EyeWorld Asia-Pacific December 2019 Issue

EWAP DECEMBER 2019 37 CATARACT Cataract fragmentation miLOOP has been making waves since its FDA approval in 2017 for its ability to fragment even the densest cataracts manually. ÃÃÌ} v > Ì w>iÌ that is deployed by a surgeon- held handpiece and pulled through the cataract like a cheese wire, as Dr. MacDonald put it, surgeons have been sharing success stories of using miLOOP in soft cataracts and brunescent cataracts. Dr. MacDonald, who mainly performs surgery outside the U.S. in developing countries where the cataracts are generally harder and manual small incision surgery is used, said the miLOOP learning curve for phaco surgeons is simple. “The device is self- explanatory. As a phaco surgeon, I’ve always thought of my second instrument as something that I manipulate, and one piece of advice I can give to someone who is using the miLOOP is to not try to manipulate the nucleus with the miLOOP. If you follow the directions, it will do exactly what it’s supposed to do,” she said. Now performing SICS regularly herself, Dr. MacDonald said miLOOP has made it possible to deliver the cataract fragments through small incisions. In the U.S. Dr. MacDonald Ã>` ÃÕÀ}iÃ Ü w` Ì >iÃ Ìi Ài ivwViÌ >` Ã>viÀ surgeons, how they incorporate it into their practice will be individualized, though she does think the technology makes surgeons better. Internationally, she said “it’s going to give phaco a run for its money.” It is a skillset that is easy to transfer and also makes for safer surgery in some of these settings, Dr. MacDonald said. Nailing IOL power postop Missing a refractive target used to mean spectacles, contact lenses, laser vision correction, or an IOL exchange for the patient. Newer technologies, like the Light Adjustable Lens, which is FDA approved, and Perfect Lens, which is not yet FDA approved, are giving surgeons the ability to lock in IOL powers (sphere, cylinder, and multifocality) postoperatively. “Since IOLs have historically been manufactured in pre-set powers, all patients have been subject to the variability of preoperatively guessing the effective lens position and how the cornea will heal,” Dr. Walton said. “Even modern IOL power estimation formulas—we say estimation instead of calculation at our practice to reinforce the truth that there is variability and not every eye will hit the target—feature about a 20–30% rate of missing the outcome by 0.5 D in most practices. The Light Adjustable Lens allows us to place the IOL power that seems best, then adjust and lock in the power with a non-invasive light treatment postoperatively.” Dr. Walton said the learning curve for this technology is easy. Surgeons who don’t have experience with implanting ÃVi " Ã }Ì w` Ì>Ì ÌiÞ unfold quicker than single piece acrylics, and the treatments with a proprietary light source to adjust the lens postop are “intuitive,” according to Dr. Walton. The biggest barrier to this technology, Dr. Walton said, is a familiar one to refractive cataract surgeons. “Many or even most surgeons are uncomfortable discussing patient pay technologies, even when they might offer the patient a more precise or more visually freeing result,” he said. Dr. Walton, however, doesn’t w` ÌÃ `ÃVÕÃÃ `vwVÕÌ° He said he tells patients that this technology allows them to wiÌÕi ÌiÀ ÛÃ ÜÌÕÌ Ìi cataract in the way, but Medicare and insurance do not cover this technology. Dr, Waltz was a principle investigator of the US FDA PMA trial for the LAL or the Light Adjustable Lens from 2012. That LAL trial was a toric trial and produced the best uncorrected visual results in a clinical trial Waltz has ever observed. The LAL is likely to have a profound effect on IOL choice and visual outcomes in the years to come. One possible drawback of the technology is that patients have to wear UV-blocking glasses ÕÌ Ìi w> ÌÀi>ÌiÌ Ã Vi` in, which can be for about 3 weeks postop. As such, Dr. Walton thinks patients will want their second cataract surgery «iÀvÀi` ÃÀÌÞ >vÌiÀ Ìi wÀÃÌ to reduce total UV protection time and allow both eyes to be adjusted together. EWAP Reference 1. Thompson VM, et al. Comparison of manual, femtosecond laser, and precision pulse capsulotomy edge tear strength in paired human cadaver eyes. Ophthalmology. 2016;123:265–74. Editors’ note: Dr. MacDonald is clinical associate professor at Tufts University School of Medicine, Boston, and declared interests in Perfect Lens and EyeCorps.org. Dr. Walton practices at Slade & Baker Vision, Houston, and declared interests in RxSight and Carl Zeiss Meditec. Dr. Waltz is Partner, Whitson Vision, and president, Ophthalmic Research Consultants Indianapolis, and declared a relevant interest in Mynosys. “Many or even most surgeons are uncomfortable discussing patient pay technologies, even when they might offer the patient a more precise or more visually freeing result.” — Bennett Walton, MD