Cataract Surgeons Look at New Approaches

Exploring the Latest Innovations in Cataract Surgery

Cataract Surgery Techniques

Cataract surgeons are increasingly adopting various techniques, both new and established, to enhance their procedures. According to a recent survey, there has been a significant increase in the use of the horizontal phaco chop technique, with a rise of nearly 12 percentage points compared to last year. Additionally, more surgeons are incorporating the femtosecond laser or Zepto devices into their cataract surgeries, with a 5 percentage point increase. The Yamane IOL fixation technique has also gained popularity, with a rise of 13 percentage points compared to last year’s survey.

The survey, which received responses from 4,159 out of 10,442 surgeons (a 40 percent open rate), provides valuable insights into the preferences and practices of cataract surgeons. If you’re curious about how your preferred surgical techniques compare to those of your peers, keep reading.

Suturing an IOL: Exploring Different Approaches

Suturing an IOL

When faced with an IOL that has little or no capsular support, many surgeons (29 percent) are turning to the Yamane technique. This represents a significant increase of 13 percentage points compared to last year. Other approaches include using an anterior-chamber IOL (28 percent) or opting for a form of scleral fixation other than Yamane (7 percent).

“The Yamane technique stands out for its relative simplicity,” says Dr. Robert Bullington Jr. from Phoenix. Another surgeon highlights its stability and least-invasive nature. Surgeons are drawn to the predictability and stability offered by the Yamane technique.

On the other hand, some surgeons prefer using anterior-chamber IOLs due to their efficiency. These IOLs provide comparable outcomes to other methods but offer quicker recovery for patients. Surgeons like Dr. Richard Wieder from Missouri appreciate the quick and straightforward nature of using anterior-chamber IOLs. Dr. D. Alan Chandler from Mechanicsville, Virginia, states that while he prefers an iris-fixated approach, it is not always successful.

Managing Astigmatism: Surgeons’ Strategies

Surgeons also shared their approaches for managing pre-existing astigmatism in cataract patients.

Managing Astigmatism

The most popular option is using a toric IOL, chosen by 55 percent of the respondents. This approach is often combined with placing the entry wound on the steep axis (12 percent) or incorporating a toric lens with femto astigmatic keratotomy (also 12 percent). Surgeons employed various other strategies as well, as depicted in the graph above.

“Toric IOLs, when used in conjunction with intraoperative aberrometry, provide excellent astigmatism improvement,” says Dr. Wieder. These IOLs are reliable, do not weaken the cornea, and do not require changes to the incision site. Dr. Bullington also favors toric IOLs for their predictability and better postoperative outcomes. Surgeons like Dr. Marc Michelson from Birmingham, Alabama, find toric IOLs appealing due to their simplicity and lack of alteration in corneal architecture.

Embracing New Technology

Some surgeons rely on technology to enhance their cataract surgeries.

Femtosecond laser and Zepto

Femtosecond laser and Zepto

On this year’s survey, 56 percent of the surgeons reported using either the femtosecond laser or the Zepto device in their cataract surgeries. Of these, 10 percent utilized Zepto for capsulotomy creation, while the remaining surgeons used the femtosecond laser for one or more stages of the procedure. The most prevalent use of the femtosecond laser was for creating the capsulorhexis (chosen by 50 percent of surgeons), followed by nuclear fragmentation (48 percent).

Surgeons highlight the advantages of using the femtosecond laser, such as its effectiveness for fragmenting hard lenses. However, opinions on its utility for creating the main incision and paracenteses vary among surgeons. The precision, accuracy, and safety of the Zepto device were praised by those who utilized it for capsulotomies.

Looking ahead, a significant portion of the surgeons who currently do not use either the femtosecond laser or Zepto expressed their likelihood of incorporating these technologies into their future surgeries.

Intraoperative wavefront aberrometry

Intraoperative wavefront aberrometry

Nearly half (47 percent) of the surgeons reported using intraoperative wavefront aberrometry technology (ORA System, Alcon) to help determine the appropriate IOL placement. The majority considered it excellent or good, emphasizing its usefulness in determining IOL power and aligning toric IOLs. However, some surgeons cautioned that the measurements can be affected by corneal incisions during phacoemulsification, and surgical decision-making is still required.

Opinions on Medications

Surgeons also provided insight into their approaches for maintaining pupil size and managing postoperative inflammation and infection prevention.

To promote a wide pupil during surgery, the most common approach is an intracameral injection of epinephrine and lidocaine (49 percent). The use of Omidria (phenylephrine and ketorolac injection, Omeros) increased to 23 percent compared to 17 percent in the previous year’s survey. Mechanical means, such as the Malyugin ring, I-Ring, or a Kuglen hook/Beckert rotator combination, were used by 17 percent of surgeons.

Topical medications remain the preferred method for managing patients postoperatively. Fifty-four percent of respondents reported using separate topical anti-inflammatories and antibiotics. Surgeons like Dr. Jon S. Jacobson from Scottsdale, Arizona, believe that an all-topical approach is both safe and effective. A combined topical mixture of anti-inflammatories and antibiotics was chosen by 13 percent of surgeons. An intraocular injection of combined antibiotic/steroid gained popularity compared to the previous year.

Breaking Up the Nucleus – Surgeons’ Techniques

Surgeons also shared their preferred methods for breaking up the nucleus during cataract surgery.

Breaking Up the Nucleus

Quadrant division remains the most popular approach, chosen by 37 percent of surgeons, although its popularity has decreased compared to previous years. Surgeons like Dr. Ligaya Prystowsky from Nutley, New Jersey, appreciate the safety and availability of instruments associated with quadrant division. Horizontal phaco chop made a significant jump in popularity, with 17 percent of surgeons selecting it this year compared to only 5 percent in the previous year. Surgeons also employed the stop-and-chop technique (15 percent) and various other nucleo-fracture methods.

Valuable Pearls from Experienced Surgeons

Surgeons also shared some valuable pearls of wisdom from their experience:

  • Consider ECCE for extremely hard nucleus cases.
  • In cases of minimal wound leakage, using a 10-0 Vicryl suture can resolve induced cylinder without further treatment.
  • Adapt techniques to each case, as one size does not fit all.
  • Anchor your hands on the patient’s face to synchronize movement.
  • Know the AXL, ACD, CCT, and lens thickness to guide phaco settings and improve surgical safety.
  • Adequately perform nuclear hydrodissection to simplify the remaining surgery.
  • Use dispersive viscoelastic to prevent posterior capsule tears.
  • Be patient and keep it simple.

This article is purely informative and does not contain any commercial sponsorships.

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