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Up Front | Nov 2008

Blurring Lines Between Cataract and Refractive Surgery?

Cataract and refractive surgery seem to go hand in hand, but some subspecialists favor one over the other. For instance, in this issue, my co-medical editor, Khiun F. Tjia, MD, provides his rationale as to why he favors cataract surgery.

We all must work within our comfort zones. It is also important to consider that every so often, through technologic advance or better understanding, our milieu changes, and we might fall out of step if we do not move with these changes. Dr. Tjia acknowledges that cataract and refractive surgery are drawing closer together, and he speculates that one day he will join his refractive colleagues.

Consider Sir Harold Ridley's innovation of the intraocular implant and the motivation behind its development. This was not developed to improve safety—rather most surgeons at that time thought it jeopardized safety—and both the concept as well as poor Ridley himself were ostracized on the basis that eyes would be harmed. Look where we are today! If the opposing traditionalists were still practicing in the same way, they would probably be disciplined for malpractice and negligence. The reality is that much of what we consider appropriate practice today will be put in the wastebasket in the future. It is probable that we shall be amazed at how medieval our current practice may be viewed in the future.

Ridley developed the IOL to improve optical, and thus visual, outcomes. Like all innovation, boundaries are challenged, and improvements are continually made. This has been the case with IOLs. I believe ophthalmologists are at the stage now where we are coming from two different directions for similar reasons. In other words, we are merging cataract and refractive surgery. Cataract surgery is no longer strictly therapeutic but becoming much more refractive. We aim to please our patients and meet their expectations.

It is a given that expectations need to be managed through education, as pointed out in this issue by Uday Devgan, MD, FACS. Furthermore, like any successful practice, we must under-promise and over-deliver. With rising expectations, patients want the added value of near vision. I often see patients who are pseudophakic in one eye with good uncorrected distance vision, prompted to contact my practice following recommendation by a previous refractive cataract patient. I have been impressed by the level of unhappiness of some patients who have commented that their original ophthalmologist was remiss in not educating them about the option of an added-value lens, even if not performed by themselves. Five years ago, I would have been dismissive of this comment; however nearing the end of the first decade of this millennium, I am beginning to see their point, especially in view of the success of premium lenses. Although these IOLs are no longer investigational, they do require more effort on the part of the ophthalmologist. Can ophthalmologists say they are just cataract surgeons anymore? I do not believe this is the case, and in my personal view, cataract and refractive surgery are no longer divided. Cataract and lens-based surgery has gained considerably from the refractive world, including better understanding of astigmatism and wavefront abnormalities, specifically spherical aberration. In developing better IOLs with a large variety of available options, ophthalmologists now have little reason not to select what is best for the patient, whether it be for therapeutic or refractive reasons. Cataract and refractive surgery are united!

We hope you enjoy this issue, which brings a variety of perspectives in this emerging time of unification of cataract and refractive surgery.