This interview has been edited for clarity.
Published in Cataract
Our Opinions on The Future of Cataract Surgery
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For Cataract Awareness Month, Eyes On Eyecare sat down with Alanna Nattis, DO, and Eric Donnenfeld, MD, for a discussion of the past, present, and future of cataract surgery.
Alanna Nattis, DO: As you know, June is Cataract Awareness Month. We've come a long way from couching, intracaps, and basic extracaps. Looking at modern cataract surgery—at the development of phaco and small incision cataract surgery—there's so much more with technology than ever before.
One of the things also on our minds is that it seems there’s going to be a huge increase in surgical volume for cataract surgery, having to do with the baby boomer population. Are you in agreement with that?
Eric Donnenfeld, MD: Completely agree. Cataract surgery is going to increase every year by about 10% due to the demographics of the population, but also due to the increased safety and accuracy of cataract surgery.
Nattis: Do you think having more technology to address presbyopia is driving that as well?
Donnenfeld: Well, I do think it's driving the clear lens extraction and some of the earlier cataract surgery, but the bottom line is that cataract surgery is a modern-day miracle.
Sir Howard Ridley performed the first cataract surgery in 1949, and my favorite quote of his is, “Extraction alone is but half the cure for cataract,” which is complete only when the lost portion is replaced. He did the first cataract surgery in 1949 with an intraocular lens, and announced it in 1951. When you think about that, it’s just not that long ago: that’s only 71 years ago! In 71 years, there have been 300 million cataract surgeries done worldwide, restoring vision.
Three hundred million patients—that’s really a miracle. It is extraordinary that we have increased the ability of people to work and to function well in the world. Cataract surgery really is one of the most important surgeries in the history of medicine. It restores our most vital sense, which is vision.
Nattis: I absolutely agree with you. And even in the past 5 years, there have been huge developments in cataract surgery that have had a major impact on how we practice and on our patient outcomes. What are some that you would call out specifically?
Donnenfeld: When I look at some of the recent innovations, it's really quite extraordinary, both in terms of what we have now and what we can look forward to in the near future.
The original multifocal IOLs were really bifocal IOLs that left a lot to be desired. There was a lot of glare and halo, and we just got it wrong. This was about 20 years ago: we didn't know what we were doing in the beginning.
But now, we have the most modern trifocal lenses available in the United States. The Synchrony Synergy and PanOptix IOLs have really changed everything. The dysphotopsia has decreased markedly and quality of vision has increased. If patients really want to be spectacle-independent, these lenses provide them with a great opportunity to totally get rid of their glasses.
I was just reading the other day that there have been 3 million PanOptix lenses implanted in the last 10 years or so, which is really an extraordinary number when you think about it. There are a lot of technologies that have become extraordinarily effective.
These lenses I'm considering are really the non-diffractive refractive lenses that don't have lights for them, that give you an additional half to three-quarters of diopter of near, but don't degrade distance vision significantly.
My new go-to procedure is doing micro-monovision, where I aim for plano in the dominant eye and minus 0.75 in the non-dominant eye with either the Vivity, the Eyhance, or the EMV from Rayner.
Interestingly, Rayner was the original company that invented the IOL, and now they’re coming back with some new IOLs that look really exciting.
Nattis: I agree completely with everything you said. I think that EDOF lenses are a big improvement in what we can offer our patients.
It’s also worth mentioning Toric IOLs. There is a huge percentage of patients who have astigmatism, and if left uncorrected, they're basically left with glasses after cataract surgery. Some patients are fine with that. But being able to correct astigmatism during cataract surgery—whether it’s with a monofocal, a multifocal, an extended depth of focus, or some other type of lens—is such a great technological advancement. And it’s such a basic thing to correct during cataract surgery.
Lens rotational stability also keeps continuously evolving. We’re not necessarily worrying as much as we did with lenses in the past, where we would have to go back and rotate a lens if it moved.
Finally, we’re able to connect the preoperative suite with the OR, and there are some technologies that allow us to make sure our preoperative alignments are correct in the operating room and to use intraoperative aberrometry to confirm the astigmatism axis as well. These are all massive recent advances in cataract surgery.
Donnenfeld: For the future, one of the things that I can absolutely guarantee is surgery will become more accurate. It will become safer. Reimbursement will most likely go down, but I think surgery will become more adjustable as we move forward.
And that’s something that I really look forward to: the adjustability of lenses. We have that now with the light adjustable lens, where you can adjust a lens and get a better result going forward. But the problem is it's only good for the first time you take care of the patient. There’s a new technology coming that looks very exciting and that will allow you to adjust lenses whenever you want to. That’s laser indexing, which is a whole new technology that we’ll be seeing a lot of going forward.
Nattis: One of the other things I think is a general evolution, in terms of cataract and anterior segment surgery, is how connected everyone can be through the digitalization of healthcare.
For example, we have Veracity, which connects the office to the OR for the surgeon so everything is very streamlined. There’s going to be a tremendous connection of surgeons through the Digital Ophthalmic Society, where we’ll be able to share cases, give and receive advice to other surgeons across the globe. I think that’s going to expand our current technologies in leaps and bounds, because you’re going to be able to be right there with another surgeon on a virtual level. That kind of collaboration is going to propel both IOLs and devices forward even more.
Donnenfeld: So we've moved from an experience-based surgery to an outcomes-based surgery. Now we have the ability, thanks to electronic device integration, to actually look at large numbers of patients and improve our outcomes.
The Digital Ophthalmic Society is a giant step in the right direction. Dr. Eric Rosenberg has done an amazing job in starting that society. I think that this is going to change everything. We’re not going to have to wonder about what we should be doing for an individual patient. The decisions will be provided to us by digital technology that looks at large numbers—I'm talking about millions of patients—and comes up with patients who have similar backgrounds to the patients we're managing. It will tell us exactly what we should be doing. That type of digital technology is really going to change everything.
In the past, we treated patients the way we were trained in our residency. Now we're going to be treating patients based on big data and that's going to, once again, change everything that we do and how we approach cataract surgery.
Nattis: Absolutely. I think that one of the things that will help is that we’re going to be able to provide connections to surgeons across the globe that before this were only made possible by mission trips hosted by groups like Orbis. This will likely start slow but then have a more direct effect.
This has the potential to have a huge impact on providing cataract care to underserved areas where, in many cases, surgery is not currently possible on a large scale.
Donnenfeld: Completely agree with that as well.
I wouldn't be complete without looking into my crystal ball for the future. If I had to give you my biggest disappointment in ophthalmology...20 years ago, when I implanted the first bifocal, refractive, and diffractive intraocular lenses, I thought this was a stop gap that was going to give us a reasonable outcome, and would be eventually supplanted by accommodating intraocular lenses, which were going to be the future of refractive cataract surgery. And to this date, 20 years later, we really don't have any accommodating lenses on the market that are really working well.
However, there are a bunch of lenses that are in FDA trials or starting FDA trials right now. The one that I'm most familiar with is LensGen, which has started FDA trials with a shape-changing intraocular lens that looks very exciting. I've actually implanted some of these lenses in the Dominican Republic, South America, and in Mexico, and the results have been quite good.
I think this is an exciting new technology that will change everything, when we have the ability to give patients refractive outcomes without splitting light. There are also other companies working on this: Alcon has the PowerVision, which is a very exciting lens as well.
I’ve also worked with a company called EAlenza, whose lens is probably a decade away from FDA approval. This is a lens that, rather than using ciliary body contraction to cause accommodation, actually harnesses a battery inside the eye that will change the shape of the lens. It sounds far-fetched, but I think it probably sounded far-fetched 30 years ago when people were talking about pacemakers and putting a battery inside someone’s heart! So I'm very excited about some of these new technologies of accommodating lenses, and when they do occur, they will be wonderful.
The last one I want to mention is the ForSight Vision 6, called the Opira AIOL. That’s another one that’s coming down the pipeline that we’re all looking forward to.
Nattis: Yesah, I agree. I think that if we can get some accommodating lenses that work really, really well, then that's also a game changer.
You know, our goal is to provide the best quality vision, but perhaps also the most natural quality vision. I think one of the biggest things when consenting patients for surgery is reminding them to remember that with cataract surgery, this is not your own natural lens that we’re using; an intraocular lens is manmade. There are going to be some drawbacks, and it’s not going to work the exact way your own eyes worked when you were much younger.
Technology is getting there, but we’re not quite there yet—perhaps we’ll be a few steps closer with accommodative lenses.
I also know that there are a couple of companies looking into the physiologic process of cataract formation and seeing if that can be reversed in one way or another using medications. So that will be exciting, but I think we’re still a little far away.
Donnenfeld: There is some work in that area, certainly. Novartis is looking at a lens-softening technology that will hopefully reverse presbyopia, and it may have an effect on cataract genesis. That's actually entering phase three trials, so it’s not that far away—hopefully.
That's the wonderful thing about ophthalmology: we, as ophthalmologists, recognize the unmet needs. And then through our partnership with industry, we're able to create companies that provide the means for us to solve these unmet needs and help our patients.
Nattis: Ophthalmology is just the best field: we’re always looking for ways to make everything better—from our technology to our patients’ experiences. It’s our eyes and our vision.