Eyeworld

I N FOCUS 40 | EYEWORLD | AUGUST 2019 CATARACT SURGERY POST-LVC Dr. Kugler echoed similar thoughts. "What I say is, 'You had this done a long time ago and it's been great for you. The downside of all these years of glasses-free vision is the calcula- tions that we're going to do for your lens at this stage are going to be more complicated,'" he said. Dr. Kugler also sees many post-RK patients who think that cataract surgery is going to give them the vision all their LASIK friends have been raving about. However, even if you deliver a 20/20 J1 outcome, the RK patient often isn't satisfied due to higher order aberrations, he said. "The post-refractive RK patient's expecta- tions are not in line with what the surgeon can realistically deliver with the current technology. This is an area where small aperture lenses, such as the IC-8 and the Light Adjustable Lens [RxSight], may have a benefit," Dr. Kugler said. It's not just what you say to the patient, however, it's what they remember. Dr. Clinch estimated that patients only remember about one-third of what physicians tell them, and that is usually the information that they wanted to hear. Dr. Clinch uses repetition in counseling by technicians, counselors, and the surgeon to em- phasize important information. He uses visual demonstrations by moving the patient's hand to different positions to demonstrate the potential visual range. He also emphasizes a delay in visu- al rehabilitation for intermediate and near vision with a presbyopia-correcting lens. Patients often gain the visual function more quickly, which makes them feel like "overachievers," Dr. Clinch said. Dr. Waltz includes family members in con- sults because collectively, the patient and their family are more likely to remember what he says to expect postop. In general, Dr. Waltz said "just about any- thing can happen postop as long as the patient is expecting it. Where it breaks down is when you surprise the patient." IOLs. He will either set both eyes for distance or will consider monovision after the patient is satisfied with distance vision in the dominant eye. Dr. Clinch noted that he uses a femtosec- ond laser in all refractive cataract procedures. Femtosecond laser-created arcuate incisions will reduce or eliminate even small amounts of astigmatism, which is beneficial to the visual outcome; however, in post-LASIK patients, the corneal flap makes the effect of the incisions less predictable. For that reason, he is more aggressive in employing toric IOLs for slightly less than 1 D of astigmatism, especially against- the-rule. In patients with coma, Dr. Waltz has experience with the IC-8 small aperture IOL (AcuFocus) and said it can fix that problem "spectacularly well." Overall, Dr. Kugler said one of the biggest considerations in his IOL selection is what his enhancement plan will be if he doesn't nail the target. In terms of monovision, if the patient al- ready has it, both Dr. Kugler and Dr. Waltz said they will optimize it, as it's likely the patient has adapted to it. Similarly, if a patient was using multifocal contacts and doing well, Dr. Waltz said he would be more likely to use a multifocal IOL, thinking it's "better to improve on what the patient has than subject them to a whole new set of compromises." Setting expectations "I think that more than ever the post-refractive patient is the one that requires the most time preoperatively," Dr. Williamson said. The "wow" factor they had if they had LASIK is more delayed with cataract sur- gery, and that expectation needs to be set, Dr. Williamson said. It could take weeks or, in the case of RK patients, months to reach complete healing and final refraction. As with any cataract surgery patient, Dr. Williamson emphasizes that the surgery will not return them to vision of their 20s. continued from page 39 Financial interests Clinch: Alcon, Johnson & Johnson Vision Kugler: Johnson & Johnson Vision, STAAR Surgical Waltz: AcuFocus, Johnson & Johnson Vision Williamson: Alcon, Johnson & Johnson Vision

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