When the surgeon must choose

What tools and products would experienced cataract surgeons opt for themselves?

They’ve been performing cataract surgery for decades, experienced with virtually every IOL, laser and drop the eye-care industry has produced. They’ve read peer-reviewed journal articles, attended the major ophthalmic meetings — and taught their own sessions.

What does the sum of all this experience and exposure mean when the time comes for their own cataract surgeries? Here are the informed choices of four leading cataract surgeons.


The desired outcome and how to get it

I had myopic LASIK refractive surgery about 15 years ago. I was originally a -7.0 D myope. But what has happened is I have a bit of mini monovision; one of my eyes is plano, and the other eye is about a -0.75 D. I still like being able to read without glasses even though I am an early presbyope. So, if I were to have cataract surgery I would likely want to do almost the same thing. I would want an aspheric IOL, because I’ve had myopic LASIK before and that would be best to optimize my vision. So either a Tecnis (Abbott Medical Optics) or AcrySof IQ (Alcon).

If I had any corneal astigmatism, I would want a toric IOL, and I would want to have a monovision with about 1 to 1.5 diopters difference between the two eyes. My left eye is my distance dominant eye, and I would remain with that aiming for plano, and my right eye for some reading up close. That difference would be sufficient for reading on a computer or iPad. For smaller print, I would just throw on a pair of readers. I wouldn’t tolerate a larger difference between my eyes.

The femto question

I don’t necessarily want femto. I would probably just go to a more seasoned, accomplished surgeon. But femto definitely has some advantages, so I wouldn’t rule it out at this point.

I think femto really excels for dense cataracts, loose zonules and white cataracts — it really benefits those patients. Obviously if the patient has corneal astigmatism that needs to be treated and a toric IOL isn’t an option, then the AKs with the femto are just as good if not better than a manual LRI. But those are the cases where I would definitely want to use femto.

As for drops

I believe in using a good drop regimen, such as a nonsteroidal anti-inflammatory with  less corneal toxicity, better penetration and lower dosing, so something like Prolensa (bromfenac ophthalmic solution, Bausch + Lomb), which is once-a-day dosing, or Acuvail (ketorolac, Allergan), which is twice-a-day. I think a topical steroid is good to treat inflammation and decrease your cystoid macular edema risk; a topical antibiotic, for seven days, also helps.

I am very reserved as to whether intracameral antibiotics are necessary. I do not think they are standard of care and although they do offer some benefits,  toxic anterior segment syndrome still worries me, so the less that goes in my eye, I think the better.

For presbyopia cataract patients?

I talk to my patients to find out what their needs are. I give all my patients a choice for IOLs if they are appropriate for their lifestyle and their eyes (as long as there is no precluding ocular condition).

However, if they have been monovision contact lens wearers, I really just discuss doing monovision with an intraocular lens, aiming for the same refractive difference that they’re used to.

If they were multifocal contact lens wearers, then, again, a multifocal IOL may be the best thing.

Or, if they are a low myope, I ask them if they like to take their glasses off to read and explain that might be an option for them, to aim for them to be a low myope postop and wear glasses for distance.

It depends on informing the patient properly; I don’t really have a go-to, it depends on the patient’s lifestyle and what he or she wants.


The desired outcome and the plan to get it

I have already had cataract surgery. It was beautifully performed 18 years ago by Dr. Richard Mackool. At the time, I had monovision with my previous RK [radial keratotomy] eye being made -1.75. It remained stable until two years ago.

It shifted to distance after a severe case of bronchitis. Since I enjoyed the monovision so much, I have always maintained that would be my preference. However, after gaining experience with the Symfony IOL, (Abbott) I would probably choose that. My reason is that the Symfony is giving our patients a significantly increased depth of focus. It is also a very forgiving lens with a large sweet spot. I have used it in multiple postrefractive surgery patients, with excellent outcomes.

The femto question

I would have femto done with the Catalys (AMO) laser, followed by phacoemulsification. I would want femtosecond laser-assisted cataract surgery because it gives the most predictable capsular opening. The laser fracture of the nucleus decreases the phaco energy required, resulting in less postoperative corneal edema. I would have my previous RK eye made -1.0 and the other eye near plano. Postoperatively I would use Besivance, (besifloxacin ophthalmic suspension B+L) BromSite (bromfenac ophthalmic solution (Sun) and Durezol (difluprednate ophthalmic emulsion) Alcon). 

As for drops

I would pretreat with Besivance and BromSite. I would want the surgery done with topical anesthesia combined with light sedation.

IOLs for common refractive issues

For 1.75 diopters or less astigmatism, I tend to use the femto. Above that I use the Alcon toric lens. For patients wanting presbyopia correction with astigmatism of 1.25 or greater, I use the Symfony toric. My treatment of choice for presbyopia is the Symfony IOL, followed closely by monovision.

We now have numerous options for the treatment of glaucoma in conjunction with cataract. If the glaucoma is mild, I will choose a MIGs, Kahook goniotomy, or endolaser. If they have a pre-existing narrow angle and need more than the cataract, I lean toward the endolaser. If the glaucomatous damage is moderate, I add the endolaser to the MIGs or goniotomy. If the damage is severe or the patient needs a lot of pressure lowering, I lean toward implanting an express shunt during the cataract procedure.


The desired outcome and the plan to get it

I would have an IOLMaster (Carl Zeiss Meditec) obtain my axial length. I would a certified technician measure my cornea three ways: IOLMaster K’s, Zeiss Topography K’s and manual keratometry. This will help confirm the power and axis of astigmatism to manage during surgery. Having an odd number of tests provides a tie breaker if not consistent. I trust a high quality topography for axis of astigmatism and notice beats an old fashioned keratometry reading for power if done properly.  I would use the Holladay 2 and the Barrett formulas to help choose the ReSTOR (Alcon) D1 IOL power after learning my surgeon’s adjusted A constant. The goal would be plano to -0.25 for the outcome in each eye; I would prefer mild myopia rather than any hyperopia to have some added benefit for reading. Thus, I would pick an IOL with predicted outcome of zero or less. I would prefer mild myopia rather than any hyperopia to have some added benefit for reading. Thus, pick an IOL with predicted outcome of zero or less.

The femto question

I would definitely have the surgery with femtosecond laser. (Dr. LaBorwit authored OM’s now defunct “Femto Factor” column).

What about drops?

I would not use drops leading up to the surgery.

If given a choice, I would prefer diluted Vigamox (moxifloxacin; Alcon) injected into the anterior chamber. Additionally, I would ask for sub-Tenon’s kenalog injected superior temporal. I would not need to use drops following surgery with this protocol.


The desired outcome and the IOL to get it

I haven’t yet had cataract surgery, but when I do, the issue I’d like corrected is presbyopia. As for the IOLs to accomplish this, I am considering either the AMO ZLB00s or the Symfony, both diffractive multifocal IOLs. The Symfony  provides a range of vision.  The ZLB00  provides pretty good distance and pretty good near but there’s not really a range. It’s a dual fixed-focal point.

So, I’ve been considering getting a Symfony in my dominant eye and the ZLB00 in my non-dominant eye, but I guess if you really limit me to one choice it would probably be the Symfony lens. The Symfony lenses gets you a range of vision, and so if you slightly skew those two ranges, you make one eye just a little bit myopic, your distance is still fairly good. So minus one-half in the non-dominant, plano in the dominant.

The femto question

I absolutely would not go for femto. From my experience with two different femtos, and from what I have read, femtosecond laser probably creates more inflammation than nonfemto cases. I do not see any advantage to femto yet. My femto cases prove to be more difficult and it seems like the only reason I do them is to justify the fact that the laser is there and try to stay cutting-edge. So, I would definitely have standard, plain old phaco surgery.

What about drops?

What I would do is somewhat unorthodox and extremely complicated, which is the reason I don’t prescribe this regimen for my patients. Starting three weeks before the surgery, I would start putting BromSite into my eye every night before I went to bed, so once a day BromSite. I would continue that until three days before the surgery, at which time I would start twice a day BromSite. One day before surgery, I would start taking Besivance, three times that day.

On the day of surgery: I would take a drop of BromSite and one of Besivance when I woke up; when I got to the surgery center, I would have another drop of Besivance.

I would be 100% sure that the surgical team put some drops of Betadine, (Alcon) pure Betadine, in the drop form in my eye before I went into cataract surgery. Those povidone-iodine drops have been proven to reduce the incidence of postoperative endophthalmitis.1

Immediately after the surgery, I would start with a regimen of BromSite twice a day. I would start with Besivance immediately as well. The first 24 hours I would probably take Besivance as close to every hour as I could and then I would probably reduce it to three times a day. And in addition to those, I would take Durezol three times a day for the first week.

I would keep up that regimen for seven days, then I would reduce the BromSite to once a day. I would discontinue the Besivance and take the Durezol once a day for a few more days. The BromSite I would continue for at least one month and maybe even six weeks because the highest incidence of CME is at six weeks postop. You want to reduce the prostaglandin formation for an extended period and six weeks is ideal. OM

  1. Shimada H, Nakashizuka H, Grzybowski A. Prevention and treatment of postoperative endophthalmitis using povidone-iodine. Curr Pharm Des. 2016 Dec 4.

If you are interested in reading more of your peers’ opinions about how they would want their cataract surgeries treated, please turn to page 24 for our femtosecond roundtable discussion.