Getting the Best Results From Cataract Surgery

Fine-Tuning the Visual Results

Hello. I am Dr. William Trattler, Director of Cornea at the Center for Excellence in Eye Care in Miami, Florida. Welcome to Medscape Ophthalmology Insights. I am here at the American Academy of Ophthalmology (AAO) meeting in Chicago and I wanted to share with you some of the latest developments in cataract and refractive surgery.

One topic that comes up all the time is getting the best results for our patients undergoing presbyopic intraocular lens (IOL) surgery. For patients having either multifocal or accommodating IOL with cataract surgery, how do we make sure that they get the best results from the surgical procedure?

It is important to conduct the proper preoperative testing. For me, it boils down to 3 things. First, carefully check for dry eye. I like fluorescein staining to look for tear breakup time as well as the corneal staining pattern. Hopefully, there is no corneal staining and the tear breakup time is normal. If not, those patients need treatment.

The second very important test is topography. Corneal topography is a critical test before performing cataract surgery. It allows me to look at the symmetry of the cornea and identify patients who have subtle conditions of irregular astigmatism or forme fruste keratoconus, which we do pick up quite often.

A third test is an optical coherence tomography of the macula to make sure that the macula is pristine. If patients have epiretinal membrane or other problems, they may not be the best candidates for presbyopic IOL surgery.

We do everything we can do to make sure that we pick the perfect patients. In general, patients are very happy with presbyopic IOLs, such as a multifocal IOL or an accommodating IOL, and the happiness rate is pretty high. However, some patients are not happy with their [results after] surgery, and those are patients in whom we end up off target. They have either residual astigmatism or residual refractive error, and those patients were expecting great vision but instead they are still not seeing the way they expected to. In our practice, we have been using a common technique, which is performing either LASIK or photorefractive keratotomy (PRK) to fine-tune the visual results.

Patients who have already undergone one surgery are not always excited about undergoing a second surgery, but once you explain to them that we can provide better quality of vision, they will typically choose to move forward.

The first step before performing laser vision correction enhancement is performing a YAG capsulotomy in all patients. This is performed first because the capsule can contract over time and may cause the lens to shift. I perform the YAG first to make sure that I know exactly where things will be long-term. Once everything is settled in, we will repeat the refraction, figure out the residual refractive error, and then at that point it is very simple to perform either a PRK or LASIK. In general, the results are very effective at eliminating the residual refractive error and that makes patients very happy.

In summary, preoperative testing is critical to pick the right patients and make the right plan for our patients having presbyopic IOL surgery. After surgery, if they are not happy, it is typically residual refractive error, and both PRK and LASIK can definitely put us right on target to make our patients very happy.

The Challenge of Post-Refractive Surgery Patients

Another topic that came up here at the AAO meeting is how to handle patients who have had previous refractive surgery. This is becoming quite a common situation in my practice. About 1 in 7 to 10 patients have had previous LASIK or PRK surgery, and a very small percentage have also had previous radial keratotomy , and those patients can be a bit of a challenge.

I have found 2 simple solutions. The first is a nice online calculator from the American Society of Cataract and Refractive Surgery (ASCRS) that helps us figure out the right power of implant to put in the eye. In patients with previous LASIK, whether it was myopic or hyperopic LASIK, if we just use the standard formulas, we will end up off target. We have to adjust the formulas, and the calculator from ASCRS helps to do this.

I have also found that one formula in particular works very well, and this is the Haigis-L formula. The Haigis-L formula is designed to be used right out of the box. You perform imaging to get the length and shape of the eye, and it comes up with a calculation for either previous myopic or hyperopic LASIK surgery. I have found these results to be on target, so rather than using the calculator on the ASCRS Website, I typically will use the Haigis-L formula. It has worked out very nicely for me.

In summary, the patients who have had previous LASIK can be a challenge, but technologies like the Haigis-L or the calculator on the ASCRS Website can really help us put patients in the right situation.

Thank you for joining me. I am Dr. William Trattler for Medscape Ophthalmology Insights.