April 01, 2019
3 min read

All cataracts go to heaven

The newest advances allow cataract surgeons to reach their best results.

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“Heaven will be the perfection we’ve always longed for.” This quote by Billy Graham is not too different from what we encounter in modern-day premium cataract surgery. One of my patients recently asked at the end of her cataract surgery if her cataract was going to heaven. Sarcastically, I responded that all cataracts I operate on go to heaven because the advanced technology we utilize is that perfection we long for as premium cataract surgeons.

The technologies I am currently using to allow this heavenly ascent include femtosecond laser-assisted technology (Lensar), pupillary dilation maintenance with Omidria (Omeros) and advanced extended depth of focus IOL technology with the Symfony toric (Johnson & Johnson Vision).

Femtosecond laser-assisted technology

Most premium surgeons already know the obvious advantages of less endothelial cell loss, lower effective phacoemulsification times, better day 1 postoperative uncorrected vision, superior capsulotomy precision, less zonular trauma and lower risk for posterior capsule rupture. However, recent advances in toric IOL alignment have evolved with Lensar’s IntelliAxis refractive capsulorrhexis, in which anterior capsular tabs are placed in the steep axis meridian for toric IOL alignment. These tabs come from preoperative planning with OPD3 (Marco), Cassini (i-Optics) and/or Pentacam (Oculus) topography via iris registration in a wireless format to adjust for cyclorotation errors on the laser table. The enhanced efficiency of not needing to mark the eye in the OR and wireless transmission of data is an extra bonus.

EDOF IOL technology

Recently, we presented data on the Symfony toric IOL utilizing IntelliAxis technology to enhance visual outcomes. The data showed that up to 95% of patients had residual cylinder postoperatively of 0.5 D or less, reduced from an average of approximately 2.3 D of astigmatism preoperatively. Our heavenly outcomes were from an analysis of 94 eyes of 47 patients, with the majority of the data utilizing Cassini data preoperatively. Our data also revealed the optimal manifest refraction spherical equivalent for the best bilateral uncorrected visual acuity across all ranges of vision was –0.07 D for dominant eyes and –0.21 D for nondominant eyes.

Maintenance of pupillary dilation

In May 2014, Omidria became the first and only FDA-approved intraocular product for use in adult patients undergoing cataract surgery or IOL replacement to inhibit intraocular prostaglandin release, maintain pupil size by preventing miosis and reduce postoperative ocular pain. Omidria is also the only FDA-approved NSAID-containing product for intraocular use, composed of phenylephrine 1% and ketorolac 0.3%, and it is a preservative-free and bisulfite-free product. Use of Omidria in children has not been established. Omidria is delivered as a 4-mL single use vial added to a 500 mL container of standard irrigating balanced saline solution, allowing for steady-state concentration delivery to the anterior chamber throughout the procedure. The main advantages of Omidria are for cases with intraoperative floppy iris syndrome caused by alpha antagonists used for benign prostatic hyperplasia, such as tamsulosin, and it has shown a lower frequency need for pupillary expansion devices such as Malyugin rings (MicroSurgical Technology).


In the end, there are many other adjunct technologies that can be used to allow our cataracts to reach heaven, such as miLOOP (Zeiss) and Zepto (Mynosys), and future IOL technologies such as the Light Adjustable Lens (RxSight). I look forward to the next wave of technologies so my patients keep singing the praise of heavenly love.

Disclosure: Jackson reports he is a consultant for Lensar, Bausch + Lomb, Carl Zeiss Meditec, Johnson & Johnson, Alcon, Omeros, Marco, i-Optics and Oculus.