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Cataract Surgery | May 2009

How Many Surgical Options Do You Give Your Patients?

CRST Europe asked leading surgeons how they present surgical options to their patients.

I started as an ophthalmologist in 1976, and over the years I have specialized in anterior segment pathology. Today, I mainly perform cataract and refractive surgery, but I also perform corneal transplantations and glaucoma surgery.

Cataract surgery. For cataract surgery patients, we propose either a monofocal (toric, if appropriate) or a multifocal IOL. We propose multifocal IOLs only for patients who are good candidates for this type of lens, and we always strictly respect the exclusion criteria.

Once patients are offered these choices, their preference is definitive. We explain to them what the probable results will be with either lens, inform them of the advantages, disadvantages, and estimated costs of surgery. I do not offer an accommodating lens at this time.

Refractive surgery options. Patients are increasingly interested in refractive surgery. We offer corneal refractive surgery, phakic IOL implantation, or refractive lens exchange (RLE), depending on factors such as their ophthalmic situation, age, and indications.

A complete ocular examination is performed before any proposition of surgery is made. Every patient interested in refractive surgery must attend an informational meeting, where we explain the different refractive surgeries and the advantages, disadvantages, and costs of each type of surgery. We also inform them of the necessary preoperative exams, the exclusion criteria, and the importance of these criteria. We are strict in applying the exclusion criteria. At this time, we find that 25% of people who express interest are ineligible for surgery. Images from the Visante Anterior Chamber OCT (Carl Zeiss Meditec, Jena, Germany) are indispensable for patient selection. It is important to select patients carefully to avoid complications.

We perform PRK in patients presenting with a maximum of -3.00 D of myopia or 2.00 D or hyperopia, or as secondary intervention after refractive surgery. Corneal collagen crosslinking is performed if necessary.

Refractive lens options. For patients with moderate or high myopia, hyperopia, with or without astigmatism, we offer implantation of the iris-fixated Artisan or Artiflex (both manufactured by Ophtec BV, Groningen, Netherlands) phakic IOL. Even after 18 years of experience, this lens is my first choice. We achieve excellent results with this phakic IOL. Implantation of the rigid PMMA Artisan is always performed under general anesthesia. Implantation of the foldable Artiflex under topical anesthesia is increasingly popular. I decide on the type of anesthesia with the input of the patient.

For patients older than 45 to 50 years presenting with hyperopia, we can perform RLE. We offer these patients either a monofocal, multifocal, or toric IOL depending on their ophthalmic situation and preference. We always strictly respect the exclusion criteria for the use of multifocal IOLs. After thorough patient education, surgeon and patient decide the best choice of lens during consultation.

Lens exchange surgery (whether cataract surgery or RLE) is usually performed under topical anesthesia. Preoperatively, the patient has a conversation with the anesthesiologist, even if the surgery is to be done under topical anesthesia.

Historically, we have offered anterior segment surgery, but since my practice was taken over by the University of Maastricht in January 2008, we offer every type of ophthalmic surgery, from the anterior to the posterior segment, including surgeries for strabismus; glaucoma; and orbital, lacrimal, and eyelid pathology.

If you were the patient and you were interested in freedom from glasses and contact lenses, you would want the best refractive surgical option for your visual requirements, individual measurements, and your specific eye. Although LASIK is a great solution for many patients, it is not the best refractive surgical choice for all patients. As refractive surgeons, our job is to offer the full spectrum of refractive surgical options and then to choose the best option for each individual patient.

Our private practice is purely surgical and devoted to offering the full spectrum of refractive and cataract surgical options. It is our duty to carefully examine each patient, understand each one's visual needs, perform our preoperative measurements accurately, and then determine what surgical option—if any—would be best for that particular patient. There is no room in refractive surgery for the one-size-fits-all mentality.

Each patient is given a detailed questionnaire to assess his daily visual demands and preferences. Ocular biometry is comprehensive, including everything from corneal topography to manifest refraction, pachymetry, pupillometry, wavefront analysis, axial length, and anterior chamber depth measurements. We truly seek to give each prospective patient the most thorough eye exam of his life.

With this data in hand, the surgeon examines the patient in detail at the slit-lamp biomicroscope and conducts an in-depth patient interview. It is the surgeon's responsibility to analyze all the data and recommend the best procedure for each patient. In cases in which multiple options are appropriate for the patient, the surgeon should hone the choices and present the patient with the best one.

Patients want the surgeon's opinion. My patients do not want to become ophthalmologists. They want me to be the ophthalmologist, and they are interested in my expert opinion. Giving patients a long list of options and asking them to choose one is the wrong approach. Choosing the best surgical option for a specific patient requires the extensive knowledge base and experience of an established refractive surgeon.

If you want to get the brakes changed on your car and the mechanic gives you a list of options—cross-drilled rotors, slotted rotors, cross-slotted rotors, carbon-ceramic rotors, metallic pads, semimetallic pads, organic pads, track pads, street pads—the choice is too complex for the average motorist. You are likely to say to the mechanic, "I don't know. Tell me: What's best for my needs and my car?" You will trust his expert opinion.

Similarly, if you have a prospective refractive surgery patient, you may recommend a corneal procedure or a lens procedure, and within each of these categories are multiple options and variations (Figure 1). The patient is relying on your expert judgment and experience to recommend the best surgical options for his eyes.

Providing the full spectrum. Refractive surgery is a fascinating field that continues to evolve. There are more options now than ever before. To be the best refractive surgeon you can be, you must have access to the full spectrum of surgical procedures. This is both challenging and expensive.

Purchasing the full line of equipment to provide all types of cornea- and lens-based refractive surgery can cost millions of dollars. Keeping up to date with the procedures and technology requires dedication to continuing education on the part of the surgeon.

The primary corneal surgical procedure we perform is LASIK; however, there are many variations and variables. The corneal flap can be made with a femtosecond laser or with a microkeratome. The flap size, position, and depth can be customized to each patient. The excimer laser ablation profile can be conventional, wavefront-optimized, or wavefront-customized. Some patients may do better with surface ablation procedures, such as PRK and epi-LASIK, instead of LASIK. There are also nonlaser-based surgical options for the cornea, such as corneal inlays, conductive keratoplasty, and incisional techniques.

The primary lens surgical procedures are the addition of IOLs, in the form of phakic IOL implantation, and replacement of the crystalline lens, in the form of cataract surgery or RLE. Phakic IOLs are available in anterior chamber models, both angle- and iris-supported, and posterior chamber models. Replacement IOLs include standard monofocal IOLs and premium IOLs. The premium IOL class is further divided into accommodating IOLs, toric IOLs, and multifocal IOLs. Each of these classes has subtypes to provide specific benefits to the patient.

Sometimes the best surgical option for the patient is a combination of two procedures. The bioptics approach allows us to tailor surgical vision correction for even the most extreme spectacle prescriptions.

The complete refractive surgery toolbox. There is an old saying: "If the only tool you have is a hammer, then everything looks like a nail." This is appropriate to refractive surgical centers that offer only LASIK. Although LASIK is a great tool, it should not be the only one in your refractive surgical toolbox.

No two eyes are exactly the same, and each patient has different visual needs for his lifestyle. By customizing the refractive surgical procedure for each patient, the refractive surgeon can consistently provide the best visual outcomes.

In most refractive practices, the most commonly performed refractive procedure is LASIK. It is quick, safe, and well established in the minds of the public as the operation you have when you want to get rid of glasses or contact lenses. But to offer only LASIK to our refractive clientele would be denying them the benefits of other, sometimes better, alternatives. I would be doing them a disservice.

One common scenario in which LASIK would be a less preferable option is a patient with a cornea that either is too thin or displays topographic evidence of inferior steepening. These factors, of course, predispose the patient to corneal ectasia. Other risk factors include high myopia, high astigmatism, young age, history of atopy, and habitual eye rubbing. In these patients, PRK must be considered, and, especially if the refractive error is high, phakic IOLs are also better alternatives to LASIK.

Phakic IOLs. I also consider a phakic IOL when the patient's error is outside the range that is comfortably treated with cornea-based surgery—greater than -10.00 D of myopia or 4.00 D of hyperopia. If the cornea is either very flat or very steep, I also shy away from flattening it or steepening it further with a cornea-based laser procedure.

There is no doubt that phakic IOLs represent a second choice in many patients. Some practitioners may remain skeptical of or antagonistic toward phakic IOLs as a surgical option and would rather label a patient as unsuitable for refractive surgery than to subject him to an intraocular procedure. Although I understand this rationale, it seems to me that this denies many patients the opportunity to be able to function without dependence on artificial visual aids. Care must be exercised that the preoperative parameters of the eye satisfy safe implantation criteria. These parameters include anterior chamber depth and corneal endothelial integrity.

In my practice, we have recently been investigating the anterior chamber AcrySof Phakic IOL (Alcon Laboratories, Inc., Fort Worth, Texas) and are pleased with the ease of implantation of the lens as well as its performance and safety. The posterior chamber Visian ICL (STAAR Surgical, Monrovia, California) and the peripheral-iris–fixated Veriflex (Abbott Medical Optics, Inc., Santa Ana, California) phakic IOLs are also available to me in Australia.

Refractive lens exchange. My practice also attracts many older patients, those well into their presbyopic years. Perhaps they started to need to wear reading glasses in their 40s, but a deterioration in distance vision followed, and they began to need help for distance in their 50s. Sometimes the crux comes when they are forced into considering multifocal spectacles. With LASIK or PRK, the best we can do is buy some time for these patients because, inevitably, they continue to worsen until they enter the cataractous age group.

Many times I have seen older hyperopes return with a drift in their refraction a few years after undergoing LASIK. I perform an enhancement, but a few years later they return once again with a shift in their refraction. By that time, their crystalline lenses no longer look clear. Sometimes, early nuclear sclerosis gives them myopic shift; this may seem advantageous for reading, but the quality of vision does not last long. Then I am forced into performing expedited cataract surgery, only to lift their flaps subsequently for a final adjustment of their residual refractive error. How much easier it would have been to offer these presbyopic hyperopes a RLE in their late 50s to begin with.

With experience, I have stopped offering LASIK to people in their 60s unless they are already pseudophakic. For hyperopes, I would think twice about offering LASIK to them even in their 50s, especially if their error is more than 2.00 or 3.00 D.

Another benefit of RLE is the possibility to offer patients an alternative to monovision with multifocal IOL technology. The pseudoaccommodating IOLs that have been used in Australia include the Array, ReZoom, and Tecnis Multifocal (all manufactured by Abbott Medical Optics, Inc.; Array no longer available), the apodized diffractive AcrySof Restor (Alcon Laboratories, Inc.), and two accommodating IOLs, the Eyeonics Crystalens (Bausch & Lomb, Rochester, New York) and Tetraflex (Lenstec, St. Petersburg, Florida). Only one of these has gained popularity, the AcrySof Restor. The Restor is a favored choice because the original model with 4.00 D add delivers sharp reading vision reliably. It now also comes in a 3.00 D add variant, which has eliminated the problem of poor intermediate vision experienced with all diffractive multifocal IOLs previously.

I still prefer to restrict the use of RLE to presbyopic hyperopes and high myopes, avoiding low myopes. There are also other conditions that must be met, including low astigmatism and absence of any other ocular pathology.

Other options. Other refractive options either never gained favor in Australia or are now becoming less common because better options are available. Conductive keratoplasty falls in the first category; induction of irregular astigmatism and less-than-perfect outcomes were disincentives to its adoption. Astigmatic keratotomy is a dying art form as laser-based procedures with greater accuracy have displaced it in popularity, and even limbal relaxing incisions are now performed infrequently with the advent of toric IOLs. Orthokeratology is not practiced by refractive surgeons.

In summary, I believe refractive surgeons must be able to offer their patients more than just LASIK. Perhaps a casual refractive surgeon can use LASIK to help some patients and refer others to a more experienced colleague. However, for the complete refractive surgeon to best serve his patients, he must have the following surgical options in his armamentarium: LASIK, PRK (or a similar surface-based laser procedure), phakic IOL implantation, and RLE. This does not mean that all of these options should be offered to every patient. The surgeon should chose the most appropriate procedure to present to the patient with, at most, a mention of alternatives.

Camille Budo is an Associate Professor at the University of Maastricht Department Ophtalmology and in practice in Sint-Truiden, Belgium. Dr. Budo states that he is a consultant to Ophtec BV and Carl Zeiss Meditec and is also a medical mentor for Ophtec BV. He may be reached at tel: +32 11 689684; fax: +32 11 688286; e-mail: camille.budo@skynet.be.

Uday Devgan, MD, FACS, is a partner at the Maloney Vision Institute in Los Angeles. He is also Chief of Ophthalmology at Olive View-UCLA Medical Center and Associate Clinical Professor at the UCLA School of Medicine in Los Angeles. Dr. Devgan states that he has no financial interests in the products or companies mentioned. He may be reached at tel: +1 310 208 3937; fax: +1 310 208 0169; e-mail: drdevgan@maloneyvision.com.

Con Moshegov, MD, is Director of Perfect Vision Eye Surgery, in Sydney, Australia. Dr. Moshegov states that he occasionally receives study and travel grants from Alcon Laboratories, Inc., and Abbott Medical Optics, Inc. He may be reached at e-mail: con@perfectvision.com.au.