SCOPE OF PRACTICE Dr. Newsom takes a close look at an intraoperative lens's advanced design.

In ophthalmic surgery, we've refined our techniques to the point that our results are very consistent and very good. We owe a large share of this success to the technology at our disposal. A look around at the latest developments shows how we can become even more precise and how we can take our outcomes even further. Here are some of the impressive innovations I saw while touring the exhibit hall at the American Society of Cataract and Refractive Surgery's annual meeting in Boston.

1. GO WITH THE FLOW Alcon's Centurion improves phaco performance through active fluidics.

1. Alcon / Centurion Vision System
Alcon showcased its Centurion Vision System as part of a suite of cataract and refractive surgery technologies, which also included its Verion image-guided measurement and digital marking system, LenSx femtosecond laser and LuxOR LX3 with Q-Vue ophthalmic microscope. The Centurion phaco machine boasts active fluidics that keep the chamber stable without the need to manually irrigate and aspirate or adjust the height of an IV pole. Users select a target intraocular pressure and the machine, by adjusting its compression of a bag of balanced salt solution and monitoring its flow rate, maintains that level throughout the procedure. It lets us focus on cataract removal and lens insertion. The angled, "camel hump" design of the system's new Intrepid Balanced Phaco Tip improves cutting efficiency by minimizing tip movement at the incision but maximizing torsional tip movement at the distal end. Centurion lists for $125,000.

2. ON THE (EYE)BALL Clarity Medical's Holos technology provides a continuous stream of real-time refractive data.

2. Clarity Medical Systems / Holos IntraOp Wavefront Aberrometer
No matter how accurate your pre-op refraction measurements are, they're essentially snapshots depicting information that's bound to change as you go along. In contrast, Clarity's Holos gives you a continuous, real-time movie. Its refractive data is synchronized to streaming video of the patient's eye and it reflects intraoperative changes to provide feedback for astigmatic correction while rotating toric IOLs, titrating limbal relaxing incisions or making femtosecond laser arcuate incisions. You know immediately how much has changed, so there's no interruption to take a measurement and no fudge factor. My only issue with the technology? It gives you cylindrical and axis but not spherical measurements. The company's reps said they're working on that, and that'll be an important addition. The system attaches to and integrates with your operating microscope without interfering with the line of sight or working distance. A built-in digital video recorder allows you to play back the entire procedure. The Holos hardware lists for $60,000; monthly software upgrades add $1,000 a month.

3. GET HOOKED Bausch & Lomb's Trulign Toric IOL rotates easily, but its haptics secure it in place.

3. Bausch & Lomb / Trulign Toric IOL
Bausch & Lomb says its new toric IOL delivers a broader range of vision than a standard toric lens can. Both correct astigmatism, but while the standard lens only provides distance vision, the Trulign Toric IOL breaks down the limits to provide distance, intermediate and functional near vision, the only lens approved to do so. That's not the only feature that makes it stand out, though. It's been designed with 4-point fixation for stable positioning. A silicone lens is slick and rotates easily, but there's a risk it won't stay in place. The Trulign's haptics incorporate a stickier material, so that once you get it where you want it, it stays in place. At $995, it's competitively priced in the accommodating IOL field.

4. EXPANSION PLAN LensTec's Softec HDO addresses a visual nuisance for some patients.

4. LensTec / Softec HDO
Dysphotopsia is the crescent of shadow that some patients see at the edge of their vision after otherwise uncomplicated IOL implantations. It's a little problem for us that can be a huge nuisance for patients. Light entering the eye at an oblique angle hits the edge of the lens and casts a shadow on the retina. While most patients get used to this phenomenon the same way you stop seeing the frames of the glasses you're wearing, it makes others miserable. It's the most common reason we remove hydrophobic IOLs. Could more coverage be the answer? That's the thinking behind LensTec's Softec HDO. The oval-shaped, foldable, multifocal IOL is almost 30% larger than conventional lenses, so the light never hits the edge of the lens and your patients are happier with the results. Its price ranges from $100 to $200.

5. LIGHT MAKES IT RIGHT A dose of UV light adjusts the IOL to near-perfect results.

5. Calhoun Vision / Light Adjustable Lens
There is often a difference, however slight, between our pre-op promises on what IOLs will achieve and the post-op outcomes their implantations deliver. The Calhoun Light Adjustable Lens may change all that. The 3-piece monofocal IOL is still an investigational device in the U.S., currently going through Phase III trials, but it could be revolutionary in enabling predictable results and customized vision. The lens, made from a photosensitive silicone material, is inserted like a conventional IOL. After 2 to 3 weeks of healing, the patient returns for a vision exam and, if necessary, the lens's power is adjusted with a 2-minute, non-invasive, painless application of UV light from a specialized delivery device, which precisely and permanently changes the shape of the implanted lens. With this technology, it's quite possible we'll be able to hit the bull's-eye of 20/20 vision every time.

6. GO DROPLESS Injectable compounded formulations simplify post-op care.

6. Imprimis Pharmaceuticals / Dropless cataract surgery
After surgery, we prescribe eyedrops: antibiotic, steroidal and non-steroidal drugs to be administered 3 times a day for up to 3 weeks. This can be an inconvenience for patients — ?if they carry out our post-op instructions — ?and expensive as well. Imprimis Pharmaceuticals promises to prevent post-op infection and inflammation droplessly, with a single injection. Their proprietary sterile formulations compound a steroid and antibiotics for intraoperative injection into the vitreous, where the "depot effect" delivers them over time. This changes the game! A single-use, 2ml vial of Tri-Moxi lists for $20 and a single-use, 1ml vial of Tri-Moxi-Vanc is $25.

7. WITHOUT A STITCH A gel sealant offers a solution to post-surgical leakage.

7. Ocular Therapeutics / ReSure Sealant
Corneal incisions are usually self-sealing, so we do what we can to avoid suturing. It's not comfortable for the patient, who has to return for removal, and it can affect our astigmatism correction outcomes. But if we need to ensure closure to prevent leakage, this first-of-its-kind ocular surgical glue looks like a safer, easier, more effective method than sutures. It sloughs off with tears in about a week. A 5-unit box of ReSure sealant lists for $500; a 10-unit box, $900.

8. MAKE A MARK The Robo-Marker improves corneal marking for improved outcomes.

8. SurgiLum / Robo-Marker
There's no end of surgical instruments that have been designed to make our techniques more consistent and efficient. Still, the Robo-Marker is a clever innovation for cornea-marking accuracy. You rotate the indicator dial to the desired axis, and a gravity-based self-leveling system keeps the marking tip there, no matter how you're holding the device. The marking tips are sterile, disposable and pre-inked, so there's no waiting for the autoclave and no looking for a marking pen. The gentian violet ink lasts up to 2 hours, so it won't get blinked off in pre-op. An integrated fixation light lets you mark the cornea the same way you measured its astigmatism. The Robo-Marker lists for $1,770 and includes 10 marking tips. A box of 10 replacements costs $100.