Like Dorothy in The Wizard of Oz, we cataract surgeons have entered a vibrant, bright, and exciting world. More potent corticosteroids, nonsteroidal anti-inflammatory drugs, and antibiotics improve patients’ healing after cataract surgery and reduce their risk of adverse events. Diagnostic equipment makes IOL power selection more accurate and helps us manage astigmatism. Advances in phacoemulsification improve followability and cutting, reduce the amount of energy expended in the eye, and make the surgical procedure safer. Our patients revel in the visual outcomes provided by today’s aspheric monofocal, toric, accommodating, and multifocal IOLs. The most exciting part of the story has yet to be written, as the products from an everexpanding pipeline of technology hurtle into our offices and ORs.

“With great power comes great responsibility,” Uncle Ben sagely tells Peter Parker, the everyday alter ego of Spiderman. As ophthalmologists, we have the power to visually rehabilitate patients—to improve their visual function and their quality of life. We also bear responsibility for improving outcomes and managing the most difficult surgical cases. Complications may be minor or vision threatening, but they affect our ability to provide quality visual outcomes.

In this issue of Cataract & Refractive Surgery Today, some superheroes of ophthalmology provide their tips for managing the most difficult cases that challenge cataract surgeons. Caused by the treatment of benign prostatic hypertrophy with selective alpha-adrenergic blockers, intraoperative floppy iris syndrome is associated with a significantly higher rate of complications than conventional cataract surgery. The dynamic duo of David Chang, MD, who originally described intraoperative floppy iris syndrome,¹ and Samuel Masket, MD, tackle this increasingly common problem. Dense cataracts present an array of potential difficulties, including an increased risk of corneal damage and vitreous loss. Roger Steinert, MD, and Ralph Chu, MD, understand the physiology of rock hard cataracts and share their secrets for managing these eyes. Traumatic cataracts represent a journey into the unknown. Readers can better prepare for the unexpected by reading the piece by Robert Cionni, MD, and Barry Seibel, MD. Shallow anterior chambers make cataract extraction daunting and dangerous. Uday Devgan, MD, and Alan Crandall, MD, share the tools they use to safely manage these potentially harrowing cases. Finally, “Skip” Nichamin, MD, and Richard Mackool, MD, two luminaries of surgical skill, describe how to manage the most devastating of intraoperative complications, the dropped nucleus.

This issue of CRSToday includes two additional focused features. The first explores advances in pharmaceuticals. An old saying among aviators is that a superior pilot uses his or her superior judgment so as not to have to use his or her superior skill. This axiom certainly applies to phacoemulsification and pharmaceuticals. The judicious use of medications can dramatically improve outcomes and reduce surgeons’ stress.

Our complication rate after cataract surgery is low but must diminish further. Our patients demand it. What I believe to be a landmark event occurred in February. My colleague and cochief medical editor, Stephen Slade, MD, performed the first femtosecond cataract surgeries in the United States. The LenSx device (LenSx Lasers, Inc., Aliso Viejo, CA) is currently cleared for anterior capsulotomy and corneal incisions. Future clearances are expected for quartering or even emulsifying the lens so it can be removed with only irrigation and aspiration. LensAR, Inc. (Winter Park, FL), and Optimedica Corporation (Santa Clara, CA) are also working in this area. CRSToday’s second focusd feature highlights this hot topic. Femtosecond cataract surgery has the potential to reduce complications dramatically and improve uncorrected visual results with refractive capsulotomies and limbal relaxing incisions.

 

Eric D. Donnenfeld, MD
Chief Medical Editor