Trusting new technology brings patients better results

An intraoperative wavefront aberrometer helps a cataract surgeon obtain better refractive outcomes by providing data unavailable in presurgical workup.

Issue: January 25, 2011

ByP. Dee Stephenson, MD, FACS

P. Dee Stephenson

I have been successfully performing cataract surgery for 20 years. About a year ago, I started using the ORange intraoperative wavefront aberrometer from WaveTec Vision Systems, and I have learned that it makes a big difference for my patients. Having the ability to check patients’ refraction while they are on the operating table guides my decisions and helps me verify any corrections that need to be made.

Premium lens case

In a particular case, a patient presented for cataract surgery and implantation of a premium channel lens, desiring to be spectacle-free after surgery. A very thorough presurgical workup is required to meet the high demands of premium lens patients. For all of my patients, I perform A-scan biometry with the IOLMaster (Carl Zeiss Meditec), make manual keratometry readings and compare manual readings with IOLMaster readings to make sure I have accurate and repeatable measurements. Corneal topography with the Zeiss Atlas is also performed, as well as optical coherence tomography (Topcon OCT) of the macula to make sure there are no hidden pathologies.

All measurements put the axis of astigmatism in this patient’s left eye at 180°. I determined that a pair of limbal relaxing incisions (LRIs) at the 180° axis would be the best solution to correct his astigmatism.

At the time of the surgery, I performed phacoemulsification and removed the cataract. I then used the intraoperative wavefront aberrometer to perform additional biometric readings. All readings showed the patient’s astigmatism on the 90° axis, 90° away from my preoperative readings. As the technology was new to me, I relied on my previous experience and performed the LRIs according to my extensive preoperative measurements, without using the technology.

Postoperative results

On the first postop day, I re-measured the corneal astigmatism and found 3.5 D of astigmatism at the 74° axis. This revealed that the LRIs I created had increased his astigmatism. In order to give the patient his desired results, a second surgery was necessary to decrease the astigmatism.

In planning the surgery for his right eye, I completed the same extensive preoperative workup as with the first eye. After removal of the cataract, I obtained new readings in the operating room using ORange. This time all measurements coincided, showing astigmatism at the 180° axis. I performed a pair of LRIs as planned on the 180° axis. On the first day postop, his right eye was 20 /20^-2, with 0.25 D of astigmatism at axis 6.

After several months, the patient now has uncorrected distance vision of 20/20 in his right eye and 20/30^-2 in his left eye. At midrange, he is 20/16 in the right eye and 20/20 in the left. And without glasses, at near he is J2 with both eyes together. With a refraction of –0.25 sphere in his right eye, he is 20/20+ at distance, and with a –0.50 + 1.25 at 75, 20/20 in the left eye. He is spectacle-free for distance vision but uses reading glasses for small print and in dim light.

This patient’s left eye was an unusual case. Most of the time, the extensive preoperative workup I perform leads me to successful results. However, there can always be an exception to the rule, and from this case I learned to value ORange as an indispensible addition to my armamentarium. The ability of ORange to measure and analyze the refractive power of the eye at the time of cataract surgery provides the surgeon data that cannot be gained through the preoperative workup. If I had followed the readings ORange gave me intraoperatively and changed my surgical plan, I could have avoided the second surgery on his left eye.

I try to give my patients as close to emmetropia as possible with every surgery, and this tool helps me achieve that. The ability to review patients’ wavefront topography while they are still on the operating table has raised the bar for surgeons like me. My patients used to tell me, “Yes, I’m happy with my vision.” Now I hear, “I love my vision and can’t believe I can see so well without any glasses.”

P. Dee Stephenson, MD, can be reached at Stephenson Eye Associates, 200 Palermo Place, Venice, FL 34285; 941-485-1121; fax: 941-486-0571; e-mail: eyedrdee@aol.com; website: www.stephensoneye.com.
Disclosure: Dr. Stephenson has no direct financial interest in the products mentioned. She is not a paid consultant for any companies mentioned.