How Workflow Efficiencies Can Support Learning

Himani Goyal, MD

For trainees, learning the basics via repetitive execution and live instruction with positive reinforcement builds confidence. I show my residents an unedited video of a cataract surgery and review each step to build the fundamentals. They need to learn how to maneuver inside the eye: working through tight wounds, lifting a nucleus, adjusting IOP and/or bottle height as needed, etc.

We use a sub-Tenon block when removing dense cataracts for patient comfort. To fragment dense nuclei, I use the MiLoop (ZEISS), which should move through the lens without any resistance if in the correct position. The MiLoop facilitates manual segmentation of nuclei, thereby saving the eye from substantial phaco energy.

Finally, I insert Dextenza intracanalicular inserts (Ocular Therapeutix) in all cataract patients. This step adds only seconds to a case, but it is a huge overall time saver, eliminating the need for patient compliance with a steroid taper.

The Importance of Visualization and Ergonomics

Alison Early, MD

To me, a clear view of the surgical field is of primary importance in any surgery. I place a lot of value on high-quality optics in my surgical microscope, and supporting overlays can be applied to seamlessly integrate biometry and keratometry. The ZEISS Cataract Suite, including the IOLMaster 700 biometer and the CALLISTO overlay, allow markerless intraoperative toric marking and alignment for precise astigmatism correction.

I am also very mindful of ergonomics in the OR. I use lumbar support and foot pedal elevators when sitting. Regardless of which equipment or technology your OR has, the most important part of setting up each case is first positioning yourself with proper ergonomics and lumbar support, and then bringing the patient’s eye into focus. Poor posture can take a toll after a long day, and over time it can even limit or end careers due to cumulative strain and musculoskeletal disorders.

A 3D Heads-Up Display and Intraoperative Biometry

Arjan Hura, MD

I operate exclusively using a 3D heads-up display, because I strongly believe in its ergonomic benefits, and I like not being tethered to the oculars. A 3D heads-up display is especially advantageous for teaching and for performing MIGS.

For performing cataract surgery on post-refractive surgery eyes and highly aberrated eyes, I use intraoperative biometry with the ORA (Alcon) to supplement traditional biometry. These eyes tend to be prone to refractive surprises, and their biometry is often less accurate compared to normal eyes. It is worth noting that intraoperative biometry measurements can be adversely impacted by factors such as conjunctival chemosis, corneal dryness or edema, a buildup of balanced salt solution in the fornices, or lack of patient fixation.

If these variables can be controlled, an accurate pseudophakic refraction can often be achieved.

Optimizing Toric Outcomes

Jonathan Solomon, MD

Since the advent of toric IOLs in the late 1990s, surgeons have tried to optimize these lenses’ axis alignment in the eye with various technologies. I currently use the Z ALIGN function on the ZEISS CALLISTO eye system, which provides a video-supported tool for markerless toric alignment. The ZEISS CALLISTO eye system uses nomograms to automatically calculate the correct toric IOL power, and then it takes the information from our biometer through a wireless integration system to our Ally Cataract System (Lensar). The ZEISS CALLISTO eye system registers the eye and overlays the visual aid in the oculars of the operating microscope. I’ve come to rely on the accuracy of this completely customizable process.

A 2017 study published in the Journal of Cataract & Refractive Surgery demonstrated that the CALLISTO eye system performs as well as or better than intraoperative aberrometry, and it improves intraoperative workflow.¹

1. Solomon JD, Ladas J. Toric Outcomes: Computer-assisted registration versus intraoperative aberrometry. J Cataract Refract Surg. 2017;43:498-504.