Volume 16_Issue 2_Supplement

ESCRS

EUROTIMES

™

Supplement February 2011

:

Supported by an unrestricted educational grant from

Surgical Techniques: Injecting the Latest Technologies

XXVIII Congress of the ESCRS, Paris, France 6 September 2010

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3 Donald Serafano MD

4 Richard Packard MD, FRCS, FRCOphth

5 Rudy Nuijts MD, PhD

6 Beatrice Cochener MD

7 Marino J Discepola MD, FRCSC, DABO

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Surgical Techniques: Injecting the Latest Technologies

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s cataract and refractive surgical technologies continue to evolve, ophthalmologists are continually being challenged to find better, safer procedures while reducing the amount of side effects their patients experience.

The traditional boundaries that existed between cataract and refractive surgery are fast disappearing. Today’s cataract patients tend to be younger and more active than those of a generation ago. They are also more likely to be well educated, Internet-savvy and more demanding about every aspect of their health and welfare. They will not readily accept a less-than-optimal refractive outcome and expect to enjoy excellent functional vision at all distances and under all conditions.

This is where the latest technologies, such as preloaded injection systems, and advanced technology IOLs (multifocal and toric) can all play a vital role.

Advanced technology IOLs represent the most technologically advanced implant designs currently available, with each lens offering distinct benefits for restoring vision and achieving optimal post-surgical refractive outcomes. Advanced injection systems allow surgeons to deliver these lenses through the smaller incisions demanded by today’s microincision cataract surgery.

At a EuroTimes Satellite Education Symposium held during the XXVIII Congress of the ESCRS and moderated by Donald Serafano MD, California, US, a panel of leading ophthalmic surgeons discussed various ways to improve the quality of their surgery.

Delegates had the opportunity to learn about new instruments and surgical techniques, with updates on cutting-edge implant technologies such as the new AcrySert® C preloaded injection system, the AcrySof® IQ Toric IOL, the AcrySof® IQ ReSTOR® IOL and the new AcrySof® IQ ReSTOR® Multifocal Toric intraocular lens.

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For international (non-USA) use only.

XXVIII Congress of the ESCRS, Paris, France 6 September 2010

Donald Serafano

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he new preloaded AcrySert® C injector system offers surgeons a safe, reproducible and efficient means of delivering an intraocular lens into the capsular bag, according to Donald Serafano MD. “Because of government regulations and increased emphasis on safety, there is a definite trend today towards these single-use devices. Using this preloaded system greatly reduces the risk of contamination or damage to the implant that comes from handling of the IOL. There is also a very short learning curve for surgeons to master the insertion technique and it can be used with either a single-handed or bimanual approach,” he said.

Dr. Serafano, associate clinical professor, University of Southern California, noted that greater staff turnover in operating theatres in recent years has put a strain on safety protocols. In cataract surgery, this sometimes results in less experienced staff loading the IOL into the injector, thereby increasing the risk of a damaged lens being injected into a patient’s eye.

“Surgeons continue to look for ways to eliminate variability from the procedure in terms of loading and handling the lens. We want to get rid of these variables as much as possible because if we can deliver reproducible surgery, we will ultimately improve the quality of our outcomes for our patients,” he said.

The ease-of-use of the preloaded AcrySert® C injector is one of the main advantages of this technology over previous injection systems, said Dr. Serafano.

“The simplicity of using this injector system can be encapsulated in three words: fill, pull and push. First we fill the injector with viscoelastic, then we pull the stopper to prevent any premature injection of the lens and then we push as a one-handed injector. If you forget any one of these steps the lens will not be delivered. I have used this many times in a laboratory setting and found it impossible to inject a damaged lens, because the lens will not advance if one of these key steps is not adhered to,” he said.

Works smoothly with smaller incisions The new injection system works perfectly well with the smaller incision sizes demanded in modern cataract surgery, said Dr. Serafano.

“It works perfectly well with a small incision and is very straightforward to use. It is designed to work with the monofocal lens AcrySof® IQ with the full dioptre range,” he said.

Another significant advance with the new AcrySert® C system is the consistent “feel” of the plunger irrespective of the dioptre of lens being inserted, said Dr. Serafano.

“This is very important because sometimes with the one-handed injectors, surgeons felt the need to push harder when they were injecting a higher dioptre lens. With extra pressure, there was always the danger of the lens suddenly being forced forward as it was delivered into the capsular bag,” he said.

With the AcrySert® C injection system, however, the tactile feel of the plunger is the same for a 6.0 D lens right up to a 30.0 D IOL, said Dr. Serafano.

“To prove the point, I conducted a blindfold test in the laboratory where I took the lens out of the inserter and just practiced with the plunger and I could not tell whether or not there was a lens in the cartridge because the resistance was exactly the same. The only thing that might conceivably change that resistance is the temperature, so if you have a very cold operating room then the lens material is a little more resistant to folding,” he said.

For international (non-USA) use only.

Looking at some of the design features of the AcrySert® C injection system, Dr. Serafano highlighted the addition of a longer plunger and the introduction of a modified plunger tip as noteworthy innovations.

“Some surgeons like to have the plunger a little bit longer so that they can actually use the plunger to dial in the lens.

The smaller diameter nozzle allows the lens to comfortably fit through a smaller incision,” he said.

The new plunger design of the AcrySert® C delivers a smooth, consistent fold of the trailing haptic over the optic, concluded Dr. Serafano.

“It really gives us a very smooth, controlled delivery of the lens into the capsular bag and we can be reassured in the knowledge that we are putting a perfect lens into the eye with no scuff marks or damage to the IOL, which was not always possible with previous delivery systems. I think this is a major advance forward for lens delivery technology and greatly reduces the risk of contamination or damage to the implant that comes from handling of the IOL,” he said.

Donald Serafano MD, serafano@gte.net

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Surgical Techniques: Injecting the Latest Technologies

Richard Packard

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urgeons contemplating a move to coaxial microincision cataract surgery (MICS) are advised to re-evaluate all aspects of their surgical approach in order to reap the full benefits of smaller incisions offered by the latest technologies, according to Richard Packard MD, FRCS, FRCOphth.

“I moved to MICS quite some time ago, starting initially with bimanual microincisional surgery and more recently coaxial microincisional surgery through a 2.0mm incision. In terms of improving the quality of my cataract surgery, this transition made me re-think my approach to every stage of the procedure. I looked at knives and incisions, the capsulorhexis forceps, hydrodissection, needles, phaco-dynamics, choppers, irrigation and aspiration and, probably most importantly, the lens implantation techniques and instrumentation,” he said.

Looking at each of these stages in turn, Dr. Packard noted that most surgeons seem to give little critical thought to their choice of blade for the incision.

“I believe the importance of the incision knife is definitely underestimated. The smaller incisions provide greater resistance to blades in coaxial MICS. We need to be able to control that incision and it can be more difficult if the resistance of the tissue is wrong. I also believe that incision architecture is just as important in smaller incisions and maybe even more so as you may get a little bit of stretching,” he said.

For the main incision, Dr. Packard uses a self-designed Windsor knife (Core Surgical Ltd.).

Exquisite control For the capsulorhexis, Dr. Packard said his preference is to use the cross-action Calladine-Inamura capsulorhexis forceps (Duckworth & Kent).

“This works very well indeed for smaller incisions because it gives you exquisite control as you perform the capsulorhexis. The blades also have a series of marks to measure the size of the capsulorhexis, which is particularly useful for training residents,” he said.

Dr. Packard said that he initiates hydrodissection near the main wound using a disposable flattened cannula.

“With a microincision you need to be aware that you cannot just push through it into the eye because this can over-pressurize the eye. It is very important to bleed off some viscoelastic first and always make sure that you have good rotation of the nucleus.”

For removal of the nucleus, Dr. Packard stressed the importance of fluidics and power modulation in smaller incisions.

“This balance between fluid into the eye and fluid and lens material out of the eye is very important with smaller incisions.

Surgeons need to watch for leakage to avoid creating an unstable anterior chamber. One significant source of leakage, in my experience, is the sideport incisions, so surgeons need to be able to match their instrumentation to mitigate this,” he said.

To this end, Dr. Packard has designed a double-ended instrument called the Packard Fat Boy chopper (Duckworth and Kent), the shaft of which is thick enough to fill the sideport and is the same diameter as the irrigation/aspiration handpieces.

Issues of surge and followability also need to be borne in mind during fragment removal, said Dr. Packard.

“The non-compliant tubing such as that offered by the INTREPID® Fluidic Management System (FMS) (Alcon) has definitely enhanced surge control thanks to its increased stiffness,” he said.

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For international (non-USA) use only.

Top tips for phaco tips In terms of optimal tip choice with coaxial MICS, Dr. Packard noted that a study of five different tips he conducted in 2009 found that the 30-degree mini-flared tip was less efficient on harder-grade nuclei than the 45-degree mini-flared tip. The most efficient tip in this study was a 30-degree non-flared tip which did not clog even with dense cataracts.

However, Dr. Packard notes that with the advent of OZil® IP (intelligent phaco), however, the situation has changed. Now, the 30-degree mini-flared tip is both easier to use and provides efficient emulsification for surgeons who prefer the chop technique.

“With OZil® IP, we get a longitudinal pulse when vacuum crosses a surgeon-set threshold. This pulse provides a little bit of repulsion which clears the tip, maintains fluid movement, brings fragments to the tip and, in so doing, helps to maintain a more stable chamber during fragment removal. So, OZil® IP makes efficient phacoemulsification with dense nuclei, even using the 30-degree tip. This is good news for many of those chop surgeons who still prefer not to use a 45-degree tip because it is more difficult to get occlusion with this type of tip,” he said.

For lens implantation, Dr. Packard said that he uses the AcrySof® IQ lens (Alcon) for standard procedures using a single-handed injector to implant the lens with a wound-assisted technique and sideport counter-traction using the Mackool* iris repositor.

For those patients whose cataract has been removed under topical anaesthesia, Dr. Packard said that it can be helpful to ask the patient to look towards the surgeon just before the lens insertion.

“Asking the patient to look towards you provides plenty of counter-traction and facilitates a smooth implantation of the lens.

One of the great things with the AcrySof® IQ lens is that it unfolds in a slow and controlled manner, allowing the surgeon to go in through the sideport to position the lens in the capsular bag and remove the viscoelastic from underneath the lens. Finally, while the irrigation handpiece is still running fluid into the eye, the right-hand sideport is closed by injecting the stroma with balanced salt solution with the hydrodissection cannula,” he said.

“Asking the patient to look towards you provides plenty of counter-traction and facilitates a smooth implantation of the lens” Summing up, Dr. Packard said that coaxial MICS results in less traumatic surgery with faster visual rehabilitation for patients.

“Coaxial MICS is eminently doable with most modern machines and with small changes in instrumentation and surgical techniques.

By concentrating on all aspects of cataract surgery necessitated

by MICS, I believe that I have become a better surgeon and have improved visual outcomes for my patients. And we have now moved the whole of my department at the Windsor Eye Hospital to coaxial MICS over the last 18 months,” he concluded. * Trademarks are the property of their respective owners.

Richard Packard MD, FRCS, FRCOphth eyequack@vossnet.co.uk

XXVIII Congress of the ESCRS, Paris, France 6 September 2010

Rudy Nuijts

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he latest generation of toric intraocular lenses offers an efficient, safe, and predictable approach to managing corneal astigmatism in cataract patients and results in a very high level of spectacle independence, according to Rudy M M A Nuijts MD, PhD. “While there are a range of options open to us to correct corneal astigmatism, my own personal preference is to address the problem using a toric IOL, and specifically the AcrySof® IQ Toric IOL,” said Dr. Nuijts, associate professor of ophthalmology in the Department of Ophthalmology at Academic Hospital, Maastricht, Netherlands. Dr Nuijts also went on to say in terms of the scientific literature, the AcrySof® IQ Toric IOL is the best studied toric lens currently on the market.

Dr. Nuijts said that toric IOLs are ideal for patients who want to have very good uncorrected distance vision, who wish to reduce their spectacle dependence for distance use.

“The nice thing nowadays is that you can correct a very wide range of astigmatism with the lenses available. For the IOL to deliver an optimal result we need an easy manipulation of the lens in the capsular bag and there also needs to be good long-term positional stability. In my experience, the AcrySof® Toric IOL, which is built on the tried-and-trusted AcrySof® platform and can be delivered through a small incision, delivers excellent stability and visual outcomes over the long term,” he said.

Dr. Nuijts noted that there is a real market need to find solutions for astigmatism, with an estimated 25 percent to 30 percent of cataract patients having corneal astigmatism of more than +1.25 D. “The trend is definitely towards greater use of toric lenses to help this population with significant corneal astigmatism. An estimated 31 percent of our colleagues in the Netherlands are now using toric IOLs. And this is not an isolated Dutch experience as the ESCRS members’ study shows a similar trend across Europe, with a steady decrease in incisional techniques over the years while the number of surgeons using toric IOLs continues to increase,” he said.

With an overall length of 13.0mm and an optic diameter of 6.0mm, the AcrySof® Toric IOL is convex on both sides, enabling it to provide both spherical and astigmatic correction. The IOL’s toricity is generated on the posterior surface of the lens and the lens is made of a soft acrylic material that can be folded prior to insertion, allowing placement through an incision smaller than the optic diameter of the lens using either the MONARCH® II injector with a B-, C- or D-cartridge.

Seven models of the AcrySof® IQ Toric SN6ATT IOL are currently available in Europe starting at the SN6AT3, which offers +1.50 D astigmatic power at the corneal plane, through to the SN6AT9 lens, enabling surgeons to correct up to +6.0 D of astigmatism at the IOL plane.

“We can correct from +1.5 D to +6.0 D and the toric lenses are available in 0.75 D steps. With this range of powers, we now have the means to correct almost the entire cataract population,” said Dr. Nuijts.

No steep learning curve He added that a clear benefit of using toric IOLs to correct astigmatism is that it allows surgeons to perform a standard cataract procedure from the capsulorhexis right through to phacoemulsification with only a minor variation needed in surgical technique.

For international (non-USA) use only.

Dr. Nuijts said that there are three main steps to bear in mind for toric IOL implantation. Firstly, the correct toric lens model must be calculated, and then the eye has to be marked in a particular way.

Finally the lens must be aligned on the correct axis in the eye. Apart from these small variations, the procedure is just like implanting a standard IOL and does not require a steep learning curve.

For the AcrySof® IQ Toric IOL, the cylinder power and alignment axis can be calculated using Alcon’s Internet-based Toric IOL calculator software (http://www.acrysoftoriccalculator.com). This calculator takes into account the patient’s keratometric values and axis of astigmatism as well as the surgeon’s anticipated surgically induced astigmatism to calculate the optimal IOL power and axis for implantation. It also predicts the postoperative residual astigmatism.

AcrySof® Toric IOL

Once the correct lens has been selected, the surgeon can then proceed to marking the eye. To assist with the preoperative marking of the eye, the surgeon can place reference marks using a slit lamp or a Nuijts/Lane Toric Reference Marker. The advantage of this marker is that the extensions of the marker leave slight impressions on the cornea even if the ink marks fade away after the surgical preparation, said Dr Nuijts.

The AcrySof® Toric IOL can then be inserted through a small incision using the standard MONARCH II injector and either the D-, C- or B-cartridge (Alcon).

“The lens is inserted through a small incision and the beauty of this AcrySof® material is that it unfolds very gently and slowly in the bag. This gives you the opportunity in the event that you have delivered the lens a little bit too far from the alignment point to rotate it back to its desired position without any problem,” said Dr. Nuijts.

Once the lens has unfolded in the posterior chamber, most of the viscoelastic is removed and the lens is placed close to its final position.

“I use a bimanual irrigation/aspiration technique to remove the rest of the viscoelastic in front of and behind the lens and to make absolutely sure that nothing is left in the eye that might compromise the positional stability of the IOL later on. We then fix the lens in its final position by aligning the marks on the lens with the reference marks on the cornea,” said Dr. Nuijts.

Rudy Nuijts MD, PhD, rnu@soog.azm.nl 5

Surgical Techniques: Injecting the Latest Technologies

Beatrice Cochener

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he AcrySof® IQ ReSTOR® Multifocal Toric intraocular lens is a major step forward in providing an all-in-one solution for cataract patients with astigmatism who want a surgical option that delivers true performance at all distances with increased spectacle independence, according to Professor Beatrice Cochener MD. “I have had the opportunity to be among the first surgeons in Europe to implant this lens and the initial results have been very promising indeed. The lens seems to be safe, well tolerated and with good alignment in the eye which is essential for any toric lens.

With this IOL, we now have the advantage of being able to treat presbyopia and astigmatism in one single surgery and avoiding the PRK or laser touch-up that we used in the past to correct any residual refractive cylinder,” she said.

Professor Cochener, professor of ophthalmology at the University of Brest, France, noted that the development of a multifocal toric IOL has been high on ophthalmologists’ wish lists for many years.

“With the AcrySof® ReSTOR® +3.0D IOL we have been able to provide near, intermediate and distance vision to many of our patients with caratact and presbyopia. Nevertheless, residual astigmatism limited the outcome for many patients and we had to resort to limbal relaxing incisions or photo-ablation to deliver optimal results,” she said.

Looking at the market potential for this type of lens, Professor Cochener said that the AcrySof® IQ ReSTOR® Multifocal Toric IOL is currently available in Europe in a T2 to T5 range, with T2 model offering 0.68 D cylinder power at corneal plane up to the T5 model offering 2.06 D cylinder power at the corneal plane.

“If we want to target emmetropia for these patients and to deliver the best results in one procedure, then there is definitely a place for toric multifocal lenses, especially in that range of T2 to T5 according to the power selected,” she said.

Lens incorporates unique design features Looking at the properties of the lens in greater detail, she said that the new multifocal toric IOL combines a number of design features of the AcrySof® IQ ReSTOR® +3 Add IOL and the AcrySof® Toric monofocal.

“The apodized, diffractive pattern of the optic is located on the anterior surface of the lens just like the ReSTOR®. The anterior surface also contains -0.1 microns of asphericity, which is designed to balance the mean positive corneal spherical aberration found

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For international (non-USA) use only.

in most corneas of patients in the cataract age population, giving patients better depth of field and contrast sensitivity. The toric component of the optic is located on the posterior surface of the lens as with the AcrySof® Toric IOL,” she said.

Professor Cochener noted that the apodized diffractive pattern of the lens has been designed to allocate light energy equally to both distance and near focal points in bright conditions. As lighting dims and pupil dilates, the lens allocates a greater amount of energy to distance vision, while maintaining the amount of light at the near focal point.

As with the standard toric lens, an essential step to implanting the new AcrySof® ReSTOR® Toric IOL is that it must be accurately aligned along the steep axis of the cornea.

Professor Cochener said that using the online toric calculator (http://www.acrysoftoriccalculator.com/) surgeons can input information such as keratometry, IOL spherical power, surgically induced astigmatism, and incision location. The toric calculator will then enable the surgeon to determine the lens model to use, the spherical equivalent lens power, the optimal axis location and the anticipated residual astigmatism.

“Inputting parameters such as the incision location allows us to predict in a more accurate way the potential induced astigmatism and gives us greater control over the final outcome. For instance, surgeons may opt in certain cases to retain some oblique astigmatism in order to enhance the quality of vision and keep some depth of focus,” she said.

In order to get the best possible results from the lens, Professor Cochener said it was very important to ensure that the IOL is aligned precisely along the attended axis determined from the limbal marks of horizontal line preoperatively performed with the patient sitting in order to avoid the cyclotorsion, and ensuring that all viscoelastic is thoroughly removed from underneath the lens so as not to jeopardize the IOL’s positional stability in the capsular bag.

Summing up, Professor Cochener said that the AcrySof® ReSTOR® Toric IOL seems to be a viable and safe option to correct both astigmatism and presbyopia, although longer follow-up with controlled studies are needed to confirm initial impressions of the lens. She said the IOL shows very good performance at all distances and should enable surgeons to achieve their desired refractive outcomes while eliminating the need for additional procedures to reduce residual astigmatism.

Beatrice Cochener MD, Beatrice.cochener-lamard@chu-brest.fr

XXVIII Congress of the ESCRS, Paris, France 6 September 2010

Marino J Discepola

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uccessfully managing patient expectations and building a motivated and dedicated team that believes in advanced technology IOLs are among two of the key factors to bear in mind for ophthalmologists considering adding toric or multifocal IOLs to their practice, according to Marino J Discepola MD, FRCSC, DABO. “I think the key thing is to recognize that you can’t do this alone, either in a hospital clinic or in an office setting. Patient selection is vital, especially in the beginning. Ultimately we want spectacle independence for our patients, and that is our goal now. The days of telling patients that we can remove your cataract and you will see better is not good enough any more,” said Dr. Discepola, assistant professor of anterior segment surgery at McGill University, Montreal, Canada.

Dr. Discepola said that the development of toric and multifocal IOLs means that ophthalmologists can now tell their patients with confidence that there is a very good chance that they will be spectacle independent.

“The key motto of ‘under-promise and over-deliver’ applies here and will result in very happy patients. However, it is vital that the entire staff believes in this technology in order to ensure that everyone is pulling in the same direction,” he said.

Surgeons contemplating introducing multifocal or toric IOLs into their practice for the first time need to educate all their staff about the benefits of the technology, said Dr. Discepola.

“It is new technology so you need to have a step-wise approach. The first step is that you have to convince everyone in your office from the receptionist to the technicians that this is the way to go. It has to be an active decision on your part that this is the direction you want your practice to evolve,” he said.

Canadian healthcare system Dr. Discepola explained that the private practice of medicine is not allowed in the Canadian healthcare system, which operates a national health service with universal coverage for every Canadian citizen. “If I did private cataract surgery even on one single patient, I would risk losing my licence. In terms of finance, about 10 percent of the gross domestic product (GDP) goes towards healthcare in Canada,” he said.

With the introduction of toric and multifocal lenses, it became apparent that the national health budget could not afford to supply these IOLs to every patient that requested them. Hence the Canadian government decided to allow patients to pay for anything over and above what is considered a standard lens, said Dr. Discepola.

To complicate the picture further, he noted that different Canadian provinces have differing definitions of what constitutes a “standard lens”.

“In Ontario, a soft lens is considered standard whereas in Quebec a hard lens is considered standard. So a patient does not have to pay for anything, as long as they are willing to have a standard lens. With a toric or multifocal IOL, however, it is the hospital that bills the patient for the lens,” he said.

Ophthalmologists in Canada are also entitled to charge patients for the extra time involved in assessing and examining the patient and explaining the advanced technology IOLs to them.

“If you are doing toric or multifocal IOLs there is a lot more effort involved, a lot more chair time and a lot more assessments, so we are allowed to bill the patient for this service which is called a refractive assessment,” he said.

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AcrySof® Toric Calculator

While European surgeons might be skeptical about the prospects of their patients being willing to pay personally for such services or IOLs, Dr. Discepola said that the Canadian experience suggests otherwise.

“Canadian patients were not used to paying for anything. If you told me five years ago that there would be patients paying for different services in Canada, I would have told you that this is just not possible and it is not going to happen. Now that has all changed and I suspect that in Europe, if you are going to be able to offer these lenses to the patients, I suspect that it will have to be at patient expense and not government expense,” he said.

Taking a leaf out of LASIK’s book In order to successfully reorient an ophthalmic practice to offering advanced technology IOLs, Dr. Discepola said that surgeons must elevate their cataract surgery to LASIK standards.

“That means that your postoperative refractive outcomes need to be within ± 0.5 D of target refraction. The only way to do this is to perform rigorous biometry using IOL Master or a similar device, to track your outcomes over time, personalize the Z-constants and be aware of how much astigmatism you actually create with the incision,” he said.

Managing astigmatism is also essential for optimal results, said Dr. Discepola, because patients with multifocal lenses are particularly sensitive to any defocus induced by residual astigmatism.

“The residual astigmatism needs to be less than +0.75 D postoperatively or the patient may be dissatisfied,” he said.

Dr. Discepola also stressed the status of the macula as having a crucial role to play in the performance of the lens.

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Surgical Techniques: Injecting the Latest Technologies

“Even a very mild cystoid macular oedema will reduce the performance of these lenses, so CME is not an option. There is no question that the use of non-steroidal anti-inflammatory agents after cataract surgery for at least three or four weeks will decrease the incidence of CME almost to zero,” he said.

For ophthalmologists who are just starting to offer advanced technology IOLs, Dr. Discepola advised toric lenses as a good introduction to refractive lenses.

“The AcrySof® Toric IOL is a good lens to start with as there are less issues with patient selection. There is no real downside with the toric IOL – it is a monofocal lens that happens to correct astigmatism. Moreover, the bigger the preoperative refractive cylinder, the easier it is to measure and the happier the patient will be postoperatively,” he said.

For the initial cases of multifocal IOL implantation, Dr. Discepola advises starting with a patient with a significant cataract, and preferably a hyperopic patient.

“Patients with a significant cataract who have previously had problems with haloes and glare may see a decrease postoperatively even with a multifocal lens. As long as you are making the patient better, they tend to be happy” “Patients with a significant cataract who have previously had problems with haloes and glare may see a decrease postoperatively even with a multifocal lens. As long as you are making the patient better, they tend to be happy. Hyperopes tend not to have seen well at near or far distances for many years, so basically you can only improve their situation and create a happy patient,” he said.

To improve workflow and get to see as many patients as possible, Dr. Discepola suggests that having a dedicated member of staff to act as surgical counselor can make all the difference.

“One of the key take home messages is that we are extremely busy as ophthalmologists in Canada because of the relatively low number of ophthalmic surgeons. It typically takes approximately 30 minutes per cataract patient, to do all the testing and explain the surgery and lens options to them. In my opinion, you need a surgical counselor in your clinic or in your office that can share the workload, carry out the preoperative assessments and build a rapport with the patient. It is impossible for the ophthalmologist to do this all himself. With a good team in place, it is more efficient and cost-effective for everyone concerned,” he said.

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For international (non-USA) use only.

With this structure in place, Dr. Discepola said that in the past six months about 57 percent of his patients have been implanted with a multifocal or toric lens, which is well above average for an ophthalmic practice in a public-funded setting.

“I think a lot of this success is down to word-of-mouth business from happy patients telling their friends or family about their successful surgery and the difference the implant has made to their daily lives,” he concluded.

Marino Discepola MD, FRCSC, DABO, marino.discepola@mcgill.ca

XXVIII Congress of the ESCRS, Paris, France 6 September 2010

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