For the past 50 years, cataract surgery has actually been the No.1 refractive surgery procedure—we just haven't yet presented it as such. Even today, with the popularity of LASIK and the growing interest in phakic IOLs, cataract surgery still provides a wider range of refractive error correction than any other surgical procedure. For a 60-year-old patient who is either a 12.00 D hyperope or a -30.00 D myope, the best correction is pseudophakia. Our one shortcoming is that we do not explain the refractive benefit of cataract surgery to our patients.
EDUCATE PATIENTS
You are a physician, yet if you were going to have hip replacement surgery tomorrow, what do you know about the procedure and the options for an artificial hip? Chances are, you do not know much. Our patients are usually not doctors; they have no idea as to the options available to them at the time of cataract surgery. Some patients may try to educate themselves, reviewing material they find on the Internet; however, the bottom line is that our patients do not fully understand the finer points of cataract or refractive surgery.
Therefore, our first goal is to educate our patients. Although it is true that the goal of cataract surgery is primarily to correct cataracts, patients must understand that this surgery is also a one-time opportunity to simultaneously achieve great vision. When we explain to patients that we can combine cataract surgery with a refractive procedure (and at a significant cost savings to them), they become more likely to pursue refractive cataract surgery as an option.
It takes time for patients to digest the information we explain about cataracts, cataract surgery, and refractive options. By mailing each prospective patient guidelines, educational booklets, and information about the surgeon and practice, we have shared the benefits of refractive cataract surgery before the patient ever sets foot in our clinic. This information should include costs of procedures so that patients can see for themselves that refractive cataract surgery is now a better option than routine cataract surgery and that they may also elect LASIK at a later date to treat any residual refractive error.
MAKE A SPECIFIC RECOMMENDATION
With so many different IOL options available to patients, there is no way to fully educate patients about each of them. Furthermore, most patients are unconcerned about the optical differences of refractive versus diffractive multifocal IOLs. Rather, patients care about their resulting vision and how it affects their typical daily activities.
Patients should fill out a brief questionnaire to delineate their typical daily activities, personality, and priorities for their vision. Biometry, topography, and ocular health are also important parameters for selection of the best IOL for each patient.
A high degree of corneal astigmatism would likely mean that a toric IOL would be a good choice to provide sharp UCVA at a specific focal point. For patients who are willing to sacrifice some image quality to achieve better near UCVA, multifocal IOLs are an option. If the patient wants better image quality but would still be pleased with a variable amount of near vision, then perhaps an accommodating IOL would be more suitable. Additionally, in cases where retinal function would limit the benefit of a premium IOL, a monofocal IOL might be a better choice. The surgeon must evaluate the patient and make a specific recommendation as to which IOL would be best for their visual needs and ocular condition.
PROVIDE REFRACTIVE RESULTS
When patients undergo routine cataract surgery, their expectation is to see somewhat better than before—most times, they are willing to use glasses to achieve that goal. However, when we perform refractive cataract surgery, patients want a refractive result: sharp vision without glasses. This means we must obtain accurate biometry and lens calculations as well as treat any corneal astigmatism. One option for treating corneal astigmatism is the use of limbal relaxing incisions (Figure 1).
With corneal refractive surgery, such as LASIK, we aim for a specific refractive outcome for the patient. If this is not achieved during the primary LASIK surgery, a free enhancement must be offered postoperatively. This same mindset is crucial for success in refractive cataract surgery. Your commitment to the patient is to do what it takes to help achieve the specific refractive outcome that you promised during the preoperative consultation.
We must also maximize results and minimize complications during and after surgery. Using a newer-generation fluoroquinolone or an intracameral antibiotic may help prevent endophthalmitis, and using a topical NSAID may help prevent cystoid macular edema. Intraoperatively, using silicone-coated soft I/A tips (Figure 2) can prevent capsular rupture that occurs when metal tips develop sharp burs and inadvertently break the posterior capsule. Newer-generation phaco platforms also provide an increased level of fluidic stability and may maintain a more stable anterior chamber during phacoemulsification. Using the best pharmaceuticals, instruments, and surgical technologies is important to providing the best results.
Finally, we must offer the best to every patient. Vision is our most precious sense, and many patients will happily elect for refractive cataract surgery if given the opportunity.
Uday Devgan, MD, FACS, is a partner in private practice at the Maloney Vision Institute, Los Angeles; Chief of Ophthalmology at Olive View UCLA Medical Center; and Associate Clinical Professor at the Jules Stein Eye Institute at the UCLA School of Medicine. Dr. Devgan states that he is a paid consultant to Advanced Medical Optics, Inc., and Bausch & Lomb; however he has no financial interest in the products mentioned. He may be reached at tel: +1 310 208 3937; fax: +1 310 208 0169; e-mail: drdevgan@maloneyvision.com; Web site: www.MaloneyVision.com.
