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 Paramus, N.J., surgeon Douglas Liva. "There are no additional side effects." Luther Fry, MD, of Garden City, Kan., says a toric IOL is "more accurate and stable than an LRI."


"The amount of correction is reliable with a toric lens," avers a surgeon from Michigan.


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 California. Frank Bowden, a surgeon from Jacksonville, Fla., agrees. "They're good for presbyopic IOLs where cylinder is less than 1.5 D," he says. "Otherwise, I use postop PRK."

 


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 San Antonio. An ophthalmologist from Oklahoma feels the same way, and says, "Bimanual is cumbersome, and I'm delighted with my results." A Texas surgeon says he's unlikely to switch to biaxial. "At this point, smaller incisions don't offer enough of a benefit," he says.


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 Paxton, Mass., is unlikely to start using biaxial because the surgeon "needs to widen the wound for the intraocular lens." A surgeon from Michigan doesn't like biaxial because it wouldn't let him use his favorite IOLs. "It's more difficult without the added benefit of being able to use my primary lens choice," he says. "And I don't foresee changing my IOL preference."


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 Virginia. "Also, the hospitals that I operate in will not buy the handpieces."

 



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 California. Dr. Liva prefers them because "they've got minimal astigmatic effect." A surgeon from Virginia describes them as "easy to make … but sometimes hard to seal."


"The lateral approach is easy with clear corneal incisions," says an ophthalmologist from Washington. "There's good wound security and no astigmatism." Jacksonville's Dr. Bowden also prefers these types of wounds, though he acknowledges there's "an occasional need for suture closure … I'm happy with the cost, speed and astigmatic predictability."


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 Massachusetts. A surgeon from Florida also prefers them. "They're stable and leak-proof," he avers. "Limbal incisions are more flexible if there are problems," says a surgeon from Wisconsin.


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 Virginia says quadrant division is her preferred method because of "familiarity, comfort and because it works for most cataracts." A surgeon from California simply says, "It's the safest."


As for the other methods, an ophthalmologist from Michigan says stop and chop is "highly efficient without sacrificing safety." Harvey Rosenblum, MD, of New York City feels phaco chop is "reliable and involves less zonular stress," while a doctor from Indiana describes the divide-in-two technique as "efficient."

 



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 Michigan uses a topical combination consisting of lidocaine gel, dilating drops, a non-steroidal anti-inflammatory and an antibiotic. "It causes less corneal toxicity," he says, "decreases the work for the nursing staff and results in a more reliable absorption than rapid drop administration." David Kim, MD, of Green Bay, Wis., prefers a topical gel, as well. "It's quick, effective and safe," he says. A Virginia surgeon swears by drops, however, saying, "Topical drops are best for the majority of patients."


Peribulbar blocks have their supporters, as well. "They give the greatest safety, greatest control and are the most efficient," says a surgeon from Oklahoma. "There's no ocular movement with a peribulbar block," says a Texas surgeon. "It's full anesthesia."

 


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 New York. Dr. Bowden thinks topical fluoroquinolones are preferable because of their method of action. "You must reduce bacterial flora on the lids and ocular surface," he says. "It's additive with povidone iodine." Dr. Rosenblum agrees, saying, "Preop topical fluoroquinolones result in high levels of drug prior to surgery."


Though some surgeons like to inject antibiotics intracamerally, an ophthalmologist from Florida doesn't see the benefit. "I'll use intracameral antibiotics as soon as their safety and results are proven," he says. A doctor from California says that, if you want to maximize prophylaxis, then "personally clean the eyelids under the microscope preoperatively."

 


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 Maryland surgeon says you can make the perfect capsulorhexis by "continuously folding over and regrasping."


A Massachusetts ophthalmologist says that "Bimanual irrigation/aspiration makes surgery much easier and safer," while a surgeon from Texas says there's a way you can make the end of the procedure easier, as well. "Subcapsular hydrodissection virtually eliminates cortical cleanup," he says.


An ophthalmologist from Oklahoma offers his advice: "Meticulous creation of incisions is essential to decrease infection risk," he says. "And the use of atropine b.i.d. one week preop decreases the need for mechanical pupil dilation in patients on Flomax or who have used Flomax in the past."


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 Wisconsin. "Let the case dictate the pace." A surgeon from Florida agrees, saying, "Don't rush. Plan in advance your approach to tough cases." A California surgeon advises, "Do everything slowly. Do not rush." "Relax and don't be in a rush," echoes a like-minded surgeon from Virginia.


Perhaps the most practical tip for staying out of trouble comes from a New York surgeon who says simply, "Refer out the difficult cases."