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Lens-based refractive procedures offer advantages over LASIK
New column by William F. Maloney, MD, will address the versatility of the IOL.
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With this issue we begin a regular monthly column that will present the latest information on the techniques and technology used in the fastest growing segment of ophthalmic surgery: lens-based refractive surgery.
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The limitations of LASIK and other keratorefractive procedures are increasingly difficult to ignore. The aberrations inherent in corneal reshaping methods simply do not always allow the accuracy and predictability most refractive surgery patients have come to expect.
Anatomical limitations (there is only so much cornea that can be ablated) combined with functional limitations (treatment zone vs. pupil size, etc.) have resulted in the realization that LASIK just cannot do it all, as many had hoped it would 5 years ago.
The steady reduction in the amount of ametropia that can be reliably corrected with corneal refractive techniques has left surgeons looking elsewhere. Anyone present at the 2002 American Academy of Ophthalmology meeting saw that the IOL has clearly emerged to fill this void, especially at the extremes of the refractive spectrum.
New IOL technologies are rapidly emerging in the refractive arena. The Light Adjustable Lens, several accommodative lenses and a prolate aspheric IOL designed to reduce or eliminate spherical aberrations (and thus enhance contrast sensitivity and functional vision) are just a few of the upcoming innovations targeting this move to lens-based refractive surgery.
We plan to treat each of these new technologies in sufficient detail to separate the science from the salesmanship in future columns.
The big picture
But before we delve into the details of specific new techniques and technologies I would like to step back for a moment and glance at the “big picture” of refractive surgery, which may now be at a watershed moment in its evolution.
This broad-brush perspective reminds us that lens-based refractive surgery does not depend upon any new technology that may or may not materialize in the near future. Lens-based refractive surgery has been evolving for 20 years in the form of “refractive cataract surgery,” the most frequent refractive procedure performed today.
This lens-based surgery has already proven itself capable of correcting large refractive errors with remarkable accuracy, without surgically induced aberration or other degradation of visual quality. The emerging IOL technologies seek to enhance an already impressive record for lens-based refractive surgery.
Therefore it seems clear that prospective lens-based refractive surgeons need to begin with what they are already doing — cataract surgery. During the past 2 decades, cataract surgery has become an amalgamation of two distinct procedures. Continuing with our parlance, it was initially a lens-based extractive procedure, designed solely to remove the obstructive visual impairment of lens opacity. With the advent of phaco, small incisions and foldable IOLs, cataract surgery was increasingly able to address the issue of vision correction. In so doing it had become the first lens-based refractive procedure.
The first step in lens-based refractive surgery for many surgeons has been to separate the refractive and the extractive components of their cataract surgery for patients who seek uncorrected postop vision. We shall discuss the rationale for this in our next column, together with the practical how-to details of informed consent, billing, etc.
Back to basics
Lens-based refractive surgery also brings us back to basics, in the sense that surgical skill is a prerequisite to successful outcomes and satisfied patients. It seems to me that at least part of the appeal of LASIK and other corneal procedures was perhaps that they presented an opportunity to circumvent this basic issue, but this did not happen.
There is no emerging IOL technology that will allow us to slip by on our skills either. This is important to understand and accept. It is also important for the ophthalmic community in the immediate future. Skill cannot be commodified. In the world of lens-based refractive surgery the surgeon matters again, and the dictum that “you can never separate the surgery from the surgeon” is truer than ever. My colleague authors and I hope to address all of these issues here in the coming months.