Cathleen McCabe, MD, one of the foremost eye surgeons practicing today, has performed more than 35,000 cataract surgeries in her career. None was more memorable or more harrowing than the case she performed last month. And not because the multifocal IOL patient with the peripheral corneal scar moved at the last second while he was under the femtosecond laser. That was heart-stopping, yes, but nothing compared to performing surgery on live TV with hundreds of your peers scrutinizing your every move. Fortunately, she had some cool new technology to calm her down.
To showcase the latest breakthroughs in laser cataract surgery and lens implantation, Dr. McCabe's surgery was transmitted live via satellite to a ballroom at the Hilton San Diego Bayfront, where more than 1,000 cataract surgeons from around the world attending the 2015 American Society of Cataract & Refractive Surgeons (ASCRS) meeting had gathered. "Something I tried not to think about," says Dr. McCabe. Nearly 1,500 miles away at the Texas Eye & Laser Center in Hurst, Texas, Dr. McCabe sat before the patient and the TV cameras for her first-ever satellite surgical broadcast. And then the patient flinched under the femto.
"It was exhilarating and exciting," says Dr. McCabe, a partner and the medical director at the Eye Associates' Surgery Center in Bradenton, Fla. The lure of the project for Dr. McCabe was to demonstrate to her colleagues technology that advances cataract surgery.
"I was able to do what I do every day, but in a way that was hopefully helpful to the surgeons in the audience who haven't had the chance to experience this new technology yet," she says.
Here's a look at a few of the technologies that Dr. McCabe previewed during her 10-minute live satellite feed:
- Intraoperative wavefront aberrometry. For starters, Dr. McCabe demonstrated the latest in intraoperative aberrometry (the ORA System with VerifEye+ Technology from Alcon) that provides real-time data validation in your ocular for more precise refractive measurements. A continuous display of refractive data lens power, sphere, cylinder and axis recommendation helps refine lens selection and remove some of the guesswork of more complex cataract surgery cases, says Dr. McCabe, adding that the technology helps her confidently refine her IOL power selections and determine the magnitude and axis of astigmatism. Intraoperative aberrometry promises improved outcomes and lower enhancement rates.
Because the refractive data is streamed through the ocular of the microscope, Dr. McCabe says you don't have to look up and away at the screen. "You're able to see the data without delay. It's just a way of feeling like you're more in control of the process and more able to actively evaluate changes," she says. "That was kind of exciting as most people hadn't seen that before."
Claire Kowalski, RN, MSN, the clinical director of the Texas Eye Surgery Center, is effusive in her praise of wavefront aberrometry. She says the device, which measures corneal curvature and calculates intraocular lens power intraoperatively, helps correct astigmatism "perfectly."
For patients who have a cataract with a secondary diagnosis of astigmatism, her surgeons use the aberrometer twice before implanting the toric IOL when the patient is aphakic and after implanting the toric IOL to check the accuracy of the alignment of the toric IOL. Each real-time reading takes only 3 to 5 seconds, she says, and offers the dual benefit of significantly increasing the accuracy of the toric IOL power, and significantly decreasing the incidence of unintended residual post-operative astigmatism and refractive surprise.
- Digital marking system. Dr. McCabe also demonstrated a new digital marking system (Alcon's Verion 2.6 software) that makes pre-operative planning more precise. The system registers landmarks from a digital photo of the patient's eye and captures such data as amount of astigmatism, axial length, lens choice and toric correction. A second part of the system lets you account for cyclorotation, which causes a ?difference in eye orientation when the patient is sitting up (when you obtain measurements) versus when the patient is lying down (when you perform surgery).
"The Verion matches up those features and you can then do a side-by-side comparison of digital images to determine how much the eye rotated," says Dr. McCabe. "Everybody's eye rotates to a different degree."
The software also places a digital marker on the microscope so you can orient the toric IOL or place the limbal-relaxing incisions where you want them to be, says Dr. McCabe. While the debate continues about the best centration spot for multifocal lenses on the center of the limbus, the center of the pre-op pupil or the visual axis the software helps you to make that choice.
- Hands-free IOL loading. Dr. McCabe used her feet to showcase a neat way to load and implant IOLs. Using the Intrepid AutoSert IOL Injector, she automatically advanced the IOL to the preload, ready-to-implant position using a footswitch, freeing one hand to stabilize the eye. "Instead of pushing or dialing a plunger to advance that lens so it goes into the eye, AutoSert lets you do that in a very smooth way with a pedal."
The benefits of the femto laser
Dr. McCabe evaluated her patient's peripheral corneal scar under the laser. She altered the main incision to avoid the scar. In the OR, she demonstrated the ease of opening the incision. She touted how the active fluidics in her phaco device let her control the patient's intraocular pressure and maintain stability in the anterior chamber during the procedure. "Because of that, we were able to remove pieces of cataract very easily and efficiently," says Dr. McCabe. "They were already fragmented with the femto, so we were able to use aspiration to remove the small cubes. This minimized the phacoemulsification energy that was needed. I love having the femtosecond laser. It improves our ability to control variables. We want every aspect of cataract surgery to be as precise and as accurate as possible to improve the predictability of our outcomes."
Now if only someone would come up with a way to keep patients from flinching.
Cataract surgery, the most commonly performed surgical procedure in the world, is also the most refined, home to more innovative products than perhaps any surgical specialty. Cataract surgeons welcome with open arms any product that makes surgery safer, faster or more efficient.
"In the world of ophthalmology, it is very exciting as new technology is developed to assist the surgeon in making a patient's outcome more accurate than ever," says Claire Kowalski, RN, MSN, the clinical director of the Texas Eye Surgery Center in Hurst, Texas.
We visited with the heads of some of the nation's leading eye surgical centers to compile this roundup of products that save time and improve outcomes.
1. Cleaning lumened devices. For post-surgical cleaning of instruments and tubing, such as phaco handpieces, vitrectomy cutters and I/A tubing, a popular choice for our panelists is the QuickRinse Instrument Rinse System. QuickRinse uses pressurized water and air to rinse lumened devices. Unlike with a syringe, QuickRinse provides consistent rinsing pressure regardless of the operator and eliminates hand fatigue associated with repetitive syringe use.
"We absolutely cannot be efficient without [QuickRinse]," says Nancy Haskell, RN, CNOR, director of nursing at the Capitol City Surgery Center in Sacramento, Calif. "It automatically delivers the amount of fluid that is most often the recommended in the directions for use, and the air-dry cycle means the instrument personnel do not have to sit with syringes and push fluid through. They can be working on cleaning other instruments."
At Cheyenne (Wyo.) Eye Surgery, staff use the QuickRinse on all lumened instruments. "It's a time-saver and it does a good job of flushing the appropriate amount of irrigation fluid," says Jeanne Koppinger, RN, the director and nursing supervisor.
2. Dropless cataract surgery. The days of sending post-op patients home with a prescription for eye drops might soon be gone. A single prophylactic injection of a steroid-antibiotic combination, delivered intraoperatively, is gaining growing support as a replacement for traditional antibiotic eye drops that patients administer (you hope) at home. Imprimis Pharmaceuticals's proprietary compounded formulations prevent the risk of post-op infection and inflammation while simplifying patients' care by doing away with post-op drops. A single intraoperative injection of Tri-Moxi (triamcinolone acetonide and moxifloxacin hydrochloride) or Tri-Moxi+Vancomycin into the vitreous enables the delivery of the meds over time and guarantees compliance with the post-op care regimen.
"We have converted to dropless with Imprimis TriMoxVanc," says surgeon Jon-Marc Weston, MD, Vision Surgery and Laser Center in Roseburg, Ore. "I'm seeing a trend toward using that more and more," adds Nancy Lord, RN, BSN, the administrator of the River Drive Surgery & Laser Center in Elmwood Park, N.J., one of the busiest cataract centers in the country. "It's fabulous for patient compliance. Patients no longer need eye drops to take home."
Dropless cataract surgery curbs the 3 C's: cost, compliance and contamination, says Maria Tietjen, RN, BSN, executive vice president of nursing with American Surgisite Centers of Somerset, N.J., which oversees 9 surgery centers that perform around 50,000 cataract cases a year.
3. Site marking. There's no shortage of ways to mark the correct surgical site in cataract cases. You can place stickers over the correct eyebrow and wristbands over the correct wrist. The surgeon can use a sterile skin marker to initial the skin next to the sticker. You can place a sticker on the gown at the right or left shoulder.
"With a very high volume of ophthalmology procedures in our facility, laterality risk is an added concern," says Cherry Maloney, RN, MBA, CSPM, the central sterile manager at the Callahan Eye Hospital in Birmingham, Ala. Her surgeons are required to "mark and band" patients. Using a sterile marker, the physician initials above the correct eye and applies an arm band to the wrist of the same side. The banded wrist is kept outside of the drape should the initials be covered after draping. "Patients do not enter the OR until this pre-time-out verification has been completed," says Ms. Maloney. "We have had great success with no wrong-site surgeries largely due to this process."
4. Pupil expanders. Nothing slows a case to a crawl more than a pupil that won't dilate. Fortunately, there's no shortage of pupil expanders that keep small pupils open during surgery: Malyugin rings, iris hooks (retractors) and compounded Shugarcaine.
"Using the pupil expander has been the difference between a hard case and one that the surgeon has greater visibility of the lens and ease of removal," says Ms. Haskell.
Dr. Weston says Shugarcaine works well for small pupils. "I think it's immoral to pay $450 for something you squirt in the bottle that does at best no better," he says.
"We use a Malyugin ring or a combination of phenylephrine and lidocaine that we have compounded," says Jennifer Brooks, RN, manager of the Virginia Beach (Va.) Eye Center.
5. Stretcher chairs. Many eye centers shave valuable minutes off their case times by keeping patients on the same eye cart or stretcher chair throughout the perioperative process, thereby bypassing the need to transfer patients onto and off of the OR bed. "The patient starts and has surgery on the same cart," says Ms. Koppinger.
A key benefit of the powered surgical chair is that you don't have to attach and reattach patient monitoring equipment, says Jody Looker, RN, CNOR, director of the Eye Surgery Center of Winchester (Va.). "We mount the patient monitor directly onto the stretcher so we never have to change the blood pressure cuff, pulse oximeter probe and EKG leads when the patient is transferred to a different level of care throughout the perioperative period," says Ms. Looker.
6. Safety sharps. When it comes to improving employee safety in cataract surgery, look no further than safety sharps. "We use safety needles and knives when available in the product that the doctor is needing," says Ms. Koppinger.
You're not alone if not all your eye surgeons use safety sharps. As Ms. Tietjen says, "Not all companies have safety knives that surgeons prefer." At River Drive Surgery & Laser Center in Elmwood Park, N.J., they're well on their way to using nothing but safety sharps. "All of our surgeons are either using them or transitioning to them," says Tiffany Trizzino, RN, director of perioperative services. It's still a challenge, she says, to convert docs who prefer a non-retractable knife.
Ms. Brooks uses the Qlicksmart blade remover system, which allows for single-handed scalpel blade removal.
7. Improved ergonomics. Heads-up screen-based surgery, microscopes with tilting oculars, and posture-sensitive chairs that move up and down are saving the spines of countless surgeons. Leica's microscope has tilt to the oculars, which many consider to be an elegant design element of ergonomic assistance. Surgeons at the JFK Mediplex Surgery Center in Edison, N.J., enjoy microscopes with movable parts and hydraulic chairs, says Nursing Director Janet Kovacs, RN, BSN, CNOR. "We have a special OR stool from Stryker that helps with the doctor's posture," says Ms. Koppinger. "They can adjust the height themselves with a foot."
For heads-up viewing during cataract surgery, there's TruVision's real-time, stereoscopic, 3D high-definition visualization system, which attaches to microscopes to display the surgical field of view in real-time on 3D flat panel displays in the OR. This lets surgeons perform and record surgery in 3D via a heads-up, 1080p display instead of looking through the microscope.
8. Custom cataract packs. The big question with procedure packs is what to include in them and what to leave out. Should they be surgeon-specific or more basic, including the supplies you use in every cataract case (outer covering, eye and lid drapes, gowns, towels,. sponges, instrument wipes, plastic disposable bowls, prep kit, syringes and safety needles). "All those things you know you're going to use on every case should be put in your pack," says Ms. Tietjen. You can store other surgeon-specific items like blades and gloves in small bins, she says.
Ms. Kovacs includes irrigating solution, viscoelastic and the phaco cassettes in her packs.
"We have a custom cataract pack that we get from the same company that supplies our lenses and other products," says Ms. Brooks. "This also saves on shipping and is much more convenient than having to order several products separately."
Donna Cooley, RN, of Scripps Mercy Surgery Pavilion in San Diego, Calif., says her custom pre-assembled packs are $8 less than pulling all items separately, "not to mention dollars saved in paying staff to gather items." She says custom packs saved her facility $18,000 last year.
9. Creating a capsulorhexis. The extremely difficult but necessarily precise task of creating a round, centered capsulorhexis during cataract surgery may be about to get a lot easier, thanks to the disposable Verus Capsulorhexis Device, a doughnut-shaped ring made from medical-grade silicone. "Verus is designed to provide surgeons with a way to create a round and repeatable capsulorhexis, while minimizing the impact to procedure time and cost," says the company, Mile High Ophthalmics. The top and bottom are micro-patterned, so once it's in place with viscoelastic over it, the device stays put on the anterior capsule, says the company. The capsulorhexis is created by lifting the anterior capsule flap along the 5.0 mm internal diameter. Studies show that the Verus consistently produces a well-centered and precisely sized rhexis. Once the procedure is complete, the device can be easily removed with a Sinskey hook. "Like a ruler for drawing a straight line or a compass for drawing a circle, it just makes sense to use a guide for this critical step in cataract surgery," says the company.