The development of premium IOL technology has given patients more options when selecting an IOL to best fit their visual needs. Surgeons must inform patients on the advantages and disadvantages of each IOL and set reasonable expectations for postoperative results. In addition, surgeons must have a phaco machine that performs safe, efficient cataract removal using fluidics rather than high power.

With the support of Bausch & Lomb, Ocular Surgery News assembled a panel of experts to discuss advancements in phaco and IOL technology. I would like to thank the faculty members for their participation and Bausch & Lomb for its support of this Ocular Surgery News monograph project.

I thank the faculty members for sharing their thoughts on ocular antibiotics and MIC testing. I also thank Inspire Pharmaceuticals, Inc., for its support of this Ocular Surgery News monograph.

Richard L. Lindstrom, MD
Global Chief Medical Editor
Ocular Surgery News

	Richard L. Lindstrom, MD, is a clinical professor of ophthalmology at the University of Minnesota and managing partner at Minnesota Eye Consultants in Minneapolis. Dr. Lindstrom is also the chief medical editor of Ocular Surgery News.
	Rosa Braga-Mele, MD, MEd, FRCSC, is an associate professor at the University of Toronto, director of the Cataract Unit at the Mt. Sinai Hospital in Toronto, and director of research at the Kensington Eye Institute in Toronto.		Jeffrey Whitman, MD, is chief surgeon and founder of the Key-Whitman Eye Center in Dallas and is in private group practice in the Dallas Metroplex.
	Uday Devgan, MD, is a partner at the Maloney Vision Institute in Los Angeles, chief of ophthalmology at Olive View UCLA Medical Center, and is Section Editor of cataract surgery for the Ocular Surgery News SuperSite.		Elizabeth A. Davis, MD, is the director of the Minnesota Eye Laser & Surgery Center, an adjunct clinical assistant professor at the University of Minnesota, and a member of the Ocular Surgery News editorial board.
	R. Bruce Wallace III, MD, is founder and medical director of Wallace Eye Surgery, Laser and Surgery Center in Alexandria, LA. He is clinical professor of Ophthalmology at LSU Medical School and an assistant clinical professor at Tulane Medical School in New Orleans.		Jay Pepose, MD, PhD, is professor of clinical ophthalmology at the Washington University School of Medicine in St. Louis, director of the Pepose Vision Institute in St. Louis and executive editor of The American Journal of Ophthalmology.
			Robert Weinstock, MD, is a cataract and refractive surgeon at The Eye Institute of West Florida in Largo.

© Copyright 2008, SLACK Incorporated. All rights reserved. Ocular Surgery News © and its logo are copyright of SLACK Incorporated. All rights reserved. No part of this publication may be reproduced without written permission. The ideas and opinions expressed in this Ocular Surgery News monograph do not necessarily reflect those of the editor, the editorial board, or the publisher, and in no way imply endorsement by the editor, the editorial board, or the publisher.

Symposium

Richard L. Lindstrom, MD: According to the 2008 Market Scope, approximately 93% of implants used in the United States are monofocal and 7% are multifocal or accommodating. Multifocal IOLs have dominated in the past, but recently, the most rapidly growing implant in the United States is the accommodating IOL, such as the Crystalens Five-O AT-50SE (Bausch & Lomb) and the Crystalens HD (Bausch & Lomb). Market Scope projects steady growth in accommodating IOLs, and according to their analysis, today 70% of U.S. surgeons offer premium IOLs to their patients. Market Scope predicts increasing growth in premium IOL usage because they improve patient outcomes and quality of life. In your practices, have you seen an increase in the number of patients selecting premium channel IOLs?

Selection of premium IOLs is on the rise

Uday Devgan, MD: In my practice, we offer the full spectrum of IOL choices and a large percentage of our patients are choosing premium IOLs to maximize their visual results. We have a high conversion rate to premium IOLs because patients want to maximize their freedom from spectacles as well as ensure that they have the best image quality possible. An increasing number of patients enter the office with a baseline knowledge of IOL options and have done the research to decide which IOL they want in their eyes.

R. Bruce Wallace III, MD: We make our patients aware of their refractive options. Some patients do not want to pay for premium IOLs, but expect to have the excellent visual results, even when choosing a monofocal IOL. At my practice, we are working on educating patients on some of the shortcomings of monofocal IOLs and explaining why the multifocal or accommodative IOLs are working better for certain patients.

Jeffrey Whitman, MD: Even in a slow economy, we are seeing fairly strong numbers of patients selecting premium IOLs. We explain to patients that we have more to offer in the area of visual results and encourage them to explore the IOL options.

Jay Pepose, MD, PhD: In my practice, we feel that one of our primary roles is to effectively educate appropriate candidates to clearly understand the differences between premium and monofocal IOLs. I have reached a threshold in my practice in which patients are entering the office and requesting IOLs by name.

Patients are developing a greater interest in the IOL options available to them and are taking a proactive approach to their vision. —Robert Weinstock, MD

Elizabeth A. Davis, MD: When patients request specific IOLs, it automatically reveals which patient has an interest in this technology and that helps guide the discussion on premium IOL options.

Robert Weinstock, MD: I have seen an acceleration of interest in premium IOLs and I think the shift is multifactorial. I have implemented an infrastructure in my practice that incorporates a tremendous amount of patient-staff interaction in the waiting room. We also have a great deal of literature available. Therefore, it is common for patients to ask about a specific IOL. Patients are developing a greater interest in the IOL options available to them and are taking a proactive approach to their vision.

Rosa Braga-Mele, MD, MEd, FRCSC: My practice has evolved significantly. I find that patients are educated on IOL options and enter the office asking questions and requesting specific IOLs. Currently, I implant more multifocal and accommodative IOLs than I did 3 years ago. I inform patients about all of the IOL choices, regardless of their socioeconomic status, and allow them to make an informed decision. With that said, patient selection is crucial. Premium IOLs cannot be used in every type of eye, and the outcomes can differ greatly among patients.

Lindstrom: In my practice, the percentage of patients undergoing LASIK has decreased by approximately 20% year over year, but the percentage of patients selecting premium IOLs and cataract surgery is increasing.

Davis: I think laser vision correction is more vulnerable to the economy than presbyopic IOLs. A LASIK procedure can be delayed, but when patients have cataracts impairing their vision, they want it corrected quickly and must decide whether to purchase a presbyopic IOL.

Transitioning from multifocal to accommodating IOLs

Lindstrom: More U.S. surgeons seem to be transitioning from using multifocal IOLs to accommodating IOLs. What has been your experience over the past 3 years with multifocal and accommodating IOLs? How has your practice evolved?

Weinstock: I was an early adopter of the Crystalens AT-45 IOL (Bausch & Lomb). My results were variable, and some patients experienced refractive problems and required LASIK touch-ups. The ReZoom IOL (Advanced Medical Optics, Inc. [AMO]) performed well immediately after surgery, but when patients came in for their 3- to 4-month visit, they were unhappy with their visual results and experienced dysphotopsias. These patients were spending more than $2,000 per eye and were unsatisfied with their outcomes. I then switched to the ReSTOR (Alcon Laboratories, Inc.) and the results were good, but again, patients were not having excellent quality of vision. Once I started using the Crystalens AT-50SE IOL (Bausch & Lomb), visual results and refractive stability improved significantly.

I recently started using the Crystalens HD and in the past month I have inserted about 30 to 40 of these IOLs. My staff and I are impressed with near vision on postoperative day 1 and in the 3- to 4-week postoperative period. I believe that the Crystalens, overall, is better for the patient because it does not incorporate light- splitting technology.

I have increased my use of the Crystalens over the past 6 months, and I am beginning to use accommodating IOLs more than multifocal IOLs. —R. Bruce Wallace III, MD

Braga-Mele: I tend to undersell premium IOLs and overdeliver on the outcomes. In the past, I implanted many multifocal IOLs, including the ReZoom and the ReSTOR. I see a shift toward accommodating IOLs, such as the Crystalens, because in my opinion, they produce less negative dysphotopsias and result in fewer complications with halos and glare.

Wallace: The ReSTOR produces excellent near-vision results, but distance acuities can lack sharpness of vision. The ReZoom was our leading IOL in the past, but we found that a few patients who received multifocal IOLs could not see well when driving at night. I have increased my use of the Crystalens over the past 6 months, and I am beginning to use accommodating IOLs more than multifocal IOLs.

Pepose: I started using the same multifocal IOL bilaterally and then mixed the ReSTOR and the ReZoom. I then transitioned to implanting a multifocal IOL in one eye and an accommodating IOL in the dominant eye. With the Crystalens HD, the vast majority of my cases are bilateral accommodating IOLs, which has greatly reduced complaints of dysphotopsia. The problem with multifocal IOLs is that we cannot preoperatively predict which patients will have adequate neural adaptive ability to handle photic phenomena, which impacts patient satisfaction. Some studies use computer-generated Gabor patch gradients to vision-train patients to neurally adapt.^1,2 I had a higher laser vision retreatment rate when using multifocal IOLs. I found that patients who have accommodating IOLs can more easily adapt to a small amount of astigmatism or defocus, whereas patients who have multifocal IOLs have more aberrations and cannot tolerate residual lower-order aberrations.

Lindstrom: I have used multifocal IOLs for 20 years and have transitioned to accommodating IOLs because I want to advance the technology behind them. In addition, I find it easier to explain the weaknesses of accommodating IOLs to patients and set proper expectations. The outcome variability is somewhat greater with an accommodating IOL than with a multifocal IOL, but that is dependent on the individual and patients seem to accept that.

Davis: When patients receive a Crystalens, the worst possible outcome is minimal accommodation, and thus, greater dependence on spectacles. However, an accommodating IOL maintains quality of vision without affecting contrast sensitivity or night vision.

Whitman: Recently, the Crystalens HD was released, and about 35% to 40% of my patients have transitioned to accommodating IOLs, such as the Crystalens, and now the Crystalens HD. I see J2 and J1 vision in patients implanted with the Crystalens HD, even on postoperative day 1, which I did not see with the Crystalens Five-O. In the last quarter, before Crystalens HD was released, Crystalens comprised 40.6% of total premium IOLs inserted. I would imagine that Crystalens will quickly become the top presbyopia-correcting IOL on the market. We have inserted about 50 to 60 Crystalens HDs. One of the patients was a 71-year-old woman with moderate cataracts. On postoperative day 1, her dominant eye had 20/25 J2 vision. When using the Crystalens Five-O, I would see J3 vision on postoperative day 1 and it was routine to see J8 or J10 vision. The Crystalens HD is an accommodative IOL, and there will be variability of positioning in the capsular bag, but patients are having better vision. A postmarket study is being conducted to report binocular visual acuity for the Crystalens HD.

My initial results with the HD indicate that there is a better degree of near vision. —Uday Devgan, MD

Devgan: At my practice, we keep an open mind and stay abreast of the new technology. I want to learn about new technologies and offer the full spectrum of products and surgeries to my patients. I have been using accommodating IOLs for many of my patients, beginning with the Crystalens Five-O and now, since July 2008, the Crystalens HD. My initial results with the HD indicate that there is a better degree of near vision and as such, my practice has phased out the Crystalens Five-O, and we now only offer the Crystalens HD as long as the HD is available in the proper dioptric power. I have also determined a new A-constant for my HD patients, 118.8, compared to the 119.0 for the Crystalens Five-O.

Pearls for using accommodating IOLs

Lindstrom: What advice would you give a surgeon who recently decided to start using accommodating IOLs? What are some pearls, in terms of patient education and surgical technique, that will give them the best outcomes?

Whitman: I recommend that surgeons new to accommodating technology use the Crystalens HD. They must also commit to being a refractive IOL surgeon and be able to correct astigmatism. They should be able to perform limbal-relaxing incisions and laser refractive surgery. When inserting premium IOLs, patients expect a premium experience and optimal vision. I recommend making a large capsulorrhexis, more than 6-mm, because it makes surgery easier and minimizes the risk for binding the accommodating IOL in place. A 6-mm OZ marker can be used to make an impression on the center of the pupil as a guide.

Davis: For my technique, I use a large capsulorrhexis of 6 to 7 mm, and I have not seen an increase in my dysphotopsia rate.

Pepose: I recommend making the capsulorrhexis the same each time because if it is very different, then this can impact the predictability of the refractive outcome and makes it more difficult to truly personalize the A-constant. Standardizing the size of the capsulorrhexis can be facilitated by applying a corneal marker before completing the capsulorrhexis.

Surgeons must also pay close attention to the plane of delivery when implanting an accommodating IOL. I fill the capsular bag with viscoelastic before injecting the IOL and place the tip of the injector below the plane of the capsulorrhexis, which will deliver the IOL into the capsular bag entirely.

Whitman: The Crystalens HD is easy to implant and center (Figure 1). I hydrate my Wong incision before completing irrigation and aspiration (I&A) to avoid chamber collapse and anterior shift of the IOL. I then rock the IOL back and forth to position it at the equator of the capsule before ensuring a watertight incision at the end of the procedure. A single suture can be used to close the eye as well. I complete the dominant eye first and I aim for plano to -0.25 D in that eye with the Crystalens HD. If patients see 20/20 or J2, I will aim for the same diopter in the other eye. However, if patients do not see J2 or better, then I may increase to a maximum of -50 D in the other eye using the Crystalens HD.

Implanting an Accommodating IOL
Figure 1. A, Phacoemulsification of the cataract. B, Preparation for implantation. C, Implanting an accommodating IOL. D, Successful implantation of an accommodating IOL. To set the stage for good patient outcomes with accommodating IOLs, surgeons must completely clean the capsule. Surgeons must then use a large capsulorrhexis to implant an accommodating IOL, insert viscoelastic, center the IOL, and seal the wound. Source: Bausch & Lomb

Lindstrom: In my experience, if a patient has two eyes that are J2, they will see J1 when used together because two J2s individually results in a J1 binocularly.

Davis: The postmarket study will show the binocular summation of the Crystalens HD, which will help surgeons better determine a target for the second eye.

Whitman: Surgeons should not be critical of patients’ immediate vision at postoperative day 1 because their vision will often improve at all distances over time. Once both eyes are corrected, assess the patient’s vision binocularly. I usually see patients 10 days after surgery, and I may start them on accommodative exercises at that point.

Surgeons may have to use LASIK correction to perfect patients’ vision, but I wait until the 10- to 12-week period to make that decision. I also monitor the posterior capsule as one would with multifocal IOLs. When the IOL starts to turn cloudy, the patient will begin to lose near vision. At the first signs of striae or “ground-glass” appearance of the capsule, a YAG procedure should be performed. If the patient develops asymmetric fibrosis, complete the YAG procedure early because if ignored, the IOL can move irregularly.

At the first signs of striae or “ground-glass” appearance of the capsule, a YAG procedure should be performed. —R. Jeffrey Whitman, MD

Pepose: Many of the patients at my practice have had previous laser vision correction. One of the advantages of the Crystalens HD is that it is available in two different lengths. Highly myopic patients may have a large capsular bag and may require an IOL that has an overall length of 12 mm. These patients understand preoperatively that they may require a LASIK touch-up after surgery. I use a suture to close the limbal wound because if a patient rubs his or her eyes and some aqueous is expressed from the wound, a myopic shift can occur. I use a different formula for patients who are highly hyperopic and have a short axial length. For these patients, I will use a Holladay II IOL calculation formula, but for all other patients who have not had previous keratorefractive surgery, I will use an SRK-T formula. For post-LASIK patients, I may use the total optical power map on an Orbscan II (Bausch & Lomb) at a 4-mm zone and enter that number into the Holladay II after checking the prior keratorefractive surgery box. I also utilize the ASCRS Web site and calculate a mean IOL power for post-LASIK patients using a variety of formulas designed for post-LASIK eyes.

Postoperatively, I do not use either cycloplegic or pilocarpine. I perform surgery on the dominant eye first and then make a decision on the nondominant eye. I see patients one week after surgery on the first eye. At that point, I ask them to give me a “report card grade” on their near, intermediate, and distance vision and use their feedback in planning my approach to the second eye.

This strategy helps me determine the amount of offset targeted for the nondominant eye. I refrain from using any exercises until surgery is performed on the second eye because many patients will see improvement in vision with bilateral summation. I start exercises approximately a week after surgery on the second eye.

Wallace: I think many surgeons are skeptical about accommodating IOLs because they are comfortable with their routine. Surgeons have to step out of their comfort zone when implanting a presbyopic IOL because it is larger and somewhat bulkier than the IOLs their technicians are used to loading. The trailing haptic of the IOL can be a challenge, especially if the patient has a small pupil, and I suggest that surgeons new to implanting accommodating IOLs practice with the placement. An accommodating IOL is somewhat more difficult to turn in the eye compared with other IOLs, but more viscoelastic can be injected to help with this. These are minor issues after implanting one or two IOLs. I think the Crystalens HD IOL will be a better IOL, and a 6.5-mm capsulotomy can be used because the optic sits far back in the capsule.

Patients are developing a greater interest in the IOL options available to them and are taking a proactive approach to their vision. —Robert Weinstock, MD

Davis: I think surgery is easier when implanting the Crystalens HD compared with the Crystalens AT-45. When using the Crystalens AT-45, we made a 4-mm capsulorrhexis, which made nuclear removal and cortical clean-up more challenging. In addition, IOL insertion required more manipulation to insert through a smaller rhexis. With a larger capsulorrhexis, intraoperative manipulation of the IOL is easier, and it is no longer necessary to cycloplege the eye postoperatively, making the visual recovery process more comfortable for the patient.

Weinstock: Surgeons new to accommodating IOLs should make sure that they are comfortable with their cataract surgical technique (Figure 2). It helps to watch an experienced surgeon insert a Crystalens to get an idea of how the IOL should be positioned when it is injected into the capsular bag. Biometry is extremely important, and surgeons should track their results and discuss them with a representative from the company to make sure that their lens power selection is accurate. Guy Kezirian, MD, has developed software called DataLink that is also excellent for tracking patient outcomes.

Wallace: In addition to learning the technique of implanting an accommodating IOL and getting comfortable with the process, surgeons should also learn how to preoperatively and postoperatively counsel the patient.

Devgan: Topography is no longer optional; it is required. Surgeons must know the effect of their incisions and correct any preexisting corneal astigmatism. If the patient shows any signs of problems in the macula, an OCT should be performed before surgery. Any signs of dry eye syndrome should be addressed before surgery.

Pepose: Surgeons have to appreciate that they are not only performing a preoperative exam for a cataract patient, but also for a potential LASIK or surface-treatment patient. This requires assessment of dry eye, corneal thickness, and possible forme fruste keratoconus or true ectasia before surgery.

Lindstrom: Surgeons should pay close attention to wound creation and closure because wound leakage can affect the outcome when using an accommodating IOL. I also recommend a larger capsulorrhexis and compulsive I&A. I oppose postoperative cycloplegia and prefer to use a diluted miotic. I inject carbachol diluted 5 to 1 with balanced salt solution and inject it once at the end of the case into the anterior chamber. I treat patients with steroids for a longer time. Capsular fibrosis must be avoided, and I now rotate the lens to the horizontal position in an effort to prevent postoperative dysphotopsia.

Davis: The issue of dysphotopsias with IOLs is complex and multifactorial. It is unpredictable and can occur with any IOL, suggesting that it has much to do with numerous ocular parameters of the individual eye as well as the lens. One might think that the Crystalens would have a higher incidence of dysphotopsias compared with other lenses, given its smaller optic and square posterior edge, so it is interesting that it may be even lower than average.

Devgan: I use a dilution of 5 to 1 of balanced salt solution to carbachol at the end of surgery. In the postoperative period, I put my patients on steroids for 3 weeks, and also keep them on an NSAID for 6 full weeks, which minimizes inflammation and discomfort.

Braga-Mele: I instruct my refractive IOL patients to use a steroid and NSAID drop a few weeks longer than with standard surgery to minimize the risk for cystoid macular edema. I also perform surgery on each eye weeks apart to determine if the patient is satisfied with the visual outcome so that I can customize surgery for the second eye. It is also important to identify and treat dry eye symptoms because they can exacerbate negative outcomes. I use tear drops or Restasis (Allergan Inc.) in these patients. I operate on eyes about 2 weeks apart, unless patients are highly myopic or hyperopic, in which case I may perform the second surgery sooner.

Whitman: Postoperatively, surgeons can use a small amount of cycloplegic or dilute pilocarpine. I have used both and have found no difference in the results. There were some reports of myopic shifts associated with the former Crystalens Five-O, but they were not actually myopic shifts, but rather the IOL settling into place. A small percentage of these IOLs will lie planar and not posterior because of the size of the capsular bag. This is not a result of improper implantation, or wound leak, but simply the positioning of the IOL.

Techniques for performing microincision cataract surgery

Lindstrom: Compare coaxial with biaxial microincision cataract surgery (MICS). Discuss the advantages and disadvantages and contraindications of each. What technique are you currently using?

Weinstock: I have been performing biaxial surgery for about 5 years. I transitioned to biaxial surgery when WhiteStar (AMO) technology was released, because it allowed the phaco needle to remain cool during surgery. I use the biaxial technique because I can achieve a stable anterior chamber necessary for safe cataract removal. In my opinion, biaxial surgery offers more intraoperative control. In addition, the independent fluid dynamics, with irrigation in one incision and aspiration and removal of material and fluid from the second incision, is optimal. The transition to biaxial surgery can be challenging without perfectly matched instruments and settings, and I think surgeons will transition slowly as microinjectable implants are developed.

I perform coaxial surgery, and one of the most impressive features of the Stellaris system is that it uses a true coaxial 1.8-mm incision. —R. Bruce Wallace III, MD

Braga-Mele: I have performed both biaxial and coaxial surgery, and I think biaxial can be performed safely on the Stellaris Vision Enhancement System (Bausch & Lomb) and the WhiteStar Signature System (AMO) and coaxial can be performed on the Infiniti Vision System (Alcon Laboratories, Inc.) and MICS 1.8 mm on the Stellaris. Although I have been an advocate for biaxial surgery, I have recently developed more interest in coaxial surgery because there is no IOL that can be inserted through a 1.5-mm incision. I am currently performing MICS through a 1.8-mm incision using the Stellaris system. In Canada, we have a microincisional IOL available, the Akreos MI60 (Bausch & Lomb), and it can be inserted through a 1.8-mm incision. I think biaxial surgery is advantageous because it provides for optimal fluidic control and is superior for cortex removal or if a vitrectomy must be performed.

Wallace: I perform coaxial surgery, and one of the most impressive features of the Stellaris system is that it uses a true coaxial 1.8-mm incision, which is increasingly important as smaller IOLs, such as the Akreos, become available. Improved fluidics will allow surgeons to reduce heat at the phaco tip, making irrigation around the phaco tip less critical.

Davis: I prefer coaxial surgery. The biaxial technique never caught on in the United States, even among some of the most talented surgeons. Many surgeons found biaxial more challenging and less efficient with minimal benefit. Advanced phaco systems, such as the Stellaris, allow surgeons to perform coaxial surgery through 1.8-mm incisions without having to modify their technique.

Pepose: I perform coaxial surgery and recently transitioned to using the Stellaris system. I began minimizing the incision size from 3 mm to 2.75 mm, and now I am transitioning to a 1.8-mm incision. Although using a 1.8-mm incision requires that I use a smaller needle and forceps and change the tubing, I have not had to dramatically change my technique. I use biaxial surgery for specific cases, such as for irrigation when implanting phakic IOLs. I will also use the biaxial technique when approaching complicated surgery in which there is rent in the posterior capsule.

Whitman: I have used the Stellaris, Infiniti, and WhiteStar Signature systems and found that I preferred using the Stellaris when performing MICS 1.8. I decided to use the Stellaris system because it has optimal fluidics that maintains a stable chamber.

Devgan: In a challenging case, I will perform biaxial I&A. When a capsule breaks, I will use the biaxial technique with a vitrector. However, when performing routine phaco surgery, I use the coaxial technique. As my practice transitions to smaller incisions, I am more concerned with improved fluidics and safety for each procedure, which is why I prefer the newer phaco platforms (Figure 3). I am fortunate to have several different phaco machines available to me on any given day, and I have noticed a clear difference between newer machines and older ones. On the Stellaris system, the foot pedal, pump, and tubing have been designed to improve fluidics and maximize safety. Hopefully, these improvements will lead to decreased rates of capsular breaks and better visual results for patients. For surgeons who are using a phaco machine that is a few years old, I recommend seriously considering test driving the newer units.

Lindstrom: Two years ago I spent several months exclusively performing biaxial surgery and designed instrumentation for this technique. I agree that biaxial surgery is an excellent way to remove a cataract. However, it is unlikely that a U.S. surgeon will transition to biaxial surgery until he or she is convinced that there is a suitable IOL that can be inserted through a 1.5-mm incision. Surgeons can perform 1.8-mm MICS on the Stellaris.

What are the advantages and disadvantages to using the Stellaris system?

I like the ability to control vacuum during the removal of the nucleus by using Dual Linear Surgeon Control. —Rosa Braga-Mele, MD, MEd, FRCSC

Braga-Mele: The Stellaris is a straightforward, user-friendly phaco machine. My OR nurses find it easy to set up and move because it has no exterior tank, a wireless foot pedal, and occupies less space. This machine offers versatility. Depending on surgeon preference, the Stellaris can be used either in a pure vacuum mode or a flow-based mode in which surgeons can interchange between flow and vacuum in the same procedure. I also like the ability to control vacuum during the removal of the nucleus by using Dual Linear Surgeon Control (Bausch & Lomb). This minimizes any surge and allows more control for the surgeon. The Stellaris also has optimal power capabilities. The pulse wave allows surgeons to increase power slowly. This feature, coupled with hyperpulse technology, increases control, followability, and holding power.

Whitman: The OR technicians appreciate the Bluetooth technology on the Stellaris system. The computer interface features a streaming video of the live surgery, which is an advantage. I use linear vertical movement of the dual-linear pedal for vacuum and lateral movement for phaco power—my maximum power setting is 10% or 12%. The stroke length is more efficient on this machine, and thus, less ultrasound power is required. With an optimized 28.5 kHz cavitation, efficiency increases. Using my technique, I can achieve efficient vacuum without chamber shallowing. I can reduce chatter and reduce phaco time. In my opinion, vacuum and I&A have always been the most important features of a phaco machine and on the Stellaris, these features are exceptional. The I&A tip has a silicone sleeve and port, which is an advantage when polishing the capsule because a separate capsule polisher is no longer needed. It is a softer silicone material than that used on the Alcon I&A tip. The disadvantage of a soft I&A tip is that it is not durable. However, the advantage is that it seems to have an almost magnetic effect on small fibrils of cortex that appear at the end of a phaco procedure.

Pepose: I tried each of the major phaco machines and what impressed me about the Stellaris was the control of postocclusion surge. I could hear the bypass valve open postocclusion and prevent surge by pulling fluid from the bottle instead of the anterior chamber. The high level of stability allows for increased vacuum during segment removal, which increases efficiency. In addition, flow and vacuum are separated. I use flow to maximize followability, and I use vacuum to maximize holding power once the nuclear fragment is on the phaco tip. Dual Linear helps me control these parameters more precisely.

The Stellaris is stable and solid and allows surgeons to reduce the amount of power, but continue to perform efficient cataract surgery safely. —R. Bruce Wallace III, MD

Davis: The lighter handpiece on the Stellaris system is also an upgrade because it makes surgery more comfortable. In addition, the inflow SureLock (Bausch & Lomb) connector prevents chamber collapse when the irrigation tubing detaches from the back of the handpiece. For surgeons who prefer high vacuum phaco aspiration or are using the MICS 1.8-mm technology, the StableChamber (Bausch & Lomb) tubing provides high outflow resistance to help prevent postocclusion surge. The Stellaris system engineers listened to what surgeons and OR staff wanted and implemented their suggestions into the design of the machine.

Wallace: When using the Stellaris system, I find that there is a reduced risk for contacting the posterior capsule, which is becoming increasingly important as surgeons perform more refractive lens procedures. Technological advancements are matching surgeon demand and helping surgeons meet patient expectations. Surgeons are shifting away from power to ultrasound-assisted vacuum aspiration.

The Stellaris is stable and solid and allows surgeons to reduce the amount of power, but continue to perform efficient cataract surgery safely. When using the Stellaris, viscoelastic does not escape from the cornea and the bubbles remain in the same place. It also minimizes movement of the anterior segment and turbulence in the eye.

Weinstock: When first using the Stellaris system, I was impressed by the clarity of corneas on postoperative day 1, which translated into increased patient satisfaction. Patients have high expectations, and when they are paying for premium IOLs, they expect to have clear vision on postoperative day 1. Surgeons need a phaco machine that has efficient vacuum because that reduces dependency on phaco power. I have performed 600 or 700 procedures using the peristaltic pump on the Stellaris and I find that it offers surgeons a slower, capable, and more predictable approach to surgery. However, for surgeons who have been interested in transitioning to a vacuum-based machine to increase efficiency with heavy vacuum, particularly during I&A or cortical clean-up, this machine offers another option (Figure 4).

Whitman: For surgeons accustomed to using a peristaltic pump, what advice can you offer for transitioning to vacuum pumps?

Weinstock: Create a moderate vacuum setting in a linear format with a maximum of 250 mm Hg or 300 mm Hg. Then, surgeons should match settings from their current machines and anticipate the tip clearing a bit and reduce vacuum on the pedal as the material begins to move through the tip when occlusion breaks. I think it will be an easy and natural transition for most surgeons. As surgeons become more comfortable with the machine, they can not only raise linear vacuum levels, but also use dual-linear settings that increase to 450 mm Hg or 500 mm Hg. As surgeons gain experience, they can increase to almost 600 mm Hg and use linear phaco to purchase it and pull it toward them. Once they are in the safety zone in the center of the eye, slide the foot to the right and the rapid rise in vacuum will quickly aspirate the fragment from the eye with minimal pulses of phaco to break the occlusion at the tip.

As surgeons become more comfortable with the machine, they can not only raise linear vacuum levels, but also use dual-linear settings. —Robert Weinstock, MD

Devgan: Latest-generation phaco systems have significant advantages over their predecessors, and in my opinion, advantages over some competing machines, especially in terms of fluidics. For surgeons who have never used the Stellaris, I suggest starting with the peristaltic pump, which can be programmed for both the flow mode as well as the vacuum mode. For most surgeons, particularly those who operate in a center in which multiple surgeons share the same machine, they will benefit from using the peristaltic machine initially.

Lindstrom: Discuss torsional phaco. Is it necessary for quality cataract surgery, or can high-quality fluidics and optimized ultrasound energy control deliver the same results?

Braga-Mele: I have had the opportunity to use torsional phaco. I think it is advantageous in some situations, but it must be combined with longitudinal phaco for dense nuclei. For those who are quick chop surgeons, the initial burying of the tip should be performed with longitudinal phaco because torsional phaco will cavitate out the nucleus. Using power modulations, such as microburst or hyperpulse, combined with superior fluidics can create followability and holdability.

Weinstock: I cannot speak directly to its capabilities, but I am sure that there is an application for it. It appears to be valid technology, but it is not necessary for successful cataract surgery.

Wallace: Power-based modalities, such as torsional phaco, are older ways of approaching cataract surgery. As refractive lens procedures increase, surgeons are changing their focus from power delivery to improved, safer fluidics.

Braga-Mele: Hyperpulse technology and optimized fluidics improves followability and holding ability. With slight movements of the phaco needle, the nucleus carousels and emulsifies on the tip and is removed. On the Stellaris, using dual-linear technology, I can modify vacuum on the fly, which gives me total control of the procedure and essentially negates surge.

Using increased stroke length, I can achieve clear corneas on the densest cataracts without torsional phaco and with low power. —Jay Pepose, MD, PhD

Pepose: When performing torsional phaco, I had excellent holding ability, but the lack of cavitation at the tip caused me to increase power. Torsional cavitation occurs at the sides and I noticed that pieces on the side were repulsed rather than attracted to the tip. Using increased stroke length, I can achieve clear corneas on the densest cataracts without torsional phaco and with low power. This reduces the risk for wound burn.

Davis: The enhanced fluidics and chamber stability on the Stellaris system allows surgeons to work at high vacuum levels using minimal phaco energy (Figure 5). The ability to simultaneously control power and flow or vacuum with the dual-linear foot pedal gives surgeons the instantaneous ability to adjust these parameters according to what is occurring in the eye at each moment.

Whitman: Fluidics is more important than the method of ultrasound delivery. The Stellaris has optimal fluidics and facilitates cataract removal. In general, vacuum-based machines are better at removing dense cataracts than peristaltic machines. Torsional phaco was developed to improve dense cataract emulsification using a peristaltic pump machine, but the fluidics were not the key change. The Stellaris can be used on any density of nucleus because it is gentle when removing soft cataracts or performing clear lens extraction. However, it can also be used to remove a dense cataract while maintaining a stable chamber and low phaco times, resulting in clearer corneas on postoperative day 1.

Lindstrom: In my opinion, when performing vacuum-dominated, ultrasound-assisted removal of the cataract, fluidic technology overshadows the method of applying ultrasound.

The future of cataract surgery

Lindstrom: Consider the future of cataract surgery 1 to 5 years from now. How will your practice evolve?

Devgan: My practice is growing every month. My LASIK volume is slightly down because of the economy, but the percentage of my patients receiving IOL implants has increased significantly, as has my conversion rate to premium lenses. A year from now, I think we will see an increase in the number of patients choosing premium IOLs. I think patients will select better-quality IOLs that provide them with better options for their vision, whether it is multifocal or accommodating. In the near future, the accommodating IOL will become the preferred premium presbyopic IOL and surpass multifocal IOLs. The number of patients having refractive lens exchange is growing rapidly and in the future, I think we will perform an equal or even greater number of refractive lens exchange surgeries as primary cataract surgery.

Improved technology will enhance surgeon confidence, which will translate into more patients selecting premium IOLs. —Elizabeth A. Davis, MD

Davis: I think we will see a steady increase in the request for and use of presbyopic IOLs. Patient word-of-mouth and perhaps IOL manufacturer advertising campaigns will inevitably increase awareness. We already have several good presbyopic IOL options available, but improved technology will enhance surgeon confidence, which will translate into more patients selecting premium IOLs.

Whitman: Approximately 30% or 40% of my patients are selecting premium IOLs and I think that number will grow to 60% to 70% within the next 2 to 5 years. Surgeons will have to perfect their technique to deliver a nearly flawless surgery because that will be demanded of them as the baby boomer generation of patients continues having surgery. Many of these patients have been working for a long time and will have the financial resources to purchase an IOL that provides optimal visual results.

Pepose: In the future, I think technology will evolve from accommodating IOLs to IOLs that work primarily by changing shape and curvature rather than by mainly moving axially. These IOLs could theoretically provide up to 8 D of accommodation, allowing a generous accommodative reserve and reducing asthenopia.

Wallace: In the short-term, I think we will see advances in biometry and improvements in results with monofocal IOLs. These advancements will increase surgeon confidence in offering patients optimal visual results. If surgeons are confident in the technology, then conversion rates to premium IOLs increase. Once surgeons have an IOL that does not need to be tailored or matched with another kind of IOL, we will see increases in surgeon confidence.

Weinstock: I think surgeons should take a more vested interest in their practice as a whole and ensure that patients are having an excellent experience from the moment they step in the door. I think surgeons who are beginning to add premium packages to their regimen and ensuring patients have an exceptional experience, will be successful. They should consider adding topography and wavefront aberrometry to the cataract process. If these improvements are made, I think the combination of cataract and refractive surgery is going to continue to expand. More time, energy, and financial resources go into creating an optimal visual result for patients. Sometimes results are immediate, but sometimes it requires future work with limbal-relaxing incisions or even corneal-based refractive surgery using a laser to optimize vision. This will translate to increased cost for the practice, and thus, increased cost to the patient. In the future, I think there will be a larger component of patient responsibility for the results they get and the level of sophistication they want in their surgical care.

Lindstrom: I think that as the baby boomers transition into the presbyopic age group of 45 to 65 years of age, corneal refractive surgery will become less important to the ophthalmologist than lens-based refractive surgery. I think refractive cataract surgery will have its golden age, and I think that we are in the beginning of that now. We have high-quality multifocal IOLs and now we have an accommodating IOL, the Crystalens HD, that is generating much interest with improved outcomes, and three sophisticated phaco platforms that make cataract surgery safer and better.

I thank Ocular Surgery News for organizing this panel and Bausch & Lomb for its sponsorship. I also thank the faculty for participating in this discussion.

References

1. Kaymak H, Fahle M, Ott G, Mester U. Intraindividual comparison of the effect of training on visual performance with ReSTOR and Tecnis diffractive multifocal IOLs. J Refract Surg. 2008;24(3):287-293.
2. Pepose JS. Maximizing Satisfaction with Presbyopia-Correcting Intraocular Lenses: The Missing Links. Am J Ophthalmol. 2008 Sep 12. Epub ahead of print.

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