Eyeworld

42 | EYEWORLD | SEPTEMBER 2019 ATARACT C Contact information MacDonald: susanmacdonaldeyecorps@gmail. com Walton: drwalton@visiontexas.com Waltz: kwaltz56@gmail.com About the doctors Susan MacDonald, MD Associate professor Tufts University School of Medicine Boston Bennett Walton, MD Slade & Baker Vision Houston Kevin Waltz, MD Partner, Whitson Vision President, Ophthalmic Research Consultants Indianapolis Reference 1. Thompson VM, et al. Compar- ison of manual, femtosecond la- ser, and precision pulse capsulot- omy edge tear strength in paired human cadaver eyes. Ophthal- mology. 2016;123:265–74. Relevant financial interests MacDonald: Carl Zeiss Meditec, Perfect Lens Walton: RxSight, Carl Zeiss Meditec Waltz: Mynosys Now performing SICS regularly, Dr. Mac- Donald said miLOOP has made it possible to deliver the cataract fragments through small incisions. In the U.S., Dr. MacDonald thinks that surgeons will find it makes them more efficient. How it is incorporated into their practice will be individualized, though she does think the technology makes surgeons better. Internation- ally, she said "it's going to give phaco a run for its money." It is a skillset that is easy to transfer and makes for safer surgery in some of these settings, Dr. MacDonald said. Nailing IOL power postop Missing a refractive target used to mean spec- tacles, contact lenses, laser vision correction, or an IOL exchange for the patient. Newer tech- nologies, like the Light Adjustable Lens (LAL), which is FDA approved, and Perfect Lens, which is not yet FDA approved, are giving sur- geons the ability to lock in IOL powers (sphere, cylinder, and multifocality) postoperatively. "Since IOLs have historically been man- ufactured in pre-set powers, all patients have been subject to the variability of preoperatively guessing the effective lens position and how the cornea will heal," Dr. Walton said. "Even modern IOL power estimation formulas—we say estimation instead of calculation at our practice to reinforce the truth that there is variability and not every eye will hit the tar- get—have about a 20–30% rate of missing the outcome by 0.5 D in most practices. The Light Adjustable Lens allows us to place the IOL power that seems best, then adjust and lock in the power with a non-invasive light treatment postoperatively." Dr. Walton said the learning curve for this technology is easy. Surgeons who don't have experience with implanting silicone IOLs might find that they unfold quicker than single-piece acrylics, and the treatments with a proprietary light source to adjust the lens postop are "in- tuitive," according to Dr. Walton. The biggest barrier to this technology, Dr. Walton said, is a familiar one to refractive cataract surgeons. "Many or even most surgeons are uncom- fortable discussing patient pay technologies, even when they might offer the patient a more precise or more visually freeing result," he said. who cannot or do not wish to spend what FLACS would cost. Dr. Waltz said he is currently transitioning his main practice from El Salvador back to Indianapolis where he will use Zepto when he thinks it's beneficial to the patient. While some surgeons use mechanical devices like Zepto in every case to get a perfectly centered and sized capsulotomy to reduce higher order aberrations and lead to more predictable outcomes, Dr. Waltz said others will use it in more complicated cases, such as those with zonulopathy or white cataracts. Dr. Waltz provided a couple of pearls for Zepto success. First, he said you have to withdraw the pushrod of the device fully before applying vacuum; if you don't, the vacuum is inadequate and you could get an incomplete cut. Second, give the vacuum time to develop. The vacuum creates bubbles inside of the system, and these bubbles move while the vacuum is building. The vacuum is being pulled through 8 feet of tubing and it takes a few seconds to fully develop the vacuum inside of the eye. Dr. Waltz said once the bubbles in the eye stop moving, the vacuum is fully engaged. Cataract fragmentation Since its FDA approval in 2017, miLOOP has been making waves for its ability to fragment even the densest cataracts manually. Consist- ing of a nitinol filament that is deployed by a surgeon-held handpiece and pulled through the cataract like a cheese wire, as Dr. MacDon- ald put it, surgeons have been sharing success stories of using miLOOP in soft cataracts and brunescent cataracts. Dr. MacDonald, who mainly performs surgery outside the U.S. in developing countries where the cataracts are generally harder and manual small incision surgery is used, said the miLOOP learning curve for phaco surgeons is simple. "The device is self-explanatory. As a phaco surgeon, I've always thought of my second instrument as something that I manipulate, and one piece of advice I can give to someone who is using the miLOOP is to not try to manipulate the nucleus with the miLOOP. If you follow the directions, it will do exactly what it's supposed to do," she said. continued from page 40

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