About Eyes and Lens Replacement Surgery by Cataract Expert

Continuing my series on what happens during cataract surgery, we have so far removed the cataract, but still have to place the new lens in the eye.

© 2009 David Richardson, MD

Finally, it is time to remove the cataract:

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

We are done preparing.  Time to get to work:

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

Today we continue our line-by-line evaluation of a typical cataract surgery operative report:

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

OK, let’s begin.  Following is the first paragraph of a typical cataract surgery operative report.

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

As promised, I have included a typical operative report in this post (it has been stripped of all identifying information).  For anyone outside of the field of ophthalmology reading this will most likely be as clear as mud.  Don’t worry, over the next few posts I will clarify this post in excruciating detail.  When you are done reading this series of posts, you’ll probably know more about how cataract surgery is done than your own internist.

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

There are so many incorrect beliefs about how cataract surgery is done that I spend a fair amount of my time with patients simply re-educating them about cataract surgery as well as what results they can realistically expect after surgery (for example: most people will still need bifocals or readers after surgery with a standard lens implant).

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

As discussed in an earlier post, one of the most common symptoms of dry eye syndrome is tearing. Even with an explanation of how this occurs, many are unconvinced. How do you know that your doctor isn’t just telling you this to give you pause while he slips out of the exam room and on to his next patient. “Ah, the old dry eye ruse:” tell the patient that having too much tear is really related to having too little tear and disappear through the door while the unsuspecting patient is mulling this over.

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

Most people consider their sight to be their most important sense. Yet, every year thousands of people have surgery on their eyes without having done any research on their eye surgeon. Who performs your cataract surgery is one of the most important decisions you will make in life.

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

I’m going to take a break from discussing cataract surgery today and focus on something even more common: dry eye syndrome.  One of the most common eye diseases I see is dry eye syndrome.  The most common symptom of dry eyes: tearing.  The most common response I get when I tell someone with tearing that they have dry eye syndrome: “My eyes can’t be dry.  They water all the time.”

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