Speed. Precision. Accuracy. Fine motor skills. The ability to make tight maneuvers. These characteristics might make some think of surgeons and their high-tech equipment — this is, after all, an ophthalmology magazine. But for the team behind CAKE Magazine, these attributes also make us think of car racing — Formula One, to be exact, with the highest performance cars, the greatest caliber of drivers, and the biggest prizes to be won. Come to think of it, these all sound a lot like ophthalmology — with its complicated surgeries, topnotch eye doctors, and prized patient outcomes.
Surgeons, like race car drivers, need the best equipment to provide optimum patient outcomes (the real grand prize). And many of those characteristics required for a race car are also key factors in surgical equipment, devices and lasers. Follow us on this circuitous route — we promise, it comes full circle.
Start your Engines
Like steering wheels to drivers, lasers are a critical tool for anterior segment surgeons. And if improving a patient’s condition is the race to be won, laser provides advantages like precision, speed and accuracy.
Dr. Francis Mah, an advanced corneal, cataract and refractive surgery specialist based in La Jolla, California, frequently uses lasers, including YAG, excimer and femtosecond lasers from J&J Vision Care Inc. (Jacksonville, Florida, USA), Nikon (Tokyo, Japan), and Alcon (Geneva, Switzerland) in his practice.
In addition to the above-mentioned advantages in using laser in his practice, Dr. Mah is also looking for one more reward: safety. “Assuming all lasers have the characteristics of precision, speed and accuracy, the main advantage for me is safety and repeatability of the laser,” he explained.
“Applying the car racing analogy, this also means I can routinely make the movements — or turns — needed to accurately perform the procedure. But, hopefully, the main benefit of laser is that I’m going to have a safety advantage.”
So, what else fuels Dr. Mah when he’s in the driver’s seat? Ergonomics, for one: “There’s a lot of companies making lasers, and they’re all fabulous. For me, it’s the ergonomics — having everything you need in a sensible place, the user interface making sense the first time you look at it, feeling comfortable as you sit there because you’ll be there case after case. You’re sitting there looking at various different aspects for a length of time, so you must be comfortable lap after lap so you can go the distance.”
“Some lasers are more efficient (or inexpensive), and they don’t offer a lot of frills. Some have a smaller footprint, so they don’t occupy as much space. Some will be more comprehensive and have all the bells and whistles, and, of course, more expensive. But generally, those are going to be a little more precise, solid and safe,” he said. And, as if describing a race car, he continued: “The ones [lasers] I have, they’re workhorses. They don’t break down, they’re super precise, accurate and safe in general.”
At the Top of the Leaderboard
In his line of business, Dr. Mah always has his eye on the laser leaderboard — and in his opinion, there are a few companies who are leading the pack, with regard to cataract. Plus, he said, there’s a relative “rookie” in the arena of refractive surgery that is also gaining traction in the United States: SMILE (small incision lenticule extraction).
Most popular. Occupying the top spot in Dr. Mah’s list of popularity is Alcon, with its LenSx laser system. “This one has to be one of the most popular lasers out there,” he said, adding that like a modular system, different pieces can be added to extend its capabilities — plus as a larger company, Alcon provides updates frequently.
Most unique. According to Dr. Mah, the LENSAR laser system (LENSAR Inc., Orlando, Florida, USA) has the smallest footprint, is the least expensive AND has a unique way of identifying structures of the eye. However, he said it is the smallest company, meaning research and developments might not be as flushed out, though it can maneuver quick and has aligned with some other smaller companies and can be used with some other unique peripherals and machines.
Most solid. As he noted above, safety is the critical factor for Dr. Mah and his J&J Vision lasers. “The advantage of J&J is precision, and it seems to have the most solid platform, making it precise and safe.”
Most versatile. According to Dr. Mah, the cataract laser from Bausch+Lomb (Bridgewater, New Jersey, USA) is popular and versatile, and it can also do LASIK flaps: “That makes it a little more capable in terms of procedures.”
Coming around the bend in refractive laser platforms are both Alcon and Carl Zeiss Meditec (Jena, Germany).
Regarding LASIK, he said: “Alcon makes lasers for flaps, as well as reshaping.” But what he’s most excited about – noting it’s their number one advantage – is that Alcon is also advancing topography guided systems. “They’re really speeding up that profile,” he added.
Gaining on LASIK is SMILE, which is a relatively new procedure in the US. “ZEISS has a new laser for SMILE — this is a brand-new type of technology for refractive surgery and people are excited about that, especially in Asia. I think it’s starting to pick up momentum, it’s kind of a new, novel type of refractive surgery.”
The Formula for Best-in-Class
Dr. D Ramamurthy, chairman of The Eye Foundation in South India, has 27 years of experience in cataract and refractive and refractive surgery. To complement Dr. Mah’s laser nominations for “best-in-class”, Dr. Ramamurthy appointed two of his own: the WaveLight Ex500 (Alcon, Geneva, Switzerland) and VisuMax for SMILE (Carl Zeiss Meditec, Jena, Germany). Let the race begin!
Great Overall. Not only does Dr. Ramamurthy own four of Alcon’s Ex500 laser platforms, he’s had one of them for seven years. “I find the Ex500 excimer laser to be great laser to have — it’s truly versatile with wavefront optimized treatment. It works very well, it is extremely fast, it is precise, and it consumes less tissue than some comparable platforms,” he said, adding that the results are predictable, too.
Dr. Ramamurthy said the Ex500 is good for a garden variety of refractive errors, but its real advantage is managing difficult situations: “We have this topo-guided treatment where we’re able to regularize an abnormal cornea. For example, if there’s a corneal scar, if there’s decentration from prior laser treatment, or if there’s significant residual astigmatism,” he explained, adding that along with corneal cross-linking (CXL), he is using the platform for treating keratoconus.
Surgeons compare to race car drivers in this sense: Both need the highest-grade equipment to perform in difficult situations, whether in making tricky maneuvers or avoiding complications (or crashes!).
Most Unique. The VisuMax from ZEISS earns this title from Dr. Ramamurthy for its flapless SMILE procedure. While SMILE is newer in the USA, surgeons in Asia have been performing this procedure for the last 10 years. Dr. Ramamurthy has about five years of experience with the procedure.
“The advantage of this laser is that you don’t have to create a flap,” he explained. “We make a very small incision through which we remove the lenticule. And because of that, all the flap-related complications have completely been done away with.”
Dr. Ramamurthy said he and his colleagues do SMILE quite often, and they believe it has some significant advantages in the refractive lane, including biomechanics, quality of vision and stability of refractive error. “When we compare it with other platforms, it does equally well, and final outcomes are quite comparable,” he added.
With two first-in-class vehicles to choose from, how does Dr. Ramamurthy decide which to ‘drive’ each day? Both are versatile, but he said the Ex500 handles better in challenging conditions.
“When I’m faced with a challenging case, I use the Ex500. But when I’m doing a routine case, like a -3.0 or 4.0 D refractive error, and the patient also wants something that is less invasive, I’ll do SMILE,” he said.
In the Final Lap
In the race of laser surgery, new modifications and innovations will continue to propel the technology forward. And whether its high-performance cars or lasers, according to Dr. Mah, there are four essential reasons users will either adopt, or be curious about new products.
“One is better outcomes — especially with cataract surgery and femtosecond lasers,” he began. “I think the big question a lot of people have is ‘where is the proof that this is going to improve my outcomes?’ So, outcomes and data are going to be really important.”
Number two, he said, is improving safety, which is already at the top of Dr. Mah’s list of necessities.
“Third is cost: Can we do it a little cheaper? And number four is making it more efficient and faster, everything else being equal,” he said.
“In terms of these lasers, if we can do it faster, cheaper and safer with better outcomes — then that’s the winning driver. If we can do something, if we can do all four, that would be winning a Grand Prix for cataract surgery.”
The Need for Speed in Cataract
In racing, it’s ‘go fast or go home’. And in ophthalmology . . . well, it’s not exactly like that. However, there are times when quicker is better– especially during postoperative recovery when patients expect rapid visual results.
Soon, there might be a new device on the market to speed things up: the CataPulse from Med-Logics (Athens, Texas, USA). The device, which is billed as providing “rapid visual recovery for refractive lens exchange”, is currently seeking FDA approval and is available in parts of Asia, including Hong Kong and the Philippines.
The CataPulse “phaco-free” lens removal system is a small incision device that dissects and extracts the cataract, using a bimanual technique and without ultrasound technology. This eliminates the risk of thermal damage, and the small incision reduces the corneal astigmatism. Med-Logics CEO Rod Ross underwent bilateral cataract surgery using the device last year.
According to Mr. Ross, it’s rare for surgeons to perform phaco bilateral procedures, in part to avoid TASS (toxic anterior segment syndrome). TASS can result from things like issues with sterilization, enzymes and detergents, preservatives, intraocular anesthetics and ointments, among other factors.
“It’s best to ultrasonically clean instruments used in cataract surgery, but the phaco handpiece cannot be ultrasonically cleaned because of the piezoelectric crystals inside the handpiece,” explained Mr. Ross. In addition to a more rapid recovery, this is where CataPulse handpiece exhibits another benefit: It is a single-use sterile disposable, so it does not have the re-use issues of a conventional phaco handpiece.
With the abundance of cataract cases worldwide – speeding up postoperative recovery is a ‘win’ for both patients and surgeons.
Glaucoma Pit Crew: The Pressure is On
In tires, as in glaucoma management, maintaining the ‘right’ pressure is key to longevity and performance. In tires, air pressure can be measured with a simple gauge. In eyeballs, detecting intraocular pressure (IOP) can also be done with a simple air – or “air puff” non-contact tonometry – test, but for a full assessment of this glaucoma-related symptom, diagnostic equipment is required.
There are several imaging platforms on the market to aid in glaucoma diagnosis and management – one of which is the SPECTRALIS OCT Glaucoma Module Premium Edition (GMPE) from Heidelberg Engineering Inc. (Heidelberg, Germany). Giving them an edge in this lap of the race, is the recent update for the module, the GMPE Hood Glaucoma Report, which highlights essential diagnostic information in an intuitive layout that enables a quick, yet comprehensive assessment.
Not only is it fast, it’s precise as well. Boosted with GMPE Anatomic Positioning System (APS), the semi-automated technology increases the precision and accuracy of results by ensuring that all glaucoma scans are anatomically aligned with the reference database and account for the individual configuration of axons in each eye. Furthermore, this report allows clinicians to visualize functional and structural measurements along with high-resolution OCT B-scans and relate this information to 10-2 and 24-2 visual field points.
Shifting gears to treatment, speed is also the name of the game for glaucoma, especially in the increasingly popular selective laser trabeculoplasty (SLT) procedure, which is carried out with the help of a reflective lens.
During the procedure, if the lens only has one reflective surface (which is the current standard), it must be rotated on the patient’s cornea to access all of the trabecular meshwork – this causes discomfort to the patient, it takes additional time, and it’s more difficult for the surgeon.
To make SLT more efficient, a new lens – the Rapid SLT (Volk Optical Inc., Mentor, Ohio, USA) – is equipped with four internal reflected surfaces, minimalizing the need for rotation (only once, if needed) . . . and cutting the procedure’s time in half. This first-of-its-kind lens is ultimately a win for both patients and doctors: Rapid SLT means the lens stays on the patient’s eye for less time, which improves the patient’s experience and increases ease of use for the doctor.
Of course, like in the name, the Rapid SLT helps ophthalmologists complete the procedure with twice the speed as before – this not only boosts efficiency, it also lowers the odds that the patient’s anesthesia wears off during the procedure, resulting in a second administration and longer procedure time.
And faster surgery times are key, as glaucoma is on the rise and more patients are undergoing SLT.
Going the Distance with Multifocal IOLs at the Indian Grand Ophthalmic Prix
Could the end be in sight for patients needing both near, intermediate and far vision correction?
According to a recent study, 99% of patients are spectacle independent following bilateral implantation with the AUROVUE DFINE multifocal IOL (Aurolab, Tamil Nadu, India). The study was conducted at Aravind Eye Hospital in India, with nearly 160 patients enrolled; of those, approximately 140 reported for follow-up.
The Aurovue DFINE (standing for Diffractive, Far, Intermediate, Near and Enhanced vision) is a hydrophobic, diffractive, multifocal, aspheric, foldable, preloaded IOL with the near addition of +3 D, uniquely designed to provide maximum energy at near and optimum energy at distance.
Mr. Saravanamoorthy V., product manager for Aurolab, says the contrast sensitivity of this IOL is higher than any other multifocal currently available– plus the patient has spectacle-free vision with very good near vision and uncompromised distance vision.
With multifocal IOLs, preoperative patient selection, both clinical and psychological, is important for optimal outcomes – and measuring the patient’s angle kappa is a key part of this.
“Currently there’s not a lot of equipment to measure angle kappa . . . not all hospitals can measure it, and they don’t have the machines because they’re costly,” explained Mr. Saravanamoorthy, adding that Aurolab has developed a portable machine that can be fitted to any slit lamp for measuring angle kappa.
“If the angle kappa is more than 5 degrees, the patient will complain of vision disturbances like halos, glare, dysphotopsia and double vision,” he said. “With this device, surgeons can decide whether the patient is clinically a fit for the multifocal IOL.”
The IOL is also preloaded which, like a Formula One car, means its fast, and precise. It’s also preloaded for another reason – to protect the multifocal rings from damage.
“When the lenses are manually loaded, the surface may get scratched or damaged, which affects the ring’s multifocality,” he explained.
Currently, the Aurovue DFINE multifocal IOL is available in Europe; Aurolab is planning to seek US FDA approval as well.