When Review has asked cataract surgeons to describe their technique in past years, there appeared to be a gradual rise in the number of surgeons adopting clear-corneal incisions. With this panel report, that trend has stopped. Not only has the percentage of surgeons doing these incisions decreased compared to last year, but 90 percent of respondents to this month’s questionnaire who don’t perform them say they’re unlikely to take them up in the year to come. In other aspects of the procedure, topical anesthesia continues to slowly win converts, while bimanual, or micro, phaco has a fair number of supporters now, but may not have a lot of momentum in the coming year.

These are some of the findings in this month’s panel report on cataract surgery techniques. This month, 85 surgeons, or 11 percent of our 750-surgeon sample, responded. Read what they have to say, and decide whether you’ll be advancing into the unknown with newer techniques or digging in with the tried-and-true.

Incision Derision
Limbal incisions and scleral tunnels grew in popularity this year in comparison to last year’s panel report, while the percentage of clear-corneal wound proponents actually decreased. Scleral users increased from 16 percent last year to 22 percent in 2004, and limbal proponents grew modestly from 32 percent to 35 percent. The percentage of surgeons performing clear-corneal incisions decreased from 49 percent last year to 40 percent.

One of the major reasons behind this trend may be the suspicion that clear-corneal wounds increase the risk of patients’ developing endophthalmitis. Though, in last year’s survey, 57 percent of surgeons said they believed these incisions increased the infection risk, 70 percent say so now. And 90 percent of the physicians who don’t currently use the incisions say they’re “unlikely” or “very unlikely” to start making clear-corneal wounds in the next two years.
Hollywood, Fla., surgeon Martin Feuerman says he will use scleral tunnel because he’s “afraid of endophthalmitis” with clear-corneal wounds.

“There’s an increased risk of endophthalmitis [with clear-corneal incisions],” opines a surgeon from Louisiana. He observes that “the risk has been increasing as the number of clear-corneal incisions has increased since 1991.”
A Texas surgeon says it’s his impression that the infection rate with clear-corneal wounds is “around three times higher than with other incision types … I don’t need that.”

Robert Lee Yockey, MD, of Scottsdale, Ariz., likes the scleral incision for other, practical reasons. He says, “The scleral wound seldom leaks and is more comfortable.”

The surgeons also rated limbal and clear-corneal incisions in six categories, from wound integrity to required skill level. With the exception of two areas, construction speed and the skill level required to create the incisions, limbal incisions amassed a better average score than clear-corneal wounds.

In the categories of wound integrity and flexibility, limbal incisions far outstripped clear-corneal wounds. Ninety-eight percent of surgeons describe limbal incisions’ integrity as good or excellent, compared to only 67 percent who say the same for clear corneal. For flexibility, 95 percent of respondents think limbal incisions are good or excellent, while just 65 percent describe clear-corneal incisions that way.

Richard Davenport, MD, of Milwaukee says, “The limbal wound heals more securely because it has a little white in the incision.”

Phoenix surgeon Sanford Moretsky says that, often, patients with clear-corneal wounds “complain of foreign-body sensation for weeks after the surgery.”
“Faster speed does not always mean better!” asserts a Louisiana surgeon.
Eighty percent of the respondents use sutureless incisions. “The incision seals itself tightly 99 percent of the time,” says Olympia, Wash., surgeon William Waugh. Gerald Roper, MD, of Batesville, Ind., doesn’t use sutures because he says a sutureless wound offers him “more rapid healing and better wound integrity.”

Micro Phaco
Though 44 percent of respondents say they perform bimanual phaco, this number may not grow at a fast rate in the coming year, with three-quarters of those who don’t do micro phaco saying they’re unlikely to begin doing it in the next 12 months.

“I hear it’s too tedious,” quips a surgeon from Louisiana.

“Micro phaco requires new phaco equipment updates, new handpieces, new entry knives, a third incision for the intraocular lens and it’s slower,” argues Dr. Roper.

Dr. R. Scott Russell of Flushing, N.Y., doesn’t see the point in transitioning to the new technique just yet. “I don’t have the equipment, and there’s no advantage to it at the present time because you still have to enlarge the wound for the IOL.”

A surgeon from Michigan agrees, saying, “Bimanual adds more complexity but no advantages—you still have to open up the wound to put in the lens.”

Dr. Waugh says micro phaco is counter to his training. “I trained in a single-handed technique,” he says. “My left hand fixates the globe with a twist pick.”
The 44 percent who perform micro phaco swear by it, though.

“It gives me better control and is more efficient,” asserts Milwaukee’s Dr. Davenport.

Dr. Yockey says he likes the way micro phaco allows him to manage the nucleus. “I deliver the fragments to the phaco tip, instead of sucking them out,” he says.

“It puts less stress on the zonules,” says a micro-phaco surgeon from Texas. “It also allows easier particle manipulation.” A California surgeon concurs, saying, “It gives me better control of the nucleus as well as the posterior capsule.”

Anesthesia
Surgeons appear to be dabbling more in topical anesthesia this year. Though the respondents gave more than one response when asked which method of anesthesia they prefer, which makes it difficult to declare a clear winner, the proportion of surgeons who say they administer some form of topical anesthesia is up significantly from last year.

Forty-nine percent of the physicians say they use either topical drops or gels, compared to just 33 percent last year. Intraocular lidocaine use also increased, from 4 percent in 2003 to 18 percent this year.

Michael Solomon, DO, of Warren, Mich., uses a combination of a drop and a gel, and rates it excellent in such categories as speed of visual recovery and safety, but says it’s not a slam dunk.

“You have to be willing to coach some patients through the procedure,” he says.

Westerly, R.I., surgeon David Rivera combines topical drops with subconjunctival anesthesia. “With the addition of 0.2 ml of subconjunctivally injected local anesthetic, the patient acceptance and comfort levels are almost 100-percent excellent,” he says.

Arthur Fleming Jr., MD, of Pittsburgh, Pa., rates topical anesthesia as excellent in all categories. “It’s the safest method because there are no risks of optic nerve damage like with retrobulbar blocks,” he says.

“It works,” says Paul Michelson, MD, of La Jolla, Calif., “but it’s not good if there are complications, extra surgical maneuvers are necessary or the patient is uncooperative.”

Stuart Shofner, a physician from Nashville, sees the use of topical as a matter of medico-legal protection. “A colleague of mine was sued for an accidental perforation with a retrobulbar block,” he says. “I stopped doing blocks at that time.”

A solid percentage of surgeons, 55 percent, also use peri- and retrobulbar blocks, however.

“I don’t like patient eye movement,” says Florida’s Dr. Feuerman, who uses blocks. “And, my patients prefer retrobulbar blocks.”

Dr. Davenport also thinks patients prefer blocks. “Patients who had topical anesthesia in one eye from another surgeon liked the retrobulbar block in their second eye better,” he explains.

Though a surgeon from Texas rates topical as excellent with regard to ease of use and visual recovery speed, he prefers to use peribulbar blocks. “Topical generally requires a lot of IV sedation,” he says. Indeed, in our survey, 96 percent of respondents say they provide IV sedation with topical anesthesia.

Sixty-nine percent of the surgeons who use blocks administer them themselves, either because they like the control over the procedure it gives them, or simply because they’re better at it than an anesthesiologist. A third delegate the task to another person, however.

Baltimore surgeon Richard Balcer has the anesthesiologist administer the block. “It makes scheduling more efficient,” he says.

Wilson Ko, MD, of Flushing, N.Y., says having the anesthesiologist administer the block “saves time … and they do more of them so they’re more proficient with the technique.” Another New Yorker, Jan Arnett, MD, agrees with Dr. Ko. “The anesthesiologist does it because it saves me time,” he says.

Preventing Infection
Most surgeons (73 percent) still don’t think there are enough clinical data to support using antibiotics in the infusion bottle, or are concerned with the possible side effects.

“There’s no evidence to support the use of antibiotics in the infusion,” says John Lantz, MD, of Olney, Ill. “It hasn’t proven its efficacy,” agrees a Florida ophthalmologist.

“Why should I put antibiotics in the infusion?” asks a surgeon from Texas. “I’ve never had an endophthalmitis case and I don’t need corneal decompensation.”

Dr. Solomon avoids doing it for other reasons. “I have been successful with my typical antibiotic prophylaxis,” he says. “I don’t want to create any bacterial resistance with infusion.” A Cleveland, Ohio, surgeon avoids using these agents in the infusion because of “potential corneal and retinal toxicity.”

A surgeon from Michigan prefers to put antibiotics in the infusion for “medico-legal reasons,” and Haslett, Mich., physician Lance Lemon does it based on his clinical impression. “I have never had a case of endophthalmitis when I used antibiotics in the infusion,” he says. “During a period of time when I stopped the practice I had some cases of infection. It could have been a coincidence, but I have gone back to using antibiotics in the infusion, and I’m happy with the outcomes. I realize that the data aren’t supportive of this, but I must stand by my clinical observations.”

Surgeons are equally as vocal about using preoperative antibiotics to
prevent infection. Eighty-six percent say they do this. “Doing so results in a statistically significant decrease in the rate of endophthalmitis according to the ophthalmic literature,” says Dr. Michelson.

“I administer antibiotics one hour before surgery,” says Rhode Island’s Dr. Rivera. “I want antibiotics to be there in the tissues during and immediately following the case.”

Dr. Solomon says, “I administer them one day prior to non-diabetics, and three days prior to diabetics. I like the bactericidal fluoroquinolones onboard prior to opening the eye, and the antibiotic concentration on the eye in addition to the immediate preoperative Betadine eye preparation.”

As in several aspects of surgical care, many of our respondents always keep an eye on the possible legal ramifications of what they do.

“Preop antibiotics may help,” says Dr. Davenport. “But it’s not proven. It’s mostly for the lawyers.”