Mark Packer, MD, FACS

Three companies in the United States have entered the nascent femtosecond (FS) phaco market: LenSx Lasers Inc. (Aliso Viejo, CA), LensAR Inc. (Winter Park, FL), and Optimedica Corp. (Santa Ana, CA). Bragging rights to the first peer-reviewed publication and US procedure have gone to LenSx; however, the “femto feuds” haven’t even gotten started yet.

The promise of this technology is a dramatic increase in the accuracy, safety and reproducibility of all the corneal and capsular incisions required to take out a cataract (or clear lens). The image-guided FS laser aims to correct pre-existing and surgically induced astigmatism, precisely open the anterior capsule and atraumatically prepare the lens for aspiration. The result of a single, rapid application of FS laser energy is an eye fully prepared to disgorge its presbyopic or cataractous crystalline lens and ready to receive a next-generation accommodative intraocular lens or futuristic flexible, injectible polymeric lens replacement.

The clear corneal incision, despite its inherent simplicity, has proven a challenge for cataract surgeons. Doubts about self-sealability and unforgiving construction techniques have led some to return to the cumbersome scleral tunnel. These concerns may become magnified when considering, for example, the larger-than-usual incision required for implantation of a dual optic accommodative IOL. However, the FS laser facilitates predictable construction of custom-designed clear corneal incisions featuring tongue-and-groove design for enhanced sealability. In fact, FS technology has already delivered this concept in corneal transplantation surgery.

Limbal relaxing incisions for the correction keratometric astigmatism have met with a mixed response from the surgical community and a relatively high rate of requisite postoperative excimer laser enhancement due in part to common errors in measurement of surgically induced astigmatism and unavoidable inconsistencies in construction technique. The FS guided laser offers the possibility of automated construction of topographically matched incisions and intraoperative enhancements such as we now have only with stand-alone intraoperative aberrometry.

The capsulorhexis, an innovation critical to the development of phacoemulsification, remains a high hurdle for surgical trainees and accomplished surgeons alike. The FS laser delivers consistent and clean precision construction of a centered, round, custom-designed capsulorhexis in any size of the surgeon’s choice. This capability alone provides adequate reason to adopt FS phaco. In premium IOL implantation, any error in capsulorhexis construction may mean a significant reduction in patient satisfaction or even elimination of the patient’s lens of choice as an option for implantation. Providing consistent capsulorhexis construction reduces the hurdle to adoption of presbyopia-correcting IOLs.

Finally, division and preparation of the lens for emulsification and aspiration is rendered safe and simple by the FS laser. Microphotolysis of lens material effectively eliminates the need for specific mechanical chopping or sculpting techniques and allows safe aspiration of the contents of the capsular bag.

Cataract surgeons are impelled by their inward drive towards perfection to love the possibilities that femtosecond phaco creates. This technology changes everything. The pioneers of phaco, and the surgical techniques they developed that are still in use today, are coming to appear as the devices of medieval artisans relative to the streamlined accuracy of a nascent industrial era. The craftsman approach to cataract surgery is ending; the automated, mechanized future is here. Laser precision and elevated outcomes will trump the old school manual achievements of our predecessors. Truly, now more than ever, we stand on the shoulders of giants.

Mark Packer, MD, FACS

Emmetropia and full accommodation remain the goal of refractive cataract and lens surgery. Already we’ve witnessed dramatic advances in the field, from a time only 10 years ago when only a single zonal refractive multifocal IOL was available in the United States to today’s array of FDA-approved refractive and diffractive multifocal and single optic accommodative designs.

Since May 2005, the Center for Medicare and Medicaid Services (CMS) has allowed beneficiaries to pay out-of-pocket for services associated with the implantation of presbyopia-correcting intraocular lenses to reduce or eliminate the need for glasses after cataract surgery. In 2005, there were 3 entries in this category: the crystalens, a single optic accommodative lens subsequently acquired by Bausch & Lomb (San Dimas, CA); the ReZoom, a refractive multifocal IOL from AMO (now Abbott Medical Optics, Santa Ana, CA); and the ReSTOR, a diffractive multifocal IOL from Alcon (Fort Worth, TX). In the past 4 years both the crystalens and the ReSTOR have undergone major makeovers, and AMO has launched an entirely new multifocal, the aspheric diffractive Tecnis Multifocal IOL. In addition, we now have available toric IOLs from both STAAR Surgical (Monrovia, CA) and Alcon.

The TetraFlex
The TetraFlex IOL (model KH-3500; Lenstec, St. Petersburg, FL) is a single piece acrylic lens with a 5.75-mm, square-edged, biconvex lens optic. The haptics have a unique design that mimics a perforated plate haptic appearance. It is foldable and can be inserted through a 1.8-mm cartridge. The lens is designed to assume an anterior flexed position in the capsular bag and to move anteriorly with ciliary body contraction.

Sanders reported on a series of 95 eyes of 59 patient customers implanted with the Tetraflex lens, including 36 implanted bilaterally. At 6 months after surgery, 63% of all cases achieved a DCNVA of 20/40 or better. Virtually all had at least 1 diopter (D) of accommodative amplitude (98% at 1 month; 100% at 3 and 6 months); 75.7% had at least 2 D at 6 months after surgery. At 6 months or later, 92.2% had 20/40 or better UCDVA. The proportion of cases achieving a UCNVA of 20/40 or better remained relatively constant at 45% to 47%. At 6 months and later, 98.7% had a BCDVA of 20/40 or better. In the bilaterally implanted series, at 1 month after surgery, all had at least 1 D of accommodative ability; 96% had at least 2 D at 6 months. One hundred percent achieved a BCDVA, 89.3% achieved a DCNVA, and 74.1% achieved a UCNVA of 20/40 or better at 6 months after surgery. The authors concluded that the Tetraflex accommodating IOL provides enhanced near vision with good distance vision 6 months after surgery.1

The Synchrony
In San Francisco at the recent American Academy of Ophthalmology meeting, the news on everyone’s lips was the acquisition of Visiogen, Inc., by Abbott Labs. Visiogen is a small, privately funded company with one product, the accommodative intraocular lens christened “Synchrony.” The lens is not yet approved for sale in the United States; a response is expected from the FDA this year.

The Synchrony promises to deliver a percentage of spectacle independence closer to that of the Tecnis and ReSTOR without the loss of contrast sensitivity and unwanted optical side effects like halos around lights at night that are part and parcel of multifocal IOL technology. A large body of data from experience outside the United States has demonstrated that the Synchrony may offer a successful alternative here as well (see xxx). In addition, the Synchrony features a preloaded injector that delivers the dual optic implant through a 3.8-mm clear corneal incision.

http://www.visiogen.com/international/VisiogenESCRSarticles.pdf

Imaging studies have demonstrated movement of the anterior optic of the Synchrony, corresponding to the clinical amplitude of accommodation. In their retrospective analysis of 5 Synchrony patient customers, DCNVA ranged from 0.0 to 0.20 logMAR (20/20 to 20/32 Snellen acuity), push-down accommodative amplitude ranged from 2.76 to 3.22 D and defocus curve accommodative amplitude ranged from 1.50 to 2.75 D. Objectively, UBM confirmed axial forward movement of the front optic, while iTrace showed dynamic power change in refraction.2

The Synchrony IOL is a new alternative for presbyopia correction in the setting of cataract surgery and in the field of Refractive Lens Exchange. Refractive Lens Exchange is increasingly seen as an advantage over cornea-based refractive procedures, especially in those over 45.3 The function of the dual optic offers the opportunity to achieve accommodative amplitude of 3 D to 4 D by virtue of its increasing power. To optimize surgical outcomes with the dual optic IOL design (as with any other new IOL technology), we emphasize the importance of careful patient customer selection, adequate and consistent biometry method for accurate power calculation, and the implementation of a consistent surgical technique: CCC size and shape, complete cortical clean-up, anterior capsule polishing, in-the-bag IOL implantation, and rigorous postoperative regimen. Further large-number studies with longer follow-up are necessary for final estimation. These data will be available following FDA evaluation of the US multicenter clinical investigation of the Synchrony, expected during 2010.

The Sulcoflex
When it comes to the correction of astigmatism, in the United States, outside of Investigational Device Exemption (IDE) clinical investigations, we are limited to FDA-approved devices, which at present include only the STAAR 4203 TF and 4203 TL in 2.0 and 3.5 D powers, the Alcon SN60T3/4/5 in 1.5, 2.0, and 2.5 D powers. Manufacturers outside of the United States who have heeded the call to provide toric solutions include Rayner (Hove, UK), which manufacturers the T-flex 573T/623T from 1.0 to 11.0 D in 0.25 D steps. HumanOptics (Torica-S, Erlangen, Germany) and Zeiss (Acri.Comfort 643TLC/646TLC, Jena, Germany) also offer an expanded range of powers in toric IOLs.

Rayner introduced its C-flex platform in the United States this year (Figure 1) and also has an intriguing line of supplementary sulcus IOLs for pseudophakic patient customers, the Sulcoflex, designed for implantation in the ciliary sulcus of pseudophakic eyes as a piggyback lens. These are single-piece hydrophilic acrylic IOLs which can be inserted through a 3-mm incision. The 6.5-mm optic and haptic edges are round. The haptic is angulated and has an undulated design to preclude rotation. A spherical, monofocal version of the Sulcoflex has been implanted in the ciliary sulcus of pseudophakic eyes in order to correct residual ametropia. Toric, multifocal, and aspheric versions of the lens are also available to correct residual astigmatism, permit presbyopia correction, and reduce higher order aberrations in pseudophakic eyes.4 The availability of these implants in the United States could significantly enlarge the potential pool of premium IOL customers by making available presbyopia and astigmatism correction for those with pseudophakic eyes.

FluidVision
Further out on the horizon, the FluidVision fluid-controlled accommodating IOL (Power Vision, Belmont, CA) utilizes natural muscular accommodating forces in the eye to transport fluids in the lens. This results in a shape change of the lens, similar to what occurs in the natural lens (changing from thin to thick upon accommodative effort), creating a large accommodative range. Roux has presented a study demonstrating clinically that the FluidVision accommodating IOL has the potential to achieve more than 5 diopters of power change.5

NuLens
Finally, there is the fascinating NuLens (NuLens Ltd, Herzliya Pituach, Israel), a novel design that mimics the accommodative mechanism of the avian eye. It uses changes in the refractive power of the lens to increase the accommodative effect. Flexible material is displaced through an opening in a diaphragm, creating a bulge. The curvature of this bulge determines the power of the lens. Implantation in primates has revealed a displacement of the lens of up to 0.80 mm with pharmacologic stimulation in the initial post-op period, and at 0.30 mm at 18 months. In addition, the change in curvature could add an additional 40 D of accommodative power, as determined with pharmacological stimulation.6

References

1. Sanders DR, Sanders ML. Visual performance results after Tetraflex accommodating intraocular lens implantation. Ophthalmology. 2007;114(9):1679-1684. Epub 2007 Mar 21.
2. Koch DD. Objective Evidence for Mechanism of Accommodation of the Synchrony Dual-Optic IOL. American Society of Cataract and Refractive Surgery Annual Symposium, 2009, San Francisco.
3. Packer M. The age of refractive lens surgery. Curr Opin Ophthalmol. 2005 Feb;16(1):1.
4. Amon M, Kahraman G, Schauersberger. Sulcoflex (Rayner 653L) a new IOL for implantation in the pseudophakic eye: Indications and first results. Presented at the XXIV Congress of the European Society of Cataract & Refractive Surgeons, Stockholm, 10 September 2007.
5. Roux P. Early Clinical Experience with PowerVision’s FluidVision Accommodating IOL. American Society of Cataract and Refractive Surgery Annual Symposium, 2008, Chicago.
6. Alió JL, Ben-nun J, Rodríguez-Prats JL, et al. Visual and accommodative outcomes 1 year after implantation of an accommodating intraocular lens based on a new concept. J Cataract Refract Surg. 2009 Oct;35(10):1671-1678.

Mark Packer, MD

Patients sometimes ask, “Can you do both eyes on the same day?” It is usually younger patients who ask this question; especially those who present for refractive lens surgery. Refractive Lens Exchange (RLE) means the replacement of the aging crystalline lens with a manufactured intraocular lens implant – essentially the same procedure that is performed 3.5 million times per year in the United States for cataracts. However, there are several crucial differences between cataract surgery and RLE:

1) RLE is performed solely for a refractive purpose – to provide freedom from glasses and contact lenses. There is no pre-existing functional deficit due to degraded vision caused by cataract.

2) The correction of presbyopia, the loss of near vision with age, is a critical component of RLE. People under age 40 can generally become free of glasses and contacts by having LASIK or Phakic Refractive Lens implants (without the removal of the crystalline lens). However, these procedures do not correct presbyopia unless one eye is intentionally targeted for near vision only (a procedure called monovision). RLE employs either multifocal or accommodative intraocular lens implants to provide distance, intermediate range and near vision simultaneously in both eyes.

3) RLE is an “off-label” procedure – meaning that FDA has approved the implants as medical devices specifically for cataract surgery, not for strictly refractive purposes. As one package insert reads, the lens is approved “for primary implantation for the visual correction of aphakia (the absence of a lens) in adult patients with and without presbyopia in whom a cataractous lens has been removed by phacoemulsification and who desire near, intermediate, and distance vision with increased spectacle independence.” [1]

4) RLE is not covered by Medicare or commercial insurance companies; however, neither is presbyopia correction at the time of cataract surgery (beneficiaries who desire multifocal or accommodative implants pay the additional cost of the services associated with these devices).

5) RLE must include the correction of any significant pre-existing astigmatism.

Historical perspective helps elucidate why cataract and lens surgery is not typically performed on both eyes the same day in the United States. A review of safety and effectiveness publications provides the clinical background necessary to making an informed choice. Finally, the misalignment of financial incentives explains the diversity of practices found around the world. Taking all this information together, along with my own recent personal experience, allows me to answer this question in the affirmative.

Prior to the introduction of small incision lens surgery and foldable intraocular lenses there used to be a rather long period of visual rehabilitation that followed cataract surgery. For example, extra-capsular cataract extraction (ECCE) — widely used until the 1980s — generally required a sutured incision of about 8 – 10 mm that was constructed around the top of the cornea (from 10 o’clock to 2 o’clock). This type of incision induced a lot of astigmatism, which could be exacerbated by tight or asymmetric sutures. As the incision healed the sutures could be removed, and by about 3 months a pair of glasses could be prescribed. Given this time frame, it made sense to wait to operate on the second eye until the first eye was healed. Unfortunately, the astigmatism from this type of incision continued to change and so a new pair of prescription glasses was needed every year (not so bad for the eyeglass manufacturers, I guess).

There was also historical controversy regarding second eye surgery – was it really necessary? Quality of life assessments have since shown that getting the second eye done makes a significant difference [2]  and provides real value [3]. Nevertheless, it is still a widely held belief that a “decent interval” should pass between the two surgeries. For example, one web site notes that “experts say it is best to wait until your first eye heals before having surgery on the second eye.” [4]   How do we square that with a recent peer-reviewed publication that concluded “bilateral cataract surgery on the same day allowed rapid rehabilitation of the patient and helped avoid suboptimal visual function in daily life while waiting for second-eye surgery.” [5]

The safety of sequential same-day surgery has been demonstrated, as long as critical precautions are followed. These include strict separation of the two procedures and have been detailed thoroughly in the literature, as in this article:

“To minimize the risk for endophthalmitis in our
patients, the procedures in both eyes were managed as
separate consecutive surgeries. The surgical staff was
aware that the cases required extra care. A rigid protocol
for proceeding from the first eye to the second was developed
with respect to who moved what where and in
what order after the first eye was completed. The firsteye
instrument tray was removed and everyone changed
gloves before a different set of sterile instruments were
uncovered for the second eye. Balanced salt solution
from different lots and OVDs from different manufacturers
were used in the second eyes. Povidone–iodine
5% solution was applied to the conjunctival lower fornix
in both eyes just before the patient entered the operating
room. The ipsilateral hemiface was scrubbed with povidone–
iodine 10% before each surgery. Finally, intraocular intraocular
Vancocin, 1mg diluted in 0.1 mL BSS, was injected
into the capsular bag, the avascular dead space containing
the IOL, at the end of the procedure to cover
gram-positive bacteria, the most common cause of postoperative
endophthalmitis.” [6]

Historically, it made sense to wait to do surgery on the fellow eye because visual rehabilitation was slow and the benefit of surgery on the fellow eye was uncertain. Today visual rehabilitation is quick and the benefit is clear. Nevertheless, in the United States cataract surgery is only performed on both eyes on the same day in rare, exceptional situations, despite consideration that “simultaneous bilateral cataract surgery is more convenient
for the patient, requiring fewer office visits, less manipulation of systemic medications, one scheduled surgical time, quicker recovery of binocular vision and return to normal life.” [7]   The reason may be quite simple. As Arshinoff has pointed out, “the greatest opposition to simultaneous bilateral cataract surgery comes from surgeons living in areas with the most severe financial penalties for simultaneous bilateral cataract surgery.” [6]

In fact, Medicare/Medicaid and most commercial insurers only pay 50% for the second procedure on the same day, a reimbursement rate that is not economically sustainable. However, as noted above, RLE is not a covered procedure. In this refractive environment, same day sequential surgery becomes possible and advantageous for both surgeon and patient.

[1] http://www.tecnismultifocal.com/

[2] Lundström M, Stenevi U, Thorburn W. Quality of life after first- and second-eye cataract surgery: five-year data collected by the Swedish National Cataract Register. J Cataract Refract Surg. 2001 Oct; 27(10):1553-9.

[3] Casado Collado A, Castells Oliveres X, Ribo Bonet C, Alonso Caballero J, Castilla Cespedes M, Badia Sala M, Buil Calvo JA; International Society of Technology Assessment in Health Care. Meeting. Second eyed cataract surgery compared with the first eye. Improvement in visual acuity, visual function and health status. Annu Meet Int Soc Technol Assess Health Care Int Soc Technol Assess Health Care Meet. 1997; 13: 119.

[4] http://www.avclinic.com/Cataract.htm

[5] Lundström M, Albrecht S, Nilsson M, Aström B. Benefit to patients of bilateral same-day cataract extraction: Randomized clinical study. J Cataract Refract Surg. 2006 May;32(5):826-30.

[6] Arshinoff SA, Strube YN, Yagev R. Simultaneous bilateral cataract surgery.  J Cataract Refract Surg. 2003 Jul;29(7):1281-91.

[7] Arshinoff SA, Chen SH. Simultaneous bilateral cataract surgery: Financial differences among nations and jurisdictions. J Cataract Refract Surg. 2006 Aug;32(8):1355-60.

Mark Packer

There was a cartoon in The New Yorker magazine many years ago now in which one socially erudite martini-wielding fashion plate said to another, “I don’t have time for instant gratification.” In the world of Refractive Surgery, the concept of the “Wow Factor” reflects the attitude lampooned in this satire. LASIK, in fact, has offered immediate relief for the vast majority of optically challenged individuals willing and able to undertake the surgical path, and 95% say they would do it again (http://www.usaeyes.org/lasik/library/lasik-success-rate.htm).

Refractive lens surgery (cataract or lens removal with implantation of a multifocal or accommodative intraocular lens for the correction of presbyopia) does not offer the same instantaneous results because time is required for adaptation to the new visual imagery. Nevertheless, 95% of people who have multifocal implants achieve the same level of satisfaction one year after surgery as people who had LASIK (Table 19, http://www.tecnismultifocal.com/package-insert.pdf).

The individual with cataracts who sees the opportunity to achieve freedom from bifocals in the context of a medically necessary procedure represents a unique hybrid in the world of medicine: a patient, by dint of having a diagnosis, and a customer, by opting for an elective procedure not covered by any type of health insurance. Who are they? (Nair BR. “Patient, client or customer? http://www.mja.com.au/public/issues/xmas98/nair/nair.html).

Because patience is required for neural adaptation to multifocal lens implants (1), the phrase “patient customer” epitomizes this new role. Also, because patience is a virtue we develop in the second half of life (2), patience is appropriate to the practice of presbyopia correction. Finally, because personal payment for a valued service carries with it all the force of the conventional customs of commerce, these individuals truly embody the identity of customers, with all the rights and responsibilities pertaining thereto.

References

1. Pepin SM. Neuroadaptation of presbyopia-correcting intraocular lenses. Curr Opin Ophthalmol. 2008 Jan;19(1):10-2.

2. Arrien A. The Second Half of Life: Opening the Eight Gates of Wisdom. Sounds True, Incorporated; illustrated edition (September 1, 2007). Pages 80, 83, 141.

In San Francisco at the recent American Academy of Ophthalmology meeting, the news on everyone’s lips was the acquisition of Visiogen, Inc., by Abbott Labs. Visiogen is a small, privately funded company with one product, the accommodative intraocular lens christened “Synchrony.” The lens is not yet approved for sale in the United States; a response is expected from the FDA next year.

Since May 2005, the Center for Medicare and Medicaid Services (CMS) has allowed beneficiaries to pay out of pocket for services associated with the implantation of presbyopia correcting intraocular lenses to reduce or eliminate the need for glasses after cataract surgery. In 2005, there were 3 entries in this category: the crystalens, a single optic accommodative lens subsequently acquired by Bausch & Lomb; the ReZoom, a refractive multifocal IOL from AMO (now Abbott Medical Optics); and the ReSTOR, a diffractive multifocal IOL from Alcon. In the past 4 years both the crystalens and the ReSTOR have undergone major makeovers, and AMO has launched an entirely new multifocal, the aspheric diffractive Tecnis.

The most complete data on the Tecnis Multifocal demonstrates that 88% of patients implanted in both eyes never wear glasses 4 to 6 months after surgery; a similar study of the ReSTOR +3 and +4 diopter implants reveals that 76% of patients implanted in both eyes with either design never wear glasses. The original FDA data from the crystalens AT-45 investigation (completed in 2003) showed that only 27% of patients never wore glasses (crystalens is now available as the HD-500).

The Synchrony promises to deliver a percentage of spectacle independence closer to that of the Tecnis and ReSTOR without the loss of contrast sensitivity and unwanted optical side effects like halos around lights at night that are part and parcel of multifocal IOL technology A large body of data from experience outside the United States has demonstrated that the Synchrony may offer a successful alternative here as well (see the collection of articles in this document,1 and, for example, “Prospective Randomized Clinical Study Comparing Synchrony Dual-Optic Accommodating IOL and ReSTOR Aspherical Multifocal IOL”2). In addition, the Synchrony features a preloaded injector that delivers the dual optic implant through a 3.8-mm clear corneal incision (see photo).

In addition, imaging studies have demonstrated movement of the anterior optic of the Synchrony corresponding to the clinical amplitude of accommodation.3 In their retrospective analysis of 5 Synchrony patients, DCNVA ranged from 0.0 to 0.20 logMAR (20/20 to 20/32 Snellen acuity), push-down accommodative amplitude ranged from 2.76 to 3.22 D and defocus curve accommodative amplitude ranged from 1.50 to 2.75 D. Objectively, UBM confirmed axial forward movement of the front optic, while iTrace showed dynamic power change in refraction.

Abbott’s confidence in this technology has sent ripples of excitement throughout the cataract and refractive technology sector. Visiogen’s early success will spur on innovation and creativity throughout the industry and provide even better solutions for independent-minded baby boomers.

References

1. http://www.visiogen.com/international/VisiogenESCRSarticles.pdf
2. Eduardo F. Marques, MD. Prospective Randomized Clinical Study Comparing Synchrony Dual-Optic Accommodating IOL and ReSTOR Aspherical Multifocal IOL. Presented at the American Society of Cataract & Refractive Surgery, San Francisco, 2009.
3. Douglas D. Koch, MD. Objective Evidence for Mechanism of Accommodation of the Synchrony Dual-Optic IOL

Performing surgery outside of one’s familiar surroundings—especially outside of one’s own country—creates challenges of personality and purpose. I have had the opportunity several times now, in various locales, to perform live surgery at international congresses and operate using new technology not yet available in the United States. I’ve successfully completed cataract surgery in India, Malaysia, Germany, Mexico, Brazil (twice) and Italy (twice). Every time I do it I learn more about surgery and more about myself.

Most recently I had the opportunity to perform cataract surgery in Sao Paulo, Brazil. I had already done so once before—in December, 2001, at the Instituto de Catarata, Departmento de Oftalmologia, Universidade Federal de São Paulo—as part of a symposium presentation. This time I was asked by one of the intraocular implant manufacturers to gain experience with some of their newer products.

I am a creature of surgical habit and punctilious protocol. At my own surgery center I insist on every little thing being just so, from the position of the microscope foot pedal to the size of each cannula. I have my own special diamond knives and a special relationship with each of my microforceps. I’m very nice, and my staff would say that I’m a lot of fun in the OR, but I’m also quite demanding. I have a huge stake in the outcome of every procedure, and I am always striving for perfection.

Arriving at the eye clinic in Sao Paulo to perform surgery, I had no instruments of my own (my luggage had been temporarily delayed back in the United States). As I observed the resident surgeon’s technique, I decided on the spot to completely adopt his approach rather than try to explain my own technique and try to adapt the Brazilian operating room to my accustomed behavior. I decided it would be easier to just go with what was going on.

I was aware that this would mean a large change for me. For example, I sit at the side of the patient when operating; the Brazilian surgeon sat at the head. I use two 1.3 mm temporal clear corneal incisions to extract a cataract; he used one 2.2 mm incision to the right (nasal in a left eye, temporal in a right eye) and one 1.0 mm incision to the left (temporal in a left eye, nasal in a right eye). I separate inflow and outflow—irrigation and aspiration—via my 2 symmetric incisions; he used an irrigation sleeve on his aspiration needle so inflow and outflow occurred through the same incision. I use a microforceps to perform the most delicate part of the operation—the capsulorhexis; he used a unique and relatively large forceps, the jaws of which actually open rather than close when firmly squeezed. I use an irrigating chopper to divide up the cataract; he used a small curved rod known as a Sinskey hook. Really, except in the broadest sense, we perform 2 very different operations. The only gross similarity is the use of phacoemulsification, ultrasound, to break up the cataract. At least he did have state of the art phaco machines, and I am familiar with those.

I reassured myself that the principles of phacoemulsification are the same no matter the specific techniques. We construct a self-sealing corneal incision, open the lens capsule, divide up the cataract, remove the pieces, leave the lens capsule intact and clean, and place an intraocular lens in the capsule where the cataract used to be. Sounds simple, but there are a lot of details, and, as I said, I am a creature of habit. I was extraordinarily nervous about following what I nevertheless was certain was the right course.

When I sat down in those unfamiliar surroundings I realized that the view through the microscope was also entirely different from what I was used to. At that moment I was incredibly relieved and thankful that my assistant scrub nurse was actually an eye surgeon herself and a rather good English speaker. Her voice and confidence reassured me, and I got the attitude of success. I knew I could make it right. Despite a pretty shaky hand and a lot of second-guessing, I did in fact persevere and accomplished 2 cataract cases without complication.

The next day, both of those patients were able to read the 20/20 line on the eye chart without correction, and I had learned a valuable lesson. It is the skill of the surgeon that makes the surgery. We possess great technology and brilliant techniques—and we should not allow them to possess us. Finding challenges that force us to adapt to different methods and think through the fundamentals of what we do leads us to greater self-confidence and ultimately makes us better surgeons.

Mark Packer & Howard Fine

Several years ago, at a meeting of the European Society of Cataract and Refractive Surgeons, we volunteered to help teach a wet lab on complications of phaco.  The lab was held down a dingy corridor in some forsaken corner of the “Congress Centrum.”  The lead instructor, Brian Little, briefly described a technique for saving the errant capsulorhexis and showed some gorgeous videos with high magnification views of popping zonular fibers.  The technique involved a counter-intuitive maneuver, essentially pulling the flap in precisely the wrong direction.  Nevertheless, the capsule consistently behaved itself beautifully and the capsulorhexis was saved.  The impression Brian gave was that he had learned this technique from a cataract surgeon much more important and probably a lot more famous than himself.  In fact, it seemed to us that he had probably learned it from a well-established textbook of cataract surgery and that we had perhaps skimmed that chapter a bit too lightly.   Brian said, “I promise you this will work every time.”  Trying it on our own in pig eyes seemed to support his argument, but we were still somewhat hesitant to throw ourselves wholeheartedly into the technique.  As with anything new, we tried to look objectively at the potential benefit to our patients rather than focus on our own anxiety.  We did indeed try, and after repeated rhexis-preserving moments at Oregon Eye Surgery Center we knew that Brian really had a winner.

Sometime after that, during a casual conversation with Brian at a subsequent meeting on our home turf, while he was importuning us to contribute material for a video textbook of Ophthalmology, it came as a shock to discover that Brian had in fact come up with this little trick all by himself.  Relief, that we had not missed an important chapter on cataract surgery, was mixed with awe, that he had not yet published the technique himself.  “Too busy to write it up,” he said.

A couple of years later, while we were giving Grand Rounds at a well known university in the western United States, Brian Little’s technique came up again.  One of the faculty members, a cataract surgeon, interrupted the lecture to explain that the maneuver actually involved grasping the torn edge of the capsular flap as close to the point of its origin as possible and pulling in the direction one wanted it to go.  We stopped, and emphasized again, in several different ways, with lots of hand waving, that the pulling was in fact in the direction opposite to that in which one intended to go.  There was an awkward pause.  We weren’t sure if we’d gotten the message across or not, but in any case there were no further comments.  The lecture resumed.

Some techniques take a moment, or longer, to be fully grasped.  Some may take a lifetime.  Brian Little’s technique takes some getting used to because it is probably different from what one was initially taught, and it is also different from what one might expect.  But, of course, innovations tend to be unexpected.  Another example of an innovation that requires a moment’s reflection, or more, is cortical cleaving hydrodissection.  Just saying it may require some reflection (it is not cortical “cleavage”).  Cortical cleaving hydrodissection actually does permit aspiration of most if not the entire cortex during removal of the epinucleus, most if not all of the time.   How is this accomplished?  The key is decompression of the capsular bag and rotation of the lens after the fluid wave.  Injection under the rim of the capsule causes the lens to bulge forward as fluid is trapped within the bag behind the lens.  Pushing posteriorly on the lens will force the trapped fluid to come forward around the lens, lysing the connection of the capsule to the cortex.  A good rotation of the lens will strip away any bridging cortical tendrils.  The cortex is now loose, and will wash into the phaco tip with the epinucleus.   Any few remaining strands of cortex can be teased away when viscoelastic is removed after IOL insertion, thus avoiding I/A as a separate step in the procedure most of the time. 

As Wayne Dyer says, “You’ll see it when you believe it.”  (Parenthetically, you may wish to gauge the openness of your own mind by honestly evaluating your inner reaction to what you have just read, including any preconceived notions you may have about Wayne Dyer, the “new age” or Oprah).  Regardless, a conceptual understanding of cortical cleaving hydrodissection and a high level of confidence in that understanding (“believing it,” if you will) absolutely must precede the successful application of the technique in your own hands (“seeing it”).  Even if it occurs by accident in your OR one day (even the proverbial monkey typing random keys on a laptop will eventually write Hamlet’s soliloquy) you will not be able to consistently and repeatedly perform the technique unless the mind first grasps what the fingers need to do.  That’s just the way the world works.  (Can you really doubt the primacy of mind over matter, when you consider the incredible achievements that have come from the seeds planted years ago by Harold Ridley and Charlie Kelman?)

The best lessons in life come from experience, not from books, video tapes or journals (sorry, but we’ll wager that the publishers agree).  What makes experiential education so valuable is that we don’t forget what we’ve learned.  That heart-stopping moment in the OR when you thought you lost it, but Brian Little’s maneuver brought it back, is not going to be forgotten.  You will recall that moment through many if not all of your upcoming capsular adventures.  For this reason cataract surgery must ultimately be taught and learned in the operating room, where sight is on the line, where a real human being, a real patient with real feelings and the real desire to see, is lying there behind the eye you are working on.  Only that intensity focuses all the desire and skill in the world to bring about a happy ending.  Only that intensity will serve to remind you of what you need to know in the nick of time.

Recent advances in ultrasound and fluidics permit the safest and most effective cataract extraction procedures. My current setting for the state-of-the-art machines from each of the major manunfacturers are attached.

Abbott Medical Optics “Signature” — Click here to view pdf

Alcon “Infiniti” — Click here to view pdf

Bausch & Lomb “Stellaris” — Click here to view pdf

If you’re unable to view the videos on your Mac, please visit Windows Media® Components for QuickTime, by Flip4Mac™. You’ll be able to play Windows Media files (.wma and .wmv) directly in QuickTime Player and view Windows Media content on the Internet using a Web browser.

The New York Times recently published a column on presbyopia correction highlighting Refractive Lens Exchange. However, the article opens with a description of an early stage Russian laser technology from an Ohio-based company called Oculatek (see Skin Deep: To Squint Or See The Light, by Camille Sweeney, January 1, 2009). I had never heard of Oculatek until I saw Sweeney’s article reprinted today in the Chicago Tribune (Taking long view on presbyopia: Light treatment a new option for loss of sight, Camille Sweeney, New York Times News Service, January 25, 2009). Searching Google, I found a press release dated 2006 stating that “Oculatek is a joint effort between 5iTech; EST, Inc., a medical electronics design company of Solon, Ohio and JSC MACDEL, a medical device company headquartered in Moscow, Russia.” To investigate further, I searched the MACDELweb site which states that “Our method … gives the hope to retain vision under any effects related to stress of eyes (computer, television, reading, games, etc.). This preventive method is most effective for the age period of 2 to 18 or 19 years. The procedures are contact-free, non-traumatic, and painless. MACDEL-00.00.09 infrared laser set for correction of accommodation and refraction disorders of vision. Therapy and prevention of myopia, amblyopia, nystagmus, strabismus, vision fatigue, prevention of complications after myopia correcting operations. The efficiency in elimination of accommodation spasm is close to 100 per cent.” The web site states that the application for presbyopia correction is under investigation. Jim Ohneck, president of Oculatek, wrote in an e-mail that “Our company is relatively new and the product is not FDA cleared at this time. The technology originated form Helmholtz Eye Institute and was originally developed for progressive myopia. Because the mechanism of action is to improve the flexibility of the ciliary muscle we felt there might be some potential here in the states for presbyopia.” (more…)