Eyeworld

intensity on the central coaxial light while maintaining centration. Dr. Steinert emphasizes center- ing—instead of tilting—the micro- scope. For Dr. Garg, a coaxial illumina- tion source—such as that used in the Lumera surgical microscope (Carl Zeiss Meditec, Jena, Germany)— is key to obtaining the red reflex needed for good visualization during capsulorhexis creation. "It is also very important to stay well centered to maintain the illumi- nation path highlighting the red reflex," Dr. Garg said. However, coaxial illumination is used by Dr. Garg primarily during the surgical steps prior to hydrodis- section. For the hydrodissection and remainder of the case he adds in some paraxial, or surround, illumination to illuminate the entire operative field. Dr. Ward said the use of the coaxial beam—usually not much larger in diameter than the cornea— helps direct his focus during capsu- lorhexis. Although Dr. Ward also has used the OPMI Lumera 700 system, he previously used other, both newer and older, microscope systems. "While the new systems tend to offer a more brilliant red reflex, I am convinced that a good surgeon who understands the fundamentals of using an ophthalmic surgical micro- scope can be successful with any system," Dr. Ward said. "Each surgeon will have his/her preference regarding the optics, depth of field, and quality of the red reflex." Focus on magnification For magnification, Dr. Garg uses 16-20x for the capsulorhexis and 8-10x for the nuclear fragment re- moval. Although he generally does not use the depth of field function on the Lumera during phacoemulsi- fication due to concerns that it cuts some of the light intensity and is not necessary given the optics of the microscope, that was a function he routinely utilized on microscopes previously. Dr. Farid sets her microscope's magnification to 0.6 to 0.7. "Over magnification can make you lose sight of the bigger picture and cause more problems," Dr. Farid said. She has found that manufactur- ers of most newer scopes have built in excellent depth of field. However, Dr. Steinert warned that microscopes that have an increased depth of field utilize a smaller aperture, "which means that the surgeon receives less light and therefore must increase the light load on the retina." Dr. Ward generally avoids any particular magnification settings because of variation in the size of each eye and cornea. "I tend to like the view to just barely incorporate both canthi and adjust the zoom to achieve that view for each patient," Dr. Ward said. "I don't make any particular micro- scope adjustments between the cap- sulorhexis and phacoemulsification portions of the procedure." Pearls Dr. Steinert said the other major variable in adjusting a microscope to optimize the view during cataract surgery is the tilt of the oculars. "To avoid neck strain, it is advisable to have the oculars as horizontal as possible while keeping the microscope perpendicular to the patient's eye and the floor," Dr. Steinert said. Dr. Farid urged surgeons to remember to use the x-y function in order to help maintain good centra- tion. Slight patient head shifts can move the eye out of centration and lead surgeons to strain to obtain good visualization. Also, less is sometimes more, Dr. Farid said. "Remember to not over blast the light intensity," she said. "This can cause macular strain on the patient's eye, especially in the longer cases." Dr. Garg noted that higher mag- nification reduces depth of focus. The decreased field size can lead to ocular fatigue and potential increase in operative time due to frequent adjustments. EW Editors' note: The physicians have no financial interests related to their comments. Contact information Farid: mfarid@uci.edu Garg: gargs@uci.edu Steinert: roger@drsteinert.com Ward: mattsward@gmail.com July 2014 The Johnston* Titanium Applanator For Perfect LASIK & LASEK Flap Replacement 3360 Scherer Drive, Suite B. 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MM /RIENTATION 2ING &OR 0ERFECT #ENTRATION !ND #ONFIRMATION /F 4HE !PPLANATED 3URFACE s %ASILY !PPLIED 4O 4HE &LAP 7ITHOUT )NTERFERENCE &ROM 4HE 3PECULUM %YELIDS /R .ASAL "RIDGE &OR 5NENCUMBERED !CCESS !ROUND 4HE #LOCK $ESIGNED 4O 0REVENT 3TRIAE 7ITH ! -INIMUM /F 4IME 3URGICAL 3KILL s )DEAL &OR 4REATING 0OST/PERATIVE 3TRIAE !ND 2EFLOATING 2EPOSITIONING 4HE &LAP 4O )NSURE #ONSISTENT 0OST /PERATIVE /PTICAL #LARITY !ND 0ERFORMANCE s 2EUSABLE !UTOCLAVEABLE -ADE )N 4HE 53! 'UARANTEED &OR ,IFE !VAILABLE &OR ! $AY 3URGICAL %VALUATION 7ITHOUT /BLIGATION !ND 0ROVIDED 7ITH ! #OMPLIMENTARY )NSTRUCTIONAL 6IDEOTAPE 5PON 2EQUEST 5 7 : JoHns on L !3) + & LaP !P PLan aT oR T iT an i u M !nT e R i o R V i e W / F # o Rnea ! F Te R & L a P 2 e P L a Ce M e n T #ALL &OR -ORE )NFORMATION /R 3CAN 4O /UR 7EBSITE 12-29 News_EW July 2014-DL_Layout 1 6/30/14 8:38 AM Page 13

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