Eyeworld

62 | EYEWORLD | MARCH 2020 I ILLUMINATING INTRAOPERATIVE TECHNOLOGIES N FOCUS Contact Donaldson: kdonaldson@med.miami.edu Fram: nicfram@yahoo.com Weinstock: rjweinstock@yahoo.com All of these guidance systems allow you to stay on the axis and can provide more accura- cy, Dr. Fram said. "However, the Barrett Toric Calculator remains the gold standard in deter- mining magnitude of toric power," she said. Dr. Donaldson said ORA is especially help- ful in post-corneal refractive surgery patients. She also likes to use ORA in patients who are highly myopic because there can be more errors with IOL calculations. Anytime there is a patient with an unusual eye, it helps refine the results, she added. The CALLISTO, although it helps with alignment, doesn't help with the post-refrac- tive patients, Dr. Donaldson said, adding that she uses ORA on 40–50% of cases for either post-refractive or toric alignment reasons. CALLISTO is the quickest device but helps mainly with toric alignment. "We would love to have an intraoperative guidance system integrat- ed into the laser itself," she added. Cataract surgery used to be very task-based with not a lot of decision making, Dr. Wein- stock said. "Now, it's become more of a dynam- ic procedure where you're thinking about things while you operate and potentially changing the plans," he said. There are now more devices to learn from and understand as you have to make decisions in the operating room. These tools do have a learning curve. "But the more tools you have in your toolbox, the higher chance you have of delivering a good outcome for your patient," Dr. Weinstock said. are aligned properly. She added that one of the hopes for future lasers is to have the laser detect the steep axis and align the AK incisions automatically. Dr. Fram noted that manual marking has been referred to as a "safety parachute" by Robert Osher, MD, in case the digital marking system fails intraoperatively. "Marking is most accurate at the slit lamp or with a level marker," she said. "In addition, using a reference of iris or scleral vessels is very useful. When manual marking is free hand, there is risk of introduc- ing inaccuracy." Are intraoperative guidance systems worth it? Past ASCRS Clinical Surveys have shown that many surgeons think 10 degrees of rotation off axis for a toric IOL is acceptable, Dr. Fram said. This means the surgeon will lose 33% of effectivity. "The digital guidance systems allow surgeons to be more precise and deliver on the promise made to the patient," she said. "In our practice, ORA took us from 83% to 92% on target for toric IOLs. We were able to look at our data and compare using the AnalyzOR [Alcon] to review actual outcomes." The IntelliAxis takes a reference image from a Cassini or Pentacam, loads it into the femtosecond laser, and creates tabs in the capsulotomy on the steep axis, Dr. Fram said. The IntelliAxis Refractive Capsulorhexis has biomechanically stable and permanent capsular marks that enable physicians to precisely mark the capsule on the steep axis to guide toric IOL alignment, both intraoperatively and postoperatively, Dr. Fram said. IntelliAxis-C steep axis corneal marking is also available. Relevant disclosures Donaldson: Alcon, Johnson & Johnson Vision, Bausch + Lomb, Carl Zeiss Meditec Fram: Alcon Weinstock: Alcon, Johnson & Johnson Vision, Bausch + Lomb, Carl Zeiss Meditec, LENSAR continued from page 61

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