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New technologies add value through better outcomes, happy patients, more efficient practices
A surgeon explains how intraoperative aberrometry and femtosecond laser have improved refractive outcomes in his practice.
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Adding any new technology to the OR almost always forces a surgeon to take one step back in terms of procedure time. But that temporary slowdown is worth it if the new technology ultimately takes me two steps forward in delivering the best outcomes for my patients. In rural Texas, my surgical volume is highly dependent on word-of-mouth marketing from satisfied patients. With that philosophy, my practice has been an early adopter of many new technologies, including femtosecond laser and intraoperative wavefront guidance for cataract surgery.
I was initially somewhat skeptical of the value of intraoperative aberrometry. My results were good already, and my confidence in contemporary IOL power calculation formulas was high, with the notable exception of post-refractive eyes. In these patients who are otherwise eager candidates for presbyopia-correcting IOLs, it is difficult to achieve the targeted postoperative refraction using existing formulas.
Robert P. Lehmann
It was for these patients that I was first prompted to try the ORA system (WaveTec Vision). The performance of the device in two toric repositioning cases and the solid improvement in overall refractive outcomes made me incorporate the device for routine use.
Toric repositioning
Toric IOLs represent about 20% of my total cataract cases. Intraoperative aberrometry is useful in identifying the true aphakic magnitude and axis of astigmatism and in aligning the lens on the correct axis intraoperatively. But what convinced me of its value were two cases in which I had to bring patients back to the OR for repositioning of a previously implanted toric IOL.
As every surgeon knows, this is a high-stress situation. You have an unhappy premium IOL patient that you are about to expose to a secondary surgical procedure without absolute certainty that you will be able to make vision better. If repositioning does not work, you may need to go back a third time to perform a corneal refractive enhancement or even explant the lens. Most of us approach such cases with anxiety — and a lot of calculating and recalculating to determine where the lens was supposed to be, where it actually is and where it should be.
In both cases in which I have repositioned a toric lens with the ORA system, however, it was a different experience. VerifEye, the latest iteration of this system, provides streaming refractive data, so I was able to see the astigmatism changing dynamically as I repositioned the lens. A quick capture confirmed that the predicted astigmatism at the new axis was close to zero. There was no guessing and less worrying, and both patients ended up with near-plano results. Even more rewarding was the fact that both patients saw a dramatic and satisfying improvement in vision immediately after the procedure.
Routine use
Intraoperative aberrometry is a step forward in power calculations for very short eyes, post-LASIK eyes and astigmatic eyes, but I now routinely rely on it to help me achieve the best possible outcomes for any patient who wants good uncorrected vision. I find the ORA system to be a nice complement to my LenSx femtosecond laser (Alcon) because both increase the precision of my surgery. I have already seen that both of these technologies are continuing to evolve in terms of ease of use and results, and I fully expect that to continue.
Since implementing the ORA system, the percentage of eyes within 0.5 D of the target refractive error has increased by 4 percentage points, from 79% to 83% (Figure 1). Four percentage points might not sound like a lot, but in a high-volume practice, that can mean that several more patients each week are within the “sweet spot” for a highly satisfactory outcome. Also, my prediction error decreased from 0.33 ± 29 D to 0.29 ± 0.25 D. This difference is statistically significant (P < .04).
The accuracy of the system increases over time, particularly for frequently implanted IOLs, because the surgeon’s postoperative results are used to optimize the regression coefficients and the surgeon factor the device uses to calculate the power and effective lens position for a given IOL.
Today, with optimized IOL constants, I alter my choice of IOL power based on the intraoperative ORA measurements in about 24% of all eyes (Figure 2). Most commonly, the change is a 0.5 D shift in the spherical power or a switch from an SN6AT5 to a T6 (both Alcon), for example. I would caution new users to be careful about larger discrepancies between the preoperative IOL power choice and the ORA-recommended choice. The intraoperative aberrometry measurement may very well be pointing to the more accurate power choice, but it is important to make sure that IOP or other variables are not affecting the accuracy. It is worth repeating the measurement one or more times in cases of large discrepancies.
Conclusion
We are fortunate in ophthalmology to enjoy a steady rate of technological advancement. Not every new gadget is worth the hype; in my estimation, the technologies that will last are the ones that add value in the form of better outcomes, more satisfied patients and stronger, more efficient practices.
Earlier developments, such as phacoemulsification and femtosecond laser flaps, have convincingly proven their worth. What we saw during the transition to these technologies becoming standard practice is that good technology always gets better as manufacturers invest in continuous improvement. Although we are early in understanding the potential of both of the new technologies I have discussed here — the LenSx femtosecond laser and the ORA intraoperative aberrometry system — I believe that current outcomes reflect the improvements these devices have already undergone and position them well for long-term success in our practices.