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The KISS principle of keeping it simple

As many of you know I am a big believer in the KISS principle of keeping it simple…

I use this principle in surgery: topical anesthesia, minimal manipulation of the eye, minimal use of instrumentation in the eye resulting in a quick and fast healing surgery. I use this principle in running our co-management practice as well.

Today I am reflecting on my one-year anniversary of limiting my practice to just surgery: that is manual and laser cataract surgery, LASIK surgery, YAG laser surgery, and second opinion cases involving cataract and LASIK surgery.

Reflecting on this decision, I have found that I am able to spend more patient time with cataract and LASIK consultations allowing me to really zero in on pre-op patient concerns. It gives me the ability to better explain refractive options available to our patients such as laser astigmatic keratotomy, toric IOLs, and multifocal IOLs. It also allows me to spend more time on the many complicated and higher risk patients that are often referred to me. I agree with the often-quoted maxim, “the more time you spend with a patient prior to surgery the less you will need to spend afterwards.” An interesting side benefit is that I am finding I enjoy the experience of helping our patients see better more than ever!

For the co-managing referring doctor, a “surgery only” ophthalmologist should reinforce the co-managing relationship. Your patients know that I only operate and there is no option for seeing me for routine eye care. They know that they are at Cullom Eye and Laser Center for cataract surgery and will not be undergoing unrelated procedures such as Botox, blepharoplasties etc. They understand the team approach I take to caring for their eyes.

We work with each individual co-managing doctor to tailor a post-operative approach that works best for your patients as well as your practice. And finally, with more time to devote to communication with co-managing doctors I hope you find our professional relationship respectful, meaningful and “simple.”

Best regards,

Doug Cullom


When I refer a patient, I want to work with a surgeon that is easy to work with, easy to get in for an appointment and surgery, be likeable and have a good bedside manner. I want a surgeon that does not keep my patient or do other –unrelated procedures. But what matters most to me is surgical RESULTS. It easy for both surgeons and referring doctors to think that most surgery is successful– so good results are just assumed. But it is important to look scientifically not just anecdotally at surgical outcomes.
Did you know that, on average, only 55% of patients come within 0.5 diopters of plano (or refractive target) after cataract surgery according to many large database studies (see footnote)? At Cullom Eye & Laser Center, we are dedicated to exceeding these standards for our cataract patients, which is why I would like to share with you our refractive results after Catalys laser cataract surgery.
We analyze every laser cataract patient’s refractive outcome in our ORA database. ORA is our intraoperative aberrometer performed after the cataract is removed but before the intraocular lens (IOL) is placed. ORA’s outcome analysis reports compare my post-operative refractive results to a national database of ORA users that currently include over 70,000 surgeries. We also compared our results to a database of 17,000 standard manual cataract cases1.

We looked first at standard IOLs (N=344 patients). These were patients that elected for a refractive cataract package that includes: Catalys femtosecond laser and ORA intraoperative wavefront aberrometer (it also includes free LASIKtouchup if necessary). We found that 89% of my patients were within a 0.5 Diopters of target (usually plano). This compares with 82% of the ORA database patients and 55% for non-laser/non-ORA patients1. We also had a remarkable 60% within 0.25 of target. Note that target is typically plano but sometimes I target -0.25 or even true near (-1.75 in the case of monovision).
Next we looked at toric implants. Cumulative post-operative cylinder distribution was analyzed and 77% of my toric patients were within 0.5 Diopters of target. This is in comparison to 72% in the ORA database. ORA analysis is particularly helpful with toric IOLs since post implant live images help guide how much to rotate the implant as well as compensating for posterior corneal astigmatism –something that office topographic measuring devices do not measure.
And finally our post myopic LASIK patients data soundly beat national database numbers. Nearly 80% were within 0.5 Diopters of intended target versus 63% in the national database control. This group of cataract patients is notoriously difficult to achieve target while being some of the choosiest patients.


I believe our refractive results are beating national averages for several reasons:
• Catalys laser surgery with repeatable perfectly centered 5.1 mm capsulorhexis improves predictability of effective lens position (ELP) a key factor in refractive outcome.
• Centered predictable capsulorhexis also virtually eliminates lens (IOL) tilt
• Catalys laser lens fragmentation allows for less lens manipulation and therefore less stretching of lens zonules possibly improving IOL positioning.
• Topical anesthesia is less disruptive to eye and orbit possibly allowing for better intraoperative ORA measurements.
• Small incision surgery with incision of 2.4 mm is less astigmatism inducing and less corneal surface distorting.
We hope that providing you with our surgical outcomes will help you make an informed decision when referring your patients for surgery. We will continue to monitor and provide you updated cataract surgery refractive results as we strive to provide the best outcomes for your patients.

1In a recent report analyzing refractive data of over 17,000 eyes after cataract surgery, it was shown that emmetropia (+/_ 0.5 Dioptors) was only achieved in 55% of eyes in which it was targeted.
2 Behndig A, Montan P, Stenevi U, et al. Aiming for emmetropia after cataract surgery: Swedish National Cataract Register study. J Cataract Refract Surg 2012; 38:1181–1186.

* One of the largest series used to analyze targeted emmetropia after cataract surgery and factors affecting it.