You know the feeling. It's that sense of personal accomplishment you get when you're sitting in front of a satisfied patient who's put his trust in you and allowed you to perform cataract surgery. Sometimes this feeling can be triggered by a quiet look of contentment from the patient that says your efforts are appreciated. Sometimes patients will even admit that they're overwhelmed with their visual results.

These happy patients now experience a new freedom in their lives. In many cases this includes the ability to drive and read without glasses -- something these patients may not have been able to do since early adulthood.

Wouldn't it be nice to be able to provide this level of spectacle freedom for almost all of your cataract patients? You can. By organizing a structured refractive cataract surgery program -- one designed to educate and motivate staff members involved in the surgery while monitoring and improving your team's tools and technique -- you can dramatically improve your level of refractive outcomes.

The following 10-step strategy has produced great results in our practice. Clear uncorrected vision for our patients has become commonplace rather than accidental.

Why not try it in your practice?

Improving outcomes will require a team effort, so the first step to take is to formally identify the team and its members. The team should include the surgeon, the biometrist, staff members involved with IOL calculations and anyone taking part in pre- and post-operative data collection. It should also include technicians involved with pre- and post-operative refractions, and anyone in your office who inputs clinical data into a computer software program for cataract surgery.

It's important that everyone on the RCS team understands the purpose of the team: to improve your patients' outcomes.

Everyone on the team will have to meet certain expectations in order to improve your surgical outcomes. For that reason, every team member must "buy into" the concept of working together to achieve better refractive results.

Assemble your team members and explain the process that will be involved in accomplishing this goal and how it will lead to improved outcomes. Make it clear that this will benefit both your patients and the members of the team. Then make sure that every member of the team is ready and willing to make the extra effort necessary to accomplish your goal.

Some parts of the surgical process -- in particular, calculating the proper IOL power -- are probably a mystery to many members of your team. (The process appears to be more complex than it actually is, and we're guilty of "muddying the water" with confusing terminology.) Team members who collect relevant information but don't really understand how it's used may see their jobs as mundane; they may not appreciate how much of a difference greater accuracy could make.

All team members should understand the essential ingredients in IOL calculations and how the calculation is done. This should lead to more job enjoyment and a real interest in improving refractive outcomes. (For help sharing this information, see "Teaching IOL Calculation Formula Basics," below.)

Some team members also may not fully understand the fundamentals of astigmatism. Teach your technicians to think of astigmatic error in three dimensions. Use the back of a tablespoon to demonstrate what with-the-rule, against-the-rule and oblique astigmatism look like. Then use actual patient examples to illustrate the unwanted visual effects of post-op astigmatism. Once your technicians understand the impact this has on real patients, they'll be much more interested in working to prevent this kind of outcome.

Also, include instruction on methods for reducing post-operative astigmatism when it does occur. (See step 10.)

I like to think of the different areas of the RCS program as "systems." This serves a very practical purpose: When problems arise within these systems, we can blame the system instead of the people. (Obviously a human element is involved, but we're often guilty of creating protocols that don't allow staff members to perform at their best. Also, focusing on correcting the "system" minimizes blame and resentment.)

Systems that should have established protocols include:

• biometry
• surgery
• postoperative examinations
• data collection.

Protocols for all these "systems" need to be established before the next steps are taken.

In order to know what goals will be reasonable, your RCS team should determine your present levels of accuracy:

• How often is the post-op refraction within 0.50D of the spherical target?
• How often do your patients have 1.00D or less of postoperative astigmatism?
• How often do your patients achieve at least 20/30 and J3 vision after surgery?

The easiest way to organize and summarize your outcome data is to use a computer. Many of the computer programs available to help surgeons with IOL calculations, such as Holladay IOL Consultant, Hoffer Programs and ICS, include databases for following postoperative results.

The software program that we use the most is the Holladay IOL Consultant. This program now has an additional database, the Surgical Outcomes Assessment Program (SOAP), which provides us with graphic analysis of postoperative IOL powers, IOL accuracy and astigmatism levels.

If you don't have a computer program to help you analyze your data and create a spreadsheet, random sampling of your data (IOL power accuracies, final postoperative astigmatism levels and uncorrected vision outcomes, distance and near) should work just as well. An "IOL worksheet" can also be beneficial. Before we began using computer programs, we used such a worksheet and found it helpful to have the pre- and post-operative data available in one area of the chart.

Once you've established your current outcome level, decide how much improvement you'd like to see in the three important areas for patient satisfaction: IOL accuracy, post-op astigmatism and uncorrected visual acuity.

Discuss the goals you set with the team members who will be directly affected by them. If they have a hand in creating them, they'll be much more likely to achieve them.

These are the goals that we've set for our team:

• IOL accuracy: �0.50D at least 80% of the time
• astigmatism: �1.00D at least 90% of the time
• VA: 20/30, J3 at least 90% of the time.

Meet with team members and look for the weak points in your current techniques and the strategies within each system:

• keratometry
• axial length measurements
• lens constants
• data entry
• post-op refractions.

These "weak points" can be the initial focus of your efforts to improve outcomes.

You can draw upon a number of resources:

• Have team members read "how to" articles.
• Seek out expert advice. This could include having experts (in areas such as biometry) visit your practice.
• Visit other practices where quality work is performed.

Don't be surprised if you find you need to upgrade techniques and/or equipment in order to improve your outcomes.

Here are some specific suggestions:

• Personalize your lens constants.
This is an important part of your team's efforts to improve results. For best results, measure at least 20 IOLs of the same type with stable refractions and good endpoint acuities of 20/30 or better (20/20's or 20/25's are best). Measure them at least 1 month post-op.
Computer programs are now available that can help you personalize your lens constants on an ongoing basis.
• Upgrade your biometry technique and equipment.
Biometry is a crucial area in which outdated equipment and techniques can seriously undermine the quality of your outcomes. (For advice on upgrading your biometry data, see "Bringing Biometry into the 21st Century," on page 86.)
• Upgrade your surgical technique.
This might include switching to small phaco incision surgery, using topical anesthesia instead of using a block, and making the effort to reduce unwanted postoperative astigmatism with techniques such as limbal relaxing incisions.
• Upgrade your surgical equipment.
New phacoemulsification technology is available in instruments such as the Allergan Sovereign, the Storz Millennium, and the latest computer software and ABS tips for the Alcon Legacy. This technology allows surgeons to perform cataract surgery using less ultrasonic energy, maintaining more stable anterior chambers.
For correction of astigmatism, look for limbal relaxing incision instruments such as those manufactured by Duckworth and Kent and by Mastel. Also, consider implanting the STAAR toric IOL, especially if you regularly implant plate haptic silicone lenses.

Once you've established your refractive goals, follow your results on a regular basis.

In our practice we have a post-op data collection system called the "Patient Satisfaction Program" that monitors our results on a monthly basis and tells us how consistently we're achieving the goals we've set. We assess the data 1 month postoperatively and report our results to the entire staff. (For an example, see "Monitoring Your Results," right.)

No matter how careful your RCS team is, an occasional patient will still be unhappy with his uncorrected acuity. To maintain your high rate of excellent outcomes, be prepared to perform further correction whenever necessary.

• Induced or residual astigmatism.
Limbal relaxing incisions are an excellent way to deal with this. However, unusually high levels of post-op astigmatism call for careful inspection of the wound. In this situation, other methods such as central corneal incisions (astigmatic keratotomy) laser vision correction (photorefractive keratectomy [PRK] or LASIK), or wound revision may be a better alternative.
• Residual myopia.
For medium to low myopic surprises, the mini radial keratotomy (RK) procedure described by Dr. Richard Lindstrom offers significant advantages (especially for elderly patients). Laser vision correction is also an alternative.
If significant error is present, consider exchanging the IOL or piggybacking a second IOL. (It's now possible to piggyback minus IOLs.) Piggybacking may be the safer procedure if the patient is more than 3 months postoperative.
• Residual hyperopia.
A piggyback IOL is a reasonable solution. (Place the lens in the ciliary sulcus.) An IOL exchange can also be effective, especially if performed early in the postoperative period.
Laser vision correction has limited benefit here compared to other techniques because of the expense involved and the potential for unwanted postoperative visual aberrations.

Throughout the entire process, it's important for us to continue to motivate, stimulate and make this a fun experience for our team. The results will be well worth the effort.

Once your RCS team members are working together and committed to better results, they'll begin to see the fruits of their efforts. The entire team will have reason to celebrate their accomplishments. Knowing that they've made a real contribution to a patient's vision will increase their job satisfaction, and that, in turn, will lead to better performance.

It's an upward spiral, and everyone wins.

To bring your RCS team members up to speed, begin by stressing the five most important ingredients in IOL calculations. (As you know, some IOL power formulas require more than these five ingredients. These, however, are the "common threads" shared by most formulas.)

• Desired postoperative refraction
. A desired spherical equivalent postoperative refraction must be assigned to each eye preoperatively. (The same target refraction may not be appropriate for every eye). Most surgeons implanting monofocal lenses set the target at -0.50D. (Because this isn't an exact science, it's better to err in the direction of myopia rather than hyperopia.) In our practice, if monovision is the desired result, the near eye is assigned a -1.00 to -1.75D post-op refraction.
Multifocal intraocular lenses, such as the ARRAY lens, have been shown to provide both excellent bilateral uncorrected distance and near visual acuity. For ARRAY implantation, most practices have found the best refractive target to be plano to +0.25D. However, post-op myopia will limit uncorrected distance acuities. Also, myopic ARRAY IOL patients may experience more halos around lights.
• The K reading.
Many practices still perform manual keratometry for preoperative cataract surgery biometry. If this is the case in your practice, be sure to calibrate the keratometer regularly. Also, because poor mire clarity can adversely influence accuracy, mire clarity should be recorded for each reading. (Sometimes it's helpful to use artificial tears or simply ask the patient to blink frequently in order to improve mire quality.)
Automated equipment can help. Newer equipment has been shown to be equal in accuracy to manual keratometry for most patients. Since corneal topography is becoming more popular throughout refractive surgery, some cataract practices are using this method for keratometry.
Cataract patients who have previously undergone corneal refractive surgery are a growing concern. However, many excellent methods are available to help ensure that you get a correct K reading for these patients. (For more information on this topic, see "Modern IOL Power Calculations: Avoiding Errors and Planning for Special Circumstances," by K. J. Hoffer, published in American Academy of Ophthalmology Focal Points, Volume VXII, Number 12, Dec. 1999.)
• Axial length measurement
. Errors in axial length measurement are the cause of most IOL calculation errors. For standard eyes, an axial length error of 0.1 mm is equal to 0.3D of IOL error. This factor becomes even more significant with shorter eyes.
A-scan measurements should require reproducible axial lengths within 0.15 mm in the same eye and 0.30 mm in the fellow eye. If your technician isn't capable of attaining this level of accuracy, you're more likely to end up with IOL power surprises.
• Anterior chamber depth.
Technicians tend to rely on anterior chamber depth as a way to gauge the accuracy of the A-scan, particularly with applanation methods. (Measured axial lengths are more reliable with the deepest anterior chamber depths because deeper chambers are less likely to be affected by corneal indentation.)
Note: It's important for technicians to understand that anterior chamber depths are not the same as the "ACD" lens constants applied in the Holladay II and the Hoffer Q lens formulas.
• Lens constants.
In my experience, this is the most common source of confusion in IOL calculations.
For starters, we tend to call all lens constants "A constants." That can be misleading because this name applies specifically to the family of SRK formulas. For other formulas, different names apply to the lens constants:
• Holladay I: "surgeon factor"
• Holladay II: "ACD"
• Hoffer Q: "ACD."

Also, these lens constants are actually variables. They probably should be called "lens variables" or "lens factors."

To add to the confusion, manufacturers of new IOLs aren't allowed to calculate their suggested lens constants using human trials. As a result, the constants they recommend are only estimations of what would be best for most eyes. Therefore, personalization is important to optimize the accuracy and usefulness of the lens constants.

Many people think that "personalization" means the surgeon's personalization for a specific IOL type. However, this formula refinement can also be influenced by the biometry technician and the equipment that's being used to perform biometry. For that reason, these factors should also be taken into consideration when a lens constant is being personalized.

R. Bruce Wallace, III, M.D., F.A.C.S.

Accurate biometry is crucial for excellent IOL outcomes. Here are some ways to improve the accuracy of your data.

• Upgrade your biometry technique.
If you're still using applanation methods for ultrasonic axial length measurements, consider upgrading to immersion ultrasound. (Some practices have abandoned applanation methods altogether because of their unreliability.) This is especially helpful when checking short eyes or eyes that produce unusual results using other applanation methods.
Most technicians aren't familiar with immersion scans; they'll benefit from visiting practices that use immersion on a routine basis. Also, an excellent video presentation on immersion
A-scan is available through Dr. James Gills' office at St. Luke's Cataract and Laser Institute in Tarpon Springs, Fla. (For information, e-mail ultrasound@stlukeseye.com, or call (727) 938-2020, extension 2343.)
If you're considering switching to immersion techniques, some simple departures from applanation methods -- such as ceiling fixation and the use of Hansen or Prager shells -- can help improve results. (The Hansen or Prager shells will allow your technician to perform immersion on patients in a semi-recumbent position, rather than totally supine. This is more comfortable for the patient.)
• Upgrade your biometry equipment.
If your ultrasonic A-scan equipment isn't immersion compatible, consider purchasing newer equipment such as the biometers manufactured by Innovative Imaging Inc., Sonomed, Quantel Medical or Marco.
Another alternative is the recently FDA-approved IOLMaster from Zeiss Humphrey. The IOLMaster uses optical coherence biometry to accurately calculate axial length, as well as perform keratometry and measure anterior chamber depth.
In our experience, this machine offers multiple advantages:
• it's non-contact
• it's precise
• it's fast
• it shows the least technician variance
• it's technician and patient friendly.

The IOLMaster produces accurate readings for 90 to 95% of preoperative cataract patients. (However, it's still necessary to perform standard ultrasonic A-scans for patients who can't be measured with the IOLMaster, such as those with especially dense cataracts or fixation problems.)

-- R. Bruce Wallace, III, M.D., F.A.C.S.

In our practice, we've created a system called the "Patient Satisfaction Program." Each month we post a summary of our patients' visual outcomes following cataract surgery so our refractive cataract surgery team members can see how close we're coming to achieving our goals. (Graphic charts like the one below make it easy to see how well we're doing.)

- R. Bruce Wallace, III, M.D., F.A.C.S.

Dr. Wallace is founder and medical director of Wallace Eye Surgery in Alexandria, La., and assistant clinical professor of ophthalmology at Tulane School of Medicine in New Orleans. He's served as primary investigator for several investigational intraocular lenses and is currently president of the Society for Excellence in Eyecare.