M.D. Toolkit

The Tools I Can't Live Without

Here, I compile a list of some of my favorite items in the OR.

By Alan B. Aker, M.D.

As part of the industry that supports our work, Ophthalmology Management is dedicated to providing timely informative articles that help us achieve efficiency and excellence in the operating room as well as the clinical and business side of our practices. Having been privileged to serve as chief medical editor during its first 5 years, I continue to be impressed with the quality and content of the material provided each month by Ophthalmology Management.

I was recently asked to provide an article describing the favorite things (techniques or instruments) I bring into surgery. After a moment, I found myself unable to supply just one thing, but rather, a list of several. Thus, this new monthly column, titled M.D. Toolkit, was born. Each installment will feature a different surgeon and his or her favorite products or techniques for cataract and refractive surgery. The surgeon will explain what makes it special — how it adds to efficiency, improves the quality of surgery, improves patient satisfaction or how it enhances the bottom line.

My List of Favorites

► The Beehler Pupil Dilator (Rumex International, St. Petersburg, Fla.)
► trypan blue
► The SofPort IOL insertion system (Bausch & Lomb [B&L], Rochester, N.Y.)
► Millennium Phaco Units (B&L)
► Phacoflip
► My new and improved IOLMaster (Carl Zeiss Meditec, Dublin, Calif.)
► The crystalens IOL (eyeonics, Aliso Viejo, Calif.)

For those of us who remember the early days of modern cataract surgery, there are a number of advances that just leap off the page in terms of significance. A partial list of these would include Kelman phacoemulsification, IOLs, viscoelastics, continuous curvilinear capsulorrhexis, clear corneal incision and sutureless cataract surgery.

Fortunately for all of us and also for our patients, these advances have undergone many refinements. Built into the pursuit of excellence in ophthalmic surgery is a wonderful ongoing, continuous quality improvement system. This process is impacted both through ongoing contributions we make as surgeons as well as those dedicated companies in the ophthalmic industry that support our endeavors.

Dilator and Dye

A great case is built upon a series of great basic steps, one of which is a round, appropriately sized capsulorrhexis. This is a challenge in patients with small or scarred-down, irregular pupils. An easy "fix" in these patients can be achieved with the Beehler Pupil Dilator.

It is important to rotate the instrument 90° when inserting and removing it from the anterior chamber. To maximize the effectiveness of the Beehler stretch, keep the instrument completely extended for a count of 30 before retracting the finger-like dilators and removing it from the eye. I then typically use Viscoat (Alcon, Fort Worth, Texas) to maintain the dilation during the capsulorrhexis, which is now easy to perform. What I love about this instrument is that it is easy to use and virtually always gives me a 6-mm pupil. In addition, the postop appearance of the pupil is virtually always round and not excessively dilated.

Another setting in which a good capsulorrhexis is challenging is in patients with a poor red reflex such as hypermature lenses, very dense nuclear or dense PSC cataracts. In these cases, trypan blue is like a bridge over troubled water. It enables excellent visualization of the rhexis. Here, the caveat is that in hypermature cases we are often still dealing with a tense capsule, so great care must be taken to keep the rhexis from suddenly extending outward to the equator. Use of proper viscoelastics help minimize this concern.

Technique, Technique, Technique

Fifteen years ago I had the privilege of observing David C. Brown, M.D., perform phaco flip. With his patient help, I was able to master the basic skills, which now enable me to protect the cornea, the posterior capsule and my coronaries. Phaco flip is certainly one of the most efficient ways to perform Kelman phacoemulsification. This technique requires a high-vacuum phaco system that provides great followability. I have used many phaco systems, but at the present time, the Millennium is clearly my favorite. My OR would lose significant efficiency and safety without phaco flip. The Millennium is what enables this superb technique to reach new levels of efficiency.

B&L Millennium phaco unit.

CZM IOLMaster.

The most controlled insertion of foldable IOLs can be achieved with the B&L SofPort IOL Insertion system. This allows for controlled placement of virtually any foldable IOL into the sulcus or the capsular bag. The slow delivery of the IOL reduces the likelihood of vitreous loss when the posterior capsule has been inadvertently opened. In addition, "off-label" use of this inserter allows me to safely and easily implant the presbyopia-correcting (PC) crystalens Five-0 premium IOL.

Because of premium PC IOLs and their associated cost to our patients, the bar is now raised to new heights for refractive-cataract surgeons. It is absolutely essential to target and hit emmetropia. The IOLMaster is the quickest and easiest method for both patients (including the elderly and handicapped) and our staff to determine IOL powers accurately prior to surgery. Its new software gives the ability to more accurately predict for post-LASIK patients. Best of all, results do not vary from technician to technician. It allows the surgeon to enter the OR with a greater sense of security regarding selected IOL powers.

Accommodating IOL

The crystalens AT-50 is certainly at the top of my list of favorite things I take into the OR. For years, the quest has been on for a true presbyopia-correcting IOL. When the crystalens gained FDA approval in 2003, I immediately began offering the crystalens Model AT-45 to our patients. I soon switched to the crystalens Model AT-45SE and then began implanting the ReZoom and ReSTOR multifocals when they became available.

Although our experience with the multifocals was initially encouraging, as our numbers grew, we became concerned about the number of patients bothered by halos and glare. Because of this and other concerns we have with the multifocal IOLs, I switched to eyeonics' improved accommodating IOL, the crystalens Model AT-50 early this year.

eyeonics crystalens.

One thing that truly makes me love the crystalens is the fact that because of our excellent outcomes, without any of the complaints we were experiencing with the multifocal IOLs, the premium IOL side of our practice is growing dramatically!

In closing, I have implanted the crystalens in many physicians, including ophthalmologists who have specifically requested this lens. I have recently done family members including my sister. She is 6 months postop and reads J1 and is 20/20 in each eye without correction. Best of all … no complaints! OM