Futuristic Approach and Advancements

Gary Wörtz

Abstract

Futuristic approach and advancements in cataract surgery provides a summary of the key features that will be changing over the next 10 to 20 years. This chapter discusses these advancements within the context of current unmet needs in the developed markets. The most important consideration is the current manpower shortage of cataract surgeons, which will be getting worse as the global population continues to age. Ophthalmologists will need to adapt processes and systems to improve their surgical efficiency and productivity while relying on optometrists and other providers to perform more of the pre- and postoperative care. Additionally, technology will need to become faster, easier to use, and more multifunctional to improve patient throughput. The second major unmet need is our ability to achieve the desired refractive results and to modify them postoperatively. Lens and laser technology are being developed that will allow for postoperative adjustment of optical style and power through less invasive and even noninvasive means. The third unmet need is the more complete correction of presbyopia, which would likely drive more patients to correct lens-based pathology earlier in their life. Finally, the idea of pharmaceutical treatment to prevent and reverse cataracts is discussed. All of these unmet needs require surgeons to adapt more efficient processes while partnering with industry to bring new technology to market.

Keywords: cataract, future lens implant, laser, ergonomics, presbyopia, management, light adjustable IOL, LAL

22.1 The Future Efficiency Centric Cataract Models

With an aging demographic in most countries, the need for cataract surgery is expected to continue accelerating, putting more pressure on the available surgeons to become increasingly efficient and productive to keep pace with demand. This will require cataract surgeons to spend the vast majority of their time in the operating room (OR), and further rely upon the division of labor model. Optometrists and other providers will be relied upon for most of the preoperative diagnosis, care, and counseling. Diagnostic equipment will need to become more useful, user independent, and efficient. With one simple scan, the patient’s visual acuity, refraction, topography, biometric measurements, anterior segment and retinal images, as well as optical coherence tomography (OCT) of the macula and optic nerve will be obtained. Once there is the ability to change the power and refractive properties of the lens through noninvasive means postoperatively, biometric measurement, predictive formulas, and refractive targets will become less important. This advancement will clear the way for immediate sequential bilateral cataract surgery to become the new standard since there will be less need to learn from the refractive results of the first eye before operating on the second eye.1

The postoperative course will be typically managed by optometrists and eventually the refractive outcome will be finalized approximately 1 month after surgery through a laser or ultraviolet (UV) treatment to the lens, allowing patients to routinely achieve visual outcomes that were previously almost impossible. Patients will be able to preview their various visual outcomes (monovision, extended depth of focus, multifocality) using virtual reality in the office, and a lock-in procedure will give patients exactly what they want with a new level of precision and accuracy.

22.2 Preoperative Technology Advancements

In any modern ophthalmic office, there is typically at least one full room of individual pieces of equipment dedicated to gathering a portion of necessary data. Each device requires entry of patient data, patient positioning, patient cooperation and participation, and technician time and expertise, and takes up precious space. The model of single function equipment will need to adapt to the present and coming challenges to decrease time for patient throughput. Multifunctional equipment that can obtain all necessary measurements for a cataract surgery workup will need to quickly come of age. Already, there are biometers that combine OCT or laser interferometry and topography. There are topographers that incorporate autorefractor/autokeratometer and wavefront aberrometer functions. OCTs incorporate fundus camera functions. The practice of the future will need to have access to equipment that places all of these functions within a single device or small suite of devices.

Another unmet need within the space of the preoperative assessment is in the realm of patient education. Great videos already exist that explain the risks, benefits, alternatives, and various options in cataract surgery. However, many patients arrive for their appointment unprepared to make the necessary decisions regarding their choice of lens technology. Many patients are hearing about the differences between near, intermediate, and distance vision for the first time and the stress of the requisite financial implications can make these choices harder. Given advancements in the field of virtual reality, it is now possible for patients to experience various visual scenarios in much more experiential ways. A virtual reality vision preview program will be essential to help patients make more informed decisions before surgery, and especially after surgery once lens technology like RxSight and Perfect lens come to market. Others have approached these decisions by utilizing technology to assess the visual needs of the patient in their normal environment. Surgiorithm and other companies are currently trying to tackle this problem by both photodocumenting vision-related activities and prompting the patient through a questionnaire.

22.3 Advances in the Operating Room

The OR equipment and organization will also be targets for innovation. To stay viable, technology will need to become smaller, more efficient, and more cost effective. It is likely that at some point, ultrasound phacoemulsification will become replaced with a new technology. One simple device that is challenging the current paradigm is the miLoop from Iantech. This device is a wire made from the shape memory metal, nitinol. Essentially, the miLoop is a retractable wire snare that when fully extended forms the shape of a cross section of a cataract, and naturally finds its way around the cortex to the poles of the nucleus. When the loop is retracted, it sections the lens into fragments. This quick maneuver can save time and potentially reduce ultrasound energy, saving endothelial cells in the process. This is a technology with a great deal of promise given its simplicity and effectiveness, especially for dense cataracts. Additionally, femtosecond laser technology will need to advance and become more efficient and cost effective. The author predicts that the majority of femtosecond lasers will eventually migrate into the OR. Downward pressure on costs for using the laser will hopefully result in a scenario where surgeons can utilize the benefits of femtosecond laser technology on all their cataract cases.

Surgical ergonomics provide another area of unmet needs in the OR. Many studies have shown that approximately 50% of ophthalmologists suffer from back and neck pain at some point in their career and many have to limit their work due to the discomfort and disability it causes. Currently, ophthalmologists face a relatively high risk for cervical disc injury due to the poor ergonomics required for operating through a microscope. Added to that are the inconsistent positions of the bed height and foot pedals, making for a multifactorial equation. If operating temporally, staff must physically move the foot pedals when changing from right to left eyes or vice versa. Phacoemulsification units, microscopes, and beds all take up a significant footprint with significant wasted space surrounding each piece of equipment. To address these issues, a surgical cockpit will need to be developed that will allow surgeons to set the seat position, incline, and support to their individual needs. It will have attached foot pedals that can also be adjusted and set to preference. Just like a luxury car, each surgeon will be able to set his or her preference and have consistent ergonomic support. This seat will be attached to a track on the floor allowing surgeons to automatically change positions without any foot pedal or cord manipulation. The patient bed will also be connected to this system, and may automatically adjust to the desired height. The unused space under the bed may be utilized by other technology as well. Microscopes will likely be replaced by better and better 3D viewing systems that allow surgeons to operate in a much more comfortable position, which will increase their health, productivity, and longevity. Companies such as TrueVision have brought this advanced technology to market and it will undoubtedly continue to improve.