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Want better refractive outcomes? Follow five simple steps
 Wallace capsulorrhexis gauge. |
Surgeons who perform refractive cataract surgery using premium lens implants know that achieving the predicted outcome is the key to satisfying a patient. While there are many uncontrollable factors that determine a patient's visual outcome, here are five elements we can control that I have found to most meaningfully influence refractive accuracy.
In my own practice, the recent adoption of steps two and four has increased my refractive accuracy to now get 92% of patients within 0.5 D of their target spherical refraction, up from 74% previously. A surgical video teaching these five principles for better outcomes is now available here.
1. Careful wound construction. Creating a square, self-sealing clear corneal cataract incision the same way every time yields a predictable impact on astigmatism while ensuring that wound leaks will not alter the effective lens position of the IOL. In my experience, a diamond keratome gives the most predictable geometry.
2. Mark the capsulorrhexis size and location. A simple circular marker such as the Wallace capsulorrhexis gauge (Storz Instruments) allows us to precisely identify the proper location and size of our capsulotomy. In my surgery practice, this instrument has greatly influenced the reproducibility of my capsulotomies and my refractive outcomes. While femtosecond lasers may further refine the precision of capsulotomies in the future, most practices do not yet have this technology available, and this far simpler alternative can achieve similar results.
3. Make a perfect capsulorrhexis. In performing a capsulotomy through a sub-2-mm incision, you can have great control with either microincision capsulorrhexis forceps (MicroSurgical Technology) or the Silverstein microincision forceps from Storz. The former forceps have a short learning curve because their configuration is not familiar to most surgeons, while the latter is designed to mimic the familiar capsulotomy forceps that most of us use.
4. Get compulsive about a clean capsule. Retained cortical remnants lead to capsular fibrosis, which can alter the effective lens position of any IOL and reduce refractive predictability. Newer silicone sleeves for irrigation and aspiration tips, such as those offered by MST, and the disposable capsule guard I&A handpiece from Storz can allow more aggressive removal of cortical material. Additionally, an instrument such as the Whitman-Shepherd capsule polisher (Storz) can allow removal of lens epithelial cells from the anterior capsular edge. This may also reduce capsule opacity.
5. Seal the wound carefully. A Seidel test performed at the end of cataract surgery will determine whether a wound is leaking. If so, placing a single 10-0 interrupted nylon suture offers the best hope for a stable anterior chamber and a predictable refractive result. We have previously shown that microscopic wound leaks (undetectable except with a Seidel test) can cause some IOLs to have an average refractive shift of 0.5 D toward myopia.
Please feel free to comment below, sharing your own thoughts on methods of improving refractive accuracy.
- Disclosure: Dr. Hovanesian is a consultant for Bausch+Lomb and Abbott Medical Optics.