2012: Completing the premium surgical suite picture

Another year, another rush of novel cataract and refractive surgical developments to assist the ophthalmic surgeon expertly. The evolution of established technologies and the implementation of new ones are greatly contributing to the premium surgical experience to optimize better outcomes for the patient. Technologies such as femtosecond lasers, accommodating IOLs, real-time imaging, and ophthalmic viscosurgical devices (OVDs) are bringing great value to the surgical practice. The integration of new technology into a surgical suite may be a difficult task in your practice because there can be certain barriers, such as cost, training, and incorporating new technologies with older ones.

However, at this point in technology, benefits such as increased practice growth and better patient outcomes can certainly outweigh the negatives.

The excitement in surgical advancements of the past year lies within the tweaks and refinements that have made old techniques even more superior.

Additionally, this year has provided clinicians with a better understanding of who the best candidates are for refractive cataract surgery, and whether candidates are appropriate for a “premium journey,” as each patient’s surgical experience is unique. For example, methods to understand which patients can receive a multifocal implant with a better outcome have improved and are significantly more accurate. These include advancements in the association between angle kappa and multifocal IOLs, as well as corneal optical clarity advancements via corneal wavefront analysis.

As of late, both extraocular and intraocular refractive procedures have continued to generate interest as new technologies become more readily accessible for clinical use. Wavefront-optimized laser vision correction has demonstrated excellent clinical outcomes with induction of fewer higher-order aberrations, improved visual acuities, increased predictability, and better contrast acuity compared with conventional ablations. With the adoption of intraoperative abberometers into the operating room, we have seen great benefit in documenting proper implant power, particularly in post-refractive cases due to the growing population of laser vision patients now reaching cataract age. As adoption becomes more prevalent into the operating room, nextgeneration technology is almost in our hands for evaluation.

There were also a multitude of software and hardware changes in femtosecond laser cataract surgery systems this year, such as the improvement in curved laser user interfaces resulting in the quality of the optical coherence tomography (OCT) image, a higher rate of freefloating capsules, and improved laser lens softening and sectioning that allows surgeons to use less phacoemulsification energy and causes less endothelial stress with resultant quieter eyes. With new technology updates, OCT now has the ability to identify those individuals with early corneal thinning or other changes in corneal shape. Ramos JL, Li Y, Huang D. Clinical and research applications of anterior segment optical coherence tomography–a review. Clin Experiment Ophthalmol. 2009;37:81-89. Early detection before the appearance of significant signs and symptoms is key, because it can yield signals for early involvement from the practitioner that can provide better patient outcomes.

Surgical improvements

OVDs have revolutionized the way cataract surgery is performed, though it has been more than a decade since a new product has hit the market. With that in mind, Abbott pharmaceuticals recently announced that it has expanded its Healon family of OVDs with the FDA approval of Healon EndoCoat OVD, a device intended for use as a surgical aid in cataract extraction and IOL implantation.Abbott receives FDA approval for Healon EndoCoat protective gel for cataract surgery. http://www.abbott.com/news-media/press-releases/abbott-receives-fda-approval-forhealon- endocoat-protective-gel-for-cataract-surgery.htm. Accessed Nov. 6, 2012. The surgical delivery system for Healon EndoCoat OVD includes a number of features for increased patient safety and ease of handling for the physician, including a smaller delivery device and improved ergonomics for a smoother and more consistent delivery of the formula into the eye than past OVDs.

syringeFigure 1 The new dispersive ophthalmic viscosurgical device, 3% sodium hyaluronate (Healon EndoCoat, Abbott Medical Optics), recently received FDA approval. The product is also available in Europe, Canada, and New Zealand. (Photo courtesy of Abbott Medical Optics)


There has been a wave of rapidly evolving technology upgrades concerning the established market of femtosecond lasers, for both cataract and refractive surgery. For instance, a new femto-cataract procedure with one femtosecond laser platform (Victus, Bausch + Lomb and Technolas Perfect Vision) is being used to perform the key steps in the cataract surgery procedure. The system is the first femtosecond laser single platform for LASIK flap, cataract, refractive, and therapeutic procedures, provides unparalleled versatility and leadingedge technology, and comprises real-time, high-contrast OCT as well as curved patient interface.Bausch + Lomb and Technolas Perfect Vision receive 510(k) FDA clearance from FDA for VICTUS femtosecond laser platform. http://www.technolaspv.com/dasat/images/6/100976- victus-us-510k-clearance-press-release-final.pdf. Accessed Nov. 8, 2012.

Additionally, a high-quality refractive laser system featuring outstanding precision and optics is the ReLEx smile technology (Carl Zeiss Meditec), which brings another innovation to the surgeon’s armamentarium. This technology, which uses VisuMax Femtosecond System (Carl Zeiss Meditec), is the first femtosecond laser to develop an intrastromal refractive procedure, and one feature of this technology includes the fact that it is flapless. Previously, a side-cut of roughly 20 mm had to be created, whereas a small incision of less than 4 mm is sufficient in ReLEx smile technology. Carl Zeiss Meditec has just recently announced that the first 29 subjects in the VisuMax IDE clinical trial in the United States have been treated with the ReLEx smile procedure for the correction of spherical myopia with the VisuMax femtosecond laser.First 29 cases treated in US clinical trial of new minimally invasive, all-femto laser vision correction method. http://meditec.zeiss.com/meditec/en_de/media-and-news/press-releases. html. Accessed Nov. 6, 2012.


Victus equipmentFigure 2 There has been a wave of technology upgrades concerning the established market of femtosecond lasers, for both cataract and refractive surgery. For instance, a new femto-cataract procedure with a femtosecond laser platform (Victus, Bausch + Lomb and Technolas Perfect Vision) is being used to perform the key steps in the cataract surgery procedure. (Photo courtesy of Bausch + Lomb)

Contact on eyeFigure 3 In ReLEx smile, in a single step, the femtosecond laser platform creates a refractive lenticule and a small incision of less than 4 mm in the intact cornea. (Image courtesy of Carl Zeiss Meditec)

Eye graphic

Figure 4 A patient interface (LenSx SoftFit, Alcon) offers a
proprietary curved soft contact lens technology that enables the
natural curvature of the cornea to conform to a soft contact lens
insert. (Image courtesy of Alcon Laboratories)

Most recently, Alcon announced at the 2012 meeting of the American Academy of Ophthalmology that the LenSx SoftFit represents the latest in femtosecond laser advancements. The new interface enables surgeons to improve surgical performance and deliver enhanced patient comfort. The patient interface provides all the features of the LenSx laser single-piece patient interface, and offers a proprietary curved soft contact lens technology that enables the natural curvature of the cornea to conform to a soft contact lens insert.Alcon introduces new LenSx SoftFit patient interface. http://invest.alconinc.com/phoenix. zhtml?c=130946&p=irol-pressReleasesArticle&ID=1755931&highlight=. Accessed Nov. 16, 2012.

Patient outcomes and your business

In a modern-day cataract surgery practice, there are typically two groups of patients. The first group, which still accounts for a majority of patients (60% to 65%), is very comfortable with wearing glasses moving forward and receiving a traditional lens implant and surgical approach.

The second group (35% to 40%) is the fastest growing category and requires significantly more time before surgery to evaluate the optimal premium strategy to minimize future use of glasses. While often coined “the premium surgery channel,” ultimately for this second group a “customized surgery” is developed by truly understanding the patient’s post-surgical desires, and utilizing the appropriate mix of technologies to optimize patient satisfaction and outcomes. An advanced multifocal or accommodating implant, femtosecond laserassisted cataract surgery, intraoperative abberometry, followed by, if necessary, an excimer laser enhancement through PRK or LASIK can all aid in providing this customized experience. These advances are adding tremendously to the overall surgical package value and accuracy.

These pivotal new components to the surgical suite offer exciting incentive to reinvigorate your practice. With patient outcomes getting better and better, the opportunity to make your practice a beacon of surgical expertise is only growing.