What’s on your instrument tray?

Cataract surgeons discuss when they break away from the same ol’ same ol’.

By René Luthe, senior editor

When Steven Dewey, MD walks into his kitchen in Colorado Springs and sees his refrigerator, it reminds him of his cataract surgery tray. It’s a silly comparison, he says, but nonetheless, he likens taking everything out of his fridge and examining the contents to doing the same with the contents of the tray.

“How often do you actually apply that to your surgical technique? How often do you say, ‘Okay, is my incision the best incision I can make? Is my viscoelastic the best viscoelastic I can use?’”

Rhein’s Folden Femto Double-Ended Dissector is designed for a smooth opening of femtosecond laser-created corneal incisions during cataract surgery. The polished, semi-blunted leading tip allows for “scoring” of the epithelium and provides a glided entry into the laser-created incision. It is designed to separate residual tissue bridges and stromal adhesions that create resistance to entry with standard instruments.

In other words, new technologies, plus new techniques, equals better practice management.

Evaluation methods

At every ophthalmology meeting, instrument makers display their latest and greatest gadgets meant to help cataract surgeons up their game — to do it faster, through smaller incisions, and with fewer complications. And certainly, ophthalmologists comprise a tech-loving crowd.

Evaluations à la the Dewey method will almost certainly reveal surgical areas that could stand improvement, and this is what should spur surgeons to consider new instrumentation, physicians say.

Audrey Talley Rostov, MD, of Northwest Eye Surgeons in Seattle, says that kind of self-edit frequently occurs following a medical meeting. Surgeons may be performing their usual surgical technique with no problems, but are vaguely aware that a different instrument may be better for a particular component. “Then you go to a show and learn about a new instrument, so you think, I need x or y,” she explains. (For additional offerings in cataract surgery instrumentation, see New Product Report).

New technology = new tools

Well, often, anyway. Innovations in technology — and surgical technique — open up new possibilities and the instrumentation that was perfectly sufficient under the old way needs tweaking.

New technologies such as femtosecond lasers are contributing to less reliance on handheld instruments as well. Scott LaBorwit, MD, Towson, Md., says he is using fewer instruments as he has embraced laser-assisted cataract surgery. Shrinking Medicare reimbursements don’t exactly encourage surgeons to spend money to fix something that ain’t broke.

But that doesn’t mean that the new technology didn’t require new tools.

The Tran Femto Ergo Chopper by Bausch + Lomb features a capsule-friendly ball tip and angled neck with a horizontal chopping edge designed to reduce force on the capsule opening when reaching under the anterior chamber, and orienting the chopper in line with the phaco needle for efficient chopping. A second tip features a blunt spatula for opening femto corneal incisions. Designed by David D. Tran, MD.

When Dr. LaBorwit took up femtosecond laser-assisted cataract surgery, he realized he needed a slate spatula.“Because it’s a different surgery, that might drive you to start looking for different tools,”he says.

Rhein CEO John Bee concurs that the advent of femtosecond laser-assisted surgery stimulated innovation for instrument makers.“It turns out that the incisions the femto laser makes are not clean; they still have adhesions to them,” he explains. “That created an opportunity to develop instrumentation to open up those incisions, be it in the AKs [astigmatic keratotomy incisions], the phaco or the paracentesis incisions, because they weren’t clean like they would be with a blade.”

Dr. Rostov says her embrace of bimanual, micro-incisional cataract surgery leads her to instruments that will fit through 1.2-mm or 1.3-mm incisions. She favors those from MicroSurgical Technology because the instruments “are interchangeable on the handles. There is a whole bunch of new instruments out there with the snare and small intraocular scissors and a micro-grasper. I tried all of them and I ended up buying them all! They just make my surgical cases go so much more smoothly,” she says.

In addition to leading surgeons to change the instruments they use, new technology and techniques tend to lead to a reduction in the number of tools cataract surgeons use. In his role as assistant professor, part-time faculty at the Wilmer Eye Clinic of Johns Hopkins Hospital, Baltimore, Dr. LaBorwit works with residents performing cataract surgery. These newer surgeons typically use about 12 instruments, he says, plus four medicines. “When I do laser cataract surgery, I have five instruments, including my phaco tip and I&A.”

Pump up productivity

The reality of reimbursement today means surgeons are under ever-greater pressure to operate more efficiently — and that entails using instruments that help them do so. “You can’t just go out and buy instruments without careful consideration,” explains Dr. Rostov. That doesn’t mean cataract surgeons are not willing to spend — the right tools can shave minutes off a surgery, she points out.

So while trends may have created a tendency to purchase fewer handheld instruments, the ones that are purchased are expected to earn their keep.“If something is going to increase your efficiency, it’s well worth the cost,” Dr. Rostov says.

The Ayres Needle Holder Scissors by Bausch + Lomb feature a delicate jaw, tying platform and scissor to add efficiency to cataract surgical procedures requiring sutures. Designed by Brandon D. Ayres, MD.

Related to the quest for greater efficiency is the desire to avoid the “untoward event,” as Dr. Dewey puts it. “A lot of doctors will look at a singular event in perspective of a body of work and they’ll try to determine if it really is worth rearranging everything to help cure a one in 500, one in 1,000 type of event. It depends on the consequences of that event.”

A good example is a silicone-tipped I&A, Dr. Dewey says. “I think everyone at this point recognizes the ultimate safety and convenience of a silicone-tipped I&A. For the doctor who has to make the judgment call, is it worth the added expense to use a silicone-tipped I&A device if he doesn’t rupture the capsule very frequently at all during I&A?” For surgeons whose I&A is complete and who never make contact with the posterior capsule, it doesn’t make much sense to purchase this device. “But a lot of times, I don’t think people fully evaluate the cost of a complication.”

Many surgeons and ASC administrators, Dr. Dewey points out, know the dollar-per-minute cost of cataract surgery — and a complication, even a rare one, can cost far more than that instrument you decided against buying solely because of its price. “If you have an open posterior capsule during I&A, sure, that isn’t nearly as challenging to deal with as ... an open capsule while you have nuclear fragments, but you still have to manipulate the vitreous, you have to get out the cortex, you have to then figure out how to place your IOL, and then, best of all, you get to explain to the patient afterwards what happened.”

Happy with what they have

For those of you who have used the same instrumentation for years, no worries: you have good company. Many cataract surgeons report that replacing old instruments on their surgical trays is not uppermost in their minds.

“I’ve not changed much of anything in years,” says Ophthalmology Management’s medical editor, Larry Patterson, MD.

Dr. LaBorwit attributes this philosophy partly to sticking to what works — and to with what instruments surgeons learned their craft. “You kind of grab onto what you learned as a resident, or what your mentor used, and you cherish it,” he explains.“That instrument is like your security blanket.” OM