Cataract Surgery with Premium IOLs and Refractive Surgery: Why I now do both

Special section sponsored by Alcon

By Robert J. Cionni, MD
Medical Director
The Eye Institute of Utah, Salt Lake City
Adjunct Clinical Professor
Moran Eye Center
University of Utah, Salt Lake City

With every passing year, surgical technology improves tremendously, providing our patients with a greater chance for improvement in vision and spectacle freedom. However, along with these improvements come significantly higher patient expectations. Having used almost every available style of presbyopiacorrecting IOL, I am assured of only one certainty … one can never be absolutely certain that the targeted refractive result will be achieved. Therefore, if we strive to meet our patients' expectations, we must be prepared to enhance the result with IOL exchange, piggyback IOL or laser refractive surgery. Although IOL exchange and piggyback IOL work quite well for purely spherical adjustments, they do not address residual astigmatism. Additionally, IOL exchange risks posterior capsule rupture and piggyback IOL risks chronic iris chafing. Therefore, for a number of patients, laser refractive surgery may be the best and most precise option.

In the past, I would ask a colleague experienced in laser refractive surgery to enhance these patients for a discounted reimbursement provided by me. Initially, he was happy to do so. However, as time passed, he became less and less excited to oblige my requests. Why? Well, these were some of the most difficult patients to manage as they were already unhappy with their initial results and now I was telling them that I had to send them to someone else to perform a procedure that I could not perform. My colleague was spending more time with these unhappy patients than with his own LASIK patients. Additionally, my patients began to doubt my abilities since I had to turn them over to another surgeon to manage my less-than-perfect results. I decided it was time to learn how to enhance these patients myself.

I began by observing my colleague with his own refractive patients; how he talked to them, how he evaluated them and how he performed the procedure. I then investigated the different laser refractive platforms in an effort to determine what might best suit my patients. I decided that a Wavefront Optimized® laser treatment was, without a doubt, the best option since the technology is designed to not induce aberrations that could worsen the quality of vision.

Although a wavefront-guided procedure theoretically might also accomplish this task, wavefront analysis is typically unreliable after placing a multifocal IOL because of the amount of light that is scattered during the aberrometry measurement, making a wavefront-guided ablation either unattainable or at best unreliable. I certainly did not want to use a non-optimized treatment that might induce additional higher-order aberrations in patients already known to have very high expectations.

Allegretto WAVE Eye-Q

Training and certification for the Allegretto WAVE Eye-Q turned out to be quite simple and straightforward and now both my patients and I feel better about my ability to enhance their refractive result without having to involve other physicians. The ability to perform a laser refractive procedure is really all that is necessary. I became Intralase approved in order to provide a more comfortable and quicker visual recovery option, and these benefits lead many of my premium IOL patients to LASIK.

As I became more and more comfortable with laser refractive enhancement, I have begun to offer primary LASIK procedures to expand my practice. Although laser refractive surgery is not the primary focus of my practice, adding it to my arsenal of procedures has allowed me to better manage my cataract and premium IOL patients as well as provide primary laser vision correction for those patients in my practice who desire less dependence on eyeglasses.

With the ability to perform Wavefront Optimized® laser refractive surgery, I can provide my patients with a full portfolio of refractive options including LASIK, phakic IOLs, RLE and customized cataract surgery with presbyopia-correcting or toric IOLs.