Take-home message: In this third of a four-part column, Arun C. Gulani, MD, continues the discussion on staged cataract surgery.
As outlined in the second part of this series on staged cataract surgery, the procedure can be categorized into two simple strategies: Inside-out and outside-in staged surgery.
The inside-out approach in most cases has a potentially measureable cornea (to determine the IOL power as accurately as possible) and the IOL placement presents the refractive endpoint for the most needed laser ablation profile, i.e., myopic/hyperopic (PRK mode) to then correct the corneal pathology as well as result in emmetropia simultaneously.
With the inside-out staged concept, cataract surgery is performed with the goal of arranging the inner optics of the eye to result in a final optical endpoint that appropriately presents the cornea as a vision rehabilitative platform for correction by laser vision surgery. Therefore, the internal surgery is performed first (cataract surgery) followed by external corneal surgery. This obtains the best vision potential and designed refractive endpoint for each eye.
Conversely, the outside-in approach can be used in patients in whom the corneal status prevents accurate IOL calculation or when the corneal status is a hindrance to safe, planned cataract surgery. These poorly measureable or scarred corneas need to be corrected (Corneoplastique as described in previous columns) with various modalities, such as Intacs (Addition Technology)/amniotic graft/lamellar graft/laser Corneoplastique, etc., and then with this measureable cornea, we proceed to the final internal IOL placement (cataract surgery) toward emmetropia.
In every case I work on, my 5S system works as my mental “coin sorter” to allow me to use more than 50 different refractive surgery techniques to be combined with unlimited permutations of technology while respecting all of my Corneoplastique principles (elegant, brief, topical, least interventional, and visually promising).