Innovation and integration combine to provide better refractive cataract surgery outcomes

In 2009, Wavetec debuted the ORange wavefront aberrometer during the annual ASCRS meeting. ORange, named because it is used in the “OR” on a “range” of applications, attaches to a surgical microscope to allow for real-time measurements of sphere, cylinder, and axis. ORange used infrared light and Talbot-Moiré interferometry (which analyzes moiré patterns produced by light passing through two gratings) optimized for the aphakic state to perform a “whole-eye” assessment of the optical system’s refractive power.

The first generation of ORange was only capable of taking pseudophakic measurements (for which I saw a small value in obtaining measurements for toric lens implantation). But with the second generation, my pocket book opened with the promise of pseudophakic and aphakic measurements and improved outcomes. I had visions of discarding my optical biometer and delivering perfect surgical outcomes to my cataract patients. Using aphakic measurements as the primary data point, the device provides guidance on IOL power selection — even in eyes that had undergone refractive surgery. Additionally, ORange assists with the orientation of toric IOLs and the placement of limbal relaxing incisions.

However, I soon realized that my optical biometer wasn’t heading for the equipment graveyard. I was disappointed. When Tom Frinzi took the helm at Wavetec, he and his team improved the product, and in 2011, ORA was released. Since then, I have seen improved reliability in the generation of IOL power calculations and toric lens placement.

In 2013, I presented data demonstrating that with ORA, I improved my outcomes from 80% +/- 0.5D of pseudophakic refractive error to 88%. In 2014, with the combination of ORA VerifEye and LenSx my outcomes improved to 94%. Since that time, we have been able to consistently produce these types of outcomes. I never work on premium lens implant patients or post-refractive patients without ORA. It is very good, but how can it be better? Alcon may have found a way.

The Next Generation

In 2017, Alcon will launch the first image-guided aberrometer called ORA with VerifEye Lynk, as well as the next generation Verion. With Verion, image-guided surgery will be streamlined to connect pre-op diagnostics, case planning, and surgical guidance. The new ORA will provide live data verification and diagnostics during a procedure. This promises to empower real-time decision making for generating targeted refractive outcomes. Here’s how it works.

Broader Measurements

To date, ORA has broadened our diagnostic picture by providing actual patient measurements during surgery, including aphakic measurements. It has been shown to improve refractive outcomes by accurately accounting for posterior corneal astigmatism, surgeon-induced astigmatism, cyclotorsion, LRI nomograms, and changes in the anterior posterior corneal ratio of post-refractive patients. It is another powerful diagnostic tool to help verify or modify preoperative surgical plans. ORA has been proven across multiple studies to improve outcomes in astigmatism management with toric IOLs, spherical lens power selection, and post-refractive cases.

Connectivity with Verion

The Verion Image Guided System helps to connect everything together to minimize potential error sources (such as transcription error, ink marking, orientation, and cyclotorsion).

How does diagnostic information and the physician’s surgical plan from the clinic follow to surgery in the OR and back to the clinic post-operatively? With Verion, the patient’s eye is registered during the diagnostic work-up when the data and surgical plan are designed based on the actual “fingerprint” of the patient’s eye. Any associated piece of technology downstream can look at that patient’s eye, match the live eye to the registered eye, and produce the surgeon’s pre-determined plan for that stage with precision. For example, LenSx can recognize the precise orientation for the surgeon’s previously planned incisions or arcuate cuts or a microscope can overlay the pre-determined axis for toric alignment.

Integrating to Improve Outcomes

By integrating these two platforms, ORA will become an image-guided aberrometer, capable of identifying the unique landmarks of the patient’s eye and “locking” on to that eye throughout the procedure. As opposed to simply tracking live X and Y movements through the live wavefront reading and fringe pattern, it will now be able to identify and follow the patient’s X, Y, and torsional movements via a registered “fingerprint” of that eye’s unique anatomical landmarks (such as scleral vessels, limbus, iris features, and so on). Surgeons can access image-guided overlays on ORA, such as incisional alignment, rhexis, and lens centration, providing a complete image-guided and live aberrometry work flow on a single platform.

For surgeons who don’t have access to a Verion system, ORA VerifEye Lynk can be used as a stand-alone image-guided aberrometer. It can take an intraoperative registration image at the start of the case. It will register the unique eye anatomy and lock on to landmarks throughout the case, providing additional benefits with tracking beyond current aberrometry options.

Combined Image Guidance

Many surgeons using aberrometry today say they prefer the value of an aphakic axis reading for toric IOL alignment over the pseudophakic axis. During aphakic measurement, the surgeon-induced astigmatism is accounted for and the lenticular contribution to the refractive equation is removed. This state provides an actual refractive measurement of the eye, completely isolating the value of the patient’s total cornea (anterior, posterior, and with incisions). However, once the lens is implanted and alignment of the toric begins, a live pseudophakic reading may yield a slight change in the location of the aphakic axis that was measured. This is due to the introduction of additional variables; the IOL is now in the eye and has not yet settled into its final position. The lens may be tilted while viscoelastic is removed or it may still be unfolding. With combined image-guidance and live aberrometry, ORA can take advantage of live registration and tracking. The system takes its real-time axis reading and maps that exact location to all of the surrounding landmarks of the registered eye. With this capability, surgeons could tell ORA during the pseudophakic alignment of the toric lens that they want to see where the aphakic target axis they measured earlier is on the eye and choose to use it as their guidance target even during pseudophakia.

The integration of ORA and Verion is more than the sum of the platforms. There are new technological capabilities that have been made possible by bringing aberrometry and image guidance together. I look forward to using this technology, because I believe this innovation will further our goal of “perfect” refractive cataract surgery outcomes. ■