Refractive Cataract Surgery represents the marriage of two converging areas of research and refinement, both of which have been developing at an astonishing rate, faster than almost any field of surgical endeavor.

The first refinement is small-incision cataract removal and inserting the foldable Intra-ocular Lens (IOL). This procedure makes it possible to do the operation without inducing significant additional astigmatism and to do it as precisely as possible with a reasonable predictability of the spherical optical outcome.

This remarkable new technology involves many components, including a powerful surgical microscope, precise and delicate knives and other instruments, immersion A-scan technology, phacoemulsification, third-generation IOL power formulas, a tiny 3 millimeter scleral pocket or clear corneal incision that usually needs no suturing or cauterization, and the splendid innovation that makes the use of a small incision possible, the foldable Intra-ocular Lens.

The second of our two converging systems of new technology is refractive surgery. For the past fifteen years or so, refractive surgical techniques have been one of the most exciting, rapidly evolving areas of our specialty. The surgical techniques are operations that reshape the corneal surface, and thus change the eye's astigmatism.

Astigmatic Keratotomy (AK) usually employs nomograms that list a certain number and size of incisions for each degree of astigmatism to be corrected. The latest refinement of performing AK is without a nomogram, by using corneal topography as a sort of road map that tells where to place the AK incisions and keratometric control as something like a combined speedometer/odometer that tells how fast you are correcting this astigmatism and how far you have gone with its correction. With this real-time feedback, you can have the result you seek, which is little or no astigmatism. By escaping the arbitrary rule of the nomogram, which assumes that the cornea the surgeon is operating on will respond the same as the average cornea in the nomogram, the surgeon can individualize the operation, tailor it to the eye being operated on, account for the eye's particular pliability (modulus of elasticity) and customize the procedure as he performs it.

Beginning with the use of aphakic spectacles and contact lenses, and even up through the development of intraocular lenses, we really were just trying to treat blindness. Now we are aiming for the correction of refractive errors. Cataract surgery is increasingly being thought of as a refractive surgical procedure to improve the quality of vision from cataracts, rather than a treatment for visual loss (blindness) from cataracts.

Cataract surgery today can even improve the quality of vision for some people to levels they never had throughout their lifetime. We have seen people who wore glasses since age eight or even before that, and refractive cataract surgery gave them better vision than ever before. Their lives have been totally changed.

Technology initiated this revolution and people's expectations are fueling it. As surgeons improve, the public wants more. People's expectations will probably even stay about half a step ahead of surgeons. Rapid rehabilitation after surgery is driving people's expectations higher, in terms of both physical activity and visual acuity. Rapid rehabilitation is made possible by phacoemulsification, small-incision lenses, and effective back-up techniques (third generation power calculation formulas, immersion A scans, Astigmatic Keratotomy, corneal topography and foldable lenses). These techniques provide good refractive results in a wide variety of cases. In addition to public demands, surgeons have also been driven by a desire to shift the risk/benefit ratio. Along with rapid rehabilitation, a complementary benefit of small-incision surgery is a reduction in inflammation and a decrease in postoperative complications.

With the advent of multifocal IOLs, it has become very important to have an emmetropic eye (no glasses needed for distance vision). A multifocal IOL allows a person to see distance, intermediate and near without glasses. Multifocal lens patients appreciate their multifocal best when they are emmetropic, and particularly when they don't have any astigmatism. If you are considering using multifocals, or want good distance vision without glasses, the surgeon has to use a surgical technique that does not create any significant astigmatism. If there is pre-existing astigmatism, techniques have to be used to correct astigmatism and maintain stable refractive results over a long period of time.

The emphasis today certainly is on rapid rehabilitation and the best possible uncorrected distance vision. We need to be able to control astigmatism in order to use the multifocal IOL's properly. The technology is available to control astigmatism to within plus or minus 0.5 diopters of astigmatism in 90% of cases (not by using nomograms) but by doing astigmatic keratotomy under tonometric and keratometric control with corneal topography (EyeSys and Orbscan). This technique actually tailors the amount of astigmatic correction for each person unlike the utilization of nomograms.

Surgical techniques, preoperative planning, and data collection are interwoven and used to achieve this new level of uncorrected vision after cataract surgery. This integrated approach to allow people to have good vision and to be less dependent on eyewear for distance is called REFRACTIVE CATARACT SURGERY.

A person has the option of choosing a monofocal IOL and can have both eyes set up for relatively clear distance vision. Then they will have to wear reading glasses for near vision. Another alternative is to have one eye set up for near vision and the other eye set up for distance vision. This is called monovision. This option allows the person to see both at distance and at near while reducing their dependence on glasses. Because there is biologic variation (each person's eyes are different) and errors of measurement there is no guaranty that you can get this desired refractive result. Approximately 90 percent of the people who have surgery do not have to wear glasses for distance after surgery. The other option is a multifocal intraocular lens. Most of these people have good distance, intermediate, and near vision.