1. What recent trends influence the technologies that you use?
Torsional ultrasound allows surgeons to emulsify nuclear material with reduced repulsion, improved followability, and less cumulative dissipated energy. Advances in fluidics such as less compliant, small-bore tubes and active pressurized infusion help to reduce postocclusion surge; create a more stable anterior chamber; and allow smaller, astigmatically neutral, self-sealing incisions.
Premium IOLs, including bifocal and trifocal multifocal IOLs, are available with different amounts of asphericity and additive power for near vision. New devices for the alignment of toric IOLs provide predictable outcomes.
Since adopting the use of mitomycin C 0.02%, I perform surface ablation rather than LASIK in about 90% of my patients. I implant the Visian V4C ICL (STAAR Surgical). The procedure is now easier, quicker, safer, and more comfortable for my patients.
Intrastromal corneal ring segments and corneal collagen crosslinking (CXL) have made a difference in the management of keratoconus, delaying the need for keratoplasty. The combination of these procedures with phakic IOLs, refractive lens exchange, or cataract surgery has opened a wide range of alternatives to address each patient individually. CXL with iontophoresis may decrease adverse effects and maintain efficacy while shortening the procedure.
With anterior segment tomography and corneal optical coherence tomography (OCT), we can measure anatomic parameters and study the morphology of incisions.
2. What has your experience with intracameral phenylephrine, administered as prophylaxis against intraoperative floppy iris syndrome, revealed thus far?
Nonpreserved bisulfite-free intracameral phenylephrine (IPH) is a highly efficient measure for prophylaxis against intraoperative floppy iris syndrome (IFIS). This drug can restore the rigidity of the iris and return the pupil to its preoperative size. My colleagues and I performed a study of fellow eyes in patients taking tamsulosin (Flomax; Boehringer Ingelheim Pharmaceuticals, Inc.) who underwent cataract surgery.1 One eye of each patient was randomized to receive 0.6 mL IPH 1.5% (group 1) or balanced saline solution (group 2) at the start of surgery.
Signs of IFIS were observed in 88.09% of eyes in group 2 and none of the eyes in group 1 (P<.001). Significant miosis, iris prolapse, or both occurred in 54.76% of eyes in group 2. These conditions were successfully reverted with IPH, however, and pupil size significantly increased after IPH was administered.
3. In your opinion, what phaco technologies have most improved cataract surgery in the past decade?
For very hard cataracts, I prefer to use the Ultrachopper tip (ASICO) designed by Luis Escaff, MD. Use of the Ultrachopper tip results in a lower amount of cumulative dissipated energy than with a standard phaco chop technique.2 The new Ahmed Capsular Tension Segments (Morcher GmbH) facilitate surgery in eyes with weak or subluxated zonules.
4. What is your advice to the next generation of cataract and refractive surgeons?
Cataract surgery is a refractive procedure, and the objective is emmetropia at all distances. Young surgeons need to focus on improving quality of vision after cataract or corneal refractive surgery. The femtosecond laser, OCTassisted surgery, and other diagnostic devices are becoming intrinsic to daily practice. The financial burden will increase, and not all surgeons will have access to the best technologies. Therefore, partnering with other surgeons may be a good solution. My most important advice is to make friends with other ophthalmologists.
5. What are your interests outside of ophthalmology?
One of my favorite hobbies is contemporary art. I usually attend important art fairs such as Volta, Basel, or Arco. I watch all kinds of sports, but I particularly enjoy football (soccer) if Lionel Messi plays. When I need to rest, I go to La Toja, an island in the northwest of Spain, to read and play golf.
- Lorente R, de Rojas V, Vázquez de Parga P, et al. Intracameral phenylephrine 1.5% for prophylaxis against intraoperative floppy iris syndrome: prospective, randomized fellow eye study. Ophthalmology. 2012;119:2053-2058.
- Lorente R. Assessment of new U/S chop tip device compared with standard phaco chop technique in hard cataract cases. Paper presented at: the 2012 Annual Meeting of the ASCRS; April 22, 2012; Chicago.