The past year was an exciting one in Ophthalmology. New product development continues at a rapid pace, and we witnessed much change in 2013. The following “Top 10 List” represents the anterior segment developments that my colleagues and I found to be most interesting.
1. IOLs: New intraocular lens implants that received FDA approval were the Tecnis Toric ZCT series from Abbott Medical Optics, and the Trulign Toric AT50T from Bausch + Lomb. The Tecnis is a one-piece acrylic lens with traditional loop haptics, while the Trulign is a toric version of the Crystalens AO having a hinged plate-haptic design. Both IOLs effectively correct astigmatism (Tecnis up to 2.74 D and Trulign up to 1.83 D at the corneal plane) and have excellent rotational stability. The Trulign lens also offers a range of vision due to its accommodating design.
2. Femtosecond lasers for cataract surgery: Four platforms are now fully approved in the US for corneal and lens incisions. Alcon’s LenSx laser, OptiMedica’s Catalys Precision Laser System, LensAR’s cataract laser, and Bausch + Lomb’s Victus Femtosecond Laser Platform. Upgrades to these devices have improved the ease of use and reduced treatment times. Although debate continues regarding whether or not femtosecond laser-assisted cataract surgery results in superior refractive outcomes, there is no doubt that phaco time and corneal endothelial cell loss is significantly reduced.
3. Surgical pearl: The central dimple-down maneuver for consistent continuous femtosecond laser capsulotomy, published by Drs. Arbisser, Schultz, and Dick (JCRS. 2013; 39:1796), is a simple surgical technique that confirms a free flap after laser capsulotomy. After injecting OVD, the blunt cannula is used to gently indent the center of the capsular flap. In addition to confirming whether the flap is free, this maneuver will usually break any tags to prevent a radial tear.
4. Corneal collagen cross-linking (CXL): This procedure to strengthen corneas with ectasia is the standard of care outside the US. FDA trials are still ongoing with excellent results, specifically, improvements in visual acuity, corneal topography indices, and higher-order aberrations. Accelerated CXL is also being evaluated in two new FDA trials, and investigators in Europe are using topography-guided CXL.
5. Topography-guided LASIK: Two excimer laser systems are now FDA approved for topography-guided custom ablation LASIK procedures. Alcon’s WaveLight Allegretto Wave Eye-Q laser with the WaveLight Allegro Topolyzer and Nidek’s Customized Aspheric Treatment Zone (CATz) for the NAVEX EC-5000 Excimer Laser System enable surgeons to provide individualized treatments based on corneal topographic irregularities.
6. Rapid point-of-care tests: InflammaDry from Rapid Pathogen Screening is a quick, disposable, in-office, dry eye screening test gained FDA approval. The device detects levels of the inflammatory marker matrix metalloproteinase 9 (MMP-9) in a small sample of a patient’s tears. RPS also manufactures AdenoPlus, which is a diagnostic test for adenoviral conjunctivitis. Sjö from Nicox is an advanced diagnostic panel for early detection of Sjogren’s syndrome. TearLab Osmolarity Test from TearLab is a simple, rapid test to determine tear osmolarity.
7. Presbyopic corneal inlays: The Kamra corneal inlay from AcuFocus, the Raindrop corneal inlay from ReVision Optics, and the Presbia Flexivue Microlens inlay from PresbiBio are implants that are placed into a corneal pocket (Kamra) or under a corneal flap in a patient’s non-dominant eye for surgical correction of presbyopia. All three devices have demonstrated improved near and intermediate vision. The Kamra inlay is a small aperture optics design based on the pinhole effect to improve near vision by increasing depth of field. Conversely, the Raindrop and Presbia lenses alter the corneal curvature and refractive power, respectively, to increase near vision.
8. Microinvasive Glaucoma Surgery (MIGS): The iStent from Glaukos is a device that is inserted into Schlemm’s canal at the time of cataract surgery to reduce IOP in patients with mild to moderated open angle glaucoma. Other MIGS devices in FDA trials include the Hydrus Microstent from Ivantis, iStent Inject and iStent Supra from Glaukos, CyPass Microstent from Transcend Medical, and Gold Micro Shunt from Solx.
9. Phaco machines: The Centurion Vision System is the newest generation phaco machine from Alcon. It was designed to integrate with other Alcon technologies like the Verion Image Guided System, the LenSx laser, and the Luxor microscope. The Centurion’s new fluidics system called Active Fluidics Technology, utilizes pressurized infusion to allow the surgeon to set and maintain a target IOP throughout the procedure, thereby reducing surge. The Balance Energy Technology enables better use and enhanced efficiency of ultrasound with OZil. Another new phaco unit is the CataRhex 3 from Oertli, a compact, portable device that hangs from an IV pole.
10. Intraoperative aberrometry: VerifEye is the new system upgrade to the Optiwave Refractive Analysis (ORA) system from WaveTec Vision. Streaming, real-time refraction data are displayed in a preview screen so the surgeon can determine stability and ensure more accurate measurements. Applications of this operating microscope mounted aberrometer include IOL power calculations including toric IOL power calculation and rotation, and corneal astigmatic incision placement guidance. Holos IntraOp from Clarity Medical Systems is another scope mounted aberrometer for real-time intraoperative determination of astigmatism.