The LASIK Blog

Piggy BackToric IOL Improves from -18.0 to 20/20 Witout Glasses

Christine was in my office today 1 week after her cataract surgery on her second eye.  She is already seeing 20/20 without glasses!  What makes this story unique is that she was an extremely nearsighted and astigmatic patient with cataracts.  Before surgery she had a correction of -18 myopia and -2 of astigmatism.  Her best correctied vision was a blurry 20/50.

After discussing cataract surgery, we decided that Christine's best chance of excellent vision was with a toric IOL.  There was only 1 problem, because of the amount of nearsightedness she had there was no toric IOL in her power.  The surgical plan I came up with was to piggy back to implants, one toric (to correct her astigmatism and most of her nearsightedness) and the other spherical (to correct the residual nearsightedness.

The results were better than expected, 20/20 vision 1 week after surgery!  Christine was kind enough to both donate her old glasses today and to discuss her results with me.

 

 

 

Dysfunctional Lens Syndrome: Describing the New Paradigm

I had a 60 year old patient in the office today who I told that she had "early" cataracts.  She was a moderate farsighted patient who was seeing 20/30 with her current glasses, and will see 20/20 with her new bifocals.  Now, without her glasses, she is able to see only 20/200 at both near and far.  Her question to me was, "Are my cataracts 'ripe' enough to come out?"  I gave her my standard "canned" answer:  "we don't wait for cataracts to be 'ripe' to remove them.  The time for cataract surgery is when you are unhappy with your vision, are unable to do all the things you would like to because of your vision, and I can't improve it to your satisfaction with a change in glasses." 

This is the standard answer that most ophthalmologists and I will give to patients when their insurance will be paying for the surgery, as there are certain criteria that must be met.  Specifically, best corrected vision should be worse than 20/40 and interfering with daily lifestyle.  With the aging of the Baby Boomer Generation, and improved refractive lens based technology, I have noticed a paradigm shift in how I view and discuss cataracts.

First, a little anatomy.  Think of the eye as a camera.  The front surface is a clear window, called the cornea.  Behind the cornea is the colored part of the eye, the iris, which acts like a diaphram in a camera.  It opens and closes to adjust the amount of light coming into the eye by changing the size of the pupil.  Behind the pupil is the lens.  When we are young, the lens is clear and able to easily change its shape to focus light onto the back of the eye, the retina.  The retina acts like the film in a camera.

Today's discussion will be limited to the lens as I will be describing a new terminology first described by Harvey Carter, MD:  Dysfunctional Lens Syndrome. 

As I mentioned, when we are young, the lens is clear and is able to change its shape, to focus.  This is called accommodation.  Aging affects the lens.  First, the lens begins to stiffen and lose its ability to change shape and focus.  This is called presbyopia, and usually manifests itself in the early 40's, when we start to need reading glasses.  Presbyopia will continue over the years, making focusing more and more difficult, ultimately leading to the need for bifocals.  As we continue to age the lens then loses its clarity and begins to opacify, leading to the formation of a cataract, or cloudy lens.  The cataract will continue to get more and more cloudy over time until it is very hard and dense, a ripe cataract.  When a cataract is "ripe", the patient is generally blind in that eye, and cataract surgery is very difficult.

So how do we treat Dysfunctional Lens Syndrome?  It depends on what the patient wants:

• Early on reading glasses are used as needed.
• When distance is also effected, bifocals are prescribed.
• Bifocal contact lenses and monovision contact lenses are prescribed to those who do not want to wear glasses.
• Refractive Lens Exchange (RLE) works very well for those patients who do not want to wear glasses or contact lenses.  RLE involves removing the dysfunctional natural lens and replacing it with a multifocal artificial lens (IOL) that is capable of focusing light near and far.  It is the same procedure as cataract surgery, except there is not enough lens changes (cataracts) for insurance to pay for the procedure.
• Once cataracts become visually significant, they may be removed to improve one's vision.  Again there are several choices here, depending on the patient's needs:
  • A standard IOL will provide excellent distance vision, provided there is no corneal astigmatism.  Astigmatism occurs when the eye is oval in shape, resulting in unequal refraction. Light rays are focused at two different points on or before the retina, and this split focus produces distorted vision.  Cataract surgery does not correct this and bifocals will be needed after surgery.  If there is no astigmatism, only reading glasses will be needed, as the standard IOL provides no focusing for close.
  • For those that do not want to wear glasses after cataract surgery, a premium IOL may be implanted. Insurance does not pay for the premium IOL, or the added visits and testing that is required.  Let’s break premium IOL choices into 2 categories:
    • No pre existing astigmatism:  In these patients, a multifocal IOL is implanted to achieve glasses free vision at both near and far.
    • Pre existing astigmatism:  In these patients there are 2 choices:
      • If one wants to have glasses free vision both near and far a multifocal IOL is implanted to address the near vision problem.  Astigmatism correction will than be addressed with LASIK about a month after the cataract surgery.
      • If one only wants good distance vision without glasses, a Toric IOL is implanted.  These patients will than only need over the counter reading glasses.

In summary, the new paradigm of discussing Dysfunctional Lens Syndrome allows me to discuss the changes in the natural lens, and how they affect my patient’s lifestyle requirements more effectively.  My discussion is no longer limited to the term "cataract", with its conotations of being a disease of "old age."

Eye Drop to Prevent Cataracts?

For many, the formation of cataracts is a natural part of the aging process, causing the eye's natural lens to cloud and distort vision. The lens is held inside a capsule, and is made of mostly protein fibers and water arranged precisely so as to permit light to pass through without interference. Over time, these fibers begin to break down and cluster together, clouding the lens. As more fibers break down, the clouding becomes denser and covers a greater area of the lens. Cataract surgery becomes necessary to restore clear vision.

In China, there is a non-prescription eye drop that has been used for over 60 years to prevent and treat cataracts.  The active ingredient of this drop is caled pirenoxine (PRX).  There has been no scientific basis for the effectiveness of PRX, until now...

In last months issue of Inorganic Chemistry is an article titled Ditopic Complexation of Selenite Anions or Calcium Cations by Pirenoxine: An Implication for Anti-Cataractogenesis.  In the study, Tzu-Hua Wu and colleagues tested PRX on cloudy solutions that mimic the chemical composition of cataracts. The solutions contained crystallin -- a common lens protein -- combined with either calcium or selenite, two minerals whose increased levels appear to play key roles in the development of cataracts. Presence of PRX reduced the cloudiness of the lens solution containing calcium by 38 percent and reduced the cloudiness of the selenite solution by 11 percent.

"These results may provide a rationale for using PRX as an anti-cataract agent and warrant further biological studies," the article notes.  Who knows, there may be a time in the not to distant future when we will be prescribing these drops to ward off cataract surgery!

No More Glasses in the OR With the ReSTOR IOL!

I work in a very busy outpatient surgery center.  We have over 20 ophthalmologists performing thousands of cataract surgeries yearly.  Several months ago, one of our OR nurses, Linda, approached me.  She was sick and tired of wearing bifocals to drive, work on the computer, chart notes, and eat.  After speaking to many of my patients and their new abilities to function glasses free, Linda decided to pursue her options.  I told her to make an appointment at my office so that I could examine her and give her a recomendation.

It ends up that Linda was moderately farsighted, she needed glasses for all visual tasks.  She also had some small cataracts that were affecting her night driving.  After some more discussion, we decided that cataract surgery with the implantation of the ReSTOR IOL would give Linda the best chance of reducing her need for spectacles.

Linda had her surgery last month, and is now 20/20 both near and far without the need for glasses.  Needless to say, she is thrilled.  In fact today she told me she is bringing a "jealous" friend to my office next week to see what her options are.

 

My Dad Turns 80 and I Find Out His ReSTOR Eyes Are Better Than Mine!

My dad turned 80 yesterday!  My sister and I decided to buy him an iPad for his birthday.  He constantly travels back and forth to Florida, and is always watching movies on a mini DVD player, or listening to a book on tape.  I figured an iPad would allow him to do all it in one.  Only one problem, he is technologically challenged.

So, yesterday, after giving him his present, I spent some time configuring the iPad.  He didn't even know if he had wireless in his house!  After finding the wireless router I had to figure out it's code and password.  Luckily they are printed on the router.

Now, at 54 years old, I consider myself lucky.  I have perfect distance vision, and generally don't wear readers.  This is certainly the exception.  The print on the router is quite small, and every time I entered the information onto the iPad it did not configure!  Finally I handed the router to my dad and asked him to read it.  He got it right the first time and the router was configured!

Now, he also has perfect distance vision and doesn't wear readers!  The difference?  I did cataract surgery on my dad 2 years ago and implanted the ReSTOR multifocal IOL.

I hate to admit it, but it appears that his 80 year old ReSTOR eyes work better than my 54 year old eyes!  Boy is that depressing...

Harvest Vision Once Again: The Music Video

I introduced Warren Barootajan back in August of this year.  Warren is a 63 year cabinet maker from upstate NY. His poor vision from cataracts have contributed to his inability to work. Without insurance he is unable to seek treatment. He has become frustrated with trying to receive treatment thru a broken system.

Warren was able to participate in this year's Vision Harvest free cataract program last month.  Besides being a carpenter, I also discovered he is a songwriter!  he was kind enough to write a song, "Harvest Vision", and produce a music video for our Vision Harvest Program!

He wrote:

It was almost 2 years ago I was declared legally blind in the state of New York and I was without work or health insurance. Now I have 20/20 vision in my right eye thanks to Dr Silverman and so many others. As a songwriter I thought it was my responsibility to thank everyone who volunteered their time,talents and supp...lies on that special day , Oct 28th-2010, hence "Harvest Vision Once Again"
It is all I can do at the moment. please accept this token of gratitude

-Warren E Barootjian

Well, here is the music video, "Harvest Vision Once Again."  I think he did a great job!~  Hope you all enjoy it!

 

Cataract Prevention? Vitamins are Not The Answer!

According to WebMD: 

Vitamin C is one of the safest and most effective nutrients, experts say. It may not be the cure for the common cold (though it's thought to help prevent more serious complications). But the benefits of vitamin C may include protection against immune system deficiencies, cardiovascular disease, prenatal health problems, eye disease, and even skin wrinkling. 

Vitamin E is key for strong immunity and healthy skin and eyes. In recent years, vitamin E supplements have become popular as antioxidants. These are substances that protect cells from damage.  Many people use vitamin E supplements in the hopes that the vitamin's antioxidant properties will prevent or treat disease. Early lab studies of vitamin E supplements were promising. But studies of vitamin E in people have been disappointing.

There was an interesting article in this months issue of Archives of Ophthalmology titled: Age-Related Cataract in a Randomized Trial of Vitamins E and C in Men.

This article assesed whether supplementation with alternate-day vitamin E or daily vitamin C affects the incidence of age-related cataract in a large cohort of men. 11,545 apparently healthy US male physicians 50 or older without a diagnosis of cataract at baseline were randomly assigned to receive 400 IU of vitamin E or placebo on alternate days and 500 mg of vitamin C or placebo daily. After 8 years of treatment and follow-up, there were 579 cataracts in the vitamin E–treated group and 595 in the vitamin placebo group. For vitamin C, there were 593 cataracts in the treated group and 581 in the placebo group.

The study concluded that long-term alternate-day use of 400 IU of vitamin E and daily use of 500 mg of vitamin C had no notable beneficial or harmful effect on the risk of cataract.

There are a few things you can to to slow down cataract formation:

• Wear sunglasses
• Quit smoking
• Maintain a healthy weight

And, if you do develop visually significant cataracts, not to worry.  Cataract surgery is the most common procedure performed in the US with 1.5 million performed annually.  Combined with the implantation of an IOL (intraoccular lens), the results are excellent..

Vision Harvest 2010 A Huge Success: 24 Receive Free Cataract Surgery

 

Friday's Vision Harvest went off without a hitch.  24 people were able to have their vision improved with free cataract surgery.  These patients all suffered with cataracts, but were unable to seek the treatment they needed, as they had no insurance nor the means to pay for their cataract surgery.

I continue to be moved by so many of the stories I have heard since founding Vision Harvest last year.  I am also amazed at how far people have traveled to receive the surgery they so desperately need; last year from as far away as Indiana, this year, Tennessee!  It is so hard to believe there are so many people in need of medical care in our own country..

Here is a breakdown of this year's patients:

• Most of these patients were relatively young to have visually significant cataracts.  They ranged in age from 27 to 78, averaging 58.
• 6 were employed, 1 was a student, and 17 were unemployed
• Geographically, 19 were from New Jersey, 1 from New York, 1 from Connecticut, 1 from Maryland, 1 from Virginia, and 1 from Tennessee.  Several of those from NJ were actually visiting family members from India, Phillipines, and Western Africa.

Getting drops prior to surgery.

Three patients had to be cancelled because they failed their free medical clearance which was performed on the day of surgery.  This points to another glaring problem, not only can't these people afford cataract surgery, they can't afford to take care of themselves, medically.  We will be referring them to an area clinic, and once stable, perform their cataract surgery at a later date.

I have downloaded many more pictures of the day's event onto flickr for your enjoyment.

Ilene and Jackson congratulated by me for winning dinners at Serenade Restaraunt.

I would like to take this opportunity to thank those responsible for making Vision Harvest 2010 possible:

• Keri Muli, Administrator, Barbara Kociuba, Refractive Surgery Coordinator, and the entire staff of EyeCare 20/20 for helping to organize and implement the program.
• Nancy Lord, Administrator, Hadley Phillips, Medical Director, all the physician-owners, and the entire staff of River Drive Surgery Center for allowing us to treat these patients at the center free of charge.
• Dr. Jay Tendler and Dr. Aruna Desai for providing free anesthesia to our patients.
• Dr. Enas Tupo for providing free medical clearance to our patients.
• Including me, the following surgeons provided free cataract surgery:

                Dr. Michael Farbowitz

                Dr. Ken Miller

                Dr. Scott Pomerantz

                Dr. Nahndi Williams

Setting up microscope for surgery.

• The following doctors will be providing post op mamagement of these patients free of charge:

                Dr. Phillip Eichler of Eye Institute of Essex

                Dr. Steven A Koenig of Nashville, Tennessee

                Dr. Earl Kidwell of Parkville, Maryland

                Dr. Nichilas Xanthos of EyeCare 20/20

• Gene Maresca and Steve Kramaritsch of Alcon Labs for supplying surgical packs, implants, and post op drops.
• Sarah MacKay of Bausch & Lomb for supplying post op drops and bags, and providing lunch for the staff on the surgery day.
• Pat Tobia of Hoya for supplying implants.
• Greg Cardone of Ista for providing post op drops.
• Mary Ann Hogue of MST for supplying surgical supplies.

 

We plan on continuing Vision Harvest again next year.  I have already received several inquiries from needy patients, and have begun a new list for next year's event.  If you, or someone you know is in need, please call our hotline at  

973-200-8250

Other people have asked what they can do to help.  It is important to spread the word.  Please join our facebook fan page and share it with your friends.  Finally, I need to mention that although many people have volunteered their time and resources, Vision Harvest is NOT run without costs.  We can certainly use financial support to keep thing growing in the future.  Money raised will help defray hard costs, such as surgical center staffing, equipment, and supplies not donated by suppliers. We are currently in the process of applying for non-profit status, and therefore this cannot be considered a tax deductable donation at this time.  If you are so inclined, please support our efforts!  I thank you, and our patients thank you as well!!

Vision Harvest 2010: From Tennessee to NJ With a Little Help From Her Friends..

So tomorrow is our second annual Vision Harvest free cataract surgery day!  I saw our final patient pre operatively today, and its a great story!  Shirley lives in Tennessee, can't see because of her cataracts, and can't afford surgery as she has no insurance.  Last year her daughter, Amanda heard about our program, after the fact, while surfing the web.  She called our office and was placed on this year's list.

When Amanda got the call about this year's program, she had only 1 concern, how to get her mom to New Jersey to get the free cataract surgery.  Her solution, a facebook campaign to raise money for transportation and hotel during Shirley's stay.  The campaign worked, raising the $600 necessary to make the trip!

I saw Shirley today, she is a good cataract surgery candidate, and will surely benefit from tomorrow's procedure.  We were even able to arrange for her to have free post op care back home in Tennessee.

As I told Shirley in the following video, "She has a great daughter!!"

 

2 Things That Excited Me at This Year's AAO Meeting

I was fortunate to spend this past weekend in Chicago at the Annual AAO Meeting.  It was great catching up with old friends and colleauges, having some awesome meals, and enjoying the beautiful city of Chicago.  I even had the time to spend a few hours enjoying one of my hobies:  taking some pictures of the city.

There was a lot to learn at this year's meeting, however, 2 things really excited me:

1. The Visian ICL Toric.  I was able get certified in the implantation of this yet to be approved phakic lens.  I have been implanting the Visian ICL for several years and find that it affordes excellent vision to both high and moderate myopes.  If these patients also have astigmatism, I currently will do LASIK about 1 month after implantation of the ICL.  The Toric ICL will allow me to treat both the myopia and astigmatism in 1 sitting, I can't wait for its final approval
2. The LenSx Laser.  I must start off by saying that I was a skeptic when I first heard about using the femtosecond laser to aid in cataract surgery.   I currently get excelent results using today's technology, my refractive cataract patients are able to read and drive without glasses or contact lenses.  I thought that the only thing this product would do would be to add cost to the procedure.  After seeing the laser in action, I realized that I was dead wrong!  "Designed to revolutionize key steps in the cataract procedure, the LenSx Laser now allows surgeons to deliver the benefits of precise femtosecond laser technology to even more of their patients. What exactly does that mean? Cataract surgery that is more precise, predictable, reproducible and safe."  The LenSx Laser will be able to produce uniform incisions, soften a cataract so less energy is used to remove it, provide uniform access to the cataract itself, and treat pre exisiting astigmatism, all in under 5 minutes.  This will translate into tighter outcomes and less complications.  Its cost will be high, so the laser will probably only be used on refractive cataract cases, where out of pocket payments will be required.  Our surgical center has already put our name on the list to hopefully be one of the first centers in the country to offer this exciting new technology!

This is what I love about ophthalmology, just when you think you know it all, just when you think you can do it all, something new comes along to make things better!