EyeWorld India June 2021 Issue

REFRACTIVE EWAP JUNE 2021 47 Dr. Nikpoor said she uses VERACITY (Carl Zeiss Meditec) for all IOL calculations to help with IOL selection and finds it particularly useful for toric lenses because she can toggle between different measurements, toric calculators, and other data. She added that VERACITY is helpful for post-refractive cases, as it has a built-in calculator for that. She described it as a useful tool that moves everything from the EHR to the VERACITY system. Dr. Williamson stressed the importance of having a healthy eye for advanced IOLs. He said the physician has to make sure they have all the testing in place to confirm it’s a pristine eye because these implants are very sensitive to any type of comorbidity or aberration. He examines the ocular surface and may use point- of-care testing, such as the InflammaDry (Quidel) and TearLab Osmolarity Test (TearLab). He also mentioned doing meibography on the Keratograph (Oculus) if the meibomian glands are a concern. “Everyone is going to get topography and tomography,” Dr. Williamson said. He also likes to get an OCT of the macula on every patient, regardless of what lens is being putting in. Dr. Williamson will sometimes use the HD Analyzer preoperatively in less dense cataracts, which he said will give him an idea of the ocular scatter index when symptoms and complaints seem to outweigh the clinical exam. This device will also offer objective data on dry eye. Dr. Walter said that he always uses the IOLMaster or LENSTAR (Haag-Streit) to get accurate measurements and calculations. “I only use the Barrett formulas, as they are the most accurate,” he added. Dr. Walter will use macular OCT to look for any potential problems that might render the patient a non-candidate for a premium lens. “Corneal topography is also important especially with prior LASIK and to rule out bad ocular surfaces or other cornea disorders,” he said. He added that he thinks that all of these technologies are “absolutely necessary, unless you have a patient with low cylinder, a great ocular surface, and no history of LASIK; then maybe you could skip the topography and just use the biometry to guide you,” he said. Most important technologies Dr. Walter said biometry is the standard of care and absolutely needs to be done. “The days of A-scans and manual Ks are over and are below the standard,” he said. He added that “macular OCT has saved me so many times in picking up ERMs or macular holes that it must be done on every patient.” The last thing you want is to do a perfect surgery and the patient is unhappy because they can’t see, he said. They typically will think that you “caused” the problem, even though it was preexisting. Dr. Williamson said it’s possible that not all ophthalmologists have access to all the advanced technologies that he’s using. Most may just be getting a biometry, he said, and if concerned about something they see on the slit lamp exam, they probably have the capability to get an OCT. “I don’t know if we can say it’s standard of care to get a topography/OCT on every cataract patient. But I do think it should be simply because the OCT can see much finer details than the human eye at the slit lamp,” he said. Intraoperative tools Dr. Walter said he likes to use the CATALYS laser (Johnson & Johnson Vision) for his premium lens patients. “It reduces complications and increases the chances they will get the premium lens they paid for,” he said. “The capsulorhexis is geometrically perfect, which ensures centration. Small amounts of astigmatism can be treated, which helps ensure elimination of all refractive error.” Dr. Williamson has used ORA intraoperative aberrometry (Alcon) for the past 5 years. He noted that it’s rare for him to have to change the spherical power, though he said he will routinely change the power of a toric lens. Dr. Nikpoor said that she uses the LenSx laser (Alcon) with VERION (Alcon) in surgery. This can also help with marking the cornea and planning her axis. She uses ORA for every premium case. “When I’m implanting a lens, if toric, I’ll use VERION and ORA axis alignment with my own marks,” she said, adding that she’ll use all three and see where the lens needs to go. She also uses the VERION system for centration of any presbyopia-correcting IOL, adding that she’s been using it to center the Light Adjustable Lens (RxSight) and Vivity (Alcon) as well. She noted that her practice also has Callisto eye (Carl Zeiss Meditec), which she uses infrequently, and OPMI Lumera (Carl Zeiss Meditec), which can help center the lens. Postop tools Dr. Williamson said postop enhancements in his practice are done infrequently. If he does have to enhance, he will use