Dr Aanchal Gupta at Alcon Focus 2025.
Alcon is renowned for hosting lively, entertaining, and interactive educational events and this year’s Focus symposium for cataract and refractive surgeons lived up to this reputation.
Held in Sydney over two days and curated by a steering committee comprising Associate Professor Chandra Bala, Dr Tess Huynh, and Dr Lewis Levitz, this year’s event attracted around 180 delegates, eager to share their experiences and to trial Alcon’s new Unity Vitreoretinal Cataract System and Unity Cataract System, which were on display for the first time in Australia.
Alcon’s Focus symposium, held in March, commenced with a session on managing patient expectations and concluded with one on ergonomics. In between, surgeons, one after another, delved into a broad range of topics ranging from managing patients with co-morbidities through to making technology work for you and, of course, improving patient outcomes.
Dr Huynh (NSW) had the momentous task of kicking things off with her panel comprising Dr Armand Borovik (NSW) who spoke on ‘choosing the lens box’ to meet the individual patient, and Dr Ben Connell (VIC) who spoke about the importance of managing the expectations of patients undergoing cataract surgery.
“If you say to a patient five times ‘this is your expectation’, and the sixth time you give them a different response, they may recall that sixth response…”
Dr Connell highlighted three key pieces of evidence: the limitations of refractive prediction accuracy, with studies showing 3–4% of patients experiencing refractive surprises of one or more dioptre;1 research demonstrating significant gaps in patient recall of pre-surgical information; and the challenge of reconciling patient expectations with clinical outcomes.
“We need to control the narrative,” Dr Connell emphasised. “The message has to be clear, the outcome is achievable, and it has to be reinforced.”
Dr Connell advocated providing written information to patients and maintaining consistency in messaging in every consultation. “If you say to a patient five times ‘this is your expectation’, and the sixth time you give them a different response, they may recall that sixth response,” he cautioned.
Concluding the first session of the day, Kate Evans from the Australian Health Practitioner Regulation Agency (Ahpra) delivered an overview of advertising regulations that held the attention of all delegates in the room. She explained that advertising includes “all forms of communication that promotes and seeks to attract a person to a regulated health service provider”.
Ms Evans stressed that testimonials about clinical aspects of care are prohibited, unlike comments about facilities or staff. She outlined a risk-based approach to enforcement, noting that practitioners who breach Ahpra’s advertising code typically receive a warning letter first, with most voluntarily correcting non-compliant advertising.
The regulatory framework requires that advertising provides “balanced and accurate information” and “describes or shows realistic results, supported by acceptable evidence”.
Ms Evans cautioned practitioners to be extremely careful with comparisons and claims of being “the best”. More information can be found at: ahpra.gov.au/Resources/Advertising-hub.
“Glaucoma patients, just like normal cataract patients, have hobbies they would like to continue. Why should we not offer them the best choice?” Dr Raniga questioned.
The Clinical Frontier
In a session led by Dr Aanchal Gupta (SA), Dr Andrew McAllister (QLD) challenged the conventional view that patients with retinal conditions should avoid presbyopia correcting intraocular lenses (PCIOLs).
Dr McAllister presented several case studies of patients who had undergone retinal membrane surgery before or after PCIOL implantation with positive results. In one notable case, a patient with silicone oil and multiple retinal breaks achieved excellent visual outcomes with a PCIOL.
“Looking at our practice data, we’re getting very good visual acuity for patients with no retinal surgery, retinal surgery, or various conditions like macular degeneration and glaucoma,” he noted.
When asked about how he decides which patients should be implanted with PCIOLs, Dr McAllister said patient-centred decision making is essential: “This is a discussion you have to have with the patient every time. There’s no right or wrong answer.”
Dr Aparna Raniga (NSW) followed, presenting her pragmatic approach to PCIOLs in glaucoma patients, and recommending a shift “from being reactive to more proactive”.
“Glaucoma patients, just like normal cataract patients, have hobbies they would like to continue. Why should we not offer them the best choice?” Dr Raniga questioned.
She shared data showing good outcomes with enhanced depth of focus lenses in well-controlled ocular hypertension and mild glaucoma, citing a case of an 83-year-old woman caring for her husband with dementia who achieved spectacle independence.
Dr Raniga advised caution with certain glaucoma subtypes. “I do not implant in cases of exfoliation syndrome because of increased risk of zonular dehiscence, nor with normal tension glaucoma due to higher risk of paracentral visual field loss,” she said.
The session continued with Dr Vivek Pandya (NSW) challenging traditional thinking about PCIOLs in patients with age-related macular disease (AMD), including those with neovascular AMD.
Presenting several illustrative cases, he said “I want to challenge the concept that a monofocal lens is the only appropriate lens for patients with macular disease”.
He spoke about the remarkable restoration of macular anatomy possible with modern surgical techniques, particularly in epiretinal membrane and macular hole cases, showing optical coherence tomography (OCT) images demonstrating near-normal foveal contours post-treatment.
Dr Huynh concluded the session by providing a practical framework for cataract surgical decision making in patients with corneal abnormalities.
“The first thing to do is confirm where the abnormality is, whether it affects the central visual axis or not,” Dr Huynh explained. “If there’s a chance that we need to replace the cornea, then I’ll go ahead and do the cataract surgery first.”
When discussing surgical timing of cataract surgery with corneal procedures such as pterygium surgery, Dr Huynh was definitive: “I never do it combined. I usually wait two to four weeks after the pterygium removal, though some studies suggest waiting one week is adequate.”
Throughout her presentation, Dr Huynh returned to the importance of consistent patient education to set realistic expectations. “Having a team on your side is quite advantageous. It means the message is repeated at least three times before patients get to you.”
The Preoperative Optimisation Frontier
The third session of Alcon’s Focus Symposium built on the second, exploring strategies for optimising preoperative assessments to enhance cataract surgery outcomes, particularly in challenging cases.
Moderated by Dr David Lubeck (SA); Dr Sheng Hong (NZ), Assoc Prof Chandra Bala (NSW), and Dr Andrea Ang (WA) discussed approaches to biometry and IOL calculations for patients with abnormal corneas, stressing the importance of finding one reliable formula and using it consistently, but also using other IOL formulae to cross-check for eyes with more extreme ammetropia.
The speakers addressed keratoconus management, suggesting that mild to moderate cases could benefit from toric IOLs, while more advanced cases might require corneal procedures before, or piggyback IOLs after, cataract surgery.
The importance of dry eye assessment and treatment before final measurements was highlighted, with speakers recommending pretreatment for moderate to severe cases using topical steroids, omega 3 supplements, and doxycycline when necessary.
Regarding astigmatism measurements, the panel recommended the use and comparison of multiple devices to confirm consistency in magnitude and axis, noting that discrepancies between devices could lead to suboptimal outcomes with toric IOLs.
The session concluded with a discussion on effective lens position as a significant source of refractive surprise, with hopes that future technologies might better predict this variable.
Technology never stands still, as Dr Joe Reich (VIC) highlighted in a presentation that reflected on his remarkable 50-year ophthalmology career and extensive experience with PCIOLs.
The Technology Frontier
Technology never stands still, as Dr Joe Reich (VIC) highlighted in a presentation that reflected on his remarkable 50-year ophthalmology career and extensive experience with PCIOLs.
Drawing on his own data from nearly 1,200 PanOptix implants, he noted that “about 50% of my lenses over these years have been PanOptix”.
Dr Reich addressed visual disturbances, acknowledging that haloes occur but typically resolve. “By 12 months, very few patients are complaining of them. The commonest response I get is ‘I forgot to look’,” he said.
Discussing the newer Clareon material, Dr Reich referenced research showing “a significant difference” with “less glare and haloes” compared to the earlier AcrySoft material.2
His patient selection favours hyperopes with cataracts, though he avoids high cylinders and certain macular conditions.
“Good distance, good reading, life changing is what the patients often say,” Dr Reich concluded, emphasising the transformative impact of trifocal technology.
Dr Lewis Levitz (VIC) expanded on the field of technology by discussing his experience implanting over 1,100 Vivity extended depth of focus (EDOF) lenses.
He showed that the post-operative refractive results of his first 160 patients were disappointing as many had a myopic result, although this may have been due to the absence of a low toric lens. He sent his results for statistical analysis to Dr Chris Hodge (Clinical Research Coordinator, Vision Eye Institute). The analysis showed that his chances of achieving 6/6 uncorrected vision were statistically better if he aimed for the first plus or plano. This change was applied to his next 585 patients and his results improved, so that 87% had 6/6 binocular uncorrected distance acuity.
Dr Michael Rossiter-Thornton (NSW) followed, presenting the evidence for integrating the Hydrus microstent into cataract and refractive practice for patients with glaucoma.
“There is an emerging paradigm in the treatment of glaucoma such that it should be proactive rather than reactive,” Dr Rossiter-Thornton explained. “We shouldn’t be waiting for our patients’ visual field [loss] to progress.”
Observing issues with the use of drops to control intraocular pressure (IOP), he said for every compliant patient, “there are many, many more who are noncompliant with their drops”.
Dr Rossiter-Thornton shared data from his personal audit of 101 patients implanted with the Hydrus microstent, showing a reduction in mean IOP from 17 to 12 mmHg and drop usage from 0.7 to 0.1 medications per patient.
“It’s incumbent upon us to offer our patients devices and treatments that can give them a drop-free lifestyle,” he said, observing that this is particularly the case for refractive cataract patients seeking PCIOLs.
Associate Professor Brent Skippen (NSW) shared his decade of experience implanting EDOF lenses in his regional practice in Wagga Wagga, NSW.
“In the first half of last year, 64% of the lenses I used were Vivity lenses,” Dr Skippen revealed, highlighting his evolution through various EDOF technologies.
Assoc Prof Skippen explained his shift away from earlier diffractive EDOF designs. “I was using these in about a third of patients, and then for a number of reasons, it tailed off.” He cited challenging cases, including a nurse who complained of disturbing haloes that prevented her from driving home at night after a shift.
The regional context shaped his approach. “In a rural setting, driving is critical. Driving at night, driving to the city, there are kangaroos everywhere… so I really don’t want the side effects.”
Reflecting on his current practice with Alcon’s Vivity and Johnson and Johnson’s PureSee lenses, Assoc Prof Skippen concluded, “These lenses really give great city outcomes without the hassle of going to the city.”
Dr David Gunn (QLD) presented a comprehensive overview of the evolution of laser refractive surgery, culminating with Alcon’s WaveLight Plus ray-tracing technology.
The Surgical Excellence Frontier
The last session of the day was hosted by Dr Levitz and titled ‘The surgical excellence frontier: Mastering techniques for enhanced cataract and refractive surgery’.
During this session, Dr David Gunn (QLD) presented a comprehensive overview of the evolution of laser refractive surgery, culminating with Alcon’s WaveLight Plus ray-tracing technology.
Describing ray tracing as “a generational shift in terms of customisation for ablations”, Dr Gunn explained that it uses an individualised eye model rather than the standard Gullstrand model and incorporates front-to-back ray tracing with AI-optimised tilt adjustment.3
His early results with 47 eyes found “98% six-six or better, 67% six-five or better… 17% of eyes gaining at least one line of corrected vision”.
“There is a huge amount of extra data being collected per eye,” he explained. “It’s like tailoring the jacket, fitting the dress.”
While acknowledging the technology’s benefits – better outcomes, staff engagement, and reputational advantages – he highlighted practical considerations including capital expenditure and learning curves.
Dr Rahul Chakrabarti (VIC) presented his clinic’s evidence for performing cataract surgery at lower infusion pressures, building on concepts introduced at Alcon’s 2024 symposium.
He shared results from his audit of 258 eyes comparing standard pressure (55 mmHg) with reduced pressure (26 mmHg) techniques. The lower-pressure cohort demonstrated “improved visual outcomes, reduced pain, reduced inflammation, and ultimately improved efficiency of surgery”.
Contrary to concerns about surgical stability, Dr Chakrabarti found lower pressures enhanced his technique. “I found removing the nuclear fragments at lower physiological pressure improved the flow of fluid from the eye… I want to liken it to fishing in a turbulent ocean versus in a pond.”
For surgeons interested in implementing this approach, Dr Chakrabarti stressed that it requires the Centurion with Active Sentry handpiece4,5 and advised starting with routine cases while progressively lowering settings.
Dr Joel Yap (NZ) presented practical strategies for managing severe cases of capsular support loss during cataract surgery, focussing on his preferred approach – the needle-guided intrascleral haptic fixation (Yamane) technique.
Dr Yap acknowledged the variety of techniques surgeons employ, noting that yearly American Society of Retinal Surgeons (ASRS) Preference and Trends (PAT) survey showed that the use of anterior chamber IOLs “is decreasing and a larger percentage of people… will refer this to another surgeon”.
For his preferred Yamane technique, Dr Yap stressed several critical points: “Marking is crucial. Take time to mark… because that will determine tilt, centration, everything, (and) do not force in anything that will not fit in.”
With any employed technique, he stressed that, “Simplicity is the ultimate form of sophistication. The simpler your procedure is, the more elegant it will be and the more teachable it is”.
Associate Professor Smita Agarwal (NSW) shared practical strategies for enhancing both efficiency and ergonomics in cataract surgery, emphasising their importance for surgical longevity.
“If we don’t look after our musculoskeletal health… one little slip can cause a posterior capsule tear or corneal endothelial trauma,” Assoc Prof Agarwal explained.
She detailed efficiency improvements in her practice, including customised packs that save “two minutes when you are averaging 6.5 to eight minutes per surgery”, online lens ordering to reduce transcription errors, and preloaded lenses to “avoid catches on lenses, save time, and avoid risk of infection”.
Assoc Prof Agarwal highlighted the Ngenuity 3D visualisation system as transformative for surgeon ergonomics.6 “It’s like operating through binoculars with a straight neck,” offering “good depth and resolution” while reducing light exposure for patients.
“3D heads-up surgery will be the future,” she concluded. “We need to adapt to the new technology earlier than later.”
She recommended a gradual approach to adopting 3D Visualisation, with simple cases first, to enable surgical teams to become confident.
References
- Seo S, Lee CE, Kim YK, Lee SY, Jeoung JW, Park KH. Factors affecting refractive outcome after cataract surgery in primary angle-closure glaucoma. Clin Exp Ophthalmol. 2016 Nov;44(8):693-700. doi: 10.1111/ceo.12762.
- Hovanesian JA, Jones M, Allen Q. The Clareon Vs AcrySof PanOptix Trifocal IOL: A Comparative Study of Patient Satisfaction and Visual Performance. Clin Ophthalmol. 2024 Oct 18;18:2977-2984. doi: 10.2147/OPTH.S476666.
- Kanellopoulos AJ. Initial outcomes with customized myopic LASIK, guided by automated ray tracing optimization: A novel technique. Clin Ophthalmol. 2020 Nov 17;14:3955-3963. doi: 10.2147/OPTH.S280560.
- Centurion Vision System user manual.
- Active Sentry directions for use.
- Cheng TC, Yahya MFN, Bastion MC, et al. Evaluation of three-dimensional heads up ophthalmic surgery demonstration from the perspective of surgeons and postgraduate trainees. J Craniofac Surg. 2021 Oct 1;32(7):2285-2291. doi: 10.1097/SCS.0000000000007645.
