With a wealth of high-tech hardware at the fingertips of modern-day eyecare professionals, patient information and the way it’s managed is a pressing issue. Three ophthalmologists explain how they are distilling data for better outcomes.
The term ‘paralysis by analysis’ was coined some decades ago, but as a practising eyecare professional in 2024, it could not be more relevant if one is not judicious about the information they rely on for chronic disease management and treatment planning.
With the increasing sophistication of ophthalmic instruments, the role of the optometrist and ophthalmologist is to absorb each measurement, image and detail of patient history and synthesise it into insights that can preserve and even restore vision.
Today, effective data management is at the centre of successful eye clinics. Without organised and easily accessible information, how can eyecare professionals be expected to spot vital physiological changes amid the hustle of daily practise?
ZEISS is one company that has realised this challenge and responded with ZEISS Forum that it describes as the leading ophthalmic data management solution. The platform and its clinical workplaces work to provide seamless data integration of various diagnostic devices that ultimately help clinicians make treatment decisions from a single workstation.
Insight speaks to three ophthalmologists about the key data they use to inform their cataract and refractive surgeries, and glaucoma management, and how ZEISS equipment and software creates confidence and convenience in their daily practise.
Cataract calculations
Dr Peter Ingham, who owns Adelaide Eye & Laser Centre and works alongside Dr Ben LaHood, performs around 900 cataract surgeries a year, with an increasing proportion of those being premium multifocal and extended depth of focus (EDOF) intraocular lenses (IOLs).
With the heightened complexity of planning for these procedures, the clinic has counteracted this by simplifying its cataract surgery workflow and investing in ZEISS Forum and by extension EQ Workplace. The latter is a cutting-edge cataract surgery planning solution that allows him to have biometry, other vital scans and a calculation platform all on a single display. As much of the data pre-populated, it requires minimal manual data entry and allows him to plan the surgery before the patient in real time.
Importantly, the software can be customised to the surgeon’s preferred settings, including A constants, most-used intraocular lenses, and formulae.
One of the key devices that feeds into EQ Workplace is the ZEISS IOLMaster 700 biometer. Dr Ingham says pre-cataract surgery, the device’s topography maps can clearly show corneal changes to pick up undiagnosed conditions like keratoconus, as well nasal flattening from previous pterygium surgery. Intel like this is vital given that some presbyopia-correcting IOLs are particularly intolerant of residual refractive error.
“It also conveniently displays other crucial information like anterior chamber depths, white-to-white measurements, as well as your X and Y offsets, which are quite helpful if you’re considering implanting a more premium-type lens.”
When planning for surgery, Dr Ingham and Dr LaHood routinely use total keratometry (TK). TK is available on the ZEISS IOLMaster 700 and combines telecentric keratometry with swept-source OCT to measure both anterior and posterior corneal surface simultaneously.
A recent study conducted by Australians Associate Professor Michael Lawless, Dr James Jiang, Dr Chris Hodge, Professor Gerard Sutton, Associate Professor Tim Roberts and Professor Graham Barrett found that in post-myopic LASIK eyes, the Barrett True K formula with TK improved the outcome predictions compared to the Barrett True K with Classic Ks within ±0.5 D by more than 12%.
Dr LaHood says although TK values over simple anterior keratometry is unlikely to yield significantly better results in eyes – other than in post-refractive laser surgery – he finds it reassuring having TK values available. He uses TK values to assess toric IOL plans even if the figures are not used in IOL calculation.
He was part of a group that published the first analysis of the ability of the IOLMaster to measure posterior corneal astigmatism and found that eyes with against-the-rule astigmatism had a wide variability in the axis of their posterior corneal astigmatism. When using anterior keratometry alone, he says it is assumed that posterior corneal astigmatism steep axis will be vertical.
“However, looking at TK values, even if I do not use them for calculation, gives me an indication of whether the adjustment for posterior corneal astigmatism is likely to be as extreme in certain eyes and I can adjust my toric IOL cylinder power accordingly. From auditing my surgical results, I can see this technique and being able to readily look at TK values when selecting an IOL has been beneficial for my patients,” he says.
While accurate biometry truly holds the key to optimal outcomes, he says data also plays a vital role post-operatively. In Dr LaHood’s clinic, all lens-based surgery patients return for repeat biometry, subjective refraction and examination. Even though it’s time consuming, it allows for analysis, auditing, and ultimately improving future outcomes.
Recently, he reviewed 150 eyes he implanted with a single type of toric IOL and used the anterior keratometric axis to align each one.
“This is different to the plan received for each eye when using the Barrett formula which recommends an adjusted axis of implantation. I had the outcome data analysed by Prof Graham Barrett and we looked at what would have been the best axis of implantation,” he says.
“It showed there would have been a small improvement following his plan rather than what I had been doing. This is the type of question that you can only answer by collecting data. It has changed my practice and I hope to see even better results for my patients going forward.”
Refining refractive surgery
Dr Ingham and Dr LaHood also offer refractive laser surgery, and while this means they can readily enhance IOL outcomes when necessary – and giving them more confidence to try new IOL designs – it also provides an important clinical service for those not ready for IOLs.
With access to the ZEISS Visumax 800 laser and the Alcon Wavelight laser, ICL surgery and keratorefractive laser procedures including PRK, LASIK, and SMILE, are all available.
Dr LaHood reinforces that accurate biometry is the lynchpin to excellent outcomes. Essentially, once the surgeon and patient enter the laser operating suite, the hard work has been done.
“To achieve accurate biometry, we need to optimise the surface we are measuring. We are trying to be precise working with a changing, dynamic, fluid surface. One problem we have is that all too often, we get the ocular surface as good as possible for biometry but fail to continue this optimisation post-op. All eye surgery temporarily worsens tear film quality as it is inflammatory,” he says.
“Post operatively an unhappy patient, who had an optimised tear film for pre-op measurements, may not be happy with their outcome due to a lapse in tear film treatment in combination with their new optical set up. It is unlikely the lens is at fault, but more likely that their ocular surface is suboptimal once again. So I think we have to move away from just getting an ocular surface primed for biometry and better educate patients that this is going to be an ongoing maintenance even after surgery.”
To refine his results, Dr LaHood has each refractive laser patient return for post-op imaging of their cornea, subjective refraction and examination. This is vital because post-operative accuracy after laser procedures can be more difficult to define as the targets are different (often mild hyperopia in young eyes) and outcomes can change with time and corneal remodelling, especially after PRK.
He adds it is easy to have the outcome of one or two cases alter one’s thinking so consider the big picture and rely on analysis of multiple cases.
“The ZEISS Refractive Workplace allows in depth analysis of refractive procedure outcomes and that has been helpful to be able to easily enter and review outcome data,” he says.
“I have previously done this in an Excel spreadsheet. The Refractive Workplace graphical displays are easy to interpret and use to refine treatment planning nomograms. Each laser is different and so for me, moving from Auckland to Adelaide and between lasers, it has been very important to be able to easily analyse a large number of outcomes and refine my treatment plans.”
Finding the gold in glaucoma management
To make a glaucoma diagnosis – and to especially spot the rapid progressors and refer for treatment – the clinician needs to make a call by combining structural and functional data, often over an extended period.
So when Dr Geoffrey Chan began his public work at Fremantle and Fiona Stanley Hospital in Western Australia, one can imagine the frustration when faced with a clunky electronic medical record (EMR) system consisting of handwritten notes and visual field results scanned into the system and printed on each patient visit. Often these were unlabelled and not filed in chronological order.
“It was very hard to make sense of that data, and incredibly inefficient if you’re having to click on each scan date to try and pull up the relevant data.”
However, this all changed when the hospital invested in ZEISS Forum software a couple of years ago, something Dr Chan was already experienced with from his private work at the Lions Eye Institute. It’s given him access to ZEISS Glaucoma Workplace – a platform that brings together all the data crucial for glaucoma from devices like the Humphrey Field Analyser 3 (HFA3), Clarus ultra widefield retinal camera, and Cirrus OCT.
The platform makes it easy for Dr Chan to access patient data, with Forum existing as the place to store and access all ophthalmology data while sitting parallel with the hospital’s existing EMR. In the clinic, he usually has the patient’s medical notes accessed via the EMR on one screen while the other screen runs Forum where he can cycle through the scans and investigations.
He says a major advantages of ZEISS Glaucoma Workplace, especially when linked with a ZEISS native retinal camera such as the Clarus, is its ability to automatically segment out an image of the optic nerve at each relevant visit. Bringing together the OCT, visual field and retinal scans, at his fingertips he has all the structural and functional information he needed to make efficient and informed clinical decisions.
“The beauty of the ZEISS Glaucoma Workplace is the summary pages it generates. My favourite is the Structure-Function Guided Progression Analysis (GPA) which integrates longitudinal data to show areas where change has been detected. The Structure-Function Maps available present the key parameters with RNFL (retinal nerve fibre layer), ganglion cell analysis, and the concurrent visual field all on the one page,” he says.
“It’s a very efficient way of managing and monitoring glaucoma, displaying all the relevant information for clinical decision making. It also helps you keep track of when the patient last had X and Y test. Also, its role in patient education is probably the most powerful aspect, removing the need to switch between tabs, and using a single screen to demonstrate optic nerve damage and how this corresponds to the patch of vision missing in the visual field result.
“It brings to life the structure and function implications for the patient.”
On Forum in Glaucoma Workplace, Dr Chan can access Trend and Event Analysis on a single page, allowing him to plot visual field progression over time and making it clear where exactly the patient might be headed.
“With that, the system can highlight with yellow and red colour coding which part of the discs might be changing over time. It is augmenting our clinical decision making by flagging areas that we should pay attention to.”
Another key metric, intraocular pressure (IOP), is captured through Goldmann applanation, but this can be manually inputted into the patient’s record at each event. The same can also be done for a medication change and surgery, plus more.
“It allows you to flag events over time to see how the visual field and how the patient is changing in a graphical representation,” he says.
Dr Chan says the Glaucoma Workplace shines in all types of glaucoma patients. In suspects, it clearly highlights any changes to the optic disc while in rapid progressors, it can quickly flag the need for intervention.
“In these cases, the technology makes it easier to see linear trends, looking at how fast the RNFL and the mean deviation are progressing over time; the people whose linear trend shows a significant downhill decline. The goal is to pick the rapid progressors in 10% to 15% of our patients.”
In terms of co-management, Dr Chan works closely with an employed optometrist within the hospital who performs screening and monitoring of glaucoma suspects, and mild and moderate glaucoma cases. They work alongside one another one day a week where the optometrist can escalate concerning cases in real time, or she can store and forward cases that Dr Chan can access virtually.
“ZEISS Forum and the Glaucoma Workplace represents the era of seamless integration where everything’s filed, dated, labelled and easily accessed,” he says. “These are vital elements of data storage and for a condition like glaucoma that’s all about longitudinal data.”
More reading
ZEISS forms Myopia Advisory Board to advise on innovations
ZEISS MyoCare lens takes an age-related approach to myopia control
Melbourne independent Eye Trend on becoming a ZEISS Vision Expert practice
