Over the past two years, the surgeons responding to our Na--tional Panel survey have expressed confidence in toric intraocular lenses, and the percentage who use them has been steadily rising. The trend continued this year, with nearly half of the respondents saying torics are their first choice for managing astigmatism in their cataract patients. Other trends include an interest in limbal cataract wounds and a distaste for both bimanual surgery and the practice of mixing presbyopic IOLs.

For this month's survey on cataract surgery, 40 respondents, or 8 percent of the surgeons surveyed, responded. Here's what they had to say about their approach to cataract surgery.


Torics on Top

Surgeons evidently like the performance of toric IOLs, and the percentage of respondents who use them increased from 35 percent last year to 46 percent on our current survey. In terms of the other ways they manage astigmatism, 18 percent use limbal relaxing incisions, 10 percent place the entry incision on the axis of astigmatism, 5 percent use a postop refractive procedure and 8 percent say they use some other method.

"The toric lens is the most accurate for me," says a surgeon from Rhode Island. A surgeon from Michigan also prefers a toric lens, saying, "It's the most exacting method." A surgeon from Vermont says, "The results of limbal relaxing incisions are inconsistent." And an ophthalmologist from New Jersey says he feels "toric lenses are more precise than LRIs."

A surgeon from Tennessee says he's found a place for all toric correction methods in his surgical practice. For astigmatism less than 1.5 D, he'll place the cataract wound on the axis or possibly use LRIs. If the patient has greater than 1.8 D, he uses a toric lens. For any astigmatism that's left, he'll use a postop refractive procedure.

Incisions and Technique

Though clear corneal incisions have been the most popular choice on the National Panel for several years, and 51 percent of surgeons on this year's survey say they prefer them, limbal incisions have jumped in popularity. This year, 35 percent of the respondents say the limbus is their preferred incision location. This is an increase of 12 percentage points from last year. Fourteen percent say they use scleral tunnels. The average width of incision, based on the respondents' answers, is 2.54 mm.

"The limbal incision rarely leaks and is stable," says a Florida surgeon. A Connecticut surgeon echoes that sentiment. "They don't leak," he avers. A surgeon from Rhode Island, however, has stuck with the most popular choice on the survey, clear corneal.
"The clear corneal incision seals well," he says. "And it induces minimal astigmatism." A surgeon from North Carolina thinks limbal incisions might cut down on a particular postop complication. "Move your incision from clear cornea to the limbus to decrease recurrent corneal erosion," he says.

One trend that hasn't changed, however, is surgeons' rejection of bimanual phacoemulsification. Eighty-six percent of respondents don't do it, and, of that number, 76 percent say they're unlikely to begin using it in the near future. Almost a quarter, however, say they're somewhat likely to use it.

"I'm comfortable with a 2.9-mm incision," says Geoffrey Rice, MD, of Ukiah, Calif. "It's small enough." A Michigan surgeon voices a complaint commonly made about bimanual, saying, "The present intraocular lens technology isn't compatible with bimanual." He adds that he's unlikely to use bimanual "until IOLs can go through smaller incisions."
Another surgeon from Tennessee lists another frequent criticism of bimanual, specifically that there's "not enough gained from the decrease in wound size." An ophthalmologist from North Carolina says simply, "I don't perceive an advantage."
Finally, Sidney Seltzer, MD, of Charleston, S.C., cites a third reason bimanual hasn't caught on with many surgeons: the emergence of coaxial micro-incision surgery that allows surgeons to keep the coaxial operation they're used to but use somewhat smaller incisions. "I have no problem using the Infiniti coaxial tip," he avers.

In terms of coaxial micro-phaco, 31 percent of the survey's respondents say they perform it. "It works well," opines Dr. Seltzer. An Arizona surgeon who uses C-MICS says he appreciates having his other hand free. "I like to use the second hand to manipulate structures in the anterior chamber," he says. It's possible that more surgeons might get into C-MICS, but some are held back by where they operate. "It's not available in our ASC," says a Vermont surgeon.

When surgeons address the nucleus, the most popular single option, chosen by 47 percent of respondents, is a quadrant-division technique. Nineteen percent like to use phaco chop, 8 percent divide the nucleus in two, 8 percent use phaco flip/tilt, 6 percent sculpt, 6 percent perform stop and chop and 8 percent say they prefer some other technique.

"Quadrant division is time-tested," says a surgeon from Michigan. "The other methods are more dependent on the type of cataract." Dr. Seltzer prefers quadrant division because, he says, "It works on all cataracts." Another supporter of quadrant division says he prefers it because it's "easy and safe."

Christopher Brown, MD, of Teaneck, N.J., however, feels a quick chop, also known as vertical chop, is superior. "It can be used effectively in any case regardless of the pupil size, lens density or zonular status," he says. California's Dr. Rice prefers phaco chop, arguing that it offers "safety and ease of disassembly of the nucleus." Michele Miano, MD, of Cherry Hill, N.J., thinks dividing the nucleus in two is the best option. "It works for almost all cataracts," she says.

Finally, mixing presbyopic IOLs, such as using a ReSTOR in one eye and a Tecnis in the other, is also an unpopular technique with our panelists; 89 percent say they don't do it.


Preop Preparation

Sixty-seven percent of the panelists say they use some form of topical anesthesia. A third use topical drops, 17 percent use a topical gel and 17 percent use a combination of topical methods. Twenty-one percent of the topical users also administer intraocular lidocaine. As for the other major methods of anesthesia, 22 percent of the surgeons use peribulbar blocks and 11 percent use retrobulbar.

Sixty-five percent of the surgeons say topical is excellent with regard to ease of use, 74 percent give it a rating of excellent for visual recovery and 42 percent say the same for its safety.

"Topical anesthesia's not for every patient," says Stanley Crews, MD, of Vancouver, Wash. "But, it's less invasive and patient acceptance is high. In retrobulbar, using needles near the optic nerve and the ophthalmic artery and vein has risks. Peribulbar is safer than retrobulbar." A surgeon from Rhode Island who uses a topical combination says topical is excellent in terms of visual recovery, but that there's "greater postop discomfort." He adds, "Peribulbar blocks are a good alternative to retrobulbar," which, he thinks, "should be abandoned." Another surgeon, who withheld his name and location, says he prefers peribulbar blocks, but says, "They're OK for routine cases, but not for a grade-4 lens." When it comes to anesthesia, an Iowa surgeon says, "Add some Alfenta IV if the eye is longer than 25 mm."

When asked about the measures they think are best to prevent infection in addition to povidone iodine, 52 percent of the surgeons name preop topical fluoroquinolones, 28 percent like postop topical fluoroquinolones and 14 percent like intracameral antibiotic injections (some surgeons chose more than one alternative). Also, 2 percent put antibiotics in the infusion fluid and 2 percent employ subconjunctival injections of antibiotic. "Preoperative topical fluoroquinolones are easy to use and offer broad-spectrum coverage," says Dr. Crews. New Jersey's Dr. Miano says postop topical antibiotics "kill germs on the ocular surface and in the anterior chamber postop." Bethpage, N.Y., surgeon Laurence Rubin likes preop topical antibiotics. "They reduce the surface bacterial load, and I combine them with watertight incisions." An ophthalmologist from Ohio agrees, saying, "Preoperative topical fluoroquinolones are proven to be effective."


Parting Pearls

Surgeons also weighed in with the best cataract surgery pearl that they try to keep in mind when they enter the O.R.

"Never tell a patient what to do," says a Tennessee surgeon. "Instead, ask, 'What do you want me to do?'" New Jersey's Dr. Brown recommends surgeons "only use phaco energy in the central 3 to 3.5 mm, as close to the iris plane as possible." Another New Jersey surgeon thinks the ophthalmologist should be well-versed in different nuclear cracking techniques. "Although every surgeon has his preferred method of phaco, be familiar with all methods—cracking, chopping and flipping," he says. "In some situations, your favorite technique may not work as well as another one. If plan A doesn't work, make sure you have a plan B and a plan C." When beginning the case, Dr. Miano recommends that surgeons "use a 0.5-mm, blunt-sided diamond blade to make the side-port incision before the phaco knife." An Arizona surgeon addresses patient positioning, saying, "Position the patient and the doctor for the best view (near perpendicular to the visual axis)." "Take time to do a thorough hydrodissection," recommends an Ohio surgeon. A couple of surgeons think it's possible to go too fast with a case. "Remember Bobby Osher's 'slow-mo' phaco," says a surgeon from Wisconsin. "Haste makes waste." Another surgeon says, "Be careful and don't hurry."
And New York's Dr. Rubin advises against incurring the wrath of the intraoperative Furies, saying, "Don't ever call a case routine."

Finally, despite all of the marvels and wizardry of technology and technique at the modern surgeon's disposal, William Basuk, MD, of San Diego says the best advice is to simply know when to stop. Says he, "Perfect is the enemy of good."