With manual processes and multiple data points, it’s little surprise cataract surgery is one of the largest sources of ‘never events’. Toric IOL calculations, in particular, are a major drain on staff time too. A WA couple have combined their automation and medical knowledge to create the Schulte Holt toric IOL calculator that eliminates these issues for busy eye clinics.
Some weeks at home, early in the morning before his children wake, Dr Lasitha Jayasinghe opens the DropBox and can review, in detail, up to 60 toric intraocular lens (IOL) calculations. It’s a manual and tedious task. He knows there are better ways to spend his time, but it’s a price worth paying to avoid the nightmare scenario of implanting the incorrect lens.
Jayasinghe, who trained in his native country Sri Lanka before moving to Australia in 2016, is one of three ophthalmologists at Southwest Eye Surgeons. Each year, the high-volume clinic can see up to 3,000 cataract patients across its two practices in Bunbury and Busselton, serving a vast community across Western Australia’s southwest.
Like other parts of Australia, the state boasts a high rate of toric IOL implantations – available to patients in the public system through Medicare, even those with very low astigmatism. It is a stark contrast to what Jayasinghe had experienced in other health systems where torics were only accessible to a select few.
Considering 95-97% of his cataract cases today receive a toric IOL – requiring a more involved work-up phase – traditionally Jayasinghe was one of three people who would manually review results provided by online toric calculators. A key part of this was ensuring each patient’s biometry data was entered correctly in the first place, often by an ophthalmic nurse.
One of those nurses was Ms Gabrielle Holt. With more than a decade of nursing experience, she was well-versed in this cumbersome aspect of cataract surgery work.
Thinking there must be a better way, she enlisted her partner Mr Ryan Schulte – a software engineer – and with their combined expertise they set out to develop a system that would create greater efficiencies and confidence in the final toric calculation.
They established Schulte Holt Technology and in February 2022 launched the Schulte Holt Toric IOL Calculator Processor. The system automatically runs the surgeon’s calculations with the Barrett, Kane and EVO toric calculators, providing a full PDF printout instantly. Soon, it will also incorporate the Holliday and Haigis formulas.
The key to the technology is the use of automation to pre-populate biometry data into the calculator – straight from the measurement device. Each surgeon within the clinic can then have the processor customised for their preferences, including surgically induced astigmatism, incision location and preferred IOLs.
Before bringing the concept to life, Schulte, with a non-ophthalmic background in robotics and software development, was surprised to learn many practices in 2023 were performing this task manually.
“I showed him how extremely tedious and time consuming toric IOL calculations are, and the potential for it to be riddled with errors,” Holt says. “He was also surprised at the volume of calculations that we do at any given time.
“In many practices, toric calculations aren’t usually done during patient time, it’ll be at the end of the day when you’re fatigued after seeing patients all day. We’ve developed a system that’s machine agnostic, meaning any machine that can abstract biometric measurements can be incorporated into the program. It was also designed with the purpose of completing high numbers of IOL toric calculations to keep up with increasing demand for cataract surgery, and to reduce errors during calculations and therefore increase patient safety.”
Creating more mental bandwidth
As an ophthalmologist with a high volume of toric IOL patients, every minute is valuable to Jayasinghe, but what’s also important is a clear mind and ability to focus.
Knowing that the pre-populated data is accurate, when he receives the results from the Schulte Holt processor, his priority becomes IOL selection, and understanding what will be required on the operating table.
“Since implementing the Schulte Holt processor, it has freed up a few hours per month, but it has afforded me more mental capacity and less mental strain when planning for my surgeries,” he says.
“There’s also a financial benefit for our clinics too. It means our staff are spending a lot less time on manual data entry. When you extrapolate that across 3,000 cases a year, that is a significant time saving that frees them up for other tasks.”
To demonstrate the effectiveness and accuracy of the Schulte Holt IOL processor in comparison to manually input data, a study was performed at Southwest Eye Surgeons.
This involved 352 manual IOL calculations versus 696 calculations with Schulte Holt’s software. The Barrett Toric IOL Calculator was the formula of choice.
The manually-calculated torics took 371 minutes, or 1.05 minutes per calculation. Of these, 40 mistakes were identified and needed to be redone.
During the manual data input, 25 distractions occurred for the user inputting data, such as patients requiring assistance (7), phone calls (3), other staff members requiring assistance (15). Importantly, distraction tracking is not relevant for the Schulte Holt processor as it runs in the background constantly.
By comparison, the automated process involving the Schulte Holt took much less time.
After biometric measurements were captured on a ZEISS IOL Master 700, the system was automatically set up to upload a PDF into the Schulte Holt processor, without adding extra steps or time to the procedure. The user then needs to open the program on the desktop computer and hit ‘run’.
The Schulte Holt processor took 138 minutes for 696 toric IOL calculations, or 0.19 minutes per calculation (the most current version has recorded speeds of 0.05 minutes per calculation).
The Schulte Holt processor recorded seven errors during this study: six were due to only the left eye being uploaded which caused an error in the code, while another was because no white-to-white value had been recorded. In all cases, mistakes were easy to identify because there was no toric IOL calculation completed. The errors have now been rectified within the program coding.
Since implementing the technology, Jayasinghe has been impressed by many other features, including the way in which the information is presented.
“The way it is formatted gives a very clear picture for me to refer to during surgery. Between cases you may only have a few minutes, so it helps me to quickly understand important information, such as the axis of the lens,” he says.
“There’s also a huge advantage for surgeons who use an optimised A Constant. Traditionally, you have to enter this manually into a toric calculator each time, but if you use the Schulte Holt processor you can key it in once and that’s it.
“Every surgeon has their preferences, so being able to create a profile for each surgeon and incorporate an optimised A Constant is a major advance. There aren’t many, if any, other programs that can do this with one click. It’s useful for us as surgeons in WA who often need to work with multiple types of IOLs depending on what is available locally at any given time. We don’t always have the same access to all IOL types like in metro areas when last-minute scheduling is needed due to logistic reasons.”
Responsive to an evolving market
It’s been a labour of love for Holt and Schulte to develop the software, but they are excited to see it working in real world clinics. The development phase involved robust feedback from four ophthalmologists affiliated with Southwest Eye Surgeons.
“Ryan is extremely efficient at learning new information. When working with the surgeons he was picking their brains non-stop,” Holt says.
“Considering how differently each surgeon works, it’s been quite an accomplishment to customise it to a level that suited every single one of those involved in the test phase.”
Now the program is fully operational, it’s all about optimisation with plans to continuously add and update calculators on the platform. As new IOLs come to market, the company can enter these into the software’s backend and make them immediately available to ophthalmologists using the processor.
Holt says this is a distinct advantage, especially for practices who might be relying on calculators built into their biometer.
“While these use great calculators, they have significant limitations. They work well in isolated environments, but the way that clinics have changed and the volume they’re dealing with, it’s not suitable anymore. Often, to add new IOLs someone has to visit the practice and enter this manually – which then leaves them vulnerable to more errors.”
For practices considering bringing the Schulte Holt processor into their workflow, Holt says they can trial the technology before committing to it. If they decide to become a customer, it involves an upfront payment, and then a smaller, ongoing subscription fee which covers all updates and maintenance costs.
“When installing the system, we can either do it remotely or visit the practice – we personally integrate it into the clinic. We watch how they normally run their practice and give advice on how they can do so more efficiently with customisations to our processor,” Holt says.
“We include training for staff to perform customisations. This includes setting it up so that immediately after biometry, the system immediately runs the toric calculations. Or if a clinic prefers to run them all at once, we can cater for this as well. For certain doctors, they receive a print out PDF straightaway, which means we can pair it with the measurement data, while others doctors prefer theirs to be online.
“The second the measurements are captured, the toric calculations are completed, it’s such a significant time-saver for practices, and eliminates worries about human error.”
More reading
Co-management of cataract patients in a real-world Australian setting
Cataract surgery: Why patient reported outcome measures matter
Performing cataract surgery … sustainably
