Dr. Steven Vold

My name is Steven Vold and I'm coming from Fayetteville, Arkansas.  And I've been asked to talk briefly this morning about my experience with CALLISTO.  And just a couple months ago we did a live surgery event in our facility and I got to chance to use this.  And I'm gonna just kind of give you some of my perspectives on using this.

And just to give you a background, I've used a lot of different machines over things.  We've used the Travision [sp] system.  We've used a lot of intraoperative aberrometry from the orange to the aura with all the new upgrades as well.

So, I'm gonna just kind of show you my perspective as where does this fit in to the really the cataract surgery paradigm.  And really what we're talking--you know, a lot of times you're hearing kind of a buzzword at this meeting is the refractive cataract surgery suite.  And I really think this is something that can really be helpful here.

In ophthalmology, you know, there's an intedevocular [sp], the disease is growing faster than the rate of ophthalmic surgeries.  We have an aging population.  So, more and more baby boomers are getting to that age where they need cataracts.  We know that there's, as you can see, optic neuropathy growth, certainly not enough ophthalmologists to really meet all the demand really at this time.

Ophthalmology will have to be approximately 21 percent more efficient to accommodate industry changes.  So, that's really--it means we're gonna have to work harder to keep our head above water and also to maintain the--provide the kind of access to our patients that they have now. 

We also know about the surgical fees and we're looking at potentially another cut in 2014.  So, it's been really kind of challenging times in medicine.  It'll be very interesting to see how all that washes out.  But, clearly, we're going to need to be doing more of these, what I call, lifestyle procedures.  I like to--the term I use with my patients is customized cataract surgery. 

So, we're looking at treating astigmatism, providing presbioptic [sp] correction and the question is how can we best do that?  And, as you know, in the past there's a lot of surgeons that just really don't want to hassle with it simply because they really are concerned about the quality of the results and if you don't do these surgeries extremely precisely you can actually have some angry patients.  And I can tell you just one angry patient with a multifocal lens can really cause a lot of time and hassle for you and not to mention frustration for the patient and potentially some arguments you don't want to have with patients.

New technologies will be needed for surgeons to accommodate these complex procedures with greater confidence and better outcomes. 

Toric iOL so this is a big, big deal.  And I'm gonna just tell you right now in years gone by if you look at the data, even more recently I think the best data I've seen is that about 70 percent of patients with real conscientious surgeons will have outcomes within plus or minus a half diopter of cylinder and sphere.  I'm gonna just tell you right now that a lot of surgeons--I said don't meet him in that bar, so there's a lot of people who have residual astigmatism after surgery.  And as you can see, the numbers are going up exponentially with Toric intraocular lenses. 

We also know that the precision of the iOL has got to be good.  If it's not, you're really losing the effect and if people are paying extra money out of pocket to get their refractive air [sp] corrected, if we don't do it effectively, again, we're going to have some angry patients. 

And I've always kind of had this thing we really need to under promise and over deliver.  And I'm gonna tell you right now I recently been using a light adjustable lens as one of our clinical trial.  And I'm just telling you that now the bar is being raised, not just for 20/20 vision.  I really think the day is very quickly upon us where we're looking at beyond 20/20.  And the only way that happens is if our precision and accuracy is better because with some of these newer lenses we're actually getting 20/15, 20/12 vision.  It's really quite remarkable.

Again, we need to be precise with the placement of our Toric lenses.  And, really, the ZEISS cataract suite and to me I really think this is really some best in class type products.  This, of course, the iOL master 500, it's the fastest device on the planet for doing this, really has the updated software with the holiday tubes, the Haigis-L for your post refractive patients and really is very nicely--and adjunct with the Lumera700, which I've had in my practice for a number of years now. 

And these are fantastic scopes.  I've used a lot of different microscopes over the years from the Lika's [sp] to the Endura [sp], which is now the Luxor [sp] and I'm just gonna tell you, it is really tough to beat the optics of a Lumarim [sp].

And now just recently we have CALLISTO.  And this is going to kind of tie all of this together.  This is really what's gonna happen is that all the diagnostic tests that we use in the office, for instance, the iOL Master will be connected to the microscope, but ultimately to our ability to take care of patients.  And so, we're gonna be able to, in surgery, we'll know exactly where the astigmatism is.  And now with CALLISTO actually manage that astigmatism using this new tool for taking care of patients.

So, as you know, as we were just mentioning, the iOL Master 500's been considered the gold standard.  As you know, there are other products out there.  But, as far as the ease of use, I think it's really hard to beat the iOL Master 500.

I'm not sure what happened to our slides here, but the iOL Master is faster.  Again, it's really a really high quality machine.  And a lot of people think it really penetrates the vince cataracts [sp] better than almost all other technologies.  There are occasions with mature lenses where you may need an ultrasound, but they're, for the vast majority of patients, the iOL Master 500 works exceptionally well. 

And I can tell you also, just comparing it to as far as the kerotometry readings and things like that I've been extremely pleased with the results that we've had there.

Now, what we're trying to do with CALLISTO again is raise the bar for our ability to take care of these refracted patients, specifically for me is the ability to take care of Toric lenses and astigmatism.  The other thing we can do here, let me just show you a little video.  See this little overlay here?  We can actually dial in the size of the rhexis and use it as a template to help make sure that we get accurate sizing of our rhexis.  I think it's a very helpful tool.

We know that for most lenses that are 6 millimeter optics, really the optimal diameter, depending on who you're talking to, is about 5 to 5.5 millimeters.  This will help us do that.  It also helps us center this thing correctly.  And we know that the people slightly nasally decentered, making sure we have it in the right place is very important.

A couple things I want to just notice.  You've got these little marks, that helps us basically center that thing so we'll automatically go to the limbus with those marks.  With some of the upgrade in software that’s coming down the line actually will do that on the vessels and from what I understand the peripheral iris as well.  This is something that will be with us shortly. 

But, again, you can see here it really helps us in the precision of our rhexis.  And with the advent of [unintelligible] cataract surgery, I really think for those that are not using it in all cases and even people that have the phentos [sp] I personally think once you've seen this and we have a phento in our practice, you know, as a surgeon I want to match that with my own surgery.  And so, this is a tool that can definitely help you in that regard.

So, here is another thing.  And this is very handy.  So when you have a Toric lens, as you can see here, those little marks on the lens, this actually will tell you so you've got the measurements.  It will tell you exactly how to line up your Toric intraocular lens. 

And as you can see here, you can dial that in there.  One of the things I think it's important when placing a Toric iOL is you have viscoelastic behind it, especially a lot of these lenses, it will actually rotate.  It's very important to get good viscoelastic removal.  I think from behind the lens this is a very good tool to do this.  And one of the things, as you know, there's been a lot of buzz about intraoperative aberrometry and I've been very fortunate to have a fair amount of experience over the last three years with this.  I will tell you one of the things that interesting, there's been some people doing studies comparing Toric placement with the CALLISTO versus an intraoperative aberrometer such as Ora [sp].  And they have found in--for the Toric lens patients and things like that they're able to get really match the results of the Ora by using this technique.  And I really think if you're really meticulous and get these--the lens placed properly along the proper axis I can see how that can happen.  Where the advantages of an intraoperative aberrometry can potentially help you are in issues with post refractive patients.  But, as far as for astigmatism, this is a fantastic tool to help make your life more--things more precise. 

And these are in the oculars.  One of the things you need to know is in each of these oculars as well.  And as you can see, it really helps line these things up.  So, this is exactly what you're seeing when you're operating.  And you have control of this.  The neat thing is, believe it or not, you can choose the appearance just by the buttons on the Lumera microscope. 

One of the things, and I'm kind of--they have a 1080P recording device on this.  So, this actually can record up to 500 gigabytes of memory for the video.  And the thing I love about it and I'm kind of a media junkie I guess, but one of the things you can do is it'll actually frame things for you.  And I can edit the video right as I'm doing surgery, right from the microscope.  So, I don't need an extra person doing that for me or doing it afterwards.  I can do that along as I operate all right through a very sterile field.  It's really pretty remarkable.

As you can see, it's a very innovative system that utilizes biometry data from the clinic to improve clinical workflow efficiency, surgical precision in the OR.  You have the graphical overlays to assist with incision, capsulorhexis and premium iOL placement, itracking and it also ensures proper alignment of the overlays regardless of the eye movement.  So, that’s what I was saying it uses those markers on--the little marks that you put on the--at the limbus.  As time goes on that will--we'll just use the blood vessels there.  And it also accounts for anterior chamber depth and true optical access to provide more accurate centration of capsulorhexis and iOL placement.  It's really an integrated data injection.  It does not compromise surgical optics which is the nice thing about this. 

As far as the microscope, as you guys know, the Lumera's by far the market leaders in there.  There's a reason for that and it's not that there aren't other good products out there.  But, if you really want to compare things, you know, apples to apples, I'm just telling you this is just a phenomenal microscope. 

Some of the things that you have with that, of course, is the SCI patent system, the stereo coaxial elimination, which is really the defining feature in my mind for it.  It's a brilliant read reflex without compromising ability to resolve details.  I also will tell you, I'm a very preferential to Zenon [sp] light compared to the other white light.  It provides just a wider, more natural light for greater detail recognition and contrast.  I mean the things you can see on the capsule it's really--it's pretty spectacular.  In fact, it's almost a little scary sometimes how much precision and how much you can see.  And when you're doing cortical claim out and you do a better job with that even on the anterior capsule when you can see all of that extremely sharply, I think it's gonna reduce the amount posterior capsule or pacification we have for our patients and ultimately, hopefully, better outcomes.

User profiles and automated workflow streamline, the transition from anterior to posterior segment viewing, again, these machines, microscopes, can certainly been used to--for retina work.  Again, this is an integrated system.  And I think that’s what everything is moving towards is to have everything kind of work together so that we can make a very nice system, reduce the amount of air.  So, for instance, if you're hopping over the iOL's on to [unintelligible] on your board like we do, there's always a chance that somebody could not copy that right or they bring up a form it's not quite correct or they got the wrong form.  You've got it all here in here you can make sure--I think that you have the correct information, the correct data and if you want to adjust the lens, know exactly where the access is, you'll have that all available right to you while you're at the operating microscope, which to me is a very encouraging thing and really a reassuring thing for me as a surgeon.

Again, why does ZEISS cataract suite, enhances surgical precision and accuracy through the use of surgical overlays injected into the eyepiece of the surgical microscope.  CALLISTO I allows surgical navigation to be seamlessly integrated into the routine surgical workflow.  And the other thing is, I can just tell you, they've got a lot of experience with this with over 250 systems and over 250,000 patients treated worldwide with ZEISS cataract suite using the CALLISTO.  And currently it's the only commercially available ophthalmic surgical navigation system with data injection into the surgical operating microscope.

Any questions about this exciting technology?  Well, thank you so much for having me and I appreciate it.  And if you've got questions don't hesitate to ask me here.