With the Right Tools, Every Procedure is Premium
Cataract and refractive technologies designed to work in tandem so you can provide the vision solutions today’s patients demand.
Y. Ralph Chu, MD, moderator: The cataract surgery market has evolved over the past several years in that, more and more, patients are looking for premium vision outcomes, i.e., the ability to see better without glasses after cataract surgery. As surgeons who are in tune with this evolution, we’re aware that delivering these desired premium outcomes involves not just one technology but a portfolio of technologies. Many of us have built technology infrastructures in our practices using products and services provided by Bausch + Lomb. We utilize the company’s advanced intraocular lens technologies, such as the Crystalens® AO IOL and the Trulign® Toric IOL, to address presbyopia, astigmatism and range of vision, as well as the monofocal intraocular lenses with unique properties, such as the enVista® IOL. Our success with these IOLs is enhanced by the Bausch + Lomb femtosecond laser and phaco technology foundations that are the Victus® Femtosecond Laser Platform and Stellaris® PC Vision Enhancement System. And of course, the Storz® Ophthalmics procedure sets and handheld instruments complete what serves as a seamlessly integrated and versatile package of products that enable quality surgical results, which in turn fuel the long-term success of a practice.
Let’s start our conversation about premium vision outcomes for patients by discussing how their growing interest in this has manifested in your practices and the markets where you’re located.
Farrell C. Tyson, II, MD: We were early adopters of the premium vision concept in our area, and our patients were very motivated from the start and have become very well educated. We had been happy with an 8-10% conversion to premium services rate, but now 60-70% of our patients are opting for premium cataract surgery of some form. With that of course is the expectation of a premium outcome, and I agree that we need the whole premium surgery portfolio to achieve those outcomes.
Anil Shivaram, MD: Our large retirement community makes our area unique compared to some other areas. It’s a conservative retirement community; therefore, adoption of new technology was something I thought patients would be reticent to take on. However, our conversion rate is excellent at 60-65%. It’s a testament to the fact that people are learning about these things and want and expect excellent quality of vision.
What Does “Premium Quality Vision” Mean to You?
Dr. Chu: What do the phrases “outcomes that stand the test of time,” “long-term outcomes” and “premium quality vision” mean to you?
Dr. Tyson: When patients pay extra for premium cataract surgery, they assume it’s going to last a lifetime, not degrade in 5 or 10 years. I don’t want to use products that have a high chance of causing problems for them down the road. The concept of outcomes that stand the test of time is precisely why my father, who’s an ophthalmologist, chose the Crystalens® AO IOL for both of his eyes. He wanted a lens technology that was going to be great on Day 1 and stay that way 10 and 20 years into the future.
Dr. Shivaram: The reality is that we’re performing cataract surgery on patients at younger and younger ages and performing more refractive lens exchanges. We strive for 20/happy patients, so it behooves us to use IOLs that can create that satisfaction over the long term. We should also take into account that patients may develop retinal or corneal pathology at some point in their lives, so it makes sense to recommend a lens that does no harm.
Dr. Pepose: I certainly don’t want to be surprised by a lens I implanted developing glistenings a year or two later. If I implant a toric IOL, I don’t want to find that it has rotated a month after surgery. While I can’t promise patients they’re not going to age or develop age-related diseases, I’d like to assure them that what I’ve done won’t make any future conditions worse, for example, a loss of contrast sensitivity comes to mind.
Dr. Chu: Baush + Lomb offers a spectrum of technologies that enable us to successfully treat young patients, the Millennials, who want to get out of their glasses for distance vision, and treat them again as they age and want to have cataract surgery but maintain the same quality of vision they had when they were 20 years old.
Dr. Shultz: I agree. Nowadays, the buzzword is dysfunctional lens syndrome. Our Baby Boomer patients want to see well. Visual acuity of 20/25 after cataract surgery isn’t acceptable to many patients, and with the B+L portfolio of technologies, I feel comfortable that I can treat them and keep them happy. In my opinion, for the younger cataract patients, the Crystalens AO IOL and Trulign Toric IOL are the best choices for providing long-term visual stability and quality. They reduce the risk of glare and halos and allow them to be functional at all times of day and under different light conditions.1,2 These are important considerations for today’s cataract surgery patients because they’re active, they’re driving at night, they’re regularly performing tasks that require excellent distance, intermediate and near vision. We can’t necessarily produce that with other IOL platforms.
We can also rely on the family of B+L products in other areas of refractive surgery, and the company is expanding in that regard.
Jay Pepose, MD, PhD: The greatest growth is being seen in the Baby Boom population, and they have totally different expectations. They don’t have a retirement mentality and they don’t want to wear glasses. They want to really decrease their dependence on visual aids. They’re always using handheld devices and computers and they do a great deal of night driving. These characteristics make them a completely different population than we had before. Many of them come in asking for LASIK. Even though they have a cataract and may be 60 years old, they view themselves as being 30 years old.
Dr. Chu: What excites me about ophthalmology in general is the bimodal nature of the patient population. We have the Baby Boomers who are looking at cataract surgery and advanced technologies to help them see better without reading glasses after cataract surgery, and we have the Millennials who are coming through looking at laser vision correction, which is driving a resurgence of LASIK patients in my practice.
Elements of Technology Suite Work in Synergy
Dr. Chu: Given the uptick in the number of LASIK procedures we’re performing in our practice, we were excited that the Victus® Femtosecond Laser is designed to be used in both LASIK and cataract surgery. We’re able to use one platform, and pay one maintenance fee rather than two, to handle both segments of the population.
How is it synergistic for you to work with Bausch + Lomb products to deliver premium vision for your patients?
Dr. Shivaram: One of the first B+L products I used was the CapsuleGuard® I/A handpiece. The company provided great support, and from there I began to realize how all of their technologies work well together. The Stellaris® phaco and Victus femtosecond platforms tie the pieces together. It’s nice to see that synergy and be a part of creating synergy for my patients.
Dr. Pepose: Our practice and ASC are in the same building, so as the number of doctors increased, particularly once we brought in retina, it was crucial to have a single unit that would function both for phaco and posterior segment work. The Stellaris PC serves that role well for us, and it was a smooth transition. Some of our surgeons had concerns about the Stellaris PC because they were accustomed only to peristaltic systems, but they’ve found that the dual-linear control and chamber control make it a delight to use. (See “A Venturi-Based Hybrid Approach to Phaco Fluidics” on page 9)
Dr. Tyson: We, too, brought in the Stellaris PC when we added retina surgery to the practice. We liked the cost-effectiveness of having one machine that could perform multiple procedures, but we didn’t want to skimp on quality. I use the Stellaris for cataract surgery, and it’s excellent. I’m able to use the fluidics to my advantage by putting very little ultrasound energy into the eye.
With the premium IOLs, patients expect LASIK-like outcomes the next day, and I want to have a wow factor built into that next day so we can schedule the cataract surgery for the fellow eye with no delay. With B+L’s excellent family of lenses, Stellaris as a great phaco platform, and good viscoelastics, I have that wow factor.
Mitchell C. Shultz, MD: For surgery centers that encompass both cataract and retina, the Stellaris PC combination platform is a great choice. For cataract cases, it functions exactly like the traditional Stellaris unit, and the cost of the packs is the same as with the traditional unit.
Dr. Chu: Dr. Shivaram, tell us about your experience with CapsuleGuard and how it helps your outcomes with your premium patients.
Dr. Shivaram: CapsuleGuard is a single-use silicone I/A handpiece that has the option of 45-degree angulation. It goes very easily through the wound for coaxial phaco. I find that it allows a good seal, not a lot of egress around the incision site. I use it on every case, and I use it to aggressively polish the capsule. There’s a small semi-rough area on the back surface of the CapsuleGuard that works very well for cleaning the posterior capsule, and I’ve found it to be extremely effective. I find that this handpiece also makes my cases much smoother in terms of cortical cleanup. I don’t feel any sort of trepidation going out into the periphery.
Victus Femtosecond Laser Platform Does Double Duty
Dr. Chu: Have you used the Victus Femtosecond Laser Platform?
Dr. Shivaram: We’ve had the Victus® laser since last year. We shopped around for quite a while because we wanted a laser we could use in cataract surgeries as well as corneal surgeries and the only laser that was really equipped to do that well was the Victus laser. We have the laser placed in the OR, which is very efficient. The patient is brought into the OR, we perform the femtosecond laser portion of the surgery, swing the patient out on the 45-degree bed, and complete the case right there. It’s different than the model of feeding cases into the OR from a separate room containing the laser, but it works well for us.
From a practice economics perspective, the femtosecond laser isn’t something we have to aggressively sell to patients. If they’re not already under the impression that a laser will be part of their surgery, which some are, they understand it when we explain. Then, the gift of the great postoperative Day 1 outcome gives them a great experience to share with friends and family.
Dr. Shultz: We definitely took our time evaluating the different femtosecond laser platforms. What stood out about the Victus laser was the dual cornea and cataract capability and, especially with the 3.2 version software, the ease of use in procedure planning and intraoperatively, and the reproducibility.
In our practice, interestingly, we had been focused on patients wanting premium IOLs and we didn’t realize that a big segment of the market was looking for something different. Now that we see that, approximately 50% of the cases in which we use the Victus laser are non-toric, non-multifocal and non-accommodative. They’re what I call my premium monofocal cases.
Portfolio of IOLs is Future-friendly for Ocular Health and Vision
Dr. Chu: What are your thoughts on the Bausch + Lomb family of IOLs? Why do you use them as part of your premium surgery options?
Dr. Pepose: All of the IOLs are built on the Bausch + Lomb advanced optics platform — the enVista® IOL, the Crystalens AO IOL and the Trulign® Toric IOL — are very forgiving in several ways. For example, patients who choose a premium lens don’t necessarily have premium corneas. They often have some asymmetry and may have dry eye, which can prevent us from achieving emmetropia 100% of the time. But these lenses are very forgiving in terms of both decentration or not hitting emmetropia because they don’t add to or subtract from the aberrations already present in the eye.3 Even if we’re off target by 0.25D or not exactly centered, particularly with respect to the visual axis, the quality of vision isn’t degraded. Furthermore, the eye is left with a bit of spherical aberration that may actually increase the depth of focus.4 These are easy go-to lenses.
In addition, it’s hard to know which patients may develop a condition later in life — such as epiretinal membrane, glaucoma or diabetic retinopathy — that could decrease contrast sensitivity. If these conditions occur in an eye where we’ve placed a multifocal IOL that’s further decreasing contrast sensitivity, we haven’t done the patient any favors. These are important considerations when choosing which type of premium IOL to use for each patient, and all of the Bausch + Lomb lenses have advantages along these lines.
Dr. Chu: What about your experience with the Crystalens AO in particular?
Dr. Tyson: I was primarily a multifocal IOL user at first, but I found I was able to use that option effectively in only a small subset of my patients. I was amazed at how the Crystalens AO opened the door to many more premium lens procedures because I wasn’t limited by corneal pathology, retinal pathology or previous refractive surgery. What I really like about the Crystalens AO is how it provides a high-definition, extended depth of focus with no harm, no foul.4 The worst case scenario is that it functions as a single-focus lens, but most of my patients experience favorable depth of focus.
Dr. Chu: Is it crucial to have access to an excimer laser for enhancements if you’re using multifocal IOLs or the Crystalens AO?
Dr. Tyson: I find the need to be relatively rare. With astute patient selection, I’m usually not off target by more than a little sphere or cylinder, which I can address.
Dr. Shivaram: I think it’s important to have access to an excimer laser because forging that bridge through to the end where patients have an acceptable outcome is a very important part of their whole experience and the connection with them we’re trying to create.
Dr. Pepose: I tell all of my premium surgery patients up front that it may take three steps to get their vision to where we want it to be. That’s important because if they’re not aware that three steps may be necessary, they see it as a complication. I use a tailor analogy. Most suits and dresses aren’t originally made for a particular person, just as IOLs aren’t customized to every possible correction power. So in both cases, we start with something “off the rack.” Also, because of variability in wound healing, we can’t predict in every patient where the lens is going to wind up in the eye. Therefore, we may need to go to the tailor, i.e., either the YAG laser and/or the excimer laser, for fine-tuning. So I do think we need to have an excimer laser or some type of arrangement that provides access to one.
Dr. Chu: Let’s talk about one of Bausch + Lomb’s newest monofocal lenses, the enVista IOL. What I love about the enVista IOL is that it has the same advanced optic as the Crystalens AO and the Trulign Toric IOLs. It’s an advantage to also have a monofocal lens with that same premium optic and the benefits associated with it. What do you like about the enVista IOL?
Dr. Pepose: In addition to the zero-aberration optic, the fact that the material is designed to be glistening-free is important. Other lenses are prone to glistenings, which can affect the quality of vision.5
Dr. Shivaram: The enVista IOL is my monofocal lens of choice. I experienced great results as soon as I began using it and I’ve seen the excellent depth of field it can provide time and time again.4 The lens is also more resistant to scratches, which is key as a technician is folding it.6
In addition, I like the bridge-like design feature that’s part of the optic-haptic junction. I use that to manipulate the lens while I’m removing viscoelastic. There are nice little visco channels as part of that. The design has to do with distributing the vector forces that can occur with capsular contraction.
Dr. Pepose: Yes, if the capsular bag does start to contract, the compressive forces are distributed so the lens won’t shift. If the bag does start to aggressively scar down, that lens is going to stay centered. My favorite thing about the lens is the way the eyes look the next day. From what I see in my practice, eyes are quiet and crystal clear. Because the enVista® IOL is so inert, it’s my lens of choice for patients who’ve had iritis or any type of uveitic problem in the past.
Dr. Chu: Any concern or experience with aberrations or dysphotopsias?
Dr. Shivaram: I haven’t seen any.
Dr. Shultz: I was surprised to find, completely by chance, that my enVista IOL patients have excellent depth of field.4 Now I almost always incorporate a mini-monovision at -0.50D so patients aren’t losing depth of field or having any problems with night vision, but they’re getting somewhat enhanced near vision.
I find it very easy to remove the viscoelastic when using the enVista IOL while the lens is only partly open, rather than completely open and sticking to the posterior capsule, which I’ve seen with some other lenses. The enVista IOL is definitely my monofocal lens of choice. ■
A Venturi-based Hybrid Approach to Phaco Fluidics
Dr. Chu: Many surgeons in practice today were trained on peristaltic phacoemulsification systems and may be reluctant to consider using the Stellaris or Stellaris PC Vision Enhancement System because, while these platforms have dual linear control, their fluidics are based on more of a Venturi-type system. Can you explain the dual linear control?
Dr. Pepose: Dual linear control allows you to isolate phaco power and vacuum, and program them in different ways depending on your preferences.7 In other words, you can use the fluidics to achieve good followability and minimize the need for high phaco power, and once you have a good purchase on the lens fragment, you can lower the vacuum so you don’t have to worry about tearing the capsule. It provides a greater degree of control. With a peristaltic system, I feel I’m always reaching out to engage lens fragments, often unable to see the edge of the phaco tip. With the Venturi-like Stellaris system, the fragments come right to me, I have great visualization and can stay in the safest part of the eye — dead center.
Dr. Tyson: With today’s Bausch + Lomb micro-processing pump technology, the surgeon is able to sense what’s going on in the eye and adjust rapidly, which helps to eliminate post-occlusion surge and allows use of the Venturi fluidics to aid us.7 We can bring lens pieces to our instrument tip rather than going out and getting them and use more fluidics and less ultrasound energy to disassemble them.
Dr. Shultz: I really like the Venturi fluidics and the fact that I don’t have to go chasing after anything. The technology has cut down on the incidence of post-occlusion surges I see with peristaltic pumps. They just don’t happen. And as far as efficiency, the tip is really as efficient as anything else I’ve used. I have access to all of the phaco technologies at my center and I choose Stellaris or Stellaris PC Vision Enhancement System over all of them. Everything is just so smooth in these cases with the new Venturi. There’s just absolutely no movement of the iris whatsoever.
Dr. Chu: I’ve noticed that the little strands of cortex that are difficult to grab when I’m using a peristaltic machine (because I need full occlusion to gain full vacuum) are much easier to clean up with Venturi.
Dr. Shivaram: Absolutely. One of the centers where I operate has a peristaltic machine. As I hear it slowly generating that vacuum, I can’t help but picture a little hamster in there churning on a wheel to ramp up vacuum. It’s so distinctly different from the instant vacuum achievable with the Stellaris or Stellaris PC Vision Enhancement System that does not rely entirely on occlusion. The pieces come to my tip instead of having to chase after them. When you couple that vacuum control with the dual linear capability of the foot pedal, you have the unique ability to titrate the dynamics of your fluidics with the variations we all see from case to case.7
Dr. Pepose: I think all of us hate to discover at Day 1 or Week 1 after surgery that a lens fragment was hidden behind the iris. I think we’re much less likely to have a small fragment with the Venturi system because of the solid purchase on each lens fragment. ■
The Stellaris® PC Vision Enhancement System enables high-performance, anterior, posterior, and combination procedures, complemented by innovative handpiece options and multifunction laser probes.
Premium Practice Mindset
Choosing and implementing technologies with foresight and an eye toward the ultimate goal.
Dr. Chu: Device manufacturers are responding to the growing demand for premium vision outcomes, including a resurgence of interest in LASIK that many of us have seen in our practices, with an array of products and services. As surgeons, we’re intrigued by every new development, but we know we have to choose and incorporate technologies carefully to maintain a healthy practice from a financial standpoint. The most important factor is how a new product or service will benefit patients. When I evaluate new technologies, I look for the potential for improvement in outcomes beyond what I can already provide. The improvement can be in one or multiple aspects of the effectiveness of the procedure or the patient’s overall experience, including enhanced accuracy and predictability, faster vision recovery, less pain and/or a more favorable safety profile.
The Victus® Femtosecond Laser Platform is an example of a technology that met our practice’s standards for adoption because it raises the level of care we can provide. Importantly, patients have been very comfortable with the idea of a laser assisting the surgeon in cataract surgery.
How do you decide which new technologies and services to incorporate into your practice?
Dr. Pepose: Once in a while, there’s a paradigm shift — advances such as the first corneal inlay or the first wavefront aberrometer — which makes the decision of whether to adopt fairly easy. In most instances, however, we’re considering changes that are more incremental. So the first question I ask is whether using the technology would result in a clinically meaningful change for patients. Beyond that, I want to know whether it would be cost effective, i.e., a good value for patients, and practical for me to provide. For example, would it add to my procedure time, make the practice or ASC more or less efficient, require more technician resources?
We recently went through this decision-making process before adding the Trulign® Toric IOL to the options we offer. All of the aspects evaluated — rotational stability of the lens, uncorrected and corrected distance and intermediate vision results compared with other torics, safety issues such as incidence of dysphotopsia, and ease of use for me — pointed to the lens being a good value for me and my patients. Trulign® Toric allows me to offset patients’ preexisting corneal astigmatism while also providing much better intermediate vision than other toric lenses can deliver.8
Dr. Shivaram: Most ophthalmologists, including myself, like to push the outcomes envelope to meet increasingly higher patient expectations. Fortunately, we’re practicing in a time in which many new technologies have come onto the market, and they allow us to provide patients with the premium experiences and outcomes they want. We’ve seen how technologies have moved us in this direction. With cataract surgery, there was a time when fewer than 50% of patients would achieve vision within a half diopter of the target. In my practice, with tools such as the femtosecond laser and innovative IOLs, we’ve moved that percentage into the 90% range.
Which technologies I decide to adopt often depends on the need I’m aiming to address, and that feeds off patient expectations. For example, an increased need for astigmatism management would lead me to take a closer look at my outcomes in that regard and consider whether a better technology could help to elevate them. For me, continuing to push the outcomes envelope also involves discussing with colleagues what they’re doing in their practices as well as personally evaluating the options. A big part of what I do is drilling down into the differences between the products each company is offering in a particular category.
Dr. Chu: How do you successfully integrate new technologies into your practice?
Dr. Pepose: First the surgeon has to believe in the technology. Then he or she needs to convey to the whole staff the reasons why it’s being implemented. We communicate the rationale in a variety of ways, including having our own educational meetings and using the training modules or certifications provided by the device manufacturers. It’s been our goal to create a practice culture based on the fact that locking into certain ways of doing things and not embracing change is not a recipe for success. As part of that mindset, our staff members know that we don’t implement new technologies unless we feel they are developed enough that we can demonstrate a noticeable clinical benefit or an increase in safety or efficiency.
Dr. Shivaram: The team approach is key. With any new technology, we have team meetings to educate the staff. I show videos of how the new addition is used in surgery or in pre-op and explain how outcomes would be different without it. We can’t expect people to adopt changes without understanding why. When they’re kept in the know, it makes them better at their jobs and breeds a sense of curiosity and interest in what we’re doing.
We also use team meetings to work out the roles each of us will play in educating patients about a new technology. For us, that process involves everyone who interacts with patients. By the time patients meet with me for final decision-making, they have already had exposure to information specific to their case and the options that apply.
Members of the team also need to know when to use certain diagnostic technologies and how to work that into the patient’s education. For example, if a technician is working with a patient who has a certain amount of astigmatism, the technician knows to perform topography and provide a general explanation of the reason and the results to the patient. When it’s time for my conversation with patients, they’ve received literature, perhaps watched a video and spent that time with a knowledgeable technician. Therefore, I’m not dumping a bunch of information on them at once. In addition, both the staff and I try to give patients the feeling that we’re open to their questions. When I feel it would be helpful for a patient, I provide my cell phone number so he can call me with questions.
Dr. Tyson: To ensure that our staff buys into a new technology, we incorporate them into the selection process as well as planning the implementation. This can be done through committee or individual research that helps to narrow down the field of options from which the surgeon/practice owner will ultimately choose. After all, in many cases of new technology, it is the staff that will be affected by a change, so they should have a voice in the process.
VICTUS® is the industry-leading femtosecond laser that provides exceptional performance across cataract and corneal applications on a single platform.
Dr. Chu: Do specific staff members have specific roles in the implementation of new technology?
Dr. Shivaram: From the efficiency, patient education and conversion standpoints, I see the time patients spend with our technicians as the “sweet spot.”
Dr. Pepose: The head technician is always involved in prepping the practice for adoption of a new technology, and if the technology is surgical, the OR nurse manager is involved. Usually, we get the business manager’s perspective, and beyond that, who we have demo equipment depends on who will be using it.
Dr. Chu: Two crucial people for us are a member of the technical team, such as an optometrist or lead technician, and a patient coordinator/counselor. The technical person needs to be able to support the surgeon in educating patients in the clinic. In a small practice, the technically oriented person might be the surgeon. The patient coordinator/counselor is the person who masters the economic/insurance aspects and can continue the patient education process. Depending on the technology, having additional staff members, such as front desk personnel, involved may be necessary or helpful.
Does anyone have any closing thoughts on how best to choose and implement new technology into the practice?
Dr. Shivaram: Implementation can be particularly challenging when the technology is one that affects both the office and the surgery center. Both staffs have to be aware of the ramifications of the change and the potential impact on efficiency. The challenges can be magnified if a practice has become complacent about efficiency. We try to determine how to maximize our current efficiency before we introduce any new technology. That way, we’re ahead of the curve and can fine-tune rather than overhaul our processes to accommodate a new addition. ■
Surgical Pearls and Preferences
Expert strategies for maximizing the benefits of the Crystalens® AO and Trulign® Toric IOLs.
Dr. Chu: Do you have any pearls for surgeons who are new to the Crystalens AO and Trulign Toric IOL platforms?
Dr. Shivaram: Thorough cortical cleanup is crucial for achieving the best outcomes, as is polishing the capsule and rotating the lens once in the bag. I recommend becoming comfortable with those steps and practicing them in standard IOL cases before transitioning to Crystalens or Trulign. As far as capsulotomy size, I prefer 5.5 mm, which has worked well for me with the Victus® Femtosecond Laser. I achieve good results with a 2.9-mm incision, created with the Victus Femtosecond Laser. I tend not to suture. If I need to, I create a supraincisional pocket incision and hydrate that. But in general, I don’t suture those. Ultimately, some of these approaches are based on the individual surgeon’s comfort level with what is necessary and what isn’t. Again, I think experimenting with incision size and all of the variables in monofocal cases first is ideal.
Dr. Tyson: It’s definitely a transition to begin using the Crystalens AO and Trulign Toric. They have a 5.0-mm optic, but the haptic platform is larger than with other lenses. I started off using larger capsulorrhexes until I felt comfortable with 6.0 mm, which made it easier to insert the lens into the capsular bag and rotate it. Most surgeons are accustomed to either a one-piece or three-piece platform, and this is just different. It takes a bit of time to get comfortable with it. It’s second nature to me now, using the 6.0-mm capsulorhexis for easy lens delivery and minimal manipulation.
Dr. Pepose: I think the key to success with the Trulign Toric IOL is capsulotomy size and centration. Marking the cornea consistently is important as well. Next, I consider it important to meticulously perform cortical cleanup and to rotate the lens to be sure both haptics are in the bag and that any residual cortex that could be there is dislodged. I still prefer to perform MICS surgery, i.e., start with a sub-2.0-mm incision for bimanual phaco and enlarge the incision for lens implantation. That approach serves me well because when I go in with a keratome, it’s very clean at the wound margin. Afterward, I hydrate the wound. I rarely need to use a suture. I perform a Seidel test at the end of every case to prove to myself I don’t need sutures, and I either go back and hydrate or make a Wong incision and try to hydrate anteriorly overlying the incision and compress it that way. Inserting the Trulign® Toric IOL is somewhat different but can certainly be mastered. The key is getting the trailing haptic in and being sure the lens isn’t flipped — so that the leading round polyamide haptic is to the right when you’re injecting.
This toric option is great because it has great rotational stability.8 It’s generally understood that for every degree a toric IOL is off target it loses 3.3% of its effective power.9 So if a toric is off target by 10 degrees, it will have lost one third of its toric power. Another advantage of the Trulign Toric IOL is that it’s symmetrical so it can be rotated either way. The surgeon doesn’t have to dial all the way around the clock if he initially rotates the lens past the intended axis. In my experience, this toric lens also provides great intermediate vision, so patients can enjoy great distance and intermediate vision as well as functional near vision. Often, I create mini-monovision with the nondominant eye to expand the depth of focus even more.
The TRULIGN Toric IOL provides a broader range of vision for astigmatic correction, and 99.2% of patients reported no significant visual disturbances.*
*Data on file, Bausch & Lomb Incorporated. Study 650.
Dr. Chu: I don’t routinely suture with the Trulign Toric IOL either. If I hydrate the wound and check to make sure the paracentesis sites and main wound are sealing nicely, I’m confident the lens will be in the position I expect it to be.
For surgeons who aren’t familiar with the Crystalens® AO and Trulign IOL platforms, I would say don’t be afraid to try them. They’re not difficult, as some people have made them out to be. You plan your surgery, execute it well, clean up the cortex, polish the capsule, insert the lens and, in the case of Trulign, line it up like a toric. I tell colleagues that these lenses work well and don’t require extraordinary skills. Do you agree with that?
Dr. Shivaram: Yes, these are excellent lenses when you take the time to learn how to use them correctly.
Dr. Pepose: Agreed. For example, I may avoid using them in patients who have pseudoexfoliation or any kind of zonular problem. Also, it’s not prudent to proceed with implanting these lenses if a rent in the capsule occurs.
Nd:YAG Capsulotomy and Other Considerations
Dr. Chu: Do you think about Nd:YAG capsulotomy differently for your Crystalens AO and Trulign Toric patients than you do for your standard IOL patients?
Dr. Tyson: Unlike a multifocal lens, Crystalens is already passing a good deal of light, so it can tolerate a fair amount of fibrosis. That said, when I begin to see PCO forming, I perform the YAG capsulotomy. I use lower laser settings than I do for my standard IOL patients, delivering more spots with less energy, to have a more controlled YAG procedure. I want to avoid extending beyond the optic edge to prevent vitreous prolapse around it.
Dr. Pepose: The surgeon does have to realize that this lens platform has a three-dimensional aspect because of the hinges. I have a very low threshold for YAG, with any kind of striae, because I don’t want vector forces to change the proper lens position. Often I YAG under the 5-mm optic, and I’m conservative.
Take-home Points
Dr. Chu: We’ve discussed some great strategies for making the most of the Crystalens® AO and Trulign® Toric IOLs, and most of them relate to the importance of paying attention to the details of our premium surgery cases, such as managing the capsule. This is something that can and must be learned with these platforms. YAG capsulotomy should be considered earlier than in monofocal IOL cases based on what we see at the slit lamp in terms of striae in the capsule. It’s also important to laser only within the optic. That’s what most of us have shared here and what Bausch + Lomb recommends.
Avoiding potential problems also depends on having a quality capsulorrhexis, and not implanting a Crystalens AO or Trulign Toric IOL if a tear occurs in the capsule or if it’s significantly asymmetrical. I have a conservative threshold on when I should put these lenses in, and I believe that’s why I’ve been successful and have never had to explant.
A final point worth mentioning is what we’ve learned from studies over the years about the importance of efforts to prevent postoperative cystoid macular edema (CME). We’ve learned that using a steroidal anti-inflammatory and an NSAID for at least 8 weeks, typically 10 weeks, is beneficial in managing the capsular opacification rate as well as vision for these patients. Based on that knowledge, I prescribe Prolensa (bromfenac ophthalmic solution 0.07%) and Lotemax (loteprednol etabonate ophthalmic suspension 0.5%) for 8 weeks. I no longer pre-treat patients because I haven’t found the need. I use those in addition to a topical medication because that’s how much I care about even a low risk of CME and managing the capsule in premium IOL patients. ■
Safety Information
VICTUS® Femtosecond Laser Platform
| Laser CLASS 3B | |
| Wavelength: | 1040 ± 25nm |
| Pulse duration: | 290 - 550 fs |
| Maximum pulse frequency: | 160 kHz |
| Maximum output power: | 0.86 W |
| IEC 60825-1:2007 | |
CAUTION: United States Federal Law restricts this device to sale and use by or on the order of a licensed physician. INDICATIONS: The VICTUS Platform is indicated for use in the creation of a corneal flap in patients undergoing LASIK surgery or other treatment requiring initial lamellar resection of the cornea, for anterior capsulotomy during cataract surgery, the creation of cuts/incisions in the cornea in patients undergoing cataract surgery or other ophthalmic treatment requiring cuts/incisions in the cornea, and for laser-assisted lens fragmentation during cataract surgery for nuclear cataracts, not for fragmentation of posterior subcapsular (PSC) and cortical cataracts. Attention: Please refer to the Directions for Use for complete use instructions and safety.
SUMMARY OF CONTRAINDICATIONS: Corneal disease or pathology that precludes transmission of laser wavelength or distortion of laser light. Patients who do not give informed consent, who are pregnant or nursing, have existing corneal implants, who have had any previous cornea surgery or pediatric patients. Conditions that interfere with intent to treat such as glaucoma, retinal disorders, rheumatic diseases, epilepsy, herpes zoster or herpes simplex keratitis, and heavy vascularization of ocular tissues. Conditions that interfere with proper docking such as chemosis, nystagmus, significant loss of stability of the conjunctiva,keratoconus, and corneal diseases requiring treatment. Conditions that may interfere with capsulotomy such as poorly dilating pupils, and anterior chamber depths (ACD) < 1.5 mm or ACD > 4.8 mm. Conditions that may interfere with creation of flap such as dry eye diseases, cataract, diabetes mellitus, severe acne rosacea, severe wound healing disorders, and immune deficiency diseases. Contraindicated for laser-assisted lens fragmentation of posterior subcapsular (PSC) and cortical cataracts.
Stellaris® PC Vision Enhancement System
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Crystalens® AO Accommodating IOL
INDICATIONS FOR USE: Crystalens is intended for primary implantation in the capsular bag of the eye for the visual correction of aphakia secondary to the removal of a cataractous lens in adult patients with and without presbyopia. Crystalens provides approximately one diopter of monocular accommodation which allows for near, intermediate, and distance vision without spectacles. WARNINGS: Careful preoperative evaluation and sound clinical judgment should be used by the surgeon to decide the risk/benefit ratio before implanting a lens in a patient. Some adverse events which have been associated with the implantation of intraocular lenses are: hypopyon, intraocular infection, acute corneal decompensation, and secondary surgical intervention. PRECAUTIONS: Do not resterilize; do not store over 45°C. ATTENTION: Refer to the Physician Labeling for complete prescribing information.
TRULIGN® Toric Posterior Chamber IOL
INDICATIONS FOR USE: The TRULIGN Toric Posterior Chamber Intraocular Lens is intended for primary implantation in the capsular bag of the eye for the visual correction of aphakia and postoperative refractive astigmatism secondary to removal of a cataractous lens in adult patients with or without presbyopia who desire reduction of residual refractive cylinder with increased spectacle independence and improved uncorrected near, intermediate and distance vision. WARNINGS: Careful preoperative evaluation and sound clinical judgment should be used by the surgeon to decide the risk/benefit ratio before implanting a lens in a patient. Some adverse events which have been associated with the implantation of intraocular lenses are: hypopyon, intraocular infection, acute cornealdecompensation, and secondary surgical intervention. SAFETY AND PRECAUTIONS: Do not resterilize; do not store over 45°C. ATTENTION: Please see Directions For Use for important safety information.
enVista® Hydrophobic Acrylic IOL
The enVista IOL is indicated for primary implantation for the visual correction of aphakia in adult patients in whom the cataractous lens has been removed. The lens is intended for placement in the capsular bag. Physicians considering lens implantation under any of the following circumstances should weigh the potential risk/benefit ratio: 1. Severe anterior or posterior segment inflammation or uveitis. 2. Patients in whom the intraocular lens may affect the ability to observe, diagnose, or treat posterior segment diseases. 3. Surgical difficulties that increase the potential for complications (e.g., persistent bleeding, significant iris damage, uncontrolled positive pressure, or significant vitreous prolapse or loss). 4. Any trauma or developmental defect in which appropriate support of the IOL is not possible. 5. Circumstances that would result in damage to the endothelium during implantation. 6. Suspected microbial infection. 7. Children under the age of 2 years are not suitable candidates. 8. Patients in whom neither the posterior capsule nor zonules are intact enough to provide support. The safety and effectiveness of the enVista IOL have not been substantiated in patients with preexisting ocular conditions and intraoperative complications. Careful preoperative evaluation and sound clinical judgment should be used by the surgeon to decide the benefit/risk ratio before implanting a lens in a patient with one or more these conditions; vitreous loss (significant), anterior chamber bleeding (significant), uncontrollable positive intraocular pressure. Patients with preoperative problems such as corneal endothelial disease, abnormal cornea, macular degeneration, retinal degeneration, glaucoma, and chronic drug miosis may not achieve the visual acuity of patients without such problems. Potential complications accompanying cataract or implant surgery may include, but are not limited to the following: corneal endothelial damage, infection (endophthalmitis), retinal detachment, vitritis, cystoid macular edema, corneal edema, pupillary block, cyclitic membrane, iris prolapse, hypopyon, transient or persistent glaucoma, and secondary surgical intervention. Secondary surgical interventions include, but are not limited to: lens repositioning, lens replacement, vitreous aspiration or iridectomy for pupillary block, wound leak repair, and retinal detachment repair. For a complete storage and handling information and for physician labeling information, refer to the enVista product package insert.
REFERENCES
1. Ang R, Martinez G, Cruz E, Tiongson A, Dela Cruz A. Prospective evaluation of visual outcomes with three presbyopia-correcting intraocular lenses following cataract surgery. Clin Ophthalmol. 2013;7:1811-1823. doi: 10.2147/OPTH.S49848.
2. Pepose JS, Qazi MA, Davies J, et al. Visual performance of patients with bilateral vs combination Crystalens, ReZoom, and ReSTOR intraocular lens implants. Am J Ophthalmol. 2007;144(3):347-357.
3. Johansson B, Sundelin S, Wikberg-Matsson A, et al. Visual and optical performance of the Akreos® Adapt Advanced Optics and Tecnis Z9000 intraocular lenses: Swedish multicenter study. J Cataract Refract Surg. 2007;33:1565-1572.
4. Pepose JS, Qazi MA, Edwards KH, et al. Comparison of contrast sensitivity, depth of field and ocular wavefront aberrations in eyes with an IOL with zero versus positive spherical aberration. Graefe’s Arch Clin Exp Ophthalmol. 2009;247:965-973.
5. Packer M, Rajan M, Ligabue E. Clinical properties of a novel, glistening-free, single-piece, hydrophobic acrylic IOL. Clin Ophthalmol. 2014:8 421-427.
6. Mentak K, Martin P, Elachchabi A, Goldberg E. Nanoindentation studies on hydrophobic acrylic IOLs to evaluate surface mechanical properties. Paper presented at: XXV Congress of the European Society of Cataract & Refractive Surgeons (ESCRS); September 8-12, 2007; Stockholm, Sweden.
7. Data on file, Bausch & Lomb Incorporated. Study 521.
8. Data on file, Bausch & Lomb Incorporated. Study 650.
9. Novis C. Astigmatism and toric intraocular lenses. Curr Opin Ophthalmol. 2000;11:47-50.
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