Live Surgical Demonstration: Cataract Surgery with Premium Intraocular Lenses

During this live surgical demonstration, surgery will be performed emphasizing techniques for incorporating premium IOLs into your practice. Pearls will be discussed to assist in the successful integration of these IOLs into your practice including pre operative selection, intra operative tips, and post operative management.

Surgeon/lecturer: Dr. Kevin Barber, Central Florida Eye Specialists, USA


DR CHERWEK: Well, I would like to welcome everyone to another Cybersight live surgical webinar. This is with Kevin Barber, again demonstrating excellence in phaco technology. He’s going to be showing how to do refractive cataract surgery with advanced technology intraocular lenses. The key things here are to look at how he examines the patients, how he sets the expectations, how he changes his technique, and really how he follows his results, looking at the UCVA over time. Before he starts the surgery today, he’s going to give us a tour of his OR to show how he has changed the patient flow pathway and gotten his entire team engaged with the refractive cataract surgical suite. Kevin, over to you.

DR BARBER: Good morning, Hunter. Good morning, everyone, or afternoon or evening, depending on where you are in the world. Welcome to my operating room. It’s a privilege to have you all here. As we get started, I just want to say thanks to Hunter and Lawrence and the whole Orbis team for doing what you guys do, bringing great education to the world. It’s a real privilege to be a part of your process today. So the goal for today, as Hunter mentioned, is to go through two live surgical cases, using advanced technology intraocular lenses or premium lenses. So the goal is, if you were just trying to incorporate this — so maybe you’re early on in your career, or you’re just considering starting or adding ATIOLS into your practice, that’s really gonna be your focus today. It’s not necessarily a deep dive into all of the finer details. So I’ll present two cases. The first case is a femto-phaco. I’ll be implanting an Alcon PanOptix trifocal IOL. That multifocal ATIOL category. Then I’ll take a short break while the room is being turned over. And I’ll give a ten to fifteen minute talk, really just sharing pearls. I’ve been doing ATIOLs for 16 years now. And so I just want to share some of the things I’ve learned along the way and maybe give some helpful pointers for those of you who are just trying to get started or considering adding these to your practice. Then we’ll come back into the operating room and do the second case. The second case will be a non-femto, a manual cataract surgery. And I’ll implant a Vivity extended depth of focus lens. A different ATIOL. And we’ll talk about some of the differences between those two types of lenses. So we want to highlight a case both using the technology of intraoperative aberrometry and femtosecond laser and then without. So no matter what setting you function in, there’ll be some applicable knowledge there. So with that, what I would like to do is just give you a quick tour, just so you can have some perspective and see how the OR is set up. So we’ve already done the femtosecond laser for this patient. The femtosecond laser is there. You can see our patient and microscope. I’ll be using the Ingenuity. The Ingenuity is the 3D visualization system. So we’ll be broadcasting from that, which gives excellent visualization. And then I have Jess, my wonderful assistant and scrub tech, standing to my right with the phaco machine. So I hope that gives you just a little bit of perspective, when we’re talking about having a technology suite for refractive cataract surgery. All right. So Hunter, I’m gonna go scrub, and I’ll turn it over to you, so you can introduce us to our first case.

DR CHERWEK: Yeah. And I appreciate you highlighting the first patient. And we’re gonna also show those clinical details on the slides. So you’re gonna see a slide coming up. And really what’s important with all cases with advanced technology is making sure your fundamentals are sound. And one of the key things I want to make sure everyone knows is you have to have confidence in your biometry. You have to have confidence and convey that confidence when you’re speaking to the patient and family. That you can deliver the expectations they have. The biggest challenge a lot of doctors have when they’re starting ATIOL surgery is they promise too much, and no matter how good the lens performs, the patient’s expectations keep growing. It’s very important to let the patient and the family know that you’re trying to reduce the spectacle dependence. Do not guarantee them anything. You can’t guarantee anything in life. Certainly you can’t guarantee perfect vision at distance and near. You see that this patient already has had the left eye with the PanOptix lens. So they’ve had that expectation. And you can see they have fantastic uncorrected vision in that eye. So in this scenario, Kevin is going to match and do the surgery in the right eye to equalize with the left. And so one of the things you’ll see, which I really appreciate Kevin doing today, is showing two different types of lenses, two different types of technology, with the femtosecond and the intraoperative aberrometry. And then also manual techniques. So you’ll see that this is a great case to begin with, where the patient already had a very successful result in the left eye. And now we’re going to match. And really, I appreciate when he details the history that the patient wants freedom from glasses. What is their motivation? What is their expectations with this surgery? So that you and your team can hit the mark. Kevin, how are you looking?

DR BARBER: All right. I think I’m ready to go if you guys are.

DR CHERWEK: All right. So we’ve presented the patient and we’re gonna be operating on the right eye, and they’ve already had the PanOptix in the left where you’ve had a very successful result, and we’re going to be showing the microscope view now. And you can see a beautiful CCC was created by the femtosecond laser. So Kevin, talk us through this procedure and what you’re doing, especially as you know you’re gonna be doing an ATIOL surgery.

DR BARBER: That’s right. Well, I appreciate all your comments, Hunter. You’re exactly right. And we’ll get into the talk about expectations and patient selection in just a few moments. As Hunter mentioned, this patient already had a very successful outcome with the other eye. So that made the choice for this eye quite easy. So she’s elected to have a PanOptix trifocal lens. So I’ve made my incision here. I choose to make my incisions manually, as opposed to with the femtosecond laser. The capsulorrhexis has already been performed. So I’m going to remove that here. If you’re not familiar with femtosecond surgery, you can see this air bubble back here. That’s all that is, is just an air bubble that’s created by the femtosecond laser application. So this is a Chang cannula I use for hydrodissection. I’ll aim just a little bit, then come back and do a little subincisional hydrodissection, and that’s a very successful way of loosening up this nucleus.

DR CHERWEK: And Kevin, even though the lens has been pretreated, you still do the exact same things you do with any cataract surgery. You make sure you have good hydrodissection, good lens mobility, good visualization, good centration. Really all ATIOL surgery does is make you step up your game with all the fundamentals you should have mastered in your phaco career.

DR BARBER: That’s exactly right. So we’re sticking to what we know. We’re sticking to what works. Even though the femtosecond laser created the capsulorrhexis, I still go in and pull it around, just like I would any normal capsulorrhexis. So I think one of the points is… When in your career as a cataract surgeon do you make that transition into becoming a refractive cataract surgeon? And I think it’s different for each person. But you do want to have a certain level of experience and confidence. And so you want to be very good with just your standard, basic cataract surgery. And all parts of that surgery, from the biometry, IOL selection, to each step of your surgical technique. All of those things need to be really comfortable skills that you already have. And then you’re just gonna build on that, as you introduce advanced technology lenses. I’m sorry. Go ahead.

DR CHERWEK: Yeah, I think what you said is important. That you have to have confidence in your phaco technique, but also your team and the biometry. If you’re not measuring your results, and you don’t know your SIA, if you don’t know what is your uncorrected visual acuity, that’s critical. That’s gonna build your confidence to hit the mark. I also want to remind the audience that if you have any questions for Dr. Barber, please put them in the chat. We’ll answer them. And we’ll also put in some resources from the Cybersight library. The first one is an excellent lecture we had about biometry in the 21st Century.

DR BARBER: That’s exactly right, Hunter. When you take the refractive cataract surgery and advanced technology lenses, it requires the whole process. It’s not just using a different lens implant. It’s the whole process, from the patient experience, staff education, patient education, really stepping up your game, as far as biometry, outcome management — it just forces you to pay attention to every little detail. Because that’s what’s required. I mean, essentially what you’re offering is a greater probability or chance that a patient might not have to wear glasses. Now, again, that’s not important to every patient. And we’ll talk about that in just a few minutes. But for the patients that do desire that, it’s a privilege to try to offer that to them. But it does require a lot of deliberate effort on your part. So here’s a tip. I do like to polish the interior capsule a little bit. I’ll be a little more… I’ll pay a little more attention to this with an ATIOL. And so as you can see here, I’m just using the polish setting on my phaco machine. And I’m just very gently removing some of the interior capsular epithelial cells here. That you’ll see. And it’s good form, one. Two, it just doesn’t happen often, but occasionally you do have to either rotate and exchange an ATIOL. And so by having less epithelial cells and fibrosis there, that can make your process — that process a little easier. All right. So the cataract has been removed. I’m now putting in my cohesive viscoelastic. If you can see on the right bottom corner of the microscope screen, that’s the intraoperative aberrometer. I just did a pressure reading here. Just to make sure I’ve got the pressure at the right physiologic level. I want to make sure the cornea is nice and wet and moist. I then use a Weck-Cel to remove any excess.

DR CHERWEK: And Kevin, two questions that we have. One is with the femtosecond laser: What do you set as the diameter for your capsulorrhexis? Do you make toric lenses or ATIOLs slightly smaller with your CCC?

DR BARBER: Fantastic question. So the size of the capsulorrhexis is important. And so I set mine at 4.9. So that comes out to an effective 5 millimeter. Perfect. So we’ll take… Now I’m checking my biometry right now. And we will use a 16 diopter TFNT0, please. I’ll come back to that question in just a moment. I want to show that we did the intraoperative aberrometer, and it’s confirming the lens, the 16 diopter lens. So in this case, aberrometry is just confirming the biometry that we did preoperatively. Now, what I would say as far as — I do not change the capsulorrhexis size between ATIOL cases and regular cases, because you want consistency. Right? So you want your surgeries to be as consistent as possible. And one of the important things with ATIOLs, and hitting your refractive target, is that capsulorrhexis size. Because that does influence your ELP or effective lens position. If that lens sits more interior or posterior, that’s going to change the outcome. Your refractive outcome. And so you really do want a consistent capsulorrhexis size. So I strive in my manual cases to try and do the same size capsulorrhexis that my femtosecond laser will do. All right. So this is the PanOptix. This is a multifocal or trifocal lens. I’m gonna focus in here. You can see the rings here. And so that’s important. Because those rings are the good and the bad of this lens. As most of you know, there’s a good side and a bad side to pretty much every lens that we use. Now, this is Trimoxi. This is an injection I’m going to give intravitreally. So I’m going through the zonules and I’m injecting 0.2 CCs of a compounded pharmaceutical that has triamcinolone and moxifloxacin. That way, my patients do not have to take postoperative drops, because the antibiotic and the steroid has been injected into the vitreous. Where the vitreous allows it to act as a depot, and you get a slow release. You get about six weeks’ worth of effect. All right. So now I’m removing the viscoelastic. I do like to go under the lens. And remove any residual viscoelastic there. Now, the next important tip with a multifocal or any of the advanced technology lenses is centration. Centration is important. Now, I have a digital marker that I can use. But I would like to just show you today an alternative way. So what I do is I get the lens pretty close to where I think it’s in the center. I’m gonna go ahead and hydrate my wound so I’ve got a stable chamber. And that lens is continuing to stay there. Oops, some air bubbles there. I’m gonna hydrate my paracentesis. So I have a moxifloxacin concentration — which is why I get the air bubbles in here. I’ll have a little more BSS. I’ll try to flush some of those out. So the way I try to get good centration is I’ll have the patient fixate on the microscope light. So I use a Zeiss Lumera microscope. And it has three light bulbs. You can see that in the image there. So if I have the patient fixate on the center of those three lightbulbs, then I will line the Purkinje images up on to the center of the IOL. So Anne, if you can look up at the three lightbulbs there and look right between the three of them. As you can see, as she does that, the center of the multifocal lens is right between the Purkinje image. So that’s a no-cost way to get really good IOL centration. I’ll check my incisions here with a Wek. They are sealed. My eye is left at physiologic pressure. And that concludes this first case. Anne, you did fantastic. Great job.

DR CHERWEK: That was a beautiful demonstration. I know you’re heading over to give your PowerPoint. One question is: Do you prefer to make the main incision temporally or superiorly? And the other question is: I notice you prefer to make your incision manually. Not by femto. So if you could just talk through those two points.

DR BARBER: Sure. Of course. So… The first question: So I think where you make the incision — the guiding principle there should be where you’re comfortable. So I am a surgeon who sits at the 12:00 position. I sit at the head. So in a right eye, it’s really easy for me to make a temporal incision. So that’s what I do. And that tends to work out better. Because most patients — or a higher percentage of patients — have horizontal astigmatism. So by making a horizontal incision or an incision of 180, you are more likely to help treat that astigmatism just with your primary incision. But I would say again your guiding principle should be where you’re most comfortable. Because again, good surgery is comfortable surgery. And if you’re uncomfortable, because you’re trying to make your incisions in a strange place, that doesn’t help you. So that’s what I would recommend. We’re gonna talk about this in a second. But calculating your surgeon’s induced astigmatism or your SIA is gonna be really important. And that requires consistency. So you do want to make your incision consistently at the same place, as often as you can. And then you just incorporate that SIA into your keratometry and your IOL calculation. So I’m gonna go ahead and share my screen here. Great. Can you guys see that?

DR CHERWEK: Perfect, Kevin.

DR BARBER: Okay. Fantastic. And then Hunter, remind me, the second question — oh, the incisions, yes. So that’s personal preference, whether you make manual incisions. I find that when I use my femtosecond laser incisions, I can’t always get it right at the limbus. And so I just choose to make it manually. I think the quality and the integrity of the incisions are very, very similar. I don’t think there’s a huge difference there. So I like being able to put that incision right where I want it. Because that’s important. All right. So let’s dive into this talk. I’m gonna keep this pretty short. Just while my OR is turning over for our second patient. This is entitled getting started with advanced technology IOLs. And this is the journey from becoming a cataract surgeon to a refractive cataract surgeon. And that’s a journey I’ve been on for the last 16 years, and I just wanted to share some pearls that I’ve learned along the way. So my three learning objectives for you today would be: To understand the patient selection and the preoperative evaluation for any patient considering an ATIOL. Secondly, I want you to appreciate the nuances to successful refractive cataract surgery process. And it is a process. It’s not just putting in a different lens. It actually is a process that involves your entire clinic, OR, everything. And then I want you to comprehend principles for managing an unhappy ATIOL patient. Because any time you have an ATIOL patient, they’re different. They are paying money for an outcome. And if that outcome or that expectation is not reached, there’s going to be some dissatisfaction. So you need to know how to handle that. So… Advanced technology lenses are becoming more commonplace, globally. And I think that it’s quickly becoming a necessary skill set for most cataract surgeons. Patients want to be educated. They want to be given options, regardless of where they are. And I think that places like Aravind have proven that ATIOLs can be an excellent way to cost cross subsidize. So if you have patients willing to pay for premium services, that helps your organization provide care for everybody who walks in your door. So incorporating ATIOLs into your practice does require deliberate effort, though. It’s not something you can just haphazardly do. It does take a lot of prethought. And deliberate action. Okay. So the types of ATIOLs. Again, this talk is not designed to go into those critical details. So I’m just gonna make some broad categories. There’s a multifocal category. You just saw a multifocal lens put in. They have the reputation of good near vision. But they also have a side effect of visual disturbances. And so you have to be comfortable or familiar with both of those. The next broad category is an extended depth of focus lens. Or an EDOF. That’s what our second case will be. They don’t have the same side effect profile. So they don’t tend to have visual disturbances, as commonly. However, they’re also not known for having as good near vision. So again, each lens or each category of ATIOLs has positives and has some negatives. And so that’s the fun part of this. Is learning that and presenting that to patients and trying to match the right lens with the right patient. Now, there’s also accommodating lenses like the Crystalens, newer accommodating lenses on the horizon. There’s pinhole lenses, which work great for complicated corneas or corneas with a lot of ectasia. There are lenses coming out with a combination of technologies, and there’s a lot of future technologies. There’s a lot of research, a lot of money being poured into this. So I think five years from now, we’re going to see a lot of new technologies on the market. So again, the market share of ATIOLs is just continuing to grow. And so if you are a cataract surgeon, you’re gonna have to stay educated and involved with this. All right. So preoperative considerations. I just wanted to share a few things. So what are the patient’s visual goals? Hunter touched on this earlier. That’s really the key. I have patients all the time say: Hey, doc. I’ve worn my glasses for 40 years. If I don’t wear glasses anymore, my spouse, my kids, my grandkids won’t recognize me. I don’t want to get out of glasses! That’s not a patient that is a good candidate for an ATIOL, probably. So really what drives this is: What are the patient’s visual goals? And when you find that patient who is highly motivated to reduce their dependence on glasses, those are the ones that could be a candidate. You also need to understand what compromises they’re willing to accept. Each of these lenses has compromises associated with it. So you need to have a good understanding of that. Now, this is a global audience. The lenses that I’m presenting today are approved in the United States. They might not be approved in your region of the world. And you might have something totally different. But the important point is that you as the surgeon become very, very comfortable and very familiar with the lenses that you’re going to use. So do your homework. Talk to colleagues. Read the literature. Find out what lenses that you have availability to — that are available to you — will work the best, and then become really, really familiar with those. Have confidence in them. Know what they can and can’t do. Because that’s what you have to communicate to your patients. Patient education is critical. It does require more chair time. If you don’t educate patients, you will have unhappy ATIOL patients. So managing expectations, understanding expectations, educating patients on what these lenses can or can’t do. So in my clinic, I’ve done some things to help with that additional chair time. One of them is I created personalized videos. Anybody can do this now with an iPhone. Right? You create a video of you talking to your patient about the different options in cataract surgery. And what these advanced technology lenses can do. And then I have my patients watch that video while they’re dilating, waiting to see me for a consult. I also have done a lot of staff education, to where my staff is very engaged. They’re very educated. About these ATIOLs. And we all speak the same language. So they never say: You’re gonna get out of glasses! I never say: You’re gonna get out of glasses! We’re gonna say: We use the best technology we have available to give you the best chance or the best probability of reducing your dependence on glasses. That’s a very different statement than: You’re getting out of glasses! And so we’re very deliberate that our entire staff is engaged in the process. Can educate patients. Can speak comfortably about ATIOLs in patients. But we do have to… There is an education process behind that. Having a little trouble advancing my slides here. There we go. All right. So you also want to consider the personality type of the patient. We have to not only be ophthalmologists, but when we take on ATIOLs, we have to become a little bit of a psychologist as well. There are certain personality types that are just not suited for ATIOLs. I think kind of the running joke is engineers. You know, that person that’s so focused on details. They might not have the same tolerance for some of the visual disturbances or side effects. So you have to tease that out a little bit. You have to know: Can the ATIOL meet their expectations? If a patient comes to you as their fourth cataract evaluation, and they have 19 pages of very detailed questions and they want to know the molecular weight of the material used to make their ATIOL… That’s probably not a good personality type for an ATIOL. So we do have to be prudent in selecting patients and making sure they’re good candidates. You can consider using a lifestyle questionnaire. So I do this in my clinic, when a patient tells me what their profession is, what their hobbies are, what they enjoy doing. Because some of the lenses work better in certain situations. For instance, if a patient is a truck driver who drives at night or a pilot who flies at night, they’re not going to be the best multifocal candidate, because they might get visual disturbances or glare or halo. A patient who loves to spend a lot of time on the computer might be a good patient for an extended depth of focus lens. Because they have good computer intermediate distance focal points. So you need to understand the patient’s lifestyle to match them to the correct lens. And as Hunter said at the very beginning, we want to underpromise and overdeliver. Because again, this is expectation management. So when you’re working up these patients, once you’ve selected a patient who might be a good ATIOL candidate, you have to make sure their eye is healthy. So I do a macular OCT on all of these patients, just to make sure I’m not missing a small epiretinal membrane or macular pathology. They need to have healthy eyes. Multifocals especially. Now, EDOF lenses are a little more forgiving. But they still require great visual potential. You also need very accurate and reliable measurements. So you have to pay attention to things like the anterior surface, tear film, corneal dystrophies, because those can affect your biometry, and if you don’t have good biometry, you’re probably not gonna have good results. So biometry is crucial. I measure keratometry with three different devices, and I can pair those. I incorporate my surgeon induced astigmatism. If you haven’t done that yet, it’s an easy thing to do. There are resources online for that. You need to optimize your IOL constants. So you don’t just use the IOL constant off the box. Each surgeon is gonna have their specific constant. So you need to go through the process of doing that. Most biometers will do it for you if you enter in the postoperative data. And you need to know who is doing your biometry measurements. So in my clinic, I have one primary person who does most of my biometry, and she is excellent. And she’s so meticulous and she’s so reliable. And that’s a big part of it. If you’re in an institution where there’s lots of different people doing biometry, there’s gonna be variability there. And that variability can affect your results. I showed this on the last talk we did in August about toric lenses. This just shows that I checked the cornea measurements three different ways. And I’m looking for consistency. So you can see here that all of the flat and steep corneal measurements are very close to each other. The axis is very close to each other. So this is good consistency. I would feel confident in using these biometry readings to pick an ATIOL. Okay. Once we’re in surgery, as I just showed you, you can use Purkinje images for IOL centration. IOL centration is very important. Which means the capsulorrhexis size is also very important. So really striving for a 5 millimeter capsulorrhexis or a capsulorrhexis that completely covers the optic of the IOL. Polishing the capsule can be helpful. Obviously you have to manage astigmatism. So either you’re using the toric version of these lenses, or doing limbal relaxing incisions. And then also just keep in mind: If you have a complicated case, if you have capsular compromise, it’s usually best to not put in that advanced technology lens. Because that lens has to be centered and the effective lens position is crucial. So that’s when you have your backup plan. You still have to put safety first. And the patient would rather have a centered monofocal lens than a decentered ATIOL any day, I promise you. Special considerations. Be very careful with postrefractive eyes. It can be done, but that’s kind of the next level of education. So when you’re first starting off, I would avoid that, and I would grow into that with experience. If you have patients with mild glaucoma or epiretinal membrane, you can consider some of the extended depth of focus lenses. But I would not be in favor of using a multifocal lens. You want to avoid those, when patients have moderate or severe glaucoma, obviously. Macular disease. Significant dry eye. Or that personality incompatibility. So you’re really having to evaluate a lot. And then also don’t forget about monovision. Right? Monovision’s been around for a long time. And monovision works and is successful at reducing dependence on glasses. So just using non-ATIOLs to do monovision. And then as I’m going to do in this next case, I’ll do mini-monovision with an extended depth of focus lens, where I set one eye for distance and intermediate and make the other eye a little bit nearsighted, half a diopter, which usually brings in better reading without sacrificing too much distance. That’s also an option. All right. I think they’re ready for me next door. So I’ll talk about the unhappy patient maybe during the question and answer. But basically if you have an unhappy patient, you just have to drill down as to what the problem is. What is it that’s making them unhappy? Our tendency is to duck and hide if you have an unhappy patient. You don’t want to see them. That’s the patient that needs your attention the most. So you walk in there confident, and you say: I understand that you’re not happy. I’m on your side. I’m going to do whatever I can to get you the vision that you want. Most of the time, it’s refractive error. And so you have to address that. So we can talk about that in a little while. But you also need to rule out, obviously, the other causes. Is it dry eye? CME? Is it posterior capsular opacification? Or is it the visual disturbance? So those are things that you’ll need to think about. And we can talk about that during the question and answer. So fire away with any questions that you have there. Okay. So in summary… Yeah. Patient education. Selection. Expectation management. And doing excellent biometry and surgery.

DR CHERWEK: I love that. And basically you can only go as high as your fundamentals and your foundation allow. And I really appreciated in the first case how you really spent time polishing. So you reduce the chance of a posterior capsular opacity. We really want to be careful — and you showed that you look at the OCT before surgery to make sure there’s absolutely no subtle or hidden macular pathology. And so with the unhappy patient, you really want to make sure you give them the fullest exam, looking at the tear film. Is there dry eye? You want to look at the lens. Is it centered? Is there any opacity? And certainly you don’t want to miss a subtle case of cystoid macular edema, or CME. I know, Kevin, there are some questions about the medicine that you inject after surgery. We have two of those. So we’ll get to those questions on the second case, as you’re injecting your compounded medicine that has the antibiotic and the antiinflammatory. But I do think that Kevin brings up the point: You’ve got to understand what’s driving the patient’s dissatisfaction. Was it their expectations? Was it the refractive error after the surgery? Or is there some subtle pathology? So Kevin, I see you’re back at the microscope. The patient is well centered. And I see this one we’re going to do manually. So as you’re getting ready to do this surgery, we do want to acknowledge that there are some people who have already appreciated the lifestyle questionnaire and hope that you can share that with us. And then also I want to talk about some very specific things that we’ll probably get to after this surgical demonstration. So we do have about 6 or 7 questions at this time for you, Kevin.

DR BARBER: Very good. All right. Yes. So we’re back started here. So again, this is a manual case. Not using the femtosecond laser. I’m going to implant the Alcon Vivity extended depth of focus lens here. You can see there’s a reasonable size TSC cataract. Making my primary incision where I customarily do. The lifestyle questionnaire… You know, a lot of industries, like Alcon, they have their own. There are some online. There’s a questionnaire that can be accessed online. We’ll try to provide some of those resources. So let me show you here. On these capsulorrhexis forceps, you can see these two marks. Those are the 5 millimeter mark. So if I put the end of my forceps here, I know the other end of the capsulorrhexis is where it needs to be. So that’s just one simple way to estimate a manual capsulorrhexis at 5 millimeters. There’s also markers that can be used. On the epithelium of the cornea.

DR CHERWEK: That was a beautiful capsulorrhexis. That’s one of the critical steps for toric as well as ATIOL surgeries. Making sure you have a very, very smooth and centered capsulorrhexis. If it’s decentered, Kevin, is that something that would change your decision making on implanting an ATIOL?

DR BARBER: Great question. I think if it’s mildly decentered, no. I think if you have an anterior capsular tear, then yes. Because that is going to most likely affect your ELT and could affect your IOL centration. So I would really think twice about implanting one when you have an anterior capsular tear. If it’s just decentered, I think that’s a judgment call. If it’s mildly decentered, no. I’m not worried about that. If it’s dramatically decentered, yeah. So again, just going back to the principle: If you have complications or difficulties, you might want to go with Plan B, and not implant an ATIOL. So I’m gonna make my central breach here. The cataract does have some density to it. We’ll go ahead and crack here. Gonna do a little chop.

DR CHERWEK: Kevin, I think this is the 72 man who has a 3+ NSE, 3+ cortical, and preoperatively, even with correction, the patient was 20/200, and is myopic with a refractive error of about -2.50. So I think this is a great case for the demonstration of Vivity and looking at targeting a plano outcome in the left eye for this case.

DR BARBER: That’s right. Yeah, this patient has a prolonged oral steroid use. So that’s contributed to the density of this cataract and PSC formation. But he loves computer. When I did the lifestyle questionnaire and had a discussion with him, he’s naturally been a -2 most of his life. And he spends a lot of his day on the computer. And he enjoys doing that without having to wear glasses. But he also lost his driver’s license. And the ability to drive. So he’s like… Hey, if I could get back to driving… But also still have some great computer vision, that would meet my goals. So that’s why we went with a Vivity or EDOF, because they have good intermediate or computer vision, but it’s also going to give good distance vision where he can drive. This is a pretty good epinuclear plate. I decided to remove this with the irrigation/aspiration, not the phaco. Because it was a little adherent to the capsule. And it’s just safer to do that. So what I’ll do is just take my second instrument here. A Seidel chopper. And I’ll just encourage or help this epinucleus along here. Again, some people have said go after this with your phaco. And you certainly can. But again, there’s a lot of fibrosis here. And I don’t want to risk any capsular damage. By phacoing too close to my capsule. I really like to keep my phaco tip right in the central safety zone and do more work with my second instrument and the IA. So I’ll just clean up the last little bit of this cortex here. So in this patient, the other thing we’re gonna do is: In his dominant eye, we’re gonna set him for a plano target. For distance. I’ll usually expect to get him reasonable intermediate vision. But I’m not expecting his near vision to be superb. Sometimes we get it, but not always. And then in this eye, we’re gonna set the vision for a -50 outcome. And by giving him a -50 outcome, he’ll probably be 20/40 or so, but that brings in the intermediate and near vision. So it’s not true monovision. It’s what’s been called mini-monovision or modified monovision. A lot of BSC here. So I’m going to my polish settings. See if we can tease off some of this. Also go here under the anterior capsule here. And do a little more polishing. I’ll show you what I use with lots of different ways. You know, if you have silicone IA tips, obviously that’s helpful. I need the bimanual. I’ll go back to that. And I’ll need the squeegee. I’ll go ahead and put in my viscoelastic. As you can see, there’s a little bit of cortex here. So I’m gonna get that after I put the lens in. That’s a higher risk piece of cortex to get. It’s way underneath my incision. So I’m gonna make a mental note that it’s there. And I’m going to use a bimanual technique to remove that. After we put the lens in. And I have the squeegee. And the other thing I’m gonna do here… The Terry squeegee… This is called a Terry squeegee silicone tip on a cannula. So you can use this when you have posterior subcapsular cataract. And it just does a nice job of delicately removing some of that fibrosis or that posterior capsular fibrosis there. And then I’ll take my Provisc again, to try to blow some of that out of the way. There. And that will allow me to get a good aberrometry measurement. Now, of course, if you don’t have aberrometry, you don’t have to do this. Again, I use it just as a belt and suspenders. So in other words, it’s just verifying the biometry I did.

DR CHERWEK: And Kevin, can you talk a little bit about how you’re selecting a target refraction in this patient when it comes up?

DR BARBER: Absolutely. So again, that’s where that lifestyle questionnaire really helps. Go ahead and capture. And understanding what the patient’s goals are. So, for instance, I did a Vivity patient today whose primary goal is: I want to be able to see the dashboard of my car. I don’t do a lot of reading. So let me have… Yeah. Give me the 19.5. So here I’m selecting a 19.5 diopter lens. Because that’s going to give him close to half a diopter of myopia. So expecting distance vision of 20/40, and then good intermediate and near. And then with his other eye, his dominant eye, I’ll set that one more for plano, for distance. So that was just a discussion that I had with the patient. Finding out what his goals were. His goals were distance vision, wanting to be able to drive at night. And then also see the computer. That’s what was really important to him. I’ve had other patients who have said: Driving is important. Seeing the dashboard of my car or my iPad is important. But I don’t do a lot of reading. So maybe we’ll do both eyes set for plano with an EDOF. The PanOptix, like we saw in the first patient, that actually gives the fullest, most complete range of vision. Patients have good distance, intermediate, and near. With that lens. And so if the goal is to get the most… The greatest range of vision with the least amount of glasses, in my hands, I’ve been most successful with that PanOptix. However, a PanOptix being a multifocal does come with the potential side effect of glare, halos, starbursts, or what I call visual disturbances. And not all patients will tolerate that. Most patients will. I will say the newer multifocal lenses on the market are much better than the earlier generations. And so the visual disturbances are lessening, as the technology improves. So as you can see, this EDOF looks like a monofocal lens. Now, if you look right here in the center, as you catch the reflection, sometimes you might see: There is a little raised button in the center of the lens. But that’s it. So you can tell that this is very different from a multifocal. And you can understand why there’s not a lot of visual disturbance with this lens. This is the trimoxi again.

DR CHERWEK: So Kevin, real quick. One question we had is: Does it matter where the IOL haptics are positioned vertically or horizontally? Does that affect anything with ELP or centration?


DR CHERWEK: I’m not aware of that.

DR BARBER: Yeah. There’s debates on that. I’m not aware that there’s conclusive evidence on that. So in this case, I’m aligning them vertically, because I need to get this piece of cortex here, and I don’t want the haptic in the way. So what I’ve done is I’ve taken the aspiration port and separated it from my coaxial into a bimanual handpiece. As you can see, I did the trimoxi injection, I hit the ciliary body. And caused a little bit of a hemorrhage. So that is one of the side effects of doing the trimoxi injection. And it happens occasionally. So I’ll show you some tricks we can use for that. So I’m gonna remove that piece of cortex here.

DR CHERWEK: And I like how you stopped and used the optic and the IOL to protect you from the bag and go over that tricky subincisional cortex. That’s always a smart move to do.

DR BARBER: Yeah. Thank you. That’s right. If you look at the center of the lens, you can see the reflection there. See the EDOF portion of this lens. I don’t hit the ciliary body very often, but I sure did today. So the trimoxi is now in the vitreous. So we have the steroid and the antibiotic there. Now the BSS. So what I’m gonna do with this hemorrhage is I’m gonna try to just inflate the incisions here, increase the pressure for a moment, and see if we can use a little tamponade. Tamponade effect here.

DR CHERWEK: Yeah. It looks like it’s slowing a bit. Yep.

DR BARBER: So if I just put a decent pressure here in the eye, pressure of about 20 or so, and let that sit there for just a moment, that should stop the bleeding. So maybe I’m gonna give that just a minute. I’ll have a little more BSS. Tell me some of the questions that you had teed up there, either about the trimoxi or…

DR CHERWEK: Yeah. So one of the questions with the trimoxi is: Does that create — is there a steroid induced glaucoma? Or do you have to worry about postoperative IOP spikes with the concentration of triamcinolone or the steroid in this?

DR BARBER: That’s a great question. So initially, yes. But — so I use the Imprimis compound that’s formulated by a compounding pharmacy. I’m not doing this compounding myself. And they have used kind of a proprietary way of titrating down the triamcinolone concentration. So now I use a little bit less concentration and a little bit less volume. And since we’ve done that, we’re not seeing pressure spikes. I have about less than 5% of patients who have a steroid-induced pressure spike. And so that is really not a problem. The only difference is… Yes. So if I have a patient with advanced glaucoma or moderately advanced glaucoma, I might not put trimoxi in, because if they have a tenuous enough optic nerve, then I don’t want to risk that at all.

DR CHERWEK: And Kevin, I appreciate how you’re trying to raise the pressure inside the eye to tamponade that bleed. Would an air bubble be something also? Or do you think we’re gonna get this to stop just by hydrating the wound and getting it above 30?

DR BARBER: That’s a great point. I guess we could try an air bubble here. So I think what I’m gonna do is I’m going to put an air bubble in. I’m gonna leave him here for just a second. We can go do the question and answer. And then I’m gonna come back. After the tamponade has been sitting there for just a few minutes, to make sure that the bleeding has stopped. And if I give him just a couple of minutes with that, I think that that’ll do it. And then what I’ll do is — as I just did, I’ll rinse out the heme as much as possible.

DR CHERWEK: Exactly.

DR BARBER: I am gonna put him on some topical steroids in addition to the trimoxi. Just to help treat that heme. And usually within two days, that heme is completely gone. And we don’t see any more.

DR CHERWEK: So Kevin, I can start reading some of the questions to you, while we wait for the tamponade to take effect. Just for the first case — it was a beautiful demonstration of a patient with a PanOptix going in the second eye as well. What was your target refraction, and what is your key? I know you really try to get an understanding of the visual needs. And what is the refraction in the contralateral eye? But what is your typical post-op target refraction, and what was it for that case?

DR BARBER: For the first case, it was plano. So again, that’s going to be IOL-dependent. There are so many different ATIOLs out there that have different focal points. That’s what’s going to dictate what target refraction you’re aiming for, along with what the patient’s goals are. But with most multifocals, I’m trying to target plano. So I’m gonna go to whatever lens is gonna get me closest to plano. The only time I don’t do that is, for instance, with these EDOF lenses. If I’m gonna do a mini-monovision and I might set the non-dominant eye to a -50. Otherwise, I’m using aiming for plano.

DR CHERWEK: And it’s always better to leave a patient slightly myopic than to have a hyperopic surprise. So if there’s any concern, you’re always gonna cheat a little towards the myopic side. Is that correct, Kevin?

DR BARBER: Most of the time, that’s correct. However, with some of the multifocal lenses, some of the near focal points are a little closer. We had this with some of the original ReSTOR lenses, the +4. So there are some lenses where you might not use that principle. But I would say by and large, you’re correct. Most lenses, we are going to aim more for plano. Maybe slightly myopic.

DR CHERWEK: That’s a great question. One of the questions was in the first case: There was some vitreous floaters. You have such a high resolution microscope. Would that ever have you lean towards a trifocal? If you find in the vitreous — if a patient has a lot of vitreous floaters, does that in any way impact your decision making for an ATIOL?

DR BARBER: That’s a great question, and that’s something that’s really hard to predict. I will tell you that some patients, just with cataract surgery in general, sometimes notice their floaters more. We stir the floaters up with cataract surgery, sometimes. So I do occasionally have patients that complain of floaters being more prominent, more bothersome. However, I find that to be true regardless of what lens implant I use. So I don’t know that I use that as a direct determinant on if the patient can get an ATIOL. Because I haven’t found a real strong corollary. I just make sure we educate the patient, so we do give that to them in writing as part of their preoperative information. Hey, floaters are part of the deal. This isn’t going to fix your floaters. So patients understand that. But I don’t think I use that information to decide between lenses.

DR CHERWEK: That’s a great question. One of the questions with ATIOLs, and I know this is more with historic lenses that you have experience with — if someone has a strong angle kappa, is that something you look at? And how do you measure it in a very busy clinic like yours?

DR BARBER: Yes. So I cheat. I have a digital marker. Which I didn’t show today, but I have the Baryon digital marker. And with that, I can have an overlay on my microscope that shows the center of the undilated pupil and the center of the visual axis. I think there’s still some debate on what we should truly be using. I tend to go for the center of the visual axis, which is why I align my lenses on the Purkinje images when a patient is fixating. And I have not to my knowledge — I have not had to reposition or have a problem with a decentered IOL. So I think that sometimes becomes a little more of an academic discussion than a discussion of true functionality, in my experience. So I don’t measure it — I don’t take the time to measure it in pre-op. I’m just using kind of the tried and true method of getting it as close to that visual axis as I can.

DR CHERWEK: And Kevin, a great question that one of the doctors asked is: Have you ever implanted a single piece ATIOL in the sulcus?


DR CHERWEK: Yeah. And why not? Is that because of rotation? Is that because of UG syndrome? What is your decision making there?

DR BARBER: Yeah. So a one piece lens is just not designed to go into the sulcus. There’s a very high probability that it will decenter. UG syndrome is a real possibility. Rotation. You know, those haptics are designed to have friction against the capsule to keep them from rotating. And when there’s no capsule there, they’re going to rotate. They’re going to move. So I would highly discourage putting any type of single piece lens in the sulcus. But especially an advanced technology lens. So again, if you have capsular compromise… Go with the three piece lens. Do something that’s more stable for the sulcus if you have to put a lens in the sulcus.

DR CHERWEK: Another great question is… I know you do meticulous polishing to reduce the chances of posterior capsular opacity. If someone needs a YAG laser, do you try to make it a very small opening, or do you try to make it a big opening with a multifocal or EDOF lens? So with an ATIOL, how does that impact your YAG size for a capsulotomy?

DR BARBER: Great question. Again, depends on the ATIOL. But we’re talking specifically about multifocals — the first question I answer is: Is there any chance that I’m going to need to exchange this lens? So most of the time, when I’m doing a YAG, it’s just because years after surgery, the patient develops PCO, and their vision drops off. They were happy with their lens before that. So I’m not going to worry about exchanging a lens. So I’ll go ahead and do a YAG, and I can make that YAG as big as I need it. So I’ll usually make it 3 to 4 millimeters at least, so that it’s incorporating most of those rings. Now, if there’s a patient who is early on after surgery, and they have early PCO, and they’re not totally satisfied with their vision, and I’m not sure if… Maybe I’m gonna have to explant this lens… But I still decide to do the YAG, I will make a smaller YAG intentionally. Just for that. But I would say most of the time, I’m going to just make a 3 to 4 millimeter — usually a 4 millimeter circumference for the YAG, in the multifocal lens.

DR CHERWEK: And one question: Certainly, Kevin, you’re managing this case and waiting for the patient to tamponade. Was the patient on any blood thinners, number one? And would intracameral epinephrine also help? I know you put in an air bubble and raised the intraocular pressure. Would intracameral epinephrine help? And was the patient on blood thinners?

DR BARBER: Yes, the patient was on blood thinners, anticoagulated, and that’s why we saw so much blood. I think epinephrine is a good choice. In a minute, I’ll step back and see if our tamponade has worked. If so, I’ll be able to finish. If not, I’ll probably go towards some epinephrine. Making sure the blood pressure is good. My staff is saying the bleeding’s stopped. So maybe I’ll sign off in a minute and finish this case. And we can follow up with other questions. Are there any other pressing questions we should hit before we leave?

DR CHERWEK: I think we got most of them, Kevin. I can answer some of them, and we’re gonna reference people to go to the Cybersight library to see some of your prior surgeries where you talked about similar things about your phaco technique. I want to thank you and your staff and a great day of ATIOL surgery. We really appreciate that you showed two different types of lenses, two different types of techniques, and two different types of technology. So again, Dr. Barber, we want to thank you for everything you do with Orbis, and this lecture, this webinar will be available on the library. For those who want to see it, you go to and then you’ll see in the far right there’s a library section that you can filter for surgeries, lectures, and cataracts. So Dr. Barber, you nailed it. You finished with two minutes to spare. We might stay a few more minutes and answer some questions. But… All of these questions that the team are asking and the audience are asking about are found in the Cybersight library. So thank you so much. And have a great day. Okay?

DR BARBER: Yeah, have a great day. Thanks again.

DR CHERWEK: Well, again, I just want to thank our audience. Obviously this was a very good day, where we did our first demonstrations of the ATIOL cases. Just a few questions that were remaining: How do you do LRI surgeries in a dissatisfied patient? Certainly those are something that you want first the eye to stabilize after surgery. You want to repeat and look at what are the Ks, and there are already in the Cybersight library lectures on how to do astigmatism management at the time of surgery. Obviously we now also have the toric intraocular lenses to manage that. But when there’s postoperative astigmatism, LRIs, or limbal relaxing incisions, are fantastic management strategies, as long as you have good algorithms and have good experience with them. Another question was about trypan blue. Obviously this was a fairly dense lens, and we noted that it didn’t have the best red reflex. So we could have used trypan blue to stain the capsule, although Dr. Barber has a lot of experience. I really appreciated how he has the forceps that have exactly the calipers or the ruler, so he can reproduce a very consistent size. And I know there were questions about the size or the diameter of the CCC. That was 5. But certainly if you have any questions about your capsulorrhexis, trypan blue is a fantastic management strategy. We did discuss using intracameral epinephrine. The good news is the air bubble and the raised intraocular pressure for a minute or two stopped the bleeding. But that is something that was a good management strategy, as well as putting in OVD in the eye, to raise the pressure and help with the tamponade. Certainly a question from an anonymous attendee about pupil abnormalities — obviously if there’s an irregular pupil, you could have irregular light entering the eye. You could have an inconsistent pupillary constriction. So certainly examining the pupil, and if there is a sphincter tear or if there’s a hole in the iris, you definitely want to rethink using an ATIOL lens, because the patient may have either glare or other problems with those lenses. Certainly — and again, I think Dr. Barber talked about this — pupillary size does matter. And that’s why if you look at the pre-op measurements, he does look at the mesopic and scotopic conditions. It’s a great question. You can’t overmeasure and overexamine your cataract patients. It’s when you go through them too quickly and miss something about a pupillary defect, a small macular membrane, dry eye, or guttata of the posterior cornea that you’re gonna find yourself with an unhappy patient. So certainly we want to measure twice and cut once on all patients, but especially the ATIOLs. Again, I want to thank the audience members who suggested ideas to tamponade or stop the ciliary body bleeding. I think it has come and has stopped with the air bubble and the raised intraocular pressure. Certainly there are — and Kevin will be giving a lecture on what to do with unhappy ATIOL patients. I know Kevin does a lot with IOL exchanges. You can certainly do LASIK if it is a refractive error. It depends on what is the cause. So certainly I think before we jump to LASIK as the solution for enhancements, we first want to make sure it is a refractive error, and not another cause. Certainly with multifocal lenses, I think you heard Kevin say: If there’s concerns about the stability of the anterior capsule, or if there is a posterior capsular rupture, I don’t think we would recommend a multifocal lens for multiple reasons. One could be decentration. The other is: If you’re trying to put this now in the sulcus, you’re now putting a one-piece IOL in the sulcus, where there can be rotational instability. There can be UGH syndrome, and other problems. And again, I just want to thank all of you for your support and for making sure that we had a great and highly interactive webinar today. We have several exciting webinars coming up this week, including… Excuse me. Next week. With glaucoma. So again, I encourage all of you to take a moment and go to the Cybersight library. And in the library, you can search for all the prior webinars, all the lectures, books, things that would you like to learn, or maybe even show your colleagues, in Cybersight. So I’m gonna show that right now in the chat. If you go to Cybersight library. All right. Well, with that, I want to thank Dr. Barber and his staff again. And I certainly want to thank the Cybersight team for such a beautiful support and really high quality video displays.

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February 1, 2022

Last Updated: October 31, 2022

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