Techniques and technology are constantly changing in cataract and refractive surgery. Several Vision Eye Institute surgeons offer their insight about some of the changes coming and how they might impact the sector.
New intraocular lenses (IOLs) are being released regularly, including extended depth of focus (EDOFs) implants that are consistently removing previous compromises and challenging monofocals’ traditional status as the standard of care in the sector.
Artificial Intelligence (AI) and other tools are raising new opportunities for surgeries and surgeons, increasing the amount of data available and potentially easing and improving the patient journey. But there are challenges as well in data sovereignty and security.
In considering the impact of these various changes, among many more, Insight approached a number of Vision Eye Institute surgeons and asked them various questions about future opportunities and challenges for the sector.
Included were Professor Gerard Sutton, NSW; Dr Christolyn Raj, Victoria; Dr Alex Ioannidis, Victoria; and Dr Rushmia Karim, NSW.
1. Given the shift towards refractive cataract surgery, how do you balance the expectations of patients with realistic outcomes, especially in complex or comorbid cases?
Professor Gerard Sutton: In many ways this is the ‘art’ of cataract surgery. There is no doubt that in countries like Australia expectations of spectacle independence after cataract surgery are very high. I don’t see that as a problem, but as a surgeon it is critical you inform the patient of the likely outcome, which is really very good with the newer EDOF IOLs. But never promise spectacle independence.
Dr Christolyn Raj: We now have the technology to triage patients to ascertain how they would benefit from a certain IOL choice. In my practice, we do this by getting to know what the patient knows and what they are willing to compromise. In my opinion this is the silver bullet. There are tested questionnaires I have used to help me here but spending time with a patient during a consult and appreciating their hobbies, what is entailed in a typical day, their commitments, etc is often enough to reach a decision on the best suited IOL. In my experience, this then needs to be weighed up with their co-existing conditions.
Dr Alex Ioannidis: This will involve a very thorough examination of the patient at the time of the assessment, because you have to make sure that you can meet the patient’s expectations for the final visual outcome. If you have comorbidities you have to guide the patient towards the best possible implant that would achieve a realistic outcome, hence a tailored approach for each patient. In saying that, it is important to discuss all IOL options with the patient so they don’t feel they’ve “missed out” on any current technology.
Dr Rushmia Karim: The key is customisation of the individual’s visual needs to the current lenses available. Ensuring patient expectations match the reality of visual outcomes after refractive lenses exchange is managed by clear, honest communication. Visual simulations can help as, does old-fashioned tables highlighting the patient’s lens option. Pre-operative planning with contact lens trials, patient questionnaires and understanding their current and future visual needs is important.
2. What are your experiences with current presbyopia-correcting IOLs, and how do you see next-generation lens technologies improving patient satisfaction and visual outcomes?
Prof Sutton: I use both the Alcon Vivity and J&J PureSee EDOF IOLs. I think with a small amount of blended vision, spectacle independence is very high but there is still sometimes a need for extra near-visual assistance. This technology will continue to improve incrementally but the real question is whether we can get true accommodating IOLs. There are currently a number in development. Intrabag approaches include the Juvene, Fluidvision and OmniVu, whilst those taking a ciliary body approach include the Lumina, which is CE marked in Europe, and the Opira. We will have to wait and see whether these concepts, which have been around for decades, will finally bear fruit. I think we will see one of the accommodative IOLs come to the fore in the next five years.
Dr Raj: I recently conducted an audit of IOL types used in my surgery and the breakdown of EDOF and multifocal versus monofocal (all astigmatism-correcting) was 40% to 60%. Given I operate on a large number of patients with co-existing retinal disease, I was pleased with these results. It suggests that co-morbid disease does not exclude patients from having a premium IOL, as they are often referred to, however expectations have to be clear from the outset. In my opinion the current EDOFs on the market are unable to offer effective near-vision that patients are after. In the context of retinal conditions, where maculopathy can further compromise near-vision, these patients are often better off with a monofocal IOL and wearing reading glasses.
Dr Ioannidis: There has been an explosion of new IOLs in the market that help to control and correct presbyopia and I’ve been using diffractive IOLs for the last 10 years, with very good outcomes. Patient selection is critical. I find that the newer generation, extended depth of focus IOLs such as the Alcon Vivity and TECNIS PureSee can offer patients with ocular comorbidities something that was not actually available to them previously – the ability to extend the range of vision for common intermediate tasks. The other advantage of the EDOFs is the low-risk profile transient dysphotopsias which can be an issue with some diffractive IOLs.
Dr Karim: After a recent audit, my use of multifocal IOLs has reduced, although I still use them in a select group of suitable patients. My use of EDOF lenses has increased over the last five years with greater reliability and comfort using these lenses. It is also important not to exclude the use of monovision. I have a large post-refractive laser cataract practice and the majority of patients coming for cataract surgery already have monovision post-LASIK. I use EDOF lenses in about 30% of my cataract and refractive lenses exchange patients. They suit a particular type of patient – usually an emmetrope or hyperope whose near-vision you are improving. A myope whose near-vision has been good all their life may not be suitable if taking away their ability to read very close, so the patient’s original refraction is also important in lens choice.
3. With increasing digitisation of surgical planning and outcome tracking, how do you manage patient data and outcomes analytics, and what would improve its clinical utility?
Prof Sutton: Mainly in IOL optimisation and surgical audits.
Dr Ioannidis: We have available a lot of information these days from a lot of devices, both diagnostic and also biometric, and this can help us focus the outcomes for the patient we have. We are able to marry together all of this information and analyse it in increasing detail. The advent of artificial intelligence is going to be interesting, because AI will be able to make refractive outcome suggestions for our patients based on the clinical data that is introduced into the algorithm, and in the future it will have a bigger role in how we how we plan surgery for our patients.
Dr Karim: I love looking at the data, however, information governance of the data is very important and having robust safety mechanisms to protect data.
4. Automation and robotic enhancements are increasingly available. How comfortable are you with increasing automation in cataract procedures, and where do you see the line between assistance and autonomy?
Prof Sutton: I use the femtosecond laser for capsulotomy and nuclear fracture for most cataract cases. It’s a preference but not essential for good outcomes. There are a number of robotic systems being developed around the world with, I think, three already placed in hospitals in Europe. The first partially robotic device was developed back in 1989 and we are yet to see large-number clinical trial outcomes, but they are coming. The challenge of course is precision. The posterior capsule is 3.5um thick and that’s the difference between a perfect and suboptimal outcome in cataract surgery. Is the sensitivity and responsiveness of these systems adequate to ensure safety? We don’t know yet but having just ridden in a driverless taxi in San Francisco recently, I don’t see why not.
Dr Raj: Having used a semi-automated process – laser assisted cataract surgery (FLACS) – now for the majority of my patients, I can definitely say that there is a role for this. Automated processes allow a technique to be performed with great precision that is repeatable. However, manual and automated surgeries are so different that they require a different pre-operative set-up, a different array of instruments, an understanding of the limitations of each, and alternative techniques to assist with these limitations (the latter enhanced with experience). At this stage, semi-automated rather than completely automated processes are probably the way to go – each person is different and so is each eye we operate on, so we need to be able to be versatile in our surgical approach, which a fully automated process does not lend itself to.
Dr Ioannidis: Yes, we’re finding that robotic surgery is becoming more prevalent in different specialties, and ophthalmology will also see its role. Current surgical interfaces basically replicate human motion, so they’re not really truly independent. You have to teach the robotic system how to respond to a given scenario. With increasing advances in these systems, you will find that robotic systems become more independent of the human operator. There is no doubt in my mind that robotic surgery will have a major role in optimising outcomes in the future. It remains to be seen whether patients will actually like to be operated on by independent artificial intelligence devices and robots or prefer to have a human-to-human interaction. This will be an evolving field in the next few years.
Dr Karim: I am an early adopter for any form of technology that will ultimately make surgery safer and more reliable. Lensx is a perfect example of how we have the ability to use a femtosecond laser to perform a near-perfect rhexis. Robotics has evolved rapidly in surgery and will continue in the future.
5. What is your perspective on the future role of femtosecond laser-assisted cataract surgery (FLACS) in routine practice? Has it reached its full potential or is there room for renewed relevance?
Prof Sutton: It provides good symmetrical capsule overlap and long-term IOL stability and is kind to the corneal endothelium. There is a new system, Keranova, which may be more efficient in nuclear fracture and eliminate the need for any phaco energy. It uses a laser detection system to assess how much energy is required for nuclear fracture. It is also in the operating theatre and doesn’t require an extra room.
Dr Ioannidis: In my 10 years’ experience with this technology I can tell you that FLACS has a role in complex cases and can effectively reduce surgical risk. In my practice patients are given a choice whether to have surgery with FLACS or via the conventional method and many do prefer the added technological advancement. With increasing advances in the future, you will find that these systems will become much smaller in size, more compact, potentially becoming incorporated into the operating microscope and within the operating theatre.
Dr Karim: I would have it for my cataracts when older. No matter how perfect you are as a surgeon, FLACS can give a near-perfect rhexis and reduce risk. I am part of the RANZCO cataract coaching seminars and repeatedly there is consensus that this step of cataract surgery is crucial. Why would you not use technology to reduce risk?
6. How has your approach to managing post-operative refractive surprises evolved, and what tools or techniques do you find most valuable for achieving optimal outcomes in such cases?
Prof Sutton: The most important tool in managing unhappy patients with refractive surprises is my voice. I personally go through likely post-operative refractive outcomes and spectacle independence with all my patients and document it in the digital file. When it does happen, I remind the patient that there was always that possibility and then tell them we have options to deal with it. Glasses work quite well actually but if these are unacceptable to the patient, I will offer either a corneal refractive procedure or a secondary IOL.
Dr Raj: My approach is fairly straightforward and hinges on open disclosure to the patient with an emphasis on the ways we are now able to manage this. I always mention the possibility of refractive surprise to my patients during the initial consultation. Should this occur, my team and I would go back and look carefully once again at the pre-op and post-op data looking for anomalies. It can be useful here to use some calculators on the American Society of Cataract and Refractive Surgeons website. AI platforms that take into account wavefront aberrometry can hopefully be more useful for this scenario in the near future. When considering options, I try to simulate this using a trial contact lenses or glasses to demonstrate “improvement ” to the patient. Then I consider one of three options: refractive laser enhancement; surgical IOL replacement/augmentation; or conservative glasses/cl correction.
Dr Ioannidis: A discussion about refractive outcomes has to happen well before you proceed to performing surgery on a patient, and you have to give the patient realistic expectations, especially if their expectations are very high, because sometimes patients don’t understand the complexity of the visual system and complex concepts such as neuroadaptation. For any refractive surprise we have a lot of tools at our disposal to manage it. We have laser enhancements that can reduce the refractive error, we have the option to do piggy-back IOLs, which can also effectively reduce any residual ammetropia. In most cases, I find patients actually accept they have a minor refractive surprise and they’re willing to accept the use of glasses, rather than undergoing another surgical intervention. I must admit in the last 10 years I have not had to explant an IOL just because there was a minor refractive surprise.
Dr Karim: The key is consistent, repeatable algorithms, reducing human error in the calculation process, and meticulous checking. Evaluating true refractive surprises have tended to occur with wrong lens selection, with errors along the cataract surgery process. Having an experienced team who understand the implications of errors and repeatable, reliable processes means this error is reduced.
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