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    Staged cataract surgery: Art of optimization to individual outcomes

    How to apply the inside-out and outside-in techniques to move toward emmetropia


    Using this approach, for example, in cases of LASIK ectasia, an Intacs segment can be implanted to stabilize and flatten the cornea and bring it to a measurable state at which time an accurate IOL can be implanted for optimal emmetropic vision.

    This approach also can be applied to patients with corneal scars after RK. The corneal scar can be peeled, leaving a measurable cornea followed by accurate lens implantation during cataract surgery. Lamellar keratoplasty can be performed in a very thin scarred cornea (Gulani 5S system), and the cataract then can be removed through a clear cornea for a myopic outcome to be followed by central ablation myopic laser to result in a regular, clear, and emmetropically neutral endpoint.

    Pearls for a successful start to your ophthalmic career

    In every case I work on, my 5S system works as my mental “coin sorter” to allow me to use over 50 different refractive surgery techniques to then be combined with unlimited permutations of technology while respecting all of my Corneoplastique principles (elegant, brief, topical, least interventional, and visually promising).

    Patient/surgeon team

    In my more than 20 years of experience with this designed, staged concept, I have seen our patients’ enthusiasm as I explain my plan to bring them to an optimal level of vision. The patients become my team member, which is a welcome side effect of the planning, and they express their excitement as we go from one stage to the next.

    The first stage has already improved the vision to a point at which they become even more confident about embarking on the second stage.

    At the end of the second stage, they are amazed that they were told previously that nothing could be done to improve their situation. As I alluded to previously, my 5S system breaks down a seemingly unapproachable problem into a series of smaller very approachable procedures, i.e., the impossible becomes possible, and unfolds in front of you.

    The key factor here is never to forget that every action of ours should be in the patient’s best interest and our mindset should be unrelenting as we aim for emmetropia.

    Next: Noteworthly cases

    Arun C. Gulani, MD
    Dr. Gulani is director of refractive surgery and chief, cornea & external disease, as well as assistant professor, department of ...

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