Eyeworld

7 7 Supported by Abbott Medical Optics and Bausch + Lomb 2. Alio JL, et al. Enhancements after cataract surgery. Curr Opin Ophthalmol. 2015;26:50–55. 3. Fernández-Buenaga R, et al. Resolving refractive error after cataract surgery: IOL exchange, piggyback lens, or LASIK. J Refract Surg. 2013;29:676–683. 4. Packer M, et al. Defining the ideal femtosecond laser capsulotomy. Br J Ophthalmol. 2015;99:1137–1142. Dr. Solomon is director of the Carolina Eye Research Institute, and adjunct clinical professor of ophthalmology, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina. He can be contacted at kerrysolomon@me.com. Conclusion To optimize outcomes from re- fractive cataract surgery, surgeons need to systematically plan their surgeries, customize procedures, and minimize residual astigma- tism. They also need to optimize their surgeon factors for each IOL they use. In addition, by developing high-quality enhancement tech- niques, in most cases they will be able to deliver the excellent refractive outcomes patients seek. References 1. Behndig A, et al. Aiming for emmetropia after cataract surgery: Swedish National Cataract Register study. J Cataract Refract Surg. 2012;38:1181–1186. Effective lens position Surgeons need to be comfort- able with all of these modalities because visual outcomes from cat- aract surgery are not as accurate as those from LASIK. One of the main barriers to achieving out- comes within 0.5 D or better in 95% of cases is that we have not been able to accurately identify the effective lens position (ELP). If we can predict the ELP, plan surgery, and achieve that consis- tently, I think we will deliver next generation outcomes. Research by Packer et al. showed that the ELP was more consistent when the capsulotomy was centered on the approximate optical axis of the lens, with a diameter of 5.25 mm. 4 Among surgeons who are skilled in capsulotomy and capsulorhexis techniques, the difference between laser-assisted cataract surgery and manual out- comes in achieving ELP probably will be negligible. However, the laser may offer advantages for those less comfortable creating capsulotomies. We will need additional tech- nology to predict the ELP of an IOL. Real-time optical coherence tomography, ray tracing, and modern IOL formulas may offer advantages. and treating the residual error with an excimer laser. A recent review of the liter- ature by Alio et al. reported that LASIK provides the most accurate means of enhancement after cat- aract surgery, and lens procedures had less predictable outcomes. 2 Fernéndez-Buenaga et al. com- pared IOL exchange, implantation of a piggyback lens, and LASIK to address residual error after cata- ract surgery, reporting that LASIK had the greatest predictability and efficacy (Figure 1). 3 Before performing laser vision correction, however, we identify dry eye and optimize the ocular surface. If patients have basement membrane dystrophy or had previous LASIK, I usually perform surface ablation. I think it is safer in those cases, and it may treat dystrophy. In patients with pre- vious LASIK, it avoids epithelial ingrowth. Because we usually perform 1.0 D or 2.0 D enhance- ments, patients do very well with surface ablation. If multifocal IOL recipients are dissatisfied or an axis was flipped with a toric IOL, I perform an IOL exchange. Figure 1. Efficacy and predictability of procedures used to correct residual refractive error after cataract surgery 3 IOL exchange Piggyback lens LASIK Median efficacy index Predictability Median efficacy index Predictability Median efficacy index Predictability 0.58 62.50% 0.75 85% 0.91 100% " If we can predict the ELP, plan surgery, and achieve that consistently, I think we will deliver next generation outcomes. " –Kerry Solomon, MD

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