BLOG: Three tools every operating room should have

ByJohn A. Hovanesian, MD, FACS

How we manage and avoid complications says more about us as surgeons than the number of procedures we perform or the refractive outcomes we strive for. Being prepared for challenging cases depends on both knowledge of maneuvers to stay or get out of trouble and the availability of tools that can help us do the same. As a cataract surgeon working in Orange County, California, the “Silicon Valley of eye care,” I have a better chance than most surgeons to try many new technologies developed both here and elsewhere. Here I present my own list of three tools every cataract surgeon should have access to to manage and avoid complications. Unlike obvious choices such as the Malyugin ring (MicroSurgical Technology), which, along with its alternatives, is already widely used in ophthalmology, this list includes items that most surgeons do not currently employ, based on utilization data. It is obviously not an exhaustive list, but each of these items is unique and has no FDA-approved alternative.

1. Omidria (Omeros) is a combination of phenylephrine and ketorolac that is added to the cataract surgery infusion bottle to maintain pupil dilation during surgery. Controlled studies and lots of clinical experience have shown that this additive maintains pupil size much better than epinephrine or epinephrine/lidocaine, especially for cases of intraoperative floppy iris syndrome (IFIS). In the fourth quarter of this year, Omidria will be reimbursed as a pass-through expense by Medicare and many private insurance carriers. In my own surgery center and others, we have seen fewer complications and faster surgery times consistent with the use of Omidria. I believe it should become part of the standard of care in cataract surgery.

2. Resure sealant (Ocular Therapeutix) is a hydrogel sealant that is painted onto the corneal incision at the conclusion of surgery. It provides a wound seal that is more resistant to leakage than sutures, according to FDA studies. It’s a soft gel that dissolves or falls off the eye in a few days, after the epithelium has healed underneath it. It is invisible to patients and causes none of the discomfort that a suture does. While Resure can be used for uncomplicated cataract surgery, it is especially a lifesaver in the event of an irregular incision, such as after a wound burn. Some of these irregular, constricted incisions are almost un-closeable by suture but respond nicely to Resure. While not a product that is necessarily required for routine cataract surgery, it has value for older patients who might rub their eye, cases of IFIS in which prolapse can occur with a leaky wound, refractive cases in which maintaining a full anterior chamber ensures an accurate refractive result, and others. My colleagues and I use it regularly and make sure it is available in every operating room at every hospital we visit.

3. MiLOOP (Iantech) has received much attention lately, including in our cover story of this issue of Ocular Surgery News. This is deservedly so. An ingenious innovation in cataract surgery, it employs a very simple nitinol loop of wire material that can be used to encircle the nucleus of the lens and fragment it without ultrasound energy. This tool can be a lifesaver for extremely dense nuclear cataracts. It is simple to learn to use and has a very low cost, given its benefits. Some surgeons use it even in routine cases because they appreciate the time savings and feel it meaningfully reduces phase energy.

Most surgeons who try these “what if” technologies will find a right fit in their practice. For myself, I use Omidria in every cataract case, while I reserve Resure and miLOOP for cases in which they are uniquely indicated. Others might use all three routinely. Whatever your approach, you’ll want to consider having these three technologies available should the need arise.

Disclosure: Hovanesian reports he is a consultant to Omeros and a consultant and/or shareholder in Ocular Therapeutix and Iantech.