The Premium Channel

Generation gaps can be meaningful for premium surgeons

Each generation will benefit from the new technologies that are available today.

Never did I realize as I started my private practice 25 years ago that I would be trying to sort out all the generation gaps and meeting the various refractive needs of all my patients, whether baby boomers, Generation X or Generation Y. Baby boomers account for at least 76 million Americans born between 1946 and 1964, and baby boomers control more than 80% of personal financial assets and more than 50% of all consumer spending. They buy 77% of all prescription drugs, 61% of over-the-counter drugs and 80% of all leisure travel. The term “Generation Jones” is typically used for those baby boomers born between 1954 and 1964, with some considering this group the later-year boomers or early-year Gen X.

Because I was born in 1964, I can see myself as a “Generation Jones,” hoping to span all generation classes so I can relate with all my patients’ needs as a premium surgeon. Gen X patients are a completely different cohort of patients, typically born from mid 1960s to early 1980s, and also called the “latchkey generation” due to reduced adult supervision as a result of increasing divorce rates and increased maternal participation in the workplace. Gen X has also been credited with entrepreneurial tendencies. Gen Y patients, most commonly known as millennials, are an even more diverse class, typically born between early 1980s to early 2000s. Millennials are often referred to as “echo boomers” due to a major surge in birth rates in the 1980s and 1990s. Millennials are basically children of the baby-boomer generation. Millennials are the digital-oriented group, marked by an increased liberal approach to politics and economics. So what do all these generations have to do with the premium surgeon? With the recent expansion of our refractive surgical options, I believe the premium surgeon can provide solutions for all the generation gaps as follows.

Baby boomers

The good news for this generation is it will receive a full array of premium IOL options during cataract surgery. Options are vast, including Crystalens and Trulign (Bausch + Lomb); low add multifocals (ZKB00 and ZLB00) and extended depth of focus IOLs (Symfony and Symfony toric) (Johnson & Johnson Vision); and ReSTOR +2.5 D and +3.0 D and ActiveFocus and Active-Focus toric (Alcon). Still to come to the U.S. are trifocal and segmental bifocal IOL technologies not yet FDA approved.

Recently, most of my experience has been with the Symfony and Symfony toric technology, in which I have found hitting a plano target yields the best distance, intermediate and near visual outcomes. Personally, the spider-type halos that can occur with this technology seem to be insignificant when plano is reached and are more prominent the more myopic a patient is postoperatively. Also, eradicating all cylinder is critical via either astigmatic incisions or the toric version, the latter especially in against-the-rule (ATR) cases of more than 1 D preoperatively. I have successfully utilized femtosecond astigmatic incisions with Lensar Streamline III wireless iris registration to avoid cyclotorsion errors intraoperatively to correct with-the-rule astigmatism up to 1.5 D preoperatively. In ATR cylinder, I prefer the toric IOL options mentioned above for cylinder more than 1 D preoperatively and will use femtosecond astigmatic incisions for cylinder correction up to 1 D preoperatively ATR. I prefer Crystalens or Trulign aberration-free optics when the patient has had prior RK/CK or other corneal refractive procedures that have left the cornea highly aberrated. I plan to use ActiveFocus and ActiveFocus toric technology in the near future with its central zone distance clarity and lower incidence of halo side effects, especially with night driving. In talking with other premium surgeons, this technology seems to do well when mixed with a ReSTOR +2.5 D in the nondominant eye to enhance near vision capability. The preferred target for ActiveFocus technology is plano or first click minus when planning preoperatively from your preferred IOL calculation planning worksheet. ActiveFocus is only available in the yellow chromophore, but the toric version is now available in a clear style but still on the same AcrySof platform, with the risk of glistenings still a possibility.

Gen X

This generation overlaps with the baby boomers in terms of the advanced IOL technology discussed above. Gen X also overlaps with Gen Y in terms of technologies such as corneal inlays, laser vision correction and the newer small incision lenticule extraction procedure. I routinely use objective scatter index with the AcuTarget HD (Visiometrics) to quantify the forward light scatter and help delineate whether a corneal or lenticular refractive procedure should be done for these patients. Corneal inlays such as Kamra (AcuFocus) and Raindrop (ReVision Optics) have provided the first defense against presbyopia as refractive surgical options before the development of a cataract.

The Kamra corneal inlay received its FDA approval in April 2015, labeled for intrastromal corneal implantation to improve near vision by extending the depth of focus in the nondominant eye of phakic, presbyopic patients between the ages of 45 and 60 years old who have cycloplegic refractive spherical equivalent of +0.5 D to –0.75 D with 0.75 D or less of refractive cylinder and who require near correction of +1.00 to +2.50 of reading add. I have found it works best in terms of uncorrected near vision gain in those patients who have –0.5 D to –0.75 D sphere preoperatively. The Kamra can be used in patients after laser vision correction such as LASIK or PRK as an off-label procedure in my hands, but if patients had prior flap creation with a microkeratome blade, then OCT imaging of the cornea is critical to make sure you create the corneal pocket at least 100 µm below the old LASIK interface and still stay 250 µm from the corneal endothelium.

The Raindrop near vision inlay is a microscopic hydrogel corneal inlay that is placed under a femtosecond laser flap and creates a prolate-shaped cornea. It measures 2 mm in diameter and 32 µm in thickness. This technology is best suited for patients who are in the low hyperopic range of +0.5 D to +0.75 D sphere preoperatively, and it should not be used in those patients who have undergone prior LASIK surgery. Many emmetropic presbyopes that come to our offices seeking presbyopic correction are typically low hyperopes functioning well in the distance without prescription glasses needed. The drawback of Raindrop is the potential for corneal haze, and most recently many of my colleagues and I have been using mitomycin C (no different than in PRK) under the flap before placement of the Raindrop to reduce this risk. Long-term data are still needed with this technique.

Gen Y/millennials

This generation especially benefits from laser vision correction such as LASIK and PRK, with advances in femtosecond laser technology such as the IntraLase FS (60 kHz) (J&J Vision) and the Ziemer Z8 platforms with high-speed, efficient ergonomics and lower energy needed for flap creation, and advances in excimer technology such as the Technolas Teneo 317 (Bausch + Lomb) not yet available in the U.S. and the WaveLight (Alcon) topography-guided treatment capability recently approved in the U.S. The FDA approved the VisuMax SMILE procedure (Carl Zeiss Meditec) for the reduction or elimination of myopia between –1 D and –8 D, with 0.5 D or less of cylinder and manifest refraction spherical equivalent of –8.25 D in the eye to be treated in patients who are 22 years of age or older with documentation of stable manifest refraction over the past year. SMILE brings a new era of sophistication to refractive correction in the U.S. in what we can call microincisional refractive surgery (MIRS), no different from MICS and MIGS in cataract and glaucoma surgery, respectively. SMILE has already been established in global markets such as Europe, China, Australia, Canada and India.

In the end, with the American Academy of Ophthalmology meeting fast approaching, the premium surgeon should evaluate all of these great technologies and implement as many as possible to meet the needs of the generation gaps we now face daily in our practices.

Disclosure: Jackson reports he is a consultant for Johnson & Johnson Vision/AMO, Bausch + Lomb, Lensar and Visiometrics.

Never did I realize as I started my private practice 25 years ago that I would be trying to sort out all the generation gaps and meeting the various refractive needs of all my patients, whether baby boomers, Generation X or Generation Y. Baby boomers account for at least 76 million Americans born between 1946 and 1964, and baby boomers control more than 80% of personal financial assets and more than 50% of all consumer spending. They buy 77% of all prescription drugs, 61% of over-the-counter drugs and 80% of all leisure travel. The term “Generation Jones” is typically used for those baby boomers born between 1954 and 1964, with some considering this group the later-year boomers or early-year Gen X.

Because I was born in 1964, I can see myself as a “Generation Jones,” hoping to span all generation classes so I can relate with all my patients’ needs as a premium surgeon. Gen X patients are a completely different cohort of patients, typically born from mid 1960s to early 1980s, and also called the “latchkey generation” due to reduced adult supervision as a result of increasing divorce rates and increased maternal participation in the workplace. Gen X has also been credited with entrepreneurial tendencies. Gen Y patients, most commonly known as millennials, are an even more diverse class, typically born between early 1980s to early 2000s. Millennials are often referred to as “echo boomers” due to a major surge in birth rates in the 1980s and 1990s. Millennials are basically children of the baby-boomer generation. Millennials are the digital-oriented group, marked by an increased liberal approach to politics and economics. So what do all these generations have to do with the premium surgeon? With the recent expansion of our refractive surgical options, I believe the premium surgeon can provide solutions for all the generation gaps as follows.

Baby boomers

The good news for this generation is it will receive a full array of premium IOL options during cataract surgery. Options are vast, including Crystalens and Trulign (Bausch + Lomb); low add multifocals (ZKB00 and ZLB00) and extended depth of focus IOLs (Symfony and Symfony toric) (Johnson & Johnson Vision); and ReSTOR +2.5 D and +3.0 D and ActiveFocus and Active-Focus toric (Alcon). Still to come to the U.S. are trifocal and segmental bifocal IOL technologies not yet FDA approved.

Recently, most of my experience has been with the Symfony and Symfony toric technology, in which I have found hitting a plano target yields the best distance, intermediate and near visual outcomes. Personally, the spider-type halos that can occur with this technology seem to be insignificant when plano is reached and are more prominent the more myopic a patient is postoperatively. Also, eradicating all cylinder is critical via either astigmatic incisions or the toric version, the latter especially in against-the-rule (ATR) cases of more than 1 D preoperatively. I have successfully utilized femtosecond astigmatic incisions with Lensar Streamline III wireless iris registration to avoid cyclotorsion errors intraoperatively to correct with-the-rule astigmatism up to 1.5 D preoperatively. In ATR cylinder, I prefer the toric IOL options mentioned above for cylinder more than 1 D preoperatively and will use femtosecond astigmatic incisions for cylinder correction up to 1 D preoperatively ATR. I prefer Crystalens or Trulign aberration-free optics when the patient has had prior RK/CK or other corneal refractive procedures that have left the cornea highly aberrated. I plan to use ActiveFocus and ActiveFocus toric technology in the near future with its central zone distance clarity and lower incidence of halo side effects, especially with night driving. In talking with other premium surgeons, this technology seems to do well when mixed with a ReSTOR +2.5 D in the nondominant eye to enhance near vision capability. The preferred target for ActiveFocus technology is plano or first click minus when planning preoperatively from your preferred IOL calculation planning worksheet. ActiveFocus is only available in the yellow chromophore, but the toric version is now available in a clear style but still on the same AcrySof platform, with the risk of glistenings still a possibility.

PAGE BREAK

Gen X

This generation overlaps with the baby boomers in terms of the advanced IOL technology discussed above. Gen X also overlaps with Gen Y in terms of technologies such as corneal inlays, laser vision correction and the newer small incision lenticule extraction procedure. I routinely use objective scatter index with the AcuTarget HD (Visiometrics) to quantify the forward light scatter and help delineate whether a corneal or lenticular refractive procedure should be done for these patients. Corneal inlays such as Kamra (AcuFocus) and Raindrop (ReVision Optics) have provided the first defense against presbyopia as refractive surgical options before the development of a cataract.

The Kamra corneal inlay received its FDA approval in April 2015, labeled for intrastromal corneal implantation to improve near vision by extending the depth of focus in the nondominant eye of phakic, presbyopic patients between the ages of 45 and 60 years old who have cycloplegic refractive spherical equivalent of +0.5 D to –0.75 D with 0.75 D or less of refractive cylinder and who require near correction of +1.00 to +2.50 of reading add. I have found it works best in terms of uncorrected near vision gain in those patients who have –0.5 D to –0.75 D sphere preoperatively. The Kamra can be used in patients after laser vision correction such as LASIK or PRK as an off-label procedure in my hands, but if patients had prior flap creation with a microkeratome blade, then OCT imaging of the cornea is critical to make sure you create the corneal pocket at least 100 µm below the old LASIK interface and still stay 250 µm from the corneal endothelium.

The Raindrop near vision inlay is a microscopic hydrogel corneal inlay that is placed under a femtosecond laser flap and creates a prolate-shaped cornea. It measures 2 mm in diameter and 32 µm in thickness. This technology is best suited for patients who are in the low hyperopic range of +0.5 D to +0.75 D sphere preoperatively, and it should not be used in those patients who have undergone prior LASIK surgery. Many emmetropic presbyopes that come to our offices seeking presbyopic correction are typically low hyperopes functioning well in the distance without prescription glasses needed. The drawback of Raindrop is the potential for corneal haze, and most recently many of my colleagues and I have been using mitomycin C (no different than in PRK) under the flap before placement of the Raindrop to reduce this risk. Long-term data are still needed with this technique.

PAGE BREAK

Gen Y/millennials

This generation especially benefits from laser vision correction such as LASIK and PRK, with advances in femtosecond laser technology such as the IntraLase FS (60 kHz) (J&J Vision) and the Ziemer Z8 platforms with high-speed, efficient ergonomics and lower energy needed for flap creation, and advances in excimer technology such as the Technolas Teneo 317 (Bausch + Lomb) not yet available in the U.S. and the WaveLight (Alcon) topography-guided treatment capability recently approved in the U.S. The FDA approved the VisuMax SMILE procedure (Carl Zeiss Meditec) for the reduction or elimination of myopia between –1 D and –8 D, with 0.5 D or less of cylinder and manifest refraction spherical equivalent of –8.25 D in the eye to be treated in patients who are 22 years of age or older with documentation of stable manifest refraction over the past year. SMILE brings a new era of sophistication to refractive correction in the U.S. in what we can call microincisional refractive surgery (MIRS), no different from MICS and MIGS in cataract and glaucoma surgery, respectively. SMILE has already been established in global markets such as Europe, China, Australia, Canada and India.

In the end, with the American Academy of Ophthalmology meeting fast approaching, the premium surgeon should evaluate all of these great technologies and implement as many as possible to meet the needs of the generation gaps we now face daily in our practices.

Disclosure: Jackson reports he is a consultant for Johnson & Johnson Vision/AMO, Bausch + Lomb, Lensar and Visiometrics.