Eyeworld

R efractive cataract surgery is a term that has been around for a long time. Since the early 1990s, with the development of capsulorhexis and the advancement of small incision cataract surgery with foldable IOLs, refractive outcomes have continued to improve. Newer generation IOL calculation formulas, a clearer focus on biometry, newer forms of biometry with immersion and optical techniques, and improved methods for evaluation of the corneal curvature have continued to improve our refrac- tive outcomes. In fact, the "field" of refractive cataract surgery is undergoing an explosive growth at the mo- ment. One could argue that there has never been a better time to be involved in this area. Technological advances such as femtosecond lasers offer a possibility to improve the treatment of pre-existing astigmatism. They also show promise of an improved "effective lens position," or ELP, which may further improve refractive outcomes. De- signer incisions, custom capsulotomies, and intraocular aberrometers may all help in this area. Presbyopia correction continues to evolve. Multifocal intraocular and accom- modative IOLs, corneal inlays, and scleral surgical approaches are being pursued with interest. Surgical correction of astigmatism is a vital necessity if refractive outcomes are to be reduced. More than 50% of the surgical cataract population has pre-existing astig- matism that could benefit from surgical treatment. In a recent poll of ASCRS mem- bers, 36% of those who responded do not perform limbal relaxing incisions—the most common reason stated for not performing them was poor predictability. Im- proved techniques and newer technologies such as femtosecond lasers may help im- prove our outcomes. While it would be nice to always achieve a plano result following cataract sur- gery, the reality is, we are just not there. While our corneal refractive colleagues can boast a 20/20 rate greater than 90% of the time, the technology and the variables for improved predictability following refractive cataract surgery have not reached that level. Dr. Warren Hill has demonstrated in his review of worldwide data sets our best practices are at about 75-80% accuracy, a number we need to and will improve over time. Enhancements after cataract surgery are therefore a reality. Surface ablation and LASIK are techniques that cataract surgeons are now more readily adopting to their practice. Enhancements are even more commonly necessary in previous refractive sur- gical patients who are now undergoing cataract surgery. How should these patients be addressed in terms of their enhancement? Based on the results of the recent ASCRS poll, many surgeons will perform surface ablation over the flap, while many others will lift the flap even years out. In this month's issue, we will explore topics that are of importance to the emerg- ing refractive cataract surgeon. This issue will explore a few key areas that can assist with a transition from a traditional cataract to a more progressive refractive cataract surgery. How to manage astigmatism is a staple for refractive surgeons. When and how to perform relaxing incisions and when to use a toric lens versus a relaxing inci- sion will be addressed. How to treat the near emmetrope for the correction of presby- opia will also be addressed. This article focuses on surgical considerations, patient selection, cornea-based options, and upcoming technologies. The management of astigmatism and presbyopia are growing areas for refractive surgeons to integrate into their practice. As a practical matter, enhancements are part of refractive cataract surgery. This issue will focus on surface ablation techniques as well as tips to avoid complications such as inflammation, haze, and scar formation. How to deal with enhancements in patients who have undergone previous refractive surgery is also addressed. With mil- lions of patients having already undergone surface ablation or LASIK eye surgery, and with baby boomers approaching the cataract age, this is expected to become more im- portant over time. Finally, as with all surgery, but especially with elective eye surgery, managing ex- pectations and providing optimal customer service is an essential part of any practice. While our goal has always been to strive to achieve 100% patient satisfaction, the re- ality is not all patients will always be satisfied with their experience, outcome, or both. Managing unhappy refractive patients is an important part of any practice. As with all elective surgery, patients' expectations can be inflated and their demands can be far reaching. Yet elective refractive procedures can be a very rewarding part of today's ophthalmic surgical practice. Some of my happiest patients are from my re- fractive practice. It is just as important to focus on unhappy patients and occasionally they can ultimately be the ambassadors for your practice. Kerry Solomon Refractive Editor Publisher Donald R. Long   dlong@eyeworld.org Editorial Editor Stephanie Graham stephanie@eyeworld.org Assistant Editor Stacy Majewicz smajewicz@eyeworld.org EyeWorld Staff Writers Faith Hayden  faith@eyeworld.org Jena Passut  jena@eyeworld.org Production Graphic Designer Julio Guerrero jguerrero@eyeworld.org Production Manager Cathy Stern cstern@eyeworld.org 703-383-5702 Production Assistant Karen Salerni ksalerni@eyeworld.org Contributing Editors Vanessa Caceres  Lakeland, Florida Michelle Dalton  Reading, Pennsylvania Rich Daly  Arlington, Virginia Enette Ngoei  Singapore Matt Young  Malaysia Senior Contributing Editor Maxine Lipner  Nyack, New York Advertising Sales ASCRSMedia 4000 Legato Road Suite 700 Fairfax, VA 22033 703-591-2220 fax: 703-591-0614 eyeworld@eyeworld.org www.eyeworld.org Advertising Sales Managers Jeff Brownstein jbrownstein@eyeworld.org 703-788-5745 Paul Zelin pzelin@eyeworld.org 703-383-5729 Classified Sales Cathy Stern cstern@eyeworld.org 703-383-5702 EyeWorld Special Projects  and Events Jessica Donohoe jdonohoe@eyeworld.org 703-591-2220 ASCRS Publisher: EYEWORLD (ISSN 1089-0084) is published monthly by ASCRS Ophthalmic Services Corp., 4000 Legato Road, Suite 700, Fairfax, VA 22033-4003; telephone: 703-591-2220; fax: 703-591-0614. Printed in the U.S. Editorial Offices: EYEWORLD News Service, 4000 Legato Road, Suite 700, Fairfax, VA 22033-4003; toll-free: 800-451-1339, 703-591-2220; fax: 703-591-0614; email: eyeworld@eyeworld.org. Advertising Offices: ASCRSMedia, 4000 Legato Road, Suite 700, Fairfax, VA 22033-4003; toll-free: 800-451-1339, 703-591-2220; fax: 703-591-0614; email: eyeworld@eyeworld.org. Copyright 2011, ASCRS Ophthalmic Services Corp., 4000 Legato Road, Suite 700, Fairfax, VA 22033-4003. All rights reserved. No part of this publication may be reproduced without written permission from the publisher. Letters to the editor and other unsolicited material are assumed intended for publication and are subject to editorial review and acceptance. Subscriptions: Requests should be addressed to the publisher. Annual subscription prices: Individual: 1 year, $120; 2 years, $220; 3 years, $320. Institutional: 1 year, $250; 2 years, $330; 3 years, $425. Foreign: 1 year, $240, 2 years $470, 3 years, $700. 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POSTMASTER: Send change of address to EYEWORLD, 4000 Legato Road, Suite 700, Fairfax, VA 22033. Periodical postage paid at Fairfax, VA 22033 and at additional mailing offices. The ideas and opinions expressed in EYEWORLD do not necessarily reflect those of the editors, publisher, or its advertisers. P U B L I S H I N G   S T A F F October 2011 Volume 16 • No. 10 A S C R S The official publication of the American Society of Cataract & Refractive Surgery World view Transitioning to refractive cataract surgery Kerry Solomon, M.D., refractive editor

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