It has never been a better time to be a cataract surgeon: trends and advancements in cataract and refractive surgery
In the latest episode of The Ophthalmic Project, Mark Dlugoss hosts Nicole Bajic, MD, a comprehensive ophthalmologist and assistant professor at the Cleveland Clinic’s Cole Eye Institute. Dr. Bajic says there’s “never been a better time to be an ophthalmologist” with all the treatment options and approaches available to patients. She and Mark talk through the latest advancements in cataract and refractive surgery care.
Mark Dlugoss:
With the latest advancements in cataract and refractive surgery, ophthalmic surgeons are achieving exceptional surgical precision in the OR, showing improved safety and, most importantly, better patient satisfaction.
Hello, this is Mark Dlugoss, Senior Contributing Editor for Ophthalmology 360, and welcome to The Ophthalmic Project powered by Ophthalmology 360. In today’s edition of The Ophthalmic Project, we will look at the latest trends, innovations in cataract and refractive surgery, and to discuss these new technologies and what ophthalmic surgeons may expect in the future. Joining The Ophthalmic Project to discuss these advancements is Dr. Nicole Bajic. Dr. Bajic is a comprehensive ophthalmologist and assistant professor at the Cleveland Clinic’s Cole Eye Institute.
Dr. Bajic, welcome to The Ophthalmic Project.
Nicole Bajic, MD:
Thank you so much for having me. Excited to be here.
Mark Dlugoss:
I guess what we want to start with, basically, when we start talking about advancements in cataract and refractive, we’re signaling a sort of a new era in ophthalmology. Before we get into some of the nuts and bolts of this, let’s begin our discussion by looking at some of the trends in both specialties that you’ve seen over the last 2 or 3 years. Are there any particular technologies that are standing out to you?
Nicole Bajic, MD:
There are so many and you’re right, there has never been a more exciting time to be in ophthalmology than now. I think in some ways, we’ve become a victim of our own success because there’s so many fantastic options and ways to customize things to help patients reach their visual goals. Sometimes it can feel a little bit overwhelming. The way that I look at things from the intraocular lens standpoint, because that’s one place that I think you’re always going to see a lot of technological advancements. There’s constantly something new coming out, it seems like each month, but it’s really exciting. The way that I organize it in my head to help better explain it to patients, but also our trainees or my other colleagues when talking on this is I look at the intraocular lenses on the market as a spectrum. Everything’s on a spectrum.
We have our monofocals at one end and then you have the enhanced monofocals or the monofocal-plus, then the extended depth of focus lenses, and then you have the hybrid multifocal extended depth of focus lenses, and then finally the trifocals. Depending on what someone’s visual goals are, you can steer them in one direction or the next. But the spectrum is getting quite full with so many fantastic options. I think there’s truly never been a better time to be an ophthalmologist. We have a lot in our armamentarium for patients.
Just with the current lens options, I know there are a couple to chat about that we’re excited over. With the Alcon Vivity that had come out some years prior, what I find as interesting is the new player coming on the market that has a unique design, but in some ways the design is reminiscent of the Vivity. With the Bausch + Lomb LuxSmart, so it is a non-diffractive, and then you’ll see that refractive aspheric surface and then the transition zone and then the focus center. It is reminiscent in that there’s no rings that split the light, but it can help bend the light to help give you an extended depth of focus. I think that that’s a very interesting lens and I’m looking forward to that coming out on the market.
Well, also, not everyone has the PanOptix Pro in the US, but that has been coming out. Those that have been lucky enough to use it have been saying great things about the decreased incidence of dysphotopsias. With the Johnson & Johnson TECNIS Odyssey, so this is a fantastic lens option. The nice thing about it is it’s marketed as a hybrid multifocal and EDOF lens. With the technology it uses, it has a digitally optimized design with the echelettes. The steps were more finely designed to minimize the dysphotopsias and also technology to optimize contrast, and patients are loving it. We’re very lucky.
Another one that’s currently being talked about quite a bit is Bausch + Lomb’s Envy. That has been another great lens offering the full range of vision. It is a diffractive lens, but the way it has been optimized to help minimize the dysphotopsia. I think a lot of great options on the market, and I’m really excited about the other options coming out very shortly. Interesting, I just gave a talk to Brazilian ophthalmologists as we discussed for their Annual Cataract Day, and they are getting the Odyssey out next month. We’ll see what they think too.
Mark Dlugoss:
Yeah, that’s one of the benefits. A lot of stuff gets out in Europe and South America before it reaches us, especially when it comes to IOLs.
Nicole Bajic, MD:
Well, so that’s what’s so interesting. They already have Johnson & Johnson’s PureSee and we don’t. We’re flip-flopping. They’re getting Odyssey, which we’ve had out, and then we’re getting PureSee, which has also been in Europe too. But my European colleagues have been really excited about it. I really am too, because the thing that’s special about the PureSee, because sometimes I think it’s hard as ophthalmologists to figure out like okay, so what’s new, what’s different about this lens, the cool thing about the PureSee is that it’s a purely refractive lens. There’s no diffractive aspect, there’s no ring splitting the light. It’s a continuous range for the surface of the optic. It’s a great potential option for eyes that we would’ve previously discounted diffractive lenses on.
I’m pretty tough when it comes to who I will offer a multifocal lens to, predominantly because I am at an academic center and so a lot of my referrals come from my retina colleagues who would not be happy with me if I implant inappropriate lenses. But to have these ever-changing technologies that can offer an advantage in eyes that maybe are not quite so perfect, it’s really exciting because there’s so many patients that I run into and they really have their heart set on a particular type of lens. We’ll guide them along a different pathway depending on what their exam shows. But to have more options out there that can be available to patients that may not have otherwise been a candidate for advanced lens technologies, it’s really exciting. That I’m excited about.
Mark Dlugoss:
Have you had any experiences with the latest cataract and refractive equipment that’s coming out? What’s your impressions?
Nicole Bajic, MD:
It is exciting. I did get a chance, previously I was working with Alcon. They were designing an updated femtosecond machine. However, big news on that development, they’re acquiring Lensar, the ALLY system, and so they’re switching it up a bit. I’m very excited to see what they end up doing, but that’s something to keep your eyes on. As far as other, in terms of phaco, so the Zeiss Quatera, the 4-chamber system is very interesting player on the market. Then we have the UNITY that’s come out from Alcon, their phaco technology, and I think that can be so helpful for those really dense lenses.
As cataract surgeons, we’re all about efficiency. For Bausch + Lomb, their new phaco platform and I was able to trial it actually 2 weeks ago and it was great. I really loved… I’m a flip and chopper, and so what was really nice is I can go directly from chop straight into essentially the quad mode without having to switch the settings. I love that because it’s just one more thing to help you be efficient. We’re also going to be trialing out the VERITAS from Johnson & Johnson the next month. Lots of great options out there. It’s all very exciting. Never been better time to be a cataract surgeon, that’s for sure.
Mark Dlugoss:
Now, with your experience in some of these technologies, have you noticed any kind of impact in the way it affects your surgical outflow, meaning both in your presurgical workup or in the operating room or even post-op results? Have you noticed how the technology’s improving your job?
Nicole Bajic, MD:
It’s interesting, I think those changes are typically gradual over time because I’m in the phase of my career where, although I’m always looking to optimize things a little bit more, cataract surgery days are now fairly boring in a good way, so I don’t notice that many changes. It just feels like just small differences here and there. But there’s so many interesting advantages that all the different platforms offer. What I find the most curious is that we’re all different types of surgeons, we all have different types of techniques. What works for one or what some might notice, the other might not like at all. Certain things that I like with flip and chop, people do not like certain platforms because they find that it doesn’t help them. For me, it allows me to feel more independent regardless of what phaco machine I use. I find it doesn’t affect me that much, to be honest.
Mark Dlugoss:
Okay, cool.
Nicole Bajic, MD:
But I do love playing with the new technology.
Mark Dlugoss:
In the early days of femtosecond lasers and of course the early phaco machines, surgeons and patients as well were satisfied with achieving 20/20 vision. With some of these new technologies, many patients have reportedly attained 20/15, 20/10 vision as early as first days postop. How amazing do you find these results? Are you seeing any of these kind of results in your practice?
Nicole Bajic, MD:
Yeah, yes, of course. But I think that we’ve come to a point where the newest thing coming out on the market next year, it’s not going to necessarily get you to 2015, 2010. First off, it depends on what the eye looks like. What’s the current health of the eye? Because some of these eyes are not going to have the potential to get there in the first place. Number 2, ocular surface is so important. I think it’s obviously so important to make sure that the surgical factors are there and that you’re minimizing CDE and minimizing the amount of time in the eye, etc. But you also have to make sure that you’re taking care of the ocular surface before and after surgery too because I find those cause the biggest fluctuations in vision. It is a factor of what you’re doing in the OR, but I think what’s just as important is what you’re doing before and after the operating room too.
Aalthough these technologies are fantastic and incredible, yes, yes, we have to make sure we’re looking at the whole picture. I don’t want people to lose sight of… The last thing I would want for patients out there to hear is, “Oh, I didn’t have X, Y, and Z phaco machine,” or “I didn’t have this, I couldn’t afford to pay for the femtosecond laser. My eye is always going to be, the quality is always going to be substandard.” I think there’s a lot of different ways to skin a cat and a good surgeon should be able to skin a cat in multiple ways.
Mark Dlugoss:
Another aspect of new technologies is a lot of the ocular biomechanics and the visual optics mostly in diagnostic equipment. How does the latest research in this area lead to some of the better technologies that are being offered, especially for precision and effectiveness for surgeons?
Nicole Bajic, MD:
This is another place where I think we have come a long way, but with the newer-generation formulas and with the newest biometries, I’m happy. I could have this forever and be good. If we have no more updates from here on out, I think we’re good. But it’s really come a long way and I’m very pleased with what we currently have at our institution. We have the IOLMaster. For us, we have good, consistent results, and I’m happy as a clam.
Mark Dlugoss:
No, we were talking about IOLs before, but next year there’s supposed to be a lot of new options available in the ophthalmic market that are expected. Some have already improved. I guess the BVI’s FineVision HP was approved in October as well as the RayOne.
Nicole Bajic, MD:
So excited about that lens. Yes, I had some time to learn more about it and also speak with the developer. I just think it’s a fantastic option for full-range vision. Patients seem to be quite happy. My European colleagues that have been using it for some time just have had the best experiences with them. I’m very much looking forward to that lens.
Mark Dlugoss:
Another one’s the RayOne EMV Toric, which was also approved in October and is supposed to come out in 2026.
Nicole Bajic, MD:
Yeah, so I think that’s a fantastic option. One of the things that it can be especially useful for is post-hyperopic LASIK. Very much looking forward to having just another lens option for the various types of patients that we get.
Mark Dlugoss:
You’re also approved in the UK or Europe rather, and they’re waiting here in US. There are several other new ones, including the Rayner RayOne Galaxy, the Bausch + Lomb LuxLife, and Zeiss AT LARA. You have any thoughts on those?
Nicole Bajic, MD:
Yes. That Rayner RayOne Galaxy is very interesting because it is the first IOL designed by AI. Although it’s non-diffractive, it has this apparent spiral. It’s not so apparent when you’re looking at it, but if you look closely, some say you can appreciate the spiral in the optic and it gives you a full range of vision. Very much looking forward to trying it. It sounds like a very exciting, different option. We’ll see how it plays out in real life.
Mark Dlugoss:
Now there’s a segment of IOLs that’s been around for about 20 years, but just recently it’s been making some strides and that’s the accommodating IOLs. As far as I know, currently there are about 8 designs going through the clinical trial process globally. Have you been able to look at some of these new designs and what are your impressions of the new stuff coming out that? To me, I find it interesting.
Nicole Bajic, MD:
Yes, so the accommodating lens market is so interesting to me because intuitively it makes sense, especially if we’re trying to get as close as we can to replacing mother nature. It’s that accommodating factor that we’re most trying to emulate. You don’t want to have any compromise of the quality of vision, but still be able to accommodate in order to get that near or intermediate. I find it very fascinating, but obviously there’s a lot of challenges. We’ve been at this for a while and there’s challenges from multiple areas.
What I think is most interesting is the JelliSee. It’s an optic with these little footplates circumferentially that allows for the accommodation, I think apparently up to 7 diopters. It’s very curious, I’m curious to see how it can work long-term as the capsule fibrosis. It’s also 3 to 5 years out from the market, so we’ll see how things progress, but I’m very excited to see what they do with it. It looks like some of the other accommodative lenses that are in development, they function either with a dual plate or there’s a reservoir outside with silicone oil or some other fluid and then it can go into the central part of the optic to change the focal point. We’ll see. I think silicone oil will make some surgeons pause, but phacoemulsification made some surgeons pause before we started doing it, and look at us now.
Mark Dlugoss:
Exactly.
Nicole Bajic, MD:
Well, look at us now.
Mark Dlugoss:
Like you say, it’s getting boring.
Nicole Bajic, MD:
Right? There’s a lot of very interesting options. I’m so curious to see how they play out. Well, let’s see in another year or 2 where we’re at.
Mark Dlugoss:
I’m always fascinated by the engineering that goes on behind the accommodating lenses. It’s noticeable, the newer designs that I’ve been able to notice is that they’re incorporating more of the physiology of the eye more than trying to adapt the IOL to the mechanics of the eye, mostly incorporating it where before it was sort of like it was there, you had to work with it. It’s probably why it wasn’t very successful ’cause the limitations were very evident.
Nicole Bajic, MD:
There’s one where it’s a sulcus-based lens, and so with the ciliary body movement, it’s supposed to change the anterior curvature. That I’m curious about. We’ll see.
Mark Dlugoss:
When it comes to complications, have you noticed that the new technologies and that includes the equipment you’re using or the diagnostics you’re using on or even the IOLs, have they been able to reduce your complication rates in the postop or even during surgery?
Nicole Bajic, MD:
Yeah, I think in ophthalmology we’re pretty fortunate that our complication rate is low, so we’re not seeing them often to begin with. I think ultimately it comes down more so with technique rather than new lenses. I suppose though with certain… It’s been a long while since I’ve implanted a crystal lens, but of course the bigger lenses could be, I’m sure, prone to more potential complications, but fortunately we don’t see them more. I would say it’s more with technique rather than the technology. But what I will say is I think with the new phaco platforms, we can see potentially even clear corneas on certain people that would be more prone to having early edema. My endothelial dystrophy patients, potentially things like that could help with that. But intraoperative complications like PC tears, and ultimately I believe it comes down more to techniques.
Mark Dlugoss:
Well, as you know, managing patient expectations is probably one of the biggest things you have to deal with in dealing with both IOLs and cataract and refractive surgery in general. Do you see these latest innovations helping both you and the patient to meet their expectations?
Nicole Bajic, MD:
Yes and no. I think it can be a dual-edged sword. I have been pleasantly surprised by the number of patients that walk in and they’ll say, “I want this lens.” They’ve already done their homework and they feel very well-educated on things. Sometimes they are, appropriately, on the money. I’ve had a patient come tell me, they’re like, “I think I’m too type A for a true multifocal lens. I think those halos would drive me crazy.” I was like, “I agree. If you’re saying this to me, you absolutely not.” But sometimes I think it can be a little overwhelming for patients because they don’t know how to put things in a context. But that’s what the surgeon is there for to help guide them. I think it is a great time to be a patient too. I think with patient education, it’s been mostly helpful in that respect.
Mark Dlugoss:
Well, one developing area of cataract surgery is basically glaucoma surgery, especially with MIG surgery. I know you’re a big advocate of MIGS, so let’s discuss how MIGS can be an asset for cataract surgeons.
Nicole Bajic, MD:
Yeah. I have noticed a trend recently where if a patient is bringing a family member or a friend with them to their consultation for cataract surgery and if that patient happens to have glaucoma or ocular hypertension, I will, of course, offer them MIGS if they’re a candidate. The patient’s family or friends, if they also have glaucoma and were not offered MIGS, that stirs up an interesting conversation about why they weren’t. They just had surgery this year or recently and why was that not out then? I think what we should all be aware of in the cataract surgery space is if you don’t feel comfortable doing MIGS, you should at least have that conversation with the patient to potentially offer them because some of these patients are becoming very upset on the backend that they were never offered that, they were never told their options, and they feel that there was sometimes maybe some deception. I think we should be careful about that.
But ultimately, the biggest message that I want to push forward is that if you’re doing cataract surgery, it’s well within your skillset to do MIGS and you should be doing it. I don’t care if you are 30 years out of practice, if you’re doing cataract surgery, you can do MIGS, you can do it. You can learn new skills. We’re always learning new skills. Imagine back when ophthalmologists were still doing extracaps and phaco came out and they were already out of practice, they taught themselves. That’s a much bigger leap than phaco to MIGS.
I think take advantage of the courses that are at local national meetings, they are so helpful and start small. You don’t have to go straight to doing a MIGS on your first patient. Start by just examining the angle on your regular cataract surgery patients. Turn the head 30 degrees, turn the microscope, get the gonioprism on with a little visco and zoom in, just get comfortable looking there. Once you get comfortable visualizing the angle, then I want you to start taking just a Sinsky and go and just lightly trace over the area that you would be treating. Once you’re comfortable with that, you’re ready to make the jump and you can do it. All cataract surgeons can do it. I firmly believe that and we should because the safety profile is fantastic. Patients are terrible at taking their drops. Glaucoma is expensive to the healthcare system and to patients. This is something that it can promise 100% compliance.
You’re doing the MIGS, it’s done, it’s done. You don’t have to worry if the patient’s taking their drops or not, if they miss a dose. It’s so much safer than incisional glaucoma surgery. We’re doing so many fewer trabs these days and that it’s a morbid procedure. Sometimes you have to do it, but I don’t think any glaucoma surgeon out there loves doing a trab, right? It’s the end of the line for a reason.
Mark Dlugoss:
It’s a messy surgery for…
Nicole Bajic, MD:
Of course. Yeah. Yeah.
Mark Dlugoss:
Or it can be, I shouldn’t say. I mean I’m sure there are…
Nicole Bajic, MD:
Yeah, of course, of course. But I think ultimately the point is if you’re doing a trab on a patient, they’re going to have a lifetime risk of infection and possibly blindness because you have that communicating channel. If you can do a MIGS procedure earlier on and help curb that or stave off as long as possible, that’s doing such a better service to the patient. Yes, highly recommend learning MIGS, everyone can do it. There’s also so many great advancements on that front too, so don’t let yourself fall behind.
Mark Dlugoss:
Yeah, leads me into my next question, which with all the new innovations going on in MIGS technology and surgical approaches, what do you see coming? What are your thoughts basically on the future of MIGS and what is the potential for cataract surgeons?
Nicole Bajic, MD:
I think the potential is great. In an era where we have to be very mindful about our resources and then we have declining reimbursements, we should be expanding our skillset and then it’s to the patient’s benefit too, 1 surgery day, but they’re getting multiple things addressed and there’s so many great options right now. What I’m really excited about right now is the iTrack Advance. It allows you to really customize the amount of treatment you do. You can do just the canaloplasty, you can do the GATT, and it has fantastic results. I really love that there’s a little blinking light. When you’re performing it, you can see exactly where you are.
Mark Dlugoss:
Where you’re going.
Nicole Bajic, MD:
Patients are loving it too. I’ve even done it on premium patients who really desire to get off multiple drops and it’s been working out really nicely so far. The VIA360 also came out recently and I’m hearing great things about that as well. There’s really so many great options, as well as the old favorites, like the Hydrus, KDBs, so many fantastic options. The STREAMLINE, I love my STREAMLINE, especially on premium patients, it’s such a great option. Yeah, if we’re going to be in the eye and the patient has a pressure problem, we should be dealing with it. It’s a no-brainer.
Mark Dlugoss:
Now you recently attended the European Society of Cataract and Refractive Surgery (ESCRS) Meeting in Copenhagen, and also the AAO Meeting in Orlando. What came out of those 2 meetings that got your attention in both cataract and refractive surgery and even MIGS? Whatever you saw in terms of technologies, presentations, surgical techniques, what struck you?
Nicole Bajic, MD:
Yeah. At ESCRS, I was really excited about the new lens technologies coming out. With the Johnson & Johnson PureSee and the BVI FineVision, those are the ones that I’m really looking forward to as far as MIGS. Like I said, I have been using the iTrack Advance with great results, but what I’m really excited about is one of my colleagues, Dr. Mary Qiu, she herself finds that she is getting such great results with that and she’s doing no trabs basically. You can really customize things so much and get great pressure control if you use everything in combination.
As far as everything else, so there was an interesting conversation I had with Dr. Lisa Arbisser. She is a big proponent of primary posterior capsulotomies, and she is of the mindset that we should all be doing these primary posterior capsulotomies for every single cataract surgery. It’s a very interesting idea. I know that that probably makes a lot of cataract surgeons very nervous, but she is of the mindset that it allows for more stability of the lens and not having to worry about effective lens positioning. Then of course, you can keep the eye as a bicameral state, so you’re not making the eye unicameral by doing a YAG capsulotomy. You keep that anterior hyaloid intact. Very, very interesting. I’m not sure that I will be regularly employing that into my practice, but I’m curious to see how that might change the landscape moving forward.
Mark Dlugoss:
Now, the innovation in ophthalmology is constantly evolving and it has a history of doing so in the past, and I’m sure it’ll continue to do so in the future. Where do you see the future of innovation in cataract and refractive surgery and throw in MIGS as well?
Nicole Bajic, MD:
I think that in another 5, 10 years, we’re going to see even more fantastic intraocular lens advancements. I think we may come closer to figuring out that accommodative lens piece. We’ll see with all the fantastic lenses in the pipeline, what ends up working well in clinical practice. Yeah, I am very much looking forward to it. With MIGS too, I think maybe looking more into the suprachoroidal space. We’ll see. There’s so many great options.
Mark Dlugoss:
With you being a younger surgeon, from my perspective, I’ve been doing this for over 30 years and covering the industry, and it amazes me how much the younger surgeons are more receptive to some of the new ideas coming out real quick. We’ll take MIGS as an example. It’s very fascinating to see that mentality because that, to me as an observer, only continues to enhance the evolution of ophthalmology.
Nicole Bajic, MD:
I think part of that is because it was ingrained to us in our training. I remember when I was a resident, really there was the iStent and the KDB. I had exposure to that, but I had seen how quickly like, “Oh, and now we’re going to do this and now we’re going to do that, and this is in the pipeline here.” It was already impressed upon me that within ophthalmology’s DNA, it’s constantly evolving and it feels like we’re in this space where it’s evolving very quickly. I think that really changed our mentality, at least in my generation and feeling… When you get exposed to that in training too, you feel more comfortable with expanding your skillset.
Of course, there were times where I would pause and say, “Oh, I think maybe that one is maybe not for me,” but because I have such good relationships with colleagues who pushed me to be the best version of myself, that’s allowed me to further expand my skillset too. I think that we should all be, as surgeons, supporting each other, helping each other because we’re all stronger in that way too.
Mark Dlugoss:
Well, that concludes today’s edition of The Ophthalmic Project. I want to thank Dr. Bajic for discussing these incredible innovations in cataract, in refractive surgery, in MIGS as well. I also want to thank you, the viewers, for watching. I hope you’ll join us for the next edition of The Ophthalmic Project powered by Ophthalmology 360.
Until next time, have a great day.
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