CATARACT 12 EWAP SEPTEMBER 2023 T he cataract patient who has had prior refractive surgery requires extra considerations in terms of consultations/patient expectations, IOL selection, formulas, use of intraoperative technologies, and postoperative potential. Nicole Fram, MD, and Warren Hill, MD, provided their thoughts on the modern management of these cataract patients. Preoperative/consult period Dr. Fram said that the first step is to take a thorough history, determining whether the patient was of presbyopic age when they had laser vision correction, what type they received, and if monovision was a strategy used for presbyopia correction. “It is also important to review their current glasses prescription and ask direct questions such as, ‘Do you currently wear glasses when you look at your phone or computer, when reading and/ or driving at night?’ I will even go as far as asking to see the font on their phone to assess their level of presbyopia denial,” Dr. Fram said. “All of these questions will help you assess the proper timing of surgery and strategy necessary to achieve the highest patient satisfaction.” In her diagnostic workup, Dr. Fram includes manifest refraction, pachymetry, corneal topography with Placido imaging, wavefront or ray tracing technology (to determine the level of spherical aberrations and higher order aberrations originating from the cornea or the lens/vitreous), and a spectral-domain macular OCT. Dr. Fram said the type of refractive treatment (myopic or hyperopic) and centration of the ablation is also important for counseling. She finds Placido imaging useful to assess quality of vision potential to set expectations. In counseling, Dr. Fram said she uses her tablet to display Rendia Exam Mode and describe how the light travels in the eye. She explains to the patient how laser vision correction affects one of the important parameters used to calculate IOL power and the potential for inaccuracies. “I explain that although we are improving our ability to achieve emmetropia and hit the targeted outcome, there is still a chance they may need glasses postoperatively,” she said. Dr. Hill said that he takes preoperative measurements in a separate visit. “During this visit, I review these with the patient using a large, wall-mounted LED display screen connected to each of our instruments. The discussion concentrates on the topographic axial curvature map and an image simulation at various pupil sizes, with and without glasses; explaining to the patient how they will see after surgery is good, but showing them is far better,” Dr. Hill said. IOL selection IOL selection, Dr. Fram said, depends on patient expectations and type of ablation pattern. The post-myopic LASIK patient, for example, will usually have a positive or neutral spherical aberration profile, so an Contact information Fram: drfram@avceye.com Hill: hill@doctor-hill.com Making Practice Perfect for Post - refractive cataract patients by Liz Hillman Editorial Co - Director This article originally appeared under the title “Best practices for postrefractive cataract patients” in the July 2023 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Dr. Fram uses Rendia Exam Mode to explain to patients how light waves travel through the eye and how laser vision correction affects one of the parameters to calculate IOL power. Source: Nicole Fram, MD
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