Josh Johnston, OD, FAAO, evaluates the nuances integral to success with new technology for premium cataract surgery. He is the clinical and residency director at Georgia Eye Partners in Atlanta. Johnston reports he is a consultant to Alcon, Allergan, Bio-Tissue, Johnson & Johnson Vision and Shire.

BLOG: Cataract surgery trends to look for in 2019

Surgeons continually seek devices and methods that further improve the cataract procedure, patients’ visual outcomes and their experience.

Heading into 2019, I see several trends continuing from last year that I expect will evolve well into 2020 and beyond.

Three of these that are top of mind include continued developments in devices that help in the creation of the capsulotomy; improvements in IOL technology, particularly trifocal and extended-depth-of focus options; and the further adoption and refinement of “dropless” surgery strategies.

Here I discuss capsulotomy aids; in the next column, I will tackle the IOL outlook and the move toward easier postoperative drop regimens.

The quality of the capsulorrhexis — round, continuous and curvilinear — is a key component to a successful cataract surgery. Many surgeons maintain that creating the capsulorrhexis is the hardest part of the procedure to learn, therefore making it difficult to perform the task optimally on a consistent basis.

The advent of the femtosecond laser represents a huge leap in this regard, making it easier to create a predictably sized capsulotomy, quickly and reproducibly. This precision potentially lowers even further the already low risks associated with cataract surgery and may improve visual outcomes. Not all surgeons, however, have access to femtosecond laser technology. New devices, some decidedly low tech, that help create a better capsulorrhexis have emerged to meet this need; others are waiting in the wings.


The Zepto (Mynosys) device was FDA approved in 2017 and it consists of a small console that provides energy to a disposable handpiece. The handpiece is outfitted with a flexible ring composed of nitinol, which is a material with shape memory and superelastic characteristics. The Zepto ring folds to be inserted through a small, 2.4-mm incision and then it springs back into shape inside the eye. The device uses a clear silicone suction cup over the membrane, gently drawing it to the ring. In this manner, the Zepto ensures 360-degree contact with the anterior capsule. A pulse of thermoelectric energy (0.4 msec) instantly creates a round capsulotomy that measures about 5.2 mm in diameter. The surgeon retracts the cutting element, withdraws it from the wound and proceeds with surgery.


The miLoop (Iantech, device acquired by Zeiss) is an endocapsular nitinol ring that acts like a snare, bisecting and chopping the cataract into smaller pieces. Users have remarked that miLoop bisects the cataract from equator to equator, even behind a small pupil. If it is deployed multiple times the lens can be broken into even smaller pieces. Surgeries are easier because the surgeon can dismantle the lens and mobilize the fragments for easy aspiration. In this way, the device allows for decreased ultrasound energy levels inside the eye. This can make complex cases easier, like in denser cataracts, allowing for faster healing and fewer complications. Another advantage is the short learning curve.