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EW SHOW DAILY 8 Sunday, April 27, 2014 ASCRS News Today by Matt Young EyeWorld Contributing Writer How to approach patients with advanced technology to provide laser-assisted cataract sur- gery for patients who desire high- quality vision postoperatively. While this superior technology exists today, communicating its value is critical. Once believing in the procedure yourself, it becomes much easier to talk to patients about the benefits of the procedure, Dr. Black said. "I agree wholeheartedly with you Dr. Black," said Scott G. Hauswirth, OD. He suggested that education and patient preparation also are key. "We used to have patients say: 'Are we going to do that laser sur- gery to take care of my cataracts?' Now we have the ability to say yes," Dr. Hauswirth said. "There is a buzz here at ASCRS and there's also a buzz in the patient population so long as we can prepare them for that." Dr. Hauswirth said that at his practice, a premium package in- cludes multifocal IOLs and even LRIs. But the bottom line is there has to be good communication between optometrists and surgeons in order to optimize a practice. "In our practice we are seeing 4 to 8 postops in a day," he said. "Surgeons take our recommenda- tions pretty seriously." by Rich Daly EyeWorld Contributing Writer Phaco pearls are fundamental "It allows setting appropriate outflow at your current settings," Dr. Devgan said. A key element of phaco surgery that is sometime overlooked is that surgeons convey needle size when providing their preferred settings. Additionally, tall surgeons need to ensure their height does not inter- fere with the bottle-induced pressure used in cataract surgery. Because the height of a taller surgeon will reduce the pressure provided by a bottle at a standard setting, Dr. Devgan said these surgeons need to keep track of the phaco pressure and raise the bottle as needed. Speakers also urged surgeons to identify their missteps by regularly recording procedures and watching complicated cases. Additionally, watching video of their procedures in slow motion with a colleague can identify missteps the performing "One of the things you have to be careful about is when you're talk- ing to patients about doing the cataract procedure with a laser and spending money," Dr. Black said. "Half of my patients will say some- thing like "My wife's [cataract] sur- gery was 5 years ago or my father's surgery was 10 years ago. They don't wear glasses except to read. How come you want to charge me more?'" It's good to be prepared to answer questions like that, Dr. Black said. His answer: "Their vision is not as good as we want yours to be with this [femtosecond] laser." Remember, Dr. Black said, cataract surgery is not surgery to get rid of glasses. Cataract surgery is surgery to get rid of cataracts. "You combine cataract surgery with the femtosecond laser if you want to get rid of glasses for distance or for [spectacle-free] multifocality," Dr. Black said. The course, which focused on an integrated model of eyecare delivery, also featured course co- instructors W. Barry Lee, MD, and David Geffen, OD. EW crease in the red reflex visible in their operating microscope after they create a trench. Kenneth Rosenthal, MD, Great Neck, N.Y., provided pearls to ad- dress complications that arise. For instance, Dr. Rosenthal said surgeons can rescue a too-large capsulorhexis by pulling in the capsular tear in the same direction from which the surgeon originally approached and then tearing toward the center of the capsule. "You are retensioning the capsule and then we are able to complete the rhexis," Dr. Rosenthal said. Additionally, in cases of suspected intumescent white cataracts, Dr. Rosenthal avoids an Argentinean flag sign through the use of a puncture—under protection of viscoelastic—to relieve some of the pressure. EW surgeon may miss, said Nick Mamalis, MD, Salt Lake City. Similarly, surgeons should ask to observe phaco procedures performed by other regional surgeons. "I've never watched someone else operate and not learned some- thing from it," said Gary Foster MD, Fort Collins, Colo. Abhay Vasavada, MS, Ahmedabad, India, recommended that phaco surgeons proceed slowly and use viscoelastic to protect the cornea. Less important, he said, is the specific nuclear cutting tech- nique the surgeon uses, as long as they are comfortable with it. A remaining area of uncertainty in cataract surgery is the exact thickness of the nucleus. Dr. Vasavada said surgeons can obtain an "indirect clue" about the remain- ing thickness of the nucleus they are removing by watching for an in- P remium IOL surgery must be presented as an "oppor- tunity" to the patient, Bradley C. Black, MD, said during "Management of the Advanced Technology Patient," part of the Integrated Ophthalmic-Managed Eyecare Delivery (IOMED) Program. "This is an opportunity that patients can avail themselves of. If they don't they will still get very good surgery and a very good result. But this also is an opportunity to educate them and let them make an educated decision." Undoubtedly, Dr. Black is a major advocate for premium IOL surgery in the right circumstances. It's not that it's right in every surgi- cal circumstance. He acknowledged that "sometimes surgeons jump at the technology before they're ready for it." Still, Dr. Black said, "Once you believe in it and once you see it— and you should absolutely watch several cases—you will believe in your heart of hearts that it is better." Currently, femtosecond lasers are combined with premium IOLs S everal pearls can strengthen the fundamental building blocks of a high-quality cataract removal proce- dure, according to speakers at a course in the ASCRS Resident and Fellows program. A clearer understanding of the specific fluidics that affect each sur- geon based on their phacoemulsifi- cation settings is possible said Uday Devgan, MD, Los Angeles, Calif. He suggested surgeons use a syringe at the beginning of a phaco case to determine the per-minute inflow they achieve with the settings they use. That specific knowledge allows surgeons to know the maximum pressure they can use before they affect their outflow. Panelists spoke about managing advanced technology patients at an Integrated Ophthalmic-Managed Eyecare Delivery course.

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