Eyeworld

60 | EYEWORLD | MARCH 2020 I ILLUMINATING INTRAOPERATIVE TECHNOLOGIES N FOCUS by Ellen Stodola Editorial Co-Director N icole Fram, MD, Kendall Donald- son, MD, and Robert Weinstock, MD, discussed guidance systems and how they can help in clinical prac- tice. They highlighted the different systems available and in which sce- narios they're best used. How the available systems compare The space has evolved quickly but also pla- teaued at the same time, Dr. Weinstock said. "Many of the technologies that were available a year or two ago have become more robust and refined with software updates and more utiliza- tion," he said. "Especially in today's world of 'high stakes' cataract surgery and refractive cataract surgery where patients are paying extra to see without glasses, it's good to have some device helping you achieve that goal," he said. While Dr. Weinstock said ORA (Alcon) may be considered the "gold standard," CALLISTO (Carl Zeiss Meditec) was intro- duced shortly after ORA and can help surgeons by feeding preoperative data into the operating room to guide surgery. It can tell the surgeon where to put a toric IOL or where to center a multifocal IOL. "That's another type of guid- ance device, but it's not as much about decision making," he said. Dr. Weinstock said that current guidance systems can be broken down into two catego- ries: those that aid decision making and those that are more guidance driven. Dr. Weinstock also discussed the concept of marrying preoperative devices and feeding them into the operating room, mentioning the VERION Image Guided System (Alcon), which couples ORA and other Alcon systems, and the IntelliAxis system (LENSAR). The LENSAR system has moved from being a device that creates a capsulotomy, fragments the lens, and makes arcuate incisions on the cornea for astigmatism correction to being a device that can guide toric IOL placement very Guidance systems: Available options and when they can help physicians At a glance • Guidance systems are con- tinually evolving and can be used both preoperatively and intraoperatively. • Some guidance systems help the surgeon with decision making, while others are more guidance driven. • Two of the major uses for guidance systems are helping with axis marking and toric IOL alignment. About the doctors Kendall Donaldson, MD Bascom Palmer Eye Institute Plantation, Florida Nicole Fram, MD Advanced Vision Care Los Angeles, California Robert Weinstock, MD The Weinstock Laser Eye Center Largo, Florida accurately, Dr. Weinstock said. He added that it can be used with several different preop corneal imaging devices such as the Marco 3D Wave, the Cassini (Cassini Technologies), and the Pentacam (Oculus). These devices can wireless- ly feed a corneal infrared image into the oper- ating room, and once the laser docks onto the eye, it has an infrared camera. Using proprietary iris registration software, it can quickly compare the preoperative iris architecture to intraopera- tive iris architecture and do an alignment of the eye to adjust for cyclotorsion. "Now the laser will make the arcuate incision at the correct axis," Dr. Weinstock said. "It's an evolving space for incorporating the femtosecond laser into intraoperative guidance, and that's becoming part of the value of the femtosecond laser," he said. According to Dr. Fram, the most common commercially available intraoperative guidance systems are VERION, CALLISTO, and ORA. VERION and CALLISTO require an upright reference image whereas ORA does not, she said. In addition, the steep axis measurement of VERION and CALLISTO does not take magnitude or power of the astigmatism into account. "They are simply measurement for digital steep axis marking," she said. "On the other hand, ORA will help with power, magni- tude, and steep axis, as it is using intraoperative wavefront aberrometry and previous history to achieve these measurements." According to Dr. Donaldson, VERION is wonderful in principle because it helps create a plan for the patient that can be executed with the femtosecond laser and also helps the doctor to create a nomogram, which can increase accu- racy long term. However, Dr. Donaldson noted there may still need to be some refinements of the system. "Alcon is working on trying to in- tegrate some of the positives of the VERION system with the ORA system, and hopefully in the future all of that will be meshed together into one higher power intraoperative guidance system," Dr. Donaldson said.

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