Practices must prepare to offer refractive cataract surgery
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Cataract surgery remains one of the most common surgeries performed today, with millions of patients treated every year.
However, with more patients looking to take advantage of the latest lens technologies, there remains an unsatisfied demand within the realm of refractive cataract surgery.
Source: Audrey R. Talley Rostov, MD
“Refractive cornea and cataract surgery is an unmet need in most practices,” Healio | OSN Cornea/External Disease Board Member Eric D. Donnenfeld, MD, said. “It’s something that’s appreciated by patients. It’s increased our ability to improve quality of life, and it’s a financially advantageous area for practice as it’s a shared billing opportunity that can significantly help a doctor’s balance sheet. The most important thing about refractive cataract surgery is that it’s good for patients. It improves their vision, their quality of life and almost every aspect of their personality. There have been so many studies that have shown that refractive surgery can actually make patients’ lives more fulfilling and safer.”
Healio | OSN Refractive Surgery Board Member Vance Thompson, MD, said that upward of 40% of patients with cataracts seek premium refractive options when undergoing surgery. Modern cataract diagnostics can be thanked for a lot of that motivation, he said.
“We’re diagnosing cataracts earlier than ever with modern-day diagnostics,” he said. “With monofocal implants, oftentimes we’re removing accommodation and giving someone the reading range of a 75-year-old. Patients want to know all their options so that they can participate in the decision. Some are going to be fine with a monofocal implant and wearing glasses. Some are going to say they want to restore everything that their lens used to do, the clarity and the reading range.”
Cataract surgeons may have questions about how to expand their practice’s refractive cataract offerings. Healio | OSN Cataract Surgery Board Member Audrey R. Talley Rostov, MD, said the best place to begin is with one’s mindset.
“The first thing to realize is how to holistically look at refractive cataract surgery or vision correction,” she said. “I consider all anterior segment surgery to have the potential for refractive surgery.”
Talley Rostov said her mission is to optimize her patients’ vision to the highest extent possible and provide them with the best refractive outcome. By having this mindset, she believes that she can help the most people and begin to chip away at a great vision burden.
“The highest burden of global blindness is refractive error,” she said. “A lot of ophthalmologists will say someone just needs glasses and think that’s not a burden for a lot of people. Looking at your mindset for refractive cataract surgery and how you can help people achieve their best vision can truly be life-changing.”
Because premium lenses are not covered by Medicare, Thompson said it is critical for practices to develop a good atmosphere and working environment. Patients who are investing in their own care are going to value a great patient experience, he said.
“You have to work on the environment of your practice and look at every aspect of your patient experience cycle,” he said. “We draw it out and choreograph how we want each stage to go. Patients leave saying, ‘I don’t know if I’ve ever been to a business where I was treated that well. I can tell these people enjoy working together. I like the way they treat each other. I like the way they treat me. I trust them to do my eye surgery, and I’ll tell my friends.’ It’s really rewarding for your practice.”
Tools of the trade
Having the necessary tools is a major part of building a practice and expanding into refractive cataract surgery. Healio | OSN Cataract Surgery Section Editor Nicole R. Fram, MD, said having state-of-the-art biometry, topography and autorefraction readings is a good place to start.
“You want to do two reading on different days with the same biometer or on the same day with different biometers to ensure you have reliable readings,” she said. “Ideally, you have topography with Placido imaging as it’s critical to examine the tear film impact on the Placido imaging. Tomography is great, especially if you’re dealing with complex keratoconus or ectasia populations, but not always necessary. Being able to look at each case with biometry and topography readings is the key to evaluating astigmatism and hitting the refractive target.”
Donnefeld said that a good biometer is critical for refractive cataract surgeons.
“You have to have a biometer that you have faith in,” he said. “You also have to have the right keratotomy, and the next-generation biometers also have excellent keratometers built into them. You’ll use that to measure corneal cylinder with topographic analysis. The old days of doing manual keratometry have faded away in the automated techniques we have today with automated keratometry, biometry, topography and tomography.”
Although it was not the case just a few years ago, Donnenfeld said he likes to look at the posterior cornea as well. Incorporating that into the nomogram will help improve outcomes, particularly for patients with low levels of cylinder, he said.
“To become a refractive cataract surgeon, you have to be a bit of a cornea specialist as well, and you need to manage the ocular surface,” he said. “The rate-limiting step for most patients in achieving superlative vision is twofold. It’s residual astigmatism, and it’s ocular surface disease. So, we’re very aggressive about improving ocular surface disease in patients who are looking for refractive cataract surgery.”
An optimized ocular surface not only improves postoperative vision, Donnenfeld said, but it also helps a surgeon choose the right IOL and toric alignment, and it can improve a patient’s keratometry axis and overall IOL calculation.
Talley Rostov said that toric lenses would be a good place to start for surgeons looking to dip their toes into the waters of refractive cataract surgery. While they are a step up refractively from monofocal lenses, there is not as much preparation as the more complicated multifocal or extended depth of focus (EDOF) lenses.
“It’s an easy step to make and helps you get used to the refractive mindset,” she said. “There are some other subtleties that you have with both the EDOF and the multifocal lenses where you need to take a look at the higher-order aberrations, for example. As a first step, the toric lenses are a nice way to go because the lens is just a monofocal that has toric in addition. When someone is used to using a monofocal lens, using a monofocal toric isn’t that big of a jump.”
Donnenfeld said toric lenses can also help a surgeon hone their technique.
“To become a good refractive surgeon, you have to have good refractive technique,” he said. “It’s very important that you have the right equipment. You have to be able to measure the patient’s axis of astigmatism and be sure about it. You have to use a nomogram that has vector analysis that incorporates your incision, and you have to be ready, willing and able to correct refractive misses. If the patient isn’t happy, there has to be an opportunity for you to go forward and to adjust their vision postoperatively. There are many ways of doing that, but you must have something that you feel comfortable with or have someone in your practice who is comfortable doing it.”
Setting expectations
Having the latest technology is important, but the best outcomes and happy patients come from communicating and setting expectations before surgery even begins, Fram said. Understanding how to communicate with patients is part of the larger plan to improve vision.
“I have to understand how they’re using their eyes currently,” she said. “That means looking at what they’re wearing in their glasses and spending time to understand things like what font size they are using on their phone.”
Setting a patient up for success with assessment of posterior segment OCT readings and optimizing the ocular surface can help funnel patients to the right IOL, but understanding their needs for everyday life is just as critical, Fram said.
“I’ll often start by asking them if they mind wearing reading glasses or if they would like to be more independent of glasses,” she said. “If they want more spectacle independence, you start thinking about a blended vision strategy, an extended depth of focus lens or a multifocal/trifocal lens. The key to being successful at refractive cataract surgery is not only having the right measurements but also not giving patients a huge menu to choose from. Our job is to give a recommendation based on our exam and history.”
Too many choices can confuse patients and eventually lead to dissatisfaction, Fram said. After a thorough exam to confirm candidacy for a premium IOL, Donnenfeld likes to ask patients for their visual “wish list” and provide a simple breakdown of their opportunities. It generally comes down to if they want to wear glasses all the time, if they want to wear them just for close-up tasks or if they want to be less dependent on glasses entirely.
“I’m very specific,” he said. “If they choose distance, that means anything that they can touch — food on their plate, dashboard of the car, makeup for women — all these things will require glasses.”
In addition to their visual needs, Donnenfeld wants to know about their willingness to accept dysphotopsias and if they have had any experience with monovision in the past, which might make them a suitable candidate for monovision in the future. Once a patient is committed to a multifocal lens, Donnenfeld makes sure that they know about the potential drawbacks.
“We have great multifocal lenses today that give you wonderful distance and up-close vision,” he said. “But I’m very clear with patients and I state very dogmatically that if you choose a multifocal option, while your vision will be dramatically improved, there is a risk that you may have glare and halo. Your vision may not be as sharp as if you choose a monofocal lens.”
Thompson likes to prepare patients and help them understand that they are going on a journey together. That journey comes in several stages.
“We need to educate them that the first 3 to 4 months is for healing and optimizing anything that needs to be optimized,” he said. “The next 3 to 4 months after that is your brain adapting to your new optical system. If you can be patient, at the end of that journey, you’re going to have some of the world’s most sophisticated optics in their eyes.”
To help patients understand what their visual outcomes might be after surgery, Talley Rostov uses the Rendia system, a model that simulates what their vision would look like.
“I will show them how they’re functioning currently and then not only what the refractive outcome will be with simulations of all distance but also the dysphotopsia profiles,” she said. “I’m showing them what glare and halo may look like at night. However, if a patient is motivated to not wear glasses, they might look at that nighttime vision simulation of dysphotopsia and think that it doesn’t look so bad and that they would be able to tolerate it.”
Unhappy patients
After refractive cataract surgery, some patients will be dissatisfied. Fram said even the best surgeons only hit their refractive targets 85% of the time, and a certain number of patients will not be able to tolerate the lenses or adapt to them.
“They might have waxy vision or unmanageable glare or halo at night,” she said. “You can give them a drop of brimonidine 0.15% to make the pupil smaller and see if that helps some of their positive or diffractive dysphotopsia symptoms. At 3 months, if they can’t adapt and are not tolerating the lens, then you do a removal and replacement. This should be the commitment you make to the patient.”
When a patient is unhappy after cataract surgery, Donnenfeld uses a system he calls “the six C’s” to go through their examination and look for reasons why they might be unhappy.
“It lets me elucidate the problem,” he said. “Then I can address it more accurately.”
The first C is cylinder refractive error. The second is cornea and ocular surface to look for dry eye. The third is determining whether the capsule is cloudy or not. The fourth is cystoid macular edema, and the fifth is centration of the IOL. The sixth C is Donnenfeld’s most recent addition.
“I just developed it in the last year. A certain number of patients have condensation of the vitreous,” he said. “This vitreous condensation can actually cause significant sequelae. I’ve sent a number of patients for optical vitrectomies, and it’s done an amazing job in improving the quality of vision.”
When it comes to explanting and replacing a diffractive IOL, Fram said she often employs a blended vision or mini-monovision strategy. This is particularly accurate with the Light Adjustable Lens (RxSight) technology. If the technology is not available or possible, she will go with a mini-monovision strategy, such as distance and–1.25 D with an enhanced monofocal IOL.
“The patient needs to understand the 80-20 rule,” she said. “The 80-20 rule is that the patient will be independent of spectacles 80% of the time but may need glasses when they drive at night or with very small print.”
Talley Rostov said it is important to have a decision tree for refractive procedures, and the two main factors are the refractive mindset and good patient selection, which is achieved thorough diagnostics. Having a plan for unhappy patients is just as important.
“You have to have a mechanism for addressing that afterward,” she said. “That could be a touchup with PRK or LASIK with an excimer laser. That could mean a lens exchange. All these things are great, but you just want to make sure that you have a plan. If someone needs an IOL exchange, you need to be prepared to do it or refer it to someone who can.”
Thompson said it takes a lot of work to build a practice to provide the best possible refractive outcomes for cataract patients, but it is worth it.
“Go for those great measurements, get comfortable with the process and then start diving into some of these advanced implants,” he said. “The practice pride, staff pride, professional joy and financial health that come along with it is just the proper way to practice medicine. Patients want this technology, and they want to be educated to the point where they can participate in the decision. But in the end, they really want a strong doctor recommendation.”
- For more information:
- Eric D. Donnenfeld, MD, of Ophthalmic Consultants of Long Island, can be reached at ericdonnenfeld@gmail.com.
- Nicole R. Fram, MD, of Advanced Vision Care in Los Angeles, can be reached at drfram@avceye.com.
- Audrey R. Talley Rostov, MD, of Bellevue Precision Vision in Bellevue, Washington, can be reached at audreyrostov@gmail.com.
- Vance Thompson, MD, of Vance Thompson Vision in Sioux Falls, South Dakota, can be reached at vance.thompson@vancethompsonvision.com.
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