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Refractive Surgery | Nov/Dec 2012

Two US Perspectives on the Trends and Breakthroughs of 2012

The Chief Medical Editors of CRST US share their thoughts on four areas of cataract and refractive surgery.

As part of a larger survey of CRST US Editorial Board members, we recently shared our thoughts on what we view as the trends and breakthroughs of 2012 in four areas of cataract and refractive surgery: (1) clinical pearls, (2) research or review article or presentation, (3) software, and (4) technology. Below is an overview of our opinions; the full article is available at bmctoday.net/crstoday/2012/12/article. asp?f=the-best-of-2012.


Clinical pearl. At the 2012 American Society of Cataract and Refractive Surgery (ASCRS) annual meeting, Stephen G. Slade, MD, and I demonstrated our technique of titrating femtosecond laser arcuate incisions. These incisions can be opened partially either at the time of surgery to titrate results with intraoperative aberrometry (Optiwave Refractive Analysis [ORA] System; WaveTec Vision) or at a postoperative follow-up visit. This unique characteristic of femtosecond incisions has dramatically increased our refractive accuracy and reduced the incidence of over-corrections.

Research or review article or presentation. Dry eye disease (DED) continues to be one of the most significant concerns of cataract and refractive surgeons. The immune nature of this disease is now firmly established; however, to date, the only pharmaceutical agent approved for the treatment of DED in the United States is cyclosporine. I am impressed by the results of phase 2 US Food and Drug Administration (FDA) trials presented at the Association for Research in Vision and Ophthalmology (ARVO) meeting by Charles Semba, MD,1 showing the safety, efficacy, and rapidity of onset of dry eye relief with a new T-cell modulator, lifitegrast.

Software. I have been impressed by the rapid development of software associated with laser cataract surgery. We have had four software upgrades in the past 18 months on our LenSx Laser System (Alcon Laboratories, Inc.) that have significantly improved the quality and speed of surgery. The technological advances are coming quickly and will continue to improve the precision and accuracy of laser cataract surgery.

Technology. This is the year of microinvasive glaucoma surgery. Ab interno glaucoma surgery promises to deliver unparalleled safety that will allow cataract surgeons to perform these procedures in patients with glaucoma and ocular hypertension. The iStent (Glaukos Corp.), recently approved in the United States, will be followed by several promising devices over the next several years.

Additionally in the technology category, corneal collagen crosslinking (CXL) has become a mainstream therapy for ectatic corneal disease. New transepithelial riboflavin compounds have decreased morbidity, pain, and delayed return of vision with this vision-saving therapy.

Eric D. Donnenfeld, MD, is a Professor of Ophthalmology at New York University and a trustee of Dartmouth Medical School in Hanover, New Hampshire. Dr. Donnenfeld states that he is a consultant to Alcon Laboratories, Inc., Allergan, Inc., Aquasys, Glaukos, LenSx, Sarcode, and WaveTec Vision. He may be reached at tel: +1 516 766 2519; e-mail: ericdonnenfeld@gmail.com.


Clinical pearl. We use the ORA System or the Holos Surgical Wavefront Aberrometer (Clarity Medical Systems, Inc.) for IOL power determination. Both devices provide better measurements than we can calculate preoperatively, and therefore use of these devices saves second surgeries. Additionally, sedation for laser cataract surgery is best done orally, with a bit more anesthesia than most surgeons are used to administering for traditional cataract surgery. To ensure that this is easy for the patient, we use a motorized gurney (USFK) so that patients do not have to move during the entire process, from preoperative to laser to surgery to postoperative.

Research or review article or presentation. Generally speaking, the presentations made at the American- European Congress of Ophthalmic Surgery (ACOS) meetings in Deer Valley, Utah, and Aspen, Colorado, were exceptional. More specifically, my vote is for the assessment of complication rates in cataract surgery written by David F. Chang, MD.2 In his article, Dr. Chang describes the current state of the art in cataract surgery and examines where and how femtosecond lasers may help to advance the field. Even without the predictions, Dr. Chang’s descriptions of where we are with endophthalmitis, limbal relaxing incisions (LRIs), toric lenses versus LRIs, and phaco technique were enlightening and educational.

Software. In this category, I would nominate the userfriendly interfaces of the femtosecond lasers for cataract surgery, specifically those focused on real-time optical coherence tomography (OCT) functions. This is the imageguided part of the laser that we often overlook for the effects of the laser cutting. I have found the wealth of information provided by these OCT images to be extremely valuable, first in planning the laser treatment but also in getting a look at the dimensions and density of the lens before I go into surgery. In our practice, routine OCT is also invaluable in examining LASIK flaps as well as IOLs and phakic IOLs.

Technology. Today’s CXL devices are faster than ever. For example, in the trial of accelerated CXL sponsored by ACOS, patients are randomized to receive treatment with the KXL System (Avedro, Inc.) in as fast as 3 minutes. This trial by itself is one of the best examples of cooperation among the FDA, surgeons, and industry that I can think of, certainly in 2012.

Stephen G. Slade, MD, practices at Slade and Baker Vision in Houston, Texas. Dr. Slade states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +1 713 626 5544; e-mail: sgs@ visiontexas.com.

  1. Semba C, Torkildsen G, Lonsdale J, et al. A phase 2 multicenter, double-masked, placebo-controlled study of a novel lymphocyte function-associated antigen-1 (LFA-1) antagonist (SAR 1118) for treatment of dry eye. Paper presented at: the Association for Research in Vision and Ophthalmology annual meeting; May 1-5, 2011; Fort Lauderdale, Florida.
  2. Chang DF. Cataract surgery complications rates: how are we doing? Cataract & Refractive Surgery Today. February 2012;12(2):53-56.