EyeWorld India June 2021 Issue

REFRACTIVE EWAP JUNE 2021 49 When discussing technology to improve premium lens outcomes, the topic of postop enhancement came up among the members of the EyeWorld Refractive Editorial Board. Lance Kugler, MD, said that for patients undergoing refractive cataract surgery with multifocal IOLs and astigmatism management, the enhancement rate should be no lower than 10–12%, which sparked a discussion among board members about how often they perform enhancements. Dr. Kugler noted that it’s difficult to compare enhancement rates among surgeons due to the inherently subjective nature of enhancements. “However, if one approaches multifocal IOLs with the assumption that anything more than 0.5 D of cylinder is unacceptable, the math suggests that an enhancement rate in the 10–12% range is required,” he said, adding that this is derived from the limitations of formulas, keratometry, axial length, effective lens position, and IOL manufacturing tolerances. A 20 D IOL may actually be significantly higher or lower power, Dr. Kugler said. He added that those who perform more RLE than refractive cataract surgery are likely going to have a higher enhancement rate than those who do predominantly cataract surgery. Additionally, Dr. Kugler said that comanaged patients are likely to have a lower enhancement rate, as they may be offered enhancement less frequently. Dr. Kugler noted that an informal survey among surgeons Enhancement rates in the Refractive Surgery Alliance several years ago found the enhancement rate was 10–12%. “Anything less than that means a significant portion of patients out there are not seeing as well as they could be,” he said. Dr. Kugler also noted the importance of having an enhancement plan in the event that one is needed and setting patient expectations prior to premium IOL surgery. Thomas Clinch, MD, thinks the variation in surgeon enhancement rates may be attributable to setting appropriate patient expectations. He practices in Washington, D.C., and said it is a very demanding market with analytical, educated patients. Dr. Clinch’s enhancement rate is low (less than 2%). “This may be based on not performing a substantial amount of RLE and recommending that cataract patients defer surgery until they are truly symptomatic,” he said. “Part of that strategy is that at the time of surgery, they have reasonable expectations rather than expecting perfection. They are usually grateful for a good outcome.” He usually has patients wait 2–3 months before enhancing to achieve refractive and neuroadaptive stability, but he noted that in instances where a toric IOL rotates or there is a substantial refractive “surprise,” one needs to be proactive. While performing a substantial surgical volume, Dr. Clinch’s practice pattern is not aggressive. He tends to allow patients to evolve toward the decision. “Building a community reputation of being a cautious but confident surgeon has been very rewarding. It has allowed me to build a large referral base of surrounding physicians and optometrists,” Dr. Clinch said. John Berdahl, MD, said his enhancement rates for premium IOLs is about 10%. Roger Zaldivar, MD, thinks enhancement rate depends on the prior state of your patients. “If you are doing RLE, you should be around 10% enhancement rate due to power estimations and astigmatism,” he said. “You can minimize this with lot of chair time.” It will depend on how aggressive you are at selling the procedure, too, Dr. Zaldivar said. “With new EDOF IOLs, since they have a larger landing zone, our enhancement rate is around 5%.” Dr. Williamson has a low enhancement rate, noting that he tries to “treat the patients and not the numbers.” “We should remember that PRK and LASIK aren’t totally benign; they are still another surgery with their own set of issues and recovery. While I’m happy to use these technologies for unhappy patients and we include this in our refractive package, I’m not going to recommend it on happy patients simply because they have small amounts of residual refractive error,” he said. Contact Berdahl: john.berdahl@vancethompsonvision.com Clinch: tclinch@edow.com Kugler: lkugler@kuglervision.com Williamson: blakewilliamson@weceye.com Zaldivar: zaldivarroger@gmail.com ADVERTISER LISTING Alcon Page 28-31 www.alcon.com Feather Page 9 www.feather.co.jp/en Johnson & Johnson Vision Page 2, 17, 24, 42-45 www.jjvision.co Oculus Page 37 www.corneal- biomechanics.com Medicontur Page 5 www.medicontur.com APACRS Page 10-13, 36, 55, 56 www.apacrs.org