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Seven habits of highly successful refractive cataract surgeons
With these preoperative and intraoperative habits, surgeons can ensure postoperative results that satisfy patients.
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by Johnny L. Gayton, MD
It is sometimes tempting for cataract surgeons to get caught up in debates over the value of technology A vs. technology B or, conversely, to think that nothing matters beyond skilled hands in surgery. The reality is that many factors go into successful outcomes, and it behooves us to master each of them. Here are seven good habits surgeons can develop to ensure success in a refractive cataract surgery practice.
1. Counsel patients effectively
Successful conversion and education of patients requires a team approach. In my practice, patients hear about their cataract surgery options at multiple touchpoints, from the receptionist who answers their phone call to the technician, surgeon and patient counselor. The more the patient knows before I talk to them, the better it is for my chair time.
We use layman’s terms to share with patients the lifestyle benefits of new IOLs and other technology. At the same time, I am careful to set realistic expectations and be transparent with patients about side effects and complications, the potential need for spectacle use or enhancements, and the cost of the procedure. It is particularly important to make sure they understand what they will gain — and what they will give up — with the planned procedure. A low myope who is used to taking off her glasses to read, for example, is going to be unhappy with a plano distance correction if you have not thoroughly educated her about what to expect.
2. Invest in accurate biometry
We have all heard the saying “garbage in, garbage out.” Achieving the desired refractive outcome is highly dependent on accurate biometry and other preoperative measurements so that we are putting good data (not garbage) into our IOL power calculation formulas. I believe it is worthwhile to invest in advanced diagnostic technologies and then take the time to make the most of these technologies in our preoperative workups.
For example, we evaluate astigmatism in multiple ways. Preoperatively, we do a Marco OPD-Scan and obtain keratometry from the IOLMaster (Zeiss) or Lenstar (Haag-Streit). For significant astigmatism and previous refractive surgery cases, I also want to see corneal topography with the Atlas (Zeiss) and/or the Cassini (i-Optics). Until recently, I used the preponderance of the evidence to guide surgical plans. If a particular test was an outlier, it was not given much emphasis. Now I place more emphasis on intraoperative measurements.
3. Determine the best possible IOL power
It is important to use the latest methods for IOL power calculation, such as the Holladay 2 and the Hill-RBF formulas, and to ensure that we are taking posterior corneal astigmatism and surgically induced astigmatism into account when planning for a toric IOL. Even with all the diagnostic technology we use on the front end, I also like to use intraoperative aberrometry (ORA, Alcon) to confirm my lens choice and astigmatism correction intraoperatively (Figure 1). We used to take a lot of patients to the clinic to refract them immediately after removing the lens. That refraction was used to help select the IOL power. Since obtaining an ORA device, we have found that step to be largely unnecessary.
4. Take care of the ocular surface
The tear film and ocular surface are the first refractive surfaces in the eye, and any problems will limit what we can accomplish with lens surgery. Using the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire and point-of-care testing for ocular surface inflammation, I determine the dry eye risk for every cataract patient. We often have to explain this carefully, as “dry eye” sounds crazy to the many cataract patients who present with epiphora. They have to be educated about the proper tear balance.
I treat dry eye aggressively with high-quality artificial tears and fish oil supplements, and for those with signs of inflammation, a topical T-cell modulator such as Xiidra (lifitegrast ophthalmic solution 5%, Shire) or Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) is used. I also have a low threshold for using a bandage contact lens or punctal occlusion. Finally, it is important to choose postoperative medications that will be gentle on the ocular surface. Drops that burn can cause reflex tearing, and those with toxic preservatives can damage the ocular surface.
5. Protect the eye
I believe that using a combination of a steroid, which generally blocks inflammation high in the inflammatory pathway by blocking phospholipase A2, and an NSAID, which decreases prostaglandin formation by blocking COX enzymes, is the best way to safely reduce the risk of inflammation and ensure rapid visual recovery. I start the steroid — either Lotemax gel (loteprednol etabonate ophthalmic gel 0.5%, Bausch + Lomb) or Durezol (difluprednate ophthalmic emulsion 0.05%, Alcon) — the day before surgery and continue it for 3 weeks postop, extending that to 8 weeks in higher-risk eyes. For the NSAID, I prescribe BromSite (bromfenac 0.075%, Sun Ophthalmics) for 3 days before surgery and 2 to 12 weeks postop, depending on patient risk factors and compliance.
I like the fact that the bromfenac molecule penetrates the ocular surface quickly to reach the anterior chamber, but the DuraSite formulation is also important. This drug delivery vehicle increases retention time of the active ingredient in the tear film on the ocular surface by holding then gradually releasing the bromfenac into the tear film. It then rapidly penetrates the cornea in its active state and quickly treats inflammation. I have personally found BromSite to be effective against pain; it is actually the only NSAID indicated for prevention of postoperative pain (Figure 2). I also prescribe Besivance (besifloxacin ophthalmic suspension 0.6%, Bausch + Lomb) twice daily or three times daily for 2 days preop and for 10 to 14 days postop for prevention of infection.
6. Perform careful, consistent surgery
If a complication such as a capsule tear keeps a patient from being able to get a premium IOL, that patient will be disappointed, no matter how well you manage the complication. That is why consistency is so important. Every step in cataract surgery serves as the foundation for all that comes after, so take exquisite care with each step, from obtaining a continuous, appropriately sized capsulorrhexis to safe nucleus removal, careful cortical cleanup, and proper lens insertion and positioning.
7. Manage astigmatism
Astigmatism simply cannot be ignored when there is a refractive outcome goal. We are fortunate to have a wide range of options for correcting astigmatism, from careful placement of entry wounds to laser incisional surgery to toric and toric extended depth of focus IOLs to postoperative relaxing incisions or laser vision correction. Remember: You want to have multiple tools in your tool belt, not just a hammer, for every problem is not a nail. The best solution is one that is customized to the patient’s individual needs (including the ability to pay).
Providing the best patient outcomes depends not only on what occurs in the operating room but on many decisions that occur well before and after the OR. These seven habits are a good start on the road to practice success.
For more information:
Johnny L. Gayton, MD, can be reached at Eyesight Associates, 216 Corder Road, Warner Robins, GA 31088; email: jlgayton9@gmail.com.
Disclosure: Gayton reports he is a consultant for and on the speakers bureaus for Omeros, Sun and Shire.