Eyeworld

129 EW FEATURE April 2016 • New technology in cataract surgery by EyeWorld staff ASCRS members weigh in S everal new technologies are being used to improve outcomes in cataract surgery. These include aberrometry, laser-assisted cataract surgery (LACS), multifocal IOLs, and drug delivery systems. In the 2015 ASCRS Clinical Sur- vey, ASCRS members were surveyed about their experience with these technologies. Here are the results. Ophthalmologists were asked, "In what percentage of cases do you end up changing the IOL power when using intraoperative aberrom- etry?" There was a nearly even split among 1% to 10% (28%), 11% to 30% (33%), and more than 30% (30%). See Figure 1. "I change the spherical power in about 40% of cases, usually by only 0.5 D," said Robert Cionni, MD, the Eye Institute of Utah, Salt Lake City. "Larger changes from the original plan are more often seen for post-la- ser refractive surgery cases. My pre- operative calculations are typically based on the LENSTAR [Haag-Streit, Koniz, Switzerland] measurements, the Holladay 2 formula, and the VERION [Alcon, Fort Worth, Texas] toric formulas, which do not cur- rently take the posterior corneal curvature into effect. We have seen better estimates of the toric magni- tude and axis recently using the Barrett toric calculator, but our recent analysis still demonstrates su- perior outcomes using aberrometry." LACS When asked what they think their mix of laser versus current hand- performed mechanical methods for cataract surgery will be 10 years from now, 94% of ophthalmologists said they think they will do at least some laser-assisted cataract surgery (LACS) in 10 years. Additionally, 38% think a majority or all will be laser-assisted. Thirty-nine percent of U.S. ophthalmologists and 38% of non-U.S. ophthalmologists think the majority or all will be hand-per- formed. See Figure 2. "In general, surgeons will make a change in practice when new technology clearly demonstrates bet- ter outcomes, improved efficiencies, or a significant cost savings," Dr. Cionni said. "We are not quite there yet with LACS. It is definitely more expensive, takes a little longer than manual surgery, and outcomes have not yet been shown to be clearly superior to manual techniques when we look at mean outcomes. How- ever, I have yet to see any surgeon produce more consistently precise capsulotomies, corneal incisions, or arcuate incisions as with LACS. LACS is already proving to help us with challenging cases such as in pa- tients with zonular compromise or intumescent cataract. In time, LACS will enable other new technologies as well, much like phaco led us to small incision foldable IOLs. Once this occurs, the uptake of LACS will grow significantly." Multifocal IOLs The survey also asked about multi- focal IOLs. Ophthalmologists were asked to select up to 3 of the follow- ing presbyopia-correcting technol- ogies that they are most interested in integrating into their practices during the next 5 years: extended range of vision multifocal IOLs, light-adjustable IOLs, shape-chang- ing IOLs, corneal inlays, dual optic accommodating IOLs, laser vision correction monovision, presbyopia femtosecond ablations, multifocal laser vision correction ablation, hinge-type accommodating IOLs, and others. The top 3 were extended range of vision multifocal IOLs (63%), light-adjustable IOLs (35%), and shape-changing IOLs (22%). On av- erage, only 2 options were selected, and the top 3 were the same for U.S. and non-U.S. doctors. See Figure 3. Dilation Ophthalmologists were also asked, "In the majority of cases, how are you dilating your patients?" The majority (70%) are dilating with topical drops, while 26% said they use topical drops and intracameral epinephrine. "I, like the majority of respon- dents, still rely primarily on topical drops for routine cataract cases and intracameral epinephrine with topical drops for complex cases, in particular those with intraoper- ative floppy iris syndrome," said New cataract surgery technology 40% 35% 30% 25% 20% 15% 10% 5% 0% 0 1 to 10% 11 to 30% >30% All U.S. Non U.S. Figure 1: Percent of cases in which ophthalmologists change IOL power when using intraoperative aberrometry All laser-assisted cataract surgery Majority laser-assisted cataract surgery Even mix Majority current hand-performed surgery All current hand- performed surgery 0% 5% 10% 15% 20% 25% 30% 35% All U.S. Non U.S. Figure 2: Ophthalmologists' anticipated mix of laser and hand-performed methods for cataract surgery in 10 years All U.S. Non U.S. Extended range of vision multifocal IOLs 63% 58% 67% Light-adjustable IOLs 35% 46% 24% Shape-changing IOLs 22% 27% 17% Corneal inlays 18% 19% 17% Dual optic accommodating IOLs 15% 18% 12% Laser vision correction monovision 12% 10% 13% Presbyopia femtosecond ablations 10% 8% 12% Multifocal laser vision correction ablation 9% 8% 10% Hinge-type accommodating IOLs 8% 8% 8% Other 5% 5% 6% Figure 3: Survey respondents selected up to 3 presbyopia-correcting technologies that they are most interested in integrating into their practices during the next 5 years Source: ASCRS continued on page 130

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