Raising cataract surgery procedure to an art and an experience

(Image Credit: AdobeStock/Mari Dein)

LenzOplastique is beyond cataract surgery; it is a custom-designed, lens-based surgery using the least interventional surgical artistry to optically manipulate regular or irregular ametropia for each patient’s best vision potential.

My guiding principle is: It’s your brain that sees; eye surgery is my anatomic avenue to holistically align your optics and maximize its vision potential.

I pioneered LenzOplastique as an ocular subspecialty that raises the bar on cataract and refractive lens exchange surgery to an art and includes unlimited permutations and combinations of lens implant–based techniques and technologies.

Each eye is unique. All of its in-depth anatomic and visual parameters are studied using advanced diagnostic technologies of different modalities and symbiotic outputs to achieve a full understanding of all the anatomic, physiologic, optical, and neuroadaptive visual potential factors, along with associated abnormalities. I then apply my vision à la carte approach, which includes the Kerato-Lenticular Refractive Extended Armamentarium algorithm concept to a single or staged Gulani Planning System customized surgery holistically to each eye regardless of the ocular complexity.

In my LenzOplastique approach, I include a range of lens-based surgeries to artistically remove the aging/damaged natural lens from the eye and compensate for anatomic abnormalities, including the cornea and anterior chamber, by indirectly canceling their adverse impact using optical manipulation with advanced lens implants and cutting-edge technologic applications without touching the abnormal cornea. This approach enhances each patient’s potential with surgical artistry using the least interventional approach to maximize their full visual capacity in the brain, which processes and provides the final vision.

Looking backward

Cataract surgery is an improper description that deserves a lens-based nomenclature (Lenz), an artistic surgical element (Plastique), and holistically optimized optics (O) to lead to LenzOplastique, which developed over 3 decades of helping patients of all presentations and complexities from around the world.

This short-sightedness of cataract surgery nomenclature has created an epidemic of confused and disappointed patients, especially considering the escalated advertising of premium lens implants that subliminally transfers the title of “premium” to a patient’s surgery and experience without delivering either of the 2. As a result, the patients have redefined the procedure to just an exchange of their natural crystalline lens to an expensive magical lens, therefore they expect perfect vision at all distances without glasses—and starting yesterday!

My practice has a large referral base of patients from around the world who present with disappointing vision following premium lens cataract surgery. In most cases, this disappointment has resulted from the associated or underlying ocular aberrations (anatomic/optical or physiological) that have been left unaddressed. The result is very unhappy patients who have spent a small fortune on lenses that are missing the mark of a premium visual experience at all levels of vision.

Looking forward

The launch of premium lens implants has made it even more important to adopt appropriate nomenclature that both defines cataract surgery more intelligently and underscores the level of surgical skill, optical calculation, and visual end point–based outcomes to help the patient understand that any advertised magical lens is nothing more than an ingredient in the vision recipe. Each eye’s unique anatomic, optical, and aberrated element composition is much more important to house the special new magical lens implant so the entire eye and its optical system are holistically aligned for best vision potential.

Moreover, the application of LenzOplastique also includes minimal anesthesia, gentle artistry, and a comfortable surgical experience, with attention to personal details at all levels. This approach will indirectly turn every surgeon into an artist. I describe this as a welcomed adverse effect of the current trend of office-based surgery.

Furthermore, patients who were previously considered to not be candidates for premium lens implants due to keratoconus, radial keratotomy, laser in situ keratomileusis, corneal scars, or irregular corneas can now be included with the skills acquired, along with using lens implants at their highest functionality.

Additionally, combination surgeries can be undertaken with what I refer to as “inside-out” or “outside-in” techniques, wherein a lens-based surgery can be staged with a corneal-based surgery. This means one can be performed as a stage I procedure in a poorly measurable eye due to any of the above-mentioned conditions, landing at a refractive and optical end point that then allows a stage II surgery to not only achieve uncorrected vision at all distances with emmetropic optics but also to address associated pathologies, such as corneal scars or irregularities.

Similarly, premium lens–based surgical complications and inadequate results can also be optically manipulated using these principles to result in 20/happy patients without exchanging their surgeon’s premium lens implants.

Thus, LenzOplastique will become the proper nomenclature for perhaps the oldest and most frequently performed ocular surgery in the world. It will also raise the value of surgical intervention in the patient’s mind and allow eye surgeons to elevate their skills to artistic levels while custom-designing unique approaches for consistent 20/happy patients. Additionally, patients will opt to undergo these techniques at a much younger age rather than waiting until their vision has deteriorated to a sufficiently low level.

All of the above are the needs of the hour and will restore the value of eye care and intricate eye surgical skills as the most important services in medicine.

LenzOplastique cases

Figure 1. A view of the lens-based optics.

Figure 2. Staged-surgery optical manipulation.

The paradigm shift in the conceptual application of LenzOplastique is representative of thousands of patients that we have treated. Figures 1 and 2 illustrate some prototypical cases that exemplify how lens-based optics can manipulate simple to complex anatomically and optically challenging eyes using the least interventional approaches, with the relentless goal of 20/20 vision.

Of course, in normal cataractous eyes, the surgical artistry must be evident even beyond the technological applications. As an example, a stable keratoconus case that is corrected with a well-centered toric lens with manual capsular access with exact coverage for effective lens position, resulting in 20/15 unaided vision (Figure 1).

Opposing examples

In staged cases, here are 2 opposite examples.

The outside-in technique first addresses the immeasurable and anatomically/optically challenged cornea to make it measurable and stable, which facilitates the cataract surgery can be performed at the highest level of accuracy and surgical artistry.

In this case of a patient with multiple complexities, including posthexagonal keratotomy with corneal ectasia, Fuchs dystrophy, extremely high keratometry, and high irregular astigmatism with cataracts, I first implanted Corneoplastique-based titratable Intacs (Addition Technology Inc) to decrease the astigmatism of the 89.90-diopter (D) cornea from 23.5 to 1.4 D and then performed cataract surgery with implantation of a toric lens while avoiding stitches under just numbing drops and maintaining patient comfort (Figure 2).

The inside-out technique was performed on a pilot who was referred with poor vision following premium cataract surgery in a keratoconic eye with resultant hyperopic astigmatism, anterior corneal scarring, and presbyopia following a capsulotomy. Previous consultations with surgeons advised the removal of his IOL, along with invasive vitrectomy and then using different ways of attaching the secondary lens implant in the sulcus.

LenzOplastique avoided invasive surgeries that would surely not bring this patient to unaided 20/20 accuracy or provide a wonderful and brief patient experience. I planned one surgical procedure (ie, myopic surface laser vision surgery) that would remove anterior corneal scarring, decrease the keratometry, increase the optical zone (night vision), and achieve emmetropia.

Piggyback lens

Figure 3. Fixing surgical complications with Intacs and

surgery.

Figure 4. The Gni instrument. (Images courtesy of

Arun Gulani, MD)

Considering the hyperopia, I implanted a piggyback lens to create myopia and then performed myopic laser surgery, resulting in 20/15 unaided vision and the patient regaining his pilot’s license (Figure 3). Thus, LenzOplastique is a conceptual advancement and paradigm shift in how one can look beyond surgery and into lens-based techniques as an avenue to optically manipulate the eye with the least interventional and surgically artistic steps to provide unaided and better vision outcomes while providing a comfortable and memorable patient experience. The “plastique” level of surgery is a mind-set, a commitment, and an unflinching desire to truly fight for each patient’s best vision potential using surgical artistry and the least interventional option while also encouraging minimal anesthesia and innovative surgical instrumentation (Figure 4).

Gni instrument technology

The Gni instrument (video) breaks through the century-old tradition of vertically held instruments in eye surgery that are used at a distance from the eye in a horizontal plane, causing indirect movement with less control and less of an intimate feel of the tissues inside the eye.

Gni also makes the cataract surgery tray extremely minimalistic with its close and same-plane application requiring few—if any—other instruments. The fact that the tips can be changed makes this a unique paradigm shift in eye surgery instrumentation and provides a more intimate and closer feel to the eye, as if you had your hand inside and at the correct horizontal plane.

Additionally, the fenestrated barrel can fit any finger with a snug and comfortable fit. Such minimalistic moves inside the eye make it very comfortable for the patient while raising the bar on the artistic appeal of surgery and resulting in excellent outcomes and premium patient experiences.

Arun Gulani, MD

E: gulanivision@gulani.com

Gulani is in private practice in Jacksonville, Florida. He holds a patent for LenzOplastique.