Optimization of IOL selection and techniques enhances cataract surgery outcomes

(image Credit: AdobeStock/Mohammed)

Monofocal IOLs are a popular substitute for the natural crystalline lens replaced during cataract surgery.

Omar Shakir, MD, MBA, who is a cataract and retina surgeon in private practice in Greenwich, Connecticut, discusses choosing a monofocal IOL for his patients during the Ophthalmology Times Case of the Quarter series. “Monofocal IOLs are very suitable for a wide range of patients and have become go-to IOLs worldwide in patients with glaucoma, macular degeneration, and DME [diabetic macular edema]. Monofocal IOLs are the best option for them,” he says.

A key factor, according to Shakir, when choosing a monofocal IOL for a patient is the conversation with the patient about their lifestyle, needs, and expectations regarding the outcomes of their cataract surgery. This information gleaned from the patient will help the physician tailor the IOL to the patient’s needs. Shakir’s pearl after having this discussion is to recap the patient’s expectations, which will prevent any miscommunications down the line.

In his practice, Shakir prefers to use the CT Lucia 621P IOL implant (Zeiss) for a few reasons, the first being that it is available in a wide range of diopters from plano to 34 diopters (D) in 0.5-D increments. In addition, the IOL is composed of a glistening-free, hydrophobic acrylic material that is coated in heparin and is not sensitive to decentration in the bag. Finally, the IOL is preloaded in a single-use system that delivers the IOL “elegantly and slowly,” according to Shakir.

Case report

When performing phacoemulsification, Shakir prefers to use the Quatera 700 phacoemulsification system (Zeiss), which works differently from the conventional systems that use vacuum- or peristaltic-based pumps. His preferred system uses the Quattro pump, which, he explained, works like the heart (ie, 2 chambers for inflow and 2 chambers for vacuum that are linked to ensure anterior chamber stability by synchronizing infusion and aspiration rates).

“My goals are to enhance surgical outcomes and to have patients leave the practice extremely satisfied and to achieve that quicker. I lean on technology to achieve those goals,” he says.

When he performs his surgeries, Shakir drives a straight needle into the nucleus and tries to chop the crystalline lens. He uses a spiderweb pattern when removing a denser nucleus.

Shakir emphasizes that the vacuum rate is high at 600 mm Hg or higher and the flow rate remains below 90 mL/min. He notes that when high vacuum is used, the IOP is not very high and that because the flow rate is good, corneal edema can be avoided.

Shakir uses a soft-tipped inspiration/aspiration tip and shows that the bag remains stable, even when pieces of residual cortex are removed. The surgery is performed through a 2.4-mm incision. He points out the key feature of the phacoemulsification system is that it is customizable, in that the flow rate and vacuum can be adjusted to surgeons’ preferences
and the anterior chamber stability is maintained while the efficiency of the procedure is increased.

Shakir explains that he has been experimenting with increasing flow and decreasing IOP and has found that this phacoemulsification system works well. Findings from recent studies have found that at high flow rates, there is no tapering of IOP control. However, he explains that this process is a delicate balance, because corneal edema can develop postoperatively with increased flow rates. He aims for an IOP ranging from 45 to 55 mm Hg with the lowest possible flow rates, allowing him to still penetrate the nucleus efficiently. “My efficiency times using the Quatera 700 are very good,” Shakir adds.

Omar Shakir, MD, MBA

E: Omar.Shakir@gmail.com

Shakir is a founding partner of Coastal Eye in Greenwich, Connecticut. He is a consultant to Zeiss.