Morton Burstyn is a very nice 92 year old man, who I saw in my office for the first time several months ago. He had poor vision in both eyes, and lost his independence. I determined that I could improve the vision in 1 of his eyes through cataract surgery.
Surgery went well last month, Morton is now seeing well enough to drive again! He was kind enough to discuss his EyeCare 20/20 cataract experience with me last week:
There has been a lot of buzz on the web this past week concerning an article in this month's Health Affairs titled: Physician-Ownership Of Ambulatory Surgery Centers Linked To Higher Volume Of Surgeries. In this article, John M. Hollingsworth, M.D., of the University of Michigan in Ann Arbor, and colleagues used Ambulatory Surgery Databases to analyze data from Florida from 2003 to 2005. They looked at all patients in Florida who underwent one of five common outpatient procedures including cataract extraction. They compared the number of surgeries performed among ASC owners before and after they acquired ASC ownership with that of physicians who were non-owners. They found that owners performed twice as many procedures as non-owners. Assuming that these are the facts of the study, you can't argue with numbers; what I have a problem with is the author's conclusion:
"To the extent that owners are motivated by profit, one potential
explanation for our findings is that these physicians may be lowering
their thresholds for treating patients with these common outpatient
procedures."
I find this conclusion offensive. Lowering treatment parameters to generate profits? Cataracts cause a decrease in one's vision, what patient is going to submit to eye surgery without the symptoms that warrant this surgery? I have been a part-owner in River Drive Surgery Center for the past 8 years. During this time, my cataract volume has certainly increased. It is NOT because profits have lowered by treatment parameters! Here are some of the reasons that I can think of of the top of my head (I find it amazing the that author's of this paper couldn't come up with any of these):
I read an interesting article today in the New York Times, by Henry Fountain titled: Laser Treatment May Work for Cataracts. The article describes some research out of Denmark, published on line in Plosone.
A cataract is an aging process whereby the eye's natural lens becomes more dense and opacified. The main treatment for cataracts is surgery, removal of the lens with its replacement with an IOL. As a worldwide treatment, this can be expensive, requiring a trained surgeon and an OR. The authors of this paper are attempting to reverse the lens' aging process with the use of a laser to bleach the lens.
The conclude:
femtosecond photolysis has the potential clinical value of replacing invasive cataract surgery by a non-invasive treatment modality that can be placed in mobile units, thus breaking down many of the barriers impeding access to treatment in remote and poor regions of the world.
This is certainly an interesting and novel approach towards addressing the world's leading cause of reversible blindness!
from http://newzar.wordpress.com/2009/01/
A recent study, soon to be published in Ophthalmology, found that taking certain anti-depressants increased one's risk of developing cataracts.
The study was based on a database of more than 200,000 Quebec residents aged 65 and older. The University of British Columbia (Vancouver) study showed a relationship between a diagnosis of cataracts or cataract surgery and the use of a class of anti-depressants called selective serotonin reuptake inhibitors (SSRIs). Patients taking SSRIs were 15% more likely overall to be diagnosed with cataracts or to have cataract surgery.
The study also showed a relationship between cataracts and specific SSRI Class drugs. Taking fluvoxamine (Luvox) led to a 51% higher chance of having cataract surgery, and venlafaxine (Effexor) carried a 34% higher risk. No connection could be made between fluoxetine (Prozac), citalopram (Celexa), and sertraline (Zoloft) and having cataract surgery.
Photo courtesy of http://www.theage.com.au/news/technology/quarks-gluons-and-corroborating-emc2/2008/11/21/1226770694126.html
There is an interesting article in this month's Ophthalmology titled Hormone Replacement Therapy in Relation to Risk of Cataract Extraction: A Prospective Study of Women.
This study included 30,861 women aged 49 to 83 years who completed a questionnaire about hormone status, use of hormone replacement therapy (HRT) and lifestyle. Of these, 4,324 women underwent cataract surgery during the 98-month follow-up interval.
Results showed:
The study concluded that postmenopausal women using HRT for a long period of time may be at an increased risk for cataract extraction, especially those drinking >1 alcoholic drink daily.
It certainly makes sense for women who are or have beenon HRT to limit their alcohol intake if they wish to reduce their risk of cataract development.
There may be another reason to take that Lipitor besides lowering your cholesterol! In last month's Annals of Epidemiology there was article titled: Persistence with Statins and Incident Cataract: A Population-Based Historical Cohort Study.
180,291 new statin users in Israel were followed between 1998 and 2007 for incident cataract or cataract extraction. During the study period, 27,301 cataracts were diagnosed and 6,976 cataract extractions were performed among the participants. The results showed that:
Persistence with statins was associated significantly (P < 0.001) with a reduced risk of cataract in men and women aged 45 to 74. Men aged 45–54 with a high (>80%) proportion of follow-up days covered with statins had an adjusted hazard ratio of 0.62 (95% confidence interval: 0.54–0.72), compared with patients with low persistence with statins. In elderly patients, no relationship or a positive relationship was observed.
Men who took what are commonly referred to as statin drugs had a 40% lower risk of developing cataracts and women had an 18% lower risk.
The study concluded:
Persistent statin use was significantly protective for the incidence of cataract in men and women under 75 years of age.
This month's American Journal of Ophthalmology has an interesting article titled: Ten-Year Longitudinal Visual Function and Nd: YAG Laser Capsulotomy Rates in Patients Less Than 65 Years at Cataract Surgery. The authors followed 102 pf 116 patients who underwent cataract surgery before the age of 65 and evaluated their 10 year results. Here is what they found:
I have been performing LASIK since its inception back in 1996. Hard to believe its been 14 years. What I am now seeing on an ever increasing basis is patients who have had LASIK in the past complaining of a deterioration in their vision. Many of these patients come in assuming that their LASIK is "wearing off" and that they are in need of a "fine tuning." What is actually going on is that they have developed visually significant cataracts.
A cataract is an aging change that causes a clouding of the eye's cryastaline lens. Once visually significant, the treatment of choice is cataract extraction with the implantation of an intraocular lens (IOL). Cataract surgery in patients who have previously had LASIK poses several unique issues.
The calculations to determine the correct IOL power are not as accurate in eyes that have undergone LASIK. To improve the accuracy of these calculations it is helpful to have records from before the LASIK surgery including:
Many new techniques are being investigated to improve on IOL calculations. Just last month an article appeared in Journal of Refractive Surgery titled: Calculation of Intraocular Lens Power Using Orbscan II Quantitative Area Topography After Corneal Refractive Surgery. It concluded that "In eyes with previous corneal refractive surgery, IOL power calculation can be performed with reasonable accuracy using the Orbscan II central 2-mm total-mean power."
Even with all these new techniques, post LASIK patients are prone to encounter a "refractive surprise" following cataract surgery. A refractive surprise occurs when a patient's final Rx following cataract surgery is off the mark. Refractive surprise can be treated in several ways, depending on the amount of the surprise:
No matter how carefully caculations are made before cataract surgery, refractive surprises will happen. In my opinion, patients who develop cataracts following LASIK, should seek the care of a surgeon with vast experience in both refractive and cataract surgery. The trick here is to both minimize the amount of the surprise and to be able to efficiently treat the surprise when it is encountered.
One benefit many of my LASIK-cataract patients have is the ability to implant a multifocal IOL such as the ReSTOR. Following the implantation of this lens, these patients are now able to see both near and far again without glasses!
This week is the annual Hawaiian Eye Meeting. This is an excellent eye meeting held at an awesome location. According to their web site:
At Hawaiian Eye 2010, you can learn from more than 80 of the ophthalmic community’s foremost experts. Speakers will use their clinical experience and subspecialty expertise to provide you with new information and fresh perspectives on the practices and procedures you use most. You’ll be learning directly from the source – the researchers and specialists revolutionizing today’s ophthalmic techniques to improve patient care.
Although I am not attending this year's meeting, I do receive daily updates through Occular Surgery News. Today I received information concerning a lecture titled: Primary posterior capsulotomy a viable option for multifocal IOLs in hyperopes. According to the article:
Primary posterior capsulotomy with IOL optic buttonholing is a tricky surgery but can have excellent outcomes when implanting multifocal IOLs in hyperopes, a surgeon said here. "I use primary posterior capsulotomy in hyperopes to avoid secondary cataract and decentration," Michael C. Knorz, MD, said in a presentation at Hawaiian Eye 2010.
This is the perfect of taking a straightforward surgical procedure and making it a very difficult procedure with a much higher complication rate! The doctor in this article is trying to minimize 2 relatively insignificant complications of refractive cataract surgery:
So, in trying to minimize these 2 easily treated sequalae, this doctor is advocating a procedure of placing a hole in the capsule at the time of surgery and trapping the implant in the hole. With this new complications can be expected:
Presbyopia is caused when the eye's lens, normally soft and flexible, hardens with age and results in blurred reading vision. The hardening of the lens makes it difficult for the eye to focus on close objects. Presbyopia is part of the normal aging process, typically affecting adults at about 40 years of age. Reading glasses and bifocals are used to treat presbyopia. These assist the eyes in focusing on nearby objects. Since presbyopia affects the lens, LASIK eye surgery, which only treats the cornea, is unable to correct the condition. Therefore, LASIK patients past their mid 40's still need to wear reading glasses.
For those who do not to wish wear readers, the answer Refractive Lens Exchange (RLE), whereby we remove the eye's natural aging lens and replace it with a multifocal, artificial lens (IOL). In my opinion, the ReSTOR 3.0 offers the best possible vision at all ranges. This lens can also be implanted at the time of cataract surgery to markedly reduce the need for glasses after surgery.
Many of our patients at EyeCare 20/20 have questions concerning the use of the ReSTOR. Because of this, we have produced a very informative video that walks you through the entire process of one of our patient's, Ian Lang, experience with the ReSTOR implant. We hope that this video answers many of your questions! If you do decide to have a premium IOL implanted, make sure you have it done by a surgeon with vast refractive and cataract experience.
