I was asked to talk at the recent Ophthalmology Updates! meeting in Sydney on the near future for cataract and refractive surgery. I began with a quote from William Gibson: “The future is already here; it’s just not very evenly distributed”. As part of that I reminded ophthalmologists that with cataract surgery, if they are comfortable with what they’re doing, then they probably need to look up, and look around, because somebody’s doing something better.
I concentrated firstly on EDOF intraocular lenses (IOLs) and urged ophthalmologists to look at the underlying optical principles behind the various lenses available and those coming to market. Some are truly innovative, others are simply modifications of multifocal IOLs and some are not even EDOF lenses at all; but if we understand the optical principles we can make sensible clinical decisions about which to use in our practice, and not be persuaded one way or the other by industry.
I also emphasised the dilemma ophthalmologists have, for example, using the Vivity IOLs, which is probably the most widely used EDOF lens in Australia at present. If I achieve a bilateral emmetropic end point in patient A and the same emmetropic end point in patient B, then Patient A may not require glasses for any activities, whereas Patient B might require +1.50 readers for near tasks. Exactly the same refractive end point with the same lenses and some people get better unaided near and intermediate vision than others. Why is that? It can be frustrating.
Dr Chris Hodge and I have studied my patients and have looked at all the variables via a multiple regression analysis, and have come up with an initial finding that pupil size is a significant indicator; that is, the smaller the natural pupil the better the unaided near vision will be, other things being equal. A cornea which has more spherical aberration likewise has a trend to better unaided near vision in this post-op circumstance. There will be other factors and perhaps combinations of factors, but over the next year we will be able to better predict patient function if we achieve a targeted end point. The same will almost certainly be true for regular aspheric monofocal lenses, and it will help us to use these better in the context of mini monovision.
I also talked about attempts to use large data sets and artificial intelligence to help with IOL selection. I used, as an example, the ZEISS Veracity surgical planner, which is not available in Australia yet, but is widely used in the US. It takes pre-operative information from the patient, both in terms of their lifestyle and expectations from surgery, combines this with the regular diagnostics and imaging of the eye, and in the mix are the lenses; the specific IOLs that a particular surgeon likes to use. The system is close to coming up with a recommended lens for a particular patient based on their lifestyle and their ocular anatomy.
I posed the conflict that will occur if surgeons have a very limited range of lenses. For example, if they never use a trifocal or an EDOF but only use monofocal lenses, then they will keep being offered monofocal lenses. If they widen their suite of lenses to what is actually available for patients, then almost certainly they will be recommended lenses they do not normally use. It will force ophthalmologists to consider a wider range of lenses and I think will be quite confronting. If in the end you as a surgeon are rejecting the lens chosen by ZEISS Veracity in favour of a more “conservative” lens, then you, the ophthalmologist, may be the problem (or barrier) to patients getting the lens best suited to their personality and lifestyle, rather than the problem being the artificial intelligence program. Something to consider.
Finally I talked about immediate sequential bilateral cataract surgery (ISBCS); that is, doing both eyes on the same day under set protocols. There is really no clinical reason not to adopt this for the majority of patients. There are plenty of reasons to adopt it: efficiency, less waste of resources, cost, less disruption to relatives and carers, even less traffic on the roads. The barriers are financial and cultural, and ophthalmology in Australia will be forced to consider this with more seriousness in the near future.
Given that I started with suggesting the future is already here, bilateral same day cataract surgery is a good example, commonly performed in the Nordic countries and by enthusiast surgeons in different parts of the world, but rarely in Australia at present.
The near future is ours to grasp, and it looks challenging and promising.
About the author
Name: A/Prof Michael Lawless
Qualifications: MB,BS. FRACS. FRANZCO
Affiliations: Clinical Associate Professor, University of Sydney. Ophthalmologist, Vision Eye Institute
Years in industry: 40