August 2019


Nuances of cataract surgery post-LVC

by Vance Thompson, MD EyeWorld Refractive Editor

A patient who enjoyed a crisp refractive surgery result years ago may have higher expectations than the typical cataract patient. They think that the process and efficiency of seeing great without glasses after cataract surgery will be like their prior precision laser vision correction. As such, it’s important to understand the nuances in education, setting pre-cataract journey expectations, diagnostics, implant choice, surgery, and enhancement for these patients. This issue’s In Focus series helps us better understand cataract surgery in those who have experienced refractive surgery vs. those with an untouched cornea.
Many prior laser vision correction patients who now have an early cataract present in our offices asking for treatment to “fine tune” their vision. Slit lamp exam might reveal an easily identifiable cataract, but as you work them up to rule out or rule in early lens changes as the culprit, remember that their lens can look deceptively clear and still be the reason for the blur. In these situations—refractive error plus a lens that is not obviously cataractous—I find patient history to be extremely important. If nighttime image quality is reduced and they have refractive error, I tell them that we do not understand how much of their blur is residual refractive error and how much is a potential lens issue. If their nighttime vision is crisp with glasses, they do not have a visually significant lens change. However, if their nighttime vision is not crisp with glasses and I have ruled out dry eye or corneal irregularity, then the lens is suspect. If dry eye or corneal irregularity is the culprit, the gas permeable contact lens over refraction will be crisp, and that information is so helpful.
If the blur is not from residual refractive error (as ruled out with glasses), dry eye/corneal irregularity (as ruled out with gas permeable contact lenses over refraction), or a retina/optic nerve problem, then the cause of blur starts to look like an aging crystalline lens.
Many post-refractive patients think they are too young for cataract to be their problem. In the past, technology did not support an early cataract diagnosis, but it does now, as the sources in this issue teach us. Even though nothing replaces being a good listener, a quality exam today uses these current technologies to diagnose and quantify optical scatter from an aging optical system.
Then there is the all-important implant. I think that the two biggest developments in my career have been laser refractive surgery to change corneal shape and the intraocular lens developments that help restore functions the lens lost—reading range and clarity. It is worth learning the details of modern-day implant options and how to maximize patient joy with them, be it a corneal adjustable implant, such as a multifocal that needs a PRK or LASIK enhancement at 3 months, or a Light Adjustable Lens (RxSight).
The doctors interviewed for this series are world leaders in post-refractive cataract surgery, and the insights they teach are so helpful to learn more about these nuances that are special to post-refractive cataract surgery. Thank you to everyone who contributed to this exciting issue dedicated to this important topic.

Nuances of cataract surgery post-LVC Nuances of cataract surgery post-LVC
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