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In Your Head | Nov/Dec '21

In Your Head: What’s New in Surgical Planning?

Gary Wörtz, MD

Although surgical planning previously involved circling a lens on the IOLMaster (Carl Zeiss Meditec) printout, it has evolved over the past decade into a comprehensive multifactorial analytical tool. Surgical planning software offers many advantages, but three specific functions truly excite me, as they will save time and leverage technology to drive better results—a real win-win.

First and foremost, integrating postoperative data into the planning software has the potential to close the loop on continuous process improvement. Beyond simply personalizing the A-constant for a lens, AI algorithms will be able to personalize the lens and power based on an exhaustive database of similar eyes and techniques. Second, with surgical planning software, we can use the preoperative measurement from multiple machines from various manufacturers to look for consistency or add missing pieces to the puzzle. For example, with Veracity Surgical (Carl Zeiss Meditec), I can use the anterior keratometry from my Lenstar optical biometer (Haag-Streit) and incorporate the posterior corneal astigmatism from my Pentacam (Oculus) to plan astigmatic correction based on the total keratometry value. I’d rather use the machines I already have and turbocharge them by incorporating new software!

Last but not least, the workflow of surgical planning software will improve efficiency and prevent errors by importing data directly into one master planning tool. The days of transposition and online data entry errors will be in the past, replaced by confidence in our new digital assistants.

Lawrence Woodard, MD

The surgical planning technology that I am most excited about is the Smart Solutions device (Alcon), a cloud-based digital health platform that allows the integration of data from electronic health records, preoperative diagnostic devices, and intraoperative surgical equipment. With Smart Solutions, all this information becomes accessible from any computer or handheld device, enabling both in-office and remote surgical planning. By transferring data between the clinic and the OR, the platform improves the surgical planning process while increasing workflow efficiency and minimizing the potential for data transcription errors.

Nandini Venkateswaran, MD

I’m excited to implement the new Catalys cOS 6.0 planning software on the Catalys femtosecond laser (Johnson & Johnson Vision). This software contains a built-in nomogram for astigmatism management, opportunities for direct input of preoperative keratometry and steep axis values from preoperative imaging, improved placement of radial laser marks for toric IOL alignment, and the addition of iris registration for automatic cyclorotation compensation. All these features will simplify my workflow for patients undergoing laser cataract surgery, which is a significant portion of my practice, as well as reduce transcription errors and improve the patient’s overall intraoperative and postoperative experience.

In addition, I’m thrilled about the approval of the AvaGen Genetic Test (Avellino) for keratoconus and corneal dystrophy screening. This tool will help me with risk stratification of patients with strong family histories of corneal ectasia or dystrophies as well as patients with irregular or suspicious corneal topographies and tomographies. This will help me determine if patients are safe candidates for laser vision correction or if they require more careful and timely screening to assess for contraindicating corneal disease.

Robert F. Melendez, MD, MBA

Toric IOLs are a great option astigmatism management and yield excellent postoperative refractive outcomes. However, what is the best approach for patients whose astigmatism is about 1.00 D with the rule and 0.75 D against the rule? The lowest-powered toric IOL will flip the axis, which I try to avoid except on the rare occasion that it flips from against-the-rule to with-the-rule astigmatism. When treating lower levels of astigmatism, my go-to is the LenSx laser (Alcon), particularly for patients receiving a PanOptix Trifocal IOL (Alcon). All it takes is leaving about +0.75 D to +1.00 D of residual astigmatism in a patient with a trifocal IOL to be reminded that this outcome is not acceptable. If you are trying to achieve emmetropia, then reducing corneal astigmatism is paramount.

The newest biometers, Argos (Alcon) and IOLMaster 700 (Zeiss), both of which I have used, allow for preplanning of the astigmatism correction. For example, they allow for the placement of corneal incisions to correct astigmatism with an expected postoperative refractive residual astigmatism with a corneal relaxing incision, a toric IOL, or a combination of the two techniques. This option enables visualization of the expected residual astigmatism. I appreciate that the Argos communicates seamlessly with the LenSx laser: It recalls the upright image of the eye taken preoperatively and sends it to the laser to account for cyclotorotation, with no marking required.

Robert F. Melendez, MD, MBA
  • Founder and CEO, Juliette Eye Institute, Albuquerque, New Mexico
  • robertmelendez@mac.com; Twitter @drrobmelendez
  • Financial disclosure: Owner (Ophthalmology Business Minute); Consultant (Alcon)
Nandini Venkateswaran, MD
Lawrence Woodard, MD
  • Medical Director of Omni Eye Services of Atlanta
  • lwoodard@omnieyeatlanta.com
  • Financial disclosure: Consultant, clinical investigator, and speaker (Alcon)
Gary Wörtz, MD
  • Private practice, Commonwealth Eye Surgery, Lexington, Kentucky
  • Founder and Chief Medical Officer, Omega Ophthalmics
  • garywortzmd@gmail.com; Twitter @cataractMD
  • Financial disclosure: Licensing agreement with Veracity Surgical (Carl Zeiss Meditec) for the Wörtz Gupta Formula