Q&A: Continuum of care, the evolution of cornea, cataract, and refractive surgery

(Image Credit: AdobeStock/jayzynism)

As part of the celebration of Ophthalmology Times’ 50th anniversary, Sheryl Stevenson, executive editor, caught up with George O. Waring IV, MD, FACS, to discuss advancements in cornea, cataract, and refractive surgery over the past 5 decades. Waring is the founder and medical director of the Waring Vision Institute in Mount Pleasant, South Carolina, and a specialist in cornea, cataract lens implants, and refractive cataract surgery.

Waring discusses the evolution of refractive surgery beyond LASIK and cataracts, emphasizing a lifelong vision approach. He highlights groundbreaking advancements in imaging, laser technology, and lens implants that have expanded treatment options and improved patient outcomes. Looking ahead, he sees emerging innovations that promise to further enhance precision and visual quality.

Note: This transcript has been edited lightly for clarity and length.

Sheryl Stevenson:

What do you see as the biggest change over recent decades?

George O. Waring IV, MD, FACS:

Cornea, cataract, and refractive surgery has now become a continuum of a subspecialty. No longer are we LASIK surgeons; no longer are we cataract surgeons. This is a broad field that now encompasses a philosophy that my late father, George O. Waring III, MD, FACS, FRCOphth, discussed and described originally, and that is “vision for a lifetime.”

Stevenson:

What do you mean by that?

Waring:

“Vision for a lifetime” is a concept where we have a vision-correction procedure for every stage of eye maturity. Whether you’re 18 or 81, we have a procedure for everybody along their visual journey. We’ve seen advancements in our field that allow us to become comprehensive refractive surgeons. High-resolution imaging with tomography has changed the game. Being able to measure the posterior cornea with optical coherence tomography has allowed us to account for posterior corneal astigmatism, and, as a result, our outcomes are much better. We now also have high-resolution wavefront sensors, which allow us to measure with levels of precision and higher aberrations than we have not been able to measure before. We also have simulators with adaptive optics, allowing us to simulate visual treatments.

Stevenson:

How has technology improved decision-making and patient outcomes in clinical practices?

Waring:

We have the synthesis of this information with software that collates all the information and allows us to make better decisions in our refractive, cataract, and refractive lens practices with technologies that also improve not only patient outcomes but safety as well. The diagnostic landscape has changed, and that’s set the stage for improved outcomes with our cornea and lens-based patients.

From a cornea refractive standpoint, we’ve had tremendous advances. We have high-repetition rate lasers with high-speed trackers that treat extraordinarily fast and also have internal nomogram adjustments, so we can treat with levels of precision that we’ve been able to publish and demonstrate that we can improve patients’ quality of vision. We can improve patients’ nighttime driving vision. We can improve and unlock lines of best-corrected visual acuity, all relative to glasses and contact lenses. Furthermore, we are of the ability to do therapeutic lasers as well for irregular corneas, and that’s also helping a group in need.

We have FDA-approved corneal-strengthening procedures with collagen cross-linking, which also nearly obviates the need for penetrating keratoplasties in the majority of cases related to ectasia. We have the ability to combine this with corneal reshaping with denatured human tissue, which allows for not only better strength but also better shape.

From a lens-based perspective, we have advancements in phakic IOLs such as the EVO implantable contact lens. Now we do not need to create laser peripheral iridotomies. We also have toric correction for these implants, and this has made the phakic IOLs much more streamlined and LASIK-like than ever before, where we can offer this lower on the dioptric scale of vision correction. For patients who perhaps weren’t previously suitable for corneal refractive surgery, we now treat a broad spectrum. Because this is more LASIK-like, we are offering this for more patients who are excellent LASIK candidates, because this is a removable procedure. It’s one of the few things that we do that we can actually undo, and that’s wonderful.

Stevenson:

How has the approach to treating presbyopia evolved?

Waring:

We now have the ability to tailor our treatments for the correction of presbyopia. We’ve learned over the years by understanding the natural history of the aging changes of the human crystalline lens, which we with our colleagues coined as the dysfunctional lens syndrome, and its various stages that it’s better to go to the source of the problem with custom lens replacement. This has opened up the surgical field of presbyopia correction, where one of the mainstays of our practice, and most rapidly growing segment of our practice, is that of custom lens replacement for presbyopia. It either provides or restores stereopsis. Two eyes always see better than one. Not only does it improve distance vision, a lot like LASIK, but it also restores reading vision, which LASIK wasn’t designed for originally.

Stevenson:

How has lens implant technology evolved in refractive cataract surgery?

Waring:

For our final stage of ocular maturity, if we wait long enough [until a patient develops cataracts] we now have amazing technology in the field of refractive cataract surgery. We’re in the Functional Vision Working Group with the American Society of Cataract and Refractive Surgery, in conjunction with the European Society of Cataract and Refractive Surgeons, on updating the
nomenclature and categorization in a functional basis for the new generation of IOL implants. The International Standards Organization has recently updated the categorization of IOL implants because there are so many technologies out today, such as extended range of vision lenses and full vision range lenses

Furthermore, we have lasers for lens surgery. [The availability of] lasers for lens surgery, in our mind, was one of the most significant breakthroughs in the past 5 decades of lens surgery. This makes lens procedures much more LASIK-like, because it’s laser. It is image guided, really, for the first time ever. It allows us to treat small amounts of astigmatism to maximize the refractive outcomes.

Stevenson:

What is your hope for the future of the subspecialty?

Waring:

We are seeing an exponential growth of technological advances, which not only do we benefit from as surgeons, but more importantly, our patients [benefit as well]. We’re seeing tremendous advances in the field of refractive surgery, corneal refractive surgery, lens implant refractive surgery, and refractive cataract surgery with advanced laser technology, both for the cornea and for the lens. We have transepithelial treatments on the way. Not only do we have topography-guided treatments with refractive excimer lasers, but we also are on the cusp of realizing ray tracing and hybrid technologies too. In the field of lens replacement, we are on the brink of modular and exchangeable and modifiable IOLs. In addition, we’re on the brink of accommodative IOLs, and that is something that we’re excited about.

We are able to merge all of this to treat further and earlier in the life cycle. It’s a great time to be not only a refractive patient but also a refractive surgeon. And when I say refractive surgeon, I mean this in a comprehensive manner: cornea, lens implant, and refractive cataract surgery.