In last year's National Panel report on cataract surgery technique, surgeons showed a marked increase in interest in toric intraocular lenses for managing astigmatism, and that upward trend has continued this year. Also continuing this year is surgeons' lack of interest in biaxial or bimanual cataract surgery, a procedure that continues to flounder due to a lack of micro-incision IOLs and its technical requirements. In addition to noting the surgical methods they use most often, panelists were also eager to share their personal cataract surgery techniques on this year's survey.
For this month's survey on cataract surgery, 58 surgeons, or 12 percent of the sample, responded. Listen to what they have to say about their approaches to cataract surgery, and see how their strategies compare with yours.
Toric IOLs Ascend
Toric lenses have found a spot in surgeons' ORs, with the percentage of respondents who use them increasing from 28 percent last year to 35 percent in this year's survey. As for the other strategies for controlling astigmatism, 31 percent of surgeons say they prefer limbal relaxing incisions, 20 percent like to place the cataract wound on the steep axis, 4 percent would rather use a postop refractive procedure and 10 percent use another method.
"They're very accurate and have great results," says
"The amount of correction is reliable with a toric lens," avers a surgeon from
Though toric lenses continue to attract surgeons, LRIs are also a popular option. "They're cheap, safe, simple and necessary for deluxe IOLs," says a surgeon from
Backing Away from Bimanual
Bimanual surgery, also known as biaxial, still hasn't caught on with our panelists, with only 9 percent of respondents saying that they use it. This is a small decrease from the 13 percent who used biaxial in the 2008 survey. Twelve percent of respondents say they're "somewhat" likely to use biaxial within a year, while the rest say it's unlikely. As with many newer techniques or technologies, surgeons say they'll need to see a tangible benefit from biaxial before they'll expend the time and money necessary to abandon methods that currently work well for them.
"My results are more than adequate for my practice," says Sebastian Mora, DO, of
Surgeons also think the lack of a sub-1.5 mm IOL may negate some of the advantages of using small incisions if they have to enlarge one of the incisions after the phaco. George Brinnig, MD, of
There are also practical concerns that prevent or deter surgeons from taking up a biaxial technique. "I'm not trained in it," says a surgeon from
Incisions and Phaco Technique
Clear corneal phaco wounds gained in popularity in this year's survey, with the percentage of surgeons using them increasing from 47 percent in 2008 to 61 percent. Limbal incisions were preferred by 23 percent of the respondents, 14 percent like scleral incisions and 2 percent say they use something else.
"Clear-corneal incisions are fast, don't bleed and don't cause conjunctival swelling," says a surgeon from
"The lateral approach is easy with clear corneal incisions," says an ophthalmologist from
Though clear-corneal incisions were the most popular, limbal incisions, too, had their fans among the panelists. "The limbal incision seals well and gives me good visualization," says a surgeon from
In terms of how surgeons like to attack the cataract, 51 percent prefer to divide it into quadrants, 22 percent use phaco chop, 11 percent divide it in half, 7 percent use a stop-and-chop technique, 4 percent use phaco flip/tilt, 4 percent like sculpting and 2 percent use another method.
"Quadrant division is very safe and has minimal complications," says Dr. Liva. A surgeon from
As for the other methods, an ophthalmologist from
Thoughts on Anesthesia
Seventy-nine percent of panelists say they use a variety of topical anesthesia. Looking at the individual methods, 38 percent use topical drops, 26 percent use a gel and 15 percent use a combination of topical approaches. For topical as a whole, this is an increase compared to the 65 percent of surgeons who said they preferred it on last year's survey. Eighteen percent of surgeons use peribulbar blocks, 12 percent use retrobulbar and 3 percent use another method. Twenty-four percent of surgeons use intraocular lidocaine.
A doctor from
Peribulbar blocks have their supporters, as well. "They give the greatest safety, greatest control and are the most efficient," says a surgeon from
Infection Prophylaxis
Preoperative application of topical fluoroquinolones is still the most popular form of infection prevention among our panelists, with 62 percent preferring it. Fourteen percent use an intracameral injection of antibiotics, 14 percent like postop topical fluoroquinolones, 5 percent employ subconjunctival antibiotic injections and 5 percent use another method. Some surgeons selected more than one response.
"The fewer the number of injections and materials in the eye, the less chance for trouble," says a topical fluoroquinolone user from
Though some surgeons like to inject antibiotics intracamerally, an ophthalmologist from
Cataract Pearls
Surgeons also took the opportunity to share their most useful tips and techniques for maximizing the outcomes of their cataract surgeries. Here's what they had to say.
In the beginning of a case, a
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An ophthalmologist from
Dr. Liva notes that the small things can make a big difference. "Adjust the patient's head position and set up the microscope for the best view," he advises. "It doesn't matter how good a surgeon you are if you can't see what you're doing."
Interestingly, several surgeons emphasized the concept that haste makes waste. "Speed kills," declares a surgeon from
Perhaps the most practical tip for staying out of trouble comes from a