It's hard to improve on the efficiencies cataract surgery — the bread and butter of any ophthalmic surgical facility for a reason — offers in its current state. But these 8 product categories have the potential to reduce case complexity, make turnover faster and thwart the delays that happen all too often, even to the best surgeons and staff.

Iris expanders
Patients who have undergone long-term glaucoma therapy may develop miotic pupils, which remain "stuck" even when dilation drugs are used. Other patients may have developed "floppy iris" syndrome due to drugs such as those used to treat enlarged prostates. Either way, using an iris expander to maintain access and visibility through the pupil may make such cases easier to handle.

I find that up to about 5% of cases worry me enough that I'll ask to have one in the OR, just in case. My typical approach is to use a highly cohesive viscoelastic to help expand the pupil, then use a blunt tip to put the viscoelastic under the iris then, finally, tear whatever adhesions are on the lens. I can usually get a 3mm or 4mm pupil to expand that way, but you do have to slow down your surgical technique, minimizing inflow and high-powered phaco.

If that doesn't work, then you might want a little help. If you do end up using an iris expander during a procedure, you can bill for a complex cataract, which provides for extra reimbursement.

MST
Malyugin Ring
www.mst-surgical.com
(888) 279-3323
List price: $125
FYI: The Malyugin Ring from MST is used to safely expand pupils in a time-efficient manner. Placed through a 2.2mm or larger incision, the Malyugin Ring is provided as a system, meaning each sterile unit is provided complete with an injector that is used to both place and remove the device from the eye. MST also provides, free to each facility, 1 Osher Malyugin Ring Manipulator that's designed to facilitate manipulation of the Malyugin Ring.

OASIS Medical
OASIS Iris Expander
www.oasismedical.com
(800) 528-9786 and (909) 305-5400
List price: not provided
FYI: The OASIS Iris Expander is a 7mm diameter polypropylene ring that expands the iris and maintains access and visibility throughout the surgical procedure. The Iris Expander is easy to insert and remove and gentle to fragile iris tissue. Each Iris Expander is packaged sterile, with its own easily loaded disposable injector. The Iris Expander is available in boxes of 5 or a single pack, and is indicated in cases where IFIS or miosis is present.

Blue capsule dye
Trypan blue dye lets cataract surgeons see the capsulorhexis in patients who have particularly dense cataracts. In these patients, you run the risk of being in a "white-out" situation — you can't distinguish the edges or what you've done, and it's essential to outcomes that the surgeon be able to see the edges of the capsulotomies. Having the ability to identify the anatomy so clearly turns these tough cases into standard cases. Trypan blue dye comes conveniently pre-packaged and, what's more, you can recoup money on its use by billing the case as a complex cataract.

Automated instrument rinse system
The traditional way to flush the phaco handpiece and other instruments is with a syringe — which may not always be the most effective way. Not to mention it's time-consuming for the sterile processing department. American OptiSurgical's QuickRinse automates the process, letting you rinse phaco and I/A handpieces, cannulas, vitrectomy cutters, reusable tubing and any other microsurgical instrument with a lumen. This could be a real go-to time-saver, not to mention it may help reduce potential damage from handling the instruments.

Placement devices for toric lenses
Toric IOLs have to be placed precisely to ensure good vision after the patient leaves your facility. Several devices are available that latch onto the microscope to allow for fine-tuning of placement. They include Leica's ToricEyePiece, WaveTec Vision's Optiwave Refractive Analysis System, SMI's Surgery Guidance and Zeiss's Toric Solution. I was at a conference recently and talking about just these sorts of devices with some colleagues. We agreed that they all work, and no one is any better than the next. This is nice, because you can work with the device and technique that you're most comfortable with, and rest assured that you're not doing a disservice to patients.

SensoMotoric Instruments GmbH (SMI)
SMI Surgery Guidance
www.surgery-guidance.com
+49 3328 3955 10 (SMI, Germany) and
(416) 665 6616 x251 (Sigmacon Medical, Canada)
List price: varies by region
FYI: The SMI Surgery Guidance solution, consisting of reference unit, surgery pilot and microscope integrated display, provides automated visual guidance for the cataract surgeon without use of manual markers. The underlying real-time eye registration and tracking technology provide a consistent coordinate system from the moment of diagnostic measurement to every moment during surgery, where accuracy matters: position of incisions or LRIs, centering and sizing of the capsulorhexis, centering of multifocal IOLs and alignment of toric IOLs.

IOP reduction for glaucoma patients
There are 2 items of interest here that let you avoid the potential side effects of trabeculotomy. The first is actually a procedure called canaloplasty, which can significantly lower IOPs in patients with glaucoma, so that they're better candidates for cataract surgery. In addition, according to 3-year data from Lewis RA, von Wolff K, Tetz M, et al (J Cataract Refract Surg. 2011;37(4):682—690), patients who underwent canaloplasty experienced a 34% decrease in IOP and a 53% reduction in glaucoma medications, so doing both procedures can really pay dividends for your patients in the long term. Even better, canaloplasty is a Medicare-approved procedure.

Another excellent addition to our armamentarium for treating glaucoma is the Glaukos iStent, which lets you reduce IOP at the time of the cataract procedure. After a perfect cataract case — the shunt is contraindicated if the capsule is broken — you take 10 minutes to implant the stent in Schlemm's canal and, therefore, create an exit drain from the anterior chamber to the canal. The FDA pre-data show the stent delivers, on average, a 1.5 decrease in drops per eye, very promising for such a simple solution.

iScience
iTRACK 250 Microcatheter
www.canaloplasty.com
(650) 421-2700
List price: not provided
FYI: Canaloplasty is an approved Medicare Category I CPT procedure to treat glaucoma that restores the eye's natural outflow system and doesn't produce a filtering bleb, therefore reducing the post-operative follow-up required. This procedure is being adopted by both glaucoma surgeons as well general ophthalmologists, because it has proven and sustained IOP-lowering performance with a low incidence of complications and provides significant medication reduction. More than 20,000 procedures have been performed to date.

Glaukos Corporation
iStent
www.glaukos.com
(949) 367-9600 or (866) GLAUKOS
List price: $2,500 (pricing programs available)
FYI: The iStent Trabecular Micro Bypass Stent is indicated for use in conjunction with cataract surgery for the reduction of intraocular pressure in adult patients with mild to moderate open-angle glaucoma currently treated with ocular hypotensive medication. iStent is designed to reduce IOP by improving aqueous outflow through the natural physiologic pathway. Two orientations of the iStent are available: one for the right eye (OD) and one for the left eye (OS).

Higher-viscosity topical anesthetic
Tetravisc Forte is more viscous than its predecessor (Tetravisc, still available), which keeps the anesthetic on the eye longer. You'll need a pre-made dilating/anesthetic drop to use it, and you may want to have it on hand in the OR in case a procedure is difficult and requires you to slow your technique. But I've generally found it lasts throughout my cases, and that patients are less likely to flinch and complain of discomfort.

Sterilizable tip inspector
There's a new, autoclavable magnifying glass that will let you inspect instrument tips in the OR: the Osher Sterile Field Magnifier, which has a 50mm lens that folds into the base so that it fits easily into your surgical instrument trays. I really like this because I'm sure I'm not the only surgeon who finds that, between 15% and 50% of the time, the tips covering the phaco aren't on correctly — and this would help the surgical nurse ensure the tips fit perfectly. Flow will be improved because it's a non-invasive way to be sure the surgeon doesn't have to stop before a case to fuss with the phaco or I/A tip.

Bausch + Lomb — Storz Ophthalmic Instruments
E7002 Osher Sterile Field Magnifier
www.storzeye.com
(800) 338-2020
List price: $250 FYI: The Osher Sterile Field Magnifier lets the technician inspect surgical instrument tips before use during the procedure. With its large 50mm lens, the magnifier is ideal for loading IOLs into the injector, aligning irrigation sleeves on the phaco or I/A tips before use, and viewing diamond blades for cleanliness and edge quality. The magnifier can be sterilized by conventional means. It can also be used at the instrument cleaning station for quality inspection.

Single-use polymer irrigation and aspiration tips
If you polled ophthalmic surgeons on their top 5 most frequent delays, I'd be willing to bet clogged microsurgery and I/A tips would be among them. Frustratingly, this usually happens during the first 2 or 3 cases in the morning, which can put you behind schedule for the rest of the day. Single-use polymer I/A tips (Alcon and Bausch and Lomb/Storz Ophthalmic), are removable and disposable, which seems to prevent clogging that typically happens right at the point of entry because flushing wasn't thorough or there was simply a lot of high-viscosity viscoelastic buildup. When clogs happen, you have to stop to try a new tip, and if that one isn't working, and the next one isn't working — well, you get the idea. We all know a 20-minute delay at the beginning of a packed surgical day can be critical. In my experience, disposing of the tips avoids overnight clogging, and has put an end to clogging-related delays.

Bausch + Lomb — Storz Ophthalmic Instruments
CapsuleGuard I/A Handpiece
www.storzeye.com/capsuleguard.aspx
(800) 338-2020
List price: $330 per box
FYI: Excellent for all phases of irrigation and aspiration, the CapsuleGuard Handpiece features a smooth silicone irrigation and aspiration port designed to reduce the capsule-rupture risk during I/A. A flexible sleeve conforms to the wound to seal the incision, and the flexible, silicone-tip design facilitates cortex removal, capsule polishing, viscoelastic removal and IOL manipulation. Further, semi-transparent silicone enhances visualization. Packaged sterile and available in single-use (12 per box) curved, straight and 45 ? angled configurations.