Strategies to manage challenging cataract cases from Storm Eye/ASCRS Clinical Update 2005

New refractive IOLs mean care and currency

Microstriae following LASIK should
be corrected as soon as possible.
Source: Eric Donnenfeld, M.D.


Six weeks post-op: Intra LASIK
intact.
Source: James Salz, M.D.


Source: James Salz, M.D.

Eric D. Donnenfeld, M.D., Ophthalmic Consultants of Long Island, N.Y., said refractive IOLs require planning, surgical precision, and post-op care after a refractive procedure. Dr. Donnenfeld made his remarks at the recent Storm Eye/ASCRS Clinical Update 2005.
Patient expectations will be high, so make certain your fees incorporate the extra time and effort you will be providing, he said.
Additional procedures such as relaxing incisions, YAG capsulotomies, IOL exchanges, and excimer laser enhancements will be necessary, so make certain your fees incorporate the extra time and effort you will be providing for these procedures, he said.
Include the cost of credit card fees and taxes in your fees. Establish a relationship with a surgery center (or preferably have an ownership) to provide facility fees at a reasonable cost, he said.

A different way of thinking

Stephen S. Lane, M.D., clinical professor of ophthalmology, University of Minnesota, St. Paul, advised attendees to think like refractive, not cataract, surgeons when considering the use of one of the “bifocal” IOLs.
He also said that surgeons should thoroughly educate themselves of all potential refractive alternatives before doing any cases. He suggested surgeons prepare a price strategy and know what it includes and further, to be certain that patients understand each option that is reasonable for their particular case. Each individual patient should have a customized treatment unique to their situation be it LASIK, “bifocal” IOL, or phakic IOL, etc.
Make sure the first patient you enroll feels like you have been doing this for years with regard to your process, he said.
Create realistic expectations and discuss with each patient the not only the potential benefits but also the potential problems.
“Under-sell and over-achieve,” Dr. Lane said.

Judgments

Lee T. Nordan, M.D., assistant clinical professor of ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, said to not judge the effectiveness of phakic IOLs by presently approved models.
Improvements in lens design, implantation, and function will occur, as with any other developing product, he said.
The correction of presbyopia is best accomplished with an IOL, not on the corneal surface. The quality of vision at all pre-op powers is better with an IOL than LASIK or PRK. Ask the experts the hard questions about this comparison, he said.
Cataract/IOL surgeons will only use aphakic IOLs to correct presbyopia and correct refractive error, while keratorefractive surgeons will use either a corneal procedure or phakic IOL, Dr. Nordan said.
Decide which group you fit into and proceed accordingly. Keratorefractive surgery will remain popular in the lower ranges of refractive error correction but will be used for enhancing phakic IOL results, as well, he said.

IOL calculations post refractive surgery

James J. Salz, M.D., clinical professor, University of Southern California, Los Angeles, said when calculating using clinical history method, use spectacle-plane refraction without vertex correction.
When using manual keratometry, reduce the K-reading by 24% of the refractive change for the K in the IOL formula, he said.
When using topography, use central average K not sim K, and reduce the power by 15% of the refractive change for the K in the IOL formula, he said.

A matter of mindset

Kerry D. Solomon, M.D., professor of ophthalmology, Medical University of South Carolina, Charleston, said cataract surgeons need to learn the refractive mindset.
Refractive surgeons need to learn cataract techniques. The importance of accurate biometry cannot be overstated. All of the presbyopic IOLs require absolutely accurate biometry: IOLMaster (Carl Zeiss Meditec, Dublin, Calif.) or immersion are the recommended tools, he said.
Treat all pre-existing astigmatism. Smaller amounts of astigmatism can be treated with limbal relaxing incisions. Larger degrees of astigmatism can be treated with bioptics (LASIK/PRK after lens surgery), Dr. Solomon said.
The timing of when to cut LASIK flaps is debatable. Some prefer to cut flaps pre-op on a patient with a known need for LASIK (large amount of pre-existing astigmatism). The flaps can then be lifted weeks after lens surgery. Others prefer to wait three to six months or longer after lens surgery.
Informed consent needs to be tailored for refractive patients dealing with under-corrections, over-corrections, the need for enhancements, subsequent procedures such as LASIK, IOL exchange, light vision disturbances, or the need for a thin pair of glasses to fine-tune vision. There are no implied guarantees, he said.
With multifocal presbyopic IOLs, aim for +0.1 D to +0.25 D for a planned outcome, he said.

Editors’ Note: Dr. Donnenfeld has a financial interest in Advanced Medical Optics (Santa Ana, Calif.), Alcon (Forth Worth, Texas), Allergan (Irvine, Calif.), Bausch & Lomb (Rochester, N.Y.), TLC Vision (St. Louis), and VISX (Santa Clara, Calif.). Dr. Lane has a financial interest in Advanced Vision Science (Goleta, Calif.), Alcon, Bausch & Lomb, Medennium (Irvine, Calif.), Surgical Specialities Corporation (Reading, Pa.), and VisionCare Ophthalmic Technologies (Saratoga, Calif.). Dr. Salz has a financial interest in Alcon and Ophthalmic Mutual Insurance Company (San Francisco). Dr. Solomon has a financial interest in Alcon, Bausch & Lomb, and IntraLase Corp. (Irvine, Calif.).

Contact Information
Donnenfeld: 516-766-2519, eddoph@aol.com
Lane: 651-275-3000, sslane@AssociatedEyeCare.com
Nordan: 760-431-1846, laserltn@aol.com
Salz: 323-653-3800, jjsalzeye@aol.com
Solomon: 843-792-8854, solomonk@musc.edu