Emerging treatments

Blue-blocking intraocular lens (IOLs)

Blue-light filtering lenses may help to attenuate retinal phototoxicity. There is, currently, insufficient evidence of benefit to recommend their routine use.[84][85][86][87]

Femtosecond laser-assisted cataract surgery (FLACS)

Femtosecond laser is used for creation of corneal incision, capsulotomy, and lens fragmentation. Currently, FLACS does not appear to offer any significant advantage over manual cataract surgery for routine cases.[88][89][90][91]​​

Precision pulse capsulotomy

Precision pulse capsulotomy is an automated method of creating a precise circular anterior capsulotomy using a disposable handpiece. The device delivers a series of electrical pulses via a nitinol ring to cut without cauterization. A precision pulse capsulotomy device (Zepto) was Food and Drug Administration-approved in 2017. Retrospective data suggest that precision pulse capsulotomy may be effective in challenging cataract surgery cases.[92]​ Radial tear of the anterior capsule has been reported.[93][94] Prospective studies are required to evaluate long-term outcomes.

Light-adjustable lenses

These lenses can be adjusted after implantation to correct residual refractive error including sphere and cylinder. Precisely targeted UV light is delivered via a slit-lamp based device that causes the photoreactive silicone in the lens to polymerize, changing its shape and refractive power. In one study of more than 600 eyes, patients who received a light-adjustable lens were almost twice as likely to achieve uncorrected distance vision of 20/20 or better at 6 months compared with those who received a monofocal IOL (70.1% vs. 36.3%).[95] One long-term follow-up study of 103 eyes showed stable refraction, good visual acuity, and no IOL-associated pathologies.[96]

Immediate sequential bilateral cataract surgery (ISBCS)

Safety and efficacy outcomes following ISBCS (surgery performed on both eyes on the same day but as separate procedures) do not appear to differ from those of delayed sequential bilateral cataract surgery.[97][98][99] ISBCS offers several advantages: it produces fast correction of vision, requires fewer patient visits to healthcare facilities, and takes less time away from everyday activities. ISBCS is also more efficient and cost-effective for healthcare systems. The main disadvantage of ISBCS is the risk of surgical complications occurring in both eyes simultaneously. Although rare, bilateral endophthalmitis or toxic anterior segment syndrome are potentially sight-threatening complications. Other disadvantages include being unable to choose a different IOL for the second eye based on the first eye outcome, and the patient requiring more support postoperatively. Risks can be reduced by selecting patients who are at low risk of ocular complications.

Office-based cataract surgery with oral sedation only

Oral sedation is a viable alternative to intravenous sedation for select patients undergoing routine cataract surgery. It does not require preoperative fasting, intravenous access, or intraoperative monitoring, meaning that cataract surgery can potentially take place in an office setting. One prospective, randomized, double-blinded study of 85 patients found no difference in satisfaction scores between those randomized to oral versus intravenous sedation.[100]

Intraoperative biometry

Intraoperative biometry (wavefront aberrometry) is being incorporated during cataract surgery to help improve refractive outcome targets. In one prospective cohort study of astigmatic outcomes in patients with toric IOL implantation, eyes with intraoperative aberrometry measurements had less astigmatism at 1 month than contralateral eyes with standard power calculations and a toric IOL calculator.[101]​ In one retrospective study of patients without previous refractive surgery who had uneventful cataract surgery, there was minimal clinical difference when intraoperative aberrometry was compared to modern preoperative formulas.[102]​ Ongoing studies are examining the effectiveness of taking biometry readings after the cataract is removed, particularly in postrefractive eyes where intraoperative biometry may have a greater impact on achieving postsurgical target refractions.

IOL power formulas

The intent of an IOL calculator is to improve the prediction of effective lens position so that residual postsurgical uncorrected refractive error can be minimized. Examples include: the Hill-RBF 3.0 calculator, which uses big data and neural networks; Hill-RBF 3.0 Calculator Opens in new window the Ladas Super formula, a combination approach with constantly increasing postsurgical data, which appears promising in increasing IOL calculation accuracy; Ladas Super Formula Opens in new window[103]​ the Olsen formula, which uses ray tracing and the C constant concept; and the Kane formula, which is based on theoretical optics and big data techniques. Kane Formula Opens in new window[104][105]​ Currently, preoperative biometry is optimized by including optical coherence tomography-based biometers and the newer Barrett formulas as built-in components. Barrett Universal II Formula Opens in new window Barrett Toric Calculator Opens in new window[106]​ It is challenging to predict IOL power in patients with previous refractive surgery, mainly due to postsurgical changes in the corneal surface leading to a less accurate estimation of corneal power, including posterior corneal astigmatism. Traditional IOL power estimation formulas such as Haigis, Holladay, SRK/T, and HofferQ may underestimate IOL power after myopic ablation and overestimate lens power after hyperopic ablation. Several new formulas attempt to overcome these errors, such as the commonly used ASCRS calculator and the Barrett True-K formula. ASCRS Calculator Opens in new window Barrett True-K Formula Opens in new window​ No-history IOL formulas after laser refractive surgery were compared in one meta-analysis of 1098 eyes, with the most accurate formulas found to be ORA, BESSt, and Triple-S.[107] Another meta-analysis of 1217 eyes found that the Barrett True-K formula, OCT, and ORA methods offered the greatest accuracy.[108]

Intracanalicular dexamethasone

Topical corticosteroids reduce ocular inflammation and pain postsurgically, and are usually delivered as eye drops. Patients with decreased manual dexterity, or those who are likely to find adherence to the tapering dosing regimen difficult, may benefit from the insertion of an intracanalicular depot that provides a tapering dose of dexamethasone over 30 days and does not need removal. The depot contains dexamethasone suspended in a polyethylene glycol hydrogel, which swells when it comes into contact with the tear film and molds to the canalicular anatomy. Unlike eye drops, no preservatives are required. Randomized, double-blinded phase 3 trials found decreased ocular pain, fewer anterior chamber cells and flare, and a lower requirement for anti-inflammatory rescue medications in the depot versus placebo vehicle group.[109][110]

Robotic surgery

In a first-in-human study, dissection took longer with the Preceyes system than with manual surgery, but increased precision compared with traditional surgery.[111]​ The Preceyes system is commercially available. The Da Vinci Surgical System has been used to perform a pterygium repair.[112]

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