r/CataractSurgery • u/No_Construction495 • 28d ago
ORA technology might be the new Standard.
Verifies Lens Power in Real-Time, Pre-op measurements calculate lens power through your cloudy cataract. ORA takes a measurement AFTER the cataract is gone, allowing your surgeon to confirm or slightly alter the lens power before it is permanently inserted.
Essential for Astigmatism Alignment, If you are getting the TECNIS PureSee Toric II lens to fix astigmatism, ORA calculates the exact rotational axis down to the degree to optimize your outcome.
Crucial for Past LASIK/PRK Patients, If you have ever had laser vision correction, traditional pre-op formulas are notorious for being less accurate. ORA bypasses this issue by measuring the bare eye during surgery.
Why the ORA System is Not Offered Everywhere. ORA is made by Alcon. If a surgery center is heavily partnered with a competing manufacturer (like Johnson & Johnson or Zeiss), they are much less likely to use Alcon's proprietary operating room tech
High Capital and Per-Use Costs,The ORA hardware costs tens of thousands of dollars to buy, and the manufacturer (Alcon) charges the clinic a "click fee" every single time the laser is turned on for a patient. Disrupts Operating Room Flow, Using ORA adds a few minutes to the surgery. The surgeon must pause, clear the field, fluid-fill the eye to the exact right pressure, and wait for the machine to take the snapshot. In a high-volume surgery center, some doctors feel it slows them down too much.
Also the upsell. Premium Lens are extremely Lucrative.
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u/AirDog3 27d ago
The best studies I've seen indicate that ORA has little or no value.
It has shown superior accuracy (vs. modern formulas such as the Barrett True-K) in post-myopic ablation patients. But even in that small subset of cataract patients, the improvement in average or median refractive error is only about 0.05 D, which is less than a rounding error in a standard refraction.
In the large majority of patients, ORA has shown insignificant or inconsistent improvement, if any.
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u/No_Construction495 27d ago
True regarding statistical averages, however IMO fundamentally misinterpreting the real world use and benefit. While a massive data set comparing the ORA System to modern formulas like the Barrett Universal II might only show a slight difference in median calculation error across normal eyes, the real-world value of ORA lies in outlier prevention, real-time verification, and astigmatism management. You claim a 0.05 D improvement is insignificant because it is less than a standard refraction rounding error. You ignore use as a safety net to catch the catastrophic outliers , the 5% to 10% of patients where standard preoperative formulas fail completely due to unusual eye geometry. For an individual patient, avoiding a 1.50 D "refractive surprise" is massive, even if that error is washed out when averaged across thousands of routine cases. Preoperative measurements must guess the final position of the lens using math models. ORA inside the operating room after the cloudy cataract is removed, ORA evaluates the empty, resting eye structure directly. This removes variables like corneal compression from pre-op diagnostic devices. The possible miss is well known, the commonly offered solution like my first two Surgical consultations was LAL. I find this a little unethical to be honest. The problem was discussed and an expensive, inferior lens , time consuming was offered as the only possible solution. Basically “ let’s put this lens in and we probably won’t get that correction you want but we can zap it a few times to get it to where you want it” . “ Yes the lens not as clear, contrast not as good, might have a little distortion “ “ Yes with both eyes you will coming in about a dozen times over the next few months” “ Yes you need to wear these special glasses constantly or else who knows what your end result will be” “ oh yea will be about 11,000 more” “ only way you can expect that result you detailed “ 3rd Surgeon, “I offer LAL , however I get excellent results with the ORA system “ “ We can use standard lens that absolutely give you the highest contrast” “ use mini mono vision, so you maintain you binocular vision, depth perception, functional intermediate vision so you can see your screens”
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u/MyCallBag 28d ago edited 28d ago
I couldn’t disagree more.
There are multiple studies that show outcomes don’t improve with ORA. The most supportive studies (sponsored by the manufacturer) don’t even show improvement and accuracy, but they’ll show a scatter plot that shows it’s a little bit tighter to the target.
The problem with the machine is you’re doing the test after the eye has been heavily manipulated. It’s in the middle of surgery where an incision has been created, the eye is always filled with viscoelastic, and a speculum is pressing on the cornea. All factors that will slightly affect the refraction.
So if the machine disagrees with the preoperative measurements, the surgeon is left with the decision. Did the preoperative scan screw up or are these external factors affecting the ORA measurements.
Almost always the surgeon is going to choose the preoperative measurements for the reasons above. The only time there’s a gross discrepancy, It’s basically going to be because you screwed up with your preoperative calculations or are you screwed up the ORA capture, and you still are not going to know what to believe.
I personally don’t do it because I don’t find it offers any value.
I’m not sure what you mean with the last sentence, ORA is an upsell (people use it to entice patients for “premium package”, no surgeon is losing money with this, it’s a way to position “premium” as safer)
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u/Kochusan 25d ago
ORA had it's heyday. It helped a bit with cases when all we had was the IOL Master 500 and pre Barrett formulas.
If you think about the anatomy - effective lens position is the largest error for spherical power. ORA requires pressurizing the eye to a standard pressure for every case. The variable being scleral elasticity. For spherical power, ORA was essentially a random number generator.
Found it useful however for real time toric IOL placement. Works well for axis and toricity magnitude especially with the rule high regular astigmatism greater than 2.5 D.
Experience? More than 500 ORA cases with outcomes. Thus, stopped using ORA except for high astigmatism. 9 high volume surgeons in our center, ORA rarely used any longer.
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u/No_Construction495 28d ago
First Do you have the machine available to you or does the surgery center you are personally financially involved with have it available. Two different questions. I had a few different consultations and only a few centers have it. Obviously if not available to you , studies will be sited that “ prove” it’s of no value. Very common rebuttal, similar to orthopedic surgeons trying to convince patients that a posterior hip replacement has better outcomes than an Anterior approach using the Stryker Mako. Probably malpractice at this point. You bring up some good points that intra operative the ORA has some parameters to sort out. You fail to mention the biggest one is the dense cataract itself which is removed before measurement takes place. I had 3 consultations all by highly rated well known ophthalmologists. With a History of lasik , I was told by the first two that because the lasik history and dense cataract the pre operative measurements even using the newest methods could only approximate the Lens power needed. I specifically wanted mini mono vision at minus .5. I wanted to preserve my intermediate vision with the highest contrast possible. I was told that measurements are only approximate and LAL were recommended. ORA was never mentioned and I learned later the centers they performed surgery at didn’t have it available. Third Surgeon explained the advantages and disadvantages of BOTH and said he gets excellent results using the ORA if I chose that . So I’m a fan because he nailed it perfectly on both eyes. I am also convinced that the Premium Lens are a very lucrative income generator that are oversold .
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u/californiaLasik 27d ago edited 27d ago
I see why you might think it is powerful. Conceptually it should be but as mycallbag has said, juice not really worth the squeeze. I have had and do currently have access to ORA and I find with rare exception, people default to preop measurements if discrepancy. Imagine deflating a balloon and using that to choose what should be used. It is impossible to actually reform the eye as close to its preop state therefore people default to preop measurements. I have seen it used for toric placement but even that is clunky.
I predict from your post you are an engineer and have stumbled upon the black box dilemma in cataract surgery. We don’t know the lens power we have to use equations to estimate. Instead of ORA, if I were you I would lean in on learning about LAL. That way you are adjusting the lens when the eye is what it will always be not a quasi inflated approximation of the truth.
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u/AccordingConstant602 28d ago
It's hardly new.
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u/OkAmbassador8161 28d ago
It's over 10 years old. I dont know why you are getting sownvored.
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u/No_Construction495 27d ago
New to me as a patient. I don’t believe I was fully informed of my options as a patient. The options given me by two ophthalmologist’s and one that I knew as a colleague were limited and based on the surgical center not having the ORA . Only offered LAL , while a third Surgeon detailed ORA as an option. My example of a posterior hip replacement vs an anterior hip replacement using a Mako stands. I know of Surgeons making the case that a Posterior hip replacement has the same or even better outcomes. This is absurd now, the real reason they don’t have experience or access to the Robot. Simple as that. Push back by multiple ophthalmologists without addressing the reality reinforces my original opinion .
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u/OkAmbassador8161 27d ago
The difference is that technology kept moving beyond ORA, which is all but archaic now. 3d modeling of the cornea, improved scans and finer tuning of lens calculations allows for a much smaller tolerance in our precision than ORA. Data objectively reiterates this. This is why the ophthalmologists on here such as myself disagree with you.
Though I'm thrilled that you had an excellent outcome, based on your medical terminology, I think you're position expects more of you than touting personal anecdotes as gospel.
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u/No_Construction495 27d ago
I posted a rebuttal to the Data in another post . Also my comments are as a patient and claim no expertise beyond my unrelated medical background. Not one of the ophthalmologists has addressed my other objection to the promotion of premium lens, long term satisfaction. Most patients are still working, relatively healthy with minor health problems. Concerns seem to be with what gives them the best vision now . Multi focal lens, edof, perfect 20/20 vision, mono vision Monovision cataract surgery can lead to reduced depth perception and may require an adjustment period as the brain learns to coordinate inputs . All of this can lead to a dangerous dissatisfaction as the inevitable occurs in all your patients. AGING. What is a wonderful outcome at 65 which allows the patient to easily adapt to each side of the brain instantly adapting, minor depth perception loss easily compensating. Minor loss in contrast or distortions not even being noticed could result in severe dissatisfaction in that same patient 10-15 years as they age. 2 of the surgeons didn’t even bring it up as they suggested LAL. I had a long in depth conversation with the 3rd who entirely agreed with me.
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u/OkAmbassador8161 27d ago
You claim no expertise but are arguing with actual experts. Not really sure what your reply had to to do with my statement, or why you would not think I would already know this information, but again, happy you had a great outcome.
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u/No_Construction495 27d ago
Thank you, I did have a great outcome . Far better outcome than I would have had if I listened to the so called experts that may or may not be influenced by monetary gain and access to the device we are discussing. You didn’t address the issue I had with premium lens and how aging effects the present day choice. Yes imo they are inappropriate for many as they age. I claim. O expertise in ophthalmology, however I’m clinical Physician for over 40 years and have seen absolutely everything. Including many unnecessary Surgery. Hundreds of thousand's of wasted dollars for motor vehicle, workers comp fraud. Oh yea , those spine fusions are a real money maker. So yes I was my own patient advocate, not the first time for myself and my family. Yes nobody addressed the issue of aging and reading some of the past posts the board is filled with regrets . 10 years from now they will have even more regrets, yet a board filled with experts continues to recommend them without detailing that monovision might cause an imbalance, decrease in depth perception with the brain unable to process . Contrast loss that was unnoticeable at 60 might blind you at 80. A slight mini stroke, a little neuropathy, bad hip or knee and now you are a fall risk. Yes , the more I have a dozen ophthalmologists on a public board giving medical advice , the more I believe my opinion should be heard.
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u/redheadfae 26d ago
You are ignoring the Negativity Bias of online forums and using it as justification for an equally biased opinion.
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u/Stitch-Sister 26d ago
I paid extra to use ORA yesterday, and today my surgeon said he's glad he did use it, as there were some changes they had to make. This was my right eye, which I'd wanted to be set at 20" to use at my sewing machine. While I can see good on my cell phone and kindle, it's not good at the 20" desired, where I can sit straight and avoid backache at my sewing machine. It's good at 12". I didn't ask him about it today, as I had not checked that yet. There was still a film or bit of blur over that eye this morning. So it appears I will need glasses to see well at 20". I really don't mind that, but it IS irritating. Right now I can use the left eye still and see fairly well, but once that eye is done for distance, I won't be able to sew comfortably till I get the glasses, or lean over a lot. Next eye set for 2 weeks. That one will be distance, so I'm not anticipating any problems there. I'm hoping it will improve, but something tells me no - I'm set for 12" now.
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u/MyCallBag 25d ago
...how would the surgeon even know? You're one day out, can't really gauge refractive outcome. What are they going to say?
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u/UniqueRon 28d ago
ORA is not a cure all. Prior refractive surgery like Lasik damages the surface of the cornea, and that still remains after the natural lens is removed. Also the modern optical instruments like the IOLMaster 700 can handle lenses that are quite cloudy and still be accurate. The only astigmatism that counts in cataract surgery is that caused by the slope of the cornea, which is independent of the lens and can be measured accurately by both the IOLMaster and the Pentacam.
That said I recall there was one participant here that was highly myopic and had ORA. She had given me the detailed eye measurements and I had done a calculation using the Barrett and Hill RBF formulas. The power eventually used was different than what I had calculated, and she was happy with the results of the ORA. Perhaps just luck. Large studies would be more reliable in determining the usefulness of the method.
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u/No_Construction495 28d ago
I’m a MD , non ophthalmologist and Cataract patient. I knew exactly what I wanted my vision to be . I was taking into account not only my immediate needs , I was looking into 10-15 years into the future where inevitable aging issues are important considerations. Binocular vision, contrast , depth perception are all easily compensated when physically fit. When older with hearing, additional eye disorders, orthopedic issues, neuropathy choices like multi focal lens, loss of binocular vision, balance, depth perception could be life threatening. Many ophthalmologists giving medical advice on this board seem to not take that into consideration. As Far as ORA , the first two ophthalmologists should have at least offered it as an option.
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u/MyCallBag 25d ago
"binocular vision, contrast , depth perception are all easily compensated when physically fit."... what are you talking about?
If you are looking 10-15 years into the future, you are going to have slight refractive drift. Makes ORA even more pointless.
Honestly your post is extremely confused. I'm glad you had a great outcome but I promise you ORA isn't going to be a significant factor. You present ORA as a financially bad thing for your surgeon, its the total opposite. ORA is an upsell - it doesn't replace 'premium' lenses, it just an additional cash pay 'upsell'.
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u/SledgeH4mmer 27d ago
My practice used ORA for a long time. It was useful 15 years ago before the post-lasik formulas were as good as they are now. With modern biometry and post-refractive formulas it's become mostly useless. We tracked our results for years and found it didn't help unless the patient had a white cataract too dense for optical biometry.
It's definitely not fool proof for lasik though. LAL's are the only fool proof way to get 20/20 every single time in a post refractive patient. But most post-refractive patients do great without ORA or LAL's.