Refractive cataract surgery vs traditional cataract surgery

I have 2 reasons for this question. (1) One cataract surgeon I visited charges extra for refraction and I didn't have a chance to follow up on what that means. (2) Another surgeon's website seems to infer that you could get one or the other. I was wondering if traditional refers to basic lenses and refractive refers to premium; or if traditional does not improve vision but refractive does.

On a related note, I have seen diagrams of all Clareon lenses online. I was surprised to see that the toric is very similar to the Vivity. Both show one tiny circle surrounded by a slightly larger circle in the center of the lens. I know that means the Vivity offers EDOF, but what does that mean for the toric?

Thanks!

Toric is an astigmatism correcting version of the same lens. So there is a Vivity and a Vivity Toric for example but you can't tell by looking at them. They look identical. Most lenses come in both a regular and toric version.

In general "refraction" is a term used to describe the power of the lens in the eye. Your eyeglass prescription is a record of your refractive error. I have not seen it used to describe an IOL or as a type of cataract surgery.

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What is essential for doing cataract surgery is a measurement of the eye dimensions with the most critical being the length of the eye. Older technology which may still be in use is to use an ultrasonic method which touches the front of the eye. The newer and better method is to do it optically. Some clinics may offer the optical as an extra cost option over the ultrasonic method. The two common optical instruments used are the Lenstar and IOLMaster.

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It is also common to use a Pentacam instrument which maps the profile of the eye. It also can give a measure of the astigmatism. Some clinics may charge extra for that too. If you are looking for an eyeglass free solution it is best to be measured for astigmatism to find out if you need a toric lens.

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As David explained Clareon is a new material. By now both the monofocal and the Vivity are likely available in the Clareon material.

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All current lenses are going to correct and improve your vision. The difference between them are the degree to which them improve a range of distances. The basic types are monofocal, EDOF, and multifocal (MF). There is a premium for the EDOF and MF types.

Is there a name for the common ultrasonic measuring instrument? Alternatively, is there a way I can determine whether my eye is being measured optically? Do patients ask this during their exam? Many thanks.

The ultrasonic method is usually called an A-Scan. I would pay the extra cost for an optical method. I believe the IOLMaster 700 is best, and the Lenstar 900 a close second. The big advantage of the IOLMaster over the Lenstar is that it takes much less time when you can't blink or move your eye to complete the test.

You would normally ask for this method during your initial consult with the surgeon.

I'm not familiar with the term ORA. Could you please explain? Thanks again!

ORA is an Alcon method of measuring the optics of your eye during the cataract surgery after the natural lens has been removed. It is a second and final check on what power of lens is needed. It may be justified if you have very high myopic or hyperopic eyes, or have had previous Lasik surgery. For standard eyes it probably does not add much, if a good method such as the IOLMaster 700 is used for the pre surgery measurement.

Interesting. I have never heard that term used. Seems more like a market description to push patients into more expensive optional procedures and lenses. All IOLs provide refraction to correct vision. They seem to be almost suggesting a standard monofocal does not provide refraction correction, but of course it does. Or, the other thought is that unless you pay extra for the "refractive surgery" they will not take as much care in the measurements and IOL power calculation. We will just get things close and then you can fix the residual with glasses... Seems to me that even with a standard monofocal you want to get the best possible measurement and most accurate calculation of the IOL power to get the outcome you expect.

I'm not sure what you mean by saying "All IOLs provide a refraction to correct vision." As the University of Central Florida posting, to which I cited, says: "Following standard cataract surgery, patients often require corrective eyeglasses to fix refractive errors, such as astigmatism, nearsightedness, farsightedness, and presbyopia (farsightedness caused by loss of elasticity of the eye’s lens)." Further: "The goal of a refractive cataract procedure is to successfully eliminate the need for prescription eyeglasses with full vision correction after cataract removal." (Original emphasis).

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To me, the difference seems straightforward. The UCF posting contains further discussion of refractive errors.

All IOLs provide refraction correction. That is the purpose of measuring the eyes with instruments such as the IOLMaster 700 and using IOL Power calculation formulas such as the Hill-RBF.

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If you want to be eyeglasses free, then it makes sense to correct astigmatism if it is over 0.75 D. And of course if you want an extended depth of focus then you need to use mini-monovision with standard monofocal lenses or pay extra for an EDOF or MF lens. There is no extra cost to mini-monovision with standard monofocal lenses.

Bilateral implantation of monofocal IOLs with the same target is refractive surgery in the sense that, of necessity, the IOL must have a power and that power, all going well, will achieve the intended refractive result. But it's not mysterious or marketing hype for (at least some) ophthalmological surgeons to use the term "refractive cataract surgery" to refer to the use of (premium) IOLs intended, all going well, to correct all (or enough) refractive errors so that the patient ends up with full vision without eyeglasses.

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Why is this such a big deal?

I think, because of the way that article is written, you may be confusing refractive error with focus range. Refractive error is when the intended target is missed, regardless of what kind of IOL is implanted. With a multifocal they still choose a target (distance) and that target can be still be missed. Refractive error doesn't mean not being able to read without glasses. If I get a monofocal targeted for distance and the surgeon nails it… perfect plano, 0 sphere, 20/20… there was no refractive error… even though you need glasses to read up close.

It is not a big deal if one understands that premium lenses are not required to achieve a full range of refractive correction. Monofocal lenses with the appropriate powers will deliver those results at no extra cost.

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Seems inappropriate for surgeons to imply that premium lenses are the only way to achieve the results. It strikes me that the term may be used to dupe patients into spending the extra money ($4-6 K) for premium lenses.

A recurrent theme in your posts is that ophthalmological surgeons and related professionals are trying to put something over on their patients. I'm sorry if your experiences have led you to this view.

I like to help people cut through the fog that some ophthalmologists and in particular private clinics like to use to up-sell, often unnecessarily. I think people come here for practical advice, not the parroting of technical sales bafflegab. My observations is that you seem to gobble that stuff up with the likes of your Shamir Autograph III lenses. If you don't like my plain speak, then I suggest you avoid reading my posts.

Plain English is great. Conspiracy theorizing is not.

Sorry, but I don't do the conspiracy theorizing stuff. You will have to read elsewhere for that.

I have a follow up question. Assuming my astigmatism is over 0.75 D, how do I know it is the astigmatism rather than general near sightedness that is the problem with my visual acuity? In other words, will toric IOLs correct near sightedness or does near sightedness need to be managed by the power of the IOL as well? I ask this question because previously astigmatism was not mentioned during my eye exams. Perhaps it was noted but not mentioned?

If you have an eyeglass prescription you should see two main numbers. One is the Sphere in diopters. If you are myopic, then it will be negative. Mild myopia is in the -1 range, which extreme is up towards -10 or higher. Astigmatism is measured by the Cylinder in diopters. Optometrists will use negative numbers and there will be an angle associated with it. An example may me -1.0 D @ 90 degrees. They are independent of each other.

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The toric lenses come in a minimum power and you don't want to over correct astigmatism. So in general astigmatism is not corrected if it is less than -0.75 D. Over that is worth correcting if the objective is to be eyeglasses free.

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This said your eyeglass prescription is not always an accurate indicator of whether or not you need a toric lens. The reason is that there can be astigmatism in the lens as well as in the cornea. Prior to surgery the overall astigmatism is the sum of both. If the lens and cornea astigmatism are close to the same angle the total is additive. If the angle is offset then they can subtract. In cataract surgery the lens is removed and that component will be gone. Most often that improves the overall astigmatism, but in some cases it may not. The bottom line is that the only way of predicting what the astigmatism will be after surgery is with the measurements taken by the IOLMaster and the Pentacam. They will both give readings and may not match. You depend on the skill of the surgeon to determine which is most accurate, and what reading to use if a toric lens is implanted.

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However if the predicted astigmatism (cylinder) is less than -0.75 D then a toric lens is not necessary. You can't really make a decision on whether or not a toric is needed until after the detailed measurements by the IOLMaster (or Lenstar), and the Pentacam. And cost may be a factor. Again if you are planning on wearing glasses then they can correct astigmatism as well as or perhaps better than a toric IOL. In that case it is not worth the extra cost of a toric lens.