Cataract and refractive surgery convergence bridges skill, mindsets

Cataract surgery and refractive surgery are merging into one discipline. This convergence reflects a bridging of the skill sets and the mindsets from refractive surgery pioneered by Jose Barraquer, MD, to the technology of the cataract and IOL surgery proposed by Charles Kelman, MD, explained Stephen Lane, MD, during the 29th Binkhorst Lecture at the American Society of Cataract and Refractive Surgery's opening general session.

"Historically, cataract and refractive surgery have been specialties separated by skill sets, equipment requirements, patient demographics, reimbursement processes, and marketing approaches," Dr. Lane noted.

"The synergism of these skill sets today allows the convergence of new treatments that are individualized to optimize patient results," he continued. Dr. Lane is in private practice in St. Paul, MN, and adjunctive professor, University of Minnesota.

Considering all the surgical options, Dr. Lane focused on refractive lens exchange.

"I believe that this is where there is the greatest potential and where the future of refractive surgery lies," he emphasized.

Dr. Lane reviewed the trends in lens removal techniques, including the use of lower ultrasonic energy, higher vacuum, and manual nucleus disassembly. He described the advantages of WhiteStar (Advanced Medical Optics), AquaLase technology (Alcon Laboratories), and torsional phacoemulsification. He also described the various IOL designs that are commercially available and their attributes.

"It should be clear that the bar for visual rehabilitation with IOLs has been raised. We now have the capability to insert IOLs through ultra-small incisions with accommodating and multifocal lens designs. These lenses can offer excellent uncorrected simultaneous distance and near vision, minimize aberrations, block ultraviolet light, and be inserted from a preloaded injector. Some day we may have the potential to adjust the power of the lens after it has been placed into the eye. When we begin to appreciate the potential synergy among all of these technologies, it is obvious that we are individualizing IOL treatments on a patient-by-patient basis," he underscored.

The barriers that ophthalmologists must overcome, according to Dr. Lane, to adopt these technologies include overcoming lack of knowledge about how to advise patient choices, and overcoming confusion in the light of few studies and many observations. He advised ophthalmologists to get involved and become knowledgeable to guide their patients.

"We have at our disposal an exciting armamentarium of technologies that offer the potential for a better life for patients," he said. Individualized care is possible, Dr. Lane said.

"But more important than what technology is available, is who we will be using it on. The advent of techniques has made removal of the crystalline lens safer," Dr. Lane said. "I believe that lensectomy with IOL implantation is the future of refractive surgery.

"Lens removal will be the procedure most commonly performed on patients under 65 years of age," he concluded. "Patients will receive a safer and effective procedure with improved outcomes long before a cataract develops."