Ophthalmic Medical Education Summit 2025: Optimizing Astigmatism Management With ZEISS VERACITY

VERACITY is a digital surgical planner that assists with Preoperative planning and works for any surgeon right out of the box. It is critical in all phases of patient evaluation, education, surgical planning, and performing the surgery.

VERACITY can be customized to include a digital questionnaire that helps the surgeon determine the patient's expectations, lifestyle preferences, and even personality traits before entering the exam room (Figure 1). “It's going to help us determine our patients' expectations, it's going to tell us a little bit about the lifestyle preferences of that patient, and even some personality traits. And this is really, really easy to do in the office. And it's all digital with no paper and captured inside VERACITY,” says Dr. Ayres.

The questionnaire is sent via a text message containing a link, or the patient can scan a QR code to access it. The patient fills out their date of birth and demographics to ensure they are taking the correct survey. This information helps Dr. Ayres with surgical planning, “And that already allows me to know how to steer the conversation as to what that patient's going to need and whether they'll need a premium lens or if they'll need a toric IOL, or if they're a monofocal, or maybe a monovision candidate.”

Patient education is crucial when deciding what IOL is best for the patient. VERACITY is portable and brings the data to the surgeon, allowing them to use a tablet to show the patient calculations, pre-operative scans and discuss the impact of a toric IOL on residual astigmatism. “I'll show them my tablet. And then we'll just simply go back, choose a toric IOL, and we'll see that that level of astigmatism drops. And patients understand that, look, your prescription is closer to zero. You're much less likely to need glasses. And then I can discuss that with the patient right there in the operating room. And before that exam is done, we've already made our selection for IOL for the day,” says Dr. Ayres.

The surgeon opens VERACITY first in the OR to see the patient list and any necessary notes. VERACITY serves as the data link from the office to the operating room, ensuring that what is done in the office directly translates to what is done in the operating room. It helps with patient safety, calculations, and visualization under the microscope.

If a patient changes their mind about the IOL (e.g., requesting a toric IOL) just before surgery, VERACITY allows the surgeon to quickly change or adapt a pre-surgical plan and approve the change on their tablet. “So a scenario like this used to be a disaster; I'd have to call the office, tell them to change the IOL, but now with VERACITY, I can just simply look up the patient's chart, unapprove the current plan, pick my new toric IOL, click approve, and by the time I get back to the operating room, that new plans are going to be ready to go, and I can get the lens and get the surgery done,” says Dr. Ayres.

By deleting and re-importing the patient's chart in CALLISTO, the new plan is quickly transferred to the microscope. “So now with VERACITY, it's relatively easy for us to get this problem solved. It really shows the synergy and the integration between the office and the operating room. And how simple that data flow is, says Dr. Ayres. This seamless data flow eliminates the need for USB sticks or manual reloading. The system is also used for surgical timeouts, displaying case information for the scrub nurse and tech to confirm the correct patient and lens.

For toric IOLs, VERACITY is the link between the office and the microscope to help ensure proper toric alignment. “Now, proper toric alignment used to be done all manually using a series of, you know, fancy markers. But it was basically a manual thing, and you can be off, and every degree of rotation decreases the power of the toric by 3.3%. So 20 degrees off and you've lost almost two-thirds of your torque power. So accuracy really is important,” states Dr. Ayres.

Digital markers, in which imaging from the office is transferred directly to the operating room helps to decrease manual errors. “Now the IOLMaster does take a picture of the eye, and it registers that picture in VERACITY. And it registers the steep axis of, of the image. So now there is more than one way that that data can be used. Some of the new lasers will actually use IOLMaster data to register this deep axis, using image guidance to show the steep axis or make marks on the steep axis during femtosecond laser cataract surgery.”

VERACITY can be integrated into patient education to demonstrate that having a specific implant may lessen dependence on glasses. It is also used in the operating room, not only for relatively urgent adjustments to IOLs but also for real-time visualization during surgery. This helps ensure toric IOLs are correctly aligned on axis, maximizing patient outcomes.“So in summary, the VERACITY surgery planner is critical in all phases of patient evaluation, education, and even surgical planning and doing the surgery. We use it in the office to help evaluate patients' needs and wants, and that helps steer patients towards premium IOLs,” says Dr. Ayres.

The most important outcome in cataract surgery is the patient's perception, and the happiest patients tend to be emmetropic. “Why do we care about astigmatism?” asks Dr. Schallhorn. “Because in cataract surgery, I strongly believe the most important outcome is the patient's perception of the outcome.”

Even small amounts of residual cylinder can negatively affect a patient's perception of their outcome and their visual quality and acuity. “Now, astigmatism really matters in this because even if they have an emmetropic spherical equivalent, small amounts of residual cylinder can really adversely affect the patient's perception of their outcome and their visual quality and acuity. And this happens at a much lower amount of residual astigmatism than I think we realized.” says Dr.Schallhorn.

Small amounts of residual cylinder, even at a quarter diopter, can adversely affect a patient's perception of their outcome, visual quality, and acuity. A study showed that for every quarter-diopter increase in residual astigmatism, starting from zero, the percentage of patients achieving 20/20 or better acuity dropped by 6% to 10% in the multifocal group (Figure 2).1 “We looked at a logistic regression analysis controlling for many other factors, including patient age and gender. All the other factors that can potentially affect residual acuity. We saw this effect persist. So, post-operative cylinder going from zero to like even a quarter diopter to a half diopter residual cylinder, you were 1.7 times less likely to get to 20/20. And the magnitude of that increases exponentially with every increasing increment of cylinder,” says Dr. Schallhorn.

Similar results were observed with monofocal IOLs.1 “I think we have a narrative in our heads that monofocal IOLs are more tolerant to residual refractive error. Or maybe the patients that are electing those are more tolerant of residual refractive error in terms of acuity. I think that narrative is probably false. So I think we need to be looking really hard at astigmatism,” states Dr. Schallhorn.l

Patient satisfaction decreased significantly with increasing residual cylinder, notably starting at the 0.75 - 1.00 D range for monofocal lenses and at the 0.50-0.75 D range for multifocal lenses.1 Dr. Schallhorn comments, “This is maybe why we think multifocal are more sensitive to residual cylinder, because the effect is pronounced in the multifocal.” Regardless, this study shows us that low levels of astigmatism significantly affect visual acuity and patient-reported satisfaction with their vision.

VERACITY is a web-based platform for surgical planning. It interfaces with biometers, topographers, and electronic medical records to automatically pull data. “The single most common reason for lawsuits in cataract surgery really is wrong IOL errors. And then the biggest reason for that is transcription errors, really. VERACITY absolutely eliminates the need for transcription at all, which I personally love as somebody who is dedicated to cataract surgical outcomes,” says Dr. Schallhorn.

It allows the surgeon to easily select lenses, change targets, and use the appropriate calculators for complex cases such as prior refractive surgery or keratoconus. OR nurses use VERACITY to easily verify that the correct implant is in the room without shuffling through paper.

As a web-based platform, VERACITY collects a massive amount of de-identified data. This data gives insight into the state of cataract surgery in the United States, including IOL formulas and types used. The data also enables continuous optimization of A-constants, reducing the mean predictive error and improving future outcomes for all users.

Accessing this de-identified data led to some interesting revelations. For one, toric IOLs generally outperformed Limbal Relaxing Incisions (LRI) or Astigmatic Keratotomies (AK) in correcting astigmatism, with a particularly substantial impact on against-the-rule and oblique astigmatism.

VERACITY enables continuous optimization because data and outcomes are continually coming in, allowing the constants used in calculations to be optimized. “So the more data that comes into VERACITY, the better your outcomes become because of the constant optimization and the better everybody else's outcomes become too, which is great for patients in general,” says Dr. Schallhorn.