Are you seeking to broaden your refractive surgical offerings but are overwhelmed by the many options? Since the debut of radial keratotomy in the 1970s, cataract and refractive surgery in the United States has exploded to include several advanced corneal laser vision correction and lens-based techniques. At the Real World Ophthalmology (RWO) meetings, many of our faculty give practical tips for successfully performing these surgeries and encourage early career surgeons to expand their refractive surgical toolbox to encompass the wide breadth of technology available. In this month’s RWO Corner column, we provide an overview of current surgical options and tips for optimal patient selection.
Refractive Cataract Surgery
With the rapid expansion of IOL technology in recent years, many cataract surgeons now consider cataract surgery to be refractive surgery. There are several IOL options available to optimize refractive results based on patients’ ocular condition and lifestyle.
Multifocal IOLs (MFIOLs): MFIOLs provide vision at multiple distances (ie, near, intermediate and far for trifocals) and reduce the need for glasses. However, they use diffractive optics that can cause positive dysphotopsias (glare, halos, starbursts) and diminished contrast sensitivity. Careful patient selection and counseling is essential. MFIOLs are best suited for patients seeking spectacle independence but should be avoided in patients with significant retinal, macular or corneal conditions.
Extended Depth of Focus (EDOF): EDOFs offer a continuous range of vision from intermediate to distance with some near capability, while maintaining a low visual disturbance profile. The ideal patients are those with healthy eyes who want some spectacle independence (though they will likely still need readers) but want to minimize the risk of positive dysphotopsias associated with MFIOLs.
Toric: Astigmatism as low as 0.5 D can diminish functional vision. Toric IOLs correct astigmatism (0.75 D to 4.75 D) and are available in monofocal, EDOF and MFIOL varieties. For smaller amounts of astigmatism, limbal relaxing incisions can be used to flatten the cornea (performed manually or with a femtosecond laser), reducing the need for glasses for both distance and near.
Light Adjustable Lens (LAL): LALs are monofocal lenses that can be fine-tuned postoperatively using UV light to adjust the final refractive power. This flexibility is particularly useful for patients with uncertain refractive outcomes (ie, postrefractive) or those desiring precise visual results.
Enhanced Monofocal-Plus: These lenses offer enhanced distance vision with additional intermediate capability, providing a middle ground between traditional monofocal and multifocal options. They are ideal for patients seeking improved intermediate functionality for tasks without glasses (ie, computer work), who aren’t candidates for MFIOL or EDOF due to lifestyle or cost considerations.
Laser Vision Correction
Laser vision correction (LVC) (LASIK, PRK and SMILE) addresses refractive error by reshaping the cornea. Each technique has unique advantages and considerations based on patient corneal anatomy and lifestyle needs.
LASIK (laser-assisted in situ keratomileusis): LASIK uses an excimer laser to reshape the cornea after creating an epithelial flap. It treats myopia, hyperopia and astigmatism in patients with adequate corneal thickness (450-550 µm). Although LASIK offers rapid visual recovery and minimal discomfort, it carries risks of flap complications and dry eye syndrome due to corneal nerve disruption.
PRK (photorefractive keratectomy): PRK involves removing the corneal epithelium with alcohol before performing stromal ablation with an excimer laser. It corrects myopia, hyperopia and astigmatism. Ideal for patients with thinner corneas or higher trauma risk, PRK avoids flap issues but has a slower recovery, more postoperative discomfort and a risk of corneal haze with epithelial healing.
SMILE (small incision lenticule extraction): SMILE uses a femtosecond laser to create a lenticule (layer of corneal stroma) which is removed manually through a small incision. It can treat myopia and astigmatism but is not yet FDA approved for hyperopia. SMILE offers quicker recovery from postoperative dry eye syndrome with greater preservation of corneal nerves.
Phakic IOL
Phakic IOLs or implantable collamer lenses (ICLs) have become an excellent option for patients seeking refractive correction who have contraindications for LVC (ie, thin cornea or high myopia) or for those who prefer to preserve their corneal tissue. An ICL is implanted into the ciliary sulcus without removing the natural lens. The EVO ICL (STAAR Surgical) is currently approved to treat myopia (-3.00 D to -20.00 D) and astigmatism (up to 4.00 D). ICLs should be avoided in patients with shallow anterior chamber depth, uveitis, cataracts, glaucoma or decreased endothelial cell density.
Build Refractive Surgery Into Your Practice
Young ophthalmologists caring for the next generation of patients should consider building refractive surgical options into their practice and include all the available lenticular and corneal-based surgical options to maximize outcomes. Mastering these surgical techniques and the nuances of patient selection allows the surgeon to personalize outcomes and improve patient satisfaction. OM
Authors’ note: Want a chance to learn more? Join us at RWO for our action-packed events offering practical, curated tips and hands-on experience with these new technologies delivered by experts from around the world. Sign up at RealWorldOphthalmology.com today to become a member (free) and receive early access to all our in-person and virtual educational events.
