^{CATARACT SURGERY
How to Succeed in the New Age of Cataract Surgery}
By Farrell C. Tyson, II, M.D., F.A.C.S.

After completing my residency in ophthalmology at the Medical University of South Carolina Storm Eye Institute in 2001, I returned to my home state of Florida and joined Cape Coral Eye Center. From the beginning, in conjunction with practice founder Benjamin G. Martin, M.D., F.A.C.S., I decided to play to my strength of being up-to-date on the "latest and greatest" in cataract surgery technology.

We advertised our use of square-edged IOLs and cold phaco and why they're good for patients. We became the first practice in Southwest Florida to perform bi-
manual microincision procedures and the first nonacademic practice in the state to implant the Tecnis IOL. In other words, we did everything we could to provide what state-of-the-art cataract surgery really is today: lenticular refractive surgery. This strategy was a perfect fit with Cape Coral Eye Center's motto: "Modern Technology With Old-Fashioned Concern." It also positioned me to quickly and effectively adopt subsequent emerging advances, including presbyopia-correcting IOLs.

Offering presbyopia-correcting IOLs alongside wavefront-designed and other modern monofocals allows us to custom-tailor an IOL option for each patient. With so many options now available, there certainly is no such thing as cookie-cutter cataract surgery anymore. Helping patients achieve their specific visual goals is more complex and requires a bigger commitment than ever. At the same time, it has opened new doors for our practice and has been well worth the effort professionally and financially. 

Those of you who are just starting out in practice will need to be proficient lenticular refractive surgeons or risk being left behind by the market. With that in mind, this article touches on what I think are the major keys to success in this area.

Learn How to Perform LRIs

If you didn't learn how to perform limbal relaxing incisions during your education and training, you'll need to learn now. Many IOLs, including the ReZoom and the ReSTOR presbyopia-correcting IOLs, are sensitive to cylinder, which you need to correct to obtain the best results. If more than 0.75D of cylinder remains postoperatively, it can begin to adversely affect near vision.

I found that LRIs are technically not very difficult, but I did need to reach a certain comfort level. They are most predictable for lower levels of astigmatism and are more reproducible when performed prior to any other manipulation of the eye. You can perform them a second time in the same patient, but if you didn't produce a good effect the first time, you likely won't the second time. Some patients' healing rates are just not compatible with maximal results.

Use the Best Measurement and Calculation Tools

Your preoperative measurements and IOL calculations are crucial steps toward achieving your desired refractive outcomes. For lenticular refractive procedures, contact biometry is not standard of care. The IOLMaster or an immersion A-scan instrument is essential. I primarily use the IOLMaster, but I also use immersion biometry for hard-to-get readings, such as in cases of dense posterior subcapsular cataracts. Immersion is highly accurate and a good option if you can't afford an IOLMaster right away.

For corneal measurements, use something that is reproducible in your hands, whether it is built into your IOLMaster, a keratometer or a topographer. I use topography so that I have information about corneal curvature beyond the central 3 mm. In order to optimize your IOL power calculations, which you also should do, you need reproducibility, as few variables as possible. Therefore, before you transition to presbyopia-correcting IOLs, you need to be getting accurate measurements and results with monofocals.

I choose presbyopia-correcting IOL powers so that the end result is plano or a little minus for each eye. Some residual myopia leaves room for the hyperopic shift patients perceive after LRIs. The ReZoom seems to tolerate minus better than plus. Also, I don't stagger the two eyes' end refractive powers. The ReSTOR needs both eyes to be the same for the best results. The ReZoom is somewhat more forgiving but works best when both eyes are the same.

Select Only Ideal Patients at First

Choose your first presbyopia-correcting IOL cases wisely. Start with patients who are ideal candidates. The ideal patient for a ReZoom lens, for example, is a low-grade hyperope, age 55 to 80, who is experiencing cataractous changes, looking for usable near vision, and has less than 1.50D of astigmatism, which can be treated with an LRI. Once you're more familiar and comfortable working with the lenses, you can implement them into a larger cross-section of your patients.

Ready to be a Cataract Surgeon? Not Unless You're a Refractive Surgeon, Too. By I. Howard Fine, M.D.

As a newly trained ophthalmologist, you are entering your chosen field at a time of significant change. Driven by the evolution of IOL technology, lenticular refractive surgery, once the purview of practices offering phakic IOLs and refractive lens exchange, is now squarely in the realm of the cataract surgeon as well. Cataract patients know that today's IOLs can do more than ever to improve their vision, and they expect their surgeon to deliver those benefits. The Medicare rule change allowing beneficiaries undergoing cataract surgery to opt for a presbyopia-correcting IOL was a major impetus for this change. The ruling represents a quadruple win. Patients have access to a wider range of options. Industry benefits from a return on its investment in research and development. The government is relieved of the burden of covering higher costs. And you have the opportunity to provide the new technology to a larger pool of patients, many of whom are willing to pay the fees required to achieve their best possible vision. All of this means that you have in front of you both a tremendous opportunity and a tremendous challenge. First, you'll need the right mindset. As a cataract surgeon, you will no longer just be treating pathology. You will be a partner in addressing your patients' quality-of-life goals. This means that the old model of high-volume, efficient, low-cost surgery is no longer good enough. You will need to practice high-quality, personalized, patient-pay care. That raises the bar significantly for you. Everything you do — measurements, calculations, surgery, explaining options and relating to your patients — has to be better. Your first order of business should be to educate yourself. Understand all of the characteristics of and compromises associated with each IOL. Then commit to cutting-edge surgery. Learn how to evaluate pre-existing astigmatism by vector analysis. Learn how to perform limbal-relaxing incisions to correct astigmatism. Make sure you have access to the best of everything: knives, phaco equipment, personnel. Take courses, hear experts speak and watch them in action at their practices. Listen to your patients so you can custom-match their vision goals with the right IOL, including creating different refractive outcomes in each eye if necessary. Work with them to achieve their goals, while being realistic at the outset about whether you can achieve them. Don't be surprised if you need to bring your senior colleagues up to speed on the opportunities and challenges. It may have to be you who pushes for access to an ASC, for example, so that you can control your operating environment. Otherwise, it will be very difficult to compete in the new practice model. Just as we saw with previous changes from extracap to phaco and from no IOLs to IOLs, we are now seeing early adopters moving the market forward. Others will follow, and some will refuse to change. It's up to you to decide where you want to fit into that spectrum. Dr. Fine is a clinical professor of ophthalmology at the Casey Eye Institute at Oregon Health & Science University in Portland. He's also in clinical practice with Drs. Fine, Hoffman & Packer, LLC, in Eugene, Ore.

Create Realistic Patient Expectations

Because all of today's vision-correction options involve trade-offs for patients, making sure they have realistic expectations about their outcomes is important. I use waiting-room videos and brochures about IOL options to start my patients thinking about what they're hoping to gain from their surgery. However, nothing replaces a one-on-one conversation with me. I spend 3 to 5 minutes longer with patients today than I did in the past, explaining options and, most importantly, listening to what they want. The good news for you is that as a new ophthalmologist, your schedule likely won't be saturated right away, affording you the time to spend with patients and hone your patient-selection skills.

Together with exam results and what I can accomplish optically, this conversation leads me to the best option for each patient. I ascertain whether they use near, intermediate or distance vision the most by asking them what they do most. Read? Sew? Use a computer? Drive at night? Do they want near vision just to get around, or are their near-vision needs more precise? Each IOL has strengths and weaknesses in these areas.

For patients considering a ReZoom or ReSTOR lens, I explain that the lens will give them the ability to do much more without glasses than a monofocal lens would, but they may still need to wear reading glasses for some activities. I also make them aware of possible glare issues even though many will not have a problem. In my experience, glare disappears for most patients over the first 3 postoperative months as their brain adapts to their new vision. Only 4% of my patients implanted with one of these lenses report problems with glare after 3 months. This compares with 2% of my monofocal lens patients. If you don't mention the possibility of glare to pa-
tients, you will surely hear about it, but when patients are informed about it, they tend to mentally minimize it if it does occur.

During the one-on-one conversation, I also ascertain whether the patient is a glass-half-empty or a glass-half-full person. Attitude has a lot to do with willingness to adapt to vision with multifocal lenses. Personality is important, too. Picky or extremely detail-oriented pa-
tients will want perfection, which I, or you, should not promise. These types of patients are often never satisfied, so I don't recommend presbyopia-correcting IOLs for them. Some of my most unhappy patients have had the best results on paper.

Parting Pearls

Before making the final decision to proceed with a presbyopia-correcting IOL, I check patients for dry eye. Early on, I realized that dry eye can add to the glare some patients experience. This has not been an issue since I've been treating all dry eye preoperatively with punctal plugs or Restasis. Also, by choosing patients wisely and using LRIs, I've been able to avoid using LASIK as an enhancement tool. LASIK after presbyopia-correcting IOL surgery is not ideal because of possible dry-eye effects as well as the potential for further reduction of contrast sensitivity. Also for contrast-related reasons, I recommend treating posterior capsular opacification aggressively in these patients.

In addition, I never hesitate to recommend against one of these IOLs. When you tell patients they aren't good candidates, they are among your happiest patients because they realize you are an ethical doctor with their best interests in mind. And they convey that to their friends and relatives. For patients who are not well-suited for presbyopia-correcting IOLs, we turn to our other effective options.

Finally, your staff members need to be just about as prepared as you are before your practice can succeed with lenticular refractive surgery. Provide them with enough information about each IOL to answer basic questions from patients, who expect everyone at the practice to be knowledgeable. I meet with our staff after-hours on a regular basis to update them on new developments and the results we are producing with each lens. Everyone needs to be confident in the products and services you are providing.

What Will be Expected of You

Given the dynamics of refractive cataract surgery, your patients, employers and partners will expect a lot from you. If I were hiring a new associate today, I would be looking first and foremost for an ophthalmologist with a great chairside manner. The paradigm shift we are experiencing means patients are looking for a more personal, comfortable interaction with their doctor, who needs to be able to relate to them.

Second, I'd look for an ophthalmologist with good hands, i.e., capable of performing high-quality, reproducible surgery, including clear cornea phaco, LRIs and lens explants.

I'd also want someone who doesn't think a practice will be handed to him or her on a silver platter. I'd want the person to be able to relate to people outside the office as well as inside to connect with patients in the community as well as referral sources. These expectations may seem high, but today, it's all about having the total package.