Game changers in cataract practice

Offering cataract patients as many options as possible is a multi-step process but well worth the effort.

Nothing has impacted the growth of my cataract practice more than offering patients the choice between traditional and advanced presbyopia-correcting cataract surgery.

Patients and referring doctors recognize when a quality presbyopia-correcting surgery is performed and know that it means a practice cares about keeping up with advances and serving the needs of all patients, independent of their desires for spectacle freedom. (See “Educating and preparing the patient”).

Here, I share the nine most significant game changers that have helped in my journey to offer cataract patients the latest, most advanced options available in 2019.


There is no doubt in my mind that multifocal implants have impacted refractive lens surgery in the same way the excimer laser impacted refractive corneal surgery. In my practice, our 15-year deep dive into understanding how to educate and deliver in the multifocal arena has been a game changer for both the premium and traditional sides of our cataract practice. Patients want to hear all the options available to them, so offering traditional and premium options and clearly explaining the unique benefits of each has helped both areas of our cataract program grow tremendously. The research that has led to optimizing optical design, including asphericity and lowering the reading add power, has brought current low-add multifocals to deliver a very high level of patient satisfaction. Manufacturers have worked hard to deliver optimized optics, and those improvements have greatly helped our patient satisfaction in advanced cataract surgery. Available low-add multifocal IOLs are J&J Vision Tecnis and Alcon AcrySof ReStor.


EDOF lenses have been a fascinating addition to the premium implant category. It is probably best to think of them as multifocal implants — simply lower adds that help patients quite nicely at distance and intermediate. They can give reasonable near vision if implanted bilaterally, but I have found that the near vision can be limited and variable between patients. EDOF lenses give surgeons confidence to get into the game of premium implants.

EDOF also allows for a more forgiving refractive endpoint. We have found that mixing and matching (EDOF in the dominant eye/low-add multifocal in the nondominant eye) works well to give patients a broader range of vision at multiple focal points. Until we have trifocality in the United States, this is our main approach to maximizing spectacle independence, and it has resulted in high patient satisfaction. The only EDOF lens approved in the United States is the J&J Vision Tecnis Symfony.


A variety of pre-operative assessment tools are now available to help us predict which patients will achieve the very best outcomes with premium lenses. Multifocal and EDOF IOLs require a healthy corneal surface and retinal contour. We are fortunate to have the ability to quantify higher-order corneal aberrations (we use the Epic Refraction System, Nidek); to perform tear film analysis (Osmolarity Testing, TearLab) and subsequent pre-operative treatment with technologies like Restasis (Allergan), Xiidra (Shire), punctal plugs and meibomian gland treatment (TearScience, J&J Vision); to use macular OCT to detect subtle macular irregularities (Heidelberg); to perform corneal topography (Pentacam, Oculus) to assess both irregular and regular astigmatism; and to detect corneal pathology that may yield a substandard visual outcome with certain lenses.

Informing a patient pre-operatively that we can perform a postoperative adjustment if we do not achieve the refractive endpoint has been critical for success in advanced cataract surgery. We explain to patients that having a smooth cornea with a low amount of corneal irregularities, a happy tear film and a healthy retina are all crucial factors to achieve optimal vision with advanced implants.


Without anterior capsular overlap of the optic, there is a higher chance of implant tilt or decentration, thus induction of internal coma. No matter how I make my capsulotomy, I try very hard to achieve 360° of overlap of the optic with the anterior capsule. Automating the capsulotomy with technologies such as the Zepto capsulotomy or the femtosecond laser capsulotomy, has taught me that I can achieve 360° of symmetrical capsular overlap of the optic at a much higher rate. Finally, another game changer for my practice is being able to use patient fixation to center cataract surgery over the visual axis with Zepto to optimize implant centration and stability, as I have previously shown in a study of mine published in May 2018 in the Journal of Cataract and Refractive Surgery.


I have been involved with intraoperative aberrometry since its beginning (over a decade ago), and even though I feel fourth-generation formulas have made it less impactful, it is still important and gives me confidence in my outcomes, especially with post-corneal refractive cataract surgery and toric IOL alignment.

Intraoperative aberrometry is performed with the Alcon ORA System. The ORA device fits right on my operating microscope and uses a super luminescent light-emitting diode and Talbot-Moiré interferometer to take 40 refractive measurements in less than one minute either in the aphakic state (to help with IOL power selection) or the pseudophakic state (to document proper IOL power or adjust toric IOL axis). The ORA analyzes and combines data from the central 4-mm optical zone and has a dynamic range of -5.00 D to +20.00 D. The Talbot-Moiré fringe patterns are produced by the reflected wavefront after it passes through two gratings. The resulting fringe patterns provide information about the sphere, cylinder and axis of the refractive error.

Educating and preparing the patient

Presenting a patient his or her options in simple terms, setting up pre-experience expectations with caring precision, and then delivering on those expectations has helped with patient satisfaction.

To help prepare patients, I have identified three “educational pillars” that have greatly improved our cataract program. First, we learned the most impactful question to ask a patient during a cataract evaluation is, “Do you want to do a lot with glasses after cataract surgery or a lot without them?” The answer to that one question separates patients into two groups and helps patients understand they are the ones choosing their final outcome following cataract surgery.

Secondly, it helps for patients to understand that some implants replace clarity of vision only and some implants replace the loss of near vision, in addition to reestablishing clarity of vision.

Finally, for those who choose the advanced implant journey, I tell them this is not for impatient people. It will be a four- to six-month journey through healing and adaptation to their new vision due to incisional healing, which can alter astigmatism and effective lens position causing intermittent blur that may need to be fine-tuned with a laser at three months. I tell them they may also need a YAG laser capsulotomy. I explain that, after the steps to get them to 20/20 vision, there is one year of neuroadaptation, during which time their brain adapts to their new optical system.

The Zepto capsulotomy system, by Mynosys Cellular Devices Inc.


Advanced, vergence formulas like the Barrett, Haigis or Holladay 2 formulas and the artificial intelligence Hill-RBF formulas have taken away some of the most stressful aspects of IOL power choice and helped outcomes immensely. Websites such as the ASCRS Calculator and have become essential tools for the premium cataract surgeon to help with post-refractive cataract IOL calculations and postoperative toric rotation fixes.


Without the excimer laser, premium implants would not be 40% of my cataract surgeries. I am able to make patients happy because I can optimize their refractive endpoint with PRK or LASIK.

I tell patients, “There is often healing blur after advanced implant surgery. If you feel like you are on the 10-yard line, we can use the laser at three months post-op to take the football in for the touchdown.” Besides the advanced implant itself, nothing has been more impactful to my advanced cataract surgery than hitting the refractive endpoint with the excimer laser.

If BCVA or BCIQ (best-corrected image quality) are not acceptable with manifest refraction, a rigid gas permeable contact lens over-refraction providing them crisp vision points me towards a surface issue (like the tear film or anterior basement corneal dystrophy) as the cause of blur. If the blurry vision is persistent after tear film rehabilitation, I use PRK to enhance rather than LASIK. With epithelial irregularities, PRK can treat both the residual refractive error and can remedy subtle epithelial irregularities to optimize image quality after multifocal or EDOF implants.

I have been a part of the Light Adjustable Lens investigation for a decade now, and I believe that will have a big impact on premium refractive cataract surgery. We know that untreated refractive error is the main reason patients are disappointed after refractive cataract surgery. To finally be able to adjust the optic at three weeks rather than the cornea at three months will be easier, more accurate and more convenient for the patient and doctor.


Because of the growing number of drugs in short supply, the high costs of prescription drugs and the rapidly accelerating out-of-pocket costs for drugs under insurance plans, our center has greatly benefitted from working with a reputable, quality company that compounds pharmaceuticals, adhering to strict FDA guidelines.

We now perform an intracameral injection (Imprimis Pharmaceuticals) consisting of a combination of antibiotic (moxifloxacin), steroid (dexamethasone) and non-steroidal (ketorolac) into the anterior chamber after nearly every cataract surgery. We also use the same drops in a combination topical drop. We have kept a close eye on the use of intracameral cefuroxime, ever since an ESCRS prospective randomized study demonstrated the efficacy of it in the prevention of endophthalmitis; about two years ago, we started this treatment at our practice. Our patients have loved the reduction in, or elimination of, the use of topical eyedrops. The advantage of an intracameral antibiotic injection is a higher drug concentration at the target site, as shown in a 2014 study by Braga-Mele R et al published in the Journal of Cataract and Refractive Surgery.

Imprimis’ MKO Melt (midazolam-ketamine-ondansetron)


Many cataract patients are nervous about intravenous (IV) anesthesia administration, particularly if they have “challenging” veins. The midazolam-ketamine-ondansetron or MKO Melt (Imprimis) is a sublingual tablet that delivers relaxing medication over a two-minute release period. At my practice, the MKO melt has made the OR experience easier for both patients and my staff. The effects of conscious sedation are evident after a few minutes and peak at about 10 minutes. Available in a two-tablet peel pack, the MKO Melt active ingredient concentrations are 3 mg midazolam (sedative), 25 mg ketamine (anesthetic) and 2 mg ondansetron (antiemetic). This dosage level is effective for more than 95% of patients. The remaining 5% (typically very young or very anxious patients) may need IV supplementation.


The above technologies have been true game changers in our practice. It is amazing to me to see the impact of premium cataract surgery over the years. The above technologies all help with the preoperative evaluation, the surgical approach and postoperative care of the premium cataract patient. It will be so exciting to see what game changers the next decade will bring. I will keep my finger on the pulse of future game changers to deliver our best to our patients, which optimizes practice health and professional joy. OM

About the Author