Disclosures: Jackson reports he is a consultant for Lensar, Johnson & Johnson, Omeros, Bausch + Lomb, Oculus and i-Optics.
September 03, 2020
3 min read

Phantoms of the OR: Premium surgeons always rise to the occasion

Better results can be obtained with newer ways to manage astigmatism and the ocular surface, to use phaco and to prevent CME.

Disclosures: Jackson reports he is a consultant for Lensar, Johnson & Johnson, Omeros, Bausch + Lomb, Oculus and i-Optics.
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During our recent COVID quarantine time, I had the pleasure of rewatching the famous 1986 musical The Phantom of the Opera, music/lyrics/book by Andrew Lloyd Weber, Charles Hart and Richard Stilgoe.

Mitchell A. Jackson
Mitchell A. Jackson

Based on the 1910 French novel by Gaston Leroux, the central plot revolves around a beautiful soprano, Christine Daaé, who becomes the obsession of a mysterious, disfigured musical genius living in the subterranean labyrinth beneath the Paris Opera House. Not that premium surgeons become obsessed with our patients in the operating room, but we actually are obsessed with using the best technologies to obtain the best outcomes for our patients. I feel at times we as premium surgeons are our own phantoms in a similar way, working diligently behind the scenes to find better ways to help our patient outcomes. Below are some of the phantom techniques we have implemented recently to make our opera house, or operating room, the best it can be.

Managing astigmatism

In modern-day cataract surgery, patients expect refractive outcomes even if insurance does not cover the refractive component. Fortunately, advances in astigmatism management make our lives easier with the recent publication of the Wörtz-Gupta formula available at for treating less than 1 D of corneal astigmatism when using femtosecond laser technology. Femtosecond laser technology specifically with Lensar also has shown improved accuracy in toric IOL outcomes when using Streamline technology, which adjusts for cyclorotation errors by placing iris registration-guided capsular marks in the steep axis using IntelliAxis-RC technology. In a retrospective analysis presented at the 2019 European Society of Cataract and Refractive Surgeons congress, IntelliAxis-RC did slightly better in terms of achieving less than 0.5 D of residual astigmatism with toric IOLs compared with placing the steep axis iris registration-guided marks intrastromally in the cornea (IntelliAxis-C). Both Cassini (i-Optics) and Pentacam (Oculus) can be equally used to determine the axis of toric IOL implantation using IntelliAxis-RC technology.

Managing ocular surface disease

As we are all aware of these days, the ocular surface effect on premium IOL outcomes is not going away and must be addressed, as clearly identified by the historic PHACO study in 2017 in which most patients undergoing cataract surgery were asymptomatic for dry eye but up to 80% of them had objective signs of ocular surface disease. A recent publication by Cynthia Matossian demonstrated how thermal pulsation treatment before cataract surgery resulted in less residual refractive astigmatism postoperatively.

Managing phacoemulsification

This category of mastery remains underestimated in my opinion, and premium surgeons are at their best when using multiple techniques with every cataract procedure. No single technique will work in every case, and so understanding a multiple of techniques, including divide and conquer, horizontal and vertical chop, flip and chip, bowl, stop and chop, and multiburst technology, becomes critical in safely removing the cataract. Multiburst technology specific to the Stellaris Elite (Bausch + Lomb), which I personally use in every case, is my preference because ultrasound power remains constant at a high duration of 80 microseconds to 600 microseconds so the true effective phaco time (commonly known as EPT) remains as low as possible with the most phaco efficiency as possible. When multiburst was combined with femtosecond laser fragmentation, EPT was 33% lower in the femto vs. non-femto group as presented at the American Society of Cataract and Refractive Surgery 2018 meeting.

Prevention of CME

The development of cystoid macular edema after cataract surgery is a fairly common cause of reduced visual acuity, even in uncomplicated cases. More recent publications show the benefit of intraoperative nonsteroidal regimens (Omidria, Omeros) in combination with postoperative topical nonsteroidals alone having a profound reduction in the rates of CME in non-comorbidity cases (history of uveitis, diabetic macular edema, retinal vein occlusions, epiretinal membranes, vitreomacular traction or any prior macular edema).

In summary, the phantom in each of us premium surgeons will always rise to the occasion, with many of the newer ways to manage astigmatism and the ocular surface, to use phacoemulsification and to prevent cystoid macular edema. Whether it is the opera house or the operating room, the phantom lives.