Eyeworld

DECEMBER 2021 | EYEWORLD | 45 C Relevant disclosures Lee: Carl Zeiss Meditec Miller: Alcon Martinez: Alcon placement, Dr. Miller said. Technologies that can achieve this are the VERION Image Guid- ed System (Alcon), CALLISTO Eye (Carl Zeiss Meditec), and the NGENUITY 3D Visualization System (Alcon). When patients lie down, the eye rotates, necessitating the need for manual marking or the use of such image guidance systems to align toric lenses. Manual marking is low tech and relies on the physician's judgment. Image guid- ance systems, like VERION and CALLISTO, Dr. Miller said, take a picture of the eye that is then used as a reference in the OR. "What CALLISTO and VERION do is show us where to make the phaco incision, where to make the relaxing incisions, and how to align a toric lens in the eye, without ever having to mark the eye," he said. With VERION, for example, Dr. Miller said a picture of the eye is taken at the same time as the keratometry readings, with the K readings locked to the reference image. In the operat- ing room, VERION allows the physician to do alignment under the LenSx Laser (Alcon) for incisions exactly where the physician planned them or under an operating microscope with an overlay of incisions or toric alignment in a heads-down display. Another case involved a patient slotted to receive a toric lens. This patient had a heavy brow, he was squeezing, oozing lipid all over the tear film, and he wasn't focusing well on the aberrometer. All in all, it was not a good ORA case. "When you don't have a good tear film and good exposure, you have to be careful about the ORA results," Dr. Miller said. Intraoperative aberrometry eventually told Dr. Miller to rotate the lens 90 degrees away from where he had originally intended. Dr. Miller didn't trust this advice and decided to leave the lens at his originally planned axis. He finished the case, pulled off the drapes, and was about to send the patient to recovery when his resident pulled up the topography; the left eye axis said 147, not 56 as was inputted in the plan. "We had input the right eye numbers for the left eye," Dr. Miller said. He reran the calculations with the patient lying on the table, reprepped him, redraped, and rotated the lens 90 degrees. Upon repeating the aberrometry, it said no rotation recommend- ed. "The next day the patient was 20/20 +2 and happy as a clam. ORA didn't save me, it was the resident, but ORA was trying to save me and I was ignoring it," Dr. Miller said. "ORA raised a red flag and it got pursued." Bryan S. Lee, MD, JD, uses ORA for LRIs, toric IOLs, and presbyopia-correcting IOLs. He also offers it as a standalone for patients with post-refractive eyes who choose a standard monofocal instead of the Light Adjustable Lens (RxSight). "Aberrometry is helpful as a tiebreaker between different power IOLs. I use it that way and almost never change by more than one increment for either spherical or cylindrical power," he said. "It is nice to have aberrometry for these tiebreakers, although the better feeling is when the preoperative and intraoperative data are consistent. There are certain eyes, such as very short eyes, where aberrometry is less accurate, but these are the hardest eyes for the IOL formulas as well." Image guidance Image guidance systems can eliminate the need to manually mark an eye for toric lens continued on page 46 "Patients don't need to know which device or combination of devices we're using. They just want to know we're using the latest technology to give them the best chance at a good refractive result." —Kevin M. Miller, MD

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