CATARACT 32 EWAP MARCH 2022 is more accurate. He thinks the results with manual marking are good, but intraoperative guidance is the way things are going. NGENUITY can perform many of the same functions as VERION and CALLISTO (and provides the surgeon additional information) in a heads-up display. Dr. Miller finds the ergonomics of NGENUITY awkward, with the camera attached to the microscope in front of the surgeon and the monitor off to the side. “You want to look straight ahead, but you have to watch a television screen 30 degrees to your left,” Dr. Miller said. Despite the ergonomic challenge, he said he thinks digital microscopy is the way of the future. Take-home messages Dr. Martinez said his biggest message is for physicians to understand that when there is cyclotorsion of the eye, it is difficult to compare preop measurements taken when the patient was sitting to intraoperative measurements lying down. “Realigning ORA to VERION is huge. … It makes the delivery of astigmatism correction much easier and more predictable,” he said. Dr. Miller said he thinks there is a benefit to these technologies but acknowledged they are still in their infancy and they do take time. “If you wanted to bang out cases, this is not for you because it will take time for you to get used to and there are a lot of little tricks you have to learn to make this work,” he said. Dr. Miller noted that patients like the technologies and said he has had no problem with them signing up for intraoperative refractive guidance, even though there is an extra cost associated with it. EWAP Editors’ note: Dr. Lee is in practice with Altos Eye Physicians, Los Altos, California, and has interests with Carl Zeiss Meditec. Dr. Miller is Kolokotrones Chair in Ophthalmology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, and has interests with Alcon. Dr. Martinez is in practice with Eye Physicians of Long Beach, Long Beach, California, and has interests with Alcon. Editors’ note: Dr. Fram practices at Advanced Vision Care, Los Angeles, California. Dr. Kim is in private practice with Professional Eye Associates, Dalton, Georgia. Neither disclosed relevant financial interests. None of the physicians EyeWorld spoke with used intraoperative OCT in cataract or anterior segment surgery in general. All understood the utility it would have for posterior segment procedures, but Dr. Miller said it doesn’t add anything to his anterior segment practice. He played with an intraoperative OCT device and said it can help determine if there is good attachment of an endothelial graft to the back of the cornea. He didn’t find it necessary for that though, and he couldn’t justify the expense of the machine for this use. What about intraoperative OCT? New Technologies have been implemented in cataract surgery to guide the surgeon's decision and improve surgical outcomes. As Drs. Lee, Miller, and Martinez summarized, intraoperative refractive guidance systems are one of those advanced technologies that can be used as a final gateway to ensuring the correct selection of IOLs. Even with these cutting-edge technologies, accurate ocular biometry with advanced formulas is still the gold standard for IOL power calculation and surgeons should understand very well the strengths and weaknesses of each formula in each patient. Sometimes, too much information can confuse the decision especially for unexperienced surgeons. If surgeons are sure to take or ignore the recommendations of the intraoperative refractive guidance system in the operating room, they have to be confident about the consistency of the nomograms of the routine formulas they are using. We are well aware that the adjustment is needed in the extreme ranges of keratometry, axial length, and anterior chamber depth. There is a good algorithmic recommendation for the selection of IOL power calculation formula (Acta Ophthalmol. 2021 Aug 11. doi: 10.1111/ aos.149xÈ.). Intraoperative aberrometry can be a very powerful tool to check any error or mistake in the routine procedure, such as laterality, astigmatic axis, or the amount of sphere and cylinder. On the other hand, various conditions may affect the measurement of aberration. These include tear film, head position, ocular alignment, and subtle corneal haâiness. Dr. Miller presented good examples where intraoperative aberrometry helped surgical outcomes. A large-scale clinical study would provide more refined guidelines to take or ignore the suggestions of intraoperative aberrometry when the results are not the same as with conventional ocular biometry. Intraoperative image guidance can improve accuracy of toric IOL implantation. As described in the article, several image guidance systems come with each surgical suite. Advancements in augmented reality technology will bring more guidance tools in the future. Current IOLs are usually provided in half-diopter increments, so we are not expecting the elimination of residual refractive error after cataract surgery. As pointed out earlier, the surgeon should understand the limitations of IOL power formulas and suspect the direction of potential error in the specific patient. When the suggestion of the intraoperative guidance system matches the surgeon’s reasonable suspicion, the surgeon may follow the recommendation. Editorso note Dr. Hyon declared no relevant financial interests. Joon Young Hyon, MD, PhD Professor, Chief of Department of Ophthalmology Seoul National University Bundang Hospital 82 Gumi-ro 173beon-gil, Seongnam, Gyeonggi, South Korea jyhyon@snu.ac.kr ASIA-PACIFIC PERSPECTIVES
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