Transforming impossible vision cases into dream outcomes with artistic precision and a patient-first philosophy
More than just science, cataract surgery is an art. I’ve spent decades honing my Gulani KLEAR™ System, a blend of cutting-edge technology and artistic surgical skill, to tackle the most challenging vision cases. My approach prioritizes minimally invasive techniques and meticulous planning, ensuring patients achieve not just clear vision, but their best possible vision.
Every day in my practice, I get referrals from around the world—patients who have often been told they’re ‘impossible’ cases, ‘not candidates’ for surgery, or just plain ‘nightmares’ to deal with.
For more than three decades, I have helped these patients by not only providing hope but also delivering results—unaided visual outcomes. This allowed them to return to their productive lives and professions. To achieve this, I have developed the Gulani KLEAR™ System—a full spectrum of Kerato-Lenticulo- Refractive techniques—and integrated cutting-edge technology. This approach overcomes surgical challenges and turns complex cases into visual successes, using minimally invasive surgical artistry, all of which is visually oriented.
This mindset and approach embody my philosophy, Gulanism: “A doctor’s inability should not result in a patient’s disability.”
A paradigm shift in vision correction
It is disheartening to see surgical demonstrations at conferences that prioritize surgical acrobatics over patient outcomes, often showcasing gory displays of blood, vitreous and stitches. These presentations usually end with the same statement, “patient did well.” Most of these patients come to me extremely disappointed, visually disabled and looking for help.
My mindset, coupled with meticulous planning and surgical artistry, allows me to transform ‘vision nightmares’ into success stories, often with single or staged techniques. This isn’t just a surgical philosophy—it’s a paradigm mindset shift, and one that I’m passionate about sharing with colleagues in the industry.
When I see patients from countries far and wide—often after enduring years of rejections, failed surgeries and declining hope—I see more than just their charts, topography and optical coherence tomography (OCT). I see their potential.
Each case is an opportunity to push the boundaries of what’s possible in vision correction. My approach is about raising the bar for our profession and redefining how surgeons think—shifting from surgical acrobatics to artistic precision with actual vision outcomes.
Besides a mindset shift, this also requires a detailed and in-depth understanding of refractive surgery and visual optics, corneal and lenticular anatomy, and surgical skills that involve the cornea, anterior segment and lens
Mastering surgical skills and technologies is akin to building with Lego pieces or composing musical minuets. Approaches can be assembled forward, backward, sideways or in combination to correct complex cases—using what I call the Gulani Planning System (GPS) to achieve unaided vision endpoints.
To illustrate this mindset, and to inspire colleagues in the industry— as documented in thousands of patients’ journeys on our YouTube channel—I will share two prototype cases: One demonstrating a ‘forward’ approach and another a ‘backward’ approach to correcting poor outcomes.
Case 1: Forward approach
This case involved a 75-year-old nurse who had undergone hexagonal keratotomy (Hex K) decades ago for hyperopia. This outdated procedure left her with severe corneal instability, high irregular astigmatism and a host of other complications. She came to me with vision reduced to counting fingers, a staggering 23.50 D of irregular astigmatism, 89.90 D keratometry, and a history of being dismissed by other surgeons as ‘untreatable.
For me, cases like these are not challenges; they are opportunities to demonstrate what’s possible with the right mindset.
My philosophy: My work always begins with the GPS. I first define the target—the patient’s ‘unaided’ vision potential—before deciding on the technique and technology. Every step of the surgery is meticulously planned to maximize vision while using the least interventional techniques.
How I Solved This Case: The solution here involved two brief, topical stages:
- Step 1: Stabilizing the Cornea I performed a no-stitch INTACS procedure to stabilize the cornea. This reduced the keratometry and astigmatism from 23.50 D to 1.4 D while maintaining corneal integrity despite Hex K cuts and Fuchs’ dystrophy. I call this step making the cornea ‘sensible’ or ‘measurable,’ which lays the foundation for future intraocular lens (IOP) precision.
- Step 2: Cataract Surgery with Precision Once the cornea was stable, I performed LenzOplastique®- based cataract surgery with a toric IOL implant to correct residual astigmatism. I ensured that every optical element was perfectly aligned—like ‘pins before bowling’—to achieve a ‘strike’ in visual outcomes.
The Outcome: This patient’s life changed in ways words can’t describe. For the first time in 60 years, she could see her face in the mirror. She returned to her life’s passion of caring for others. My mantra has always been, ‘Once your mind is decided, your hands follow.’ That’s exactly what happened here.
Case 2: Backward approach
Another prototype case involved a 75-year-old male patient who came to me after unsuccessful premium cataract surgery and lost his pilot’s license. His case had resulted in hyperopia, presbyopia, anterior corneal scarring and high keratometry from keratoconus, compounded by a YAG capsulotomy. His vision was 20/200, and he had been told by multiple surgeons that the only option was an invasive lens implant exchange with vitrectomy.
Why I Took a Different Approach: I believe that complex cases demand innovative thinking, not more invasive surgery. Using my 5S system, I developed a staged solution that prioritized functional vision over anatomical fixes. So in this case, the single surgery that would address all these issues of anterior corneal scarring and high keratometry along with emmetropia would be myopic surface laser surgery.
The question then was how do I turn this hyperopic patient into a myopic patient and then proceed with that single, least interventional surgery?
- Step 1: Inducing Myopic Astigmatism I implanted a piggyback lens on the existing pseudophakic lens. This altered the eye’s refractive state from hyperopia to myopic astigmatism, setting the stage for my planned myopic laser surgery.
- Step 2: Surface Laser Surgery After confirming stability, I performed LaZrPlastique® laser surgery. This refractive laser technique flattened the corneal center, reduced keratometry, removed the scar and increased the optical zone while bringing the patient to emmetropia.
The Outcome: This patient’s vision progressed to unaided 20/15 and he resumed his pilot’s license. Seeing his reaction to achieving a perfect vision was incredibly rewarding. Cases like this reinforce why I’m committed to thinking differently. By carefully staging the procedures, I addressed all impacting factors while avoiding invasive techniques. This patient’s journey from hopelessness to clarity exemplifies my belief that every complex case deserves a tailored, least interventional approach.
From ‘midzone’ to ‘endzone’
The above two prototype cases are examples of those I have helped using this mindset. However, in many referred cases, I must point out that achieving their ‘dream vision’ from the so-called ‘nightmare vision’ was just a simple step. In fact, I believe their surgeons had actually done a good job, but left the outcome ‘midzone.’ All I needed to do was guide these patients to the vision ‘endzone’ and ‘claim the trophy.’
Among the most common cases I encountered involved surgeons who celebrated technical surgical success, like clear corneal grafts, symmetric stitches or topographical changes, but completely neglected the patients’ request for unaided vision endpoints.
These cases often involve keratoconus patients who have undergone successful INTACS, CAIRS or other intracorneal implants, DALK or penetrating corneal transplants.
These surgeons did not perform bad or incorrect surgery. However, had they only believed in their own abilities and the patients’ potential for unaided vision, they would have experienced a greater sense of achievement. Not to mention extremely happy patients.
Inspiring surgical artistry
These cases are more than just surgical successes; they represent a new way of thinking about vision correction. My Vision a La Carte, ‘3T’ concept—“Target first, Technique second, Technology last”—is at the core of my philosophy.
I’m confident that all our colleagues can achieve this level of surgical expertise and technological adaptation if only they would change their mindset from presenting chart data and colorful topographies to actual unaided visual endpoints. And more importantly, show the patient’s reactions and life changes after their vision restorative work.
This will then inspire every eye surgeon to perform for that relentless goal, turning into surgical artists in the process. Not only will so-called ‘routine’ patients achieve beyond 20/20 vision endpoints, but those that are discarded and neglected as ‘impossible’ and ‘nightmares’ will truly achieve their ‘dream’ vision.
Contributor
Dr. Arun C. Gulani is a world-renowned LASIK, cataract, and corneal surgeon. He performs the entire spectrum of advanced vision surgeries to reduce dependence on glasses and contacts, customising vision correction surgery to meet each patient’s unique goals. He has extensive experience in a wide variety of eye surgery techniques and technology. He was formerly the Chief of Cornea and Assistant Professor of Ophthalmology in the University of Florida’s School of Medicine before founding the Gulani Vision Institute in 2003, where he receives a global clientele and acts as a consultant to eye surgeons and the eye care industry as well. With an eye of an artist, his passion is to make people see; and with his no-hype, one-on-one personalized care, he has turned Jacksonville, Florida, into a vision destination for the world.
