EyeWorld India September 2021 Issue

FEATURE EWAP SEPTEMBER 2021 9 sub-2-mm incisions. In terms of complications, he had only 13 cases of posterior capsule rupture (0.16%); he has never had even one case of endophthalmitis in 30 years using the technique. Asked whether femtosecond laser prechop would supersede the manual technique, he categorically said no. In phaco prechop, he said, the most important point is complete separation of the nucleus; by laser, only a limited area of the nucleus can be prechopped, the posterior plate and periphery of the nucleus are not separated completely. In the last 30 years, Dr. Akahoshi said that he has performed 183,905 cases using the manual phaco prechop technique; from his experience he concluded that the manual technique exceeds prechop by femtosecond laser. Thomas Kohnen, FEBO, Germany, in making the case for the “automated” side of nucleus management, saw advantages in the use of OCT during surgery with femtosecond laser cataract surgery machines, reduced effective phaco time dependent on nucleus density, and further reduced complications such as corneal endothelial cell damage. In terms of fragmentation, Dr. Kohnen found that the pattern matters depending on cataract density—for low to moderate lens density, a grid pattern is best, while high density lenses should be treated with a pie pattern. Dr. Kohnen said that laser-assisted lens extraction allows optimal IOL centering, reduced energy, endothelial cell protection, and individual positioning of incisions. Furthermore, combining femtosecond laser with ultrasound reduced endothelial cell death compared with ultrasound alone, and though long-term studies are needed, the technology continues to develop. Precision outcomes For his routine phaco surgery, Graham Barrett, MD, Australia, detailed his preference for “low tech,” saying he preferred manual control to automated technologies. His preferred technique is the vertical chop using a phaco axe, which requires careful, manual control of both vacuum and ultrasound as provided by a dual linear foot pedal; a virtually instantaneously responsive Venturi-based vacuum system; and continuous ultrasound delivered via MicroFlow Phaco Needle, which he invented and licensed to Bausch + Lomb. Dr. Barrett said that comparing the direct surgeon control he prefers to automated methods of fluidics control is analogous to driving a car with manual transmission to an automatic. “An automatic may seem easier to drive, but there is no doubt about which method provides optimal control, particularly in challenging circumstances,” he said. Arguing for the use of high-tech instruments and tools to achieve precision outcomes, Elizabeth Yeu, MD, U.S., said that the process for planning cataract surgery has become longer and more tedious. Surgeons have to check and recheck various devices and instruments that are often unconnected, perform data evaluation that is analogue- driven and prone to transcription errors. Moreover, the process is time consuming and, when performed manually, potentially inaccurate. However, the refractive cataract surgical process can be made more efficient using tools such as the Zeiss veracity suite, which automatically populates data from EMR and diagnostics equipment in organized sections; eliminates transcription errors; is configurable to the surgeon’s process and saves time per plan; automatically integrates various toric IOL formulas and calculations; integrates EMR for postop visits; and analyzes outcomes. Another high-tech device that help achieve precision outcomes is intraoperative aberrometry which has been shown to refine cylinder power selection in over half of cases. “Refractive astigmatism management is an essential foundation to providing high-quality uncorrected vision,” Dr. Yeu concluded. “While it can be achieved with modern formulas, analogue, inefficient, and low-tech…[h]igh-tech preoperative and intraoperative devices and instruments can increase surgeon efficiency, precision, and outcome accuracy.” Editors’ note: Dr. Ribeiro declared no relevant financial interests. Dr. Tipperman is a consultant for Alcon. Dr. Akahoshi is a consultant for Zeiss. Dr. Kohnen has interests with various ophthalmic companies. Dr. Barrett is the author of various IOL power calculation formulas licensed to various companies. Dr. Yeu has interests with various cataract and refractive surgery companies.