התמלול המלא של Refractive Cataract Surgery: Insights, Innovations and What’s Ahead

However, in patients who are good candidates for refractive cataract surgery specifically, it is very, very important to really build a little bit of a relationship with the patient and to understand what is it that the patient really wants. What are these critical things that they're trying to get out of this notion of being, relatively speaking, glasses independent? Because it turns out it means quite different things for different individuals. And then, just focusing in on the exam, I think really evaluating the cornea and the ocular surface to make sure that there's not going to be any surprises in terms of prolonged recovery, and looking very carefully at the macula, that there are no surprises there. I tend to get preoperative OCT pretty much on every cataract patient at this point. Avrey Thau, MD: So, I practice quite a lot at one of our satellite offices, and I'm the primary cataract surgeon there. So, we've organized in our testing area our biometer, a Pentacam, as well as an OCT of the macula. So for every single patient I see, in addition to a good quality exam, I'm humble enough to say I will potentially miss some fine detail on a retina exam and really rely on some additional testing as well to help with that assessment. Surendra Basti, MD: I agree with both of you. I think having a good understanding of what the patient's looking for is really key, and that takes a lot of our chair time, which is why I'm hoping that we can have an efficient questionnaire that perhaps will give us a start to the conversation, at least know critical elements like have you had refractive surgery previously? Are you currently a contact lens user? These have major bearings on the biometry that we do in these patients. So, I think getting a sense for what a patient's really looking for is really critical in refractive cataract surgery. And one of the things that has really been striking to me is the myope who already has good uncorrected reading vision And I've been surprised to note that in conversations related to cataract, if you don't specifically indicate that you're not going to have that reading vision, unless we specifically target that with the lens we pick, that's a clarification that sometimes can come back to haunt the surgeon if you haven't really made that. So, I'm increasingly bringing that up as an additional factor in every patient, not just refractive cataract surgery, but telling patients this is a reset with the lens and that the lens is going to be the single determinant of how you're going to see, which is why ensuring the patient's a good candidate with investigations, I think, OCT, like you guys pointed out, is really important. I initially would use this OCT image that you get of the macula and fovea really that IOL Master will give you. I used to rely on that as the primary modality, but that's really not the way to go. I think that having OCTs done in these patients is important, especially when the cataract is sizable. And even if the cataract's not sizable, we've all had surprises where we didn't think that a patient had anything going on with the macula, but the OCT was revealing. So really, investigating these patients with imaging is key. Avrey Thau, MD: I had a very subtle case recently in which the eye we were doing cataract surgery on my review of even the OCT, it looked normal. But we got an OCT of both eyes, and there was about a 10 micron difference between the thicknesses of these retinas. And after surgery, this patient had pseudophakic macular edema develop. And I did not recognize preoperatively that difference, and it just kind of highlights that even a good exam would not have identified that. I'm just going to circle back on two items that you brought up. One, just to highlight a really good wording that I really liked to hear you say, which was reset. I think that's a really challenging a factor to communicate to patients, this idea of, "I don't know what you are seeing now. We're talking about after surgery, what you will see." So, thank you for that nugget. I'm going to add that to my vocabulary. Surendra Basti, MD: Yeah. And the reset pretty much tells the patient that the lens is going to be the single determinant. So, segueing into the lens, you know, we have so many choices now. We're fortunate actually to have that because each of them has strengths and weaknesses. So in that regard, Dmitry, what is your approach when a patient is expecting or wanting a range of vision that's uncorrected that the lens will provide? How do you go about picking a lens? Dmitry Pyatetsky, MD: Right. And that's a good question, and it's a bit of a discussion with a patient. And before I go into that, I just want to highlight this concept of, you know, we're talking about refractive cataract surgery. And in my mind, every surgery I do is refractive cataract surgery. That's kind of like my perspective on it. So in terms of lens selection, I really try to get an understanding of what the patient's needs and expectations are. And then, I talk to them about options, and I do think of it in terms of the three distances in which human beings tend to work: the far, the intermediate, and the close-up. And I give them examples of each of those, and I explain to them what the options are. We have these kinds of lenses, and we have these kinds of lenses, and we have a, you know, a standard lens, which also we can play around with in terms of what happens depending on whether, you know, we plan for one eye or for both eyes. And then, I try to really give it back to them and have them talk a little bit about what does that mean to them after I just told them what the options are. I hear them out. And then, once they kind of give me a sense of what it is that they want, which, you know, it's one thing for you to say something to the patient, and it's a totally other thing what it is that they have actually taken away from what they said. And so, then, they kind of repeat it

back to me as to what it is that they want. And oftentimes, it actually is still not quite what it is that I'm trying to portray to them. Surendra Basti, MD: That's a great point. Dmitry Pyatetsky, MD: Right. So then, what I do is I try to really narrow it down. Okay, you know, managing patient expectations begins very early in this conversation process. Okay, there are certain things that I can help you with. There are certain things that we can accomplish. But there's ultimately a limit as to what we can accomplish. I cannot give you supervision, which is going to give you absolutely everything in every possible light and every possible distance. But there are things we can do for those activities that are so important to you. And that's kind of like my general approach. Surendra Basti, MD: So if a patient wants the widest range you can give them, what lens do you typically prompt them or offer them? How do you suggest that? Dmitry Pyatetsky, MD: Yeah. Yeah. And that's a good starting point for us to discuss. So, you know, we have at this point all these different technologies, and the ones that people use most often are either monofocal lenses, extended depth of focus lenses, or effectively a version of a trifocal lens. And for the patient who wants the greatest degree of options, not discussing the monovision aspect of it, greatest depth of focus, I offer a trifocal lens. And within that family of trifocal lenses, it's not just one that's available, and that's a great thing for us surgeons to know that and to be practicing at this time. Having said that, to me, as I think about the various options in the trifocal family, I have a basic framework of thinking about it, and that is this: that ultimately, it's a fairly mature technology. And the differences between these intraocular lenses, there are—there definitely are differences, but they all come with trade-offs. And each company's going to market what it's good for. But listening to the marketing and patient experiences, it is very clear to me that wherever you gain, you end up having to give up on something else. So, the three most common trifocal lenses that I offer to my patients are either PanOptix or PanOptix Pro, the Envy or the Odyssey, okay? And so, these are the options. And then, we can talk a little bit about how the three differ. But let me just say that some of them offer probably better mesopic vision, vision under low light conditions. And that likely comes a little bit at the expense of better near vision. And other platforms will offer better near vision, but probably at the expense of having higher aberrations and a little bit more halos, et cetera. For the most part, the modern lenses are very, very well-tolerated. There are very few patients who somehow end up hating them. Really, these days, it's almost unheard of. But that being said, really listening to those patients' expectation is critical. So, I find that an ideal patient for a trifocal lens who wants the widest range of options is somebody who is older and who is retired. Because it seems to me, for the activities that that subgroup of patients participates in, they're happy as a clam with having this trifocal. And a lot of these patients will proactively say, "You know what? I don't need to go out at night all that often, and I don't need to drive at night all that often." So if I give them a lens that is a little bit higher on these aberrations and halos, but they're rarely in conditions where they notice it, it matters less to them, and they're perfectly happy with this wide range. A patient, on the other hand, just to contrast, who is younger and somebody who is somehow a professional that relies on doing a lot of intensive reading or looking at information that's fairly small, and they have to discern it for prolonged periods of time, and their livelihood depends on it, for those patients, I prompt them that even with the trifocal that I think gives the best possible near, for these prolonged activities of intense reading, they will still likely benefit from wearing reading glasses, at least to some extent. Because invariably, such individuals, and they're often attorneys, accountants, they end up coming back if you don't prompt them. They will come back and say, "You know what? I thought I was going to get better spectacle independence than what I got." And then, it's a conversation about, right, all these lenses prioritize distance vision rather than the near. I'm going to throw it back to you. Surendra Basti, MD: Yeah. I think it's a great point. I think it's a great point that you have to emphasize that this is not your ticket to never wearing eyeglasses ever again. You know, I make that amply clear to them, and I say it at least a couple of times during the conversation. Just so you're kind of leveling the playing field and perhaps setting the bar a little lower than the true reality. There'll be at least 80% of patients who will come back and say they rarely wear glasses. But that 20% can truly be a thorn in the flesh if you don't make this point clear. And I definitely agree with you that it's reading that most often is the source of unhappiness. And often, especially the myopes, they're underwhelmed with the reading vision that even the diffractive multifocal lenses provide. So, Dr. Thau, on that note, in terms of these different choices of lenses that we have, what's a lens that you steer a patient towards, a lens where you've built a lot of experience that perhaps would be your prompt to the patient if they said, "I want a lens that gives me the widest range of vision"? Avrey Thau, MD: So, it's a simple question, but a really challenging question. One thing that I think want to give perspective on whoever is listening into this conversation, is for the new graduates. I think this is a very excellent time to be able to have all these lenses available. But my analogy is if you've just graduated, you're a new attending, going to a

new house, you need to furnish it. It feels like mattress shopping, where all of these mattresses, you're looking up reviews, they all have cloud foam technology, whatever this proprietary term is that means nothing to the consumer. And it can be really challenging to discern between everything that we have to offer. So before I say kind of my general approach, I want to just emphasize that these comments that we've discussed as far as how do we counsel patients and how do we use that lens overwhelmingly outweighs the difference in what lens might be better in what lighting condition or what range of vision. So, the first thing that I would say is that getting experience with a lens and getting comfort in knowing how to use it is more important than trying to decide Odyssey versus Envy in this attorney who's doing these activities in this setting. So, that's the first thing that I really want to emphasize. And I think with that, my lens of, I'll say, choice, which is really due to a product of what I use the most often, because it's one of the first lenses that I chose and I've had good experience, but I use by far the Odyssey the most often. I think in this conversation, as an ophthalmologist, we default in saying a monofocal lens is going to get people good distance vision, and we're all focused on what about that near vision? And at the end of the day, the patient experience, if they don't have good distance vision, if you don't nail that, they're not going to be happy. And I feel amongst the modern full range of vision lenses, the Odyssey, what I would discuss, is a very forward heavy. It really nails the distance vision. And one thing amongst that is the defocus curve is pretty broad at your target. And I think that broad defocus curve allows for two things. One is it's forgiving. I have patients who are very happy with their distance vision as a -0.5, and they're still very happy with that. And what that allows you to do is also take that strength of high distance vision, and if they are a little myopic, you make up for what I will say is a bit of that trade-off you were discussing. It is a little bit weaker on the reading side, and it allows you to kind of bring that focus back and get a little bit of the best of both worlds. So, that's kind of one experiential thing that I've learned with it, is I definitely target the first minus typically. I'm not trying to get closest to plano. Even in some of my hyperope patients, I'm not aiming for the closest to plano all the time. Surendra Basti, MD: It's a great point. I'm going to briefly interject here. Please, Avrey, because putting together what the two of you said, I think is something worth emphasizing, that in this day and age, all of these multifocal lenses, if I can broadly put them in a basket, they're all actually exceptionally good. And they're exceptionally good because of the kind of defocus curve that you get, meaning that if you are a little bit off in your refractive target, you'll still nail the distance almost always. And they're forgiving in that sense, in the sense that, if you have a small amount of cylinder left or you have a small spherical error, these lenses will almost always deliver what they promise. And we can, as surgeons, use that to our advantage by picking in the non-dominant eye, a slightly more myopic target, -0.37, -0.5, which whether it's the Envy, whether it's the PanOptix Pro, whether it's the Odyssey, they'll all provide an even stronger reading vision when you do that. So, I think it's the defocus curve and how the optics have evolved that really have helped us get good outcomes in a majority of our patients. Dmitry Pyatetsky, MD: Surendra, if I may just jump in here. Surendra Basti, MD: Of course. Dmitry Pyatetsky, MD: I had a very similar experience with Odyssey. But I do want to mention that the other intraocular lenses, as Surendra mentioned, are really great and come with specific little advantages. One of the advantages that Envy offers is the lower toric version of it. I think you can correct as little as three-quarters of a diopter of astigmatism, which the other platforms don't quite offer. And then, you have to start looking at a corneal correction of that astigmatism if you want to reduce it. And the trifocal implants, I think, are—it is important to correct that astigmatism. The residual astigmatism makes a significant difference, in my experience, with the happiness of these patients. So, that's a unique aspect of the Envy, aside from the way that the technology is built that they try to emphasize. And on the other hand, by no means am I suggesting that Envy is somehow end-all be-all. I think in my experience, the PanOptix, PanOptix Pro is the one that really gives you the highest chance of satisfying that near desire, so to say, for the patient. But ultimately, these are not world of differences between these implants. Surendra Basti, MD: And I think it's important while discussing the range of these different lenses that we make one distinction, which is, you know, at this time we have two categories of extended range of vision lenses, those that are diffractive in their optics, PanOptix Pro, which is called a trifocal. But, you know, you have the rings and they are diffractive in how the optics really function. And then, there's the second group, which is the refractive extended range of vision lenses, such as the Vivity and now the PureSee. Do you guys lean in a particular direction in picking one of these for the dominant eye and another for the non-dominant eye, or you prefer to stay with the same lens in the two eyes? Dmitry Pyatetsky, MD: I can answer that question. Surendra Basti, MD: Please. Dmitry Pyatetsky, MD: For most patients, I use the same lens for both eyes, but it's not a must. And most often, the situation in which I end up putting different lenses in the two eyes occurs as follows. I have my usual conversation with the patient about the trade-offs,

between the EDOF lens and the trifocal lens. And the patient, being nervous about halos and other such phenomenon, chooses to go with an extended depth of focus lens. And I place that lens, and they tend to be quite happy with their distance and intermediate vision, but they express regret at the fact that their near is just not quite... It's there, but it's not quite, and it doesn't quite satisfy this world that they exist in, their needs. Surendra Basti, MD: Yes. Dmitry Pyatetsky, MD: And that is the most common circumstance in which I say, "You know, we can put a different lens in your eye, or we can go with a mini-mono approach." And both of those work. I find that having a trifocal lens is probably a little bit more effective than the mini-mono approach, at least, in my hands. Surendra Basti, MD: You mean for reading? Dmitry Pyatetsky, MD: For reading. For near vision. Surendra Basti, MD: Yes. I agree. Do you have a way to look at it? Do you mix and match? Avrey Thau, MD: I do a mix and match, but one of the things to highlight, especially if they have an EDOF in the first eye and it's the reading that isn't getting, and you're trying to decide between mini-mono versus a trifocal, is the pupil size. Pupil size has a huge effect on the near vision you get from an EDOF. So if I'm looking and I'm at the first eye, and the reason I feel that they're not quite getting the near vision they're hoping for, if they have a large pupil, I'm going to the trifocal lens in that case. So in some degree, I think options are good for patients, but that's a very challenging option. And when you give it to the patient, they usually give it back to me, and then it's kind of a back-and-forth conversation, and we don't end up too many places. Surendra Basti, MD: I think you bring up an important point that's often overlooked, which is the pupil size. We all have our patients who have a refractive lens, like the Vivity, who are perfectly happy with their reading vision, and there are most who are not at all happy with their reading vision. And that happens because the pupil size is what's helping the first of these two categories that I spelt out. In this day and age, with the PureSee lens being available, I've been particularly impressed with the quality of vision that these patients get, especially for distance and intermediate. And so, over the years, I really wasn't big on mix and match. But at this time, I'm very much leaning towards using the PureSee in the dominant eye or the first eye we're going to operate and hearing what the patient's telling me in terms of their level of satisfaction determining the choice for the second lens. And exactly like you pointed out, Dmitry, if it seems like the reading is inadequate, then we'll add a true diffractive lens, PanOptix Pro, Odyssey for the second eye. So, I think we are now in this particularly advantageous situation where the refractive lens that we have currently is actually an exceptional lens. We've had a refractive lens, the Vivity, for a very long time, but we've all had our patients who've told us about contrast not being as good with that lens, which is an important factor in terms of quality of vision, and I think the PureSee really nails it on that one. So Dr. Schumaier, what's your thought process as someone who's going to start practice very soon? Do you feel like these options that you've seen over the year give you a sense of excitement and hope to offer that to your patients once you start practice? Nahrain Schumaier, MD: Yeah, I mean, I think it's a really exciting time for patients. I think everyone's nailed it, and this was very much a big theme at ASCRS, is that setting patient expectations is very critical. Making sure they're an ideal candidate for these multifocal lenses, whether it's managing ocular surface disease, making sure that the retina or the macula is in good shape. But yeah, I think it's very interesting, this conversation, that you've also sort of changed your approach throughout your career, where now you might put in EDOF in one eye, and then sort of tailor the second eye based on a second conversation with the patient. So just having an ongoing conversation with the patient, I think, is something that I will also take with me when I start, you know, my own practice as well. So at least, you know, seeing where they're at after, you know, or how they feel after their first eye, and then sort of figuring out, well, maybe we had decided going with a multifocal lens or the trifocal lens in the other eye. But maybe they're unhappy with that or whatever it may be, so just sort of an evolving conversation with them, or at least keeping that open conversation with them. Avrey Thau, MD: I'll highlight for new graduates, my first few trifocal lenses I put in, we're all talking about range of vision. We haven't discussed too much about dysphotopsias and glare and halos. And I'll say my first few that I put in, the extent of my conversation was, "You can read? "Without gl—Okay, good." And I never asked people about any of these negative trade-offs. And I had this incorrect perception if I didn't ask about it, that it wasn't occurring. So, one of the highlights here that we've all mentioned was talking to the patient, and I think it's okay to normalize some of these, not only the expectation before surgery, but after. I'll often ask the patient, "It's normal to have some glare and halos. Are you doing okay with those? Are they overly bothersome, or you just happen to notice it?" And I think that normalizes it, and I do that after the first eye, and that allows us to have some of the conversation with what to do on the second eye. Surendra Basti, MD: How do you approach unwanted night vision symptoms, dysphotopsic symptoms? Do you bring that up before surgery? Is that something you try to normalize? What's your approach there? Dmitry Pyatetsky, MD: Certainly, I have extensive discussion before surgery on the trade-offs,

on the negative aspects of these refractive, diffractive intraocular lenses that we put in. And to a significant extent, it's the fear or the worry about these unwanted phenomenon that determine my patient's selection as I guide them through the process. I do not shy away from conversations, as you just mentioned, afterwards. I think it's a good idea to bring them up rather than patients somehow sit there and worry, et cetera. And just having an open discussion about it, I think, is the way to go, especially after the first eye is done and you're planning surgery for the second eye, and there are still opportunities to effectively change, you know, what the plan is without, you know, any kind of radical approaches afterwards. It's also interesting, you know, just to put it out there, to hear the perspective of patients where you went with a mix-and-match approach. It's interesting to ask them how they feel about their vision afterwards. And I don't know if anybody here has had these conversations. Patients are definitely aware of the differences in the quality of their vision between the EDOF eye and the trifocal eye. Luckily, these days, the differences are often not perceived as somehow negative, but rather unique qualities of the experience that they're getting is what I'm finding. Surendra Basti, MD: Yeah, that's a good way to put it. You know, I think clarifying that everything's a trade-off, and if you want stronger reading vision, it'll come with some night vision symptoms, is something that I think is important to bring up before surgery as even patients and us collectively are trying to pick a lens for that given eye. And discussing that after surgery, I think is equally important before we do it to the second eye, so you're not duplicating any unhappiness that the patient may have. But in the context of, you know, night vision symptoms and undesirable refractive symptoms with the refractive and diffractive lenses, I do want to bring up the light adjustable lens, which is the other lens in our armamentarium now. And I think the light adjustable lens is a lens that, you know, essentially is a monofocal lens, but gives you the opportunity to really nail the refraction. And, you know, in my armamentarium, the light adjustable lens is the lens that I really lean towards in patients who previously had refractive surgery or patients who are very specific about the distance at which they want to be doing their near vision tasks. One of the first patients I did with the light adjustable was a pilot who'd not had refractive surgery before, but she came to me saying, "Hey, the panel that I have to look at on the plane is at this distance, and I really want to be able to do that without glasses." And I feel like that's really the strength of the light adjustable lens. And so, you know, in this day and age where we're trying to customize our offering to the patient to their needs, I think each of these lenses has a role to play. And in my book, the

light adjustable comes into play when patients have very specific vision needs or if they have had previous refractive surgery where we inherently know that there could be challenges with IOL power calculation. So, moving on, Dmitry, at the start, you mentioned how every patient you approach really is a patient who you're thinking has refractive goals as well. And, you know, if a patient doesn't want to commit to the costs that come with premium lenses, that doesn't mean we don't want to give them the benefit of as much eyeglass freedom as possible with the technologies available. So, that's where some version of monovision and using a toric lens to achieve that if need be, those come into play. So towards that realm, how do you bring up your recommendations for monovision if a patient did not want to use EDOF or a refractive-diffractive multifocal lens? What lens do you pick? What refractive goals do you suggest with monovision? Dmitry Pyatetsky, MD: Yes, that's a great question. And once again, we are lucky to be practicing at a time where even our monofocal lenses are really great and provide some really nice options for patients. So first of all, addressing the traditional monovision approach, it's not my favorite thing to offer to patients who have not had experience with it before, but there are plenty of patients out there who have been walking around wearing contact lenses or somehow naturally less common and being perfectly happy with monovision. That's an ideal candidate for a situation where you can offer them a monofocal lens for their monovision, one for each eye, and they tend to be happy as a clam with the setup. And, you know, they walk away knowing that they achieved their vision goals, which they're already very much used to, and it doesn't necessarily cost them specifically any more than having just have both eyes focused, let's say, at distance. And just to put it out there, there are also patients out there who really want to have both eyes focused at near, and it's important to hear that. They tend to be patients who are low myopes, who are just used to having that near vision. Surendra Basti, MD: Absolutely. Dmitry Pyatetsky, MD: They're often, in my experience, somehow scientists, engineers who just love being able to sit there and look at their computer or read their book or draw or whatever it is that they do, and that makes them perfectly happy, and they don't mind wearing glasses for distance. The modern monofocals, we do have these enhanced monofocals or monofocals plus, however you think about them. They're really nice in the sense that, number one, they actually become a little bit more forgiving to us as surgeons in case we miss just a little bit. Patients are barely aware of these differences. And also, there is this whole concept of a little bit of a mini-mono approach with a standard monofocal, which is not the traditional monovision, but having the dominant eye a little bit closer to plano and the non-dominant eye a little bit closer to -0.5. And using these enhanced monofocals really does extend their range to the point that many patients will say, "Yeah, I can see my phone." And, you know, that's what so many people care about these days. So, that has been very positive. We have the Eyhance, the Tecnis platform, which has been on the market for years and years now, and I've been using that with great success. Now, we also have the Aspire lens from B&L. The technology there is just a little bit different. But ultimately, the patient outcomes, I find patients are just equally happy. It's a newer lens. I found no negative, so to say, to using that. So, I have been very pleased with having both now available. And many times, when I do my lens calculations, it is actually the targets, my predicted targets that will often determine for me which of the two lenses I will pick for this particular patient, because sometimes, you know, that situation for your predicted lens selection, one lands you at like a -0.1 and the other one is -0.54. And you're like, "Okay, well, which one do I really pick here?" But if you have the other platform, it often ends up landing at like that -0.25. And, I don't know, this is more like managing my own expectations because I know I'm not that accurate ultimately, but it makes it easier for me to make these selections. Surendra Basti, MD: Yeah, I think these monofocal pluses, they are not extended depth of focus in the true sense. They don't have that tag, but they certainly do more than traditional monofocal lenses like all of us have noted. And why not? I mean, for the patient who wants a monofocal lens, offering them just a little bit more, most often that amounts to half a diopter of stronger intermediate vision compared to what they would have had with a monofocal lens, I think, is to great advantage. And, you know, you talked about two of the lenses, Dmitry, the Eyhance and the Aspire. And I've heard of good reports also from the Rayner lens. It's called the RayOne. That is thought to provide just that little bit of spherical aberration in the lens that gives them a little better intermediate vision. Certainly nowhere close to a true EDOF lens, but I think it permits us to pick refractive targets that might help patients get more than just one level of vision. Dmitry Pyatetsky, MD: And Surendra, if I may jump in here, since you bring this up. So, there are slight differences between these three platforms in the way they achieve this enhancement, so to say, that they offer to patients. And, you know, in my mind, they are a little bit theoretical. In other words, I'm not a hundred percent sure that these differences in design actually somehow meaningfully play out in real world. But there is one situation, to answer your question that you proposed as a hypothetical, why not? There is one situation or there's a couple of situations where I do ask myself that question. So, I would like to pose that question. So,

I'm not a corneal refractive surgeon. I do not do LASIK or PRK, but I do all this refractive cataract surgery. And so, I'm interested in hearing the two of yours perspectives on the following patient. Patient who has had hyperopia and has had LASIK. So, they've had hyperopic LASIK adjustment, does it matter which enhanced monofocal lens do you put in? Does it matter this notion of the negative spherical aberrations that Eyhance introduces into the picture and Aspire avoids and the RayOne lens actually counteracts in the other direction? I'm curious to hear what you think. Surendra Basti, MD: Yeah. So theoretically, it definitely factors in, and I think if you want to get very granular with it, keeping that in mind is actually prudent. It's true in the hyperopic refractive surgery patients to not add further negative spherical aberrations. So, that would be an instance where I'd prefer to use zero aberration or an aberration-free IOL in terms of what it actually induces, meaning such as the Aspire. Dmitry Pyatetsky, MD: Aspire. Yeah. Surendra Basti, MD: So, I think there's tangible value to that. The other group of patients where I prefer to avoid lenses that induce some negative spherical aberration is patients with some amount of keratoconus. They already have negative spherical aberration in how the cornea is. So, there are instances where I think a zero aberration lens, such as the Bausch + Lomb platform, has some advantages. I think it's reasonable to keep that into consideration when you're picking a lens. Avrey Thau, MD: I don't disagree with any of that. The few times that I have used one of these lenses in that setting, I've not been burned, so to speak. But the conceptual portion of it, I think, is so strong that typically I don't even give it a chance. I will just default to our tried and true. I don't want to introduce any more abnormality than there already is. So, I'll go with one of the more traditional monofocals in that case. Surendra Basti, MD: So, we've talked about the different offerings that we have in the realm of refractive cataract surgery. And if I was to extend that a little bit into an important area that, you know, many cataract surgeons and many patients really want addressed, that's refractive lens exchange. These are patients who don't truly have a cataract, but they have refractive goals that they want to achieve. And towards that goal, there are surgeons on two ends of the spectrum, those who will remove a clear lens and put in one of these lenses we talked about, and those of us who probably have reservations in that regard. So, what's your approach to refractive lens exchange, Dr. Pyatetsky, at this time? Dmitry Pyatetsky, MD: Yeah. At this time, I do not really offer that to my patients. And for those patients who do ask for it, I do refer them to—you know, I'm not against it. it's just not part of what I do. Surendra Basti, MD: Yeah. And is there a reason for that? What might be your, you know, biggest

concern with refractive lens exchange? Dmitry Pyatetsky, MD: Right. It has to do with my internal notion of first do no harm. And of course, there are risks to cataract surgery, risks to any surgery. The risks are very small, but they're real. And in patients ultimately who have really good spectacle corrected vision, in my mind, they don't quite pass the bar for that benefit versus risk. But that's in my mind, and I'm very well aware that I don't want to impose my worldview onto their preferences, and that's why I'm happy to provide them with a referral. Surendra Basti, MD: Yeah, I think it's all well-founded. I don't think there's anything wrong in what you said in terms of your reservations. How do you look at it? Avrey Thau, MD: I've, for a while, have had the same approach. I'm not currently offering refractive lens exchange. But as in my mind, I'm tackling this conversation, the approach of do no harm. And I'm going, "Well, there's no problem. Why would I want to introduce the small but potential risks that come with surgery?" We know in this category of patients, they're younger, their vitreous is behaving a little differently, increased risk of retinal tears and subsequent consequences. And then, I through time, have kind of changed my perspective a little bit in terms of there is an active problem. We've all engaged with patients who've had blinding corneal infections that now we're talking about a corneal transplant, let alone refractive lens exchange. So, something as simple as complications from a contact lens or whether it's an infection or there's a number of issues they introduce. But even glasses could be the case. Some of these patients who are seeking this kind of treatment, if you are on vacation, you are in an unfamiliar environment in hotel, and you don't know where your glasses are and a fire alarm goes off, that is a life and death safety issue as well. So, the bottom line is I don't have a clear answer, but I am starting to lean more toward obviously having the discussion with patients, introducing it to them, but being more inclined to offer it in the near future. Surendra Basti, MD: Yes, Avrey, I definitely am on your side on this one. For the longest time, I didn't do refractive lens exchange at all. But more recently, I've begun to think about them in three buckets. The bucket of somebody who's a hyperope to start with and has gotten presbyopic That's a category I think that's a low-hanging fruit for refractive lens exchange because these are patients who are unhappy at multiple levels for multiple distances. And if their motivation is really high, I think that's a group that doesn't necessarily have a particularly high risk of one of our major concerns, which is retinal detachment. So in the hyperope who's presbyopic, I have much less reservation about doing refractive lens exchange. In fact, one of my most grateful patients is somebody who was 8-diopter hyperope, a very high-functioning individual. And we did the

light adjustable lens for this individual. Because in high hyperopes, the intraocular lens power calculation is less accurate. So, the light adjustable really came in very handy to get that person the outcome he wanted. And he brought up the exact same instance that you brought up, Avrey, about a fire. He said, "You know, when I was +8.00, whatever my status was before surgery, I really had this constant fear of there was an emergency at home that came up unexpectedly, how I would function, and I feel so much better just mentally on that note." So, you know, I feel like in the hyperope who's gotten presbyopic, I feel very comfortable at this time thinking about it and offering it. Obviously, there are always insurance-related considerations. And these patients will have significant out-of-pocket costs. But at least conceptually, that's where I stand right now. I continue to have concerns in the myope. Because in the myope, we all know of a higher risk of retinal detachment and doing refractive lens exchange in myopes is something I have never done. Having said that, again, when we look at evidence, there's this recent ASCRS study that studied the incidence of retinal detachment after clear lens extraction in myopes. And they pointed out that the risk of retinal detachment is 1% in people who've had a PVD before refractive lens exchange, and 5% in people who've not had a PVD, which is why I think beginning to think of it a little more granularly, trying to determine if there is a PVD in these eyes; if necessary, sending them to a retina specialist before we make a decision. Those are all, I think, concrete and objective things that we can do if we're beginning to reconsider the notion of refractive lens exchange. And finally, to round out our topic, you know, there are situations where we have these grand plans and, intraoperatively, we are not able to achieve the goal, because something happened. So Dr. Pyatetsky, how do you approach that situation? How do you discuss that with the family and the patient? Is this something you talk about before surgery? Is this something that you leave for after? Dmitry Pyatetsky, MD: That's a great question. Of course, it's uncomfortable to end up in that situation, and invariably it happens. I do tell all my patients before surgery that once it's done, it's done. That's a concept that I try to instill in their minds ahead of time. But that being said, if I'm really off on my targeting, sometimes you just don't have a choice but have to deal with the consequences. Now, that being said, it is ultimately important to understand what it is that the patient is experiencing. I have had situations where, in my mind, I have not come as close to my goal as I wanted to come, but the patient is perfectly happy, or at least not actively complaining. In those circumstances, I don't push it. I don't want to go out there and exchange these lenses. But there are also times when the patient is complaining, and I think the most

common situation is actually when I put in a toric lens that rotated. And there it's not a situation where I need to exchange it. It's more going back and rotating into the more proper axis. But on occasion, it does come up with lens exchange is a consideration. And then, ultimately, it's discussing that it is an option. It's not the only option. They can wear glasses. They can wear a contact lens. You know, sometimes putting a lens in the other eye really addresses their needs ultimately. And that's another way in which sometimes going back into the eye, you can avoid going back into that eye. But sometimes it's unavoidable, and then you just have to do it. Surendra Basti, MD: So, those were great points, Dr. Pyatetsky. And Dr. Thau, how do you approach a situation where you couldn't deliver? Avrey Thau, MD: This conversation is very challenging. I'm very fortunate that I've not had to encounter it very often. I do think whether we're specifically talking about we're unable to get the correct lens that we're intending, one of these advanced technology lenses we're talking about, part of my routine preoperative conversation is the risks of surgery. And one of the risks that I always mention is that there's a chance that the support system in the eye, referring to the zonules, is not going to be strong enough to put any lens, the lens that we intend, and so on in the moment. So, that is part of my preoperative counseling. Now, if it makes me feel like I've brought that up amongst what the patient hears in that, I'm not too confident. I have had a specific case that I can recall in which a patient was extremely motivated to get rid of their about four diopters of corneal astigmatism. And this was a extremely high myope, and it was a combined surgery. I was doing cataract surgery among some other challenging conditions in this. And by the end of it, the support of the rhexis, I did not feel was adequate to get a toric lens into place. And at the end of the day, I did an optic capture of a three-piece IOL and was unable to deliver the intended goal. And both to myself, I felt in the moment it was the right thing to do, and it was kind of leading first on what I felt was right. And ultimately, that was the best that could be for the patient. And I think that's what led the conversation of safety first and ability to do that. And thankfully, the patient was very understanding in this case. How have you been able to handle these situations? Surendra Basti, MD: Yeah. I think, you know, I want to dwell on kind of the approach that we as surgeons should take in discussing with patients when we are not able to deliver. And you mentioned a toric situation where you put in a monofocal lens and the patient didn't bat an eyelid. I had this patient who is still very regular in my practice, who is quite the opposite, in that she wanted a toric lens, and we had every intention of putting that in. And we did put it in. But at the end of the surgery when I was removing the viscoelastic from underneath the lens, the lens was about 10 degrees off. And as I was removing the viscoelastic, I tore the capsule. And I don't know if this is your experience, but when I have these violations of the capsule in toric patients, I've almost always had it where the lens actually has to finally go and rest, whether it's extension of the rhexis or whether it's posterior capsular tear. In this case, that's exactly what happened, that the tear was in the area where the lens needed to finally rest to fully correct the astigmatism. And Dr. Schumaier, you'll remember this patient very well. And so, I effectively couldn't correct all of her astigmatism. And this is a patient who keeps emphasizing to me each time I see her how understanding she is of uncertainties of surgery, but she never fails to bring it up, that, you know, she is having significant blurring of vision in this eye that we couldn't completely deliver. And while we all understand that there are limitations in how much we can do as surgeons, I think the key in discussing this with patients is to be very honest about what actually happened, and at least try to convey to the patient what my thought process was to call it a day in a lens position that perhaps was not exactly what we wanted or a lens choice that wasn't exactly what we wanted. So, I think in terms of takeaways, what we really want to do is have honest conversations with patients, continue to be with them in the journey after surgery, meaning whether it's refraction after surgery, whether it's periodically seeing them till they get to a good point. I think these are responsibilities that we have to take on as surgeons. These are not things we want to relegate to others, you know, especially in situations where we were not able to deliver. And on that note, you know, I do want to bring up kind of takeaways from a symposium that we had at the AAO meeting in October of 2025 that I had the privilege of co-chairing with David Chang. And the theme of that symposium was cataract surgical crisis. You know, managing the stress and managing expectations. So, that was the theme. And we had 14 speakers talk about different clinical scenarios where you have a suboptimal outcome and how you manage it in the first place, and then how you discuss that with the patient. That really was the theme. And there are various clinical scenarios that surgeons discussed, whether it was intraoperative problems or even catastrophic problems like a nucleus drop in a patient who came to you and was a board member of the hospital. Or we had a surgeon who shared with us his experiences with toxic anterior segment syndrome, TASS, which is every surgeon's worst nightmare. And the surgeon had a cluster of TASS patients after surgery, some of who were litiginous, some of who, you know, just wanted to get to a good place before they moved on. And the single most important takeaway that came out of the symposium was, you know, how it's

important for us as surgeons not to try to give excuses for what happened. I think it's important to be very upfront with patients. Tell them what actually happened and why things became the way they were, and kind of confirm to them very early in the process that, you know, you're with them in the journey ahead. And, you know, you're not in any way having them see another doctor in this regard. So, you really want to be the quarterback in managing these patients. And, you know, one of the quotes that Bobby Osher mentioned really stayed with me. He said, "Patients don't so much care about how much you know. What they really care about is whether you really care. And once they know that you really care, then yes, of course, they want your knowledge and they want your expertise. But if you don't make that clear that you really care for them, it's a clear breach in the trust that you have with patients. So, it's something that I think all of us will do well to constantly remember and not necessarilly have to prove it, but prove it in action that, you know, we are with the patient. It's a journey that we do together. And, you know, we are there despite things not exactly being the way we thought they would go. Avrey Thau, MD: I can reiterate a lesson from one of my mentors that I've had, and whether it's trying to get the right lens in the eye, but this applies to any complication, and it's very similar to what you mentioned, is that if there is a complication, the last thing to do is to give space, to say, "Okay, I'll see you back in a couple months," hoping that time will resolve it. Quite the opposite. Those are the patients that you need to see closer to kind of help shepherd along the journey of resolving this potential complication. Surendra Basti, MD: Great point. I mean, I can't agree with you more. And I think these are patients you want to schedule when you have a little more flexibility in your schedule, you know? Towards the end of clinic or wherever is the window where you can make it amply clear that you are in absolutely no hurry, and that discussing every detail the patient wants to is really a goal. I think, I think it's incredibly important. Avrey Thau, MD: You mentioned this was a symposium at the AAO. I know all three of us recently were at the 2026 ASCRS meeting in Washington, DC. I think it was an exciting time. I'm curious if either of you have any takeaways from that conference. Surendra Basti, MD: Yeah, I think the ASCRS meeting is the highlight for me in terms of meetings that I go to each year. And at this ASCRS, there were, you know, several areas that I particularly got excited with in terms of takeaways. I think, you know, the buzzword's become AI now. And in that realm, I attended the symposium that highlighted, you know, resources that are available for us as ophthalmologists that, you know, very much help us garner the strengths of AI in knowing what's the latest. You know, there's this resource from Doximity, it's called DocsGPT. That is a good resource. There's one called Perplexity that helps you get the latest information related to any aspect of our field that's scientifically sound. So, I think there are so many resources that are currently available now for us in terms of utilizing some of the strengths that AI has. And even when I was walking through the trade exhibits, you know, there were some things that caught my attention. I was particularly intrigued by an ambient scribe, eScribe called Eva. And Eva is one of those ambient scribes that has software that is agnostic to the EMR that you may be using. So, I was particularly intrigued by that and, you know, did discuss that with my chair to determine if it's something that's compatible with the EMR we have. So, we're currently in the process of making that determination. And the last thing I do want to mention about the ASCRS in terms of what I saw was the simulator called the Virtual Lens, which really caught my attention. It's something that we will have in our practice very soon. It's a virtual reality headset that patients put on that gives them a real visual of what is glare, what is halos, what's monovision, you know, at the mini-monovision level, and what's monovision at the true monovision level. So really, an exceptionally high-quality VR simulator is something that really caught my attention, something that I think will have immediate benefit to our patients, and something that I'm very excited about. And in terms of, you know, looking ahead innovation-wise, I was particularly intrigued with real-world data that is now available with robotic cataract surgery. I mean, none of us wants to feel any less important as cataract surgeons. But I found it amazing that we are already at the stage where there are two companies, probably more, but at least two companies that have done human cataract surgery. One of them is a company called Horizon that's, I think, housed at UCLA, where they did human eyes in El Salvador in October 2025 with the robotic system. There was similar experience from another company based in Israel, Foresight, I think is their name, where they reported human experience with eyes operated in April 2026 in Manila by Dr. Ang. So, you know, I think we're not too far from the age that I really didn't think would come into play during my career. But I think there's so many exciting innovations that really are not too far from the current time that we likely see happen in the years ahead with technology, you know, augmenting, if not, actually taking the place of what we do. Avrey Thau, MD: On some of those topics also that I found very interesting as far as AI is concerned, an area I didn't think about it was in trainee simulation. So, we can only simulate physics to a certain degree, but a lot of the simulators engaging in AI to help make the case more realistic, I thought was really an excellent point. And regarding robotic cataract surgery, whether it's robotic cataract

surgery, one of the big takeaways from this conference that I loved is the relatively simple ideas that are extremely innovative. And robotic surgery, the potential for it right now is to try and simulate what we're currently doing. But robotic surgery has so much greater potential, not necessarily as a replacement, but we only have two hands. We can only articulate our hands in particular ways. I could imagine doing some kind of four ports access for the cataract surgery to make it less stressful on zonules, and I'm so excited to hear what kind of innovative things I can't even imagine right now comes out of that. Surendra Basti, MD: I completely agree. Avrey Thau, MD: Yeah. Surendra Basti, MD: And Dr. Schumaier, what's a new surgeon's perspective from the ASCRS? Nahrain Schumaier, MD: Yeah. I mean, this was my first time actually going to ASCRS. So, I agree. I mean, there was a focus on premium cataract surgery, all the new technology. But then, I think also really the tried and trues of phaco, just how important all those surgical fundamentals are. There were lots of great talks, lots of really esteemed, well-renowned clinician surgeons there. I think one of my favorites, and I know you had co-chaired the AAO, but there was a similar talk with Dr. Osher in regards to cataract surgery crisis management. And I think it was just great to see all these sort of esteemed surgeons with several years of experience sharing their own complications. And it was actually a full auditorium, and you could see sort of a broad audience of both young surgeons like myself, up-and-coming, and really experienced surgeons. And there were lots of surgical pearls to learn from them. But I mean, it's a great conference for anyone sort of in their level of training, whether it's even a medical student, resident fellow, or even in their first five years of being an attending, for example. And so, that sort of is where the young eye surgeons group comes into play. And it's a great sort of membership opportunity for networking, mentorship, wet labs, you know, access to all of these videos. So, it was a really great experience for me, and I was happy to go. Surendra Basti, MD: Is there any research you yourself shared at the meeting? Nahrain Schumaier, MD: Yes. So, actually, Dr. Basti and I worked on a study together, and we submitted an abstract for light adjustable lenses. So, there is this hypothesis that light adjustable lenses with treatments may induce some spherical aberration. And whether these spherical aberrations sort of allow for some sort of improvement in vision, whether it's near, sort of almost like an extended depth of focus, but not really. It's almost like a monofocal plus. And so, we submitted that abstract. And you know, our sample size is small, but it's an ongoing study. And so, some of our preliminary data actually did not demonstrate that there was any significant correlation that with each myopic treatment, that there was at least a notable trend in the amount of spherical aberration that was induced. So, it's small, like I said, our sample study. So, that data is still ongoing. There's lots of research in regards to light adjustable lenses. It's kind of still an uncharted territory in that regard. So, we'll see what that shows ultimately. Surendra Basti, MD: Great. So, you know, we've had a nice overview of refractive cataract surgery. Just in closing remarks, Dr. Thau, is there anything that you're particularly excited about as you look into the next few years? Avrey Thau, MD: I mean, I think it's the small refinements that just continue to improve. We'll see what role AI has to play in all this. Some of the refinements could be as simple as the IOL calculations that we do. Our current formulas are excellent, but I'm seeing ideas related to OCT capturing the contour of the anterior and posterior lens capsules to get better effective lens position. Something as simple as that to kind of interpret where that will be, I think has a lot of potential power. We're still talking about these lenses today. However, we know there's a galaxy lens using a new spiral design that whether AI is a buzzword in that, in its development is still at ASCRS was presented and still very exciting and promising thing. So, from that to robotic cataract surgery, it's really interesting to see where things will go. Surendra Basti, MD: Yes. And I certainly second all that you said, I think one of the areas that I'm particularly hoping will bear true is using a femtosecond laser in eyes that have already an intraocular lens placed in them previously. And now for a few years, we have been hearing about a femtosecond laser that is able to etch the anterior surface of the lens, even with an acrylic lens. And this truly can be a huge paradigm shift for us as surgeons in what we offer. Because imagine a situation where you can tell a patient, "Hey, let's start with this lens, and if you don't like it, I will certainly be able to change the optics of the lens to let you see a different way." And, you know, that's something patients ask us mostly out of fear, "Oh, if I don't like this lens, what will we do?" And if there's a way we can actually etch the lens post-operatively with the femtosecond laser to change the refractive focusing of the lens or to remove these diffractive rings that the lens has if the patient really doesn't like the night vision symptoms, I mean, it's truly mind-boggling if we can achieve that. And there are many, I think, laboratory examples of this being actually technology that's not too far away from us. In fact, at the AACRS, one of the award-winning videos was one where Mike Snyder showed using this very technology, obviously in a lab setting, in patients who had an iris prosthesis where, you know, being able to change the refractive goal and target using the femtosecond laser would be particularly advantageous even in a setting such as a patient with an iris prosthesis. So, that's one of those technologies that I'm particularly excited and hoping will bear true in the years ahead. Avrey Thau, MD: It's incredible what we have available, whether it's something as advanced as using femto to reshape the lens that's already in the eye, or as simple as we're familiar with Apthera lens in which we have a mask on the lens that acts as a pinhole. Surendra Basti, MD: Yes. Avrey Thau, MD: Well, it doesn't have to be part of the lens. You could implant a very small similar type of mask as well, and that was something that was shared as AACRS. So whether from a simple circle as an implant to some of these advanced technologies, it's really exciting. Surendra Basti, MD: Yes. So on this note, you know, all of us are very much of the opinion that this is a very exciting time to practice refractive cataract surgery, and we are very motivated to stay on the cutting edge here at Northwestern, offering patients literally everything that's available in the field of cataract surgery. Melanie Cole, MS (Host): Thank you all so much for such a lively discussion. That was great information. Thank you again. To refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/ophthalmology to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole.