My go-to device is the IOLMaster 700 with Veracity (Zeiss). It takes scans and measures the front and posterior cornea. As a swept-source machine, it accurately visualizes through any cataract density. Also, it links to Veracity, which is a software program that allows me to pick and choose the right lens and change lenses on the fly.

As a refractive surgeon, I have performed numerous LASIK cases over my career and am now seeing these patients for cataract surgery. I used to spend hours calculating what lens to implant and where to put the limbal relaxing incisions in these post-LASIK patients. Now, I can do everything on this platform, which makes cataract planning so much easier and increases my efficiency.

I use the Pentacam (Oculus) for corneal tomography and identifying irregularities. I find that the device’s cataract module helps surgeons stay out of trouble when it comes to using multifocal lenses. If the system identifies a decentered angle kappa and too much corneal irregularity, it gives a warning.

I cannot do without an OCT; I use the Cirrus (Zeiss). I perform OCT on the macula to make sure it is clear prior to surgery, so there are no surprises. Along with its role with glaucoma, this technology is instrumental for me in evaluating the cornea and anterior segment. If I have a patient who has an irregular cornea and I am worried about potential keratoconus, I look at the epithelial mapping to get more information.

I perform OCT on all patients. As an Ophthalmic Mutual Insurance Company malpractice consultant, I have an enhanced appreciation for the importance of identifying retinal pathology preoperatively. Up to 50% of patients have pathology on OCT that was not readily identifiable on exam (PLoS One. 2018;13(12):e0208980).

Having swept-source biometry, specifically the Argos Swept-Source OCT Biometer (Alcon), has made a huge difference in my IOL calculations. The technology allows me to get through information for multiple patients quickly, without the need for ultrasound biometry. This is a time saver in the office, and I find it provides great accuracy even with dense cataracts. It also provides numerous keratometry readings, so I can be assured of accuracy. All of the swept-source OCT devices come with surgical planning software, which is another advantage.

In my OR, the Lensar femtosecond laser syncs with my topographer, the OPD-Scan III (Nidek). I can import the iris registration from my topographer, and it links directly to the laser, tracking the eye and allowing for accurate astigmatism correction and alignment of a toric lens. The laser places small nonrefractive corneal incisions, as well as a capsular nub for creating the capsulotomy. It currently works with three topographers: Pentacam, Cassini and the OPD-Scan III. I do not have to perform astigmatism axis markings on the patient in the preoperative area, plus, I can see if the lens has rotated off axes after surgery. This has been a huge gamechanger for me.

I highly value the iTrace (Tracey Technologies) for refractive/cataract surgery to give me insight into appropriate candidates for surgery and lens technology. The information obtained may steer me away from LASIK for example, or a multifocal lens. In patients who present postoperatively for a consultation, iTrace can identify the source of the problem: Is it the cornea or the lens? Also, the device lets me monitor cataract progression based on the way the light beams reflect in and out of the eye.

Additionally, I can use iTrace to assess toric IOL placement after the fact without dilating the eye and looking for marks using the slit lamp. With essentially one click, I can see the location of the toric and the corneal astigmatism to determine how far off they are and whether a lens rotation is needed. My technicians can have this information for me before I enter the exam room.

Further, I value iTrace as an educational tool. It helps facilitate my conversations about astigmatism and allows me to show patients visually what their vision looks like now and how it could be after correction. They can get a sense of what will happen based on lens choice — iTrace saves me a lot of chair time in explaining why I recommend a toric lens.

The technology is also a Placido disc topographer and an aberrometer. I can look at centration, angle kappa and topography-assisted astigmatic axis alignment. Once I mastered some of its nuances, I found that iTrace helped me be a better surgeon.

In addition, I recently incorporated Visumax (Zeiss) into my practice in preparation for small incision lenticule extraction (SMILE) procedures. While LASIK is not going anywhere, this femtosecond technology can perform both procedures, plus it can create pockets and channels. It has lots of bells and whistles as well, such as a highly advanced user interface, and the ability to record cases.

The most important thing, however, is that it benefits patients. A key factor to creating LASIK flaps is the laser’s patient interface — some have a flat interface, which is associated with the need for high suction. This can be uncomfortable for patients and may cause them to move. I prefer the curved interface of the Visumax, as it does not require as much pressure and is more comfortable. As a bonus, there is no opaque bubble layer, the eyes are very quiet and white postoperatively with a faster visual recovery.

I look forward to performing more SMILE procedures, and I believe the Visumax device will be increasingly utilized in the United States as surgeons become more familiar with its advantages: SMILE offers LASIK-like outcomes with the benefits of PRK in terms of less dry eye and more biomechanical stability.

Astigmatism is very common in our patients scheduled for cataract surgery. Although we have many devices that can measure astigmatism, they are not always in agreement. This presents a challenge when we are trying to determine exactly how to treat patients with astigmatism.

The Cassini is my primary device for determining astigmatism power in axis in potential cataract surgery patients. It provides good accuracy for measuring the contribution from the front and back surfaces of the cornea. I use additional devices to confirm the astigmatism measurements, including the Pentacam and either the Argos Swept-Source OCT Biometer (Alcon) or the IOLMaster 700 Swept-Source OCT (Zeiss). Of note, the IOLMaster 700 also provides both front and back surface measurements of corneal astigmatism.

Once the total corneal astigmatism has been determined, the next challenge is marking the astigmatism axis on the eye on the day of surgery. Automated systems, including the Callisto (Zeiss), Verion (Alcon) and ORA (Alcon), can help to make it easier. In my practice, we use Cassini preoperatively, and that information is sent to the Lensar laser, which we have at two surgery centers. During the laser procedure, the laser uses the preop Cassini images of the iris to perform iris registration, which ensures proper alignment of the astigmatism marks. The laser then creates two nubs on the capsule on axis to provide a precise target for aligning the toric IOL intraoperatively. The laser also creates two marks on the cornea on axis to further assist with alignment. Once the intraoperative portion of cataract surgery has started, there is very little additional time needed in toric IOL cases compared to standard IOL cases, as the capsular marks are in place. The surgeon just has to align the marks on the toric IOL to the capsular marks.

While intraoperative alignment technologies are effective options for optimizing alignment of toric IOLs during surgery, the final axis is not visible once the patient leaves the OR. If the toric IOL ends up off axis by 10-15 degrees (for example), it is impossible to know if this is due to improper alignment intraoperatively or the toric IOL rotating. With the presence of capsular nubs by the Lensar laser, the alignment of the toric IOL can be checked at any postop visit where the pupil is dilated to confirm that the toric IOL has remained on the same axis. If the toric were to rotate, the surgeon can easily go back into surgery and reposition the IOL to the marks.

Along with the Cassini as a preoperative technology for evaluating astigmatism in patients scheduled for cataract surgery, having the Pentacam or a placido-based topography is important to identify irregular astigmatism. Combined topography/wavefront systems such as the OPD-3 and iTrace are also effective technologies for surgeons who place toric IOLs, as they can provide an analysis on the toric IOL power and axis postoperatively. If an adjustment to the toric IOL axis is needed postoperatively, the OPD-3 and iTrace can help with planning the direction and amount of rotation needed.

In summary, there are many preop and intraoperative technologies that can assist with the placement of toric IOLs. As technology has advanced, surgeons can feel more confident that they can successfully treat astigmatism during cataract surgery. OM