EyeWorld Asia-Pacific September 2014 Issue

3 EWAP September 2014 Letters from the Editors Dear Friends D his month’s issue of EyeWorld Asia-Pacific addresses an important aspect of refractive enhancements: patient counseling. Contemporary techniques for refractory enhancement use highly sophisticated systems that superimpose the ablation pattern on the optical map of the eye. It is no wonder that the majority of patients with lower levels of myopia have an uncorrected vision of 6/6 after the procedure, though corrections in higher levels of myopia are not so accurate. Keratorefractive enhancement in pseudophakics is a new challenge for phaco-refractive surgeons especially when dealing with those patients who are highly demanding. Several options are available for subsequent correction of refractive surprises, including prescription of spectacles or contact lenses, IOL exchange, keratorefractive surgery, or implantation of a supplementary IOL. It is necessary for a surgeon to discuss a patient’s options and counsel them about the necessity of refractive enhancement preoperatively. There are a number of factors to consider in this conversation, including what type of lens the patient is receiving, cost issues, and the possibility of patient dissatisfaction after the surgery. Patients expect very good uncorrected vision and freedom from glasses after cataract operation. The demand for keratorefractive correction has been expanding with the arrival of newer technologies. It is essential that the surgeon understands the needs of the patient and helps the patient set a realistic goal. An interesting article in this issue deals with educating versus selling. Doctors are often mistaken for suggesting certain technologies or implants. The physician should endeavor to educate the patient to ensure complete transparency and faith. I hope you enjoy learning through this issue and I look forward to welcoming you all to the Pink City, Jaipur, for the upcoming APACRS conference to be held there in November. I extend a traditional Indian welcome to all of you! Namaste! Here is a Thirukkural from ancient sage poet Thiruvalluvar to tantalize your thought process: They who thoughtfully consider and wait for the right time for action, May successfully meditate the conquest of the world. - Thirukkural 485 Warmest Regards, S. Natarajan, MD Regional Managing Editor EyeWorld Asia-Pacific Dear Friends 3 ataract and implant surgery in the modern age has become an extremely safe and predictable procedure. Patient expectations are high and improving refractive outcomes continues to demand our attention. In this issue of EyeWorld Asia-Pacific you will find several articles focusing onmethods to improve predictability such as femtosecond cataract surgery and intraoperative aberrometry to improve outcomes with toric IOLs. The question, however, remains how to deal with residual refractive outcomes following surgery. This issue has become increasingly important with the concept of premium lens surgery and the promise of being spectacle independent following surgery. What was considered an acceptable refractive result a decade ago no longer holds true, when a patient has outlaid considerable expense for the promise of being spectacle independent following surgery. The issues of cost and the most effective methods to deal with residual refractive error are featured prominently in our current issue. Not all cataract surgeons have access to refractive lasers and may be reluctant to refer patients for further treatment. If patients have not been counseled appropriately about the possibility of requiring laser treatment after surgery, the issue of additional costs can be challenging. As surgeons we have several different options, including lens exchange and laser correction following cataract surgery. Lens exchange is usually reserved for unsatisfactory vision, particularly with multifocal implants, but could be considered in the presence of a large, unexpected refractive outcome, particularly if hyperopic. LASIK is attractive in that the visual recovery is so rapid and there is less discomfort associated with the procedure than surface ablation. Nevertheless, in the older age group with an increased risk of dry eye, surface ablation for a minor residual error is certainly attractive. The availability of lenses designed specifically for sulcus placement, piggybacked on an existing IOL offers another alternative. A secondary IOL can incorporate a toric element or even a multifocal element if desired by the patient. New intraocular lenses in which the optic can be modified either mechanically or adjusted with UV radiation and are now available. The concept of an adjustable IOL has been around for many years and studies now indicate that this is indeed a viable option. Technical issues such as the need to wear sunglasses before the lock down procedure still remain and one wonders whether 2 weeks is long enough for postop refraction to truly stabilize. Experimental work using other means to adjust the power of an IOL such as Femto energy are also feasible and the day may yet arrive where the postoperative refraction can be adjusted in a simple and effective fashion and can become a routine part of postoperative care. Until we reach that stage, I’m sure all our readers will agree that we should do our very best to refine our prediction of refractive outcome with improved formulae, greater precision in the surgery, and accurate alignment of toric IOLs. Our efforts continue to provide more predictable outcomes but it is gratifying to have available several approaches to correcting residual refractive error if required. Warmest regards Graham Barrett Chief Medical Editor EyeWorld Asia-Pacific