Refractive lens exchange culminaton of two disciplines

"Historically, cataract and refractive surgery have been specialties separated by skill sets, equipment requirements, patient demographics, reimbursement processes, and marketing approaches," Dr. Lane said. "Although some surgeons perform cataract and refractive procedures, many have chosen to practice exclusively only one or the other. However, new technologies are shifting the landscape, demanding new combinations of skills, equipment, and marketing approaches. The convergence of the two specialties reflects a bridging of the skill sets and the mindsets from refractive surgery pioneered by Jose Barraquer, MD, to that of the technology of the cataract and IOL surgery proposed by Charles Kelman, MD. The synergism of these skill sets allows the convergence of new treatments that are individualized to optimize patient results."

Dr. Lane is in private practice in St. Paul, MN, and clinical professor of ophthalmology, University of Minnesota, Minneapolis.

Perhaps even more important than technology, he pointed out that there are keys that are critical: proper patient selection, patient education, and performing accurate preoperative measurements that are used to determine the IOL power. He believes that patient education is the "cornerstone of successful high-technology IOL implantation. Ophthalmologists must understand and discuss the individual patient's lifestyle and expectations if they are to have a truly well-informed consumer. New vision-correcting options raise issues that are distinct from issues involved in the decision making for traditional cataract surgery. Use of newer technologies in younger patients who have high expectations of a return to a spectacle-free experience demand additional time spent with these patients."

He also emphasized the responsibility of surgeons to be knowledgeable about all the vision-correcting options available today in order to inform patients properly of the risks and benefits associated with each technology.

Technologic advances

"Technologic advancements and new product development represent a continuum designed to help ophthalmologists effectively treat their patients. Despite tremendous successes, ophthalmologists have constantly sought innovation in our methods and products in an effort to make surgery a pleasant experience for our patients while promoting higher levels of safety, efficacy, and efficiency," Dr. Lane said.

Dr. Lane reviewed the trends in lens removal techniques, including the use of lower ultrasonic energy in the eye, higher vacuum, and manual nucleus disassembly. He described the advantages of WhiteStar (Advanced Medical Optics [AMO]), namely, delivery of energy to the eye in very brief microsecond bursts that are interrupted by rest periods. "With this technology, significant thermal energy is never generated; cutting ability is retained while greatly reducing the amount of energy introduced into the eye," he explained. In addition, small incisions can be used because sleeveless instruments can be placed in the eye without concern about thermal damage.

Another energy-minimizing technology is AquaLase Technology (Alcon Laboratories). No thermal energy is used, rather, water is used to break up the lens material. "This technology is best for softer lenses where safety and efficiency are maximized, making this an ideal procedure for refractive lens exchange," Dr. Lane stated.

Torsional phacoemulsification is a recent innovation that uses a Kelman tip. In this technique, torsional oscillations at ultrasonic frequencies break up the lens material, which maximizes followability and minimizes chatter.