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Modern-day cataract surgery: Bad and boujee
Technologies and combinations are evolving for presbyopia-correcting IOLs.
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For those premium cataract surgeons with a musical know-how, “Bad and Boujee” is a recent well-known hip-hop song by Migos and Lil Uzi Vert, known for the concept of “bad” meaning good-looking and “boujee” meaning stuck up, where pretty ladies were seen in regular environments such as wearing silk shirts on dirt bikes. So how does this concept translate to the modern-day cataract surgeon?
Bad and boujee can be related to the type of cataract being removed, from an early dysfunctional lens (boujee) to a mature cataract (bad) LOCS III classification based on preoperative diagnostic testing with devices such as the HD Analyzer (Visiometrics); to the type of technology being used to remove the cataract (femtosecond laser as boujee); to the type of IOL being used to replace the cataract, with monofocal IOLs as bad and presbyopia-correcting IOLs as boujee; to the personality of the premium surgeon performing the cataract surgery, which hopefully we all are bad and boujee.
I am going to review some of the current presbyopia-correcting IOL technologies and combinations that can be considered bad and boujee with modern-day cataract surgery. Currently, there are corneal options to correct presbyopia, including laser vision correction (monovision or multifocal ablation), Supracor (Bausch + Lomb) and corneal inlays (Kamra, AcuFocus; Raindrop, ReVision Optics). Scleral options for presbyopia are still in the FDA pipeline, and studies outside the U.S. include scleral bands (VisAbility, Refocus Group) and Er:YAG laser microporation (LaserACE, Ace Vision Group). Below I will discuss some of the current bad and boujee approaches with presbyopia-correcting IOLs.
The classic bad and boujee premium IOL patient is that 55-year-old who complains that her LASIK surgery has “worn off” and she can no longer see as well as she used to despite 20/20 correctable vision. In my practice, we utilize optical quality measurements with the HD Analyzer to objectively measure visual quality with a quantitative objective scatter index (OSI). This OSI number quantifies forward light scatter and correlates highly with LOCS III cataract classification. Patients with a normal OSI may benefit from a corneal procedure as mentioned above, but those with high OSI scores most likely need a lenticular-based IOL procedure.
Current FDA options include accommodating IOLs (Crystalens and Trulign, Bausch + Lomb), multifocal IOLs (ReSTOR, ReSTOR toric, ActiveFocus, ActiveFocus toric, Alcon; low add Tecnis multifocals, Johnson & Johnson Vision) and extended depth of focus IOLs (Symfony, Symfony toric, Johnson & Johnson Vision). In my experience, my best outcomes with Crystalens and/or Trulign come when targeting plano to –0.25 sphere in the dominant eye and –0.25 to –0.50 sphere in the nondominant eye, typically giving uncorrected distance visual acuity in both eyes of 20/20 to 20/25, uncorrected intermediate visual acuity in both eyes of 20/20 and uncorrected near visual acuity in both eyes of J2.
My strategy when using multifocals and/or EDOF IOLs includes preoperative inclusion criteria of low or clinically insignificant angle alpha/angle kappa, absence of macular pathology, absence of poor ocular surface or optimization of ocular surface, and realistic patient expectations. My intraoperative strategies to achieve optimal outcomes with low add Tecnis multifocals includes placement of ZKB00 in the dominant eye or both eyes and placement of the ZLB00 in the nondominant eye if more near add is needed. My EDOF IOL strategies intraoperatively include Symfony in the dominant eye or both eyes and placement of the ZLB00 if more near add is needed in the nondominant eye. I will use the Symfony toric IOL when cylinder correction is needed and include femtosecond astigmatic incisions when the toric IOL option is not available. I also try to avoid too much myopia postoperatively with EDOF IOL technology to avoid spider halo and night driving vision patient complaints. My strategy when using the distance-dominant ActiveFocus technology is to place the ReSTOR 2.5 add ActiveFocus in the dominant eye or both eyes and the ReSTOR 3.0 add in the nondominant eye if more near add is needed. I will also use the ReSTOR 2.5 add ActiveFocus toric when cylinder correction is needed.
Future bad and boujee presbyopia-correcting IOLs for U.S. premium surgeons include the At Lisa refractive/diffractive hybrid (Carl Zeiss Meditec), Lentis Mplus segmental bifocal (Oculentis) and FineVision trifocal (PhysIOL). Nevertheless, premium cataract surgeons are already bad and boujee, using bad and boujee diagnostic and therapeutic technologies to achieve the bad and boujee outcome for their patients.
- References:
- Artal P, et al. PLoS ONE. 2011;doi:10.1371/journal.pone.0016823.
- Fishkind WJ. Crystalens/Trulign Intraocular Lenses. Phacoemulsification and Intraocular Lens Implantation: Mastering Techniques and Complications in Cataract Surgery. 2nd ed. Thieme Publishers; 2017:374-386.
- For more information:
- Mitchell A. Jackson, MD, can be reached at Jacksoneye, 300 N. Milwaukee Ave., Suite L, Lake Villa, IL 60046; email: mjlaserdoc@msn.com.
Disclosure: Jackson reports he is a consultant for Bausch + Lomb, Johnson & Johnson, Lensar, ReVision Optics, LaserACE and Visiometrics.