EyeWorld India March 2012 Issue

22 EW FEATURE March 2012 Views from Asia-Pacific Kimiya SHIMIZU, MD, PhD Professor and chairman, Department of Ophthalmology Kitasato University 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, Japan 252-0374 Tel. no. +81 (0)42-778-8464 Fax no. +81 (0)42-778-2357 kimiyas@med.kitasato-u.ac.jp S ince I developed the world’s first toric IOL (published in the Journal of Cataract & Refractive Surgery in 1994) in 1991, I have been using toric IOLs in patients with corneal astigmatism of 1.5 D or higher. However, during an operation, if there are any problems with anterior capsular, posterior capsular, or long axis eye of 28 mm and larger, I use CRI. This is because the lens may rotate to a large degree regarding in special cases of eyes with a long axis. Editors’ note: Prof. Shimizu is a consultant for STAAR Surgical but has no financial interests related to his comments. reticle and real-time imaging. In post-keratorefractive eyes, “I use the ORA to align the toric lens to its optimal location, which may be different after I’ve made the incisions,” Dr. Packer said. He cites an advantage of the system is the ability to measure corneal astigmatism intraoperatively. The SensoMotoric Instruments (SMI, Teltow, Germany) uses a pre- op keratometry measurement in combination with a high-res image of the patient’s eye to register the limbal blood vessels and iris details, Dr. Lane said, meaning the surgeon has registered the eye as soon as the patient is in the supine position. “It saves all the pre-op markings, so during surgery there are no ink marks, no dilution from ink pens. It’s an incredibly accurate tool that lets me put the lens on the axis I determined pre-op,” he said. Dr. Lane puts the lens into position according to the SMI, and then re- measures with the ORA to ensure he’s hit the mark. Dr. Osher is also a fan of the SMI technology. He is working with Stephen G. Slade, MD, and David F. Chang, MD, to develop Holos (Clarity Medical Systems, Pleasanton, Calif., USA), “an intraoperative wavefront, dynamic scanning, real-time device”, he said. “It offers real-time feedback on meridian location for better lens alignment.” The iTrace (Tracey Technologies, Houston) gives surgeons the ability “to see where to line up the IOL in relation to the astigmatic axis on the topography,” Dr. Trattler said. Post-op surprises Dr. Weinstock said the STAAR toric lens (Monrovia, Calif., USA) and the Alcon toric lens (Fort Worth, Texas, USA/Hünenberg, Switzerland) each have advantages and disadvantages. The STAAR lens “In Germany, there are centers that make the patient pay $1,000 (U.S.) more,” he said. Dr. Nuijts said the costs of the procedure cannot be addressed from one standpoint and will depend on the healthcare system where the practice is located. In the Netherlands or in Western Europe, it is difficult at present to incorporate this technology into regular cataract surgery because insurance companies and regulatory affairs want to know what the benefits of the new technology are in terms of efficacy and safety in comparison to the existent methods. Dr. Grabner believes prices will drop and the click fee will be in the range of US$117 to US$200 per case, while the machines may come down to about US$315,000, and servicing will come down to about US$25,000. The future of the femtosecond laser Currently, there are some limitations to the laser including the density of nucleus that can be fragmented, Dr. Nuijts said. There is also the question of how far away surgeons have to stay from the posterior capsule. “I think in time we will have better visualization and better OCT technology, which will give us more reliability on how far we are from the posterior capsule,” he said. “Ultimately, I think femto phaco will make it into the market, but it will take some time because this is a totally different strategy that cataract surgeons will have to follow in the next couple of years.” EW Editors’ note: Drs. Dick, Grabner, and Nuijts have financial interests with Alcon. Contact information Dick: +49 234 299 3101, burkhard.dick@kk-bochum.de Grabner: +011 43 662-4482-3701, g.grabner@salk.at Nuijts: +31-43-3875346, rudy.nuijts@mumc.nl is easy to manipulate, but can also rotate more easily post-op. The Alcon lens is more challenging to position, but remains in place post- op. “Even after doing everything right intraoperatively, some will still need an enhancement,” Dr. Packer said. “My enhancement rate is 4% with incisions [actually less than with LASIK], and that’s using the WaveTec ORA wavefront aberrometry.” Surgeons are getting better at managing astigmatism, “and we’ve got great technologies for when we’re not on target—LRIs, LASIK, or PRK,” Dr. Trattler said. “We have tools today that make correcting astigmatism easier,” Dr. Lane said, but surgeons still need to weigh the costs of these tools against the improved accuracy. “All patients who have significant astigmatism should be given the opportunity to reduce their cylinder at the time of their cataract surgery,” Dr. Osher said. “We now have the technology to achieve in the OR what has been previously accomplished with spectacles.” EW Editors’ note: Dr. Lane has financial interests with Alcon, SMI, and WaveTec. Dr. Osher consults for industry, but has no financial interests related to this article. Dr. Packer consults for industry. Dr. Trattler has financial interests with AMO and Carl Zeiss Meditec. Dr. Weinstock has financial interests with WaveTec and TrueVision. Contact information Lane: 651-275-3000, sslane@associatedeyecare.com Osher: 800-544-5133, rhosher@cincinnatieye.com Packer: 541-687-2110, mpacker@finemd.com Trattler: 305-598-2020, wtrattler@gmail.com Weinstock: 727-244-1958, rjweinstock@yahoo.com Femtosecond - from page 15 Aligning - from page 21