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Cover Focus | May/June '20

Fine-Tuning the Art of Cataract Surgery

Five pointers for continued surgical improvement.

Regardless of age or experience, all ophthalmologists can benefit from a continued commitment to improving their surgical skills. Surgeons should learn from every case they encounter, from the routine to the complex. In truth, surgeons can learn from every case they encounter, from the routine to the complex. Below are five key areas of cataract surgery mastery—but the list goes on. In addition to these takeaways, consider how you learn best and how you can truly commit to your improving your craft; a full, free library of videos and articles is available at www.CataractCoach.com to assist.

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1. Take pride in your capsulorhexis and incision. The capsulorhexis is your cataract surgery signature, and it will last forever. A decade from now, when other ophthalmologists examine your patient at the slit-lamp microscope, they will see your capsulorhexis and incision. Use a diamond keratome or steel blade—however you prefer to create your incision—and make a balanced incision with good architecture. Create a beautiful capsulorhexis, centered over the Purkinje images and with a good overlap of the optic edge. Use a diamond keratome or steel blade—however you prefer to create your incision—and make a beautiful capsulorhexis, centered over the Purkinje images. I use forceps that are marked at 2.5 and 5.0 mm from the tip so that, as I am creating my capsulorhexis, I can continue to assess its size. I prefer a generously sized capsulorhexis of 5.0 to 5.5 mm.

A small capsulorhexis makes cataract surgery more difficult because it limits access to the capsular bag and makes it tougher to bring nuclear pieces out of the capsular bag. When the capsular tissue opacifies with time, it can also restrict the effective pupil size and compromise night vision. The risk of complications may also be higher with an overly small capsulorhexis.

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2. Learn from every case. As surgeons, we must be self-critical in order to continually advance our surgical skills and judgment. To this day, I try to record every surgical case, even though I may not save all of the videos. I find it incredibly valuable to revisit a particularly complex case and see how I can improve my technique going forward. Even after 20,000 cases, I want to keep improving. You will also perform better when you know that you are being recorded—this is the Hawthorne effect that has been studied extensively in psychology.

Additionally, the field of ophthalmology continues to evolve, and adopting new techniques takes practice. Just as athletes review game-day footage to assess their performance, reviewing surgical videos is an excellent way for surgeons to visualize and hone their skills. The pursuit of perfection in cataract surgery requires this self-analysis.

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3. Evolve your IOL calculations. Over time, experienced surgeons develop an intuition that enables them to work through the IOL power decision-making process. But what if that intuition could be converted into an approach that could be available to and useful for even novice surgeons?

AI has challenged the most brilliant minds in chess. IBM’s Deep Blue computer beat grandmaster Garry Kasparov in 1997; 20 years later, Google’s Alpha Zero taught itself chess in a few hours and is now the undisputed world champion at this complex game. The same approach can be applied to IOL power determination via the Ladas Super Formula 2.0 (Advanced Euclidean Solutions), developed by John Ladas, MD, PhD. Instead of outright predicting IOL power like a traditional formula, the Ladas Super Formula 2.0 incorporates AI and uses big data to predict differences or displacements between an existing formula and perfection for a given eye. These predicted displacements are then incorporated back into the existing formula, yielding an unprecedented accuracy of 94% to 95% for most surgeons. For example, the AI of the Ladas Super Formula 2.0 predicts the adjustment needed for long axial lengths and incorporates that back into the baseline formula.

Multiple refinements are being made to this big data approach with the Ladas Super Formula backbone. The result is more accurate refractive outcomes for patients and greater surgeon confidence in the ability to deliver optimal results. Current IOL formulae are useful, but they are static and yield only about 80% accuracy in IOL power determination. In order to truly optimize our cataract results, we must move toward a formula that is dynamic and can evolve over time.

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4. Be able to perform an IOL exchange. From time to time, cataract surgeons may be required to explant an IOL. This may occur at the time of cataract surgery due to an observed defect in the lens, or it may be needed later in the postoperative course due to issues such as undesired IOL power, IOL dislocation, or opacity of the IOL optic.

For IOL exchange, I have found great value in the twist technique, which was first introduced to me by Jack Chapman, MD. With this technique, the first step is to get the IOL out of the capsular bag or sulcus and into the anterior chamber. Viscodissection with a dispersive ophthalmic viscosurgical device (OVD) is helpful, and it is also important to protect the corneal endothelium. Once the IOL is in the anterior chamber, more dispersive OVD is injected in front of and behind the IOL.

For the twist technique, no special instrument is required—just straight tying forceps and a spatula or similar long, thin instrument. Once the incision is open, one haptic is brought out through the incision, bringing the optic closer to the incision. The optic is then grabbed with the straight tying forceps at one edge (not in the middle). The spatula is then inserted via a paracentesis and placed above the optic. While the spatula protects the corneal endothelium, it also helps roll the optic into tube form as the tying forceps are twisted 360°. The IOL should now be compact enough to be easily pulled out of the incision.

Once explanted, the IOL can be placed on the corneal endothelium for examination. The surgeon should ensure that it is completely intact and that no pieces are left inside the eye. A new IOL can now be implanted. Importantly, this technique can work through an unenlarged 2.75 mm incision.

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5. Embrace the future of accommodating IOLs. The pipeline for presbyopia-correcting IOLs looks promising. Once such innovative technology is the Juvene (LensGen), a dual-optic, curvature-changing, modular IOL that provides a range of presbyopia correction. This lens has been in development for more than a decade, and I implanted the first batch in humans in initial clinical trials in 2015. The Juvene IOL is composed of two parts that are implanted and then coupled inside the eye, and it has a big base component that actually fills the capsular bag.

In laboratory testing, the latest iteration of the Juvene lens shows more than 3.00 D of accommodative amplitude. The latest design was recently used in an exploratory trial outside the United States, named the Grail Study. In the 17 patients (34 eyes) implanted in this study, binocular defocus curves showed a wide range of vision, with both eyes corrected for plano distance, achieving a mean 20/25 intermediate vision at 60 cm and 20/32 near vision at 40 cm. At all ranges, patients are provided with high-quality vision with normal contrast and no night glare or halos. Patients were functionally spectacle-free and were pleased with their wide visual range and lack of dysphotopsia.

Over the past 5 years, clinical investigators have implanted more than 100 Juvene IOLs, and surprisingly, no patients have had clinically significant posterior capsular opacification. We surmise this is due to the nature of the Juvene lens, which fills the capsular bag and keeps the anterior and posterior capsular leaflets in their normal physiologic positions, preventing them from fusing.

We are now preparing to start US clinical trials to seek FDA approval. With a straightforward surgical technique, implantation through a standard-sized phaco incision, and 3.00 D of fluidic visual range without light splitting, I’d say the future looks bright.

Uday Devgan, MD, FACS
  • Private practice, Devgan Eye Surgery, Los Angeles, California
  • Partner, Specialty Surgical Center, Beverly Hills, California
  • Clinical Professor of Ophthalmology, Jules Stein Eye Institute, UCLA School of Medicine, and Chief of Ophthalmology, Olive View-UCLA Medical Center, Los Angeles
  • devgan@gmail.com
  • Financial disclosure: Owner and publisher (CataractCoach.com); Scientific advisor and stockholder (LensGen); Principal (Advanced Euclidean Solutions)