Efficiency in cataract surgery is crucial. Not only does it optimize workflow, but it also enhances the patient experience and postoperative outcomes. In my clinic, integrating new technologies to streamline procedures has yielded improvements, including reduced surgical time, decreased surgical risks, and more consistent outcomes.
SURGICAL EFFICIENCY MATTERS
As the world’s population ages and life expectancy increases, more patients will require cataract surgery. With a projected 12% decrease in the ophthalmology workforce by 2035, strategies that increase efficiency and streamline workflow are becoming increasingly important. The key is to achieve these metrics while simultaneously improving surgical safety and efficacy.
Several innovations for enhancing workflow in the clinic and during preoperative phases have been discussed previously. For example, patient intake software can streamline check-in and automate appointment scheduling and reminders, and digital media and video calls for surgical consultations can reduce practice bottlenecks and improve the patient experience. Additionally, digital and cloud-based solutions such as Eyetelligence (Bausch + Lomb) and Veracity (Carl Zeiss Meditec) offer myriad advantages by facilitating patient data management across various clinical settings and diagnostic platforms, aiding surgical planning, and individualizing workflows.
In the OR, many technologies are designed to streamline cataract surgery and improve workflow. For instance, devices such as Cassini Connect (Cassini Technologies) offer real-time guidance and customizable surgical overlays, thereby reducing surgical time. Incorporating a femtosecond laser into my surgical routine has saved a significant amount of time during various steps, such as the capsulotomy, lens softening, and astigmatism correction with laser incisions.
Optimizing energy efficiency in phacoemulsification is indispensable for streamlining cataract surgery while enhancing the patient experience. Improved energy efficiency facilitates more precise case management in the OR, and it helps minimize tissue damage and optimize surgical outcomes. Although factors such as surgeon experience and preferred nuclear disassembly technique affect energy efficiency,1 several intraoperative metrics—including surge control, total ultrasound time, and fluid consumption—also play a role by directly influencing procedural stability and the comfort of both the surgeon and the patient.
In my experience, the R-Evo Smart system (BVI Medical), particularly when used in combination with laser cataract surgery, has been associated with lower ultrasound time. This observation suggests that the system may help achieve a reduction in ultrasound exposure while maintaining high safety standards.
STRATEGIES FOR REDUCING ULTRASOUND TIME
Several strategies have been proposed to reduce ultrasound time during phacoemulsification. These include using torsional and burst phaco modes,2 modifying the timing and duration of ultrasound power, selecting a pulse rate and duty cycle appropriate to the surgical situation,3 and performing cataract surgery at a more physiologic IOP.4,5
In a recent study, the R-Evo Smart system was associated with lower ultrasound time compared with the Centurion Vision System (Alcon)—in some cases, ultrasound time was reduced by nearly half.6 (Editor’s note: This study compared the R-Evo Smart system to the Centurion Vision System without Active Fluidics technology.) This reduction may be attributable to the R-Evo Smart’s Minimal Stress technology, which is designed to maintain consistent phaco tip movement regardless of cataract density. Additionally, the system’s Agile Fluidics feature modulates IOP based on aspiration demand, which may contribute to reduced surge and improved fluid control. The study focused on total ultrasound time and fluid consumption across 301 eyes undergoing cataract surgery (for more details, see Reducing Ultrasound Time).
REDUCING ULTRASOUND TIME
A prospective, consecutive, comparative study of 301 eyes undergoing routine phacoemulsification or laser cataract surgery with either the R-Evo Smart (BVI Medical; n = 155) or the Centurion Vision System (Alcon; n = 146) demonstrated that ultrasound time was significantly reduced with R-Evo Smart technology—by nearly half in some cases. (Editor’s note: This study compared the R-Evo Smart system to the Centurion Vision System without Active Fluidics technology.) There was no statistically significant difference in mean cataract grade between the R-Evo Smart and Centurion groups (3.07 ±0.78 vs 2.96 ±0.85; P = .12). However, a correlation between cataract grade and ultrasound time was observed in both groups, and there was no statistically significant difference in fluid consumption between the groups.
All laser cataract surgery procedures were performed with the Catalys Precision Laser (Johnson & Johnson Vision). A 5-mm capsulotomy was created through a 2.2-mm temporal clear corneal incision.
Surgical efficiency was measured by total ultrasound time during lens removal and fluid consumption during both lens removal and irrigation/aspiration (Table). In the R-Evo group, fluid consumption was measured by drainage bag weighting. The mean total ultrasound time for the R-Evo Smart and Centurion groups was 18.99 ±12.85 seconds and 40.24 ±21.91 seconds (P < .01), respectively, while the mean total estimated fluid aspirated—as determined by drainage bag weighting—was 53.00 ±14.56 g for R-Evo Smart and 54.33 ±14.88 g for Centurion (P = .21). In a subgroup of routine phaco cases (98 R-Evo Smart eyes and 63 Centurion eyes), the mean total ultrasound time was 19.96 ±11.20 seconds for R-Evo Smart and 42.84 ±28.35 seconds for Centurion (P < .01), and the estimated amount of fluid aspirated was 55.95 ±14.76 g versus 55.97 ±13.62 g, respectively (P = .49).
Improved control over phaco parameters was accompanied by a reduction in surgical time, which may translate into cumulative time savings over the course of a surgical day.
ADDITIONAL BENEFITS OF INCORPORATING NEW TECHNOLOGY
Integrating new technologies into cataract surgery can enhance the predictability of surgical outcomes and reduce variability in surgical times. (Editor’s note: Multiple manufacturers offer advanced fluidics management systems designed to address the challenges discussed in this article.) For example, maintaining a stable anterior chamber and controlled fluid dynamics may contribute to more consistent procedural results. Laser cataract surgery can improve precision during steps such as the capsulotomy and lens fragmentation and may reduce the energy required for lens removal. When these factors are combined with improvements in ultrasound time and fluid management, they may contribute to shorter turnover times between cases and overall improvements in surgical workflow.
CONCLUSION
Adopting new technologies that enhance efficiency and improve outcomes is an important aspect of modern cataract surgery. In addition to streamlining clinic workflow, reducing bottlenecks, and facilitating the management of patient data and surgical planning, incorporating a femtosecond laser into my surgical routine and optimizing energy efficiency in phacoemulsification have been two key changes in my practice. These adaptations have contributed to increased efficiency and patient throughput while enhancing patient care. By focusing on key metrics such as ultrasound time, fluid consumption, and chamber stability, more predictable surgeries and improved patient experiences can be achieved.
1. Bui AD, Sun Z, Wang Y, et al. Factors impacting cumulative dissipated energy levels and postoperative visual acuity outcome in cataract surgery. BMC Ophthalmol. 2021;21(1):439.
2. Yang WJ, Wang XH, Zhao F, Mei ZM, Li S, Xiang Y. Torsional and burst mode phacoemulsification for patients with hard nuclear cataract. Medicine (Baltimore). 2019;98(22):e15870.
3. McKinney S. Phaco update: getting the right setting. Review of Ophthalmology. April 15, 2021. Accessed October 8, 2024. https://www.reviewofophthalmology.com/article/phaco-update-getting-the-right-setting
4. Rauen MP. Phacoemulsification at high IOP and physiologic IOP: impact on anterior segment physiology. Paper presented at: ASCRS Annual Meeting; May 5–8, 2023; San Diego, CA.
5. Beres H, de Ortueta D, Buehner B, Scharioth GB. Does low infusion pressure microincision cataract surgery (LIPMICS) reduce frequency of post-occlusion breaks? Rom J Ophthalmol. 2022;66(2):135–139.
6. Ibarz-Barberá M, Orts-Vila P, Martínez-Galdón F, Martín-García N, Tañá-Rivero P. Surgical efficiency comparison between two phacoemulsification systems. Clin Ophthalmol. 2024;18:1095-1102.
