This is the 7th and final episode of this GENEYE POD series on getting started with presbyopia correction at the time of cataract surgery.

Residual ametropia is one of the most common reasons for patient dissatisfaction after presbyopia correction at the time of cataract surgery, so it’s really important to look for this and treat it whenever necessary. With a few exceptions, presbyopia correcting IOLs, whether bifocal, trifocal or EDOF are more sensitive to residual refractive error than monofocal IOLs. Failure to hit refractive target might result from inaccuracies in biometry, inadequate selection of IOL power, limitations of the formulae that we have, or inability to adequately predict effective IOL position in the eye amongst other reasons. Laser enhancement, usually by either LASIK or PRK has been shown to be efficient, effective, predictable and safe, and would be the most common choice for refractive adjustment post-operatively. IOL rotation or exchange is required less frequently.

As presbyopia correction, particularly with trifocal IOLs continues to gain popularity across Australia, New Zealand and many other countries, residual refractive error has been identified as a real problem. Surgeons now need to be aware of the importance of residual refractive errors and solutions for corrections need to be considered at the time of starting out with these lenses. Presbyopia correcting IOLs are not as forgiving as monofocals. Residual refractive errors not only blur vision but enhance dysphotopsias and other side effects. Residual refractive errors can be regarded as “make or break” in terms of success for each individual patient, so it’s very important to have a strategy for correction when they occur.

In this episode, Dr Jacqueline Beltz is joined by Dr Laurence Sullivan. Laurie is a cornea, cataract and laser refractive surgeon in Melbourne, Australia. Laurie only recently retired from his public appointment at the Royal Victorian Eye and Ear Hospital where he worked for many years. At the Eye and Ear, Laurie was integral to the training and education of registrars and fellows including Jacqui.

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This is episode 6 of our 7-part series on getting started with presbyopia correction at the time of cataract surgery. So far, we’ve discussed options for correcting presbyopia, patient selection and optimisation, astigmatism correction, assessing corneal tomography and patient conversations and consent. So, now we are finally up to the surgery.

In this episode, Dr Jacqueline Beltz and Dr Andrea Ang discuss optimising surgical techniques for presbyopia correction as well as managing complications. Even though these cases are often not the most complex cataract surgeries that we do, of course, complications will still occur, and it can be difficult when a patient is expecting presbyopia correction.

Andrea is a cornea, cataract and refractive surgeon in Perth, WA where she is also Director of Training for RANZCO WA. Andrea graduated with the gold medal in medicine from UWA and also has a Masters in Public Health from Harvard. Andrea is double fellowship-trained in Cornea – she did this training at Cincinnati Eye Institute and Singapore National Eye Centre, giving her a really broad and interesting experience.

Please subscribe to this podcast and remember that the full digital course is available at geneye.org.au

This is episode 5 of this 7-part series on getting started with presbyopia correction at the start of cataract surgery. This series forms part of a virtual and real-life training package on the same topic. The intended learners are advanced ophthalmology trainees in Victoria, but at least some of this information will be relevant to anybody involved with cataract surgery in some way. The entire package is accessible on geneye.org.au.

So far, we have covered available options for presbyopia correction, patient selection and optimisation, astigmatism correction, and corneal assessment. In this episode, Dr Jacqueline Beltz and Professor Michael Lawless sit down to discuss patient conversations.

Patient conversations might even be the most important part of presbyopia correction. It’s so important for a patient to be well informed so that they can make a smart decision based on their own priorities and circumstances as to what sort of IOL they might wish to receive. There is no one size fits all model, and every option has its own pros and cons.

Professor Michael Lawless is a cataract, cornea and refractive surgeon in Sydney. Mike is double fellowship trained in Cornea and truly one of the greats when it comes to not only achieving excellent results for his patients but in providing them with the information that they require to make a sensible decision. He also happens to be really great at helping the rest of us to do the same.

Please subscribe to this podcast and remember that the full digital course is available at geneye.org.au

This is the fourth episode of a 7-part series on presbyopia correction at the time of cataract surgery. This podcast series forms part of a GENEYE digital course that has been developed by Dr Jacqueline Beltz for Advanced Ophthalmology Trainees in Victoria, Australia. The full course is available at geneye.org.au under online training.

So far, we’ve covered IOL options, patient selection and optimisation, and astigmatism correction and refractive targets. There’s a lot to consider, especially when trifocal or EDOF IOLs that utilise diffractive technologies are planned.

Corneal tomography has come up as an important topic in every episode so far. One of the reasons why it’s important to know the status of the cornea is to consider the impact of higher order aberrations when combined with diffractive IOL technologies. Patients with aberrated corneas can be highly symptomatic of positive dysphotopsias such as glare and haloes after trifocal IOLs, so it’s best to consider other options such as monofocal IOLs, small aperture IOLs or maybe even negative spherical aberration EDOFs in those cases.

Should we or should we not ALWAYS do tomography when we’re considering trifocal IOLs? In this episode Dr Jacqueline Beltz is joined by Associate Professor Elaine Chong to answer this question and to discuss corneal tomography in this setting. Elaine is a cataract, cornea and refractive surgeon in Melbourne. She is director of ophthalmology at Royal Melbourne Hospital and also part of the Corneal Unit at The Eye and Ear Hospital. Prior to these positions, Elaine underwent double subspecialty fellowship training - first in medical retina and later in cornea and refractive surgery. It was at Singapore National Eye Centre that Elaine completed her corneal training.

Please subscribe to this podcast and remember that the full digital course is available at geneye.org.au

This is the third episode of a 7-part series on presbyopia correction at the time of cataract surgery. This podcast series forms part of a GENEYE digital course that has been developed by Dr Jacqueline Beltz for Advanced Ophthalmology Trainees in Victoria, Australia. The full course is available at geneye.org.au under online training.

Astigmatism management is one of the hottest topics in cataract surgery today. It’s essential if we are to aim for excellent results and happy patients. Uncorrected astigmatism leaves patients with blurry vision and resultant decrease in contrast sensitivity. In Australia, we are fortunate to have amazing access to astigmatism correcting IOLs, with it being common for surgeons to implant toric IOLs in up to 80% of cataract patients.

Unfortunately, astigmatism management in the public setting lags behind what we can access for our patients in private. Whilst there is some state-to-state variation, in Victoria at least we do not generally have access to low power torics for our patients. This leads to many more patients in the public setting being spectacle dependent for all distances post-cataract surgery than would be expected in private. There’s a massive gap in the provision of care here and I know at least at my institution a lot of work is being done to improve access of toric IOLs for these patients.

Meanwhile, this gap in patient care translates to a gap in training and experience of our next generation of ophthalmologists. With the reduced emphasis on refractive outcomes resulting from many patients needing glasses for clear vision anyway, trainees are not getting adequate exposure or education in refractive cataract surgery.

Astigmatism management when utilising presbyopia correcting IOLs is non-negotiable. It’s absolutely essential to treat as much astigmatism as possible as any residual will not only degrade image quality but also further exacerbate side effects such as glare and haloes.

Dr Ben La Hood is an Ophthalmologist from New Zealand and now practicing in Adelaide. Ben has worked really hard to develop his knowledge and skill in terms of understanding astigmatism, correcting it and most importantly helping others to also succeed. Ben hosts two podcasts of his own - Ophthalmology Against the Rule in which he talks about surgical topics with his colleague Dr Nick Green, and The Second Look that features interviews with some leaders in our field. In episode 3, Ben and Jacqui discuss some of the critical features in relation to astigmatism correction at the time of Presbyopia correction.

Please subscribe to this podcast and remember that the full digital course is available at geneye.org.au

This is the second episode of a 7-part series on presbyopia correction at the time of cataract surgery. This podcast series forms part of a GENEYE digital course that has been developed by Dr Jacqueline Beltz for Advanced Ophthalmology Trainees in Victoria, Australia. The full course is available at geneye.org.au under online training.

If I could give you one piece of advice when it comes to this topic, it would be to not use presbyopia correcting IOLs for the wrong patient or the wrong eye. It turns out that is simple but not easy. We can cause a lot of problems with these technologies, and the last thing that we want to cause is dissatisfaction for our patients. That said, we do have good options and when we match outcomes to expectations patients are thrilled!

In Episode 2, Dr Jacqueline Beltz and Dr Georgia Cleary discuss how to determine the “right” patients and the “right” eyes for presbyopia correction. Georgia is a cornea cataract and refractive specialist in Melbourne as well as a consultant on the Corneal Unit at RVEEH. Georgia has a ph.D in cataract surgery and IOL design. She’s the perfect person to discuss this topic with.

Please subscribe to this podcast and remember that the full digital course is available at geneye.org.au.

Welcome to season 2 of GENEYE POD. This is the first episode of a 7-part series on getting started with presbyopia correction at the time of cataract surgery. This podcast series forms part of a GENEYE digital course that has been developed by Dr Jacqueline Beltz, Director of GENEYE for Advanced Ophthalmology Trainees in Victoria, Australia. The full course is available at geneye.org.au under online training.

Cataract surgery is one of the most common operations performed worldwide. Microsurgery but particularly cataract surgery forms a significant part of the 5-year ophthalmology training program in Australia and New Zealand. Due to improvements in technologies and data analysis, cataract surgery results have improved significantly over the last few decades. These days, as well as the aim to restore sight, we also aim to reduce dependency on spectacles after cataract surgery. Reducing the need for spectacles for distance after cataract surgery has become standard in many countries around the world. Reducing the need for spectacles for intermediate and near is more complex and finding the perfect solution for this is perhaps the “holy grail” for cataract surgery within the developed world.

To date, correction of presbyopia at the time of cataract surgery has not been routinely taught in training in most parts of Australia and trainers have varied and sometimes limited experience with these technologies themselves.

This podcast series forms part of a GENEYE digital and real-life course providing active and structured training in getting started with presbyopia correction at the time of cataract surgery. This course is available for both teachers and trainees. Whilst parts of the course could be applied anywhere, the live and assessment components have been specifically developed for accredited advanced trainees in their 3rd and 4th year of ophthalmology training at the Eye and Ear Hospital, Victoria, Australia. The full course can be found at geneye.org.au under online training.

In this podcast series, together with some great colleagues, Jacqueline covers some of the important aspects of presbyopia correction at the time of cataract surgery. She delves into the nuance and discussions. The things you actually need to know to make sure you start off safely and with success. Episode 1 covers some of the different options that we have available to us in Australia at the moment. Later episodes will cover patient selection and optimisation, astigmatism correction and IOL calculations, assessing corneal tomography, mastering the patient conversation, surgical tips and managing complications, refractive enhancements and IOL exchange. Bear in mind these technologies are changing all the time – covering everything at one point in time would be ineffective. Rather, she covers some of the general considerations and methods, so that you understand the concepts and are experienced and equipped when it comes to trying or developing newer and hopefully better technologies in the future.

In Episode 1 Jacqueline introduces Dr Benjamin Au. Ben recently completed the advanced cataract surgical fellowship at the Royal Victorian Eye and Ear Hospital. Ben’s involved in several trials, does a lot of the complex cataract surgery at the hospital and is heavily involved in teaching. Ben has a really interesting background, with many different influences on his cataract surgery that he shares during this episode as he explains the different technologies that are available to us.

Please subscribe to this podcast and remember that the full digital course is available at geneye.org.au.

In this episode of GENEYE Pod, host Dr Jacqueline Beltz talks with Associate Professor Carmel Crock, OAM, Emergency Physician and Director of the Emergency Department at The Royal Victorian Eye and Ear Hospital about diagnostic error and medical professionalism.

Medical Professionalism is a complex topic. At first glance it can seem straight forward but professionalism is difficult to define. Professionalism is important within medicine for our patients’, our own and our workplace experiences, but it is also important for clinical outcomes. We’re more likely to make mistakes if we behave unprofessionally. Professionalism in the medical setting is also associated with increased patient satisfaction, trust, and adherence to treatment plans; fewer patient complaints and reduced risk of litigation. Professionalism has also been associated with physician excellence.

In this episode, Dr Beltz talks about why professionalism should be considered a buildable skill rather than a personality trait. She discusses some of the concepts linking unprofessional behaviours to diagnostic errors and suggests that this is not only bad for our patients but for us too. Dr Beltz and Associate Professor Crock take the discussion further, with particular focus on strategies to improve knowledge, skills and culture relating to diagnostic error. They discuss why management of diagnostic errors is so difficult and why professionalism is critical. They also discuss management strategies and ways to improve these skills, highlighting the importance of positive role modelling.

At GENEYE, we care about ourselves and each other, so we can care for our patients. We can’t even begin to truly think we will serve our patients adequately if we don’t care about ourselves. Associate Professor Crock and Dr Beltz conclude their discussion with conversation about medical culture and wellbeing – what they have seen improve and what they hope will come next.

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Acknowledgments

Jacqueline Beltz and GENEYE would like to thank The Mind Room, Collingwood for supporting our program and allowing us to record in their studio.

Thank you also to Professors Ian Incoll and Debra Nestel from University of Melbourne Masters of Surgical Education program for their ongoing support, teaching and encouragement.

GENEYE POD is written, and hosted by Jacqueline Beltz and produced with the help of Nick Green from CORP COMM.

We would like to acknowledge the people of the Kulin Nations who are the traditional custodians of the land on which this podcast was recorded. We would also like to pay our respects to Elders past, present and emerging and to any Aboriginal and/or Torres Strait Islander people who might listen to this podcast.

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Further resources:

GENEYE https://www.geneye.org.au

Society to improve diagnosis in medicine (SIDM) https://www.improvediagnosis.org

Australasian Diagnostic Error in Medicine Conference https://www.ashm.org.au/Conferences/conferences-we-organise/AusDEM-Conference/