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."

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.

 

ICLs Surpass 200,000 World Wide Implants

STAAR Surgical has announced that more than 200,000 of its implantable contact lenses (Visian Implantable Collamer Lens) have been implanted in patients worldwide.

Since 1994, these lenses have been used in refractive surgery as an alternative to LASIK.  I have been using the ICL for the past 4 years, since their introduction to the US, to effectively treat my myopic patients who either have a degree of myopia too high to be treated with LASIK, or who would not do well with corneal refractive surgery. 

Since it was introduced in 2006, the Visian ICL has been improving the vision of the bravest people in our nation under the harshest of conditions imaginable. In fact, to date surgeons in the US military have implanted over 3,000 ICLs with results that are nothing less of heroic. In a retrospective analysis of outcomes in 139 consecutive eyes of US military personnel implanted with the Visian ICL:

• 100% of patients believe the Visian ICL enables them to function and perform better
• More than 80% patients achieve UVCA on 20/15 or better
• 86% achieve UCVA the same or better than per-op BCVA

The bottom line? If the Visian ICL can meet the needs of US soldiers on the battlefield, one can be confident it will deliver excellent vision for demanding younger patients with active, fast-paced lifestyles – every day.

 

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...

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!

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.

Coming Soon to an Optician Near You: Electronic Bifocals!

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. There are currently 3 ways to use glasses to treat presbyopia:

1. Bifocals with the line
2. Progressive bifocals without the line
3. Separate distant and reading glasses

A company called PixelOptics has announced their intention to release a forth option this fall:  emPower lenses.  According to PixelOptics:

If you wear bifocals or progressive lenses, this technology will revolutionize the way you see and use your eyeglasses. emPower!™ will:

• Focus as fast as you can blink your eye
  
• Provide an invisible electronic near focus zone when desired
  
• Offer three modes of operation: automatic, manual on, manual off
  
• Provide wider fields of view compared to a progressive addition lens
  
• Allow for less distortion than a progressive addition lens
  
• Provide vision correction for all ranges of sight: far, near, and in between
  
• Allow you to turn near reading power off when desired Rechargeable hidden battery

Here is a demonstration of this new technology.

Since presbyopia affects the lens, LASIK eye surgery, which only treats the cornea, is unable to correct the condition.  The most effective surgical treatment in my practice is clear lensectomy:  removing the natural lens and replacing it with a multifocal lens implant.  Following this procedure, my patients are able to both read and drive without glasses!

Treating Astigmatism: No Distace Glasses After Cataract Surgery With Toric IOL

Paul Cooper was a nearsighted patient with astigmatism who developed cataracts.  He has spent much of his life dependent on glasses.  After consultation, Mr. Cooper opted to have a toric IOL implanted during his cataract surgery.  This allowed him the best possible spectacle free vision.  One day after the surgery, Mr Cooper is seeing 20/20 and anxiously awaiting surgery on the second eye.

Mr. Cooper was kind enough to share his experience with us at EyeCare 20/20:

Nora Kirk Loves Her New Vision Following ICL

Dr. Sapna Parikh interviewing Nora Kirk for Fox 5 News.

As I mentioned yesterday, Fox 5 was at EyeCare 20/20 this week for an upcoming story.  Nora Kirk was one of our patients who was interviewed.  Nora sent us an e-mail today about her experience:

Hi Kerrie.

How are you . I just wanted to say thank you for thinking of me for the fox 5 news interview.  It was very exciting. I really have not given Dr. Silverman, you & your staff the proper thank you for all you have done.  I've been pretty busy with my family & work all of this time,  I have never forgotten the gift of sight that was made possible through Dr, Silverman and your staff.  I have very high regards for all of you and I always try to encourage those I come into contact with about the services you provide. I have and always will have the upmost respect and confidence in Dr. Silverman and his associates. Again if I may be of any service in the near future, please do not hesitate to contact me.
 
 
Yours truly,
 
Nora Kirk