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Cataract surgeons need to embrace refractive strategies
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CHICAGO — Rising patient expectations and burgeoning IOL technology require cataract surgeons to assume the role of cataract-refractive surgeons, a clinician said here.
 David R. Hardten |
David R. Hardten, MD, presented pearls on optimizing refractive outcomes and patient satisfaction during Refractive Subspecialty Day preceding the joint meeting of the American Academy of Ophthalmology and Middle East Africa Council of Ophthalmology.
"Cataract surgery is not a one-time job," Dr. Hardten said. "It's essentially a chess game where we're trying to anticipate the next move or the next thought process of our patients. So, we have to have a plan if the patient does something that we don't expect. If they're unhappy, we need to be able to fix them."
Results of a recent poll showed that 30% of cataract surgeons also perform corneal refractive surgery.
The increasing need to perform refractive surgery is attributable to the availability of presbyopic IOLs and patients' high expectations. In addition, patients are increasingly willing to pay for presbyopic IOLs, Dr. Harten said.
In addition, managing astigmatism is increasingly critical; 87% of patients have 0.25 D or higher astigmatism before surgery. More than 30% of patients have 0.75 D or more astigmatism.
Limbal relaxing incisions may be combined with presbyopic IOLs and laser vision enhancement may be performed postoperatively. However, previous relaxing incisions may be problematic for LASIK, Dr. Hardten said.
"We all need to be able to provide both cataract surgery and refractive surgery to really succeed in the modern era of cataract surgery in 2010 and beyond," Dr. Harden said.
Dave Hardten’s presentation emphasized that the most common complication of refractive surgery is a patient not getting what he or she expects. While we surgeons focus on precisely performing an LRI or choosing the right power implant, our patient is only interested in the final result—did he or she get what was expected? Our job as surgeons, then, is to first find out what our patients want and then use whatever technology is available to deliver it. When we fail to do a complete job of understanding and delivering, no matter what enhancements are required, we discredit the “value proposition” for one patient, who influences the next. When we do deliver, we can enjoy the satisfaction of performing noble work, and our practices will thrive with patient referrals.
– John A. Hovanesian, MD
OSN
Cornea/External Disease Board Member
Many cataract IOL patients require a LASIK procedure to correct any residual refraction, particularly cylinder, in order to meet increasing visual expectations from patients. While multifocal IOLs have improved since first introduced, they are still somewhat unsatisfactory in a proportion of patients. The difficulty is in knowing in advance of performing a multifocal implantation if someone will eventually neuroadapt or not. Probably for now, the platinum premium option for cataract patients is to implant a high-quality monofocal lens with a proven low posterior capsule opacification rate (multifocals are still plagued with very high PCO rates) and then perform presbyopic depth-of-field-increasing LASIK on the visual axis into the cornea with an excimer laser. This means that both residual sphere and cylinder can be corrected, as well as allowing continuous near to far distance with perfect centration and control of spherical aberration to optimize near vision without compromising contrast sensitivity. Laser presbyopic corneal surgery (laser-blended vision) is generally better tolerated than multifocal IOLs because it demonstrates binocular neural summation, which the brain is naturally programmed to handle, rather than expecting the brain to resolve more than one image in the same eye.
– Dan Z. Reinstein, MD, MA, FRCSC, DABO, FRCOphth
London
References:
- Reinstein DZ, Couch DG, Archer TJ. LASIK for hyperopic astigmatism and presbyopia using micro-monovision with the Carl Zeiss Meditec MEL80. J Refract Surg. 2009;25(1):37-58.
- Reinstein DZ, Archer TJ, Gobbe M. LASIK for myopic astigmatism and presbyopia using non-linear aspheric micro-monovision with the Carl Zeiss Meditec MEL 80 Platform. J Refract Surg. 2010; doi:10.3928/1081597X-20100212-04.