34 posts categorized "Refractive Lens Surgery"

February 09, 2010

Young Patients with Cataracts do Better with Surgery

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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:

  • 37% of the patients under 65 at surgery had YAG capsulotomies in comparison to 20% of the older patients.  A YAG capsulotomy is used to treat an opacification of a membrane left in the eye at the time of cataract surgery (PCO) to improve vision.
  • Visual acuity diminished by more than 0.1 logarithm of the minimal angle of resolution (logMAR) units of the operated eye in 18% of the younger patients and 37% of the older patients.
  • A reduction in VF-14 score of 10 points or more was found in 9% of the younger and 28% of the older cataract surgery patients.
What this study shows is that younger cataract patients retain their improved vision more than their older counterparts.  This is good to know, as I am definitely seeing and treating more patients than ever under the age of 65.  When these patients opt for their premium lenses to help eliminate their need for glasses, I can reassure them that the vision will be lasting!

January 21, 2010

In the Pipeline: Toric ICL Shows Promise


There was an interesting article in last month's Ophthalmology titled:  Toric Implantable Collamer Lens for High Myopic Astigmatic Asian Eyes.  This article evaluated the early results of using the Toric Implantable Collamer Lens (TICL) in the treatment of patients with high myopia and astigmatism.  The results were very encouraging: 

  • 70.59% of eyes had uncorrected vision of 20/20 or better
  • 68.57% of eyes had better uncorrected vision better than the best corrected vision before the surgery
When a patient presents to my office at this time with high myopia and astigmatism, and they are not a candidate for LASIK, their only option is to have an ICL implanted followed by LASEK to correct their residual astigmatism.  The results of these two procedures is excellent.  The TICL is currently unavailable in the US at this time, but once approved, the entire refractive correction may be addressed with one procedure...  Very exciting!

January 19, 2010

Surgical Innovations: When the Enemy of Good is Better


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:

  1. After cataract surgery there is a 20% incidence of getting a clouding of a capsule we leave in the eye.  If this occurs, it is easily treated with a simple laser procedure called a YAG capsulotomy.
  2. There is a slight chance of decentration of the refractive IOL.  If it is mild, nothing needs to be done as there is no effect on vision.  If the decentration does effect vision, the implant can be repositioned easily through surgery, or the pupil can be moved with a laser treatment.

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:

  • increased retinal detachment
  • increased inflammation of the macula (CME)
  • increased vitrectomy (removal of the jelly in the back of the eye)
  • dislocation of IOL
As a surgeon, we need to be wary of innovations that purport to improve outcomes.  Many times these solutions have inherent risks which far exceed the risks of those procedures they claim to improve upon!

January 11, 2010

5 Reasons Not to Get LASIK at a Corporate LASIK Center


Corporate LASIK Centers have long touted themselves as the largest providers of LASIK in the US.  I have previously blogged about why I think it is important have your LASIK at a local LASIK provider that provides diversified eye care services.

Here are my top 5 reasons NOT to go to a corporate LASIK Center:

  1. Here today, gone tomorrow.  Corporate LASIK centers are large companies.  They are subject to all the external pressures facing corporate America today.  If our banks and auto industry have difficulty in an economic downturn, imagine the problems corporate LASIK centers face with diminishing consumer spending.  A case in point:  TLC, at one time a darling on Wall Street and one of the largest corporate providers, filed for bankruptcy in December.
  2. One trick ponies.  Most corporate LASIK centers specialize in LASIK only.  Many times a different procedure, such as ICL or Refractive Lens Exchange (RLE), may provide a superior outcome.  If the corporate center does not do these procedures, they are not offered.  By going to a diversified eye care practice, the correct procedure is paired with a patient's needs.
  3. Revolving doors.  The LASIK surgeon at a corporate center is generally an employee.  The turnover at these centers is very high.  One of the centers in my area is on their third surgeon in 5 years.  I know continuity of care is important for my patients.  I still see LASIK patients that I originally treated in 1996, 14 years ago!
  4. Commoditization.  Corporate LASIK centers would like you to believe that LASIK is a commodity.  They would like you to believe that LASIK surgery can be done by anyone, and the most important decision a patient can make is to find the best price.  I beg to differ!  Surgical experience and expertise go a long way in achieving superior outcomes.  I always tell patients to shop results, not price.  It is often difficult for a patient to shop outcomes.  The best way to do so is to do your homework.  Ask around and find that practice that has people raving about how well they see, how easy the procedure was, and how well they are treated every time they are seen.  This is who should be doing your LASIK!
  5. Lifetime Guarantee?  A great selling point that corporate centers give is the Lifetime Guarantee.  These Lifetime guarantees come with many strings attached.  The Laser Eye Center of Carolina recently blogged about many of these strings:
  • The lifetime guarantee only applies to patients within certain parameters. They typically are not available for farsightedness, or for patients with more significant amounts of nearsightedness or astigmatism. The lifetime guarantee only applies if you get an excellent outcome on your initial LASIK procedure.
  • The guarantee is void if you need an enhancement or “touch-up” procedure. 
  • The guarantee only applies if your vision changes to significantly more nearsightedness (worse than 20/40). What if you drift to 20/30 or become farsighted as you age? Sorry, you’re on your own.The guarantee allows only for additional LASIK procedures. Of course, there is a limit to the number of times a LASIK procedure can be performed and the guarantee does not apply to procedures such as conductive keratoplasty which may be a better option for you as you age. 
  • The center determines the advisability of further LASIK. This does not allow for the participation of the patient in the decision making. The “lifetime” referred to may be the lifetime of the center. With the current economic downturn, most LASIK-only centers are operating in the red. One large center in Charlotte, NC recently closed its doors. We have seen several patients who were patients of now defunct laser centers who found that their lifetime guarantees were worthless.
  • You may be required to undergo yearly exams at an affiliated doctor’s office. Miss one of these mandated exams and your guarantee becomes void. But what difference does it make how often you go in for an exam or where you go? The truth is, unless you have diabetes, glaucoma or some other eye condition, eye exams every two to three years may be sufficient according to the American Academy of Ophthalmology. Such restrictions are an unnecessary burden and expense making it difficult and in some cases, impossible for a patient to meet their obligation under this arrangement.

January 04, 2010

2010: Lose Those Bifocals! ReSTOR Your Vision!!

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.

November 19, 2009

Visian ICL Vision: Still Awesome After All These Years!


Frank Gallina is one of EyeCare 20/20's go to guys.  Whenever a patient is considering having an ICL implant to improve their vision, Frank is the person who we recommend they speak with.  Frank was a -12 myope who came in for a LASIK screening, he was not a candidate.  The ICL option was offered to him, he did it, and the results are awesome.  We even posted a letter Frank wrote us last year about his vision.

Frank is now 3 years post op.  His vision is still 20/20 without glasses.  Frank was nice enough to talk about his ICL experience with me on this video.

October 27, 2009

Who Should Implant Your Cataract Premium IOL?


There was an interesting presentation Sunday at the Annual AAO meeting in San Francisco given by Dr. Vinjay Shah.  EyeWorld Magazine summarized his findings:

Residents lacking in premium IOL, pediatric cataract procedure experience

Third year residents are not getting enough hands-on experience leading pediatric cataracts and implanting premium intraocular lenses (IOLs) according to Vinay A. Shah, M.D., University of Missouri, Kansas City, and his colleagues. Dr. Shah sent a survey to every third year resident accredited with the Accredited Council for Graduate Medical Education (ACGME) in the United States; 154 (35.5%) of the 434 residents completed the survey. Through this self-reported survey, residents responded that they were getting ample chances at extra-capsular cataract extraction (ECCE) with 40 residents having done more than 50 surgeries. But in terms of pediatric cataract surgery and premium IOL implantation, their experiences were lacking. For example, 102 residents never implanted a premium IOL, and all but seven residents had implanted premium IOLs in 10 patients or fewer. Similarly, 118 residents never performed a pediatric cataract surgery, and only three residents had done more than 10 procedures.

This interesting study leads me to ask two important questions:

  1. Should residents even implant any premium IOLs?
  2. Who should one go to if they want a premium IOL at the time of their cataract surgery?

Let me answer these two questions by first defining my goals of different surgical procedures:

  1. Cataract surgery is preformed on a patient when their cataracts are causing a decrease in vision that is interfering with their daily lifestyle.  The goal of cataract surgery is to improve the patient's best corrected vision.  If a patient has pre existing astigmatism, they will most likely still need distance glasses after cataract surgery.  All patients will also still need to wear reading glasses after cataract surgery, as the IOL does not focus for near objects.
  2. Many patients would like to decrease their dependence on glasses.  This is the goal of premium IOLs.  A toric IOL will decrease pre existing astigmatism and improve distance vision without glasses.  A multifocal IOL will allow one to read without glasses.  Uncorrected vision after cataract surgery may be further improved with LASIK surgery.

In my opinion any surgeon who is offering premium IOLs MUST have the following attributes:

  • Must be performing perfect, pristine cataract surgery, on a very consistent basis.  This only comes with experience and volume.  I would suggest going to a surgeon who does over 30 cataracts a month.
  • Must fully understand refractive surgery.  One of the biggest complaints I get from patients who see me for second opinions after premium IOL implantation is that they are unhappy with some aspect of their vision.  Most of these patients have a residual refraction in their eyes.  A simple LASIK procedure will usually correct this problem.  Many times, their operating surgeon does not offer this as an option, as they do not provide LASIK services.
  • Must have vast experience in premium IOL implantation.  There are many nuances that must be overcome to achieve success in the refractive cataract patient.  I would suggest going to a surgeon who does at least 20% premium IOL implantations of his cataract volume.

So, to answer the two questions I posed earlier:

  1. I do not believe residents should be implanting premium IOLs.
  2. If one is interested in reducing their dependence on glasses following cataract surgery, I would suggest going to a high volume surgeon with vast experience in both premium IOL implantation and refractive LASIK services.

October 25, 2009

Newest Trends in Eye Care From Annual AAO Meeting I


This week is the Annual Meeting of the American Academy of Ophthalmology (AAO).  Over the next few days I will report on a few of the latest trends being presented at the meeting in San Francisco.  Many of these short synopsises will be taken from "Academy Live" an e-mail; alert from the AAO.  Each synopsis will be followed by some of my personal commentary.

LASIK safe for Form Fruste Keratoconus?  Damien Gatinel, MD, went back and looked at outcomes after LASIK and PRK when they were performed inadvertently in patients with suspected keratoconus.  “Three years later, the results are so far satisfactory,” Dr. Gatinel said, “There was no topographical sign of ectasia in these patients.  Even if it’s not recommended, he concludes that refractive surgery seems safe in topographically diagnosed keratoconus suspect eyes with a good biomechanical profile. When the audience was polled as to whether they would perform surgery on patients with forme fruste keratoconus, 77 percent said they would not.  Even after hearing this evidence, I personally feel that it would be foolish to do LASIK on a suspected keratoconus patient, the risks are just too high!

New Phakic IOL from Alcon holds promise.  Ronald R. Krueger, MD, medical director of Refractive Surgery at Cole Eye Institute, evaluated safety outcomes from clinical trials of the AcrySof Phakic Angle-Supported IOL.  Vision increased by two or more lines for 20 percent of subjects, one line for 44.6 percent and unchanged for 33.8 percent.  Phakic IOLs are an excellent method of providing superb vision in high myopes.  I currently use the Visian IOL, a posterior chamber IOL manufactured by Starr.  The Alcon lens will allow more ophthalmologists to provide this technology to their patients once it is approved, as it will be a much simpler IOL to implant.

Avastin vs Lucentis Trials underway:  Avastin and Lucentis are competing in a hefty schedule of six head-to-head randomized clinical trials directly comparing their use in AMD patients, said Daniel F. Martin, MD.   Initial study results are expected to be available in early 2011.

Here’s the status of each of the studies:

  • The NEI-sponsored CATT (Comparison of AMD Treatments Trial) study began enrolling an estimated 1,200 wet AMD patients at 44 sites in the United States in February 2008. The four-arm study comparing bevacizumab and ranibizumab on fixed and variable schedules is proceeding well, according to Dr. Martin, with one-year results targeted for 2011.

  • In April 2008, researchers in the United Kingdom began enrolling an anticipated 600 patients at 17 sites in the IVAN (Inhibit VEGF in Age-related choroidal Neovascularization) study. This four-armed study compares monthly bevacizumab 1.25 mg and ranibizumab 0.5 mg injections given over two years with three monthly injections followed by PRN dosing.
  • The four-site German VIBERA study started enrolling 360 AMD patients in 2008 to receive three monthly bevacizumab 2.0 mg or ranibizumab 0.5 mg injections and additional injections as needed.
  • The Austrian MANTA study began assigning an anticipated 320 AMD patients in June 2008 to three monthly bevacizumab or ranibizumab injections, with additional treatment as needed.
  • Researchers in Norway began enrolling an anticipated 450 patients in the 12-site LUCAS study in March. Subjects receive bevacizumab 1.25 mg or ranibizumab 0.5 mg monthly as needed until dry, with intervals between doses decreasing over time.
  • French investigators opened enrollment this fall in the 600-patient, 20-site GEFAL study. Subjects are randomized to receive three initial monthly injections of one of the two drugs.

I am anxiously awaiting the results of these studies, as I am a strong advocate for the use of Avastin as a primary therapy in the treatment of SMD.

September 09, 2009

The ICL Option: When LASIK Won't Correct Your Vision


Lisa Velasquez was very disappointed when she came in for her free LASIK screening last month after I told her she was not a good candidate for the procedure.  With a -11.0 diopter prescription, I determined that there was not enough corneal tissue to safely perform LASIK on her.  I went on to explain that I could treat this amount of nearsightedness by implanting an ICL into her eye.

The Visian ICL (Implantable Collamer Lens) is a Phakic intraocular lens. It is an alternative to laser eye surgery, and is similar to the intraocular lenses (IOLs) used in cataract surgery but does not permanently alter the structure of the eye. No corneal tissue is removed as in LASIK and other laser eye surgery procedures. The ICL resembles a traditional contact lens and is surgically placed behind  the iris, in front of one's natural lens. Unlike the intraocular lenses used in cataract surgery, ICLs do not replace the eye's natural lens, but work with it, to correct moderate to large amounts of myopia (nearsightedness). Though phakic IOLs are intended to be permanent implants, they can be removed if complications arise or if the patient's vision changes.The insertion of the Visian ICL™ Implantable Collamer® Lens is  made through a small incision in the surface of the cornea. The Visian ICL™ is folded, requiring a smaller incision than other implantable lenses. Once inserted, the lens unfolds to its full size. No sutures are required in the procedure.  The procedure takes about 10 minutes, and is performed on an out patient basis.  One eye is treated at a time, a week or two apart.  Visual acuity is remarkably good, even 1 day after the procedure.

Lisa had her surgery last week on her right eye, and "has never seen better!"  She is anxiously awaiting surgery on her left eye.

July 29, 2009

Throw Away Your Bifocals With the ReStor Implant

Joan Gellis has been wearing bifocal glasses and monovision contact lenses for the past few years.  When Joan developed cataracts, she learned that there was a possibility of eliminating both, with the implantation of the ReSTOR IOL at the time of her cataract surgery.

With the help of this multifocal implant, Joan is now able to read, work on the computer, and drive without the need for glasses or contact lenses!  Her only complaint, "I didn't do it sooner!"

Joan was kind enough to share her experience with the ReSTOR at EyeCare 20/20.