States. The high cost of pharmaceuticals driving the push for nil drop cataract surgery is not such an issue outside the United States, but that said, surgeons and patients would like to avoid all drops perioperatively as much as possible. Digital alignment systems for toric IOLs do remove some of the cumbersome marking and in my view, will lead to better outcomes although there is no data to con rm this just yet. It is a logical next step though. Even better is the ability to link the toric digital alignment with preoperative markings taken in the clinic prior to surgery and some systems exist to provide this facility. Connectivity within the operating suite is desirable, but it does lock surgeons into choosing equipment from the one manufacturer, which we can all understand, but it is still nice to have the ability to pick and choose, if possible, the best of speci c technologies and I think surgeons have to demand the right to do so if it is in the best interests of patients, rather than being stuck with a raft of technologies, some of which are less than ideal. How much intraoperative aberrometry brings to IOL selection accuracy will be played out over the next few years and, certainly, the data suggests it will result in more accurate outcomes, not just in the dif cult post-laser refractive and the short and long eyes, but really in every individual. Regarding femtolaser, Dr. Donaldson makes the good point that it can be performed just as ef ciently as and indeed more ef ciently than manual surgery if the set-up is correct, with delegations of responsibility. One of the results of better technologies for toric alignment, IOL power selection, and precisely placed capsulotomies is that the value of smaller toric IOL corrections are more viable. There was a period a few years ago when I would not have bothered to use a T2 toric lens because I felt there was so much noise in the system from measurement, to marking, to placement, that I could not get value, but with the technologies available today, I commonly use a T2 lens and nd that all these technologies combined have allowed me to get value from low toric IOLs in a way that was not possible just a few years ago. Just one example of how the outcomes are being improved with the judicious use of good technology. How to pay for it all? Well, that’s a question for another article. Editors’ note: Dr. Lawless has no nancial interests related to the comments. Sudeep DAS, MD Senior Consultant Narayana Nethralaya 121/C, 1st R. Block, Rajajinagar, Bangalore – 560010, India Tel. no. +919480587929 drsudeepdas@gmail.com Towards Safety & Surety T here was a sea change in diagnostic and surgical tools for cataract between the 1960s and the 1990s. Phacoemulsi cation and foldable intraocular lenses (IOLs) became entrenched in this period. So did important IOL technologies such as toric IOLs and multifocal IOLs. Since then there has been a slow but inexorable evolution in technology and 10 years down, we are going to be doing things quite differently. The femto-assisted cataract suites have been evolving rapidly and now have excellent consistency and predictability. These are excellent tools in challenging surgeries like mild to moderate subluxations, brunescent cataracts and in the presence of corneal endothelial cell dysfunction. The capsulotomy and fragmentation are stress-free on the zonules increasing the possibility of in-the-bag implantation in subluxated cataracts. The pre-fragmentation reduces the effective phaco time, thus preserving the corneal endothelium and outcomes in conditions such as Fuchs’ endothelial dystrophy. As we were noticing between 0 to 10 degrees of rotation from the intended axis of toric IOLs on the rst postoperative day, we decided to check the axis on a slitlamp immediately after implantation of toric IOLs. We noticed that rotation was the same as on the rst postoperative day. This was not a post-implantation rotation, but implantation along the wrong axis! Obviously this was due to errors in marking. This is what excites me about markerless systems such as the Verion and Callisto Eye. I have used the Verion with the LenSx and with a regular operating microscope. In the majority of cases it is extremely accurate. Marking pens leave a broad mark that occupies 5 degrees, while the alignment lines on the Verion are extremely thin. However, the technology needs to be more consistent, as in some eyes the system showed the wrong axis probably due to faint conjunctival vessels. We are debating whether to move to these systems permanently to save time and improve accuracy, but with caution as with any new technology. The Centurion is my primary machine for cataract surgery. Initially, I did not realize the advantage over the In niti. In the next few weeks, I noticed the rock-steady anterior chamber stability under all circumstances and the lack of clogging with the balanced tip (unlike in the Kelman tip). I do not toggle the footpedal between positions 2 and 3 even while emulsifying the last nuclear fragment in brown cataracts. I can keep it oored knowing that the Active Fluidics will take care of any potential surge. This has increased our speed by around 30% with reduced complications. The ORA/Verifye is again a technology with a lot of promise. I do not have any experience with this technology, but the ability to align toric IOLs without depending on any marks physical or projected and the ability to tweak IOL powers more accurately on the table will improve our precision and surgical outcomes tremendously. But I will wait for the technology to mature before I jump on this bandwagon. Editors’ note: Dr. Sudeep Das has no nancial interests related to his comments. What’s new - from page 19