May 25, 2017
Not too many years ago, there was a clear separation between refractive surgery and cataract surgery. Refractive surgery was limited to modification of the cornea, while successful cataract surgery was typically followed by a new bifocal glasses prescription. Early pioneers such as Robert Osher began advocating combining astigmatic keratotomy with cataract surgery to reduce spectacle independence in the mid-1980s, but this was not widely adopted at that time. It took many years for the combination of improved biometry, modern IOL formulae, small-incision surgery, astigmatic keratotomy and toric IOLs to allow surgeons to routinely achieve good uncorrected distance vision after IOL surgery. The advent of multifocal, accommodating and extended depth of focus IOLs has essentially transformed cataract surgery into a form of refractive surgery. These new options have created a complex array of choices for the surgeon and the patient. And with multifocal IOLs now available in several add powers, the choices have become even more complicated. This trend will continue as new technologies emerge.
As a participant in early clinical trials for presbyopia-correcting IOLs, I was excited when we received approval for these lenses in 2004. But I soon found that a problem was brewing in my clinic. Suddenly, I was spending a huge amount of time explaining all the various IOL options to cataract patients. Sometimes after a long discussion, the patient would state that he had no interest in spectacle independence. Educational videos and surgical counselors helped, but I needed a way to quickly assess what my patients wanted their vision to be like after surgery, what compromises they would be willing to make to achieve those goals, and whether they would be willing to pay for this result. The result was a Cataract and Refractive Lens Exchange Questionnaire, which I first published in 2004. The questionnaire was helpful in streamlining my clinic, and other surgeons found it useful as well.