Cataract surgeons are caught in a constant push/pull: The tried-and-true methods that have gotten them good results for years keep pulling them back while, at the same time, they’re continually pushed toward new techniques and technology that may yield better outcomes or make them more efficient. Here, surgeons share what relatively new approaches they may be working with, such as femtosecond cataract, and comment on the old standby techniques that have seen them through many a challenging case.

This year, 4,158 of the 14,590 surgeons receiving the survey opened it (28.5 percent open rate), and 108 completed the survey. To see where your techniques fit on the continuum beside theirs, read on.

Breaking the Nucleus

As in years past, the most popular method for nucleofractis is quadrant division, chosen by 38.5 percent of the respondents. This is followed by stop and chop (20 percent) and horizontal phaco chop (13.5 percent). The surgeons shared why they prefer a particular method.

“[Quadrant division] debulks the nucleus away from the endothelium,” says Lawrence Minardi, MD, of Charleston, West Virginia. “Then, I perform quadrant removal with pulsed phaco.” Another surgeon says quadrant division provides “better control of phaco with small fragments.” Krishnarao Rednam, MD, of St. Louis prefers quadrant division because, he says, “It works to divide and remove easily—it’s a time-tested habit.” A Connecticut surgeon says the technique is “safe and effective for most nuclear densities.”

The stop-and-chop proponents say it fits their surgical approach better, however. “It’s both efficient, and attractive!” says Bruce Cohen, MD, of St. Louis. A surgeon from Minnesota says stop and chop is a “hybrid of speed and safety in my hands.” An Indiana surgeon describes how he uses the technique: “I’m debulking the nucleus with a groove then getting a deeper chop of each half,” he says. A surgeon from Nebraska says she prefers stop and chop because it “works on most cases.”

Fans of horizontal phaco chop like its minimal use of energy in the eye. “It’s efficient and low on total cumulative dissipated energy,” says a surgeon from California. A Georgia surgeon agrees, saying, “It’s how I was trained—to use less phaco energy.” Another surgeon from
California says he likes horizontal phaco chop because it’s “efficient, zonule friendly and I don’t have to judge how deep I have to sculpt.” A Virginia surgeon says it’s his preferred technique because of its “safety and reproducibility.”

Some surgeons also say they’ve modified their technique in the past couple of years.

“I’ve begun using Omidria,” says a surgeon from Texas, “because our center quit supplying epi-Shugarcaine.” Dr. Minardi says he has “Started offering paired incisions on the steep axis for a nominal fee.”

A surgeon from Indiana adjusted the technique used for breaking up and aspirating the nucleus. “I do more tilting nucleus out of bag. It’s more efficient,” he says. A Florida surgeon, however, says he’s “doing more stop and chop.”

Along the lines of pupil dilation, surgeons say that they promote a wide pupil in most cases through the use of an intracameral epinephrine/lidocaine injection (chosen by half the respondents). The next most popular option is mechanical pupillary dilation, such as with a Malyugin ring (26.9 percent). Thirteen percent of the surgeons use Omidria.

“I usually use intracameral epi/lidocaine,” says Dr. Minardi. “If inadequate, though, I use a ring.” A surgeon from Minnesota takes a belt-and-suspenders approach, saying, “Epi in BSS and Malyugin ring.” A New Jersey surgeon says he doesn’t use Omidria, and instead opts for “Beehler [dilator] or two Kuglen hooks … intracameral phenylephrine works in some cases.”

Some surgeons are employing new devices for old problems. “I added the MiLoop for very dense cataracts,” says a surgeon from California. A Georgia ophthalmologist says he’s employing “more femto and toric IOLs for improved accuracy of alignment.” Another surgeon says she’s “using more iris hooks.”

Fifty-one percent of the respondents use either a femtosecond laser or the ZeptoLink device for their cataract procedures. For our respondents, the most popular use is the femtosecond capsulotomy (chosen by 47 percent), followed by femto-fragmentation (45 percent) and femto astigmatism correction (39.7 percent). For the Zepto, 4.7 percent of the respondents say they use it.

“[The femto] makes a perfect capsulorhexis every time,” says Jimmy Hu, MD, of Englewood, New Jersey. “It’s especially useful for traumatic white cataracts.” Ivan Mac, MD, of Charlotte, North Carolina, agrees, saying, “I like the precision of femtosecond cataract surgery. It also allows for less time inside the eye.” Andrew O. Lewicky, MD, of Chicago uses the femto, and notes that it does have limitations. “I like everything [about it] except the fact that the nucleus cuts still require manual separation,” he says. A Texas surgeon who primarily uses the femto for the capsulorhexis says, “Love it—not sure why it’s not fully embraced.” A Zepto user, Dan Bergsma, MD, of Salisbury, North Carolina, says, “The Zepto can efficiently and inexpensively incorporated into routine and complex cataract cases.”

Managing Astigmatism

For the perennial problem of preop cylinder, most surgeons on the survey have kept with the trend of past surveys and said they turn to toric intraocular lenses (57.9 percent). This is actually a slight increase over the past two years. The next most popular option is a tie between combined toric IOL and femto AK incisions and femto AK incisions alone (10.3 percent each). The next largest percentage, 7.5 percent, say they prefer implanting a toric lens and putting the entry wound on the steep axis. Interestingly, 4.7 percent of surgeons say they use the Light-adjustable Lens (RxSight), which is up from 1 percent last year.

A surgeon from California says the toric IOL is the best choice because it offers “more reliable results and is effective long term.” A physician from Minnesota says that a toric lens is “effective and typically stable through time relative to relaxing incisions, etc.” A North Carolina surgeon says, “I don’t like to change my main incision and I don’t use a femtosecond laser.” Anne Zaki, MD, of Phoenix, Arizona, says, “If it’s regular astigmatism, the toric IOL can be very predictable with good outcomes.”

Dr. Minardi says his approach depends on a couple of factors. “[I’ll use] paired incisions on the steep axis up to 1.25 diopters,” he says. “If the astigmatism is greater than that, then a toric IOL if the patient can afford it.”

When it comes to the practice of combining a toric lens with femtosecond AK incisions, a surgeon from California says he likes it because it’s “more predictable” than other methods. Another surgeon from the Golden State says she chooses it because of its “accuracy.”

For the group that just likes femto AK incisions alone, they say they like them for a variety of reasons. “There’s no possibility for IOL rotation,” avers Dr. Hu of New Jersey. “It corrects things where the problem is,” says a surgeon from North Carolina. Abe Kaplan, MD, of Sycamore, Illinois, says, “It gives predictable outcomes for lower levels of astigmatism.” Dr. Mac of North
Carolina, agrees, saying, “I do this for the majority of patients under 1 diopter. If over, I prefer toric IOLs.”

Dr. Bergsma says he primarily uses the Light-adjustable Lens. “The LAL is easily and accurately performed after the healing process has occurred,” he says. “The toric IOL is my second choice.”

Support Systems

Surgeons shared their strategies for dealing with eyes that have weak or no capsular support.

The most popular option was to refer the patient, chosen by 36 percent of respondents. Next, which may come as a surprise for some, was the use of an anterior-chamber IOL (29.6 percent). Scleral fixation with the Yamane technique was the choice of 21.3 percent of surgeons.

Dr. Bergsma leans toward an AC IOL in such cases. “I’ll use an AC IOL, if possible, because it only requires one surgery for the patient,” he says. A surgeon from Indiana would also choose this method, saying, “It’s quick, has a long track record of safety and avoids late dislocations of the IOL with suture or haptic breakage/degradation [that can occur] with intrascleral fixation.” Jonathan Adler, MD, of Bradenton, Florida, says, “This works wells as long as patient doesn’t have glaucoma.”

Dr. Rednam uses the Yamane technique. “It works well with good sustained visual outcomes,” he says. A surgeon from Montana thinks the Yamane is least of the available evils, saying, “I don’t like it but when it works well, it’s less traumatic than an ACIOL and more comfortable than scleral fixation.”

“For in the bag IOL dislocation I prefer scleral fixation with GoreTex sutures,” says John C. Hart Jr., MD, of Farmington Hills, Michigan. “This is technically easier than a Yamane fixation approach and doesn’t require a core vitrectomy.”

Infection Prevention

With the evolution of dropless and less-drops surgeries, surgeons have more options for avoiding infection than ever before.

Similar to years past, the most popular choice on this year’s survey was topical anti-inflammatory and antibiotic drops for postop use, selected by 44 percent of the physicians. 

Increasing in popularity, however, is the combination of a topical steroid with an intraocular antibiotic injection (20 percent). The rest of the options appear on the graph on this page.

Surgeons also shared their specific approaches to infection prophylaxis.

“I use intraocular antibiotics and postop topical antibiotic, NSAID and steroid,” says a surgeon from Texas. Another Texan says his approach consists of “topical steroid and antibiotic and intracameral Vigamox and subconjunctival steroid.” A surgeon from Georgia describes his regimen as “injected steroids/antibiotic and topical antibiotic/steroid/NSAID.”