Cataract & Refractive

Didier Ducournau talks about the development and growth of the EVRS and on his personal vision for vitreoretinal surgeons.

Postoperative endophthalmitis is a rare but potentially devastating intraocular infection, which could lead to severe and permanent visual impairment or even the loss of an eye.1-3 With the average life expectancy on the increase, the prevalence of cataract in the older population and therefore the cataract surgical rate has increased in recent decades.1,3 Many have voiced their concerns that this rise in the number of surgical procedures could bring with it a rise in incidence of endophthalmitis, hence, evaluation of postoperative infection incidence is extremely important in every clinical setting.

CE marked in April of 2006, the KS-3Ai has become the first preloaded aspheric silicone IOL to be approved in Europe for use in cataract surgery. Although the product has yet to gain approval in the US market, it is already available in Japan and will shortly be entering clinics in Europe.

Wound distortion by manipulation of two rigid cannulas during bimanual phaco through tight corneal incisions has been shown to be significant.

Research, development, innovation and the quest for excellence go hand in hand with the evolution of the ophthalmology industry. With the new wave of phakic IOLs entering the market, each with its own unique offering and capabilities, it's hard to know which lenses will suit you and your patient best. Furthermore, does the introduction of these new refractive correctors threaten the position of the lasers that we have all come to grow to love? It seems that the laser refractive surgery industry is still going from strength to strength.

IOL implantation in older, cataract patients often fails to enhance vision to a level that is greater than that of the average non-cataractous lens of a similar age.

Surgeons should not feel ashamed if they only manage to see a few patients, devotion to the patient and then to your practice is of paramount importance. Then, and only then, will you be doing your job well.

Results of a study evaluating post-cataract surgery endophthalmitis at a regional tertiary referral centre in England show no evidence of an increase in incidence over a recent period of almost eight years, reported Omar M. Durrani, FRCS.

The corneal endothelium is able to function adequately, even after losing a large number of endothelial cells.

The techniques and materials employed for cataract surgery have improved significantly over recent years, resulting in enhanced functional surgical outcomes, smaller incision sizes and reduced incidences of astigmatism and endophthalmitis. Consequently, cataract surgery has become the most frequently performed surgery in Germany, with around 600,000 conducted each year.

May 2005 saw the birth of the term Microphakonit, when Agarwal removed cataracts using a 0.7 mm phaco needle tip with a 0.7 mm irrigating chopper, through the smallest incision ever documented.

New technologies, advances in phacoemulsification and better instruments have improved outcomes and reduced complications in cataract surgery. However, a similar advance has not been achieved in the same manner with intraocular lens (IOL) development.

Since we have been using the femtosecond laser, we have not had to fit a single therapeutic contact lens

Refractive surgery has radically changed the nature of clinical practice, with its success spawning the proliferation of commercial clinics owned and directed by non-medical personnel

Accommodative lenses on the whole are showing significant promise and have certain advantages over multifocal IOLs because they do not have different refractive zones, contrast or glare problems

Anterior chamber angle-supported phakic intraocular lenses have now become a viable alternative for the correction of moderate and high refractive errors with excellent levels of efficacy, predictability and safety.

CE-marked since October 2004 and approved by the FDA in March 2005, the ReZoom IOL (AMO, Santa Ana, California, USA) was designed to provide hyperopic cataract patients with greater independence from glasses, although good visual outcomes can also be achieved in other patients. However, patient selection is essential and one of the criteria that candidates for multifocal IOLs must fulfil is an adaptable and open-minded personality. Patients should not have unrealistic expectations and should not be looking for perfect vision. Surgeons must also emphasize to patients that neuroadaptation is required to adjust to a new visual system and this might take a few months.

The implantation of IOLs in the eye has been part of cataract surgery practice for many years; however, it is only in more recent years that these implants have become available for refractive correction. To date, the resulting vision outcomes have been impressive. In fact, most refractive surgeons believe phakic IOLs will become the procedure of choice for certain forms of refractive correction. Because patients are wary of the perceived invasive nature of this procedure, however, phakic IOLs still have a long way to go in the race to gain patient popularity and trust.

The bimanual technique still has a role to play even if it is now possible to perform a coaxial phaco through a microtunnel

This procedure has distinct advantages over conventional surgery for keratoconus and may eventually supersede it

AquaLase? lens removal is an exciting new method, offering benefit to both cataract and refractive patients. The system is designed to work with the INFINITI? Vision System from Alcon. In theory, this technique was to be fully equivalent to phacoemulsification, but in fact, several important differences exist.

I would like to share my clinical experience with the AcrySof? ReSTOR? intraocular lens (IOL) in patients with cataract. We performed a prospective study of 63 eyes of 32 patients (31 bilateral and 1 unilateral). All surgeries were performed by 1 of 2 surgeons, and second eyes were operated on within 2 weeks of the first eye. The inclusion criteria were senile cataract with corneal astigmatism less than 1.5 diopter (D) and IOL power between 16 and 25.5 D; ocular comorbidity was excluded. Based on these criteria, about 56% of our cataract patients were eligible. Our outcome measures were both refractive status and quality-of-life issues.

Robert J. Cionni, MD

The AcrySof? ReSTOR? lens is the first apodized diffractive intraocular lens (IOL) to become available, and clinical results with this lens seem to be different from those seen with older technology. We're familiar with previous lens technology, either zonal refractive or full aperture diffractive designs. I will discuss the advantages and disadvantages of these older designs and explain how the new AcrySof? ReSTOR? lens represents a breakthrough technology.

Refractive lens exchange has become the procedure of choice for correcting high ametropia in the presbyopic patient. From the refractive surgeon's perspective, the AcrySof? ReSTOR? lens is a wonderful option for refractive lens exchange. It is safest in eyes without high or excessive axial length. Until recently, the only implants available for refractive lens exchange were monofocal intraocular lenses (IOLs). These provided patients with a single focal point, either for reading or for distance. The Array? multifocal IOL became available several years ago, but my experience, and the collective experience of many other surgeons, was that this zonal refractive, multifocal IOL did not provide a satisfactory result for most patients.

Robert J. Cionni, MD

With lengthening follow-up, the posterior chamber ICL (STAAR Surgical) continues to be associated with encouraging results in the management of refractive amblyopia in children who have failed conventional therapy with contact lenses or spectacles, said Laurence C. Lesueur, MD.

Approved by the FDA in March 2005 for use in cataract patients with or without presbyopia, Alcon's AcrySof ReSTOR lens is the first apodized diffractive intraocular lens (IOL) to be made available. The approval was granted based on clinical trials which found that patients experienced the highest level of freedom from glasses ever achieved in IOL clinical trials.

Major advances have been made in the understanding of the pathogenesis of posterior capsule opacification (PCO) post-cataract surgery, and improvements in surgical technique and lens biocompatibility and design have reduced the rates of opacification in recent years. Nonetheless, opacification remains an important complication in patients undergoing phacoemulsification or extracapsular cataract extraction combined with intraocular lens (IOL) placement, with approximately up to 25% of patients developing visually significant PCO during the first five years post surgery.

Epi-LASIK combines the advantages of both LASEK and LASIK while minimizing the disadvantages of each