ADDED PRESSURE Surgeons want to work with technology that lets them meet the increasing expectations patients have for how well they'll see after surgery.

Cataract patients don't just want to see better than they did before entering your ORs. They want to see better than they did before middle age brought on bifocals and readers. They want to reduce or even eliminate the need for glasses after surgery. "No matter what patients tell you, their expectations for how well they'll see after surgery are even higher," says Jeffrey Whitsett, MD, founder of the Whitsett Vision Group in Houston, Texas.

Is your facility equipped to let surgeons deliver the optimal refractive outcomes more cataract patients are demanding? Several new advances empower ophthalmologists to impact post-op vision outcomes like never before. These include lasers, premium multifocal lens implants and intraoperative aberrometry. We asked leading ophthalmologists how these advances have helped them achieve better refractive cataract surgery outcomes.

1. Femto lasers
If you want a sexy new technology that's almost certain to attract new patients who seek out care at cutting-edge facilities, by all means drop several hundred thousand dollars on a femtosecond laser platform. If you want to add equipment that truly impacts refractive outcomes, you might want to spend your money elsewhere. "There's been no long-term, peer-reviewed study that's shown femtosecond laser surgery provides better safety and efficacy than manual techniques," says Dr. Whitsett.

That may be true, and we hear from some high-volume surgeons who believe lasers are more marketing hype than meaningful tool, but that doesn't mean the technology doesn't add clinical benefit during complex cataract cases.

"The laser's best application is during surgery on patients with low to moderate levels of astigmatism," says Ronald Krueger, MD, MSE, medical director of refractive surgery at the Cleveland (Ohio) Clinic Cole Eye Institute. "Surgeons can use the laser to make specific limbal-relaxing incisions to achieve the desired astigmatism correction and optimal refractive outcomes."

The next step in multifocal lens development is to come up with implants that are more forgiving and that provide depth of focus without post-op visual side effects.

Anat Galor, MD, an assistant professor of clinical ophthalmology at the Bascom Palmer Eye Institute in Miami, Fla., and a staff physician at the Miami Veterans Administration Medical Center, agrees that femto lasers don't provide significant benefit in terms of refractive outcomes, at least not yet. Dr. Galor says the laser is currently ideally suited for complex cataract cases involving patients with very dense lenses, poor dilation and loose zonules. Some experts argue that precutting dense lenses with the laser before the fragments are removed requires less phacoemulsification energy and therefore limits damage to surrounding structures, which, according to Dr. Galor, would benefit patients with compromised corneal endothelial function.

"But those aren't the patients who require refractive procedures," says Dr. Galor. "Those are the patients who are having necessary cataract surgery, and using the femto makes it safer for them."

The laser does make prettier capsulorhexes, but whether that translates to better outcomes hasn't been shown, notes Dr. Galor. "As with all technologies, the laser will continue to develop and prices will continue to fall," she adds. "It's an exciting technology with many future potential applications, especially as implants become more sophisticated."

She says lenses are being developed that can be folded through incisions smaller than the typical 2.5 mm cuts, so surgeons could restore accommodation by making a very small opening in the capsule. "You can imagine doing that manually would be difficult," says Dr. Galor. "Using the femto laser will be an important way to perform that procedure."

2. Multifocal lens implants
Dr. Galor says multifocal IOL implants provide adequate depth of focus, but can result in slightly compromised visual quality. "Although designs are improving, some patients experience glares and halos after implantation," she says. Patients who are good candidates for multifocal lenses are extremely happy with the results, but Dr. Galor points out that the lenses aren't as effective in patients with any type of pathology, such as epiretinal membrane and irregular astigmatism. "The next step in multifocal lens development is to come up with implants that are more forgiving and that provide depth of focus without post-op visual side effects," she says.

Implanting toric IOLs for astigmatism correction is a "no-brainer," says Dr. Galor, because patients with astigmatisms are motivated to get the best possible vision outcomes, at least in one focus plane at distance. She adds that the ideal lens implant would restore lens function by providing good clarity and accommodation, even in eyes with other pathology. "We're not there yet, but there are many companies working on that type of technology," she adds.

One of the more exciting developments in lens offerings occurred in July 2016 when the FDA approved the presbyopia-correcting Tecnis Symfony IOL. The lens is designed to provide patients with extended depth of focus, which is said to improve visual acuity at close, intermediate and far ranges, and thereby reduce the need for patients to wear contact lenses or glasses after surgery.

The Symfony lens doesn't get patients all the way to J1 plus in reading, but it does provide accommodation without aberration, says Dr. Galor. It also provides more precision for astigmatism management, adds Dr. Whitsett. "We haven't yet had an extended range of focus lens that has a toric component," he says. "The ability to manage patients' astigmatisms while at the same time improving their distance, immediate and near vision is a huge clinical benefit."

Dr. Krueger says trifocal lenses are impressing surgeons on the international market and the Symfony lens is getting a great deal of uptake stateside since being approved, because it provides patients with a greater range of vision. He adds, "Ultimately, if we can get to having a lens that truly does accommodate or gets as close to accommodation as an actual lens, we'll see implants be even more widely accepted."

UNPRECEDENTED OUTCOMES Several new advances empower cataract surgeons to impact post-op vision outcomes like never before.

3. Intraoperative aberrometry
Dr. Whitsett will not operate on post-refractive patients without referencing intraoperative wavefront aberrometry, which combines real-time information about the eye's optical characteristics with pre-op biometry data to let surgeons better predict the optimal lens power that results in the best refractive outcome.

"For us to operate without being able to scan eyes in real time involves our best guess [of the optimal implant placement]," says Dr. Whitsett. He says his surgeons switch out lenses 25% to 30% of the time based on intraop aberrometry readings. "Usually by only half a diopter," he says, "but that's oftentimes the difference between happy and unhappy patients, and patients who need post-op vision enhancements and those who don't."

Newer wavefront aberrometry platforms are user-friendly and linked directly to surgical microscopes, notes Dr. Krueger. "If you have real-time wavefront information and perform surgery in a consistent manner, you can use intraop data to predict surgical outcomes," he says.

Dr. Galor finds intraoperative aberrometry helpful in patients who have a history of refractive surgery, but doesn't rely on the technology when deciding on the optimal lens implant power — she instead uses the readings as a tiebreaker if she's deciding between 2 diopters. Part of her hesitancy is based on the findings of a study she co-authored that found intraoperative wavefront aberrometry failed to achieve ?0.5 diopters of emmetropia in more than half of cases in which it was used. As the technology improves, Dr. Galor believes it will provide more clinical benefit.

Surgical microscopes with integrated IOL alignment displays are also helping surgeons place lens implants more precisely. Dr. Krueger says the technology incorporates a mechanism of biometry into microscope optics to provide surgeons with real-time images of implant positioning, which is especially important when working with toric IOLs. The lenses are extremely sensitive to misalignment and rotation, which can occur due to cyclotorsion when the patient is supine, so it's critical to place them in the right axis or meridian.

"That's what these displays are best designed to do," says Dr. Krueger. "They make alignment of the lens as pristine as possible in order to drive optimal refractive results."

Dr. Galor says she really likes using the alignment displays, which employ iris registration technology and account for cylcotorsion. "Toric lenses are so susceptible to error — 10 degrees of rotation reduces the cylindrical power of the lenses by approximately 30% — so anything we can use to help place the implants properly makes a big difference in refractive outcomes."

Will patients seek your facility out?
With cataract surgery technology advancing so quickly, today's cataract patient will seek out a surgeon who has access to the most advanced techniques. Does that describe your facility? OSM