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Cataract surgery moves beyond basics to reach a refractive mindset
One of the most important things an ophthalmologist can do preoperatively is address ocular surface disease.
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Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a joint society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.
While the latest technology in surgical equipment, femtosecond lasers and IOLs has been grabbing the cataract surgery headlines, a critical aspect of cataract surgery may be underappreciated. This month, Neel R. Desai, MD, discusses the importance of optimizing the ocular surface before cataract surgery. We hope you enjoy the discussion.
Kenneth A. Beckman, MD, FACS OSN CEDARS/ASPENS Debates Editor
Cataract surgery is not just cataract surgery anymore. Although a simplistic observation, it belies the complexity of patient interactions, lens selection, technologies, and physical and psychological factors that must be weighed carefully to produce successful outcomes in this era of refractive cataract surgery.
The time has come, I believe, for us as a community of ophthalmic surgeons to raise the bar and redefine “success” when it comes to cataract surgery and, further, for each individual surgeon to decide for himself or herself whether he or she is fully committed to achieving such outcomes in this new era. Is simple removal of a cataract and replacement with an IOL any longer an adequate definition of success? Are surgeons who still do not offer patients any form of astigmatism correction meeting an evolving and rightfully ascending standard of care? Is anatomic success really success if the patient does not see as well as he could have had he been offered instead a more customized treatment plan that heeded the patient’s refractive goals? I posit such questions not to cast derision but to stimulate the kind of introspection within the community of our peers that moves a profession collectively into the future to the benefit of our patients. It is the same introspection, I believe, that helped the standard of care in cataract surgery evolve from the days of intracapsular cataract surgery to modern phacoemulsification and ultimately to femtosecond laser-assisted cataract surgery, for instance. At some point in time, we collectively decided that the safety and benefits of phacoemulsification outweighed the interests of those who would cling to the status quo.
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As we ponder these questions from a philosophical standpoint, our patients can benefit in concrete ways, here and now, by our raised awareness of and attention to factors that may preclude the best possible outcome for our patients. Achieving reliable and accurate biometry through a systematic protocol for ocular surface optimization is one such area. For all the focus on the seductively high-tech femtosecond lasers, intraoperative aberrometry, and multifocal and extended depth of field lens implants, there has been inadequate attention paid to the simple things such as ocular surface disease (OSD), which we all have the skill set to treat and which may have far more impact on outcomes. It is nonsensical to promote the cutting edge when the failure to address the simple things blunts the outcome even before the first pass. A newly elevated standard of care is within the reach of every ophthalmologist — without the need to make large capital expenditures.
We can reduce or eliminate refractive surprises that frustratingly follow apparently uneventful and successful cataract surgery by adequately addressing pre-existing OSD such as dry eye syndrome or epithelial basement membrane dystrophy that may otherwise lead us astray in lens recommendations and lens power selection. This is low-hanging fruit that pays off in better outcomes, happier patients and less frustrated surgeons. Data presented by Bill Trattler, MD, at the 2015 American Society of Cataract and Refractive Surgery meeting confirms that up to 25% of patients presenting for cataract evaluations had OSD that negatively impacted biometric analysis in ways that would predictably lead to errors in lens choice and power calculation. We must commit, as a community, to do things not the fast way, but the right way.
In our own practice, we have developed a systematic protocol that assesses the degree to which OSD may impact biometry and ultimately refractive outcomes following cataract surgery. We begin with a battery of diagnostic modalities that might include tear film MMP-9 testing (InflammaDry, RPS), tear osmolarity (TearLab), meibomian gland imaging (LipiScan, TearScience), topography and tomography, and wavefront analysis of higher-order aberrations (especially the root mean square value). Slit lamp examination of the lid margin, inferior fornix/tear reservoir, conjunctiva and cornea aims to reveal often-overlooked forms of OSD. Use of vital stains such as fluorescein and lissamine green can reveal decreased tear breakup time or positive and negative staining patterns consistent with various manifestations of OSD. OSD noted within the central 6-mm optical zone, appearing to affect topographical symmetry or resulting in a RMS value of greater than 0.4 µm, serves as a red warning flag for OSD that would lead to erroneous biometry and suboptimal outcomes. This initiates a customized treatment protocol for the long-term treatment of OSD that may include optimized artificial tears, topical immunomodulatory agents (Restasis from Allergan, Xiidra from Shire and/or steroids), Bruder mask warm compresses, lid cleansers (Cliradex from Bio-Tissue, Ocusoft, Avenova from NovaBay Pharmaceuticals), autologous serum, intense pulsed light or LipiFlow (TearScience).
We also harness the power of biologics and regenerative healing with the use of self-retaining cryopreserved amniotic membrane (Prokera, Bio-Tissue), which helps rapidly normalize the ocular surface via potent anti-inflammatory, pro-healing properties, to get the patient more quickly positioned for accurate biometric analysis in preparation for refractive cataract surgery. Many surgeons fear losing the patient to this delay in cataract surgery, but in my experience patients far more appreciate the thoughtful approach by doctors interested in producing the best possible outcome rather than the most expeditious. Furthermore, trying to explain the role of OSD in a patient’s suboptimal outcome after surgery is far more difficult (and likely to be seen as a complication) vs. addressing this preoperatively and inherently setting appropriate expectations.
We must all aim to evolve from identifying ourselves as cataract surgeons to adopting a refractive mindset as true refractive cataract surgeons — our patients deserve this much. However, as we reflect upon the changing landscape filled with a vast array of complex technologies, we must also not lose sight of simple and practical ways in which we can commit ourselves to better outcomes for our patients on an individual basis while producing the sea change that propels our beloved profession toward the future.
- For more information:
- Neel R. Desai, MD, can be reached at Eye Institute of West Florida, 1225 West Bay Drive, Largo, FL 33770; email: desaivision2020@gmail.com.
Disclosure: Desai reports he is a consultant and speaker for Alcon, Abbott Medical Optics, Bausch + Lomb, BioTissue, Lensar, TearLab and TearScience.