Most ophthalmic surgeons today consider cataract surgery their bread and butter. Refractive cataract surgery, however, is a different animal—one that requires new skills, both clinically and from a performance perspective, in the pursuit of perfect visual quality for our patients without the aid of spectacles.
Right now, this is quite a challenge, and we are still figuring out how to get the spherical IOL power right and manage astigmatism sufficiently, be it preexisting or surgically induced. Then there is the matter of overcoming presbyopia. If these issues are not yet part of your daily challenge as a modern cataract surgeon, they soon will be. The great majority of cataract patients today demand postoperative outcomes akin to those of refractive surgery.
When one is planning a toric IOL implantation to correct corneal astigmatism, the first step is to determine the correct magnitude of corneal astigmatism and the correct axis to use. The next step is transferring that information to the cornea. The IOL delivers on its promise only when placed in the correct axis. Errors with determining the axis, marking the cornea preoperatively and remarking it intraoperatively, and aligning the IOL can all wreak havoc with refractive outcomes. I am amazed at how good some colleagues have become at doing these things, but, in the modern era, several technologies are available to now help us all excel. New technologies are available for each step, from preoperative diagnostics all the way through to placing the toric IOL on the correct axis.
This issue highlights some of these technologies, and several of those aforementioned colleagues share pointers on how we can achieve the lofty ambition of correcting all refractive errors with an IOL. Image-guided cataract surgery is one of the latest technologies to help us realize this goal, and four authors share their experiences with the available systems. Stephen S. Lane, MD, tells us about the first system to come onto the market. Verion (Alcon) made a big impact at the 2013 ESCRS meeting in Amsterdam, Netherlands, and the news was on everybody’s lips. This system can transfer data to and from the Centurion phaco machine, the LenSx Laser, and the Luxor LX3 with Q-Vue Ophthalmic Microscope (all by Alcon). Gilles Lesieur, MD, discusses the Callisto Eye (Carl Zeiss Meditec), which allows accurate and markerless toric IOL alignment and makes placement of limbal relaxing incisions and the capsulorrhexis more accurate with an overlay in the oculars of the microscope. Richard Awdeh, MD, introduces the Cirle Surgical Navigation System that integrates with the Stellaris PC (Bausch + Lomb), using a three-dimensional perspective within the microscope. Lastly, A. John Kanellopoulos, MD, and George Asimellis, PhD, discuss the role of the multicolored light-emitting diode Cassini topography device (i-Optics) in obtaining corneal astigmatism data to help with toric IOL planning. Recently a partnership was announced between Lensar and i-Optics using TrueGuide software to help further refine this process.
Intraoperative aberrometry is also useful to help surgeons nail the postoperative refraction; however, some argue that now is not yet the time to rely solely on this data. Stephen G. Slade, MD, and Jonathan Talamo, MD, share successful experiences and positive views on intraoperative aberrometry with the Holos IntraOp (Clarity Medical Systems) and ORA with Verifeye (WaveTec) systems. When you consider that each degree of rotational misalignment reduces the toric effect of an IOL by 3.3%, you can see how important accurate alignment of the toric IOL is. On the other hand, Jan O. Hülle, MD, and Stephan J. Linke, MD, have identified six areas in intraoperative aberrometry that may originate surgical errors. Many of these issues can be addressed, but for the moment their advice is not to depend on intraoperative aberrometry alone.
Lastly, a panel of surgeons presents views on additional diagnostics to further enhance refractive cataract surgery outcomes. The ideas range from use of optical coherence tomography, accurate preoperative optical biometry, and the iTrace aberrometer (Tracey Technologies) to paying attention to the tear film. The variety of suggestions drives the message home: Attention to detail must be the same in cataract surgery as it is when planning a customized LASIK correction.
This issue of CRST Europe will be a time stamp for the era in which mainstream ophthalmology accepted that cataract surgery = refractive surgery. Enjoy the issue and the annual ESCRS meeting, where much of what you will read herein will be on display.
Arthur B. Cummings, MB ChB,
FCS(SA), MMed(Ophth), FRCS(Edin)
Associate Chief Medical Editor