EyeWorld India March 2013 Issue

32 EWAP CATARACT/IOL March 2013 between seven to eight cases per hour at least,” realized positioning the femto in its own room “would improve the efficiency of patient flow and keep the surgeon from being idle.” With almost 50% of their patients undergoing limbal relaxing incisions, toric lenses, or premium IOLs, the center has turned one OR into an advanced cataract room complete with intraoperative aberrometry and 3D guidance software. The patients move directly into this room after their femtosecond laser treatment in another room. There is also a standard OR for traditional cataract surgery. “We made the decision to take one of our remaining two ORs and put both the LenSx [Alcon, Fort Worth, Texas, USA/Hünenberg, Switzerland] and the Catalyst in there,” Dr. Rivera said. Sharing responsibilities Surgical centers will need to evaluate not only patient workflow, but also surgeon workflow. Dr. Soscia said in the previous three months, he’s probably performed “over 600 femtosecond cases.” He volunteered to be the ASC’s femto expert and has reorganized his schedule so that three days a week he’s doing femto for his partners, and one day a week he’s doing the femto for his own patients. “With this setup, I can do about eight laser cases an hour, therefore allowing the cataract surgeons to perform the same number of cases as they were prior to the femtosecond laser,” Dr. Soscia said. Dr. Miller will likely have each surgeon do his or her own femto cases initially, “and then we’ll have to figure out what makes the most sense. We’ll have a technician be the femto laser technician just like we have in our laser practice center. It may even be the same person.” Eventually, he predicts fellows will do part of the procedure. Dr. Weinstock split the responsibilities with his partners— one day they each do only the femto, the next they do only the cataract surgery aspects. Dr. Rivera has not transitioned into this model yet, but his new facility will allow them to do so. “If I have 20 patients scheduled for cataract surgery on an afternoon, at least 50% of those are getting femto,” Dr. Weinstock said. “So that’s the equivalent of doing 30 procedures, not 20. [You have to] take into account bringing the patient into the room, programming the laser, getting the patient in position, doing the procedure, and on and on. This takes just as long as the cataract surgery itself. So far, it’s working great to divide the tasks with two surgeons. We can each keep our focus. And if you’re the guy who’s just doing lasers, you’re 100% focused on just doing the laser.” For the other surgeons? “They’ve got 50% of the procedure already done,” Dr. Soscia said. “Me? I’m just in the zone.” EWAP Editors’ note: Drs. Miller, Rivera, and Soscia have no financial interests related to this article. Dr. Weinstock has financial interests with Alcon and Bausch + Lomb (Rochester, NY, USA). Contact information Miller: 310-206-9951, kmiller@ucla.edu Rivera: 801-568-0200, rpriveramd@aol.com Soscia: 941-806-9784, sosh@tampabay.rr.com Weinstock: 727-244-1958, rjweinstock@yahoo.com such as evacuating all the OVD from behind the lens. Some have suggested that not polishing or vacuuming the underside of the anterior capsule increases the ‘stickiness’ of the lens. I don’t believe this to be true. “This patient is highly sensitive to a less-than-spectacular result and is willing to travel great distances to achieve that. First, his astigmatism clearly needs to be managed surgically. Because of the slight skewing of the astigmatism on topography, and because of my confidence in the toric lens, I would still implant the toric. But in order to reduce the odds the lens rotated, I would implant a CTR prophylactically prior to implantation of the lens.” I agree with Dr. Horn here, and this is basically the approach that I took. I have seen or consulted in a handful of cases of toric rotation, and all have been in high myopes who rotated within the first week or so. Since rotation occurs before the LECs remaining on the anterior capsule have undergone any fibroblastic transformation and prior to any resultant bag contracture, I see no benefit to purposefully leaving LECs behind. They will not be able to prevent the early rotation that we typically see in these cases, although later on they will certainly cause fibrotic changes that will “lock things in place.” Within the first week or so, I don’t believe the presence of LECs helps and, in fact, may prevent some of the tacky adhesion between the optic and the capsule that we typically see with the AcrySof material. Anyone who has tried to rotate a toric lens after removing all the viscoelastic knows that there is an immediate adhesion between the tacky AcrySof material and the capsule that is somewhat unique to this material. To rotate the lens without stressing the capsule, one often needs either additional viscoelastic or an infusion line to dilate the bag. As Dr. Horn stated, I believe that in high myopes the bag may be a bit too large for the lens and it may not be perfectly round, which creates a “preferred axis” that the lens may gravitate toward. I believe that the use of a CTR will both round out the bag and make the equator of the bag slightly smaller, creating a frictional resistance to early rotation. If the lens does not rotate immediately (within the first 10 days or so), then it is extremely unlikely to rotate at all. In this case I did choose to use an 11 D T5 toric lens (Alcon) to correct astigmatism and targeted a –0.25 spherical outcome for better distance vision as per the patient’s request. I used my normal surgical approach, creating a centered round rhexis (effectively achieved without the benefit of a femtosecond laser) that covered the optic 360 degrees followed by meticulous removal of LECs with a Singer Sweep (Epsilon Surgical, Ontario, Calif., USA). I did choose to place a CTR with the hope that this would prevent rotation and then removed all viscoelastic from behind the lens and took extra precaution to press the optic down against the posterior capsule at the end of the case to create adhesion against the posterior capsule. The patient did very well with no IOL rotation post-op and a –0.25 refractive outcome with 20/20 uncorrected distance vision. He was very happy with this. Figure 4 is an image of the eye 1 month post-op. It does appear that the use of the CTR inhibited the rotation of the lens in this patient. I do think that it is reasonable to consider the primary use of a CTR for toric IOL cases at high risk for rotation. All of the cases of rotation I’ve seen so far have been relatively young, highly myopic males, so in a patient fitting this demographic, especially with a history of rotation in the first eye, I would certainly consider using this approach again. EWAP Contact information Arbisser: drlisa@arbisser.com Horn: jeff.horn@bestvisionforlife.com Lane: sslane@AssociatedEyeCare.com Wong: mwong2020@gmail.com Taking - from page 26 The business - from page 30