These newer IOL models will correct astigmatism ranging from 2.5-4D (prior models corrected up to two diopters). The SN6AT6-SN6AT9 Toric lens models will be available to order on June 3rd so patients who were waiting for these IOLs won’t have too much longer to wait.

Now, time to take another long nap as we wait for the FDA to approve the next advanced IOL in the pipeline: the AMO Synchrony. Yawn…

FDA Finally Approves Higher Powers of Alcon Toric IOL is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

I’ve been remiss these last few months and have left this blog to lie fallow.  There are a number of reasons for this:

1) There is simply very little going on with regard to advanced IOLs in the USA.  Even the larger power Alcon Toric IOL has been delayed by the FDA.  This IOL is simply an extension of an already existing (and proven) technology.  What could possibly take so long?  Nothing much to write about there (unless I wish to lambast the FDAf or these delays – plenty of others doing that)

2) My clinical practice has been at its busiest to date.  I’m now in the office from 8a-7p every weekday and spend Saturday catching up on paperwork.  Not much time to blog.

3) Since nothing much has been going on in the “Advanced IOL” arena, I have taken an interest in new glaucoma treatments.  Amazingly, this field (which was pretty sleepy for the last few decades) has suddenly taken off with a plethora of very promising new surgical treatments for this blinding condition.

4) My daughter is now 4 years old.  For those of you who are parents, you know just how great this age can be.  So, I find myself playing with her more now and typing at the keyboard less.

What does this mean for About-Eyes.com?  I wasn’t certain myself for awhile (even considered making this my last post).  However, I do think there is so much exciting work being done in the world “about eyes” that I could get up a little earlier once a week to post an interesting tidbit about eye-related issues.

So, I’m changing the focus and direction of this blog.  No longer will it focus strictly on advanced IOLs or cataract surgery.  Instead, it will be a regularly updated source of the latest news and information relevant for those who have eye disease.  I will still post on advanced IOLs when there is something happening in that field.  It just won’t be the only focus of this blog.

I hope those of you who have followed this blog in the past will find this broader focus to be an improvement.  Now, gotta go set that alarm for a few minutes earlier…

A New Direction for About-Eyes is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

I find this interesting coming from a company that infuriated many doctors and their patients when they introduced the Crystalens^® HD at a $200 premium over the previously available “5-0.”  Adding insult to injury, the HD often did not meet surgeons’ or patients’ expectations so it was difficult to justify the extra fee.

In the auto industry cars that are selling well generally don’t have rebate programs.  Such programs are created to move stagnant inventory of less popular models.  Just wondering…

Crystalens® Rebate Extended is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

Unfortunately for my US readers, this lens is currently available only in Europe. As even the LENTIS Mplus multifocal IOL is not currently available in the US, it is unlikely that we will ever see the LENTIS Mplustoric on this side of the pond.

And so we wait…

Europe Gets Another Multifocal Toric IOL is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

Like Dr. Trattler, Dr. Uday Devgan is a paid consultant of AMO.  Also like Dr. Trattler, I respect his opinion and have chosen (with his permission) to relay it to you:

ReStor® +3 (SN6AD1)
- This IOL has a +3 add on anterior (front) surface of the IOL.  This translates to about +2.25 at spectacle plane (what would be placed in bifocal glasses).  In other words, the strength of this IOL is intermediate vision (computer use, arms-length work, shopping).

-Diffractive rings are located in the central 3mm of the optic.  This makes the IOL “pupil dependent”.  In other words, the IOL is distance dominant for larger pupils and near dominant with small pupils.  What does this mean?  Practically, it means that there should be good night-time vision with minimal halos noted (though they will be there, most people do not find them too bothersome); and that reading will require a good source of light in order to keep the pupil small.

- The IOL has ayellow chromophore (tint) intended to protect the retina from “harmful” blue wavelengths of light (note: the benefit/detriment of the filter is controversial)

-Optimal near point of about 17-18 inches (the distance from your eyes at which you can expect to have the best near vision – see above comments about intermediate vision)

Tecnis® Multifocal (ZMB00)
- This IOL has a+4 add on posterior (back) surface of the IOL.  This translates to about +3.00 at spectacle plane(what would be placed in bifocal glasses).  In other words, the strength of this IOL is near vision (reading books, threading needles, etc.)

-The diffractive rings are located throughout entire optic.  This makes the IOL “pupil independent”.  In other words, the near and far vision are equally good at all pupil sizes.  Practically, this means that it should be easier for patients to read in dim lighting but that halos may be more bothersome with night-time activities such as driving.

-The optic does not have a “blue-blocking” tint.  Again, there is controversy regarding whether this is a good or bad thing (see my earlier posts on this topic).

-Optimal near point of about 13-14 inches (near activities)

Dr. Devgan also notes that since the central 1 mm of the Tecnis® Multifocal IOL is pure distance, it tends to give great vision for daytime activities such as golf, daytime driving, etc without any complaints of waxiness.

Dr. Devgan can be reached at:

Devgan Eye Surgery
11600 Wilshire Blvd, Suite 200
Los Angeles, CA 90025
800-337-1969
www.DevganEye.com

AMO Tecnis Multifocal vs. Alcon ReSTOR +3 Advanced Technology IOLs (Part 2 of 2) is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

The first communication is from Dr. William Trattler.  I have paraphrased him in as follows:  Elizabeth Davis, Carlos Buznego, William Trattler, and Guy Kezirian reviewed the Datalink database of visual results from many surgeons across the USA.    Liz Davis presented these results at the Aspen Invitational Refractive Symposium meeting (this data was also presented as a poster at ASCRS in 2010).

Other IOLs were also assessed in the retrospective review.  However, relevant to this discussion – part of the study was a comparison of the Restor D1 (+3) and Tecnis MF (Multifocal).  In order to compare apples to apples, only a subset of eyes were evaluated (essentially those with normal anatomy and whose “target refraction” was achieved).   In all, 391 Restor® +3 IOLs were compared to 145 Tecnis® multifocal IOLs.

The results of vision without glasses were as follows:

Distance Vision: They each achieved (on average) 20/25 vision.  No statistical difference was noted between the two IOLs.

Intermediate Vision:  Similar results.  Again, no statistical difference between the two IOLs.

Near Vision:  Not surprisingly, there was a statistical difference between the two IOLs with the Tecnis multifocal IOL just barely edging out the ReSTOR® +3.  I say “not surprisingly” as the Technis® multifocal IOL has a stronger “add” so one would expect a better near result.

Dr. Trattler points out the following potential limitations in the study.

A. Some sampling bias may be present

B. Number of eyes analyzed are different with each lens

C. Tecnis eyes  contributed by a small number of surgeons

D. This analysis does not control for pupil size (Pupil size may affect performance of Advanced Technology or “Presby-IOL’s”)

E. Vision quality was not evaluated (glare, visual function in low light, contrast acuity, etc.).

F. Pre and postoperative medications can be completely different between the groups.  We do not know if one group was more aggressive at treating preoperative dry eye and blepharitis (note – Dr. Trattler contributed cases to both the Restor and Tecnis MF data.)

Thus, it appears that both of these Advanced Technology IOLs are performing very well with regard to what we call “Snellen vision” (the black letters on white background vision tests done in a dark room).  Clearly, as our lives are lived in a world of complex colors, textures, and lighting, the Snellen vision is not a true measurment of the performance of a particular IOL.

Also, as Dr. Trattler points out, it should be noted that this group of patients were optimal patients, with low preop and postop astigmatism, and on target spherical equivalents.  So, these results will not apply to everyone considering cataract surgery with an Advanced Technology IOL.

So, what other information can be used to choose between these two IOLs?  I’ll discuss that in my next post.

To be continued…

——————————————-
BTW, Dr. William Trattler can be reached at:

Center For Excellence In Eye Care
8940 North Kendall Drive; #400E
Miami, FL 33176
305-598-2020
www.centerforeyecare.com
——————————————-

Alcon ReSTOR® +3 vs. AMO Tecnis® Multifocal Advanced Technology IOLs (Part 1 of 2) is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

Unlike earlier pseudoaccommodating IOLs (Such as the Crystalens^®) which just distort to provide an incomplete range of vision, the NuLens^® works like a piston. The NuLens^® is made of a flexible silicon gel that uses the eye’s own muscles to push against the lens.  This pushes the gel through an opening within the lens.  This results in a change the shape of the IOL.  This change in shape increases or decreases the power of the IOL accordingly.

Because the NuLens^® has a truly flexible lens, it has the ability to produce a wider focusing capacity compared to other rigid and flat intraocular lens. Amazingly, the design of the NuLens^® may even beat the focusing power of a 20 year old by up to 40%.  It also offers the promising prospect of better contrast, fewer aberrations and ghost images and a better range of intermediate (activities such as cell phone dialing) to near focus (such as with reading the phone book) without negatively affecting distant vision (as with driving or watching TV).

Good candidates for NuLens^® procedure generally include patients over 50 with cataracts and no other serious eye diseases. Patients who wish to reduce their dependency on eye glasses and contacts (and who value this enough to pay up to $3,000 per eye) will be prime candidates for the NuLens^®.

Currently available studies show that NuLens^® is safe and effective. NuLens^® hopes to obtain CE marking in Europe by early 2011. It is expected to be available in the United States by 2014 (depending on the FDA clinical trial results).   Not everyone, however, will be a candidate for this IOL.  Only your eye surgeon can determine the most appropriate option for you and help you choose the right course of treatment.

The NuLens^® is not a magic trick, it’s a science.  But, like the best of scientific advancements, it has the potential to awe us like a great magic trick.

References:

1. Ben-nun J,e t al. Cataract and Refractive Surgery Today Europe 2008;3:20-21.

2. Dick HB. Curr Opin Opthalmol 2005;16:8-26.

3. Rosen E. Accomodation: The dynamic range of vision. Available

4. Innovations in ophthalmology 2010. The NuLens^® Dynacurvature IOL. p72-73.

NuLens® IOL Is No Optical Illusion is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

Modern eye surgery has changed the way people look at heavy-rimmed glasses and contact lenses. It has been possible for decades to replace the natural lens with a synthetic intraocular lens (IOL).  Unfortunately, most people with IOLs still needed glasses after surgery.  However, newer advanced intraocular lens implants can restore and maintain clear vision even without glasses and with little risk of developing complications.

Existing IOLs in the market help the eye see images at different distances. Multifocal lenses (ReSTOR^®, ReZoom^®, Tecnis^®) are able to focus near and distant images while accommodating lenses are currently limited to distance and midrange images. These latter lenses increase the eye’s focusing ability (accommodation) by shifting the position (Crystalens^®, Tetraflex^® and Akkomodative 1CU) or shape (Nulens^®, FluidVision Lens, HumanOptics’ Superior Accommodating Lens) of the lens.  Of particular note to my US readers is the Synchrony IOL (pictured) as it is most likely the next presbyopia-correcting IOL to be approved in the US.

With all of those choices, it’s not always easy choosing the one that is best for you.  Some eye surgeons will “mix and match” different lenses to optimize near vision without compromising distant vision. For example, they may use a multifocal IOL in one eye for near vision (e.g. reading papers) and an accommodating IOL in the other eye for stronger midrange vision (e.g. web browsing or reading price tags).

The additional range of vision, however, comes at a price.   IOLs are expensive (and don’t expect your insurance to pick up the cost). In addition to the basic fees for cataract surgery, expect to pay anywhere from $1,500 to $2,800 per eye, depending on the surgeon and the IOL used.

Both those with cataracts as well as those who simply have an ”aging lens” (presbyopia) may profit from these newer IOLs. Experts agree that up to 92% of patients achieve better vision without glasses after the procedure and can sustain good vision even years after lens replacement.

As newer IOLs function in different ways, it is important that the choice of IOL be customized to the individual patient. Patients should discuss each lens option and discuss their important lifestyle needs with their surgeon.  Only then can your surgeon pick the best lens for you.

References:

1. Vukich J. New Accomodating IOLs. Advanced Ovular Care 2010.
2. Schor C, et al. Adaptive Collaboration of Dynamic Accomodation—Implications for Accomodating Intraocular Lenses. J Refract Surg 2008;24:984-990.
3. Saiki M, et al. Biconvex posterior chamber accommodating intraocular lens implantation after cataract surgery: long-term outcomes. J Cataract Refract Surg 2010;36:603-608.
4. Intraocular lens implants editorial. BMJ 2000;320:73-74.

An Update On Current And In-The-Works Advanced IOLs is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

This last week, I had one of those “Wow! I can’t believe this is possible” moments that we all likely (but rarely) experience when we are at the very top of our game and pushing the limits of what’s possible.  I had a patient who really wanted a ReSTOR +3 multifocal IOL but had a dense posterior subcapsular cataract (PSC).  Now, a mild PSC is not usually a problem.  In his case, however, the cataract had formed a fibrous plaque on the surface of the posterior capsule.  This plaque simply refused to come off using the traditional techniques of light vacuuming and polishing of the posterior capsule.

In a previous post I explained how the posterior capsule is only a few millionths of a meter thick and many surgeons will avoid touching it if they can.  I am in the minority that “polish” every posterior capsule and feel that I have developed a “sense” of how much manipulation a particular capsule can bear.  Rather than fear the capsule, I have attempted to get to know it.  Now, I’m not going to suggest that I am some sort of “Capsule Whisperer.”  I don’t care whether it is baking cupcakes or polishing a membrane that is only as thick as a speck of dust, the more you interact with it the better sense you get of how it will come out (BTW don’t ask me to bake, I can tell you it won’t come out tasty).

Back to the challenge at hand: this plaque was thicker than the capsule itself and just would not come loose.  Finally, I got an edge free, but it was too small to occlude the vacuum handpiece so I was unable to pull it free.  The best analogy I can think of is that of peeling a sticker off of something.  You get a little edge, pull it off, but the sticker tears, so you have to do it again.  Only, in this case it was like having to peel a sticker off of Saran Wrap (very thin Saran Wrap).

Suddenly, it occurred to me that retinal surgeons peel very delicate membranes off of the retina using extremely delicate forceps.  It just so happened that I was operating that day in a hospital which also served retina surgeons.  What if, I thought, I used these micro-forceps (pictured below) to peel this plaque off of the posterior capsule?  By this time, I had a pretty good sense that this particular capsule was sturdy enough to tolerate this.

Well, it was either get the plaque off or no multifocal IOL for this patient.  I knew how disappointed he would be so I had the OR staff open the forceps.  These things were SMALL!  I increased the magnification of the microscope, controlled my breathing, grasped the edge of the plaque and pulled…

Off it came and the capsule did not tear.  Over the next 30 minutes in a very quiet operating room (as the staff watched the LCD monitor in awed silence) I patiently repeated the steps of polish, grasp, pull – again and again until finally the capsule was clear.  Exciting and exhausting and deeply satisfying.

That afternoon I saw this patient in my office.  His range of vision was simply astounding.  I doubt I’ll be pulling out these retina forceps on a regular basis, but just knowing it can be done is enough.

Patience and Tenacity Succeed with a ReSTOR +3 is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

I had dinner last night with one of LA’s top cataract surgeons, Dr. Barry Seibel.  He is one of the few surgeons on the Westside of LA who actually did write an influential textbook on cataract surgery, Phacodynamics (I have a dog-eared copy in my office).  For those of you who don’t know it already, almost every cataract and refractive surgeon on the Westside says he or she has taught (insert ridiculously large number here) other surgeons or was one of the first to do this or that surgery…yadda, yadda, yadda (oh boy am I gonna get flamed by some slick Westside surgeons for that comment).  The difference is that Dr. Seibel actually did write a real textbook that has been read (or should have been read) by most ophthalmology residents since the book was originally published.  This was not some sort of ghostwritten vanity press book produced as a marketing shill.  It’s the real thing and a continual source of reference for me and other surgeons.

If you live on the Westside and have cataracts I’d recommend scheduling a consultation with him (BTW, I have no financial interest or arrangement with Dr. Seibel and suppose I should be asking you to come and see me, but I know that if you live on the Westside you’re not going to schlep out to the San Gabriel Valley anyway – so just save the gas, stay off the freeway, and go see Dr. Seibel).

In any case, Dr. Seibel and I had a wonderful conversation which had nothing to do with phacodynamics but made me realize that most people have no idea about the complexity involved with physically removing a cataract.  In order to give you an idea of the dynamic process involved in emulsifying and removing a cataract try the following mental experiment (don’t really do this as it’s just a metaphor):

Imagine you have a plastic trash bag (the cheap thin ones from a discount store, not the Heavy Duty Hefty bag) – this is going to be our imaginary capsular bag.  In the eye this bag is only a few millionths of a meter thick.  Now fill it up with oatmeal – this is our model cataract.  Let it sit overnight so that the oatmeal gets real hard and sticky.  Now, in order to remove the cataract we are going to use an instrument that both pours fluid into the bag and vacuums the oatmeal out of the bag.  For imaginary purposes we’ll use a vacuum cleaner with the hose attachment and ducttape a garden hose to it so that both nozzles face the same direction.

OK, turn on the vacuum cleaner and water hose.  Stick it in the bag full of crusty oatmeal – uh, this is actually a bit messier than cataract surgery.  Can you see the water hose breaking up the oatmeal and he vacuum sucking it out?  Good.  Not too difficult, right?

Oh, but wait, there’s oatmeal stuck to the sides of the plastic bag.  You’ve got to get that out too.  In real cataract surgery if you leave part of the cataract stuck to the capsular bag your patient won’t see any better after surgery than they did before – in fact, they might be worse off with inflammation, poorer vision, and a painful eye.

Anyone who has ever used the vacuum cleaner attachments knows that if you get them anywhere near loose fabric, the vacuum will suck the fabric into the nozzle.  If you get your nozzle too close to the side of the plastic bag, the bag will get sucked into the nozzle and tear.  Now you’ve got a big hole through which all of the oatmeal has just spilled out onto your floor.  In cataract surgery we call this a “capsular rent” and try to avoid it at all costs because such a tear will allow the remaining cataract to spill into the back of the eye resulting in floaters, inflammation, and increased risk of infection or retinal detachment.

Right about now you might be thinking, “That sounds like a bad idea, why would anyone try to do something like use a water hose and vacuum to take a cataract out?”  Well, it does sound risky and early pioneers of phacoemulsification such as the late Dr. Charles Kelman (a true renaissance man) were severly chastized by their fellow surgeons for taking “unnecessary risks.”  However, the method of cataract surgery used at the time was called “delivering” the cataract (as in delivering a baby).  It required a large incision, took weeks to months for the eye to heal, and had it’s own set of surgical risks.  Fortunately, the techniques and technology of phacoemulsification have significantly evolved over the last 40 years.

A major reason we can now remove cataracts safely using a microscopic water hose and vacuum is that the fluidics of phacoemulsification have been studied and taught by doctors such as Barry Seibel.  Tools and techniques have been developed that allow cataract surgeons to get very close to the capsular bag (close enough to remove individual microscopic strands of cataract) without tearing the bag.

In short, modern cataract surgery is nothing short of miraculous.  Even after performing over 2,000 cataract surgeries, I often find myself in awe at what can be done thanks to the imagination, efforts, and risks of the many pioneer surgeons (and their patients) that preceeded me.  We all owe them a debt of gratitude.

Thanks.

You’re Going to Vacuum Out my Eye? is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert