By Robert J. Weinstock, MD

THE LANDSCAPE OF CATARACT and refractive surgery has undergone a transformation over the past 20 years and will continue to evolve rapidly. Surgery used to be an invasive procedure where the primary goal was to remove a cloudy lens that was interfering with vision and replace it with a basic intraocular lens (IOL) to restore vision and to have patients wear glasses for all ranges of vision.

In 2021, in the hands of the right team, surgery is a minimally invasive, quick recovery procedure where patients potentially no longer need to wear glasses for the remainder of their lives. This is primarily due to the introduction of a host of new technologies that allow cataract surgeons to deliver more precise visual outcomes, leading to cataract surgery being performed at younger ages and earlier stages of cataract formation.

Advanced diagnostic preoperative biometry and imaging devices have helped tremendously in choosing the most accurately powered implant for the cataract patient. Femtosecond lasers are helping surgeons deliver a more precise procedure and are creating arcuate incisions for the correction of a low amount of astigmatism. Toric and presbyopia-correcting lenses continue to evolve, providing freedom from spectacles in both the intermediate distance and near visual ranges for patients postoperatively. All of these technologies add a tremendous expense to the surgical practice and also require a substantial amount of training and education, not only for the surgeon but also for the entire staff and operating room team.

As new technologies always continue to enter the market, additional burdens are placed on a practice. The good news is that, because many of these new technologies correct visual problems not typically covered by insurance, an opportunity is created for surgeons to ask their patients to invest in their vision and spend out-of-pocket dollars to achieve their visual goals. If implemented properly with the appropriate pricing structure, this step can often be a significant financial benefit to the practice.

Practices that have embraced refractive cataract surgery are finding that, over the years the percentage of patients who choose to invest out of their own pockets to achieve spectacle freedom at the time of cataract surgery continues to grow. Some leading surgeons also feel that offering cataract surgery with astigmatism correction and presbyopia correction is becoming the standard of care, and it can be considered negligent not to explain to patients who are good candidates that this is an available option and technology opportunity.

With a growing number of patients who will need cataract surgery and the added burden on the surgeon to manage all these patients comes the opportunity for increased collaborative care with physician extenders, such as optometrists, nurse practitioners, and physician assistants. Comanagement arrangements, where the physician extenders are part of the refractive surgery process both on the preoperative side and the postoperative side, let these providers benefit from the additional costs incurred by the patient for more sophisticated and elaborate care.

It is the responsibility of the ophthalmologist to help educate and inform these other providers who are going to be caring for refractive cataract patients pre- and postoperatively in the necessary skills and handling issues that arise. All providers who are evaluating cataract patients and helping these patients make decisions about their visual goals and the technologies to choose must be armed with the adequate preoperative information, such as astigmatism axis and magnitude through some type of corneal analysis device. They must also take a detailed look at the macula using optical coherence tomography (OCT). Past ocular history with regard to the use of glasses and contacts, as well as the patient’s lifestyle and any other previous refractive corneal surgery, is also a critical component of decision making.

Things are moving away from a one-size-fits-all mentality to a highly customized process for each individual cataract patient. Bilateral distance vision, bilateral myopia, monovision, minimonovision, extended depth of field optics, and multifocal diffractive optics are just a few of the different solutions an eyecare provider must help the patient navigate. Ophthalmologists and optometrists who embrace reflective-based lens surgery and its entire spectrum of tools and technologies are the ones who are most likely to succeed in the years to come. It is certainly a challenge but, at the same time, continues to be one of the most enjoyable aspects of medicine—to be able to make such an impact on a patient’s life and rejuvenate their vision. ■

By Selina McGee, OD

THE TREATMENT OF PRESBYOPIA presents an incredible opportunity. Let’s talk first about how many people suffer with presbyopia. There are 128 million presbyopes currently in the US. Thirty-one million of those are buying over-the-counter readers at drugstore chains. Imagine the kind of impact we as eyecare professionals can have on those 31 million people who may not be receiving comprehensive eye care.

These potential patients aren’t currently being evaluated for diseases like glaucoma and dry eye disease, and they aren’t being educated on the preventative measures for age-related macular degeneration (AMD), cataracts, or skin cancer on the eyelids, just to name a few disease states. They don’t know our value as a profession when it comes to the overall health or that we can diagnose 270+ systemic diseases with an eye exam.

The fallacy still exists with the public that, because they see “fine,” their eyes are healthy. Many people of presbyopia age have younger children who may be at risk for developing myopia due to environmental risk factors and how much time their children spend on near work and using digital devices. How amazing will it be to have these types of discussions with people who don’t know what we have to offer and how we can help?

There is great potential for them to come into our offices when there is a new prescription available to help them with their presbyopia. Notably, they have no idea there is a name for this condition, what it really means, and why they have it. While they are in the office, they can learn the importance of comprehensive eye care and why having a great relationship with their eyecare professional is so beneficial.

What about the patients who are already coming in to see us and have an established relationship? There is a great opportunity to expand our services beyond what we currently offer. The upcoming therapeutic medications aren’t going to work around the clock. In my practice, we have a high-end optical department, where we fit contact lenses, including specialty contact lenses. Having a drop available to prescribe should expand these services as well.

Patients’ visual demands continue to increase. Currently, the average American spends 11+ hours per day on a screen and checks their phone 96 times. The more options I have to help them have functional vision throughout their entire day in all of their activities, the more it’s going to be beneficial. In our clinic, we dive into how the patient is using their vision everyday and really dig into their lifestyle. With the option of a drop, we could expand to patients who choose to wear contact lenses or could keep them in a specific modality longer. We could expand workspace prescriptions that patients utilize with the drop or standalone toward the end of the day. Weekend warriors may invest in sport-specific sunglasses if it means they can play golf, ride their bike, run, etc., while still being able to have functional near vision. Niche customizations would also be possible. For example, for a patient who wears ortho-K lenses at night and uses the drop during the day, it would effectively give them a nonsurgical solution to be the least glasses dependent. There will be many potential scenarios and treatment combinations as we start to utilize this option clinically.

Millennials begin to turn 40 this year, and having intentional conversations about presbyopia will be important. Over-the-counter readers are not going to be “good enough” for this demographic. We need and must have more to offer to our patients.

The presbyopia revolution is upon us. It will be incumbent on our profession to embrace new technology to help these patients. Is this disruptive technology? Absolutely, and it’s coming in the best possible way. This is disruptive technology where we as eyecare providers get to lead conversations and encourage a new journey with patients. When we choose to be intentional with our presbyopia conversations, we give patients another reason to develop a relationship with us. Out of that relationship we get to help people live their best lives. That is a powerful reason to be excited about the future of presbyopia. ■