Cataract Surgery Program at Vance Thompson Vision
Cataracts Top Line
- Educate cataract patients on all implant options
- Refractive cataract packages can include correction for distance vision, astigmatism correction and/or presbyopia correction.
- Mostly recently introducing the PanOptix trifocal and the Light Adjustable Lens to the cataract program.
- New Multifocals available with reduced night-time halo and variable add power options
- Refractive cataract surgery is a 2-3 step process including YLC and corneal laser enhancement
- Drop A Day Cataract Surgery Most Common
Want More on Our Cataract Program?
The most common reason for removing the crystalline lens is cataract surgery. The second most common reason is refractive lens exchange. It is ultimately the patient’s decision to choose which implant will best match their visual expectations and best correct their vision after removal of the natural lens. This is a permanent, big decision. It is our job as doctors to educate them on all their options, and the pluses and minuses of each.
More and more cataract patients are considering the option of using advanced implants to correct their vision after cataract surgery. We educate all patients on monofocal technology, wavefront adjusted aspheric monofocal technology to maximize night time vision, toric implants for astigmatism correction and presbyopia correcting implants that address distance, intermediate, and near vision. We find that even if a patient chooses a traditional monofocal implant and bifocals postoperatively, they are at peace, because they were educated on all the options and feel that they made an informed decision. The flow of the conversation about how patients want to use their vision after cataract surgery can be seen below. Click on the image to view detail.
What is the Procedure?
We perform cataract surgery in two ways: Traditional Cataract Surgery and Refractive Cataract Surgery
Traditional Cataracts Surgery:
- Manual micro-incisional surgery to remove the crystalline lens under sterile conditions using topical anesthesia with sub-lingual or intravenous sedation.
- A manual capsilorhexis is performed with phacoemulsification for lens dissection and removal while retaining the lens capsule intact.
- Insertion of a foldable intra-ocular lens within the capsular bag with a targeted power determined by Lenstar or immersion A-scan IOL calculation.
- Removal of viscoelastic and self-sealing micro-incisions without suturing.
- Glasses or Contact Lens correction of refractive error and presbyopia following surgery.
Refractive Cataract Surgery:
- Femtosecond laser assisted micro-incisional surgery to remove the crystalline lens under sterile conditions using topical anesthesia with sub-lingual or intravenous sedation.
- An anterior segment OCT guided femtosecond laser used to create custom corneal incisions, a custom capsulorhexis, and crystalline lens segmentation with phacoemulsification for lens removal while retaining the lens capsule intact.
- Insertion of a foldable intra-ocular lens, monofocal, toric, or presbyopia correcting, within the capsular bag with a targeted power determined by Lenstar or immersion A-scan advanced IOL calculations assisted by intra-operative aberrometry (prior to and post insertion) for correction of refractive error.
- Corneal laser enhancement for correction of refractive error following surgery.
When and Why Do It?
Patient Exam and Selection
The importance of a thorough examination and counseling session with any eye surgery patient preoperatively cannot he overemphasized. All patients considering refractive corneal or lenticular surgery need to have a complete examination of their anterior and posterior segment.
Our definition of when a patient should consider cataract surgery is:
- When a cataract causes a reduction in patient’s vision so they cannot function the way they need to in their life and cannot be corrected with glasses, contact lenses or corneal refractive surgery, then cataract surgery should be considered.
Patients arrive at the decision to have cataract surgery at different levels of vision and for various reasons. We employ an Activities of Daily Living survey to help patients identify their symptoms and determine when they are bothered by the cataract enough to consider surgery. Certainly, cataract surgery does not have to be performed and a well-informed patient is the only one to make the decision to proceed.
The cataract evaluation is a comprehensive ocular evaluation in addition to the determination of the cataract’s effect on vision, measurements to determine IOL power, an extensive discussion on cataract surgery and IOL options, a discussion of risks/benefits with informed consent, patient education and counseling on costs and instructions. For patients who desire a specific refractive outcome through our Refractive Cataract Surgery program there are additional diagnostic and educational components of the refractive surgery evaluation included in this evaluation. As you can see in Table 1, there are many similarities between the refractive cataract and refractive corneal evaluations.
1 - tests performed for refractive patients who are phakic implant candidates
2 - performed if slit lamp exam suggests endothelial abnormality
3 - to aid in determination of multifocal IOL candidacy
THE PATIENT’S ULTIMATE IMPLANT DECISION
Once the patient has decided to proceed with cataract surgery the next decision is which IOL they will choose and hence the type of cataract surgery they will have. This decision can be simply based on whether they mind wearing glasses after surgery or want to function mostly without optical devices.
Sixty percent of our patients do not mind or want to wear glasses after cataract surgery and opt for Traditional cataract surgery with a monofocal implant.
MONOFOCAL IMPLANTS and ASPHERIC MONOFOCAL IMPLANTS
The invention of the monofocal implant (and it’s placement in the capsular bag after phacoemulsification) revolutionized cataract surgery. However, we can still learn from the natural optical system principals to help in the choice of the best monofocal implant.
From birth, the cornea has a positive aspheric surface and remains positive for our entire life if surgery like laser vision correction is not performed. In a young person, this positive corneal asphericity is counterbalanced by the crystalline lens’ negative asphericity. This neutralizing of asphericity allows young people to have sharp night-time and low-light image quality.
As we age, our natural lens transitions from a negative aspheric state to a positive aspheric state. This is why our night-time and low-light image quality worsens as we get older.
Many monofocal implants that have been developed also have a positive aspheric surface. In a sense, this is a missed opportunity and can lead to a lower quality night-time image after cataract surgery. Fortunately, there have been implants developed that address this issue. These implants are created in with a negative aspheric surface to better mimic the natural lens in a younger individual. This negative aspheric lens implant helps to counteract the corneas positive asphericity, which in turn has been shown to produce a better night time image quality. For patients who want great night time image quality and are fine with reading glasses or bifocals, we typically recommend a negative aspheric surface lens (example the Tecnis monofocal lens, ZCBOO).
Forty percent of our cataract patients desire to reduce their dependence on optical devices and will select one of our refractive cataract surgery packages.
Refractive Cataract Surgery
Refractive Cataract Surgery is our term for advanced refractive cataract surgery packages designed to help patients reduced their dependence on optical devices.
Refractive Cataract Surgery packages include:
- Light Adjustable Lens
- Monofocal IOL for distance vision correction or monovision
- Toric IOL for astigmatism correction or monovision
- Advanced presbyopia correction
- Accommodating IOL (Crystalens) for correction of refractive error, with or without astigmatism, as well as presbyopia.
- Multifocal or extended depth of focus IOL for correction of refractive error as well as presbyopia
Although the emphasis tends to be placed on the advanced IOL, Refractive Cataract Surgery packages are all inclusive much like our corneal refractive options. These packages include, advanced pre-operative diagnostics, laser assisted cataract surgery, intra-operative aberrometry, advanced IOLs when indicated, refractive YAG laser capsulotomy, extended post-op care and corneal refractive surgery enhancement. Considered elective, these packages are an additional out-of-pocket expense for patients.
REFRACTIVE CATARACT IOL Options
Light Adjustable Lens
The RxSightTM Light Adjustable LensTM (LAL) is a three-piece foldable lens that is implanted like any other monofocal lens implant. But unlike other lenses, it can be adjusted and reshaped after implantation to treat any residual myopia, hyperopia, or astigmatism. As you know, because of the final effective lens position and incisional healing it is not unusual to wish a different power lens was placed when the patient's healing refractive error is known. The beauty of the LAL is that after the healing refractive error is known, the lens implant power can be changed to match that patient's refractive desires. This is the first ever FDA-approved lens implant that can be adjusted postoperatively in the patient's eye, making it what we consider the world’s most precise implant. The lens, which is made of photoreactive silicone, can be reshaped by applying UV light via the Light Delivery Device (LDD) to the LAL which changes its power in a very specific and mathematical way. Adjustments to the lens are made three weeks after surgery when the final effective lens position and incisional astigmatism healing is known. To increase the power of the implanted lens, the surgeon treats the center of the lens with the LDD to increase the curvature. To decrease the power of the lens, the periphery of the lens is treated, and a flattening effect occurs in the center of the LAL. A toric light pattern can also be applied to reduce astigmatism. Over a period of two days, the lens
will change shape in a very precise way. Up to three light adjustments can be performed at least two days apart.
When the patient’s desired correction is achieved, the surgeon uses the LDD to “lock in” the prescription. Before the prescription is locked in, however, patients must wear UV-blocking glasses to protect the new lens from incidental UV exposure. Most cataract patients are ideal candidates for the LAL.
We continue to participate in research with the LAL, including a trial for an extended depth of focus (EDoF) option. Results in our FDA monitored trial for patients have been remarkable with 92% of the eyes with the LAL device being within 0.5 D of the target which is better than any other technology currently available. The FDA-monitored trial allowed for two light adjustments. We feel we can achieve even better accuracy post FDA approval we can do three light adjustments to dial in the patients desired refractive outcome and then lock it in for life. You can see why the LAL is called the world’s most precise implant.
Monofocal IOL for Distance or Monovision
Many patients, especially those who have had previous refractive corneal surgery, are looking to achieve good distance vision without spectacle dependence.
They may have had good distance vision and used readers for near or had some measure of monovision that worked well for them prior to developing cataracts.
These patients tend to like doing refractive cataract surgery with a monofocal IOL and targeting distance vision or a form of monovision. We still use the advanced diagnostic technology before and during the cataract surgery as well as a corneal laser enhancement, if necessary, to allow them to be less dependent on optical devices, but will still use them for some things. Some are ok with glasses after surgery, but just want to reduce their level of refractive error in their prescription.
We use an aspheric monofocal to help improve night time vision and reduce chromatic and spherical aberration.
Toric IOL for Distance or Monovision
For those patients with greater corneal astigmatism we offer the option of correcting their astigmatism as well as refractive error for distance vision or monovision. The refractive cataract surgery package for astigmatism may use an intra-operative AK performed by the femto second laser or a Toric IOL.
In general, with less than 1.00 diopter of astigmatism, intra-operative AKs can be performed or the main incision can be made on axis to reduce astigmatism up to 0.50 D.
Toric IOLs can correct up to 6.00 diopters of astigmatism.
Advanced Presbyopia Correcting IOLs
IOLs that correct for presbyopia have been available for almost 17 years now. The technology continues to develop at an accelerated pace. The newest presbyopia correcting IOLs are no exception as they do a great job at providing distance, intermediate and near vision for cataract patients. Newer designs with advanced optics to decrease night time glare and halo, along with more available add powers have allowed patients to confidently choose an IOL that can reduce their dependence on optical devices at all distances. With two categories, accommodating and multi-focal, there are multiple options for patients to choose from depending on how they use their vision.
Accommodating IOLs (Crystalens and TruLign Crystalens)
The Crystalens AO and Crystalens TruLign Toric accommodating IOL uses flexible haptics to translate and flex to create a pseudo-accommodation of between +1.00 and +1.75 D. The anterior aspheric optics added to the Crystalens create excellent clarity of vision, night time image quality and enhance depth of focus. Having a monofocal optic makes the Crystalens ideal for post corneal refractive surgery patients. Because the amount of accommodation can be variable with the Crystalens, patients must understand they may still use readers for some detailed near activities.
The capsulorhexis and the developing tension of the capsular bag can have a significant effect on how well the Crystalens is able to accommodate. The use of the femtosecond laser for a precise capsulotomy is key to predicting effective lens position. As the capsule contracts around the implant after cataract surgery it can restrict the Crystalens and possibly shift or tilt the lens position causing reduced vision and induced astigmatism. Our standard is to perform a YAG laser capsulotomy at 2 months post cataract surgery with the Crystalens.
Patients with astigmatism can take advantage of accommodating technology with the Crystalens TruLign toric which can correct from 1.25 up to 2.75 diopters of astigmatism.
Multifocal IOLs have had an up and down following over the years. Even though they can provide extremely good near vision, the glare and halo issue with some implants has over-shadowed their advantages.
Fortunately, new optic designs and more available add powers has greatly improved the function of the multifocal for cataract patients. The addition of wavefront designed aspheric optics to the concentric diffractive multifocal optics has reduced night-time glare and halo for patients. Multifocal designs now offer differing strengths of add power to customize working distance for patient’s needs.
Thanks to the U.S. approval of a new technology, Vance Thompson Vision offers the first and only trifocal lens for patients undergoing cataract surgery, AcrySof® IQ PanOptix® trifocal intraocular lens (IOL). PanOptix® is clinically shown to offer patients a combination of near, intermediate, and distance vision while reducing the need for glasses after surgery. This new trifocal IOL from PanOptix® uses a proprietary design, ENLIGHTEN® Optical Technology, that optimizes outcomes for cataract patients looking to correct their vision at all distances. A toric version is also available for patients with astigmatism.
“I think the most amazing thing we notice with the PanOptix® lens is the range of vision it gives patients and how that excites them,” Dr. Vance Thompson said. “Patients are surprised they can experience the vision of their younger years as part of their cataract surgery experience.” Dr. John Berdahl says, “Until now, no single lens available in the U.S. provided distance, intermediate, and near vision. The PanOptix® lens gives each eye the ability to see well at those distances.” Vance Thompson Vision was one of 12 investigational sites in the U.S. who took part in the FDA-monitored clinical trial for PanOptix®. The results of this study showed high patient satisfaction with more than 99% of PanOptix® patients saying they would choose the same lens again.
The Tecnis Multifocal can be ordered in three different add powers, +4.00 (ZMBOO), +3.25 (ZLBOO) and +2.75 (ZKBOO), which provide +3.00 D, +2.37 D and +2.01 D add power at the spectacle plane.
Patient selection becomes most important with multifocal IOLs. We consider not only that the patient has realistic expectations and is comfortable with some night-time glare, but that their eyes also fit specific criteria to help ensure a good outcome. Multifocal IOLs do not come with toric availability, so patients with astigmatism must know a laser enhancement will be necessary at around three months post-op.
Angle Kappa and Angle Alpha
The diffractive multifocal surface requires that the IOL be perfectly centered on the patient’s visual axis and not too far off center of the normal pupil. Angle Kappa, the angle created between the visual axis and geometric pupil center is measured on all cataract patients. If the difference is greater than 400 microns, we do not recommend a multifocal for that patient. Angle Alpha, the angle between the visual axis and the geometric center of the cornea is also considered. The geometric center of the cornea, as measured from white to white, is a directly proportionate to the crystalline lens geometric center. Angle Alpha will therefore give us information about the centration of the IOL with respect to the visual axis, and if a large difference may reduce visual quality. If Angle Alpha is greater than 300 microns we would not recommend a multifocal. Angle Alpha or angle Kappa tend not to have a significant effect on monofocal IOLs or the Crystalens.
Advanced presbyopic correcting IOLs perform best with clean optical systems. We perform all the diagnostic corneal testing during our cataract evaluation that we would for a refractive corneal evaluation. We want to make sure the patient is a candidate for laser refractive surgery to enhance their vision if needed after refractive cataract surgery.
Expectations of cataract patients have grown due to advances in vision-correcting technology. We find that after a thorough discussion of implant options, many implant patients choose the monofocal or wavefront designed implants. This allows them to achieve great distance vision and compensate for near with either bifocals or reading glasses. Even when they choose these monofocal implants they are still appreciative that they had an honest discussion about the advanced implants that could have provided them with distance and near vision.
The patients that choose the advanced implants for distance and near are the ones that have expectations like younger, LASIK patients. They want to be able to experience life without glasses or contacts. They are fine having a pair of glasses for certain activities, but they have a great desire to function throughout the day without optical devices.
The reason we offer the full array of advanced implants is that just like in the corneal refractive surgery arena, we want to maximize the chance of delivering the very best outcome for any particular patient’s needs and expectations. Again, even the ones who do not choose the advanced technology tend to appreciate the discussion and options.
How is the Procedure Done?
Informed ConsentVideo of Intraoperative Dex-mox-ketoralac Injection
Educating the patient on the risks of cataract surgery through an adequate informed consent procedure is paramount. Informed consent can be accomplished through written documents or video tapes and can include written tests on the material. An informed consent document contains descriptions of the procedure, alternative treatments and options, and a thorough list of potential risks.
Risks that should be included in a cataract informed consent document should include blindness, infection, cystoid macular edema, retinal detachment or hemorrhage, overcorrection, under correction, corneal scarring, irregular astigmatism, anisometropia, reduced BCVA, difficulty wearing contact lenses postoperatively, the potential need for permanent glasses correction, and that it is impossible to list every complication that may occur as a result of surgery.
The document should also review that if the postoperative refractive error is not correct for their situation, they may need an enhancement procedure or rarely an implant exchange or piggyback procedure. A list of possible temporary or permanent side effects such as pain, fluctuating vision, night glare/halos, ptosis, increased IOP or any other side effects inherent to the procedure under consideration is also important. It should be documented that the patient states that he or she has read the informed consent and that he or she understands the possible risks, complications, and benefits that can result from the surgery and, finally, that it is his or her decision to undergo cataract surgery.
- Patients are seen at 1 day, 1 week, 1 month, 3 month and 6 mos after surgery
- Refractive cataract surgery patients may also be seen at 2 mos for YLC especially with Crystalens
- Patients who elect the Light Adjustable Lens will follow the post op schedule detailed in the post op schedule featured above.
At the one week post-op exam, especially between the first and second eye surgery, we like to see uncorrected and best corrected vision with a MRx , slit lamp exam and IOP, as well as a statement of how the patient is doing with their first eye. This information becomes critical when performing their second eye to know we are on the right path and it is medically the right thing to do proceeding with the second eye.
All refractive cataract surgery patients are educated that it is a project or process to correct their vision. It may be a 2 to 3 step process including YLC and laser corneal enhancement to get to final vision outcome.
Patients now have a choice with pre and post-operative medications. An antibiotic, a steroid and a non-steroidal anti-inflammatory will always be used following cataract surgery. The choice patients now have is how those medications are administered. Traditional drops can be taken, or the patient may elect Drop A Day Cataract surgery, with intra-operative injectable antibiotic and steroid medication. With traditional drop cataract surgery patients will take drops 9 times per day the first week and 3 times per day for the next 3 weeks. With Drop A Day cataract surgery the patient, obviously as the name implies, uses one drop per day for 4 weeks. We now offer a combination drop which contains all three medications - antibiotic, steroid and non-steroidal anti-inflammatory, in one bottle and which patients can pick up at Vance Thompson Vision prior to surgery. Below is an explanation of the various pre and post-op protocols patients may follow prior to and after surgery, as prescribed by their surgeon based upon individual need. Each is supplemented with a printable drop schedule as a visual and for daily tracking.
Drop A Day Cataract Surgery: These patients will be administered an injection of Dex-mox-ketor (Dexamethazone - Moxifloxacin - Ketoralac) at the time of surgery.
- Combination drop of Prednisolone-Moxifloxican-Bromfenac QD x 3 days prior to surgery and QD x 4 weeks post operatively
- NSAID Ilevro, Prolensa or Bromsite QD QD x 4 weeks post-operatively
- NSAID Ilevro, Prolensa or Bromsite QD x 12 weeks post-operatively
No Injection Cataract Surgery:
- Combination Drop (Prednisolone-Moxifloxican-Bromfenac) QID x 1 week, BID x 3 weeks post-operatively
- Combination Drop (Prednisolone-Moxifloxican-Bromfenac) QID x 1 week, BID x 3 weeks, followed by Ilevro, Prolensa or Bromsite QD for the next 8 weeks post-operatively
3 RX Post-Op
- Vigamox: QID for one week
- NSAID: Ilevro, Prolensa or Bromsite - QD for three days prior to surgery, plus the morning of
- Prednisolone Acetate 1.0% - QID x 1 week, BID x 3 weeks
Maximizing Patient Outcomes
There are three primary components to maximizing patient outcomes: Pre-operative examination, Intra-operative technology and experience and Post-operative management.
Managing patient expectations and aggressively treating the tear film will aid in successful outcomes.
During surgery: It is imperative to make sure the inlay is centered.
After surgery: It's important to emphasize the length of time it takes for the vision to completely recover and continue to aggressively treat the tear film.
See and Do Cataract Surgery
The See & Do Cataract program is designed to cut down on the number of trips patients have to make to our clinic for cataract surgery. Each week, all of our surgeons in Sioux Falls, Fargo, Bozeman, Omaha, Alexandria, Billings and Sioux City have clinic and surgery center appointments available for patients to be seen in clinic in the morning, have surgery early afternoon, and be back to see you for their one-day post-op appointment. The process for referring patients for this type of surgery is as easy as completing the referral form and indicating See & Do. Our team will send the patient everything they need ahead of their visit to our office. The idea is to make the process as easy as possible on you, your staff and your patients, while ensuring your patients understand all of their options related to their surgery.