Cataract surgery technology innovations continue apace, constantly responding to surgeons’ evolving needs. Today’s systems allow for multiple procedures on a single platform, customization, enhanced safety and predictability. Here’s a snapshot of some of the key technology available from top manufacturers.

ALCON

Phacoemulsification

The Centurion Vision System boasts Active Fluidics technology designed to significantly reduce occlusion break surge, according to the company. The unit allows the surgeon to dynamically manage IOP in various surgical settings.^1-3 By using compression plates to adjust pressure on a BSS or BSS Plus irrigating solution bag, the system detects and compensates for changes in the eye to help the surgeon maintain IOP.^1-3

Active Fluidics technology has been combined with the company’s Active Sentry Handpiece, which contains an integrated pressure sensor to measure IOP very near the tip, eliminating adjustment delay.

Centurion accelerates cataract removal with its Energy Delivery platform, enhances torsional efficiency and reduces repulsion compared to the company’s previous system.⁴ OZil technology plus innovative fluidics reduces heat transfer to the eye.⁵ The Intrepid Balanced tip delivers a lower temperature rise than traditional and ultrasound modalities.⁵

Femtosecond laser

The LenSx laser can deliver precise, reproducible and reliable capsulotomies and self-sealing cataract incisions.^6-15 The LenSx’s SoftFit patient interface aids in precision with easy docking of the eye to the laser.⁷ Surgeons can customize their approach with versatile fragmentation selection, while recent enhancements allow for more corneal applications.

Biometry and planning

The ORA system with AnalyzOR technology is the company’s intraoperative aberrometer that allows for precise, real-time confirmation during surgery. ORA’s continuous assessment of the eye facilitates customized surgical planning. The AnalyzOR stores, tracks and analyzes outcomes. Combined with the company’s Argos biometer, surgeons can better plan cases for enhanced efficiency and accuracy, improving clinic flow.

Surgical microscope

Personalized illumination is the differentiator with the LuxOR Revalia ophthalmic microscope. Offering six times larger visualization, the microscope has a more stable red reflex and enhanced depth of field.^16-18 The LuxOR is integrated with the suite of Alcon technologies and can be paired with the company’s Ngenuity 3-D Visualization System.

3-D visualization

The Ngenuity 3-D Visualization System gives an immersive, digitally enhanced surgical view for heads-up surgery that is customizable and facilitates training and collaboration with its 55-inch display.

Surgeon experience

Kevin M. Miller, MD, was one of the surgeons who helped develop the Active Sentry handpiece. “Just as the advent of phacoemulsification made cataract surgery less traumatic, major advances in fluidics have continued to make procedures safer and more efficient. Active Fluidics technology broke new ground in this area, now enhanced by the Active Sentry Handpiece,” says Dr. Miller, Kolokotrones chair in Ophthalmology, chief of the Cataract and Refractive Surgery Division, director of the Anterior Segment Diagnostic Laboratory at UCLA Stein and Doheny Eye Institutes, Los Angeles.

BAUSCH + LOMB

Phacoemulsification

As procedural factors change, the Stellaris Elite System reacts in real-time to maintain stability and surgeon control. Its vision-enhancement feature provides a premium platform for advanced lens-based surgery. Designed to complement the surgeon’s technique, Stellaris enables sub-2-mm lens surgery through a flexible, hybrid approach to fluidics and advanced, efficient cutting dynamics.

StableChamber Fluidics provides safe, efficient and predictable chamber stability, according to the company. Surgeons can customize fluidics with flow or vacuum control. The powerful Attune Energy Management System enables cataract removal with less energy. The six-crystal 28.5-kHz frequency Attune Handpiece delivers optimized, consistent power delivery and increased stroke length.

Femtosecond laser

The Victus Femtosecond Laser Workstation offers versatility for both cataract and corneal procedures on one platform. Surgeons can perform capsulotomies, fragmentation, arcuate incisions, corneal incisions and LASIK flaps. With an efficient design, Victus’ key features include swept-source OCT, called RealEyez, which delivers real-time, high-resolution visualization. The Verafit patient interface is gentle and stable, according to the company, and the device reaches pulse rates of up to 160 kHz.

Surgeon experience

A number of advantages and features set the Stellaris apart, says Douglas D. Koch, MD, one being anterior chamber stability. “The vacuum-based phaco device creates little surge, providing remarkably stable anterior chambers,” says Dr. Koch, professor and the Allen, Mosbacher, and Law chair in Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston.

The cutting is powerful and smooth, he adds. “I have no problem tackling many dense lenses that might otherwise be very challenging to remove,” Dr. Koch says. In addition, he touts the dual linear foot pedal as one of the machine’s more unique features. “It can be programmed in myriad ways. I have mine programmed to reduce the duty cycle when I yaw to the right; I do this to engage quadrants, then yaw to the center to increase the duty cycle to emulsify them.”

For Dr. Koch’s epinucleus setting, “I have only irrigation/vacuum in the central position and can add phaco by yawing to the right. In all settings, yawing to the left generates reflux.”

The system’s Adaptive Fluidics means the surgeon sets a baseline bottle height and, when occlusion is detected, air is pumped into the top of the infusion bottle to increase pressure. “The surgeon can customize this function, allowing for additional options in terms of chamber stability and managing fluidics,” says Dr. Koch. “I find it to be very responsive. It greatly enhances the inherent chamber stability found in vacuum-based systems.”

HAAG-STREIT

Biometry and planning

The Lenstar provides accurate laser optic measurements for every section of the eye — from the cornea to the retina. Further, the company says it is the first optical biometer on the market that can measure the thickness of the crystalline lens. With integrated Olsen formula and the optional toric planner featuring the Barrett Toric Calculator, Lenstar provides surgeons with an array of IOL-planning tools.

Lenstar captures axial dimensions of the eye’s optical structures in a single measurement scan using optical low-coherence reflectometry. The device measures corneal curvature and white-to-white and features dual-zone keratometry or T-Cone topography for precise astigmatism and axis measurement. The closely spaced 32-measurement point pattern improves precision, delivering more data and minimizing the need for data interpolation.

Surgical microscopes

From the HS Hi-R NEO 900 with its optional integrated intraoperative OCT — the first of its kind — to the compact HS ALLEGRA microscopes, Haag-Streit has offerings to match surgical centers’ needs. The iOCT camera scans the anterior and posterior segments during surgery in real time, providing high-penetration depth and visibility of transparent structures. The technology also supports corneal surgeries.

Visualization is created by the binocular image injection superimposing the scan to the live view into both oculars. Window depth is 3.8 mm for an overview of the whole anterior segment. The iOCT was designed to focus on the same focal plane as the microscope, for ease of handling.

3-D visualization

MIOS 5 — the Microscope Imaging and Operation System — combines HD camera recordings with high-quality iOCT images. Synchronized videos connect with patient data, and an additional external display can be incorporated for training. The iOCT images, video recordings and 3-D volume stacks can be saved on the iOCT as raw files, including the system’s meta data.

Surgeon experience

Optics and ergonomics are the major reasons why Michael Snyder, MD, favors the HS Hi-R NEO 900 as his operative microscope. “It has superb optics with true, exact colors. The relative resolution is unparalleled, and the red reflex is phenomenal,” says Dr. Snyder, who is on the board of directors and chair, Clinical Research Steering Committee, at Cincinnati Eye Institute, and a professor of ophthalmology, University of Cincinnati.

The Hi-R NEO 900 is designed with a wide separation between the optics, which augments the surgeon’s depth perception, Dr. Snyder says. “The light path and oculars extend out a bit from the stack, so we do not have to lean forward into the scope.”

The monitor is directly hooked up to the microscope, which can swing over the patient’s chest area, allowing Dr. Snyder to view the Lenstar imaging for astigmatic adjustments. “For a toric implant, I can pull up the image capture at the moment keratometry was performed and use it as a registration and to identify the steep axis.”

When it comes to ergonomics, Dr. Snyder says surgeons also have to be cognizant of how they sit. “Across multiple studies, more than 50% of ophthalmologists have reported neck, back or arm pain, and 15% say they have had to curtail their professional careers as a result of these symptoms.”^19,20

Haag-Streit developed the CO:RE surgical chair designed for ophthalmologists, providing full support along the lumbar and thoracic spine and is adjustable for depth, height and angle. “It is narrow enough that it doesn’t contaminate the sleeves on our sterile gowns when our elbows move backwards,” says Dr. Snyder.

JOHNSON & JOHNSON VISION

Phacoemulsification

Early next year, Johnson & Johnson Vision will unveil Veritas, the company’s next-generation Phacoemulsification Vision System. It delivers improved chamber stability, ease-of-use and reliability as well as excellent fluidics management with ergonomic touch points in a modern design, the company says.

Femtosecond laser

The FDA recently granted 510(k) clearance for the Catalys Precision Laser System cOS 6.0 update to simplify astigmatism management workflow and increase efficiency. This is a collaboration with Cassini Technologies that builds on the essentials of the Catalys system. Features include advanced visualization with full-volume, 3-D, high-resolution and streaming OCT imaging, plus reliable, accurate laser incisions for a premium patient experience, the company says.

According to Johnson & Johnson Vision, Catalys cOS 6.0 astigmatism management can streamline workflow, speed up the surgical process and improve accuracy. Data entry verification and manual transcription errors are minimized with direct input of preoperative keratometry and steep axis data. The upgrade includes arcuate incision parameters using built-in nomogram and automatic input into the treatment planning screen.

The advanced astigmatism upgrade also reduces the need for intraoperative aberrometry to align toric IOLs with radial laser marks placed within a mean accuracy of 0.6°.²¹ According to the company, this provides 5.5 times greater precision compared to manual marking of the cornea with an ink pen (mean accuracy 3.3°).²² The system has added iris registration for automatic cyclorotation compensation.

Surgeon experience

The Catalys software update provides more stability and confidence when it comes to aligning toric IOLs, says Wendell Scott, MD. “The system is a real improvement when it comes to the programmability of astigmatism management and will enhance our ability to correct patients with smaller amounts of cylinder, 0.50 D to 1.25 D.”

“This well-researched cOS 6.0 advance eliminates translational issues with manual transcribing, as data is now imported directly from machine to machine with the Cassini integration,” adds Dr. Scott’s colleague Shachar Tauber, MD. “The system also offers subtle improvements when it comes to the fragmentation settings. Our initial impression has been fantastic.” Drs. Scott and Tauber are both in practice at Mercy Clinic Eye Specialists/Mercy Surgery Center in Springfield, Mo.

LENSAR

Femtosecond laser

The LENSAR Laser System was “built from the ground up” specifically for refractive cataract surgery, according to the company. Its four upgrades in only two years underscores LENSAR’s commitment to advancing technology to help cataract surgeons deliver “LASIK-like outcomes.” LENSAR’s latest upgrade, Streamline IV, includes Augmented Reality, which enables precise laser delivery by creating a 3D model of the relevant anterior segment, and IntelliAxis Refractive Capsulorhexis, which incorporates steep axis markings on the capsule for precise toric IOL alignment, providing surgeons with new options for managing astigmatism and optimizing patient outcomes. Other features include cataract density imaging, arcuate incision planning at the laser and up to 20-second laser treatment times that improve surgical efficiency, the company says.

ZEISS

Biometry and planning

The system’s IOLMaster 700 cornerstone added swept-source biometry. A software update includes central topography to detect visually relevant asymmetries along with posterior and anterior refractive powers. Its EQ Mobile feature lets surgeons access biometry data and scleral reference images on any mobile device via the cloud to Zeiss Callisto eye for computer-assisted surgery. The system’s Total Keratometry can be used in classic IOL calculation formulas, obviating the need for a second device, third-party software or an online calculator, according to Zeiss. Graham Barrett, MD, developed three formulas exclusively for Total Keratometry: Barrett TK Universal II, Barrett TK Toric and Barrett True K with TK.

The IOLMaster’s cornea-to-retina scan shows anatomical details on a longitudinal cut through the entire eye. The Fixation Check ensures confidence and verification, and the system is fast, reliable and repeatable for optimal refractive outcomes, according to the company.

Zeiss Veracity Surgical plus EQ Workplace and EQ Mobile combines for a streamlined process that saves preoperative planning time, allowing increased case capacity while also reducing the risk of human error, the company says. Veracity incorporates patient data from the EMR and diagnostic hardware, and EQ Workplace is fully integrated with Zeiss Forum.

Surgical microscopes

Data is displayed into the eyepiece of Zeiss’ surgical microscopes Opmi Lumera and Artevo 800, making preoperative corneal marking and additional measurements for toric IOL alignment obsolete. The Opmi Lumera 700 features detailed views with excellent contrast, color and high resolution. The Artevo 800 is a completely integrated digital microscope for heads-up surgery with excellent resolution, outstanding depth of field and 25% better light transmission, according to the company’s on-file data.

Surgeon experience

“We began using the IOLMaster ocular coherence biometer when it was first introduced two decades ago,” says Joseph L. Parisi, MD. “The 700 is a re-invention of the biometer to be OCT-based, allowing accurate measurement of corneal and lens thickness through very dense cataracts. Its Total Keratometry is the only biometer that measures the posterior cornea, which has allowed me to be more predictable in my astigmatism planning and treatment.” Dr. Parisi is the medical director for South Carolina Eye Health America, Cataract and Refractive Surgery at Clemson Eye, Greenville, S.C.

The Veracity planning software integrates with Dr. Parisi’s EMR software and diagnostic devices to put all of the preoperative data in one place. The result is simplified, efficient IOL planning. “Direct integration of data ensures no transcription errors and diagnostic images can be viewed on the Veracity platform,” he says. “Postoperative tracking and analysis can be done as well.”

He adds that the Lumera 700 surgical microscope with Callisto completes the package. “All data is transmitted from Veracity to Callisto via a cloud-based system, and this provides me with a digital marking system in the OR. This improves patient flow and is far more accurate for toric IOL alignment.” OM

REFERENCES

1. Sharif-Kashani P, Fanney D, Injev V. Comparison of occlusion break responses and vacuum rise times of phacoemulsification systems. BMC Ophthalmol. 2014;14:96.
2. Alcon data on file. 2017.
3. Nicoli CM, Dimalanta R, Miller KM. Experimental anterior chamber maintenance in active versus passive phacoemulsification fluidics systems. J Cataract Refract Surg. 2016;42:157-162.
4. Solomon K, Lorente R, Cionni R, Fanney D. Prospective, randomized clinical study using a new phaco system with intraocular system target pressure control. ASCRS-ASOA Symposium and Congress; April 25-29, 2014; Boston, MA.
5. Zacharias J. Comparative motion profile characterization of the mini flared and balanced phacoemulsification tips. ESCRS; September 5-9, 2015; Barcelona, Spain.
6. Alcon data on file, 2019.
7. Yeu E, Scoper S. Retrospective comparison of clinical outcomes associated with manual and femtosecond laser cataract surgery. Paper presented at: American Society of Cataract and Refractive Surgery–American Society of Ophthalmic Administrators Annual Meeting; May 5-9, 2017; Los Angeles, CA.
8. LenSx Laser System Operator’s Manual, Rev B. Alcon Laboratories, Inc. Published September 2017.
9. Kohnen T, Mathys L, Petermann K, et al. Update on the comparison of femtosecond laser-assisted lens surgery to conventional cataract surgery: a systematic review and meta-analysis. Paper presented at: 35th Congress of the European Society of Cataract and Refractive Surgeons; October 7-11, 2017; Lisbon, Portugal.
10. Kránitz K, Miháltz K, Sándor GL, Takacs A, Knorz MC, Nagy ZZ. Intraocular lens tilt and decentration measured by Scheimpflug camera following manual or femtosecond laser-created continuous circular capsulotomy. J Refract Surg. 2012;28:259–263.
11. Ali MH, Ullah S, Javaid U, Javaid M, Jamal S, Butt NH. Comparison of characteristics of femtosecond laser-assisted anterior capsulotomy versus manual continuous curvilinear capsulorrhexis: A meta-analysis of 5-year results. J Pak Med Assoc. 2017;67:1574-1579.
12. Mastropasqua L, Toto L, Mastropasqua A, et al. Femtosecond laser versus manual clear corneal incision in cataract surgery. J Refract Surg. 2014;30:27-33.
13. ClinicalTrials.gov: US National Library of Medicine. A Real-World Registry to Investigate the Performance of LenSx Laser in Chinese Patients. http://clinicaltrials.gov/ct2/show/NCT02396719. Updated June 6, 2019. Accessed Oct. 14, 2019.
14. Wang L, Zhang S, Zhang Z, et al. Femtosecond laser penetrating corneal relaxing incisions combined with cataract surgery. J Cataract Refract Surg. 2016;42:995-1002.
15. Toto L, Mastropasqua R, Mattei PA, et al. Postoperative IOL axial movements and refractive changes after femtosecond laser-assisted cataract surgery versus conventional phacoemulsification. J Refract Surg. 2015;31:524–530.
16. Cionni RJ, Pei R, Dimalanta R, Lubeck D. Evaluating red reflex and surgeon preference between nearly-collimated and focused beam microscope illimuation systems. Trans Vis Sci Technol. 2015;4:7.
17. Schwiegerling J, Dimalanta R. Depth of focus measurements of ophthalmic surgical microscopes. Poster presented at: 2016 Annual Meeting of the Association for Research in Vision and Ophthalmology; May 1-5, 2016; Seattle.
18. Alcon data on file.
19. Kitzmann AS, Fethke NB, Baratz KH, et al. A survey study of musculoskeletal disorders among eye care physicians compared with family medicine physicians. Ophthalmology. 2012;119:213-220.
20. Dhimitri KC, McGwin G, McNeal SF, et al. Symptoms of musculoskeletal disorders in ophthalmologists. Am J Ophthalmol. 2005;139:179-181.
21. Scott W, Schultz T, Valim N, et al. Accuracy of Intra-Stromal Corneal Toric IOL Alignment Marks in Patient Eyes and PMMA Spheres with a Femtosecond Laser System. Paper presented at: ASCRS; May 16-17, 2020; virtual.
22. Read SA, Vincent SJ, Collins MJ. The visual and functional impacts of astigmatism and its clinical management. Ophthalmic Physiol Opt. 2014;34:267-294.