Post-cataract surgery visual issues persist
Adi Abulafia MD
Despite all the advances in technology and surgical techniques, post-cataract surgery visual issues persist in some patients and must be dealt with honestly and practically while continuously striving to improve outcomes, heard delegates watching the “20/20 in 2020: The Lens” symposium during the 38th Congress of the ESCRS.
A key challenge for cataract surgeons continues to be residual visual issues in post-surgery patients, while the search for the ideal customisable IOL continues, so the session heard from a panel of leading experts on how visual outcomes can be improved in cataract patients.
Never overpromise results to patients, advised Giacomo Savini MD during his talk entitled “The quest for emmetropia”. About 15% of eyes after surgery will have a prediction error of >0.5D and patients with multifocal lenses should be advised that laser touch-up may be necessary in about 10% of cases to reach emmetropia, he said, so “if this happens then patients will not complain”.
There is very little difference among the refractive results based on the measurements of the current range of optical biometers, which is not surprising as all manufacturers follow the measurements of the original IOLMaster, Dr Savini said.
Looking at what IOL formula is best, Dr Savini said no current formula is better than another for short eyes.
Also speaking during this session, Scott MacRae MD highlighted the success of early studies on novel femtosecond laser-induced refractive index change for IOL touch-ups, which he explained is biocompatible, relatively non-invasive and can treat refractive error, presbyopia and high-order aberrations. “We are very, very excited about this technology and look forward to presenting more information in the future.”
Gerd Auffarth MD discussed restoring accommodation with IOLs. The reality is that there isn’t any real accommodative lens in use currently, but there are some promising developments, including fluid lenses that change curvature, “which is more exciting than changing the position of the lens”, he said.
Looking further into the future, Dr Auffarth said work is ongoing on lenses using artificial intelligence and ‘bionic IOLs’, which looks interesting, while he also questioned the use of the capsular bag as the standard location for accommodative lenses.
Also speaking during this session was Gregorius Luyten MD, who said that positive and negative dysphotopsia can occur in up to 20% of patients following uncomplicated cataract surgery. In terms of avoidance, perfect centration of the lens is key, as is putting haptics in the horizontal position, and using larger optics (6.5 or more), while regarding treatment, he said IOL exchange with a larger optic size leads to up to a 100% success rate.
Speaking about correcting astigmatism, Adi Abulafia MD said toric lenses are becoming the standard of care for these patients but the results are not always predictable.
He outlined seven key tips to improve toric IOL outcomes including validating data and looking at the corneal topography; using several measuring devices, taking into account the posterior corneal astigmatism, being alert for unusual corneas; accounting for the corneal surgically induced astigmatism; optimising toric IOL alignment and having a low threshold for toric IOL calculations.
Meanwhile, Béatrice Cochener-Lamard MD, PhD, spoke about the importance of objective wide- ranging evaluation when assessing post-op eyes, outlining a number of useful assessments and questionnaires, and adding that ocular surface issues are also an important consideration.