Measure Success With Optical Biometry

Learn how this diagnostic scanning technology can improve efficiency and outcomes in your ASC.

By Sean McKinney, Contributing Editor

Optical biometry helps deliver better results with multifocal IOLs, says R. Bruce Wallace, III, MD, FACS. His practice has been an investigator site for these lenses since 1988. “With the responsibility of offering premium implants comes a higher level of patient expectations for positive refractive outcomes. These are much more easily achieved when optical biometry is used,” says Dr. Wallace, owner of Wallace Eye Associates and lead partner at Wallace Eye Surgery in Alexandria, La.

This three-step surgical plan helps him target postoperative refractive outcomes more precisely:

Step 1: Technicians conduct biometry measurements, complete necessary paperwork, schedule surgery, enter the measurements into the Holladay IOL Consultant & Surgical Outcomes Assessment 2 software, generate a surgical plan and insert the plan into the patient chart. The biometry technician records the selected lens and power and puts the chart on the desk of Robert T. Crotty, OD, clinical director at Wallace Eye Associates.

Step 2: Dr. Crotty verifies the selected lens and power and writes it on the surgical plan. He evaluates other factors relevant to the surgery, such as medication history and previous surgeries, (ie, LASIK or RK) and leaves an amended plan on Dr. Wallace's desk.

Step 3: Dr. Wallace reviews the amended surgical plan and makes any needed adjustments, such as changes in spherical power, typically required in less than 10% of cases.

“This process is a team effort,” says Dr. Wallace. “By the time the case gets to me, we rarely need to make any changes in IOL calculation. That's because of the high level of certainty with which we start when using biometry. The three-step approach is critical because it creates important checks and balances to ensure the best outcomes possible.”

Improving Efficiency

In less than 2 minutes, optical biometry simultaneously records axial length, autokeratometry readings, anterior chamber depth, central corneal thickness, lens thickness, horizontal corneal diameter and pupil diameter.

Cataract surgeons in ASCs are using optical biometry to streamline preoperative workups, achieve better target refractions for IOL implants, meet patient expectations and increase refractive cataract opportunities. The technology is also trusted to minimize mistakes that could lead to unsuccessful procedures or, worse, malpractice suits.

“In the old days, we needed to take corneal measurements one instrument at a time, leaning the patient back for emergent scans,” says Dr. Crotty. “It was necessary to anesthetize the eye and, if the eye wasn't fixated properly, we weren't able to obtain some of the data we can gather today. Acquiring accurate data typically required 30 minutes. Now, we can scan 20 or more patients in a single afternoon.”

Another advantage of optical biometry is that it can be used by technicians who need only minimal training, contrary to the high level of training required in the past. This expands staff capability and improves efficiency.

“Biometry also affects the ASC when you handle more complicated cases, such as patients who have undergone refractive surgery,” Dr. Wallace says. “In the past, we couldn't predict outcomes in challenging cases and, more often than not, we would just provide a prescription for eyeglasses to be used after surgery. Now we tell patients that we can help them to pass their driver's tests without eyeglasses.”

Some conditions — such as severely hyperopic eyes, very myopic eyes or staphyloma — can also be managed effectively to produce optimal outcomes because of accurate preoperative measurements.

“Using biometry measurements in our clinic, we hit our target correction 90% of the time,” says Dr. Crotty.

Incorporating Biometry Into Practice

Most ASCs rely on biometery in the clinic, which, for Dr. Wallace, is next door to his ASC. He says incorporating the technology into practice is straightforward. “All of these instruments now have confidence signals that tell the operators that they have obtained good measurements,” he says. Operators must also have some understanding of tear film issues, for example, so they know when to instill artificial tears to ensure an accurate scan, he adds.

As a surgeon completes more cases, the IOL powers become more precise. “Each surgeon has a different technique that may cause the constant to vary slightly,” explains Dr. Wallace.

“Higher expectations, especially as they relate to premium IOLs, must be met,” says Dr. Crotty. “These patients are paying more out of pocket to reduce the need for eyeglasses.”

Adds Dr. Wallace: “If there's a problem after these surgeries, the surgeon has to fix it, either by using LASIK, an IOL exchange or a piggyback IOL. Biometry reduces the need for these postoperative interventions.”

What Patients Don't Know

Bret L. Fisher, MD, agrees that meeting patient expectations may be the most important benefit of optical biometry.

“Patients can't tell whether they have a perfectly round, perfectly sized capsulorhexis, whether their implant is perfectly centered and in the bag, or if the extreme demands of their surgery challenged the skills of the surgeon,” says Dr. Fisher, medical director, of the Eye Center of North Florida and Panama City, Fla. “Everything about the surgery may be technically perfect and above reproach, but if the lens implant power is off because of inaccurate biometry, patients perceive their results as suboptimal.”

With accurate axial length calculations for all lenses, the operating surgeon enhances his odds of achieving the targeted outcome in terms of spherical equivalent, Dr. Fisher says.

“Now, with the ability to obtain consistent and reliable validated keratometry measurements, hitting the refractive goal for our advanced-technology IOL patients is further enhanced,” he says. “Knowing the magnitude and axis of corneal cylinder with greater confidence allows the operating surgeon to reduce or eliminate postoperative astigmatism in the cataract surgery patient.”

The steadily increasing use of toric and multifocal lens implants also speaks to how important accurate biometry is to achieving success in the ASC. “The goals of refractive-cataract surgery, using these advanced technology IOLs, can't consistently be met without the ability to obtain good data from which to calculate implant power and perform surgical planning,” says Dr. Fisher. “Residual errors in spherical power or refractive astigmatism after otherwise successful surgery can lead to decreased patient satisfaction and may ultimately have a negative impact on the surgeon's clinical practice and the success of the ASC.”

Long Distance Patients

Patients who must travel a long distance to undergo surgery also benefit from biometry on the same day as surgery. “These patients may have already been seen by an optometrist or ophthalmologist at an outlying office, but they need to see their surgeon and have measurements taken. Same-day scans save them the expense and inconvenience of making long, repeated trips to an ASC,” says Dr. Fisher.

Accommodating same-day patients can be a great practice builder. “Although these scans can disrupt your normal operative routines initially, with time and experience, you can incorporate these patients into the flow of your surgical day with few challenges,” comments Dr. Fisher. “Similarly, patients returning for their second eye surgery, whether from local areas or from out of town, can often undergo refractions and repeat measurements on the day of their surgeries.” This saves patients from missing additional time from work or needing to plan for additional travel.

Biometry in the ASC

Rich Tipperman, MD, in practice at Main Line Surgery Center, Bala Cynwyd, Pa., says biometry within the ASC setting can result in better care. “Some surgeons who don't have this instrument in their practices can come to the ASC and use it to achieve better measurements,” he says. “You may also be asked to perform surgery on a patient who is sent from an office that doesn't have biometry. Offering optical biometry is a value-added service, although you must make sure to charge for the service. It wouldn't be ethical to recruit surgeons based on the availability of your optical biometry.”

On the day of surgery, a previously scanned patient who has been mulling over IOL options may change his mind about the type he wants implanted, requiring a same-day biometric scan at the ASC.

“The patient may want more near or distance vision after giving the outcome some thought,” says Dr. Tipperman. “Or a multifocal may be desired.”

It's important that the surgeon communicate realistic expectations.

“There's still no way to guarantee a perfect implant,” says Dr. Tipperman. “Biometry no doubt makes for happy patients, which leads to practice growth and more efficiency. It allows you to take care of patients easier, faster and simpler. With even with the best measurements, though, you don't always get the lens implant perfect every time.”

Dr. Tipperman says patients need to be made aware that less-than perfect outcomes are “fixable problems” that may involve a lens exchange, contact lenses, spectacles or refractive surgery. “Anytime you have to go back and fix a problem, it's not efficient for the patient, the surgeon or the ASC,” he points out. “But sometimes, that's a reality.”

Avoiding Errors

“I know of a case in which the surgeon sent a fax to a surgicenter, indicating that he wanted a +19.00D IOL implanted in the patient,” says Dr. Tipperman. “A smudge on the fax machine cartridge made the +19.00 look like an +18.00, resulting in the implantation of the wrong lens.”

He says the availability of digital data from biometry helps avoid situations like this. “It also is easier, more convenient and efficient to use digital records,” he says.

The doctors in his practice share an electronic medical record (EMR) system. However, a uniform EMR system isn't needed for a biometer to be used by multiple offices. “Different offices use different EMR systems that don't talk to each other. A surgeon can always open his laptop, at the ASC or at some other location, and access digital biometry records stored at his office. The lack of a consistent EMR doesn't prevent you from benefitting from the use of digital data from biometry at multiple sites,” says Dr. Tipperman.

How You're Perceived

“Years ago, I was told by a residency program director that patients judge how good a cataract surgeon you are based on the prescription strength of the spectacles they need after surgery,” says Dr. Tipperman. “I think we've found this to be true. How a patient sees after surgery is a direct reflection on the surgeon and the surgery and an indirect reflection on the quality of care provided at the ASC. Biometry can go a long way toward helping us maintain a positive reputation.” ◊