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!

Pupil Size Not A Factor in LASIK Outcomes

There is an interesting article presented for publication in Ophthalmology titled:  Effect of Preoperative Pupil Size on Quality of Vision after Wavefront-Guided LASIK by Annie Chan MD and Edward E. Manche MD out of Stanford University.  This paper studies what I have noticed for a long time:  pre operative pupil size does not effect quality of vision in wavefront guided LASIK. 

Although large pupil size is viewed by some ophthalmologists as a relative contraindication to undergoing LASIK, preoperative pupil size does not affect quality of vision after wavefront-guided LASIK.  There is no doubt that with first generation lasers, pupil size was an important factor in determining night vision issues,.  However, I soon noticed that this was not the case when I upgraded to the Allegretto laser over 5 years ago.  This study supports my observations.

The study evaluated the effect of pupil size on quality of vision after wavefront-guided LASIK in a  study of 51 patients undergoing the procedure for mild to moderate myopia or astigmatism.  Pupil size was divided into 3 groups:

• 31 small pupils (up to 5.5 mm)
• 36 medium pupils (5.4-6.4 mm)
• 32 large pupils (at least 6.5 mm)

Night time glare, haze, and halo scores were increased for all pupil sizes in the first month, but improved over the folowing months. There was no significant differences among the 3 groups.   Visual clarity at night and day improved from baseline at all visits, and there was no association between pupil size and these measurements.

The authors conclude:

A number of previous studies found a strong correlation between the level of attempted correction and visual symptoms, particularly glare, after refractive surgery.  It is possible that the use of wavefront-guided ablations may play a role in reducing visual symptoms after refractive surgery, especially in eyes with higher levels of myopia and astigmatism.

Further comparative studies are needed to validate this hypothesis.

This paper supports what I have been telling my patients for a long time:  although it has been reported in the past that night vision issues may be related to pupil size, I do not see it with the Allegretto laser, in fact, I more commonly see an improvement in night vision as compared to glasses or contact lenses.

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...

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..

Eye Can Hear! Dual Sensory Impairment & EyeCare 20/20...

I see it every day in my office, a patient with cataracts and decreased vision who also has difficulty with their hearing.  It seems to me that a decline in vision goes hand in hand with a decline in hearing.

According to Lighthouse International:

Vision and hearing impairments are among the most common age-related conditions affecting the elderly. While there is an emerging literature regarding the profound functional, social, and physical and mental health consequences of either a vision or hearing impairment in later life, there is a dearth of existing knowledge regarding both short- and long-term consequences of dual sensory impairment for older persons. Yet, with the aging of the population, the numbers of older people experiencing a concurrent age-related loss in vision and hearing can be expected to grow substantially. Even current estimates of the prevalence of dual sensory impairments among the elderly range from 4% to 21%, depending upon used definitions and/or sources of data.

Here are some interesting statistics:

• Approximately 30 million Americans are hearing impaired.
• Hearing loss is the third most prevalent chronic condition behind arthritis and high blood pressure.
• 1 out of 4 people over the age of 65 has a hearing loss and 50% over the age of 75 have a hearing loss.
•  You could be at risk if you work or spend a lot of time around noise without protecting your ears. Professions at risk may include: musicians, construction workers, military personnel, firefighters and police officers.
• Hearing loss can be caused by a number of factors – the aging process, heredity, disease, noise and build-up of earwax, among others.
• Noise can be dangerous. If it is loud enough and lasts long enough, it can damage your hearing.
• If you experience a number of warning signs or if people often tell you that you’re not hearing well, you may have a hearing loss.

Some warning signs of hearing loss include:

• People seem to mumble more frequently.
• You experience ringing in your ears.
• You often ask people to repeat themselves.
• Your family complains that you play the TV or radio too loudly.
• You have been told that you speak too loudly.
• You have trouble understanding all of the words in a conversation.

A big topic of conversation at this years AAO meeting was the implementation of hearing evaluations in ophthalmology offices.  Well, today at EyeCare 20/20 we have decided to do something with what we call Dual Sensory Impairment.  As part of the annual eye exam im patients over 50, we will also do a brief hearing screening.  We will than go over the results, and if a problem is detected, we will offer a free full hearing evaluation by a liscensed Hearing Care Practitioner.  We have also installed a full service BellTone hearing aid center in our office to deal with our patients hearing issues.

For more information on Dual Sensory Impairment at EyeCare 20/20, click here.  Or, to take a hearing self test, click here.

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!

Chicago, Here I Come!

Just getting ready to pack my bags for a working weekend in Chicago.  I will be attending the annual AAO (American Academy of Ophthalmology) meeting.  This meeting, along with the ASCRS (American Society of Cataract and Refractive Surgeons) meeting in the spring, are the two "big" eye meetings of the year.

Personally, I plan on getting certified in using the Toric ICL by Staar, looking for new equipment, checking out EMR (Electronic Medical Record) systems, and reconnecting with old friends and colleauges.  If anything intersting crops up, I will either blog or tweet about it.  @aao_ophth has asked me to use #aaochi10 hashtag on twitter to follow tweets and pearls live at the conference!    

American Medical Care Continues to Lag: AcrySof® IQ ReSTOR® Multifocal Toric IOL Released Outside the USA

Alcon labs announced this week the release of the AcrySof^® IQ ReSTOR^® Multifocal Toric intraocular lens (IOL) outside the United State.  The AcrySof® IQ ReSTOR® Multifocal Toric IOL combines the technologies of the ReSTOR® +3 add multifocal IOL and the Toric IOL.  Data demonstrated that the AcrySof^® IQ ReSTOR^® Multifocal Toric IOL delivers similar quality of vision when compared to the AcrySof^® IQ ReSTOR^® +3.0 D IOL.

This lens will allow surgeons to offer their patients who have pre-existing astigmatism a lens that provides quality vision at all distances after cataract surgery or clear lens exchange. Up until now, I have treated these patients with the ReSTOR^® Multifocal implanted at the time of cataract surgery.  Residual astigmatism is then treated about 1 month later with LASIK.  This new lens will allow me to treat both conditions at the same time, and use less surgery. 

There is only 1 problem:  this new lens is NOT AVAILABLE IN THE UNITED STATES!  Alcon plans to file a Pre-Market Application (PMA) for the lens with the U.S. Food and Drug Administration (FDA) in early 2012.  Once again, the draconian ways of our FDA have allowed medical care outside the US to out pace our own, we continue to provide third world medical technology to our patients...  Another part of our broken health care system in need of repair.