EyeWorld Asia-Pacific June 2020 Issue

EWAP JUNE 2020 9 FEATURE to create a nomogram, which can increase accuracy long term. However, Dr. Donaldson noted there may still need Ì Li Ãi ÀiwiiÌÃ v Ìi system. “Alcon is working on trying to integrate some of the positives of the VERION system with the ORA system, and hopefully in the future all of that will be meshed together into one higher power intraoperative guidance system,” Dr. Donaldson said. Automated vs. manual axis marking Dr. Donaldson said she still marks all of her patients sitting up before starting her cases. “Any patient I’m doing astigmatism correction on, I still sit them up and mark them beforehand,” she said. “Many people don’t do that, but it >iÃ i vii Ài Vw`iÌ°» Marking them before hand allows her to make adjustments at the femtosecond laser, Dr. Donaldson said, adding that this is one scenario where ORA wouldn’t help. Dr. Donaldson uses both the LenSx (Alcon) and the Catalys (Johnson & Johnson Vision) femtosecond lasers, marks the patient sitting up beforehand, and uses rotational alignment to make sure the AK incisions are aligned properly. She added that one of the hopes for future lasers is to have the laser detect the steep axis and align the AK incisions automatically. Dr. Fram noted that manual marking has been referred to as a “safety parachute” by Robert Osher, MD, in case the digital marking system fails intraoperatively. “Marking is most accurate at the slit lamp or with a level marker,” she said. “In addition, using a reference of iris or scleral vessels is very useful. When manual marking is free hand, there is risk of introducing inaccuracy.” Are intraoperative guidance systems worth it? Past ASCRS Clinical Surveys have shown that many surgeons think 10 degrees of rotation off axis for a toric IOL is acceptable, Dr. Fram said. This means the surgeon will lose 33% of effectivity. “The digital guidance systems allow surgeons to be more precise and deliver on the promise made to the patient,” CALLISTO VERION Source (all): Nicole Fram, MD she said. “In our practice, ORA took us from 83% to 92% on target for toric IOLs. We were able to look at our data and compare using the AnalyzOR [Alcon] to review actual outcomes.” The IntelliAxis takes a reference image from a Cassini or Pentacam, loads it into the femtosecond laser, and creates tabs in the capsulotomy on the steep axis, Dr. Fram said. The IntelliAxis Refractive Capsulorhexis has biomechanically stable and permanent capsular marks that enable physicians to precisely mark the capsule on the steep axis to guide toric IOL alignment, both intraoperatively and postoperatively, Dr. Fram said. IntelliAxis-C steep axis corneal marking is also available. All of these guidance systems allow you to stay on the axis and can provide more accuracy, Dr. Fram said. “However, the Barrett Toric Calculator remains the gold standard in determining magnitude of toric power,” she said. Dr. Donaldson said ORA is especially helpful in post-corneal refractive surgery patients. She also likes to use ORA in patients who are highly myopic because there can be more errors with IOL calculations. Anytime there is a patient with an unusual eye, Ìi«Ã Àiwi Ìi ÀiÃÕÌÃ] Ãi added. The CALLISTO, although it helps with alignment, doesn’t help with the post-refractive patients, Dr. Donaldson said, adding that she uses ORA on 40–50% of cases for either post- refractive or toric alignment reasons. CALLISTO is the quickest device but helps mainly with toric alignment. “We would love to have an intraoperative guidance system integrated into the laser itself,” she added. Cataract surgery used to be very task-based with not a lot of decision making, Dr. Weinstock said. “Now, it’s become more of a dynamic procedure where you’re thinking about things while you operate and potentially changing the plans,” he said. There are now more devices to learn from and understand as you have to make decisions in the operating room. These tools do have a learning curve. “But the more tools you have in your toolbox, the higher chance you have of delivering a good outcome for your patient,” Dr. Weinstock said. EWAP Editors’ note: Dr. Donaldson practices at Bascom Palmer Eye Institute, Plantation, Florida, and declared relevant interests with Alcon, Johnson & Johnson Vision, Bausch + Lomb, and Carl Zeiss Meditec. Dr. Fram practices at Advanced Vision Care, Los Angeles, California, and declared relevant interests with Alcon. Dr. Weinstock practices at The Weinstock Laser Eye Center, Largo, Florida, and declared relevant interests with Alcon, Johnson & Johnson Vision, Bausch + Lomb, Carl Zeiss Meditec, and LENSAR.