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EW Boston 2014 5 make a difficult case successful of the LuxOR Microscope is its broadly available red reflex. It has a six-times larger red reflex zone, greater red reflex stability, and greater depth of focus than traditional focused light micro- scopes. Because of these LuxOR features, I didn't need to make as many X-Y and focusing adjust- ments, and I could see what I was doing at all times. Another asset of the Cataract Refractive Suite is the CENTURION Vision System. This phacoemulsifi- cation machine is an intelligent phaco platform designed to dynami- cally optimize every moment of cataract removal. It is designed to provide a new standard in anterior chamber stability and emulsification efficiency. In this difficult case, the CENTURION Vision System allowed me to emulsify the firm nucleus within the capsular bag and iris plane. Because of its advanced flu- idics and its INTREPID Balanced Tip, the CENTURION is particularly good at emulsifying hard fragments, and we needed that efficiency in this case. Fortunately, we had used the Figure 4. Two features were especially helpful while removing the quadrants in this moving patient: the broad-area red reflex provided by the LuxOR operating microscope and Active Fluidics from the CENTURION with its improved control and safety. Figure 5. Bimanual control during IOL implantation was provided by the AutoSert injector cartridge and the cyclodialysis spatula. Figure 6. The VERION System shows that the IOL is just slightly inferior to perfect position with respect to the preoperative pupil. Figure 7. Dr. Davison performs live surgery at the 2013 American Academy of Ophthalmology meeting. chop pattern during LenSx Laser nucleus dissection. This made it much easier to create four equally sized fragments without having to sculpt as deeply as usual. The chop was created so that it stopped 500 µm from the posterior capsule. The AutoSert feature of the CENTURION was also beneficial in this case because it allowed me to use both hands to control the eye and insert the IOL in a controlled fashion. Prior to insertion, I injected ProVisc but had to open another vial to add even more in order to deepen the anterior chamber enough to make sure that the posterior capsule was concave and taut. The IOL haptics could catch a flaccid flat or convex posterior capsule and create a posterior tear and potentially a sunken IOL. It would have been a shame to struggle all the way to that point and then have a problem, so it was worth it to take the time to put in extra viscoelastic. Before we introduced the I/A handpiece and silicone tip for viscoelastic removal, we adjusted the target IOP from 55 to 26 mmHg so that the eye didn't overinflate, pushing the IOL/capsu- lar bag complex posterior and causing pain that could have caused additional patient movement. After the viscoelastic was removed, we used the final compo- nent of the Cataract Refractive Suite, the VERION Image Guided System, which had received preop patient data and images digitally from the Reference Unit. The VERION system is designed to add greater accuracy and efficiency for the incision, toric IOL orientation, as well as capsu- lorhexis and IOL optic centration. The system helped me to ensure that the multifocal lens was perfectly centered on the preoperative undi- lated pupil At the conclusion of surgery, the incisions looked good and were watertight, and the procedure was complete. On postop day 1, no one would have ever known that the case had been challenging. The patient was happy, and everything looked fine, with uncorrected vision of 20/25. We all have cases of suboptimal cooperation and anatomic challenge like this from time to time, but thankfully all of the features of the Cataract Refractive Suite helped me achieve a high-quality successful outcome here. In this particular case, I had more than 1,000 of my peers observing the case via live satellite feed at the 2013 American Academy of Ophthalmology meet- ing, so the pressure was really on. The Cataract Refractive Suite has great value because each component is designed to help you consistently achieve your targeted refractive goal. The Suite can afford critically needed additional value with difficult cases such as steep brows, pseudoexfoliation, small pupils, or a patient who is not perfectly cooperative, to name a few. Dr. Davison is in private practice at Wolfe Eye Clinic in Marshalltown and West Des Moines, Iowa. He can be contacted at jdavison@wolfeclinic.com. *The VERION Image Guided System is composed of the VERION Reference Unit and the VERION Digital Marker.

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