2010 was a fantastic year for ophthalmologists, full of
new innovations not only in surgical but medical treatments of ophthalmic disease as well. In this article we highlight some of the most exciting changes in 2010 for anterior segment specialists.
1. Size Matters.
In both cataract and retinal surgery, the focus has been on creating smaller and smaller incisions. Thought to decrease risk of infection and astigmatic change, the adoption of these changes have picked up quickly thanks to devices such as Alcon's Intrepid and Bausch & Lomb's Stellaris systems. Alcon's Infiniti machine, while capable of 2.2 mm incisions, offers its Ozil IP technology which is capable of more efficient phacoemulsification. The Stellaris device allows even smaller incisions, as small as 1.8 mm. For intraocular lens technologies, multiple single piece IOLs are now available for microincision use including but not limited to the Akreos MI60L (Bausch & Lomb), Softec HD (Lenstec), and SN60WF (Alcon). The first two lenses have zero asphericity while the SN60WF lens incorporates negative asphericity. The Abbott ZCBOO lens, while not developed for microincision injection, can be delivered via 2.4mm incision with the Alcon Monarch D cartridge. For those surgeons who prefer a 3-piece IOL, Hoya offers two models including the PC-60AD which comes preloaded and is also capable of microincision insertion. Presbyopic correction continues to improve as well as each of the major companies release updated IOLs, specifically the +3 Restor, Tecnis multifocal, and Crystalens AO; The +3 Restor has been shown to deliver almost equal near vision performance as the +4 model, but with much improved intermediate vision. The Tecnis multifocal appears to give a better range of spectacle freedom compared to its Rezoom counterpart. The Crystalens AO, with its AO aspheric technology, delivers a greater range of depth of focus with better refractive stability than the prior HD model.
2. Focus on the Surface.
2010 saw a greater appreciation for the ocular surface, including dry eye and blepharitis. The concept of dysfunctional tear syndrome became more commonplace, and the role of a healthy tear film became more appreciated for patients following presbyopic IOLs. Alcon released Systane Balance, an artificial tear specially formulated for patients with meibomian gland disease. Maskin probes, developed by Dr. Steven Maskin and Rhein, offer the ability for ophthalmologists to reopen diseased meibomian glands. IPL therapy, introduced by Dr. Rolando Toyos, has also found a place in treating these patients. Ocular surface reconstruction surgery has increased in prevalence for those patients with significant conjunctivochalasis and the role of demodex in recalcitrant blepharitis has also become more the focus of therapy.
3. Save the cells.
With the rapid growth of DSAEK surgery, surgeons have looked for ways to minimize endothelial trauma, which commonly occurs during implantation of the donor button. To addess this need, several inserters have been developed. Examples include the Tan Endoglide (developed by Dr. Donald Tan), and the Endosaver (developed by Dr. Keith Walter)
4. Femto fever.
Femtosecond laser technology, while greatly advanced for producing LASIK flaps, had also been modified for other procedures. Offering more precision over hand held blades, it has been used for producing limbal relaxing incisions. Modifications have also allowed surgeons to create consistently shaped paracentesis and keratome incisions for cataract surgery. Corneal transplants can be shaped with the laser, whether for partial or full thickness procedures, but perhaps the most exciting application is the use of the laser to perform a capsulorhexis and divide the intraocular crystalline lens into tiny fragments. While each laser is currently approved for specific procedures, in time all lasers will likely be approved to perform a complete cataract surgery, including limbal relaxing incisions or a shaped capsulorhexis indicating the proper orientation for a toric intraocular lens.
5. Anti-viral edge.
The treatment of herpetic keratitis has always been challenging; patients may suffer multiple recurrences as well as develop vision limiting corneal scarring. Bausch & Lomb purchased Zirgan from Sirion and brought it to our pharmacy shelves. A gangciclovir gel, it allows for treatment of herpetic keratitis at a less frequent dosing. More beneficial, perhaps, is that it is much less toxic to the epithelium than traditional trifluridine.
6. OCT.
That's right, OCT. While used by retinal specialists daily, OCT has found greater importance in anterior segment practices as well. In addition to detecting small amounts of pathology like CME, it can be used to uncover pathology which can be difficult to detect on clinical examination. For example: the patient with a dense cataract can not only be informed of their macular degeneration/epiretinal membrane preoperatively but can be better identified as an appropriate candidate for a presbyopic lens. While improvements such as higher resolution 3-D imaging and Doppler OCT will ultimately teach us more about retinal pathology, portable OCT units will help all anterior segment ophthalmologists. Smaller than older generation counterparts with nearly equal imaging capability, these units will bring a cost-effective solution to the majority of surgeons desiring this technology.
Overall, 2010 was full of advances for the anterior segment surgeon. Based on the rate of changes we have seen in the past few years, 2011 will likely be even more exciting for us all. Several things we can look forward to include the Synchrony and Tetraflex IOLS, the implantable telescope for patients with cataracts and macular degeneration, and the Acufocus corneal inlays for treatment of presbyopia.