CATARACT EWAP DECEMBER 2022 17 be a useful tool for almost all patients,” he said. Dr. Solomon stalled his official adoption of the LAL for about 6 months after getting the opportunity to start using it, having some hesitation after looking at the numbers and assessing the effort it would take to incorporate it. Ultimately, he did decide to bring it into practice and was surprised that the adoption was less arduous than he originally thought. Patients also gravitated to the technology with very little effort. “Despite the added work that is associated with it, the patient flow can be effectively streamlined easily, and the patient expectation is met in the overwhelming majority of cases,” Dr. Solomon said. With the LAL, Dr. Solomon said the first and second eye are done very close together so their adjustments can be timed accordingly. You have to wait for the tissue to heal, for the corneal edema to resolve, and get a steady refraction, he said. Being able to treat both eyes around the same time for adjustments is important because that’s more time in the postop window, and of course there’s a lock in where after you’ve achieved your ultimate refractive outcome, you’re going to fix the lens in that current state. There’s more work that goes into an LAL patient, and the mindset for the patient needs to be managed ahead of time. “People hear ‘adjustment,’ and there’s a certain mentality that it’s infinite, that you can move this around, and that’s not the way it works, and you have to set a healthy expectation.” “The accuracy and ability to precisely hit targets is impressive,” Dr. Solomon said. In the future, Dr. Solomon said one advancement he would be looking for is the option of a multifocal or true EDOF version of the optic itself. EWAP References 1. Abulafia A, et al. Accuracy of the Barrett True-K formula for intraocular lens power prediction after laser in situ keratomileusis or photorefractive keratectomy for myopia. J Cataract Refract Surg. 2016;42:363–369. 2. Haigis W. Intraocular lens calculation after refractive surgery for myopia: Haigis-L formula. J Cataract Refract Surg. 2008;34:1658–1663. 3. Lawless M, et al. Total keratometry in intraocular lens power calculations in eyes with previous laser refractive surgery. Clin Exp Ophthalmol. 2020;48:749–756. 4. Yeo TK, et al. Accuracy of intraocular lens formulas using total keratometry in eyes with previous myopic laser refractive surgery. Eye (Lond). 2021;35:1705–1711. 5. Wang L, et al. Evaluation of total keratometry and its accuracy for intraocular lens power calculation in eyes after corneal refractive surgery. J Cataract Refract Surg. 2019;45:1416–1421. Editors’ note: Dr. Fram practices at Advanced Vision Care, Los Angeles, California. Dr. Hoopes practices at Hoopes Vision, Draper, Utah. Dr. Nikpoor practices at Aloha Laser Vision, Honolulu, Hawaii. Dr. Solomon is Director, Solomon Eye Physicians & Surgeons, Bowie, Maryland. All the doctors have interests with RxSight. Phaco fluidics - from page 7 won’t want to go back to a less efficient system. Dr. Lubeck compared the switch to an advanced fluidics system as similar to transitioning from doing LASIK with a microkeratome to a laser. “Anyone who wants to be as safe and successful a cataract surgeon as possible will be working with an advanced fluidics system,” he said. When transitioning from a gravity system to an advanced pressurized system, Dr. Lubeck said one of the challenges is that, in general, there isn’t a deep understanding of fluidics. It can be hard for surgeons to explore and realize all the capabilities of the new system. New fluidics technology provides more safety and efficiency, he said, but often physicians don’t fully maximize the benefits of these systems. Once a surgeon understands the capability of the system, they can make the procedure more efficient. They can do the procedure at a lower intraocular pressure, he said, adding that there is data to suggest that operating at a lower pressure is better for the eye. They can also make the procedure more comfortable for the patient and use higher power settings, vacuum and flow to accelerate the cataract removal portion. The gravity systems require that you operate with a pressure in the eye higher than a normal pressure, and this can lead to mild to extreme discomfort for patients. “But with advanced fluidics systems, we can operate at a lower pressure, so that the patient never experiences that level of discomfort,” he said. Dr. Lubeck has seven different procedures pre-programmed into his machine settings for various situations of cataract densities, different ways the eye may be compromised, and different levels of stability. “It’s about understanding why you would want to change the fluidics and ultrasound settings for different situations,” he said. The primary options for surgeon education on advanced fluidics systems are local and national meetings, the internet, and the knowledge of company representatives and technicians. He thinks most of the learning happens between the company representative and the surgeon. Dr. Lubeck said it’s important for surgeons to give themselves the time and mental space to learn about fluidics and how they want it to fit into and improve their practice. EWAP Editors’ note: Dr. Lubeck is Director of Cataract, Cornea, and Advanced Anterior Segment Surgery, Arbor Centers For Eyecare, Homewood, Illinois, and disclosed interests with Alcon and BVI.
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