A new monofocal IOL

With all the technological advances in torics and multifocals, monofocal IOLs haven't received much attention lately. Bausch & Lomb is hoping that will change with the enVista monofocal IOL. The company claims its new lens enjoys several advantages over competing products:

• The lens incorporates what the company calls "advanced, aberration-free optics," with uniform power throughout. Clinically, the company says that means better visual results. The lens performs well even if it's decentered, and it provides excellent depth of field, image quality and contrast sensitivity.
• The company says there are no "glistenings" or edge glare, complications that have occurred with other IOLs.
• The material is 16 times harder than traditional hydrophobic IOLs, making it hard to scratch.
• The haptics provide exceptional contact with the capsular bag, promising superior stability.

"I'm in a small town. If something is going to go wrong with an IOL 15 years from now, that's a big, big deal to me," says Dr. Mahootchi. He likes the enVista lens material for that reason — it's stable, and in the unlikely event that a patient requires an air or gas bubble for a retinal procedure, the lens doesn't opacify. "I recommend it for my neighbors," says Dr. Mahootchi. "Previously, the disadvantage was that it unfolds a little slowly. Now it unfolds much quicker."

Pupillary dilation and maintenance

X1 Ready-Loaded Iris Speculum. Diamatrix launched its X1 Ready-Loaded Iris Speculum, so named because it comes prepackaged in an injector. To use it, the surgeon injects the ring, engaging the leading hook into the distal iris. As the speculum emerges from the injector, the surgeon watches to make sure the lateral hooks engage on both sides. The surgeon leaves the last hook on top of the proximal iris and then engages it using an instrument called the Williamson hook. Dr. Mahootchi did some practice maneuvers with the device, liked it and plans to soon try it.

Diamatrix President Ron Dykes, who invented the device, says the ring creates the widest opening of any device on the market and says it's very gentle on the iris. The ring opens the pupil to 6.7 mm. The 4 "cradles" are said not to pinch the iris margin, so you can actually rotate the speculum in the eye without rubbing off pigment. The devices come 4 to a box.

Omidria pass-through status. Omidria, the intracameral phenylephrine/ketorolac injectable that helps maintain pupillary dilation intraoperatively, is about to be very affordable once again. The drug enjoyed 3 years of "pass-through" status, meaning that the cost was fully refunded in hospitals and refunded 80% in ASCs, but that ended on Dec. 31, 2017. This spring, though, Congress voted to give the drug 2 more years of pass-through status. Following a 9-month hiatus, that new period begins October 1, 2018. The HCPCS code is C9447.

Laser cataract surgery

Lots of high-tech devices can assist with toric IOL orientation. But Lensar's new Streamline IV program may win the prize, for now.

Like other laser cataract systems, the Lensar makes your capsulorhexis for you. Unlike other systems, it places 2 notches in the capsulorhexis to give you the vertical orientation for your toric lens. The notches are permanent, so surgeons can use them to evaluate orientation both intraoperatively and post-operatively. Dr. Lahners, who's widely experienced with a number of laser cataract systems, says the system "gives us 100% authority that the toric lens is exactly where we want it" because the mark is almost at the same plane as the IOL. There's none of the parallax that can be present with intrastromal marks. By the way, the system still makes intrastromal marks if you want them to guide arcuate incisions.

Sleep easier

Good news for patients and physicians who hate IVs — you can now get Imprimis's MKO Melt without individual prescriptions for individual patients. That's because Imprimis is now approved by the FDA as a 503B compounding pharmacy.

"The MKO makes even the grumpiest patients nice," says Dr. Mahootchi. Patients put it under their tongues as they're getting dilation drops. They start becoming relaxed in about a minute, he says. It's "a gradual onset of calm. Then you have 30 minutes or more of happy magic." He says patients who take it stare into the microscope light, can follow directions and recover from sedation just as quickly as they do with IV anesthesia. He says a lot of patients prefer it because they hate IVs. "The problem with it before was that I needed a prescription for each pill. I had to make sure no one cancelled because I couldn't use the drug. Now I don't have to have an Rx — I can just keep it in stock. It's phenomenal."

MKO Melt contains 3 mg of sedative, 25 mg of ketamine HCI and 2 mg of the anti-emetic ondansetron. It's available in lemon flavor.

Stop prescribing steroid drops

Your patients can avoid weeks of drops with Dexycu (dexamethasone intraocular suspension 9%), a long-acting corticosteroid that surgeons apply as a single injection at the end of cataract surgery to treat post-op inflammation. It contains a novel extended-release drug-delivery technology called Verisome that supplies the intraocular space with steroids over an extended period.

New for MIGS glaucoma surgery

Omni Surgical System. Surgeons can do 2 glaucoma procedures with 1 device using the new Omni Surgical System from Sight Sciences. The device can enable surgeons to viscodilate Schlemm's canal, expanding the conventional aqueous outflow pathway. Surgeons can also use the same device to do up to 360 degrees of trabeculotomy. Or they can do both.

The system incorporates a stainless steel curved cannula that enables surgeons to pierce the trabecular meshwork. Once the device has gained access to Schlemm's canal, the surgeon can push a flexible blunt cannula through Schlemm's canal as much as 180 degrees. As you slowly pull the cannula back, you inject viscoelastic. Turn the steel cannula around and viscodilate the other 360 degrees. Trabeculotomy works pretty much the same way, although here you fully feed in the flexible cannula and then simply withdraw the device from the eye, tearing open the trabecular meshwork.

The economics are favorable. Facilities and surgeons can bill for both 66174 and 65820. For ASCs, the combined facility fee is $2,625. For hospitals, it's $3,418.

Cypass Micro-Stent. The Cypass Micro-Stent, which bypasses Schlemm's canal to channel aqueous to the supraciliary space, should be easier to use now that it comes in a preloaded version. Originally staff needed to assemble the Cypass insertion apparatus by inserting an applier into a loading device, extending the guidewire through the lumen of the Cypass and then pulling the applier out. Now the stent comes preloaded. Just pick up the applier, fully depress the reset button and the Micro-Stent is loaded onto the applier.

"MIGS is a very exciting part of glaucoma treatment. It's changing the way we think about glaucoma and glaucoma surgery," says Dr. Lahners. "The ability to take an extra 30 to 60 seconds more at the end of cataract surgery and help reduce IOP is exciting. This is a little more powerful than the devices that bypass the trabecular meshwork. Of course they also carry the risk of hypotony."

In the 2-year Compass trial, the Cypass achieved a mean IOP drop of 7.4 mm Hg. And 85% of subjects were able to cease using glaucoma medications altogether.

The ASC facility fee for the Cypass procedure (code 0474T) is $2,440. For hospitals, it's $3,610.75.