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Three wishes: What the premium surgeon longs for today

Advancements in cataract and refractive procedures are surpassing most surgeons' expectations.

Today’s premium surgeon is constantly challenged with achieving perfect visual outcomes in the world of refractive and refractive cataract surgery. The infamous “three wishes” joke involves a protagonist such as a genie granting three wishes, in which the first two are ideal and the third is either misinterpreted or intentionally granted in an awkward literal fashion and cannot be reversed because it is the final wish, resulting in the punchline of the joke.

A perfect example: The premium surgeon is granted a new femtosecond laser with built-in aberrometry and hands-free remote capability from his or her beach chair and as a second wish is granted an IOL that is truly bionic, yielding emmetropia and the freedom of all visual correction for the patient. Unfortunately, the patient postoperatively needs psychological counseling with 20/15 vision and complains of “not seeing well.” The surgeon’s third wish is to make this patient disappear, which the genie grants, but the patient ends up on the beach chair next to the surgeon indefinitely.

This three wishes scenario is a commonplace occurrence daily even for the best and most prestigious surgeons. Despite all the advanced technology at our disposal, certain patients just never go away, even with what we perceive as perfect results.

The patient selection process

When deciding to perform refractive surgery such as LASIK, PRK or corneal inlays vs. refractive cataract surgery such as femtosecond laser-assisted cataract surgery, intraoperative aberrometry and advanced IOLs, the patient selection process is most critical.

Most premium surgeons, especially in a co-managed situation, initially meet a patient and know little about the patient’s visual wants and needs based on occupation and recreational lifestyle. My office typically uses a lifestyle questionnaire on the day of consultation to help guide me in my decision process for a patient once all the advanced diagnostics have been performed. The survey has questions about the patient’s current glasses status (distance only, reading only, computer only or all of the above) and desire to eliminate and/or reduce glasses dependence. It also has a checklist of activities performed on a regular basis, such as daytime and/or nighttime driving, golfing, cell phone usage, cooking, crossword puzzles, needlepoint/sewing, reading newspapers and books, and computer use, and how many hours per day these activities are performed. Lastly, the questionnaire asks the patient to describe his or her personality from easygoing to perfectionist on a liner scale.

Advanced technologies that measure objective scatter index, or OSI, (AcuTarget HD, AcuFocus) can be helpful in deciphering if a corneal-based vs. lenticular-based refractive procedure should be performed. A low OSI suggests clear media and a normal corneal surface in which a corneal inlay such as the recently FDA-approved Kamra (AcuFocus) would work well; a high OSI usually suggests lenticular opacity or cataract in which the patient would benefit more from an advanced IOL option such as the newly approved low add Tecnis multifocals (ZKB00, ZLB00, Abbott Medical Optics) or ReStor +2.5 D (Alcon) or accommodating lenses including the Crystalens AT-50 AO, Crystalens AT-52 AO and Trulign toric (all Bausch + Lomb).

Building the ideal cataract surgery suite

I remember performing my first cataract surgery 26 years ago; that cataract suite is far from what I can offer my patients today. The evolution of cataract surgery has been amazing, going from extracapsular extraction to small-incision phacoemulsification to microincision phacoemulsification to femtosecond laser-assisted cataract surgery with microburst phacoemulsification. The reduced effective phaco times achieved with the latter has resulted in lower postoperative corneal edema and faster visual recovery overall.

Introducing Streamline to the Lensar platform, in my experience, has taken femtosecond laser-assisted cataract surgery to the next step by enabling automation of key surgical elements via wireless integration with the Cassini TCA topography analysis system (i-Optics), astigmatism management with iris registration to adjust for cyclotorsion, arcuate incision planning and self-adjusting nomograms, steep axis corneal marking for toric IOL placement, automatic cataract density imaging, and automatic fragmentation patterns. Utilizing intraoperative aberrometry with devices such as ORA (Alcon) or Holos (Clarity) and the introduction of post-RK algorithms have brought post-refractive surgery challenging cataract cases to their knees. I look forward to the era of compete wireless interaction of all my advanced technologies in my OR, integrated with my EMR system, so I can hit the “easy” button with every surgical case.

In the end, there is no “easy” button, and there is no genie granting us three wishes. The advancements in cataract and refractive surgery go way beyond either in today’s world and will only get better. It is an awesome time to be a premium cataract and refractive surgeon. Just be careful what you wish for.

Disclosure: Jackson reports he is a consultant to Bausch + Lomb and i-Optics.

Today’s premium surgeon is constantly challenged with achieving perfect visual outcomes in the world of refractive and refractive cataract surgery. The infamous “three wishes” joke involves a protagonist such as a genie granting three wishes, in which the first two are ideal and the third is either misinterpreted or intentionally granted in an awkward literal fashion and cannot be reversed because it is the final wish, resulting in the punchline of the joke.

A perfect example: The premium surgeon is granted a new femtosecond laser with built-in aberrometry and hands-free remote capability from his or her beach chair and as a second wish is granted an IOL that is truly bionic, yielding emmetropia and the freedom of all visual correction for the patient. Unfortunately, the patient postoperatively needs psychological counseling with 20/15 vision and complains of “not seeing well.” The surgeon’s third wish is to make this patient disappear, which the genie grants, but the patient ends up on the beach chair next to the surgeon indefinitely.

This three wishes scenario is a commonplace occurrence daily even for the best and most prestigious surgeons. Despite all the advanced technology at our disposal, certain patients just never go away, even with what we perceive as perfect results.

The patient selection process

When deciding to perform refractive surgery such as LASIK, PRK or corneal inlays vs. refractive cataract surgery such as femtosecond laser-assisted cataract surgery, intraoperative aberrometry and advanced IOLs, the patient selection process is most critical.

Most premium surgeons, especially in a co-managed situation, initially meet a patient and know little about the patient’s visual wants and needs based on occupation and recreational lifestyle. My office typically uses a lifestyle questionnaire on the day of consultation to help guide me in my decision process for a patient once all the advanced diagnostics have been performed. The survey has questions about the patient’s current glasses status (distance only, reading only, computer only or all of the above) and desire to eliminate and/or reduce glasses dependence. It also has a checklist of activities performed on a regular basis, such as daytime and/or nighttime driving, golfing, cell phone usage, cooking, crossword puzzles, needlepoint/sewing, reading newspapers and books, and computer use, and how many hours per day these activities are performed. Lastly, the questionnaire asks the patient to describe his or her personality from easygoing to perfectionist on a liner scale.

Advanced technologies that measure objective scatter index, or OSI, (AcuTarget HD, AcuFocus) can be helpful in deciphering if a corneal-based vs. lenticular-based refractive procedure should be performed. A low OSI suggests clear media and a normal corneal surface in which a corneal inlay such as the recently FDA-approved Kamra (AcuFocus) would work well; a high OSI usually suggests lenticular opacity or cataract in which the patient would benefit more from an advanced IOL option such as the newly approved low add Tecnis multifocals (ZKB00, ZLB00, Abbott Medical Optics) or ReStor +2.5 D (Alcon) or accommodating lenses including the Crystalens AT-50 AO, Crystalens AT-52 AO and Trulign toric (all Bausch + Lomb).

Building the ideal cataract surgery suite

I remember performing my first cataract surgery 26 years ago; that cataract suite is far from what I can offer my patients today. The evolution of cataract surgery has been amazing, going from extracapsular extraction to small-incision phacoemulsification to microincision phacoemulsification to femtosecond laser-assisted cataract surgery with microburst phacoemulsification. The reduced effective phaco times achieved with the latter has resulted in lower postoperative corneal edema and faster visual recovery overall.

Introducing Streamline to the Lensar platform, in my experience, has taken femtosecond laser-assisted cataract surgery to the next step by enabling automation of key surgical elements via wireless integration with the Cassini TCA topography analysis system (i-Optics), astigmatism management with iris registration to adjust for cyclotorsion, arcuate incision planning and self-adjusting nomograms, steep axis corneal marking for toric IOL placement, automatic cataract density imaging, and automatic fragmentation patterns. Utilizing intraoperative aberrometry with devices such as ORA (Alcon) or Holos (Clarity) and the introduction of post-RK algorithms have brought post-refractive surgery challenging cataract cases to their knees. I look forward to the era of compete wireless interaction of all my advanced technologies in my OR, integrated with my EMR system, so I can hit the “easy” button with every surgical case.

In the end, there is no “easy” button, and there is no genie granting us three wishes. The advancements in cataract and refractive surgery go way beyond either in today’s world and will only get better. It is an awesome time to be a premium cataract and refractive surgeon. Just be careful what you wish for.

Disclosure: Jackson reports he is a consultant to Bausch + Lomb and i-Optics.