Eyeworld

SUMMER 2025 | EYEWORLD | 33 C Contact Behshad: sbehshad@hs.uci.edu Lee: bryan@bryanlee.pro Osher: RHOsher@cvphealth.com Weikert: mweikert@bcm.edu Having the manual markings, Dr. Osher added, is also a safety net should the digital marking system fail when needed for whatever reason. "There's a beauty to having this dual approach, a safe approach, because you never know," Dr. Osher said, noting that images might not make it into the medical record, digital sys- tems can freeze, and thumb drives can be lost. "I carry every iris fingerprinting in my briefcase with me every day." Both Bryan Lee, MD, JD, and Mitchell Weikert, MD, said they prefer digital marking for their toric IOL cases. "Digital marking has been shown to be more accurate than manual marking, and it also improves workflow in the preop area and oper- ating room," Dr. Lee said. "Additionally, if you adjust the axis based on intraoperative aberrom- etry, you can reposition the digital marker more easily for your final check at the end of surgery." The pro of manual marking, Dr. Lee said, is that it is a fallback option if digital images can- not be used, and digital marking is not available 100% of the time. But, he said, "whenever it is, I would always use it." Dr. Weikert relies primarily on digital marking and for those where the cost of such a system isn't an issue, he would say "digital marking all the way." "If you are investing in this technology, you need to do a little bit of legwork to make sure that, economically, it makes sense the way you're handling it," he said. Dr. Weikert mentioned the creation of laser capsulotomy marks via the femtosecond laser. This is available on the LENSAR Laser System (LENSAR) and eliminates the issue of parallax error that we have with other digital markers, he said. But just because you have a digital marking system does not mean you're out of the woods from using manual marking, Dr. Weikert said. "I had a of couple patients last week where we couldn't get a quality image. It could be that they have ptosis, or we can't get them lined up to get a complete image to be able to use the digital marker." Dr. Weikert also said that with digital mark- ers, you need to make sure you can reconcile what you're seeing under the scope with what's up on the monitor. "Sometimes there's a little bit of a delay [with digital marking systems]," he said. "I will often mark the eye with the location of the toric lens at the beginning of surgery when I first get my reference, then I'll look between what I've marked on the eye and up at the monitor because the image that you see on the monitor is more static and locked in than the image that you're looking at under the microscope." The discussion of manual and digital marking is still an important one, Dr. Weikert said, especially when you think about it in the context of toric IOL market penetration, which he said is "shockingly low." "The penetration of toric lenses was 8.4%," Dr. Weikert said, citing 2023 data. "Penetration of presbyopia-correcting lenses was 9.1%, so some of those are going to be toric as well. This means that more than 80% of surgeries have a non-toric, monofocal IOL. Why is that? Some of it is cost and the burden of patient expectations, but part of it may be concern about accurate results. Are [surgeons] worried about aligning the lens? What's the deterrent? If their comfort with aligning the lens is part of it, maybe this is one way to increase the comfort with that." Belt and suspenders approach: Callisto and iris fingerprinting photos on the microscope for accurate alignment of toric lenses Source: Robert Osher, MD

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