Article Date: 6/1/2011

The Changing Face of Cataract Surgery

The Changing Face of Cataract Surgery

As our patient population ages, demand for premium procedures and products will increase.

By David Geffen, OD

As the baby-boom generation enters their 60s, the demand for improved refractive procedures is increasing. A major change we're seeing today is the increased incidence of nuclear sclerotic changes in younger individuals. It's common to see patients in their 60s who have moderate amounts of lens yellowing. Many—when asked—say they need more light to do near work and driving at night has become more problematic. These patients are purchasing anti-reflective lenses as well as tints to assist them, especially with night driving. This is a youthful population. They're physically active and don't think of themselves as “seniors.” Many insist on better technology to correct their vision problems. They have more disposable income than their younger counterparts, so they're asking what surgical advances are available to help them in a more meaningful way.

The total vision care market is more than $31 billion, according to the Vision Council's Consumer Barometer, released in March 2010.1 Refractive surgery is almost 6% of this total.1 More than 78% of the individuals over 55 in this country are wearing spectacles.1 There were about 925,000 LASIK procedures done in the United States in 2010—down from a high of 1,500,000 in 2007.1 Predictions for cataract surgery show huge growth in that segment as the baby-boomer population ages and develops cataracts. When the economy stabilizes and consumer confidence increases, the market for refractive procedures will grow. These consumers are very aware of advances in technology. They are talking to their friends, family and colleagues. They will come into your offices armed with research and information gleaned from the Web and other resources.

Even though patients are armed with information, they still may not understand their options. Two of the largest factors in the low penetration of presbyopia- and astigmatism-correcting lenses in the market today are cost and the lack of education provided by practitioners. First, as with any premium product, there will be an associated price. Advanced technology lenses offer this patient population a quality of life that resonates with their personalities. But they must understand and believe in the added value of these devices. This is a group of individuals with more disposable income than many—if not most—younger patients. As consumer confidence rebounds, I believe we'll see an increase in demand for these IOLs. Second, we've done a poor job of educating our patients about these lenses. As optometrists, we understand the visual demands of our patients. In many cases, we've been treating some of these patients for more than 10 years. We owe it to our patients to educate them about their options for cataract surgery.

Too often, we simply send a patient to a surgeon and tell him the surgeon will go over the procedure. Patients may choose a surgeon based on insurance coverage. As such, some patients end up with surgeons who don't offer IOLs or who have little experience with advanced lens care options. Giving patients an education about their options will enable them to ask the critical questions that will help them make the best choice. This will also show the value of the optometrist participating in the future care of the patient, including co-managing the cataract procedure. We're uniquely qualified to handle the post-operative care of the advanced technology IOL patient. We should assist in getting the patient through the adaptation to new visual phenomenon and provide the time the patient deserves when he encounters problems or simply has questions. In this patient population, it's critical to under-promise and over-deliver on your patient's expectations.

Toric IOLs

The benefits of toric IOLs are easy to explain and easy for patients to understand. Patients are typically aware of having astigmatism. They may not know what it is but they know they don't want it. Offering the ability to correct astigmatism with the implant, so eyeglasses for distance are not needed may be a no-brainer for patients who choose to be spectacle free. The cost for toric lenses is less than presbyopia-correcting IOLs. In our office, we've found our patients are readily accepting this option. Until now, we've been limited by the lack of a full range of astigmatism-correcting powers for this lens. Earlier this year, the AcrySof® IQ Toric IOL received FDA approval for additional astigmatism correction. The lens is now available in T3-T9 powers. This allows the lens to correct from 0.75 D of preexisting corneal astigmatism to 4.11 D of preexisting corneal astigmatism. The AcrySof IQ Toric lens has been shown to be within 4 degrees of axis 6 months after implantation. This is very important because for every degree off axis the lens rotates, you lose 3.3% of the total toric effect. Coupled with the aspheric correction, the IQ Toric lens provides one of the best optics of any lens on the market today. Our experience also shows that correcting the astigmatism with an IOL yields better acuity than that achieved with corneal procedures.2

LenSx® Laser

The newest addition to the rapidly changing cataract surgical market is the LenSx® laser. This technology may be the most revolutionary we've seen to date. Femtosecond laser technology historically has been used in the LASIK market. It's apparent that flaps made with a femtosecond laser are the standard of care in the industry. The safety and efficacy of the procedure also have been well documented.3-6 We're now at the beginning of a paradigm shift in the cataract market as doctors are incorporating the femtosecond technology.

The LenSx laser has an integrated OCT imaging system that allows precise intraoperative measurements to be performed and monitored, giving the surgeon the added benefit of live monitoring of the procedure to ensure the most accurate results possible. Phacoemulsification will follow the use of the LenSx laser to remove the fragmented natural lens. By using the OCT device, the anterior and posterior lens capsule can be measured so the lens can be cut into a variety of shapes to assist with removal. This may eliminate the need for chopping and sculpting, thereby reducing the phaco power applied to the eye. We're entering a new age of safety and accuracy in the cataract arena. Our aging population will welcome these new developments.

LenSx® Laser Key Features
True image-guided surgical planning
Enables the surgeon to precisely program the size, shape and location of each incision
Real-time video imaging with integrated OCT
Provides 3-D visualization of the entire anterior segment during docking, planning and procedure
Intuitive touch screen graphic user interface
Allows each step of the procedure to be easily planned, customized and executed
Curved patient interface
Designed for patient comfort, ease of use and optimal laser performance

1. Consumer Barometer, March 2010, The Vision Council.
2. Mingo-Botín D, Muñoz-Negrete FJ, Won Kim HR, et al. Comparison of toric intraocular lenses and peripheral corneal relaxing incisions to treat astigmatism during cataract surgery. J Cataract Refract Surg. 2010;36(10):1700-1708.
3. Kullman G, Pineda R. Alternative applications of the femtosecond laser in ophthalmology. Semin Ophthalmol. 2010;25:256-264.
4. Binder PS. Femtosecond applications for anterior segment surgery. Eye Contact Lens. 2010;36:282-285.
5. Issa A, Al Hassany U. Femtosecond laser flap parameters and visual outcomes in laser in situ keratomileusis. J Cataract Refract Surg. 2011;37:665-674.
6. Vryghem JC, Devogelaere T, Stodulka P. Efficacy, safety, and flap dimensions of a new femtosecond laser for laser in situ keratomileusis. J Cataract Refract Surg. 2010;36:442-448.

Dr. Geffen is director of optometric and refractive services at the Gordon & Weiss Vision Institute in San Diego. He has lectured and written extensively on contact lenses, refractive surgery procedures and intraocular lenses. He's the president-elect for the Optometric Council of Refractive Technology and is serving as the Chair for the Optowest Advisory Panel for the California Optometric Association.

Optometric Management, Issue: June 2011