At Press Time

Everything You Wanted to Know About Refractive IOLs

Dr. David Chang Compiles 1,000 Pages of Insights.

By Jerry Helzner, Senior Editor

■ "Cataract surgeons are spoiled in the sense that we have historically exceeded the expectations of the vast majority of our patients. Facing an unhappy refractive IOL patient despite flawless surgery with a 20/20 outcome is therefore a very uneasy and unfamiliar prospect. Patient selection and patient communication are the keys to the success, and therefore the growth of this premium channel."

So says David F. Chang, M.D., of Los Altos, Calif., one of the world's most highly respected cataract surgeons. Because Dr. Chang believes that presbyopia-correcting IOLs are one of the most important new developments impacting the practice of ophthalmology, he recently completed the most time-consuming project of his career — editing a 236-chapter, 1000-page textbook called "Mastering Refractive IOLs — the Art and Science" (Slack 2008). He contends that there has never been a greater need for physician-to-physician education than on this subject. For this book he enlisted more than 200 international authors who offer a wide diversity of opinions and practices.

Dr. Chang's basic impetus for compiling the book is his belief that we are currently in a time of revolutionary change for all cataract and refractive surgeons.

"Most cataract patients are now potential refractive patients and most presbyopic refractive patients are now candidates for refractive lens exchange. For cataract surgeons in particular, this new paradigm requires us to do far more than learn about new IOL technology," he asserts.

David F. Chang, M.D.

Dr. Chang says that cataract surgeons have had to quickly adapt to a greatly changed practice landscape.

He notes that surgeons have had to develop new skills in patient education and selection. They have had to learn how to choose the best IOL for each individual, while also managing their expectations and potential unhappiness with the results.

"In addition," he says, "we have had to train and educate our staffs, allow for additional chair time and preoperative testing, and deal with setting refractive pricing and financial policies for the first time.

The bottom line is that cataract surgeons have never before been faced with such a major transition in the way that they practice.

"Right now, we are all feeling both excited and a bit intimidated in this new environment," he says.

The book is designed to help surgeons cut through the diverse array of information and resources available on presbyopia-correcting IOLs and obtain helpful insights from a single source. It is designed to answer such questions as: "Where can the beginning surgeon go to learn the basics? Where can the experienced surgeon learn ways to improve or find help with challenging cases? How and where can all of this information be organized together?"

"I took an unusual approach by asking several different consultants to write chapters on the same topic," says Dr. Chang. "For example, there are six different chapters on the subject of setting patient expectations. I believe we can learn more from hearing how different surgeons approach this problem."

Dr. Chang says that his book covers "every imaginable topic and problem in the field of pseudophakic refractive IOLs." Beyond the fundamental material about refractive IOL design and surgical technique, there is a strong emphasis on preventing and managing complications and unhappy patients.

"I wanted to assemble a comprehensive collection of all of the clinical and non-clinical information that I think is essential to success, as well as topics that I personally wanted to learn more about. Therefore, most of the questions and topics arose out of my own experiences in transitioning to — and teaching others — about refractive IOL surgery."

Four other top cataract and refractive surgeons served as associate editors on the project.

"Doctors Steven Dell, Warren Hill, Dick Lindstrom and Kevin Waltz helped me to develop the list of topics and authors," notes Dr. Chang. "For every topic, I sought out those experts that I would most want to interview about their experience, opinions and approach. More than 200 authors generously wrote original chapters for this project. They really are an international "Who's Who" of refractive IOL experts." OM

GIVING BACK:

A Tropical Island Suits Dr. Khorram Dr. Khorram

He's the Only Ophthalmologist on Saipan.

By Jerry Helzner, Senior Editor

■ Every ophthalmologist has had the kind of day when the commute is horrible, the weather is miserable, the office is crowded, half of the staff calls in sick and the computer system decides to go on the fritz.

It is days like these that has doctors wishing they had decided to practice on a quiet tropical island.

Meet David Khorram, M.D. He is the only ophthalmologist on the Pacific island of Saipan and for the last 15 years has been building his practice, the Marianas Eye Institute, into one of the best-equipped eyecare practices in the Asia-Pacific region. The practice offers a full range of both retina and general ophthalmology procedures, utilizing state-of-the-art equipment such as optical coherence tomography and phaco.

After a residency at Northwestern University, Dr. Khorram passed up a fellowship because he wanted to practice in a part of the world that had a great need for an ophthalmologist. He chose the Pacific islands and, after a year practicing in American Samoa, made his way to Saipan. The island, located north of Guam, is the capital of the United States Commonwealth of the Northern Mariana Islands. Saipan was the site of fierce fighting in World War II as the United States established a base on the island for B-29 bombers that could reach the home islands of Japan. It was from here that the atomic bombs left for Hiroshima and Nagasaki.

It's no surprise that Dr. Khorram wanted to practice in an underserved area. Of Persian descent, he was raised in a small Appalachian coal mining community in Kentucky where his father still practices as a pediatrician. He attended Northwestern University, returning home for medical school at the University of Kentucky College of Medicine, where he graduated in the top 10% of his class. Dr. Khorram later scored in the highest 1% of ophthalmologists in the nation on his board-certification exam.

Dr. Khorram with a patient.

Dr. Khorram spent 1 year as the director of ophthalmology at the Lyndon B. Johnson Tropical Medical Center in Pago Pago, American Samoa, before coming to Saipan. For his first 5 years in Saipan, he worked at the Commonwealth Health Center before co-founding Marianas Eye Institute in 1998.

"There are about 20,000 permanent residents of Saipan and maybe another 40,000 contract workers, most of whom are from the Philippines and China," says Dr. Khorram. "Because people don't access eye care on a regular basis, we see a great deal of end-stage disease, such as white cataracts where the patient only has light perception. We also see cases of pterygium from ultraviolet exposure and we have had two cases of corneal worms."

Dr. Khorram sees "a ton" of diabetes-related eyecare problems but almost no AMD, which he attributes to the island's relatively young population as well as genetic factors.

At Marianas Eye Institute, Dr. Khorram has received national recognition through his listing in "Guide to America's Top Ophthalmologists."

"I am fortunate to work with such an exceptionally talented group of people at Marianas Eye Institute," says Dr. Khorram. "This national recognition belongs to them as well."

Dr. Khorram has immersed himself in community activities. One of his biggest projects was co-founding the Brilliant Star school with his wife, Mara, a former public health administrator who has served as school principal and is now active on the board of trustees. He has also written a weekly column for the island newspaper, organized a Marianas national soccer team and recently wrote a book ("World Peace, A Blind Wife and Gecko Tails"), much of which deals with his experiences as an ophthalmologist on a Pacific island. The book is available on Amazon.com

The Khorrams have four children, ages three, five, seven and nine. Despite drawbacks such as only getting to meet with colleagues at the annual Hawaiian Eye conference and not being able to easily obtain a wide variety of fruits and vegetables, the family is committed to Saipan.

"We've been here 15 years and don't anticipate moving. I'm always thankful to be here. The simplicity of life here far outweighs the inconveniences," Dr. Khorram concludes.