Informative Tools for Cataract Treatment
Technologies that provide fast and accurate data guide key treatment decisions.
BY FAISAL HAQ, MD
One of the most important aspects of professional growth for ophthalmologists involves the adaptation of technology. Cataract surgery in particular has been completely revolutionized over the past two decades due to numerous technological advances. New surgical techniques, better IOLs and increasingly sophisticated diagnostic equipment have all contributed to the cataract surgery revolution. With the advent of the baby-boomer era, the demand for our services and the demands of our patients for precision will only increase. We all face the challenge to provide top-notch eye care while retaining efficient processes. Once again, technology has come to the rescue.
I work in a practice with multiple office locations where we see several hundred patients a day. The technologies that we’ve invested in have enabled us to not only provide ever-improving patient outcomes, but have also been instrumental in optimizing our efficiency and improving our patient flow. The EPIC refraction system (Marco) has been a key addition to our practice that has helped us achieve this improved quality of care while simultaneously improving our efficiency. We purchased our first EPIC system 8 months ago and were so impressed with it that we added a second unit 3 months later. The system, comprised of the TRS digital refractor and the integrated OPD-Scan III (Marco) component, gives us a reliable, fast refraction as well as a detailed corneal analysis that aids us in multiple ways in the pre- and post-operative management of cataract patients.
Refraction and Pre-Op Exam
The EPIC system allows our technicians to obtain an accurate refraction in 2 to 3 minutes. The OPD takes about 30 seconds for autorefraction, keratometry, pupillometry, corneal topography and wavefront aberrometry. Additionally, if the patient has a glare complaint, we can perform a quick glare test with the EPIC system that takes another 30 seconds.
With the data obtained by the EPIC system, we can quickly access information that is useful in determining a patient’s need and eligibility for cataract surgery or for a YAG capsulotomy. In addition, the OPD device provides me with a wealth of information that I can use to determine a patient’s eligibility for a specific type of IOL. For example, if the corneal aberration profile shows significant higher-order aberrations, I won’t recommend a multifocal lens. Also, if the OPD shows a high angle kappa, I will be less likely to implant a multifocal lens due to difficulty centering the lens over the visual axis. The OPD also allows me to separate the aberration profile of the cornea from the lens. It’s helpful to show patients the degree of their aberration coming from their cataract versus that originating in other parts of their eyes.
Some patients require “fine tuning” post operatively with laser refractive surgery to achieve the desired refractive outcome. With the OPD axial corneal topography, I can determine patients’ eligibility for laser vision correction. If they’re not good candidates, I can have a candid discussion with them regarding their potential final outcomes.
Glare Testing
Consistent, reliable and reproducible data derived from the glare testing feature on the EPIC unit aids in determining a patient’s eligibility for either cataract surgery or YAG laser capsulotomy. Previously, we used the Brightness Acuity Tester (BAT, Marco) to measure the degree of glare related impairment in our patients. We found that there was significant technician- and patient-related variability with this test. With the EPIC glare test, the patient and the doctor can both quickly ascertain how much impairment a patient faces when exposed to glare in real-life situations. We’re in a better position to determine the level of impairment that the patient faces due to glare, and this allows us to make better clinical decisions regarding the need for cataract surgery or for YAG capsulotomy.
| An OPD-Scan III Q&A |
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| By Mitchell A. Jackson, MD, Medical Director of Jacksoneye in Chicago and Lake Villa, Ill. Q Does the OPD-Scan III help you choose the right IOL? “I often speak on the three ‘hidden threats’ to patients’ satisfaction with their IOLs: pupil size, spherical aberration, and angle kappa. The OPD III measures photopic and mesopic pupil size, wavefront data to 9.5 mm, and angle kappa in easy-to-interpret mm or degrees, all in a single, fast sitting 20 second bilateral diagnostic evaluation. With this data I will know if I should insert a multifocal lens based on angle kappa data as I presented at the recent ESCRS meeting in Milan, Italy. I can select a lens implant based on spherical aberration data as well. I have all the data I need to choose the most appropriate IOL implant based on OPD III data, which relates directly to satisfied patients after surgery.” Q Do you use the OPD to educate patients? “One great way to use the OPD III is to show a patient a map of the astigmatism created by both the lens and the cornea, and then easily demonstrate in the exam room what corneal astigmatism will remain by removing the lenticular portion during cataract surgery. The OPD III graphic in this setting saves a lot of chair time especially when trying to upgrade a patient to a toric IOL implant. I basically tell the patient, ‘After we remove your cataract lens, we need to correct this remaining corneal astigmatism. We could do it with glasses or a toric lens implant.’ Q Using one multipurpose device is efficient. Is there a clinical advantage? “In addition to pupil size, spherical aberration, and angle kappa, the OPD III performs blue light corneal topography and measures lenticular astigmatism, and it only takes 20 seconds for both eyes. That helps patient flow, but it also means we get greater accuracy. With older (especially less mobile) and/or dry eye patients, using multiple devices can dessicate the ocular surface and eventually compromise the accuracy of later diagnostic tests. In contrast, most patients are fine with keeping each eye open for 10 seconds with the OPD III.” |
Post-operative Assessment
I perform an OPD and EPIC refraction on all of my patients that have a presbyopia-correcting lens or a toric IOL. Beyond the obvious refraction and topography data, the OPD provides an aberration profile that separates the cornea from the lens. That way, if a multifocal IOL patient is having difficulty with his vision, I can quickly determine if there are any significant aberrations present in the IOL itself (for example if there is subtle lens tilt or decentration) or if the problem is purely refractive in nature. This information helps me decide between an IOL exchange or laser refractive surgery.
Similarly, for a Crystalens (Bausch + Lomb) patient, if there’s significant astigmatism that is lenticular in nature, I very carefully look for any asymmetric vaulting that may need to be corrected prior to any consideration of laser refractive surgery. For patients with a toric IOL, I can quickly assess the level of their corneal astigmatism and compare this to the level of lenticular astigmatism. In an ideal case, the two numbers should be similar in magnitude and exactly 90° away from one another.
A Wise Investment
The EPIC system provides our practice with a diagnostic tool that helps not only to improve our clinical outcomes, but also improves our patient flow and overall efficiency. It’s an investment that we feel easily pays for itself. Patient wait times have been reduced, we’re seeing more patients than before and we’re performing more surgery than we did in the past. Also, a larger percentage of our patients are choosing presbyopia-correcting lens implants because we’re able to actually show them the results of their OPD scans and talk to them about customized lens choices based on their unique eyes. The dual clinical and financial benefits of this technology have made it an integral part of the pre-operative and post-operative management of our cataract patients.
Faisal Haq, MD, specializes in cataract, vision correction surgery, corneal disease and glaucoma management at Key-Whitman Eye Center in Dallas and Plano, Texas.
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