Lane: Convergence of cataract and refractive surgery a reality

SAN FRANCISCO — Until recently, ophthalmologists viewed cataract and refractive skill sets as separate, but the two are now converging, said Stephen S. Lane, MD.

Dr. Lane presented the Binkhorst Lecture here at the American Society of Cataract and Refractive Surgery meeting.

“This convergence is a bridging of skill sets and mindsets,” he told attendees. He likened it to “a merger of Barraquer and Kelman.”

The future holds many options for the refractive surgeon, Dr. Lane said.

“I believe refractive lens exchange is the future of refractive surgery,” he said, and the key to its success is careful patient selection.

“We, as surgeons, need to undersell and overdeliver” on the promise of improved near and distance vision, he said.

To achieve that goal, Dr. Lane said, new general IOL calculation formulas will be needed, and a different approach to patient outcomes.

“How are we going to measure success in the future?” he asked. “I think we’ll move away from 20/20. Metrics will be more subjective, where success will be defined by less spectacle dependence, a ‘20/happy’ patient and quality-of-life surveys.”

Other trends Dr. Lane sees influencing the convergence are the use of less ultrasound energy and higher vacuum power in phaco machines; these trends make phaco “ideal” for refractive lens exchange, he said.

Heralding May 9, 2005, as the “best day in ophthalmology,” Dr. Lane spoke about the directive issued that day by the Centers for Medicare and Medicaid Services that allowed patient-share billing for presbyopia-correcting IOLs.

While the approved IOLs that were affected by that ruling — eyeonics’ crystalens, Advanced Medical Optics’ ReZoom and Alcon’s ReSTOR — have advantages in restoring near and distance vision for patients with presbyopia, there are disadvantages to each technology as well, he said. These include a potential for decreased contrast sensitivity and a potential for low-grade glare and halo, he said.

“Pupil size determines the outcome,” Dr. Lane said. Patients with small or large pupils may have decreased vision after implantation of some of the lenses, he said, and surgeons must be meticulous in their patient selection.

He also said surgeons must understand and explain neural adaptation to their patients. “Patients see better after 1 year with these lenses than after several weeks,” Dr. Lane said. “We’re just now starting to understand neural adaptation.”

On the horizon, Dr. Lane said, ophthalmologists should expect to see lenses that truly accommodate by changing their power rather than their position. He specifically referred to the NuLens accommodating IOL, the Synchrony IOL and Calhoun Vision’s Light Adjustable Lenses as potential innovators in that arena.

“The bar for visual rehabilitation has been raised,” he said. “I believe in the future we’ll be able to customize individual IOLs on a patient-by-patient basis.”

As a group, he said, surgeons may initially be mistrustful of new technologies, but he said it is his belief that accommodating lenses will eventually benefit all sectors.

“Who are we going to use these on? The patient will be under 65 years old,” he said. Because that patient will not be covered by Medicare, the surgeon will be more fairly reimbursed, Medicare will not be involved in setting rates, and industry will be rewarded as well, he said.

“It’s time to stop thinking about it, and time to just do it,” he said.