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Refractive-cataract surgery: Overview of the current landscape


Demographic shifts, improving technology continue to bring patients in at younger age

While the number of candidates for cataract surgery continues to rise, the number of cataract surgeons is declining. Physicians who are willing to make a commitment to excellence in their practice and go that extra mile can succeed.

As the global population that is prone to developing cataracts continues to grow, ophthalmologist could be facing challenges as people live longer, increasing their odds for cataracts. Though this is a worldwide issue, in the United States, surgeons are performing about 4 million cataract surgeries each year.

It is estimated that there are about 30 million people worldwide who have cataracts of 20/400 or worse, and there are almost 250 million people who have cataracts between the range of 20/60 and 20/200. Cataracts are endemic.1,2

As technology improves, patients are more willing to undergo cataract surgery at an earlier stage as the reward of cataract surgery becomes much greater than the risk associated with it because it provides an opportunity to improve their quality of life.

Here are my thoughts on the ever-changing current landscape of cataract-refractive surgery. Patients’ growing confidence in cataract surgery is a byproduct of better technology. As technology has improved, it has made cataract surgery not only more efficacious but also safer. When I evaluate cataract surgery, I look at a procedure that has become extraordinarily successful, with much less risk and much greater reward.

Cataract surgery, for many patients, has become the “fountain of youth” because they can reverse the aging process and restore natural vision in a way that was not possible before. When I first started practicing in 1985, cataracts were the defining moment of old age, and postoperative quality of vision was significantly diminished. Therefore, it was common to wait until patients’ visual acuity was 20/70 before performing surgery.

Our goal was to remove the cataract and restore the patient’s vision with glasses. Now we can remove the cataract to improve their quality of vision and remove their refractive error- including hyperopia, myopia, and astigmatism. We can also improve their vision at near as well-with either monovision, extended-depth-of-focus (EDOF), or multifocal IOLs-to resolve refractive error and in some cases presbyopia as well.

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Expectations changing

During my career, I have noticed an extraordinary increase in patient expectations, and that frightens many cataract surgeons. I view that in a different light and consider demanding patients to be opportunities to meet or exceed their expectations. Demanding patients, while more challenging, also present an opportunity to provide patients with better-quality vision.

These are the patients who need to have the best diagnostic instruments available to make sure the cataract surgery is done with the greatest chance of achieving emmetropia.

It means you should have good surgical technique, and you should use the best equipment available to achieve these results. Part of any refractive cataract surgery procedure is having an “escape valve,” a technique for resolving residual refractive error.

That “escape valve” might be limbal-relaxing incision, an IOL exchange, LASIK, PRK, or small-incision lenticule extraction (SMILE). New technologies help improve outcomes, allowing refractive cataract surgery to truly come of age. Surgical technologies should allow cataract surgery that is extremely accurate, low risk, and effective.

That means using advanced diagnostic technology to make certain that we diagnose patients correctly with cataracts, rule out concomitant pathologies, implant the correct IOL with a high degree of accuracy, and treat astigmatism accurately.

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Diagnostic technology

Refractive cataract surgery began with the advent of optical biometry (IOLMaster, Carl Zeiss Meditec) because it dramatically improved the accuracy of IOL measurements that allow us to achieve emmetropia in significantly more patients than we ever could with previous generations of biometry.

As optical biometry has improved, we have new generations of this technology that provide telocentric keratometry, which is able to locate the fovea and diagnose foveal disease; it can see through dense cataracts and improve the accuracy of IOL power and toric IOL measurements.

Macula OCT (Cirrus-HD OCT, Carl Zeiss Meditec) is another diagnostic technology that I use preoperatively to image macular pathology and health prior to cataract surgery. When I can view the macula, I can more accurately advise patients on what IOL is in their best interest because I have different levels of expectations for patients who have macular pathology, which is difficult to diagnose just by visualizing the retina.

I also use a topographer (Atlas, Carl Zeiss Meditec) to familiarize myself with the health of the cornea and the existence of astigmatism. Being able to document the cylinder quantitatively and qualitatively is predicated on having a good topography image. It aids in managing both their astigmatism and irregular astigmatism, which may change my choice of IOLs.

Once diagnostic decisions have been made, the next step is the execution of the cataract surgery. In our operating room, we also use a surgical microscope with stereo coaxial illumination (OPMI Lumera, Carl Zeiss Meditec), which provides a great red reflex.

For astigmatism management, we use a computer-assisted cataract surgery instrument (Callisto, Carl Zeiss Meditec), which takes information from the optical biometry to find the steep axis of the cornea and is instrumental for accuracy of toric IOL placement.

Finally, we have adopted lenses IOLs (Alcon Laboratories, Bausch + Lomb, Johnson & Johnson Vision) that have great optics with aspheric optics as well, including EDOF IOLs and multifocal lenses. I have found that low-add lenses provide better-quality vision.

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Reimbursements down

Out-of-pocket spending is now more frequent and accepted among patients. Patient-shared billing has become an important part of cataract surgery in the United States as refractive outcomes are not covered by traditional insurance.

Providing technology that improves the accuracy of refractive outcomes or treats astigmatism or presbyopia, benefit patients’ quality of life. These are technologies that patients want, and they believe that it’s a worthwhile investment in their future.

There is little that patients will benefit from more than cataract surgery. Many patients are willing to pay out of pocket for the best technology that meets their needs. As the technology gets better, patients are more willing to use patient-shared billing because the delta between the traditional surgery and the premium surgery has become more significant.


We anticipate that 2019, in hindsight, will have been another great year for cataract surgery. The number of surgical patients continues to increase, along with their expectations. The number of cataract surgeons is declining, however.

Surgeons who are willing to make a commitment to excellence in their practice and go that extra mile to give patients the quality of vision they desire, will have extraordinarily successful practices, grateful patients, and will be able to practice ophthalmology at the highest possible level. Refractive-cataract surgery is the future of our profession, and one of the most rewarding aspects of being an ophthalmologist.

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Eric D. Donnenfeld, MD
E: ericdonnenfeld@gmail.com
Dr. Donnenfeld is a consultant to AcuFocus, Alcon Laboratories, Allergan, Aquesys, Bausch + Lomb, Beaver-Visitec International, Glaukos, Johnson & Johnson Vision, Novaliq, Ocular Therapeutix, Omeros, Pfi zer, and Shire Pharmaceuticals. He consults and has investment interests in Katena, Novabay Pharmaceuticals, PRN Pharmaceuticals, and RPS Diagnostics.


1. Market Scope estimate based on WHO 2014 Global Data on Vision Impairment.

2. Chandra S. U.S. Consumer Confidence Just Hit Its Highest Level in Almost 17 Years. https://www.bloomberg. com/news/articles/2017-10-31/u-sconsumer-confidence-index-rises-tohighest-level-since-2000 Accessed May 13, 2019.

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