Cataract surgery is enjoying remarkable advancements in the field of ophthalmology. We delve into the perspectives of two leading experts in the industry, who shared the cuttingedge innovations they utilize in their practice, their most anticipated developments, and their visions for the future.
Ophthalmology has come a long way. And when it comes to the anterior segment and cataracts in particular, the progress has been nothing short of breakneck — especially considering that for much of human history, cataracts were known but poorly treated. Some scholars have hinted that cataract surgery might have first taken place during the Bronze Age, but none of the evidence is definitive.
In Egypt, copper needles or probes were found in 1900 in the tomb of King Khasekhemwy at Abydos. And in ancient Babylon, the code of Hammurabi specified the charges and penalties for making an incision that heals a man’s eye.
Indeed, the history of cataract surgery is long and august, but the developments we are experiencing right now are unparalleled compared to any previous era.
Thankfully, we don’t have to consult ancient hieroglyphic inscriptions to scry the latest in cataract surgery. At CAKE Magazine, we have our very own squad of oracles to help out.
Redefining phacoemulsification performance
Dr. William Trattler, a cataract, refractive and corneal surgeon enjoys any opportunity to take advantage of the latest technology medical sciencehas to offer. And he was happy to share his experience with us.
He was particularly keen to point out the considerable promise of a device made by Carl Zeiss Meditec (ZEISS), the German manufacturing giant headquartered in Jena. The QUATERA®700 is a phacoemulsification system that measures and simultaneously controls both infusion and aspiration volumes during cataract surgery. It includes automated ultrasound power on demand, can be easily integrated into the other devices in the ZEISS portfolio, and, as the company states, “provides maximum efficacy during surgical procedures.”
“The QUATERA 700 does seem to be very promising for cataract surgery. It’s a device designed for phacoemulsification, one that has new fluidics, which helps provide a very stable chamber. We’ve had several advances in this area recently, but the QUATERA 700 appears to be another step up,” Dr. Trattler shared.
He enthused that he has been very fortunate to work with a number of great technologies, “and the QUATERA 700 is something that makes me very excited,” he said. “It works using a four-pump mechanism and it’s perfect at maintaining pressure throughout the surgical process, no matter how much energy or vacuum you’re using. As such, it provides a safe and efficient environment in which to perform cataract surgery,” he added.
Lenses are lit
Devices such as ZEISS’ highlight the impact of technology on cataract surgery. And that’s something that can be seen across the board, particularly in the realm of lenses.
Dr. Chelvin Sng is a leading cataract specialist and the medical director at the Chelvin Sng Eye Centre in Singapore. And when we asked her about the new tech developments that excited her the most, her answer was clear: Lenses. Her excitement stems not only from her scientific interest but also from her practical experience in the field.
“Cataract surgery has evolved to become ‘refractive surgery,’ as patients expect not only to have a good clinical outcome but also good unaided distance and near vision,” Dr. Sng shared. “Cataract surgeons have to be wellversed in new technologies, such as new intraocular lens (IOL) implants and artificial intelligence-guided biometry, to improve their surgical and refractive outcomes. Preoperative patient counseling has become increasingly important so that the patient’s expectations are aligned with their choice of intraocular lens,” Dr. Sng explained.
She shared that she uses extendeddepth- of-focus (EDoF) IOLs in her practice. “These allow my patients to enjoy excellent distance and intermediate vision without compromising their contrast or night vision as much as conventional multifocal intraocular lenses do. Recently, more variations in EDoF lens designs have allowed a wider range of patients to enjoy a greater degree of independence from spectacles compared with monofocal lenses,” she continued.
Dr. Trattler was also keen to point out how lens technology has improved cataract surgery. In his case, he was focused more on the importance of lens placement, pointing to the Zepto IOL Positioning System™.
Created by Centricity Vision, Inc. (California, USA), the Zepto System is described by its maker as the world’s “first and only device that creates an instantaneous capsulotomy for precise, 360-degree overlap and improved outcomes.” Dr. Trattler views it as an intuitive, easy-to-use device that can ensure considerable efficacy during the surgical process, especially for patients who represent more difficult cases.
“A lot of research has been focused on trying to automate the capsulotomy step, which can be difficult in certain patients. For example, if you have a patient with corneal scars, it’s going to be tougher to view their cataracts. Patients who have undergone radial keratotomy (RK) will also be more difficult to treat because the laser has to go through the cornea, and the RK scars can interact and affect the laser,” Dr. Trattler explained.
“This is why I’m excited about the Zepto device, as it goes directly inside the eye. Even if the patient has small pupils, you can use Zepto as an expansion device that will help make the pupils larger. I’m really looking forward to having access to that technology on a routine basis,” he shared.
The robots are coming
Of course, we would be remiss if we didn’t consider not only the current developments in cataract surgery that are making leading clinicians excited but also what innovations are on the horizon.
For Dr. Sng, the way ahead is clear — thanks to advancements in imaging technology in the anterior segment and ophthalmology as a whole. Improvements to widely used technologies such as optical coherence tomography (OCT) will provide numerous benefits, especially as they are already commonly used around the world.
“I am most excited about innovations to improve the accuracy of predicting refractive outcomes for our patients. These include the new biometry techniques using total keratometry values and OCT based imaging. Such innovations will enable us to achieve better refractive outcomes for our patients who want the best possible unaided vision,” Dr. Sng noted.
“This is particularly important to me as it will help me maintain my clinical gold standards for cataracts. These are ensuring accurate biometry, which may require repeated measurements, and detailed preoperative assessment to detect subtle or early ocular pathology, including OCT of the macula. Specular microscopy is also important to detect early Fuchs endothelial dystrophy or low endothelial cell count,” she continued.
As for Dr. Trattler, he’s looking forward to a subject that will always pique everyone’s interest: Robots. While robotics in cataract surgery may be in its infancy, it’s not difficult to imagine how quickly AI-driven technology will become more common in the operating room — and anterior segment ophthalmology is no exception.
In particular, Dr. Trattler pointed to the work of Horizon Surgical Systems (California, USA) as promising. This company is a newcomer to the ophthalmology industry, having only been registered last year. But it is already generating considerable buzz.
Its mission is to revolutionize microsurgery by using advanced robotics along with AI. However, rather mysteriously, Horizon’s website describes its current operations as being in ‘stealth mode.’ Luckily, Dr. Trattler was able to give us a glimpse into their work.
“Horizon Surgical Systems is developing robotic cataract surgery, which may sound far fetched. But consider how only a few years ago, driverless cars were thought to be impossible. Surgery will still require the supervision of an in-house ophthalmologist, just like many laser techniques today, but this will allow it to become automated,” Dr. Trattler shared.
“This technology may not appear for five years, for example, but I believe Horizon is looking to start human trials in the next year or two. If they’re successful, cataract surgery could become all the more precise, with improved safety and efficacy,” he concluded.
- Leffler CT, Klebanov A, Samara WA, Grzybowski A. The History of Cataract Surgery: From Couching to Phaecomulsification. Ann Transl Med. 2020;8(22):1551.
Editor’s Note: A version of this article was first published in CAKE Magazine Issue 19.