Tips for Optimizing Results

CRST Europe asked Editorial Advisory Board Members: What have you done in your practice to make patients say “wow”?

By Michael Amon, MD; A. John Kanellopoulos, MD; Thomas Kohnen, MD, PhD, FEBO; and Robert H. Osher, MD

Michael Amon, MD

• Spend increased chair time, manage patient expectations appropriately, and perform a thorough preoperative work-up, especially when using premium IOLs
• Perform meticulous, almost atraumatic surgery (resulting in a short rehabilitation period) under sufficient topical anesthesia (resulting in no pain during surgery);
• Candidates for multifocal IOLs receive an additional multifocal IOL during the same surgery (duet procedure) because of the reversibility of the procedure;
• Treat astigmatism greater than 1.00 D (with either limbal relaxing incision [LRI] or toric IOL); and
• Follow-up is performed in an organized fashion.

A. John Kanellopoulos, MD

• A 70-year-old patient who received a toric IOL was “wowed” by the reduction in cylinder for probably the first time in his life!
• Patients’ relatives or friends can observe the procedure and track the patients’ whereabouts through glass-partitioned operating rooms.
• We webcast all cases on our website via live stream so that family and friends can watch. Believe it or not, this boosts patient confidence and reduces anxiety.
• We assign a team member to be the patient’s exclusive companion throughout the whole experience in our center. This individual welcomes the patient at the doorstep; fast-tracks his or her registration; administers drops; instructs and answers questions; performs anesthesia prep; stays with the relative to explain the live procedure; attends the postop; and finally calls at night to check on the patient at home, which patients love.
• Femtosecond laser has helped us achieve a big “wow” factor for many patients.
• Most important, stellar outcomes are key.

Thomas Kohnen, MD, PhD, FEBO

The “wow” factor is achieved when

• Cataract surgery is performed under topical anesthesia;
• Toric IOLs are recommended for patients with appropriate levels of astigmatism;
• Bifocal and trifocal IOLs are implanted in patients requesting correction of presbyopia;
• Femtosecond laser is employed to create corneal incisions and perform lens fragmentation;
• Fast but precise surgery is carried out; and
• Perfect refractive outcomes are achieved.

Robert H. Osher, MD

The “wow” factor depends on attaining emmetropia following cataract surgery. It is just that simple. Therefore, every surgeon needs to feel comfortable correcting not only the spherical component but also the cylindrical component of the pseudophakic refractive error. Having introduced astigmatic keratotomy combined with cataract surgery in the early 1980s, I have been elated with the more accurate results afforded by toric IOLs. Challenges still exist regarding more precise diagnostics, understanding of the role of posterior corneal astigmatism, intraoperative alignment, and the postoperative analysis of our outcomes. Yet it is still necessary that every cataract surgeon strive to become a refractive cataract surgeon. The truest definition of the “wow” factor is crystal-clear postoperative vision!

New-Technology IOLs Help Achieve Optimal Outcomes

By Allon Barsam, MD, MA, FRCOphth; Francesco Carones, MD; and H. Burkhard Dick, MD, PhD

Allon Barsam, MD, MA, FRCOphth

I use the Mplus MF30 and Mplus Toric (both by Oculentis GmbH) for patients who are motivated to have good uncorrected distance and near vision. For patients with corneal astigmatism who want excellent distance vision, I use the T-flex toric IOL (Rayner Intraocular Lenses, Ltd.), which has excellent rotational stability and a superb online toric IOL calculator for ease of use. This lens also works well for patients who have previously tolerated contact lens monovision. For high myopes who are young enough to remain phakic (younger than 40 years old) and who are outside the range of safe and predictable LASIK, I use the Visian ICL (STAAR Surgical). The safety profile of this phakic IOL in properly selected highly myopic patients makes it a far superior choice to a refractive lens exchange.

All of these lens options include aspheric optics optimized for reduction of positive spherical aberration to consistently achieve a high-definition postoperative visual outcome for patients. In the unlikely event that patients are left with small amounts of significant postoperative refractive error, I fine-tune them with Z-LASIK or advanced surface ablation.

Francesco Carones, MD

I am better able to help patients achieve the “wow” factor after cataract surgery since I started implanting the AcrySof IQ ReStor 2.5 (Alcon Laboratories, Inc.) in the patient’s dominant eye and the AcrySof IQ ReStor 3.0 (Alcon Laboratories, Inc.) in the nondominant eye. This gives the patients the best of two worlds: spectacle independence and quality of vision, especially at nighttime.

H. Burkhard Dick, MD, PhD

Despite the multitude of IOL solutions available to cataract patients today, limitations remain, particularly relating to suboptimal postoperative outcomes. The Light Adjustable Lens (LAL; Calhoun Vision, Inc.) takes an innovative approach to this problem by providing patients with outstanding and customizable postoperative results.

The LAL produces a final refractive outcome within 0.25 D of target in more than 98% of cases.¹ Its unique level of precision relates to the presence of light-sensitive macromers in the lens. These molecules change configuration on exposure to ultraviole light of a specific spatial intensity, allowing the lens’ refractive power to be noninvasively altered after implantation. The lens power offered by the LAL is set only when a patient’s residual error is known, and the light-based adjustments, which can correct up to 2.00 D of sphere and 2.00 D of cylinder, are guided by both refractive measurements and patient feedback. Multiple adjustments can be performed until the patient is happy.

The LAL is effective when implanted in myopic, hyperopic, and astigmatic eyes^2-4 and in difficult cases, such as eyes after refractive surgery and very short or long eyes. Excellent results have been achieved due to the LAL’s ability to provide customized presbyopia solutions, such as adjustable monovision, customized near add, and asphericity control, positioned in the line of sight. A study of the LAL’s customized near add function showed that it achieves good uncorrected distance and near visual acuity more frequently than an accommodating IOL.⁵

The LAL, used in conjunction with femtosecond laser-assisted cataract surgery, is a comprehensive solution to the increasing visual expectations of cataract surgery patients. This technology offers early postoperative correction and adjustment based on individual patient feedback, enriches our portfolio of premium lenses, and is able to deliver the “wow” factor even for challenging or demanding patients.

1. Dick HB. Change in paradigm refractive cataract surgery. Paper presented at: XXIX Congress of the European Society of Cataract & Refractive Surgeons; September 17-21, 2011; Vienna, Austria.
2. Hengerer FH, Dick HB, Conrad-Hengerer I. Clinical evaluation of an ultraviolet light adjustable intraocular lens implanted after cataract removal: eighteen months follow-up. Ophthalmology. 2011;118:2382-2388.
3. Hengerer FH, Hütz WW, Dick HB, Conrad-Hengerer I. Combined correction of axial hyperopia and astigmatism using the light adjustable intraocular lens. Ophthalmology. 2011;119:1236-1241
4. Hengerer FH, Hütz WW, Dick HB, Conrad-Hengerer I. Combined correction of sphere and astigmatism using the light adjustable intraocular lens in eyes with axial myopia. J Cataract Refract Surg. 2011;37:317-323.
5. Hengerer FH, Böcker J, Dick HB, Conrad-Hengerer I. Light adjustable intraocular lens. New options for customized correction of presbyopia. Ophthalmologe. 2012;109:676-682