Fluid-Based Accommodating IOL

Dr. Louis “Skip” Nichamin gave an interesting talk at the 2013 Hawaiian Eye Meeting titled “Update on a Fluid-based Accommodating IOL.” This technology being developed by PowerVision involves an IOL with the lens optic and haptics filled with silicon oil.  The idea is to use the power of the ciliary body (the presumed driving force behind accommodation which changes the focus of the natural lens from far to near).  This tiny muscle within the eye would essentially  pump fluid from the haptics into the optic.  This extra fluid within the optic would increase the curvature of the lens effectively increasing the power.

One of the other unique strengths of this IOL technology is that it has the potential to provide five (or more) diopters of accommodation!  Considering that the currently available pseudo-accommodating IOLs struggle to achieve 2-3 diopters this would be a real “game changer” if the promise is realized.  We might know soon enough as a CE Mark study in humans is set to begin in Germany and South Africa later this year.

FluidVision Lens Concept Animation.  Part of Dr. Nichamin’s Presentation Slides.

Ever Wonder What Happened to Waterbed Technology? Don’t Look Now, But Someday It Could Be in Your Eye. is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

The Electro-Active Accommodating IOL 

I just finished watching a truly mind-blowing presentation by Dr. Jay S. Pepose (Washington University School of Medicine). In it he describes an experimental intraocular lens (IOL) that changes focus from distance to near. “So what,” you say? Well, for starters, the focus of the IOL is controlled by a computer chip that is part of the IOL itself! Talk about microcomputers.

It gets even more bizarre as this tiny little computer learns an individual’s unique pupil patterns of accommodation in order to control the focus of the IOL. That’s right, in addition to focusing light (the primary role of an IOL), this little miracle of technology can detect the pupil size and learn whether the pupil is constricting from bright light or from the desire to focus at near (accommodating pupil constriction). Why is that important? Because you wouldn’t want the lens in your eye to suddenly change its focus to near every time you stepped into bright light.

This device, introduced as the Electro-Active Accommodating Intraocular Lens Implant, has no less than six different functional units – all of which must fit within the space of the eye’s natural lens. Absolutely amazing! These components include the following

• Aspheric “single piece” IOL: The “ho hum” portion of an IOL that is shared by all lenses used in modern cataract surgery.  It refracts (or focuses) light onto the retina
• A thin film of liquid crystals sandwiched between a circular array of transparent electrodes within the IOL material.  When a charge is placed across these crystals they form concentric rings that diffract light (similar to current multifocal IOLs).  Only, because these rings are not active at all times one would expect to have fewer halos around lights with this technology.
• Two computer chips (one on either side of the optic) that control the liquid crystal display (LCD).
• Photovoltaic cells (to detect light)
  • A single photocell positioned at the center of the IOL to detect light intensity
  • A linear series of photocells to detect pupil diameter
• Rechargeable ceramic power cells (batteries)
• Radiofrequency Microcoils to allow for wireless inductive recharging of the
  • In theory a person could recharge these IOL batteries with either a special sleep mask or pillow in which an inductive power supply was located.

Screengrabs of Dr. Pepose’s Presentation Slides.  Hover to pause.  

Seriously, seriously cool! I half expected Dr. Pepose to end the presentation with a “and then I woke up from my dream” slide – it just seemed way too futuristic to be nearing reality. And to be fair, it will be a VERY, VERY long time before anyone in the USA ever gets to have one of these implanted within the borders of the United States. I mean, really, if the FDA can’t even approve a toric multifocal when it has been safely available everywhere else in the world for years; don’t hold your breath in anticipation of getting an Electro-Active Accommodating Intraocular Lens Implant for at least a decade.

Still, Dr. Pepose did state that the components necessary to develop this IOL are currently available. What is needed is “simply” the final engineering of the product…followed by thousands of hours and millions of dollars of wading through the tar pits of FDA bureaucracy. Oh well, it was fund to dream…

Honey, Did You See Where I Placed The Charger…For My Eye?! is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

So, You’ve Got a Cataract? Book is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

Luckily, it doesn’t take a lot of time to do the research necessary to find an excellent eye surgeon. The following list of 10 things you must know before choosing your cataract surgeon will explain how to go about it. With this list you can find an exceptional eye surgeon in less time than many people devote to choosing their next car.

(1) Use caution when evaluating “in-network” physicians.

Despite what’s stated in your health insurance’s marketing materials, don’t assume in-network physicians provide better quality care. Currently there isn’t a tried-and-true, scientifically sound method for rating the quality of physicians. Any insurance company that suggests physicians participating in its own network provide better quality care is painting an inaccurate picture.

(2) Ask people you trust.

Good sources of information include your internist, optometrist, and friends who have had cataract surgery. Even better sources are the operating room nurses and staff at your local hospital. They are often in surgery with eye doctors and know who has the “best hands.” Nurses are, by nature, very helpful people and will often be happy to answer your questions. The challenge will be getting past the hospital’s automated telephone menu and gaining access to a live operating room nurse. I would suggest calling the hospital’s main number in the morning. Choose the option for a live operator. Once you have a live person, ask to be transferred to the operating room nursing station. A nurse will often pick up once the line is transferred.

(3) Research your surgeon’s education.

Where did your eye surgeon train? It’s fairly easy to check the ratings for various training programs. Two objective resources are U.S. News & World Report’s annual rating of “Best Medical Schools” at

http://grad-schools.usnews.rankingsandreviews.com/best-graduate-schools/top-medical-schools/research-rankings

and U.S. News & World Report’s annual rating of “Best Ophthalmology Hospitals”  at

http://health.usnews.com/health/best-hospitals/ophthalmology-hospital-rankings/

Don’t get too hung up on the ranking order. Surgeons trained at any of the top 20 institutions received a top-notch education.

(4) Research your surgeon’s state licensure.

Make sure your surgeon is licensed to practice medicine in your state. Go to your state medical board’s Web site and do an online search. In addition to confirming a surgeon’s licensure, many state license Web sites will also tell you whether there has been any disciplinary or legal action taken against your surgeon. In California, for example, you can look up this information at

www.medbd.ca.gov/lookup.html

(5) Confirm that your surgeon is board-certified.

When physicians becomes board-certified, it guarantees they have met minimum competency requirements. In order to become certified, an eye surgeon must successfully pass both a written and oral examination. Additionally, younger surgeons must recertify every 10 years. Confirm that your ophthalmologist is board-certified by visiting

www.abop.org

or

www.abms.org

(6) Visit your surgeon’s Web site.

You can often obtain very useful information from your eye surgeon’s Web site. However, keep in mind that the primary goal of most Web sites is to market the practice. You won’t find anything negative about your doctor there, but it can give you more insight into the surgeon’s background and practice philosophy.

(7) Find out what other patients have experienced.

Are testimonials from satisfied patients available on your surgeon’s Web site or physician-ranking Web sites? Can you review testimonials in your surgeon’s office? Will your surgeon provide the names and phone numbers of patients who have offered to act as references? It shouldn’t be too hard for your surgeon to come up with a list of people willing to discuss their cataract surgery experience with you. Keep in mind, however, that federal privacy regulations limit the amount of information a surgeon may be able to offer regarding other patients who have had surgery.

(8) Find out how many cataract surgeries your doctor has performed.

There is a reason they call it the “practice of medicine.” Just like a sports pro, a surgeon’s abilities improve with practice and experience. Every surgeon requires a minimum number of “cases” to become proficient. For cataract surgery, this number is probably around 500. Still not comfortable? Find someone who has performed over 1,000 cataract surgeries.

How do you find out the number of cataract surgeries your surgeon has done? Just ask. If you are uncomfortable asking this question, then bring someone to your appointment who will ask for you. This is a very important question. These are your eyes. You only have two. Get over your hesitation.

(9) Meet your surgeon.

One of the most important criteria for choosing surgeons is your ability to trust them. Meet with your surgeon. Make sure you feel comfortable with what your surgeon says and with the level of care that will be provided. Trust is an important consideration that cannot be sufficiently developed until you talk with your surgeon face to face.

(10) Finally, get a second opinion.

Most people wouldn’t purchase a car without test-driving at least one other car. Cataract surgery is a very important decision and getting a second opinion is a smart idea. Many people are uneasy about getting another opinion, but a second opinion is a common medical practice encouraged by the best surgeons. In fact, one quick test of your surgeon’s comfort with their own abilities is to let them know that you’ll be getting a second opinion. If the surgeon becomes defensive about this, then you’ll know a second opinion is a good idea, after all.

Unless you are completely comfortable with your surgeon, get a second opinion.

I would, of course, be pleased if you selected me as your surgeon (or would be happy to offer a second opinion). Call my office at 626-289-7856 or request an appointment online at

www.David-Richardson-MD.com.

My staff will be happy to set up a time for us to meet.

How to Choose a Cataract Surgeon is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

As with many things in life, medicine is not immune to fads. Lasers evoke images of the future, science fiction, and advanced technology. It is no surprise then that somebody came up with the idea of using a laser to remove a cataract. The problem is, the initial attempts at using a laser in the late 1990s didn’t work as well as other treatment options, so the technology never took off and very few eye surgeons used this technology.

So why do so many people believe they have had “laser cataract surgery” when so few doctors were even offering this as an option?  Because the second most commonly performed surgery in the USA is a laser procedure used to remove haze that can sometimes form behind the lens after cataract surgery.  This haze (properly called “posterior capsular opacification”) used to be described as a “secondary cataract” or “after cataract.”  Because the terms doctors used with their patients had the word “cataract” in them and the treatment to remove this haze used a laser, it is not surprising that many people confused the terms “after-cataract” or “secondary cataract” with “cataract” and mistakenly believed that their cataracts had been removed with a laser.

I’m not suggesting that some of the people you’ve talked to haven’t had laser surgery. They might have had refractive laser surgery, such as LASIK, to improve their eyesight. But it is very unlikely that they actually had their cataract removed with a laser.

Enter the Femto Laser

Fast forward now to 2011.   A newer laser technology previously used by LASIK surgeons has recently caused quite a stir among cataract surgeons (and not all of the “buzz” is positive).  Touted by some as “Laser Cataract Surgery,” it would be more aptly named “Laser Assisted Cataract Surgery.”  Among cataract surgeons it is more commonly termed Femto-Phaco as it requires a combination of Femto laser treatment and phacoemulsification to complete the surgery.

So, what exactly does this Femto laser do and is it better or safer than standard phacoemulsification?  That is, as they say, is the $24,000 question.  To date there is no clear answer, but to help you form your own view I will try to briefly outline the pros and cons of this new technology.

A Brief History of Femto Laser use in Eye Surgery

This technology was originally used by eye surgeons to create the flap in LASIK surgery.  The flap is made by creating a very thin slice of the cornea.  Prior to using the Femto laser, this flap was made using an oscillating metal blade called a microkeratome.  As with any mechanical item these microkeratomes occasionally malfunctioned resulting in sight-threatening complications.  The Femto laser has the ability to create microscopic spaces in clear tissue (such as the cornea).  If you think of these separations as similar to the holes in a perforated page, you can easily imagine that if you placed many of these spaces side-by-side that you could then peel away a flap of corneal tissue rather than cutting it with a metal blade.  In practice, Femto-LASIK met with its own set of complications (such as flaps that did not “tear away” as predictied (similar to how perforated paper doesn’t always tear the way you think it should).  Nevertheless, this technology took off and is in wide use today.  Whether its current popularity is a result of marketing “All Laser LASIK” or because it is a safer, better method of performing LASIK is still debated among eye surgeons.

A short while after the development of Femto laser technology a well-respected and forward-thinking eye surgeon, Dr. Sam Masket, showed that the same Femto technology used in LASIK could create the corneal incisions made at the beginning of cataract surgery.  Since this laser can cut most clear tissues it also made sense that this laser might be able to create the capsulorrhexis as well as “soften” certain types of cataracts before removal.  As with Femto-LASIK, however, the practical reality does not always live up to the promise or the hype.  Let’s discuss each potential advantage of Femto-LASIK and compare it to the possible downside.

Femto Laser use in Cataract Surgery 

The Achilles Heal of Femto Laser use in Cataract Surgery – Cost

Assuming you feel the potential advantages of Femto-phaco outweigh the disadvantes (or perhaps you just think that lasers are “cool” and would like to say to your friends that you had “laser cataract surgery”), why not chose the laser option?  There is one very good reason to forgo Femto-phaco: cost.

Cost

Femto-phaco is not cheap.  Depending on where you have it done it can add $500-2,000 per eye to the cost of cataract surgery.  This is in addition to the fee for “refractive cataract surgery” or the “premium lenses” (IOLs).  And, as with refractive surgeries, Medicare and most major commercial insurances do not cover it.  So if you want laser, you’ll have to pay for laser.

Value – Is Femto-Phaco Worth the Price Tag?

OK, so let’s say you’re part of the 1% (or 5%) that is at risk of being mobbed at an Occupy Wall Street demonstration.  You don’t give a whit about cost – this is about scoring points with your buddies at the country club or wine tasting event.  By all means, Femto-phaco will give you bragging rights.

But, for the rest of us, what are we really getting for our hard-earned money?  Well, it’s not so clear that there is a real, measurable advantage to using Femto-phaco.  Let’s take another look at the current uses of Femto laser with cataract surgery:

Femto-Phaco Final Tally: Bragging Rights, +3, Real Value, -1 

So, assuming you agree with my scoring, what does one get with the currently available (2012) Femto-Phaco technology?  Basically bragging rights, but…these bragging rights come not only with significant extra cost, but also extra risk.

It just seems to me (as well as many other surgeons with whom I’ve discussed this topic) that if someone is going to spend the extra money on “laser refractive cataract surgery” that the best current option would be to choose either an “advanced IOL” or blended vision and correct any residual refractive error with the Eximer laser once the eye has fully healed.  Maybe it’s not the “newest” version 10.X.Y cataract surgery available, but its risks are known and the “value” is high.

Then again, I’ve never understood why people pay over $1,000 for a set of golf clubs or a handbag either…

A Word About Laser Cataract Surgery is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

Diabetic Retinopathy

Unfortunately, when you have diabetic retinopathy (eye damage that occurs with long-term diabetes) you are at higher risk of macular edema (swelling of the retina) or infection. These conditions can be challenging and require prolonged treatment with steroids or other topical medications or injections in the eye, as well as laser treatment. If you have diabetes, the most important thing you can do to limit additional risks of cataract surgery is to maintain good control of your blood sugar.

Macular Degeneration

There has been a lot of controversy surrounding cataract surgery and macular degeneration, a degenerative condition of the retina. A few years ago, some published studies suggested a link between cataract surgery and the progression of this disease.

As of the date this article came out, the most up-to-date studies have shown little evidence that cataract surgery causes macular degeneration to progress, offering some reassurance to patients with the condition. I have also discussed this very issue with multiple retina specialists. In general, they recommend proceeding with cataract surgery for patients with macular degeneration, as it is much easier for them to follow and treat retinal disease once the cataract has been replaced with a clear artificial lens.

Prostate Medications

Prior to cataract surgery your surgeon must dilate the iris to safely remove the cataract. It must stay dilated to enhance the surgeon’s view inside your eye so as to avoid damaging your pupil — a very delicate tissue — when removing the cataract.

A few years ago Dr. David Chang, an ophthalmologist in San Francisco, noticed that the iris of certain patients would become “floppy” during cataract surgery, which interferes with dilation and increases the risk of damaging the pupil. This interference is called intraoperative floppy iris syndrome (IFIS).

Drs. David Chang and John Campbell, with the help of others, collected all the information they could about those patients who suffered from IFIS and discovered that they had one thing in common: the use of a prostate medication called Flomax^® (tamsulosin).

Flomax is a medication that relaxes the smooth muscle of the prostate, allowing men with an enlarged prostate, or benign prostatic hyperplasia, to urinate more easily. Doctors also prescribe this medication for women as a treatment for urinary retention. Unfortunately, it appears that this smooth-muscle relaxant also has a permanent effect on the muscles that control the iris, interfering with the pupil dilation necessary for cataract surgery.

Other medications used for enlarged prostate include the newly released RAPAFLO^® (silodosin), as well as a group of medications known as “non-selective” alpha-1 adrenergic antagonists. This group includes Hytrin^® (terazosin), CARDURA^® (doxazosin), and Uroxatral^® (alfuzosin). These drugs are less likely than Flomax^® to cause IFIS, although it can still happen.

Make sure your surgeon knows if you are taking any of these medications.

Cataract Surgery with Other Eye Diseases is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

After cataract surgery, there is a risk that your eye pressure could increase. Fortunately this pressure elevation is usually temporary and treatable with drops, laser treatment, or, occasionally, additional surgery. In a healthy eye, it’s rare for this pressure elevation to cause vision loss.

However, if you have ocular hypertension, glaucoma, or a condition known as pseudoexfoliation syndrome (deposits on the surface of the lens), you may be at an increased risk for vision loss due to a spike in eye pressure. Especially if you have glaucoma, your eye might not be able to tolerate even a temporary elevation in pressure. At times it may even be necessary to surgically treat the glaucoma at the same time as cataract surgery.

If You Have Early or Well-Controlled Glaucoma

I have good news for you.  Recent studies have shown that cataract surgery alone may decrease the intraocular pressure (IOP).  Thus, if you have only mild (or well controlled) glaucoma both your vision and your IOP may improve with cataract surgery alone.

If You Have Moderate or Glaucoma Requiring the use of Multiple Drops

Good news again – there are now multiple glaucoma treatment options that can be performed at the same time as cataract surgery.  At the time this article was published the following were available (or were likely to be approved by the FDA):

If You Have Advanced or Poorly-Controlled Glaucoma

With advanced glaucoma the risk of vision loss after any surgery is higher.  An IOP spike could result in sudden (even complete) loss of vision.  Therefore it is critical that the IOP be controlled during the post-operative period.  For this reason a “combined” procedure is generally recommended at the time of cataract surgery.  The most commonly recommended procedures for those with advanced glaucoma who need cataract surgery are:

Summary of Glaucoma Treatment Options

Cataract Surgery and Glaucoma is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

According to the National Eye Institute, cataract surgery is one of the safest and most effective types of surgery.¹ Serious problems are rare. In fact, more than 97% of people have no complications with cataract surgery. That being said, any surgery still has risks.

However, if your surgeon tells you there are no risks to the surgery or that they have never had a complication, I’d question that statement. All surgeons worth their salt have met with some complications. In fact, better surgeons tend to get the more difficult cases, so their experience with complications may be even higher than those of lesser skilled surgeons.Prior to cataract surgery, you will receive a consent form.  Generally, this form is written by attorneys who feel it necessary to list nearly everything except for “acts of God” as a risk of surgery. I’m not really sure why they leave out “acts of God.” I practice in southern California, where we have both earthquakes and rolling blackouts. Either of these events, were they to occur during cataract surgery, would have devastating consequences. Fortunately, my center, like most surgery centers, has backup electrical power for emergencies. As for the earthquakes…

If you would like to find out how to choose a cataract surgeon, I have included a bonus chapter in my upcoming book outlining 10 things you should know about your surgeon prior to cataract surgery. You may request extra copies of this chapter by calling my office at 626-289-7856. My staff will be happy to drop some extra copies in the mail for you.

OK, back to the risks of cataract surgery…

Possible Complications

Capsular tear

During surgery the biggest concern is often with the lens capsule. As I mentioned earlier, this delicate membrane occasionally tears, allowing fragments of the cataract to slip into the back portion of the eye. If a part of the cataract falls into the gel of the eye, you might notice floaters, or bug-like objects or specks that travel across your field of vision. Floaters are common and something you might notice when you go outside on a sunny day. However, if you notice a new floater after surgery, you should immediately let your surgeon know. If a lens fragment is causing the floater, it should be treated with a separate surgery (vitrectomy) at a later date.

Infection

Infection is one of the greatest risks. An infection from cataract surgery, known as endophthalmitis, can possibly lead to a loss of vision — even blindness — and can do so in a matter of hours. Fortunately, it is very rare: Only 1 person in a 1,000 gets it.

If you had an infection, you would know. Your eye would be red and/or painful, or you would have a sudden loss of vision. If you suspect an infection, call your surgeon immediately, even if it’s 3 a.m.!

Retinal detachment

Your lifetime risk for retinal detachment increases after cataract surgery to about 1 in 100, and even greater than this if you have moderate to severe nearsightedness or if the lens capsule tears during surgery. Symptoms of retinal detachment include floaters or flashes in your field of vision or a loss of an area of your vision. If symptoms are severe, your vision might appear shaded, as if a curtain had been placed over your eye. Fortunately, a detachment can often be treated with surgery. Call your doctor immediately.

Inflammation

Inflammation, or swelling, is the body’s natural healing response. Inflammation from cataract surgery can cause blurry vision. It usually goes away after a few weeks with treatment. Occasionally, it can cause elevated eye pressure, swelling of the cornea, or swelling of the retina. If it persists, inflammation can often be treated with eye drops or an injection. It is rare, however, for inflammation to cause a permanent loss of vision.

Posterior capsular opacification

Once your cataract has been removed, it won’t come back. That being said, it is possible for your vision to become worse after surgery from what’s called posterior capsular opacification. Simply stated, the lens capsule shrink-wraps around the IOL. As the capsule contracts, it can opacify (scar), causing glare, halos, or blurred vision. Because these symptoms are similar to those of a cataract, this used to be called a “secondary cataract.” However, this is a misnomer as it is not actually a cataract, but rather your body’s natural healing response. It has just healed a little too well. The risk of this happening with a modern IOL is somewhere between 5% and 15%. Considering that not so long ago surgeons told patients to just expect it, this low incidence is remarkable.

Fortunately, posterior capsular opacification can be removed with laser treatment. The procedure is painless and does not take very long. There are very few risks to this laser treatment. The vast majority of people who have it done notice their vision improves within days. As with any surgery, however, there are risks. If you were to require this treatment, ask your surgeon to discuss these risks prior to scheduling the surgery.

Is That It?

I just covered some of the potential complications of cataract surgery.  Read the sample informed consent at the end of  my upcoming book, “So You’ve Got A Cataract?” to learn about other possible risks. Come to grips with the fact that, although rare, occasionally people have complications.

It is important to keep in mind that everything we do in life involves risk. When you cross the street, you know that even if you stay within the crosswalk something could happen. But you usually take that risk and cross the street anyway, because there is some place you need to get to on the other side.

With cataracts, the question you must ask is whether your vision is bothering you enough that you feel it is worth taking those real, but unlikely, risks of cataract surgery. If your cataracts are affecting your daily activities, then coming to terms with these rare complications might be the only way to stop poor eyesight from interfering with your life.

Risks of Cataract Surgery is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

Why You Need an Implant

I often get asked whether it’s necessary to insert an artificial lens inside the eye during cataract surgery. My immediate thought is often, “Well, why wouldn’t you want a new lens in your eye?” I realize, however, that for many people the idea of placing a foreign object inside their eye is loaded with uncertainty, making them ask such questions as: “Are they safe?” “Will the lens move or dislocate?” “Will I feel it?” Indeed, there was a time when these concerns were justified. But that was about 50 years ago.

Today, however, lens technology has advanced so much that a surgeon must have a good reason not to replace the cataract lens with an artificial lens. Without a lens implant, or an intraocular lens, you would become very hyperopic (farsighted) and need very thick glasses or contact lenses to see anything clearly.

Modern IOLs are made primarily of acrylic and silicone. Both materials are clear, able to refract (bend or focus) light rays, and flexible. They’re safe, and you won’t even notice that they’re there.

In other words, with the advanced materials and designs used to manufacture today’s IOLs, there is little reason not to get one.

Your Options

Cataract surgery and coffee have something in common: Ten years ago there were few, if any, options for either one. If you wanted coffee, your options were simply with or without cream, sugar, or both. Similarly, if you had cataracts, you really didn’t have many IOL types to choose from.

Now, however, there is a dizzying array of options available to anyone who saunters up to the barista: “Coffee? Would you like a grande or venti? Cream, low-fat milk, or soy? Vanilla, sugar-free vanilla, caramel, mocha, or flavor-of-the-week?” The same is now also true of IOLs for cataract surgery: “Would you like a spheric or aspheric IOL? Astigmatism correction? How about the ability to see distance, intermediate, or up close?”

Since you can now select among multiple IOL options — a major improvement over just a few years ago — how do you choose? As an eye surgeon who has performed thousands of cataract surgeries, I can tell you it is not an easy decision but a very important one. If you’re planning to wait a little while before having surgery, chances are technology will improve even more over the next few years, increasing your menu of choices by the time you’re ready.

Currently, there are 2 categories of IOLs you can choose from:

• Standard monofocal IOLs – These are traditional implants that have been available for many years. The lenses are called monofocal IOLs because they are single-focus lenses: They’ll give you either good near vision or good distance vision — but not both. If both of your eyes have cataracts, it’s possible to have one corrected for near vision and the other for distance vision, a choice called monovision.
• New, advanced IOLs – These are premium and technologically advanced implants, such as multifocal, accommodating, or toric IOLs. They can provide for near, intermediate, and distance vision, with some being able to treat astigmatism.

The Decision Points

So, which IOL should you choose? It depends. Take the time to research thoroughly and evaluate your options. You’ll want to choose an IOL that is the best for your eyesight, lifestyle, and budget. The following questions can help guide your choice.

Intraocular Lenses is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

At the first postoperative visit, I tell my patients that they no longer need to wear the shield during the day. However, for the week following the procedure, I ask them to continue wearing it whenever they sleep. It’s likely that your surgeon will want you to continue using your eye drops for the next 3 to 4 weeks.

Generally, I like to see my patients again the following week. You should not have any problems during this period. If you have any questions, concerns, pain, or loss of vision, call your surgeon. Even if it’s 3 a.m., call your surgeon. I am available around-the-clock for my patients, and it is never a “bother” for me to answer their questions.

Typically, it takes a month or so for your eye to heal completely.

Depending on the type of IOL you have, you’ll most likely still need to wear glasses some or most of the time. About 4 weeks after surgery, you should return to your optometrist for new glasses or contact lenses because your prescription will have changed.

Wearing sunglasses with ultraviolet protection is a good idea. However, if you have a Bausch & Lomb Crystalens^® IOL, it is mandatory that you wear sunglasses with UV protection whenever you go outdoors.

Activities

I tell my patients that, starting 24 hours after surgery, light aerobic activity is okay, such as riding on a stationary bike or walking on a treadmill. It’s also okay to wash your hair and face or to shower. Try to avoid lifting heavy items (those over 20 pounds) or engaging in high-impact aerobic activities, swimming, or gardening. Don’t submerge your eye under water, but you can have water run over your eyes when they’re closed. It’s okay to wear makeup, but avoid eyeliner and mascara. Drive a car only if your vision is better than it was before surgery and if you met the legal requirements for driving prior to surgery.

 Most people can return to their normal activities 2 to 4 weeks after surgery.

Why You Might Still Need Glasses

Many people mistakenly think after cataract surgery they will no longer need glasses or contact lenses to see well. Unfortunately, this is not true for many people. Nearsightedness, farsightedness, and astigmatism are usually caused by irregularities of the cornea. During “standard” cataract surgery (the type covered by Medicare and most insurances) nothing is done to correct irregularities of the cornea. Only the clouded lens is replaced. This means most people still need to wear glasses or a contact lens for either near and/or distance vision and astigmatism. However, depending upon the type of IOL you chose, it’s possible to get by with needing glasses only on occasion. I’ll discuss IOL options in the next post.

The Days After Cataract Surgery is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

Get a ride to the surgical center because you will not be able to drive home after surgery; you could be very woozy from any sedatives that may be given to you. See your ride to the center as an opportunity to reflect on how your surroundings look. Very soon, your world is going to be clearer, brighter, and more vibrant!

At the Surgery Center

When you arrive at the surgery center, chances are there will be some additional paperwork to fill out. After you finish this, someone will take you into a pre-op area, where you may need to change out of your clothing and into a patient gown.

Normally, staff will ask you multiple times which eye is undergoing cataract surgery. You may be thinking, “Don’t they know? Maybe I’m at the wrong place.” There’s no need for worry. Surgical staff  are often instructed to check and re-check to ensure they are operating on the correct person and the correct eye. At some point before surgery actually begins, your surgeon might even put a pen mark on your forehead above the eye. This is for your protection and serves as a reminder to everyone which eye is to be operated on. After surgery, you can remove this mark with an alcohol swab or let it disappear on its own after a few days.

Either in the pre-op area or the operating room, you’ll have an intravenous (IV) line placed in your arm.  You’ll also have drops placed in your eye multiple times. The drops dilate your pupil, making it easier for the surgeon to get a clear view inside your eye. It may take 20 to 60 minutes for your eye to dilate enough for surgery. Be patient. The larger your pupil, the better your surgeon’s view into the eye.

Once in the operating room, you’ll most likely be there for 45 minutes to an hour. About half of this time will be spent cleaning the area around your eye and placing a drape over your upper body. This protects your eye from any bacteria that could cause an infection.

A blood pressure cuff will be placed on one of your arms. Don’t be alarmed. It is routine to monitor blood pressure during surgery. The cuff will periodically inflate and squeeze your arm. Just try to relax and ignore it. It will deflate soon.

You’ll most likely be given a sedative through the IV to relax and bring you into a state called conscious sedation. This is not like general anesthesia, where you’re unconscious. Instead you’re brought into a sleepy, relaxed state.

I find that playing music during the procedure further relaxes patients. If you have a particular type of music you would like to play during the surgery, let your surgeon know. I offer my patients the opportunity to choose from more than 9,000 songs on my iPod, or I let them bring in their own CD or digital music player.

One of the effects of the sedative is temporary amnesia, so don’t be surprised if you don’t remember what happens next.

To numb the eye, your surgeon will give you either an injection of numbing medication or topical anesthetic. Traditionally, numbing medication is injected next to and behind the eye. This requires using a needle, which could potentially puncture the eye and lead to a loss of vision. For this reason, I prefer to use a topical anesthetic, which does not require an injection. Topical anesthetic is a liquid or gel applied to the surface of the eye prior to surgery.

There are multiple benefits of topical anesthetic — the main one is avoiding the risks associated with using a needle next to the eye. (Recall what your mother told you about sharp objects and the eye. The same motherly wisdom applies here.) Also, an injection often makes a patient’s vision blurry for several hours after surgery. With topical anesthetic, you’ll be able to enjoy your improved vision shortly after surgery.

While you’re still in a relaxed, sleepy state, your surgeon will begin the procedure. Typically two things will happen next: You’ll hear buzzing and bells coming from the equipment and possibly feel some cool fluid on the side of your face. The fluid helps keep the ultrasound cool and is nothing to worry about.

While your surgeon is removing your cataract and replacing it with an intraocular lens (IOL), you might feel pressure in your eye. However, you should not feel any pain during the surgery. If you do, let the surgeon know so that you can be given more anesthetic.

When the procedure is over, your surgeon will place a protective eye shield over your eye. You’ll need to wear the shield continuously for the next 24 hours and then only when sleeping or napping for the week after surgery.

 Staff will then transfer you to a recovery area for an hour or so where you’ll recover from the IV sedation. The entire process — from the time you arrive at the surgery center to the time you leave typically takes 2 to 4 hours.

After the Procedure

The afternoon and evening following surgery, it’s normal to feel as if there is something in your eye, such as a grain of sand. This usually lasts for only a few hours, but can last up to a few days. Using the eye drops prescribed to you before the surgery can relieve the discomfort. Although it seems obvious, I’ve learned the hard way never to assume anything, so I’m going to say it: Don’t rub your eye!

You may be prescribed more eye drops. These will help prevent infection and treat the inflammation caused by surgery.

You should not experience significant pain. If you do, call your surgeon. If needed, you may take acetaminophen for minor discomfort. Try to avoid aspirin or non-steroidal anti-inflammatory drugs (NSAIDs), such as Advil^® and Aleve^®, as they increase the chance of bleeding.

Your surgeon will likely tell you to take it easy for the rest of the day. Watching TV is generally what I recommend. This is a great time to get the family to wait on you. Let someone else make dinner for a change.

You may still be groggy from the sedative, so don’t try to operate any machinery (such as a car). It’s okay to read, but your vision may seem “jiggly.” Because the lens capsule has not yet contracted around the IOL, there may be a slight jiggle of the lens with each eye movement. This is most noticeable when reading and will improve over the next few weeks.

The evening of surgery, your vision may or may not be already restored. However, even by that evening, many people notice that they can see things more clearly through the holes of the eye shield.

What to Expect the Day of Surgery is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

Every surgeon, including myself, has a written list of instructions for patients to follow before surgery. Your list will most likely include many of the items below.

The Weeks Before Surgery

• Get pre-op medical clearance – Your internist or family physician will need to clear you for surgery. You may need a blood test, EKG, and physical exam. These assessments typically must be completed at least one week — but not more than one month — prior to surgery. Because modern cataract surgery is usually performed with local anesthetic and light intravenous (IV) sedation, medical clearance is usually granted to most patients, unless a patient has significant heart or lung disease.
• Schedule a pre-operative (pre-op) assessment – A week or so before the surgery, you’ll have a pre-op visit with your surgeon. The purpose of this visit is to take your eye measurements in order to determine the proper strength of the artificial IOL implant. Plan on spending some time reviewing and completing paperwork. It seems that every year the government adds more paperwork requirements, so be prepared. The pre-op visit is also a perfect opportunity to discuss any of your concerns. Don’t be afraid to ask questions.
• Stop wearing contact lenses – Are you a contact lens wearer? If so, at least 3 weeks before your pre-op visit, stop wearing the contact lens in the eye that will be undergoing surgery. Why? Because contact lenses can distort the surface of your cornea and affect measurements that your surgeon needs to take for selecting the most optimal IOL for your surgery.
• Start using artificial tears or dietary supplements – Your surgeon may recommend that you start using artificial tears at least 4 times a day prior to the pre-op visit. Artificial tears help to prepare the eye for the pre-op measurements. Other things that can help prepare the eye include taking omega-3 fatty acid supplements, such as fish oil and flaxseed oil by mouth.
• Start using eye drops – During your pre-op visit, you will be given prescriptions and instructions for eye drops that you’ll need to start using prior to surgery. These drops provide protection from both infection and inflammation.
• Be ready for more paperwork – Thanks to the good intentions of a new federal government rule, you may need to go to the surgical center to fill out some paperwork at least one day before your surgery.

The Night Before Surgery

You may be instructed not to eat or drink anything after midnight before your surgery. Normally, you’re allowed very small sips of water for taking your medications the morning of your procedure.

Preparing for Cataract Surgery is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

Modern Cataract Surgery

So, let’s talk about modern cataract surgery. It safely and painlessly treats cataracts and is usually very successful — more than 90% of patients experience improved vision after their surgery. It’s normally done as an outpatient procedure that uses ultrasound technology. Rarely does it require general anesthesia. Instead, surgeons typically use a local anesthetic to numb the eye and a sedative to help the patient relax.

During modern cataract surgery, the surgeon makes a micro-incision at the edge of the cornea. These incisions used to be quite large (at least by today’s standards) and required many stitches. In fact, years ago people had to stay in bed for weeks with sandbags on their eyes in order to keep these large incisions from opening up. Today, however, the incision is really tiny, often less than 3 millimeters wide, which is about the size of an average pen tip. The incision is so small that stitches are often unnecessary.

The surgeon typically removes the cloudy lens through this tiny incision with an utlrasound-based technique called phacoemulsification.

The process begins by injecting a clear gel, called a viscoelastic agent, into the eye. This gel protects the cornea from the ultrasound energy and keeps your eye pressurized during surgery.

For many surgeons, the most challenging part of cataract surgery comes next: creating a small round opening in the bag-like lens capsule, a membrane that surrounds the cataract and holds it in place. As membranes go, this one is pretty thin: somewhere between 5 and 15 millionths of a meter thick (about the size of a tiny speck of dust). Hard to imagine? Well, it’s hard to see. Not only is the capsule at the limits of what the human eye can make out, it’s also transparent!

Amazingly, most experienced cataract surgeons have no problems creating an opening in this delicate, transparent membrane. Occasionally, however, the capsule does tear. If this happens, all is not lost. Surgery may take longer to complete, but good results are still possible.

The surgeon will then insert a very tiny ultrasound probe through the opening in the capsule. The probe emits ultrasound waves that break the cataract into tiny pieces. The pieces are suctioned out (aspirated) through the small opening, leaving behind an empty lens capsule.

Next follows the insertion of the artificial lens implant — known as an intraocular lens (IOL) — into the empty capsule. The surgeon adds more protective gel to the eye and then folds and slips the implant through the incision. The IOL unfolds in the capsule to fill the space where the old lens (the cataract) used to be. After the implant is in place, the surgeon removes the protective gel and, if necessary, closes the incision with a stitch.

The entire procedure often takes less than half an hour.

A word about no-stitch surgery

Single stitch surgery

Sutureless surgery

Many cataract surgeons have started advertising “suture-less” or “no-stitch” cataract surgery. This obviously implies that surgery with stitches is somehow inferior to surgery without stitches. It is important to note that stitches can be a good idea as they may reduce the risk of infection (something we’ll discuss in more detail in the chapter covering cataract surgery risks). Don’t be drawn in by glitzy advertisements. The most important thing is to get the best possible surgery. Not everyone is a good candidate for suture-less cataract surgery.

What You Need to Know About Cataract Surgery is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

How the Eye Works

Let’s start with a review of how the eye works. It’s helpful to think of the eye as a video camera hooked up to a TV. A video camera has a lens to focus an image, film to capture or record the image, and a cable to transmit the image to a TV.

Your eye works in a similar way. It has two surfaces that focus an image: the cornea and the natural lens of the eye. The cornea, which is a clear, curved surface, bends light passing through the eye; the lens fine-tunes the light before passing it onto the retina, located at the back of the eye. The retina records the light, much like film in a camera, and then converts it into an electrical signal. From here, the signal is transmitted to your brain through the optic nerve, which is similar to the cable that connects a video camera to a TV. The brain then processes the signal to let you see the image.

What Is a Cataract?

Although the cornea is responsible for most of the focusing (refractive) power of the eye, the lens is critical for crisp, clear vision. Without it, we would need glasses as thick as the bottom of a Coke^® bottle to see the world clearly.

For most of our lives, the natural lens is flexible and clear — allowing us to focus on objects both far and near. Around age 45, however, the lens becomes less flexible and loses its ability to change focus. It becomes difficult to see objects up close. In order to focus, you begin holding reading materials further away. This condition is called presbyopia, or “aging eyes.” Although annoying, reading glasses or bifocals often help.

As time passes, the lens continues to lose its flexibility. Eventually it hardens and becomes cloudy and discolored. Just as a piece of plexiglass exposed to sunlight will slowly turn grey, then yellow, then brown, a lens loses clarity and becomes discolored. A cloudy, discolored lens interferes with light passing through it, causing blurry vision. When the clouding blocks enough light and impairs vision to the point where glasses won’t even help, the lens is generally considered to have become a cataract.

Can you avoid getting one?

I often tell my patients that I hope to be fortunate enough to get cataracts. Why? Because cataracts are a natural part of the aging process. As many as 70% of those over the age of 75 have a cataract. In other words, if I get a cataract, it means that I’ve lived a long life.

So, just because we are all destined to get them, can we postpone them? As a matter of fact, you might already be doing the one thing that can possibly delay the development of a cataract: wearing sunglasses with ultraviolet (UV) protection when outdoors. If you are not doing this, it is never too late to start.

You see, ultraviolet  light from sun exposure affects the proteins in our bodies and causes oxidative damage or free radical damage (from high-energy particles that damage almost anything they come into contact with). When ultraviolet light passes through the eye’s natural lens, some of it is absorbed by the eye, resulting in free radical damage to the lens. Over time, this damage builds up and the lens becomes cloudy. The best way to postpone damage from UV light, and perhaps delay forming a cataract, is to wear sunglasses that block it.

Smoking and excessive alchohol consumption are among other causes of free radical damage.

Since free radicals produce oxidative damage, you may think that antioxidants should have a protective effect. This may very well be the case. However, to date no well-designed clinical trial has demonstrated that antioxidant therapy can delay the onset of cataracts. That being said, I still recommend over-the-counter antioxidant multivitamins to my patients. There is very little risk to taking them and the possible benefit is compelling. However, I also warn my patients against paying large sums of money to purchase the multivitamin “cataract cure,” which is often advertised in magazines. There is absolutely no evidence that these “special” vitamins do anything other than lighten your wallet.

Is age the only thing that causes cataracts?

Though aging is the most common cause of cataracts, a host of other things can cause cataracts. I already mentioned sun exposure. Cataracts may also be congenital (present at birth), metabolic (caused by too much or too little of one of the chemicals produced in your body), toxic (from medications or other external chemicals), nutritional (from a lack of vitamins or minerals), postsurgical (as a result of prior eye surgery), traumatic (from a blunt or sharp injury), or secondary (related to other diseases of the body, radiation, or any other cause that is not age-related). In short, there are a lot of things that can damage the eye and cause the formation of a cataract.

To summarize, if you are not getting older, are never exposed to the sun or any other source of oxidative damage, have no eye disease, and enjoy perfect nutrition, then you might be able to avoid cataracts. For the rest of us who are mere mortals, it’s a foregone conclusion that life leads to cataracts.

Cataract Symptoms

Often cataracts develop slowly. People typically don’t realize their vision has deteriorated until the cataracts interfere with something they need or like to do. Some people start to have trouble reading or completing crossword puzzles. Others begin to have difficulty with such things as driving, watching TV, or playing golf.

Because the change in vision is so gradual, many people are convinced it is the world, and not their vision, that has changed. I often hear patients say, “Those charts in the DMV are smaller than the last time I got my license,” or “The newspapers must be trying to save money on ink, because it’s not as dark as it used to be.” When I hear these things, I pretty much know I’m about to diagnose a cataract.

Typical symptoms of cataracts include:

• Blurry vision
• Cloudy vision
• Change in vibrancy of colors or yellowing of colors
• Glare or halos around lights at night

Some people say their vision with cataracts is like looking through a dirty windshield.

When to Consider Treatment

When cataracts interfere with your normal activities, such as reading a newspaper or driving a car, and your vision cannot be corrected with glasses or contact lenses, it’s time to consider treatment, which means cataract surgery. Fortunately, many recent advances have made cataract surgery one of the most effective and safe surgical procedures.

Unlike years ago, you no longer need to wait until the cataract is “ripe,” or so advanced that your vision is seriously impaired. If cataracts affect your daily activities, and your eye surgeon feels you have a significant cataract, then most insurance companies, including Medicare, will cover the cost of the procedure.

Myths about Cataract Treatment

There is an incredible amount of misinformation about the treatment of cataracts. The most common myths are that you can make cataracts disappear by eating certain foods, taking various supplements, or using eye drops that make them disappear.

The truth is, cataracts are a normal part of aging. As with other aging changes, there is no proven way to reverse the hands of time. Let me be clear: There are no drops, vitamins, herbs, or beyond-the-border remedies that will make your cataract disappear.

You may be able to relieve some of the symptoms of an early cataract with glasses or contact lenses. But eventually, as the cataract progresses, even these will fail to help your vision.

If a clouding eye lens interferes with your everyday activities, then cataract surgery may be worth considering. The only other option is to limit your activities.

About Cataracts is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

1) As you can see, the look and feel of the blog has changed. It is my hope that you will find this new look both more appealing and functional. Specifically, we have added the following benefits:

• Improved contrast
• Bigger fonts  for added readability
• Cleaner  unobtrusive interfaces
• Better compatibility with the most popular internet browsers
• Responsive Design – mobile and tablet friendly
• Search within post functionality
• Archived Posts Section
• Sharing function (share on your social networks)

2) I’ve been busy working on a project that is finally ready to go live: the publication of a patient-centered book about cataract surgery. This book has been written using terminology that is both friendly (not too clinical) and informative. It will be available through Amazon.com later this year in both a Kindle format as well as paperback. It will also be priced well below the other available cataract surgery books as my goal is to get this information out there, not to make $$ selling books. As a member of this blog, you will have the opportunity to read the book before it is available on Amazon.com – I will be rolling out the book content as posts over the next few months.

I hope you will enjoy the new site appearance as well as find the content of my book about cataract surgery informative.

Cataract Awareness Month 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

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 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

Before we begin the discussion about cataracts and cataract surgery, I’d like to first introduce you to the way the eye works.  I find it most helpful to think of the eye as a video camera hooked up to a TV monitor.  A video camera has a lens to focus the light, film (or electronic sensors) to capture the image, and a cable to transmit the image to the monitor or recording device.  In a similar manner, the eye has two surfaces that focus light: the cornea, or clear surface of the eye; and the lens which sits behind the iris, or pupil.  The cornea and lens, together, focus light onto the retina which is similar to the film or electronic sensors in a camera.  The retina then converts light into a signal that is transmitted to our brains through the optic nerve, which is similar to the cable that connects a video camera to the TV or VCR.

how-the-eye-works (iTunes)

02-how-the-eye-works (MP3)

How the Eye Works is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

It has been awhile since I have had a chance to update my blog. However, I have good reason: I have been working on an audio project for my patients with cataracts. I will now share this project online through my blog (and eventually my website).

As many people with significant cataracts have, by definition, poor vision it seemed odd to me that we were handing our patients reams of paperwork describing the surgery and instructing them in writing what to do in preparation for the surgery as well as what to expect from the surgery. Clearly, pun intended, this method was inadequate for those whose vision was too limited to read even large print.

With this in mind, I’ve worked on a series of presentations to address my patients’ information needs prior to surgery without the use of written text. Please note that this presentation was created with my patients in mind. If you are a patient of mine I hope you will find this informative and you are encouraged to share it with others. However, it should be noted that these presentations are based on my professional opinion and the instructions are catered to the way I do surgery. Other cataract surgeons will have their own methods and preferences.

OK, then. Let’s get started…

The following link is just a test link to an audio version of the above transcript. Below the audio link you will find a Table of Contents to the audio segments that will be posted over the next month or so. I invite feedback so that I may improve this series over time.

01-introduction-to-the-cataract-audio-series

Cataract Surgery Essentials:

1. Introduction to the Cataract Surgery Essentials Audio Series

2. How the Eye Works

3. What is a Cataract?

4. What are the Symptoms of a Cataract?

5. What Treatments are available for Cataracts?

6. Why your friend did not have her Cataract removed with a Laser

7. How is a Cataract removed from the Eye?

8. Risks of Surgery

9. Do I have to have a lens put in the eye?

10. Will I Need Glasses after Cataract Surgery?

11. New Options in Cataract Surgery

12. Preparation for surgery

13. What You Should Experience the Day of Surgery

14. Care of the Eye During the First Month After Surgery

15. Can my Cataract Come Back?

16. Conclusion

Supplementary Material:

How Other Eye Diseases may Affect the Outcome of Cataract Surgery

17. Diabetes and Cataract Surgery

18. Glaucoma and Cataract Surgery

19. Macular Degeneration and Cataract Surgery

20. Prostate Medications and Cataract Surgery

For Patients Who are Still Choosing their Cataract Surgeon

21. How to Choose a Cataract Surgeon

Cataract Surgery Informed Consent

22. Cataract Surgery – What You Must Know

23. Cataract Surgery – Informed Consent

Cataract Surgery Essentials Audio Series – Introduction is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

Suddenly that 42 cent stamp required to send a letter to Washington DC doesn’t seem so bad.  Hey, you can even email your representatives now for free.  You’re online already, what’s stopping you?

It Slices. It Dices. It Even Treats Glaucoma… is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

If the manufacturer can get the cost of this technology below $10 per use then cataract surgery can be both sexy and safe.

© 2009 David Richardson, MD

How Ink Jet Printers and Shellfish Could Reduce Infection After Cataract Surgery is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

The final post in my three part “Expectation” series:

© 2009 David Richardson, MD

What to Expect After Cataract Surgery is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

© 2009 David Richardson, MD

What to Expect Prior to Cataract Surgery is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

© 2009 David Richardson, MD

Why a Diabetic’s Cataract Surgery may not be a “Piece of Cake” is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

© 2009 David Richardson, MD

So then, How is Cataract Surgery done? (post 9 of 9) is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

© 2009 David Richardson, MD

So then, How is Cataract Surgery done? (post 8 of 9) is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

© 2009 David Richardson, MD

So then, How is Cataract Surgery done? (post 7 of 9) is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

Hydrodissection and hydrodelineation were then completed with a visible fluid wave and good nuclear mobility noted.

‘Hydrodissection’ is a technique used to free the cataract from its attachments to the capsular bag.  Without freeing the lens, all surgical forces that act on the lens would be translated through the capsule to the zonules (the delicate cables that hold the lens in place).  If these zonules are damaged during surgery then there will not be sufficient support to place a clear new lens in the eye.

During hydrodissection fluid is injected between the capsule and lens.  This fluid travels around the lens creating a space between it and the capsule.  If this step is not completed the remaining steps of catarct removal are more difficult and dangerous to perform.

Hydrodelineation is very similar to hydrodissetion except the layers separated are those of the lens nucleus (hard, central part of the cataract) and epi-nucleus (softer outer part of the cataract).  This step does not have to be performed unless the surgeon uses an advanced technique call ‘phaco-chop’ (more on that next).

Phacoemulsification of the nucleus was then completed using a horizontal chop phacoemulsification technique requiring 0.6 minutes of phacoemulsification at 24% power.

Phacoemulsification is the ultrasound technology currently used by the majority of US surgeons.  Essentially, a hollow tip vibrates at an extremely high frequency (faster than the speed of sound) breaking up the cataract into small pieces.  These fragments are then vacuumed through the central opening of the tip and out of the eye.   Other methods of breaking up the cataract do exist including laser and pulses of water.  However, neither of these has really caught on in the US as the ultrasound works so well for most types of cataracts.

There is, however, a downside to ultrasound.  If the tip of the ultrasound handpiece touches the capsule, the bag will tear allowing vitreous (the gel behind the capsular bag) to come forward.  This is the main thing all cataract surgeons try to avoid as it often significantly complicates the surgery.  Additionally, as discussed earlier, the ultrasound energy is not only absorbed by the cataract, but also by the cornea resulting in swelling.  An advanced technique such as phaco-chop can reduce the total amount of ultrasound time used (compared to older and more basic techniques such as ‘divide and conquer’) and thus limit the amount of corneal edema.

The remaining cortex was then removed using bimanual automated irrigation and aspiration.

The cortex is that part of the catarct still adherent to the capsular bag.  It has a stringy, tenacious character to it and is usually still present even with hydrodissection.  It must be removed or the bag will not be optically clear resulting in blurred vision and inflammation.  However, the capsule is very delicate an tears with any significant traction on it.  To get an idea of what this is like lay out some cheap plastic wrap (the stuff you use to cover leftovers before you put them in the refrigerator) and stick some painter’s tape on it.  Now try to remove the tape without stretching or tearing the plastic wrap.

As you can imagine, this is another step in cataract surgery which has a high risk of  ‘capsular rupture,’ resulting in ‘vitreous loss,’ or tearing of the capsule allowing the vitreous gel to come forward.

In order to decrease this risk I use a technique called ‘bi-manual’ irrigation and aspiration.  This requires the simultaneous use of two instruments (rather than one) allowing me to obtain better control in the eye.  Not every surgeon, however, uses the bi-manual technique as it requires (1) expensive handpieces that many surgery centers will not pay for (I own my bi-manual handpieces); (2) phacoemulsification equipment with excellent fluidics (a topic that would require its own post); (3) is technically more challenging to perform; (4) takes longer to complete than with ‘co-axial’ or one-handed irrigation and aspiration.

Next post: placing the new lens into the eye

© 2009 David Richardson, MD

So then, How is Cataract Surgery done? (post 6 of 9) is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

The microscope was moved back into position…

Cataract surgery is microsurgery.  Without a microscope it would not be possible to complete the steps to follow.

…and a paracentesis was created at the one and five o’clock positions…

A ‘paracentesis’ is a small incision (usually 1.0mm wide)  in the cornea that allows the surgeon to place instruments or inject fluids into the eye (more on that next).  In general when discussing orientation durging surgery the eye is compared to a clockface with 12:00 the uppermost portion of the cornea (near the upper eyelid or brow) and 6:00 being the lowermost portion (near the lower eyelid or feet).

…through which 0.14 cc of Epi-Shugarcaine was injected into the anterior chamber.

‘Epi-Shugarcaine’ is a sterile solution of anesthetic and dilating medications developed by the late Dr. Joel Shugar.  Not all surgeons use this solution.  However, it can result in better anesthsia and dilation.  I do not use it in all cataract surgeries but if a patient is on Flomax or has a small pupil I will instill Epi-Shugarcaine.

The ‘anterior chamber’ is a clinical term for the space between the iris (the colored part of the eye) and the posterior (backside of the) cornea (the clear front part of the eye on which a contact lens sits).

Viscoat was then injected into the anterior chamber firming up the globe.

Viscoat and Provisc are just two of many brands of viscoelastic.  A ‘viscoelastic’ material, aka ‘viscosurgical device’ is a gel-like material that is placed in the eye in order to (1) create and maintain space to work-in, (2) protect the corneal endothelium.  The corneal endothelium is made up of cells that pump fluid out of the cornea (keeping it clear).  When these cells absorb the phacoemulsification energy (decribed in a later post) it ‘shocks’ them resulting in ‘corneal edema’ or a thickening of the cornea.  Although usually self-limited, if this edema does not go away the vision would be blurred and a corneal transplant might be necessary.  Thus, you can see why we would want to use something to protect the corneal endothelium.

A clear cornea temporal incision was then created with a metal keratome…

In order to remove the cataract and later place a new lens in the eye an incision must be made in the cornea.  Currently there is no way around this.  Thus, cataract surgery requires an incision.  That being said, the incision is usually very small – on the range of 2.2-3.5mm wide.

This incision can either be made with a very sharp metal or diamond blade.  Either one would make a standard razor blade appear dull by comparison.  Because these blades must be manufactured to very exacting specifications they are quite expensive.  A disposible metal blade runs anywhere from $35-70 per knife.  Diamond blades, on the other hand, can be used hundreds of times before needing to be repaired or replaced.  However, they are exceedingly expensive ($1,100-4,000) and are easily dulled or damaged.

…following which a continuous curvilinear capsulorrhexis was created using a bent needle cystatome on a Provisc syringe followed by capsulorrhexis forceps.

This is considered by many surgeons to be the most challenging element of the surgery.  In order to get to the cataract an opening must first be made in the ‘capsule’ a delicate film-like material that holds the lens in place.  This material is very thin (measured in microns, or millionths of a meter) and transparent.  It is held in place by cables called ‘zonules’ that stretch it out over the surface of the lens.

Ideally, the surgeon wants to make a circular, or ‘curvilinear’ opening in the capsule.  However, as you can imagine, tearing an opening in a thin, clear material on stretch is not a task for the faint of heart (considering that if the tear extends beyond the edge of the lens the rest of the cataract surgery becomes challenging, at best).  There are two main ways of doing this: with a bent needle cystatome or with forceps.  I use both.  My father is a mechanic and taught me to use the best tool for the task at hand.  As such, I find that the cystatome works best to start the capsulorrhexis and the forceps give me the most control over the shape of the opening.

Next post: getting to the actual cataract removal (finally)

© 2009 David Richardson, MD

So then, How is Cataract Surgery done? (post 5 of 9) is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

The patient was transported to the operating room in a supine position on a Stryker gurney.

This just means that the person about to have cataract surgery is lying face-up.

Once in the operating room, Tetracaine 0.5% drops were placed in the left eye following which Xylocaine 2% jelly was placed in the fornices on the left.

There are many ways to anesthetize the eye. Some doctors give an injection behind or beside the eye. However, this has risks associated with it which include perforating the eye (rare, but more likely in someone who is very nearsighted), bleeding, damage to the optic nerve, etc. For this reason, I prefer a ‘topical’ anesthetic. Anesthetic drops are placed on the eye for immediate anesthesia following which a gel is placed between the eyelids and eye in order to obtain a longer-lasting effect. The drops and gel do sting for a few seconds after they are placed in the eye, but there should not be any pain during the cataract surgery.

The microscope was moved into position and the patient was asked to look at the microscope light which she was able to do without difficulty.

Under topical anesthetic, movement of the eye is possible (indeed, preferred). This can be used to my advantage as a surgeon to direct the patient to look in a certain direction. However, if the patient cannot tolerate the bright microscope light then it might be best to give a retrobulbar or peribulbar injection of anesthetic (mentioned above). The benefits of giving an injection are that the anesthetic lasts longer and the eye is ‘frozen’ (meaning it cannot move during the surgery).

The microscope was moved out of position and the patient was prepped and draped in the standard sterile fashion using a povidone-iodine solution over the left face and lashes and a Betadine 5% ophthalmic solution in the fornices followed by a sterile saline rinse.

Prior to surgery the area around the eye must be cleaned, or ‘prepped’ using a Betadine solution to kill any bacteria on the skin (this helps to prevent infection). A dilute Betadine solution is also used to kill bacteria on the surface of the eye after which it is rinsed out using a salt solution or sterile water.

Steri-Strips were used to drape the lashes out of the operative field, following which Tegaderm was placed over the left face through which a lid speculum was placed.

One of the most commonly asked questions I hear is ‘How will I keep my eyes open during surgery?’ This is the answer to that. A sticky drape acts like scotch tape to keep the lashes away from the eye following which a device that looks like a bent paperclip is used to keep the eyelids open.

Now we are almost ready for surgery. In the next post we will actually get down to the business of surgery.

© 2009 David Richardson, MD

So then, how is Cataract Surgery done? (post 4 of 9) is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

Preoperatively, Nevanac, Vigamox, Omnipred 1% drops were prescribed or given to the patient to use in the left eye four times a day beginning four days prior to surgery.

Before cataract surgery many surgeons will have the patient start eyedrops to prepare the eye for surgery.  These drops perform the following functions:

Anti-inflammotory drops generally are split into two categories: (1) steroids or (2) Non-Steroidal Anti-Inflammatory Drugs aka NSAIDs. There is some evidence that beginning drops a few days prior to surgery can reduce the inflammation associated with surgery. The results of these studies are suggestive but not conclusive so not all surgeons begin anti-inflammatory drops prior to surgery.

Infection is one of the few complications of surgery that can lead to loss of vision or blindness. Therefore it is worth taking every precaution to avoid it. By starting antibiotics prior to surgery, the bacteria living on the surface of the eye and eyelashes can be reduced. Additionally, the antibiotic builds up in the corneal tissue resulting in a depot of antibiotic that is slowly released into the eye after surgery.

The brand of the drops each surgeon uses may differ, but most surgeons order at least one drop from each of the above categories.

On the morning of surgery, the following drops were placed in the patient’s left eye every 10-15 minutes x4 beginning approximately one hour prior to surgery: Mydriacyl 1%, Phenylephrine 2.5%, Vigamox, Nevanac.

Mydriacyl and Phenylephrine are dilating drops. These are used to enlarge the pupil so that your surgeon can get good visualization of the cataract prior to removal.  Again, the brand of dilating drops and method of instillation may differ but dilation is necessary for safe and effective surgery

Next post we will be looking at the following section of the operative report:

The patient was transported to the operating room in a supine position on a Stryker gurney. Once in the operating room, Tetracaine 0.5% drops were placed in the left eye following which Xylocaine 2% jelly was placed in the fornices on the left. The microscope was moved into position and the patient was asked to look at the microscope light which she was able to do without difficulty. The microscope was moved out of position and the patient was prepped and draped in the standard sterile fashion using a povidone-iodine solution over the left face and lashes and a Betadine 5% ophthalmic solution in the fornices followed by a sterile saline rinse. Steri-Strips were used to drape the lashes out of the operative field, following which Tegaderm was placed over the left face through which a lid speculum was placed.

© 2009 David Richardson, MD

So then, How is Cataract Surgery done? (post 3 of 9) is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

Procedure in detail:

Preoperatively, Nevanac, Vigamox, Omnipred 1% drops were prescribed or given to the patient to use in the left eye four times a day beginning four days prior to surgery. On the morning of surgery, the following drops were placed in the patient’s left eye every 10-15 minutes x4 beginning approximately one hour prior to surgery: Mydriacyl 1%, Phenylephrine 2.5%, Vigamox, Nevanac.

The patient was transported to the operating room in a supine position on a Stryker gurney. Once in the operating room, Tetracaine 0.5% drops were placed in the left eye following which Xylocaine 2% jelly was placed in the fornices on the left. The microscope was moved into position and the patient was asked to look at the microscope light which she was able to do without difficulty. The microscope was moved out of position and the patient was prepped and draped in the standard sterile fashion using a povidone-iodine solution over the left face and lashes and a Betadine 5% ophthalmic solution in the fornices followed by a sterile saline rinse. Steri-Strips were used to drape the lashes out of the operative field, following which Tegaderm was placed over the left face through which a lid speculum was placed.

The microscope was moved back into position and a paracentesis was created at the one and five o’clock positions through which 0.3 cc of Epi-Shugarcaine was injected into the anterior chamber. Viscoat was then injected into the anterior chamber firming up the globe.  A clear cornea temporal incision was then created with a metal keratome following which a continuous curvilinear capsulorrhexis was created using a bent needle cystatome on a Provisc syringe followed by capsulorrhexis forceps. Hydrodissection and hydrodelineation were then completed with a visible fluid wave and good nuclear mobility noted.  Phacoemulsification of the nucleus was then completed using a horizontal chop phacoemulsification technique requiring 0.7 minutes of phacoemulsification at 19% power. The remaining cortex was then removed using bimanual automated irrigation and aspiration. Provisc was then injected into the anterior chamber and capsular bag following which the lens was inspected for proper power and good integrity. The lens was placed in the insertion device which was used to insert the lens through the temporal incision, guiding the leading haptic into the capsular bag. The trailing haptic was positioned in the capsular bag using a lens manipulator. The remaining viscoelastic was then removed using automated irrigation and aspiration, taking care that no residual viscoelastic was trapped behind the optic. A single 10-0 Vicryl suture was then placed in the temporal corneal incision and the knot was buried in the corneal stroma.

The incisions were then hydrated and the anterior chamber was formed to physiologic pressure (confirmed by intraoperative tonometry) at which pressure the incisions were checked and felt to be watertight and of good integrity. The lid speculum and drapes were then removed followed by placement of Vigamox drops in the fornices on the left. A shield was then placed over the left eye which the patient was instructed to keep on the eye except during placement of Nevanac, Vigamox, Omnipred 1% drops which she is to use including the day of surgery. She was instructed to avoid any heavy exertion and is to follow up in my office the day after surgery. She tolerated the procedure well.

© 2009 David Richardson, MD

So then, How is Cataract Surgery done? (post 2 of 9) is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

There are plenty of explanations about how surgery is performed (and even a few descriptive videos or animations available online). However, these are all simplifications of the actual procedure. For anyone interested in more detail there are very few resources available to the general public. Fortunately, there is a detailed description of every cataract surgery performed in the USA. This description, known as the operative report (or ‘op report’) is generated by the surgeon after each case and becomes part of the medical record.

Unfortunately for those interested in reviewing these detailed reports, they are not available to the public as they are ‘protected health information’ (or PHI) that cannot be released except to a very limited number of approved entities (such as the insurance company) and individuals (such as the actual patient and his or her health care providers). Fortunately for the readers of my blog, I have created a draft of my standard operative report without any of the usual identifying information. Over the next two weeks I will publish this report as well as a line-by-line explanation of the terminology used in the report.

I believe this will be the only such example of an actual operative report template available online. Even if there are other PHI-stripped copies floating around on the net, the explanations I will provide over the next few posts are truly an exclusive inside look into the workings of a typical cataract surgery.

Next post: The operative report

© 2009 David Richardson, MD

So then, How is Cataract Surgery done? (post 1 of 9) is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

Well, as much as the demands of modern medicine do limit that amount of time doctors can spend with their patients (and, BTW, this really is not in the doctors control – topic for another post), the dry eye explanation is not a ruse. Dry eye syndrome is something that can often be objectively diagnosed at the slit lamp (aka biomicroscope) in the eye doctor’s office. Following is a description of how an ophthalmologist would typically diagnose dry eye syndrome.

Assess Symptoms
As with most medical disorders, the diagnosis of dry eye syndrome is 80% listening to the patient. Following are the things I listen for:

Tearing

Ocular irritation

Foreign Body Sensation (a sense that something is in the eye)

Red eye

Tired eyes

Flucturating vision with certain activities

First thing in the morning

Later in the day

After extended periods of concentration

With reading

With computer use

With TV use

Blood pressure medications

Diuretics

Hormone replacement therapy

Allergy medications

Examine the Eye
Even with the best listening, the diagnosis must be confirmed by examining the eye. Following are the things I look for:

Test the Tear Film
Sometimes special testing is required to diagnose dry eye syndrome. Following are some common tests for dry eye syndrome:

Not all of the above examination or testing methods are necessary to diagnose dry eye syndrome. However, some combination of the above is used to provide a more objective assessment of the presence or absence of dry eye.

© 2009 David Richardson, MD

How your Eye Doctor can tell if you have Dry Eyes is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

It doesn’t take a long time to choose your surgeon if you know how. The following list of 10 Things You Must Know Before Choosing Your Cataract Surgeon will tell you how. With this list you can decide on an excellent eye surgeon in less time than many people devote to choosing their next car.

1.  Don’t limit your choices to only those doctors in your insurance network.
Despite what your insurance company’s marketing materials may suggest, the main factor in determining who is “in-network” is who is willing to accept that insurance contract. Currently there is no validated method of grading doctors and any insurance company that suggests their network of doctors is the most qualified is disingenuous at best.

2.  Ask those you trust
Good sources of information include your internist, optometrist, and friends who have had cataract surgery. Even better sources include the operating room nurses and staff at your local hospital. They are often in surgery with the eye doctor and know who has the “best hands.” Nurses are by nature very helpful people and will often be happy to answer your question. The challenge will be getting past the hospital’s automated telephone menu and gaining access to a live operating room nurse.

3.  Research your surgeon’s education
Where did your eye surgeon train? You may not know which training programs are the best, but it is easy enough to check their ratings once you know where your surgeon trained. Two objective resources are U.S. News & World Report’s Annual rating of Medical Schoolsand Eye Hospitals

Don’t get too hung up on the ranking order – if your surgeon trained at a top 15 institution he or she received top-notch education.

4.  Research your surgeon’s State Licensure
Your surgeon must be licensed to practice medicine in his or her state. In addition to confirming licensure, many state license websites will also tell you if there is any history of disciplinary or legal action against your surgeon. In California you can look up this information online at http://www.medbd.ca.gov/lookup.html

5.  Confirm that your Doctor is Board Certified
Board certification is a type of “seal of approval” for all doctors. In order to obtain certification an ophthalmologist must successfully pass both a written and oral examination. Additionally, younger ophthalmologists must recertify every ten years – a process that can take up to three years to complete. You can confirm that your surgeon is board certified by checking the website: http://www.abop.org or http://www.abms.org

6.  Visit your surgeon’s Practice Website
Assuming the above background check is favorable you can sometimes obtain useful information from your eye surgeon’s website. Although some sites do provide educational materials, keep in mind that its primary goal is to market the practice. You won’t find anything negative about your doctor there, but it can confirm the positive information you have already obtained and give you some insight into the surgeon’s background and practice philosophy.

7.  Find out what others have experienced.
Are testimonials available online (doctor ranking sites or practice website)? Are testimonials available in your surgeon’s office for your review? Will your surgeon provide you with the name and phone number of someone who had surgery that you can talk to?

Keep in mind that Federal privacy regulations limit the amount of information your surgeon may be able to provide to you regarding other patients who have had surgery. Nevertheless, it shouldn’t be too burdensome for your surgeon to come up with a live person who would be willing to discuss the cataract surgery experience with you.

8.  Find out how many cataract surgeries your doctor has performed.
There is a reason they call it the “practice of medicine.” Just like a sports pro, a surgeon’s abilities improve with practice and experience. Every surgery differs in its “threshold” number (the number of surgeries required for the average surgeon to become proficient). For cataract surgery I think this number is probably around 500.

If you are uncomfortable asking directly then bring someone with you to the appointment to ask for you. This is a very important question. These are your eyes. You only have two. Get over your hesitation. Just ask.

9.  Meet the Surgeon.
The above research can give you an idea if your surgeon is qualified to perform your eye surgery. However, you cannot know if this is the person you want working on your eyes until you meet with him or her. In addition to confirming his or her credentials, you need to be comfortable with this person.

Trust is an important consideration that cannot be sufficiently developed without meeting your surgeon face-to-face.

10.  Finally, get a second opinion.
Most people wouldn’t purchase a car without test driving it and at least one other car. Why would you limit your choice of surgeon because “he’s on my plan” before getting a sense of how comfortable you are with the choice your insurance has made for you? This is a very important decision.

Unless you are completely comfortable with your surgeon, get a second opinion.
The best surgeons do not mind that you have or are going to get a second opinion. In fact, one quick test of your surgeon’s comfort with his or her own ability is to let him or her know that you would like a second opinion. If the surgeon becomes defensive about this then you know the second opinion was a good idea, after all.

In summary, there are many things you can easily do to confirm that you have made a good decision about who will perform your cataract surgery.  Considering the importance of your eyesight, you owe it to yourself to complete this research before having cataract surgery.

© 2009 David Richardson, MD

10 Things you should know about your Cataract Surgeon is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

Yes, it appears to be contradictory but it’s a fact.  The reason dry eyes lead to tearing is as follows: dry eyes (like dry skin) are more sensitive to irritation; irritation is interpreted by the brain as “there is something in the eye;” the brain’s response to this is to flush it out resulting in a flood of tears being release by the lacrimal gland.  It’s an issue of too much, too late.

It is common for the eyes to dry out with any activity that involves extended concentration such as computer use. In addition to tearing, symptoms of dry eyes include: an “awareness ” of the eyes, soreness, redness, discharge, “sticky” eyes, itching, foreign body sensation, blurred vision, “tired” eyes.

Treatment options include the following:

1) Tear Replacement Therapy (artificial tears). There are so many brands out there it is difficult to recommend just one. Some of the better brands include:

- Blink

- Endura

- Optive

- Refresh

- Soothe (my personal favorite)

- Systane

- Theratears

Each one is formulated differently so which one works best is hard to determine without first trying it.

2) Nutritional Supplements. There is some evidence that taking Omega-3 fatty acids (such as fish oil or flax seed oil) by mouth can benefit the symptoms of dry eye. These come in gelcaps and are generally recommended once or twice a day with food.

3) Prescription medication. Currently only one medication, Restasis, is approved by the FDA for treatment of dry eye. This must be used twice a day for at least a month. It stings, is expensive, and only works in 50% of people who take it.

4) Punctal plugs. When someone’s eyes are not producing enough tears to keep the eyes lubricated it does not help that tears drain through “puncta” into the nose (this is why you get the sniffles when you cry). The solution: plug these drainage duct with small silicon plugs. This can be done by an eye doctor in the office. It is a painless procedure that only takes a few minutes.

© 2009 David Richardson, MD

My eyes can’t be dry. They tear constantly. is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

In fact, the vast majority of cataract surgeries are done using ultrasound energy (also known as phacoemulsification). That being said, it is possible (though unlikely) that the friend in question had laser cataract surgery. During the late 1990s and into the early 2000s there was a brief interest by a very few surgeons in using a laser to remove the cataract. Even so, this still required making a 3mm incision in the eye (so no, you cannot avoid “going under the knife”).

However, the laser technology was far inferior to the advanced ultrasound technology (which has been steadily improved upon since the 1970s). The only surgeons still using this short-lived laser technology are those who invested in it and feel they have to get some mileage out of their investment. Oh, and it does sound sexy to say that a laser is used to remove the cataract.

Ultimately, if someone has a cataract the best option available in the US is an advanced ultrasound technology called “cold phaco.” This beats the pants off any laser still hanging around. Perhaps in a future post I’ll discuss cold phaco in more detail.

So why, then, are so many people convinced that they had their cataracts removed with a laser? The answer is that a laser is used to treat “after cataracts.” This term is actually a misnomer for posterior capsular opacification (or PCO). A PCO is actually a type of scar that forms behind the IOL months to years after cataract surgery. Think of it as similar to frost on a window.

In order to remove this haze and improve vision a YAG laser is used to tear open the capsular bag behind the intraocular lens (IOL). Prior to the use of this laser surgeons used to poke a needle into the eye and scratch the capsule to tear the scar out of the visual axis. Needless to say, the laser is a big improvement over the needle.

As YAG capsulotomy is the second most commonly performed surgery in the world (cataract surgery is the most commonly performed surgery), it is not surprising that many people mistakenly think that cataracts are removed by lasers.

Click on this link to read more about posterior capsular opacification and YAG capsulotomy.

© 2009 David Richardson, MD

Why your friend didn’t really have his or her cataract removed with a laser is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

Contestant 1: “I can name that tune in 5 notes.”

Contestant 2: “I can name that tune in 4 notes.”

And so on…

At times it would get just ridiculous with a contestant trying to name a tune in only one note.  This type of one-upmanship has a place in entertaining game shows but unfortunately has found its place in modern cataract surgery.

We’ve all heard that cataract surgery only takes 15 minutes, or 10 minutes, or some other ridiculously small amount of time.  And, it is true that a talented cataract surgeon can usually complete a straightforward, uncomplicated cataract surgery (from incision to closure) in 10-15 minutes.

Unfortunately, the impression is that because the surgery only takes a small amount of time it is “a piece of cake” to do.  Nothing could be further from the truth.  Although it is every surgeon’s goal to make the surgery “a piece of cake” for the patient, cataract surgery (done correctly) takes a great deal of preparation, concentration, and skill.

Have you ever seen a Cirque du Soleil performance?  The way those performers gracefully execute their acrobatics conceils the intense concentration, strength, agility, and balance required.  Indeed, the best performers “make it look easy.”  If you’ve ever gone home after a show and tried to replicate even the easiest of the positions you probably threw out your back.

I’m no athlete, but I know those Cirque du Soleil performers have practiced for hours each day, every day for years to make their 5 minute performance look “easy.”

A similar kind of dedication, skill, and inate talent is required to become an expert cataract surgeon.  Most cataract surgeons in training take one to two hours to complete their first cataract surgery.  Over the next couple of hundred cases they will often improve their skills enough to complete surgery in 20-30 minutes.  Most surgeons never get down to 15 minutes per surgery.

Does it matter?

It does, but not for the reasons you may be thinking.  Unfortunately, because some ego-centric surgeons started to advertise that they could complete cataract surgery in less than 10 minutes, Medicare and other insurances have cut their rates of payment from an inflation-adjusted rate of $6,000 in the 1970s to a little over $600 today.  What this does not recognize is that (1) most surgeries take longer; (2) cataract surgery involves a significant amount of time planning prior to surgery; (3) there is a value that should be assigned to the skill required to perform modern cataract surgery.

Unfortunately, this reduction in perceived value of cataract surgery has resulted in pressure from surgery centers and hospitals to cuts costs, cut time, and cut corners.  My average cataract surgery may take only 12 minutes, but if I feel that I need to take a little longer and place a suture I’ll do so.  However, I know that the surgery center feels the financial pain everytime I do so as operating room time is very expensive (as is the suture).  I’m just waiting for the day when the center tells me, “I’m sorry Dr. Richardson, but we can no longer stock that suture (or other device) because we lose money every case it is used.

Modern cataract surgery is a truly amazing convergence of technology and skill.  It is a joy for most cataract surgeons to perform and is usually a “piece of cake” for the patient.  However, modern financial constraints are placing undue burdens on both the surgery center and surgeon to cut costs in an attempt to keep pace with ever decreasing Medicare and insurance reimbursement.

There are appropriate venues for competitive one-upmanship – game shows, for example.  But when reimbusement pressures result in surgery centers and hospitals competing for cataract surgeons based on how much they can save in time and equipment costs, I fear that patient safety could be at risk.

© 2009 David Richardson, MD

“Name That Tune” Cataract Surgery is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

The single largest contributor to risk of infection with any surgery is incision size.  The smaller the incision, the lower the risk of infection. With cataract surgery, the larger the incision, the greater the risk that bacteria can enter the eye with blinking.  Current cataract surgery requires an incision of only 3mm in length.  Now, one might think that an incision size of less than 3mm is pretty small, but there is evidence that if we could get the incision below 2mm it could be truly water-tight keeping bacteria out of the eye.

So, what’s keeping us from doing everything through a 2mm incision?  We can now remove the cataract through a 2mm incision safely.  The problem is getting a new lens (IOL) into the eye.  Presently all lenses must be folded or placed in a cartridge and squeezed through the incision.  The smallest incision that we can tire-iron these lenses through is 2.2mm (and that’s pushing it – pun intended).

If only there were a way to get an IOL through a smaller incision…

Turns out there are two material technologies that could be used to place an IOL through such a small incision.  I’ve already mentioned the SmartLens material which changes shaped according to temperature.

The other material being researched is a polymer that could be injected through a small incision into the capsular bag (this holds the IOL in position) where it would then “cure” or harden into the correct shape.

There are, however, many technical hurdles that must be overcome prior to implementing this technology.  For one, how do we know how much material to place in the capsular bag.  Presumably, the more material we place in the bag the stronger the IOL will be.  But how do we customize this to the needs of that individual eye?

Additionally, how do we cap off the polymer so it doesn’t leak out of the bag?  Finally, there is the issue of cure rate.  If the material cures too fast the surgeon won’t have time to make the adjustments necesary for a good refractive result.  Too slow and surgeons won’t use it (more on the modern time-constraints of surgery in a later post).

I’d give this technology a high probability of appearing on the horizon, but I’d set that horizon at 5-10 years at least.

© 2009 David Richardson, MD

Softserve IOL? is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

Those who are strongly in favor of using a yellow tinted IOL cite the evidence supporting an association of macular degeneration with shorter-wavelength blue light while pointing out the lack of strong evidence supporting any disruption in sleep-wake cycles or notable detriment in color perception.

Those opposed to the use of a yellow tinted IOL cite the evidence supporting a disruption of sleep-wake cycles, and loss of night vision and color sensitivity with blue-blocking IOLs while pointing out the lack of strong evidence supporting a causal effect of blue light on the progression of macular degeneration.

The answer, clearly, is that we don’t know.  So what is one to do?  Most likely, if you have cataract surgery in the US you will have a blue-blocking IOL implanted in your eye as the Alcon AcrySof is the most commonly used IOL by US surgeons.  If this bothers you then discuss it with your surgeon.  If this all seems like much ado about nothing then I wouldn’t lose any sleep over it.

…or will you (pun intended)?

© 2009 David Richardson, MD

Is blue light special? (part 4 of 4) is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

Color perception concerns

If you have ever tried on a pair of blue-blocking sunglasses, do you remember your initial impression?  Many people find the yellowing of their world to be a bit disconcerting.  Contrast is usually notably improved, but at what cost?  I personally do not like the tint though I do appreciate the improved contrast sensitivity when I’m on the slopes.

But, unlike my ski goggles, an IOL cannot be put in or taken out based on one’s activities.  Once it’s placed, it’s there for life (one hopes, anyway).  Does a tinted IOL significantly affect color perception?  Current studies are conflicting on this point.  Of those who have had a tinted IOL placed in one eye and a non-tinted IOL in the other most do not perceive a difference.  However, some do notice it.  It may be that those who notice this color difference are the ocular equivalent of audiophiles.  Most of us cannot tell the difference between a song played back on CD or 128bit MP3 – but run the same comparison by a professional musician or audiophile and the difference will be obvious to them.  Could the same be true of color perception?

Possible disruption of the natural circadian rhythm

Our normal sleep-wake cycles are set by exposure to light – specifically, the blue wavelengths of light.  Blue light suppresses the production of melatonin which is thought to be the main hormone that controls our sleep-wake cycle.  Theorhetically, blocking these wavelengths of light could disrupt this cycle.  However, the available clinical studies are not conclusive one way or the other.

Lack of strong evidence of any benefit

The blue-blocking filter in the Alcon Acrysof IOL mimics the yellow tint present in the average 50 year old human lens.  This begs the question: why would anyone want an IOL that mimics a 50 year old lens?  The answer presumes that there is a definite benefit to blocking these wavelenghts of light.  But is there?  And if there is not, wouldn’t you rather have a lens that mimics that of a 20 year old?

So, is there or isn’t there a benefit to blocking the shorter wavelengths of light?  I’ll pick up this thread in my next post.

© 2009 David Richardson, MD

Is blue light special? (part 3 of 4) is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

First, let’s look at the reasons touted to block the far blue spectrum of light and clarify that no one is suggesting that all blue light be blocked, only the shorter “near-ultraviolet” wavelengths of light.  The main reason touted by those in favor of blocking these shorter wavelengths of blue light is the evidence that these wavelengths may increase the risk of macular degeneration.

This evidence is largely culled from population-based studies.  Essentially a large number of people were observed for years and examined for the development of various diseases such as macular degeneration.  Those who developed macular degeneration were compared to those who didn’t.  Attributes such as nutrition, activity, and environmental exposures were evaluated.  A correlation between macular degeneration and exposure to light was noted.

Additionally, there are some studies that have suggested a correlation between cataract surgery and worsening of macular degeneration.  There are many reasons why this could be (inflammation, ease of detecting macular degeneration after a cataract is removed, etc.).  One theory is that because most synthetic IOLs allow a greater spectrum of light into the eye than the natural cataractous lens that these rays of light may be capable of damaging the retina.

Indeed, there is laboratory evidence of “phototoxicity” when retinal cells are exposed to near-ultraviolet light.  This is suggestive that a similar effect could occur in a living eye.

So, with the above evidence suggesting that a blue-blocking IOL may protect from macular degeneration and improve contrast sensitivity, why wouldn’t all surgeons be using them?

As it turns out, there are quite a few reasons not to place a blue-blocking IOL in the eye.  I’ll discuss the main arguments against use of these IOLs in my next post.

© 2009 David Richardson, MD

Is blue light special? (part 2 of 4) is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

Cataract surgery has a long history of controversy.  Early cataract surgery shared a complication of modern surgery: blindness.  Whereas this is a rare complication of modern surgery, it was relatively common in early attempts to remove the cataract.  What was probably uncommon was finding someone willing to perform cataract surgery.  This was due to the Code of Hammurabi which prescribed a very harsh penalty for cataract surgery gone wrong: cutting off the surgeon’s hands.  Compared to the fee for cataract surgery (ten shekels of silver – not even gold!) the risks do seem to have outweighed the benefits to the ancient cataract surgeon.

Fast forward to the mid-1950′s: Dr. Harold Ridley first’s attempts to place a lens inside the eye after removing cataract surgery.  He was severely ostracized by the medical community for what was seen as reckless behaviour.  Here in the US the FDA was even ready to ban the use of IOLs until Robert Young (the actor who played Marcus Welby, M.D.) testified in favor of the IOL.

So what is the current source of online and in-print flame wars among otherwise professional and staid ophthalmologists?

Blue light.

Huh?

Yep, blue light.  Or, rather, the blocking of this light with a yellow-tinted filter.  The correct way of thinking about these filters is not that the filter adds yellow, but rather that it absorbs blue (when blue is subtracted from the visible light spectrum an object takes on a yellow tint).

Skiers have known for years that blocking blue light with a yellow tint increases contrast sensitivity on the slopes.  “Blue blockers,” or yellow-tinted sunglasses are also very popular with those involved in watersports.  There is even a pair of glasses advertised in some magazines to cut glare from nighttime driving that has incorporated a yellow-tint.

So, if filtering the blue spectrum of light provides the benefits mentioned above, why wouldn’t a blue light filtering IOL be a good idea?  Indeed, the major manufacturere of IOLs in the US (Alcon) does not offer any of its popular single-piece IOLs without a blue-filtering pigment.

Herein lies the controvery.  Not everyone agrees that filtering blue light is a good idea.  It’s one thing to put on a pair of sunglasses with a yellow tint.  But, should we really be surgically implanting these lenses in the eye after cataract surgery?

In my next three posts I will summarize the support for and against blue light filtering IOLs.

© 2009 David Richardson, MD

Is blue light special? (part 1 of 4) is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

First, a little background on cataract surgery.  Prior to cataract surgery the iris must be dilated in order for the surgeon to get to the lens (cataract).  This is done both to obtain good visualization of the cataract and to protect the pupil which is a very delicate tissue and is easily damaged when it comes into contact with metal instruments.

Dr. Chang noted a few years ago that the iris of certain patients would become “floppy” during cataract surgery and dilation would be lost.  This resulted in a very poor view through the small pupil, increased intraoperative complications (secondary to the poor view), and damage to the iris (because it flopped around inside the eye during surgery).  This syndrome became known as Intraoperative Floppy Iris Syndrome (or IFIS).

David Chang, MD, and John R Campbell, MD, with the help of others (whose names I cannot recall – my apologies), collected all the information they could about these patients and discovered that they all had one thing in common: use of a prostate medication called Flomax®.

Flomax® (or tamsulosin) is a selective alpha-1 adrenergic antagonist that relaxes the smooth muscle of the prostate allowing men with Benign Prostatic Hyperplasia (BPH) to urinate more easily. Doctors also prescribe these medications for women as a treatment for urinary retention. Unfortunately, it appears that Flomax® has a permanent effect on the iris muscle that greatly increases the challenge of cataract surgery.

Other medications in this class include the newly released Rapaflo® (silodosin), as well as a group of medications termed “non-selective” alpha-1 adrenergic antagonists which include Hytrin® (terazosin),  Cardura® (doxazosin), and Uroxatral® (alfuzosin).  These non-selective drugs are less likely to result in IFIS.

Fortunately, if a cataract surgeon is aware that someone is taking one of these medications, he or she can take some additional precautions prior to or during cataract surgery to minimize the risks of IFIS.  If you are taking any of the above medications or if your primary medical doctor is recommending that you start, it is a good idea to let your ophthalmologist know about it.  If you don’t yet have an ophthalmologist, this would be a good time to get one.

© 2009 David Richardson, MD

What the Prostate has to do with Cataract Surgery is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

Just as in the delivery of a baby, squeezing through a small canal has its risks.  The IOL can be deformed or torn.  The incision can be stretched resulting in a leaky wound.  The later can result in an increased risk of infection.

Enter the thermoplastic hydrophobic acrylic material.  This material has a science fiction-like ability to change shape as temperature changes.  At room temperature it is shaped like a rod allowing the surgeon to easily slip it through a small incision and into the eye.  As the material heats up to body temperature it transforms into a biconvex lens.  Truly amazing!

This IOL is still experimental so we won’t see it for a couple of years (at least).  Nevertheless, it is an exciting technology and worth watching.

© 2009 David Richardson, MD

SmartLens or science fiction? is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

One way to picture how this works is with a peanut butter sandwich.  If you are generous with your peanut butter and press the two slices of bread together the peanut butter will ooze out the sides of the bread.  Now instead, imagine that you have created a central hole in the middle of the top slice of bread (the iris).If you push on the bottom slice of bread the peanut butter (the lens) will bulge forward through the central hole. This is essentially how the lens of a water bird works.

The NuLens® is essentially a very small peanut butter sandwich with the peanut butter replaced by a silicon gel and the bread replaced by a rigid clear material.  Initial studies in monkeys have been very promising.  However, it will be awhile before this is approved for use in humans.

The recession will be over long before the FDA gives its blessing so it is not going to be an option for you if you need cataract surgery in the next couple of years.  Nevertheless, the technology is exciting and many baby boomers will have quite a few awesome choices when it is time for them to have cataract surgery.

© 2009 David Richardson, MD

A NuLens® design for presbyopia correction is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

Lenstec Tetraflex® IOL
This IOL platform, presented by Paul Dougherty, M.D., seemed to have only one benefit over multifocal IOLs: minimal post-operative glare. However, that benefit already exists with the Crystalens® IOL.

This talk actually began with a discussion of the near acuity patients really need to read magazines, newspapers, etc. After a not very convincing explanation about why we really don’t need to see the equivalent of 20/20 up close, Dr. Dougherty presented results that were objectively worse than what any of the presently available IOLs were capable of delivering.

One caveat: the patients in his study preferred the Tetraflex® over the Crystalens® even though the vision from the Crystalens®eye could see smaller letters on the near eye chart. Now, I’ll be the first to admit that our visual requirements in the real world do not directly correlate with what we can see on an eye chart. So, it is possible that the vision patients experience with the Tetraflex is somehow superior to what is measured with the eye chart.

It will be awhile before this IOL is approved for use in the US. Unless studies are able to show a clear benefit of this IOL over the currently available Crystalens®, however, I seriously doubt this lens will become a major player in the IOLs offered by most surgeons.

© 2009 David Richardson, MD

The Tetraflex® IOL is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

Yesterday I discussed the most exciting new IOL technology on the horizon for monofocal (single-distance) IOLs. Today, I’m going to talk about what I think is the most exciting technology in the “presbyopia-correcting” IOLs.

First, a word about presbyopia. When we are young, our eyes are able to focus over a wide range from distance to near. As we age we lose this ability to change focus. Eventually, we need to help our eyes with the near portion of this range with reading glasses, or “cheaters.”

Currently, the only options available to return that range of vision involve removing the natural lens (or cataract) and replacing it with a multifocal IOL (more on these in a future post) or accommodating IOL. The problem with current multifocal IOLs is that they result in little rings around lights at night. The problem with the currently available accommodating IOL (the Crystalens®) is that is doesn’t work for everyone. So, what’s on the horizon…

Synchrony IOL
Visiogen
This lens was presented by David Chang, M.D. (UCSF) who is one of the most impressive cataract surgeons alive today. It uses a unique two-lens approach to providing a range of vision (distance and near) after cataract surgery. Once inserted into the eye these two lenses would move relative to each other resulting in a variable range of vision.

Unlike most presently available presbyopia-correcting IOLs this lens does not result in halos or glare after surgery. The initial results are very impressive and I am looking forward to offering this IOL to my patients as soon as it becomes available in the US.

As it is such an unusual type of IOL (two lenses instead of one) many surgeons will not be comfortable implanting this IOL when it first becomes available. Nevertheless, this may be worth searching out as the initial results are quite impressive. I’ll keep this blog posted when new results are available as I’m very bullish on this IOL.

© 2009 David Richardson, MD

A new paradigm in IOLs – The Synchrony is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

The new intraocular lens study results created quite a buzz among the attendees. None of these IOLs will be available in the USA for at least another year or so. Nevertheless, anyone who is on the fence about their cataract surgery might consider waiting as their options will only get better as these new IOLs become available.

Today I will discuss the most revolutionary design change in IOL technology, the Calhoun light-adjustable IOL. Over this next week, I will write about the exciting IOLs that were presented at this meeting.

Calhoun light-adjustable IOL

http://www.calhounvision.com/

Although this lens is not a presbyopia-correcting IOL (more on that in my later posts), this lens embodies what is probably the most exciting and revolutionary technology on the horizon for cataract surgery.

Presently, when someone needs cataract surgery the surgeon chooses the IOL based on measurements taken of the cornea and size of the eye. However, the calculations used to choose the IOL are “best estimates” of what that particular patient will need. They don’t work for everyone. Additionally, IOLs come in 1/2 diopter increments meaning that the best we can possibly hope for is that the post-surgical refractive error will be plus or minus 1/4 diopter. It’s like buying shoes: if you have a 10 1/4 foot it will be a bit too large for a size 10 shoe and too small for a 10 1/2.

Unlike buying shoes, however, your don’t get to try on an IOL before buying. It’s a lot like having a shoe salesman measure your foot and forcing you to buy the shoe he thinks will fit without trying it on. Oh, and there is a no return policy. Would this make you uncomfortable buying a shoe? Welcome to the life of a cataract surgeon – present IOL technology forces us to choose the IOL for the patient without really knowing (beyond what the measurements suggest) what they will finally need.

Enter the light-adjustable IOL. This amazing technology allow the surgeon to adjust the strength of the IOL after surgery using an ultraviolet light. Even astigmatism can be corrected. Once the post-operative refractive error has been minimized, the strength of the IOL can be “locked-in.” After this is done there would be no need for distance glasses. Reading, however, would still require “cheaters.”

Of course, this technology will probably be quite expensive so don’t expect Medicare or most insurances to pick up the cost of these adjustments. How much will it cost? That’s unknown at this time. Since the IOL and the equipment to adjust the strength of the IOL has not been approved yet the company has not released pricing information. Although this is a shot in the dark, I would expect it to be at least $1,000 extra just for the IOL and another $1,000-2,000 for the surgeon’s fee.

Tomorrow I’ll discuss what I think is the most exciting advancement in “presbyopia-correcting” IOL technology.

© 2009 David Richardson, MD

Exciting new IOL technology on the horizon is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert

So I created a website http://www.sgveye.com (or rather, my web designer did) that would function both as a forum to allow questions and answers about cataract surgery or general eye disease and as an online brochure for my medical practice, the San Gabriel Valley Eye Associates, Inc. However, despite the best efforts of my web designer, I have found that the website is just not the best format for what I would like to do.

My hope is that the blog format will allow me to provide real-time updates to those questions my patients are asking. As a secondary benefit, I hope that this blog will be informative to anyone with cataracts or eye disease who shares similar questions about the eyes.

In the spirit of a blog (and at the request of my patients) I will also be somewhat indulgent in the following manner: the single most common question I hear is not about eye disease, but about my daughter, Arden.

To those who are internally moaning “Oh no, not another ‘Isn’t my child cute’ site,” I have the following to say: I understand your reaction; I was there. Prior to Arden’s birth I thought most parent’s gushing about their kids was about as bearable as fingernails on a chalkboard. All that changed with her birth. If you’re not a parent and don’t get it, you won’t until you are. And, I promise that the primary focus of this blog will be on eye disease.

Another thing: as an eye surgeon I have learned the importance of managing expectations.  I truly love what I do and am ‘old school’ when it comes to many things such as taking call for my patients after hours and on the weekends (rather than forwarding my office phone number to a message that directs patients to the emergency room for after-hours problems).  However, I would like to avoid the trap many doctors get into: sacrificing their family life for the professional demands of practicing medicine.  As such, I will try to update this blog most weekdays but will generally not publish posts on the weekend.

I look forward to what I hope will be an interactive and educational experience for my patients, other readers of this blog, and myself.

Sincerely,

David D. Richardson, M.D.
Medical Director

San Gabriel Valley Eye Associates, Inc.
207 S. Santa Anita Street, Suite P-25
San Gabriel, CA 91776
626.289.7856

About Eyes Introduction is a post from: About Eyes and Lens Replacement Surgery by Cataract Expert