Would you like your Cataract Surgery with a Double Shot?

Cataract surgery and coffee have something in common. Five to ten years ago they shared this attribute: there were few, if any options. You wanted coffee? OK, would you like that with cream or sugar? Had cataracts? Would you like... Actually, there were no real options five to ten years ago. If you needed surgery it was scheduled and your surgeon chose the intraocular lens (IOL) for you.Now, however, there is a dizzying array of options available to anyone who saunters up to the barista or the cataract surgeon. Coffee? Would you like that in a Grande or Venti? Cream, lowfat milk, or soy? Vanilla, sugar-free vanilla, caramel, mocha, or flavor-of-the-week? The same is now true of cataract surgery. Would you like a spherical or aspheric IOL? Astigmatism correction? How about the ability to see distance, intermediate, and up close? , You can now select for two out of the three -- a major improvement over just a few years ago.

So how do you choose? As a cataract surgeon who has performed over 2,000 cataract surgeries, I can tell you it is not an easy decision. You only have two eyes so it's an important decision to make if you are presently in need of cataract surgery. (If you're not in need now, you should be assured that the technology improves every year – increasing your menu of choices by the time you’re ready.). The best way to begin is to consider your goals.

With coffee, there is one initiating decision: caffeinated or decaf? With cataract surgery there is one key question: "Do you mind wearing glasses?" If the answer is "No," then you're done. Stop reading this article because the rest is not applicable to you.

If you dream of throwing away your glasses after cataract surgery, keep dreaming.
There are currently no IOLs that will allow you to do that. If, however, you have certain activities that you would like to do without glasses and wouldn't mind wearing glasses "occasionally," then read on - because the newer advanced IOLs can provide for that. Following is a list of available alternatives sorted by need. Simply find the description that fits you best to find the IOL for you.

One caveat: all of the options except the first will require an out-of-pocket expense. Medicare and most insurances do not pay for the IOL "upgrades." If you want your insurance to cover the entire tab then Option #1 is for you.

Option #1: You don't mind wearing glasses all the time. Congratulations. The standard IOL covered by insurance will meet your needs just fine and with the money you've saved you can upgrade your coffee for a year or so at your local barista. Take note, however, Medicare does not cover the fee for refraction (an exam to determine what glasses you will need after surgery), so save back $50-100 (plus the cost of those designer frames) for this.

Option #2: You would like good distance vision without glasses but don't mind wearing glasses to use the computer and read. You may be a candidate for either an aspheric or toric IOL. The aspheric IOL corrects what are called "higher order aberrations" resulting in excellent distance vision. However, if your cornea has any significant astigmatism, this will have to be corrected with either a "toric" IOL or corneal refractive surgery. Both of these would be at an additional cost.

Option #3: You would like good distance and intermediate (computer) vision without glasses but wouldn't mind wearing glasses for reading. You have two options available to you: the ReZoom multifocal IOL or the Crystalens accommodating IOL. The ReZoom IOL simultaneously focuses two images onto your retina so you can see both distance and intermediate objects at the same time. The trade-off, however, is that there will be small circles (halos) around lights at night. Most people get used to this with time but a small number of people (about 5%) find these halos to be a significant distraction. The Crystalens uses what is called pseudo-accommodation: it uses tiny muscles in the eye to move the lens back and forth changing the focusing power of the IOL. Although there are no halos associated with this IOL, not all people are able to "train" their eye muscles sufficiently after surgery to get the desired range of vision.

Option #4: You would like good distance and reading vision without glasses but wouldn't mind glasses for intermediate (computer) vision. You also have two options available to you: the Alcon ReSTOR IOL or the AMO Tecnis IOL. Both use what is called "diffractive optics" to split light into both a distance and a near image. Since two images are simultaneously focused on your retina, there will be small circles (halos) around lights at night. As with multifocal IOLs, most people get used to this with time but a small number of people (about 5%) find these halos to be a significant distraction. Glasses are often still required for intermediate (computer) work.

An additional caveat: no matter which IOL you choose, you may still need night-time glasses. The reason for this is that your pupil dilates in the dark allowing rays of light from the edges of your cornea into the eye. These rays are focused at a different strength than those from the center of the cornea so you end up a little near-sighted when driving. Generally, a simple pair of night-driving spectacles correct this condition.

If you are currently considering cataract surgery I hope this helped you make this ever-more-difficult decision. If you don't need surgery yet, I promise to provide updates on my website http://www.sgveye.com/ or blog whenever there are significant technological changes that increase your menu of choices.

"My eyes can't be dry. They tear all the time."

I'm going to take a break from discussing cataract surgery today and focus on something even more common: dry eye syndrome. One of the most common eye diseases I see is dry eye syndrome. The most common symptom of dry eyes: tearing. The most common response I get when I tell someone with tearing that they have dry eye syndrome: "My eyes can't be dry. They water all the time."

Yes, it appears to be contradictory but it's a fact. The reason dry eyes lead to tearing is as follows: dry eyes (like dry skin) are more sensitive to irritation; irritation is interpreted by the brain as "there is something in the eye;" the brain's response to this is to flush it out resulting in a flood of tears being release by the lacrimal gland. It's an issue of too much, too late.

It is common for the eyes to dry out with any activity that involves extended concentration such as computer use. In addition to tearing, symptoms of dry eyes include: an "awareness " of the eyes, soreness, redness, discharge, "sticky" eyes, itching, foreign body sensation, blurred vision, "tired" eyes.

Treatment options include the following:

1) Tear Replacement Therapy (artificial tears). There are so many brands out there it is difficult to recommend just one. Some of the better brands include:

- Blink

- Endura

- Optive

- Refresh

- Soothe (my personal favorite)

- Systane

- Theratears

Each one is formulated differently so which one works best is hard to determine without first trying it.

2) Nutritional Supplements. There is some evidence that taking Omega-3 fatty acids (such as fish oil or flax seed oil) by mouth can benefit the symptoms of dry eye. These come in gelcaps and are generally recommended once or twice a day with food.

3) Prescription medication. Currently only one medication, Restasis, is approved by the FDA for treatment of dry eye. This must be used twice a day for at least a month. It stings, is expensive, and only works in 50% of people who take it.

3) Punctal plugs. When someone's eyes are not producing enough tears to keep the eyes lubricated it does not help that tears drain through "puncta" into the nose (this is why you get the sniffles when you cry). The solution: plug these drainage duct with small silicon plugs. This can be done by an eye doctor in the office. It is a painless procedure that only takes a few minutes.

Why your friend didn't really have his or her cataract removed with a laser

Not a week goes by in which I am told by a patient with 100% conviction that her friend had cataract surgery done with a laser. Although it is remotely possible that this conviction is well-founded, I'm going to explain why it's far more likely that her friend is mistaken.

In fact, the vast majority of cataract surgeries are done using ultrasound energy (also known as phacoemulsification). That being said, it is possible (though unlikely) that the friend in question had laser cataract surgery. During the late 1990s and into the early 2000s there was a brief interest by a very few surgeons in using a laser to remove the cataract. Even so, this still required making a 3mm incision in the eye (so no, you cannot avoid "going under the knife").

However, the laser technology was far inferior to the advanced ultrasound technology (which has been steadily improved upon since the 1970s). The only surgeons still using this short-lived laser technology are those who invested in it and feel they have to get some mileage out of their investment. Oh, and it does sound sexy to say that a laser is used to remove the cataract.

Ultimately, if someone has a cataract the best option available in the US is an advanced ultrasound technology called "cold phaco." This beats the pants off any laser still hanging around. Perhaps in a future post I'll discuss cold phaco in more detail.

So why, then, are so many people convinced that they had their cataracts removed with a laser? The answer is that a laser is used to treat "after cataracts." This term is actually a misnomer for posterior capsular opacification (or PCO). A PCO is actually a type of scar that forms behind the IOL months to years after cataract surgery. Think of it as similar to frost on a window.

In order to remove this haze and improve vision a YAG laser is used to tear open the capsular bag behind the intraocular lens (IOL). Prior to the use of this laser surgeons used to poke a needle into the eye and scratch the capsule to tear the scar out of the visual axis. Needless to say, the laser is a big improvement over the needle.

As YAG capsulotomy is the second most commonly performed surgery in the world (cataract surgery is the most commonly performed surgery), it is not surprising that many people mistakenly think that cataracts are removed by lasers.

Click on this link to read more about posterior capsular opacification and YAG capsulotomy.

"Name that Tune" Cataract Surgery

Some of us remember the game show "Name That Tune" in which contestants would compete to name a tune in the least number of notes. The back and forth would go something like this:

Contestant 1: "I can name that tune in 5 notes."

Contestant 2: "I can name that tune in 4 notes."

And so on...

At times it would get just ridiculous with a contestant trying to name a tune in only one note. This type of one-upmanship has a place in entertaining game shows but unfortunately has found its place in modern cataract surgery.

We've all heard that cataract surgery only takes 15 minutes, or 10 minutes, or some other ridiculously small amount of time. And, it is true that a talented cataract surgeon can usually complete a straightforward, uncomplicated cataract surgery (from incision to closure) in 10-15 minutes.

Unfortunately, the impression is that because the surgery only takes a small amount of time it is "a piece of cake" to do. Nothing could be further from the truth. Although it is every surgeon's goal to make the surgery "a piece of cake" for the patient, cataract surgery (done correctly) takes a great deal of preparation, concentration, and skill.

Have you ever seen a Cirque du Soleil performance? The way those performers gracefully execute their acrobatics conceals the intense concentration, strength, agility, and balance required. Indeed, the best performers "make it look easy." If you've ever gone home after a show and tried to replicate even the easiest of the positions you probably threw out your back.

I'm no athlete, but I know those Cirque du Soleil performers have practiced for hours each day, every day for years to make their 5 minute performance look "easy."

A similar kind of dedication, skill, and innate talent is required to become an expert cataract surgeon. Most cataract surgeons in training take one to two hours to complete their first cataract surgery. Over the next couple of hundred cases they will often improve their skills enough to complete surgery in 20-30 minutes. Most surgeons never get down to 15 minutes per surgery.

Does it matter?

It does, but not for the reasons you may be thinking. Unfortunately, because some ego-centric surgeons started to advertise that they could complete cataract surgery in less than 10 minutes, Medicare and other insurances have cut their rates of payment from an inflation-adjusted rate of $6,000 in the 1970s to a little over $600 today. What this does not recognize is that (1) most surgeries take longer; (2) cataract surgery involves a significant amount of time planning prior to surgery; (3) there is a value that should be assigned to the skill required to perform modern cataract surgery.

Unfortunately, this reduction in perceived value of cataract surgery has resulted in pressure from surgery centers and hospitals to cuts costs, cut time, and cut corners. My average cataract surgery may take only 12 minutes, but if I feel that I need to take a little longer and place a suture I'll do so. However, I know that the surgery center feels the financial pain every time I do so as operating room time is very expensive (as is the suture). I'm just waiting for the day when the center tells me, "I'm sorry Dr. Richardson, but we can no longer stock that suture (or other device) because we lose money every case it is used.

Modern cataract surgery is a truly amazing convergence of technology and skill. It is a joy for most cataract surgeons to perform and is usually a "piece of cake" for the patient. However, modern financial constraints are placing undue burdens on both the surgery center and surgeon to cut costs in an attempt to keep pace with ever decreasing Medicare and insurance reimbursement.

There are appropriate venues for competitive one-upmanship - game shows, for example. But when reimbursement pressures result in surgery centers and hospitals competing for cataract surgeons based on how much they can save in time and equipment costs, I fear that patient safety could be at risk.

Softserve IOL?

Modern cataract surgery has come a long way from the days of "couching" (an ancient surgery that essentially involved sticking a needle in the eye and pushing the cataract out of the visual axis). Nevertheless, modern surgeons still worry about the most devastating complication of cataract surgery: post-operative infection, or "endophthalmitis." Granted, in ancient times this risk was probably quite common. Today rates of post-operative infection range from 1 in 500 to 1 in 2,000 (depending on the study).

The single largest contributor to risk of infection with any surgery is incision size. The smaller the incision, the lower the risk of infection. With cataract surgery, the larger the incision, the greater the risk that bacteria can enter the eye with blinking. Current cataract surgery requires an incision of only 3mm in length. Now, one might think that an incision size of less than 3mm is pretty small, but there is evidence that if we could get the incision below 2mm it could be truly water-tight keeping bacteria out of the eye.

So, what's keeping us from doing everything through a 2mm incision? We can now remove the cataract through a 2mm incision safely. The problem is getting a new lens (IOL) into the eye. Presently all lenses must be folded or placed in a cartridge and squeezed through the incision. The smallest incision that we can tire-iron these lenses through is 2.2mm (and that's pushing it - pun intended).

If only there were a way to get an IOL through a smaller incision...

Turns out there are two material technologies that could be used to place an IOL through such a small incision. I've already mentioned the SmartLens material which changes shaped according to temperature.

The other material being researched is a polymer that could be injected through a small incision into the capsular bag (this holds the IOL in position) where it would then "cure" or harden into the correct shape.

There are, however, many technical hurdles that must be overcome prior to implementing this technology. For one, how do we know how much material to place in the capsular bag. Presumably, the more material we place in the bag the stronger the IOL will be. But how do we customize this to the needs of that individual eye?

Additionally, how do we cap off the polymer so it doesn't leak out of the bag? Finally, there is the issue of cure rate. If the material cures too fast the surgeon won't have time to make the adjustments necesary for a good refractive result. Too slow and surgeons won't use it (more on the modern time-constraints of surgery in a later post).

I'd give this technology a high probability of appearing on the horizon, but I'd set that horizon at 5-10 years at least.

Is blue light special? (post 4 of 4)

You've now read a summary (by no means exhaustive) of the arguments for and against using a blue-blocking tint in IOLs. So, is it a thumbs up or thumbs down? As you might have guessed from the first paragraph of the first post in this series, there is no straighforward answer.

Those who are strongly in favor of using a yellow tinted IOL cite the evidence supporting an association of macular degeneration with shorter-wavelength blue light while pointing out the lack of strong evidence supporting any disruption in sleep-wake cycles or notable detriment in color perception.

Those opposed to the use of a yellow tinted IOL cite the evidence supporting a disruption of sleep-wake cycles, and loss of night vision and color sensitivity with blue-blocking IOLs while pointing out the lack of strong evidence supporting a causal effect of blue light on the progression of macular degeneration.

The answer, clearly, is that we don't know. So what is one to do? Most likely, if you have cataract surgery in the US you will have a blue-blocking IOL implanted in your eye as the Alcon AcrySof is the most commonly used IOL by US surgeons. If this bothers you then discuss it with your surgeon. If this all seems like much ado about nothing then I wouldn't lose any sleep over it.

...or will you (pun intended)?

Is blue light special? (post 3 of 4)

In part 3 of my 4 part series on blue-blocking IOLs I am going to discuss the reasons why it might not be such a great idea to implant a blue-blocking IOL into the eye.

Color perception concerns

If you have ever tried on a pair of blue-blocking sunglasses, do you remember your initial impression? Many people find the yellowing of their world to be a bit disconcerting. Contrast is usually notably improved, but at what cost? I personally do not like the tint though I do appreciate the improved contrast sensitivity when I'm on the slopes.

But, unlike my ski goggles, an IOL cannot be put in or taken out based on one's activities. Once it's placed, it's there for life (one hopes, anyway). Does a tinted IOL significantly affect color perception? Current studies are conflicting on this point. Of those who have had a tinted IOL placed in one eye and a non-tinted IOL in the other most do not perceive a difference. However, some do notice it. It may be that those who notice this color difference are the ocular equivalent of audiophiles. Most of us cannot tell the difference between a song played back on CD or 128bit MP3 - but run the same comparison by a professional musician or audiophile and the difference will be obvious to them. Could the same be true of color perception?

Possible disruption of the natural circadian rhythm

Our normal sleep-wake cycles are set by exposure to light - specifically, the blue wavelengths of light. Blue light suppresses the production of melatonin which is thought to be the main hormone that controls our sleep-wake cycle. Theorhetically, blocking these wavelengths of light could disrupt this cycle. However, the available clinical studies are not conclusive one way or the other.

Lack of strong evidence of any benefit

The blue-blocking filter in the Alcon Acrysof IOL mimics the yellow tint present in the average 50 year old human lens. This begs the question: why would anyone want an IOL that mimics a 50 year old lens? The answer presumes that there is a definite benefit to blocking these wavelenghts of light. But is there? And if there is not, wouldn't you rather have a lens that mimics that of a 20 year old?

So, is there or isn't there a benefit to blocking the shorter wavelengths of light? I'll pick up this thread in my next post.

Is blue light special? (post 2 of 4)

In my last post I introduced the controversy concerning blue light filtering IOLs. You may be asking yourself, "If it's good for skiers and helps with contrast sensitivity, why wouldn't I want an IOL to block the blue rays of light?" Tomorrow I'll address that question.

First, let's look at the reasons touted to block the far blue spectrum of light and clarify that no one is suggesting that all blue light be blocked, only the shorter "near-ultraviolet" wavelengths of light. The main reason touted by those in favor of blocking these shorter wavelengths of blue light is the evidence that these wavelengths may increase the risk of macular degeneration.

This evidence is largely culled from population-based studies. Essentially a large number of people were observed for years and examined for the development of various diseases such as macular degeneration. Those who developed macular degeneration were compared to those who didn't. Attributes such as nutrition, activity, and environmental exposures were evaluated. A correlation between macular degeneration and exposure to light was noted.

Additionally, there are some studies that have suggested a correlation between cataract surgery and worsening of macular degeneration. There are many reasons why this could be (inflammation, ease of detecting macular degeneration after a cataract is removed, etc.). One theory is that because most synthetic IOLs allow a greater spectrum of light into the eye than the natural cataractous lens that these rays of light may be capable of damaging the retina.

Indeed, there is laboratory evidence of "phototoxicity" when retinal cells are exposed to near-ultraviolet light. This is suggestive that a similar effect could occur in a living eye.

So, with the above evidence suggesting that a blue-blocking IOL may protect from macular degeneration and improve contrast sensitivity, why wouldn't all surgeons be using them?

As it turns out, there are quite a few reasons not to place a blue-blocking IOL in the eye. I'll discuss the main arguments against use of these IOLs in my next post.

Is blue light special? (post 1 of 4)

There is a war being waged in ophthalmology with all the zeal of a religious war. And, like a religious war the two camps each believe with all their heart and soul that they are right and doing what is best. So what could make an IOL so controversial?

Cataract surgery has a long history of controversy. Early cataract surgery shared a complication of modern surgery: blindness. Whereas this is a rare complication of modern surgery, it was relatively common in early attempts to remove the cataract. What was probably uncommon was finding someone willing to perform cataract surgery. This was due to the Code of Hammurabi which prescribed a very harsh penalty for cataract surgery gone wrong: cutting off the surgeon's hands. Compared to the fee for cataract surgery (ten shekels of silver - not even gold!) the risks do seem to have outweighed the benefits to the ancient cataract surgeon.

Fast forward to the mid-1950's: Dr. Harold Ridley firsts attempts to place a lens inside the eye after removing cataract surgery. He was severely ostracized by the medical community for what was seen as reckless behaviour. Here in the US the FDA was even ready to ban the use of IOLs until Robert Young (the actor who played Marcus Welby, M.D.) testified in favor of the IOL.

So what is the current source of online and in-print flame wars among otherwise professional and staid ophthalmologists?

Blue light.

Huh?

Yep, blue light. Or, rather, the blocking of this light with a yellow-tinted filter. The correct way of thinking about these filters is not that the filter adds yellow, but rather that it absorbs blue (when blue is subtracted from the visible light spectrum an object takes on a yellow tint).

Skiers have known for years that blocking blue light with a yellow tint increases contrast sensitivity on the slopes. "Blue blockers," or yellow-tinted sunglasses are also very popular with those involved in watersports. There is even a pair of glasses advertised in some magazines to cut glare from nighttime driving that has incorporated a yellow-tint.

So, if filtering the blue spectrum of light provides the benefits mentioned above, why wouldn't a blue light filtering IOL be a good idea? Indeed, the major manufacturer of IOLs in the US (Alcon) does not offer any of its popular single-piece IOLs without a blue-filtering pigment.

Herein lies the controvesy. Not everyone agrees that filtering blue light is a good idea. It's one thing to put on a pair of sunglasses with a yellow tint. But, should we really be surgically implanting these lenses in the eye after cataract surgery?

In my next three posts I will summarize the support for and against blue light filtering IOLs.

What the Prostate has to do with Cataract Surgery

I'm going to take a break from discussing IOLs in order to summarize another very important talk given by David Chang, M.D. from UCSF. Really, anyone in the Bay area who needs cataract surgery should stongly consider at least an opinion from Dr. Chang. Mind you, I've never been in surgery with him and have absolutely no financial connections to him. However, his papers and presentations (which include videos of his work) are awe-inspiring among cataract surgeons (at least this one).

First, a little background on cataract surgery. Prior to cataract surgery the iris must be dilated in order for the surgeon to get to the lens (cataract). This is done both to obtain good visualization of the cataract and to protect the pupil which is a very delicate tissue and is easily damaged when it comes into contact with metal instruments.

Dr. Chang noted a few years ago that the iris of certain patients would become "floppy" during cataract surgery and dilation would be lost. This resulted in a very poor view through the small pupil, increased intraoperative complications (secondary to the poor view), and damage to the iris (because it flopped around inside the eye during surgery). This syndrome became known as Intraoperative Floppy Iris Syndrome (or IFIS).

David Chang, MD, and John R Campbell, MD, with the help of others (whose names I cannot recall - my apologies), collected all the information they could about these patients and discovered that they all had one thing in common: use of a prostate medication called Flomax®.

Flomax® (or tamsulosin) is a selective alpha-1 adrenergic antagonist that relaxes the smooth muscle of the prostate allowing men with Benign Prostatic Hyperplasia (BPH) to urinate more easily. Doctors also prescribe these medications for women as a treatment for urinary retention. Unfortunately, it appears that Flomax® has a permanent effect on the iris muscle that greatly increases the challenge of cataract surgery.

Other medications in this class include the newly released Rapaflo® (silodosin), as well as a group of medications termed "non-selective" alpha-1 adrenergic antagonists which include Hytrin® (terazosin), Cardura® (doxazosin), and Uroxatral® (alfuzosin). These non-selective drugs are less likely to result in IFIS.

Fortunately, if a cataract surgeon is aware that someone is taking one of these medications, he or she can take some additional precautions prior to or during cataract surgery to minimize the risks of IFIS. If you are taking any of the above medications or if your primary medical doctor is recommending that you start, it is a good idea to let your ophthalmologist know about it. If you don't yet have an ophthalmologist, this would be a good time to get one.

SmartLens or science fiction?

All currently available IOLs have one thing in common: they are the same shape in the manufacturer's package as they are inside the eye. In order to get these IOLs through a small incision and into the eye these lenses must be folded or squeezed into an insertion cartridge and "delivered" into the eye.

Just as in the delivery of a baby, squeezing through a small canal has its risks. The IOL can be deformed or torn. The incision can be stretched resulting in a leaky wound. The later can result in an increased risk of infection.

Enter the thermoplastic hydrophobic acrylic material. This material has a science fiction-like ability to change shape as temperature changes. At room temperature it is shaped like a rod allowing the surgeon to easily slip it through a small incision and into the eye. As the material heats up to body temperature it transforms into a biconvex lens. Truly amazing!

This IOL is still experimental so we won't see it for a couple of years (at least). Nevertheless, it is an exciting technology and worth watching.

A NuLens for Presbyopia Correction

Probably the most unique approach to the problem of presbyopia-correcting IOLs is the mechanism used in the NuLens. This lens tries to mimic the natural process that occurs in some water birds such as penguins. These birds' eyes have a rigid iris and a soft lens. To increase the power of the lens these birds have a muscle that pushes the soft lens up against the iris resuling in a protrusion of the lens through the iris. This central bulging results in a greater power of the lens.

One way to picture how this works is with a peanut butter sandwich. If you are generous with your peanut butter and press the two slices of bread together the peanut butter will ooze out the sides of the bread. Now instead, imagine that you have created a central hole in the middle of the top slice of bread (the iris). If you push on the bottom slice of bread the peanut butter (the lens) will bulge forward through the central hole. This is essentially how the lens of a water bird works.

The NuLens is essentially a very small peanut butter sandwich with the peanut butter replaced by a silicon gel and the bread replaced by a rigid clear material. Initial studies in monkeys have been very promising. However, it will be awhile before this is approved for use in humans.

The recession will be over long before the FDA gives its blessing so it is not going to be an option for you if you need cataract surgery in the next couple of years. Nevertheless, the technology is exciting and many baby boomers will have quite a few awesome choices when it is time for them to have cataract surgery.

The Tetraflex IOL

Of the new technologies presented at the joint meeting of the American Society of Cataract and Refractive Surgery (ASCRS) / University of California, Los Angeles (UCLA) Jules Stein Institute in Century City, the Tetraflex was probably the least likely to be remembered.

Lenstec Tetraflex IOL
This IOL platform, presented by Paul Dougherty, M.D., seemed to have only one benefit over multifocal IOLs: minimal post-operative glare. However, that benefit already exists with the Crystalens IOL.

This talk actually began with a discussion of the near acuity patients really need to read magazines, newspapers, etc. After a not very convincing explanation about why we really don't need to see the equivalent of 20/20 up close, Dr. Dougherty presented results that were objectively worse than what any of the presently available IOLs were capable of delivering.

One caveat: the patients in his study preferred the Tetraflex over the Crystalens even though the vision from the Crystalens eye could see smaller letters on the near eye chart. Now, I'll be the first to admit that our visual requirements in the real world do not directly correlate with what we can see on an eye chart. So, it is possible that the vision patients experience with the Tetraflex is somehow superior to what is measured with the eye chart.

It will be awhile before this IOL is approved for use in the US. Unless studies are able to show a clear benefit of this IOL over the currently available Crystalens, however, I seriously doubt this lens will become a major player in the IOLs offered by most surgeons.

A new paradigm in IOLs - The Synchrony

This first week of my blog I am summarizing some of the exciting new technologies presented at the joint meeting of the American Society of Cataract and Refractive Surgery (ASCRS) / University of California, Los Angeles (UCLA) Jules Stein Institute in Century City.

Yesterday I discussed the most exciting new IOL technology on the horizon for monofocal (single-distance) IOLs. Today, I'm going to talk about what I think is the most exciting technology in the "presbyopia-correcting" IOLs.

First, a word about presbyopia. When we are young, our eyes are able to focus over a wide range from distance to near. As we age we lose this ability to change focus. Eventually, we need to help our eyes with the near portion of this range with reading glasses, or "cheaters."

Currently, the only options available to return that range of vision involve removing the natural lens (or cataract) and replacing it with a multifocal IOL (more on these in a future post) or accommodating IOL. The problem with current multifocal IOLs is that they result in little rings around lights at night. The problem with the currently available accommodating IOL (the Crystalens) is that is doesn't work for everyone. So, what's on the horizon...

Synchrony IOL
Visiogen
This lens was presented by David Chang, M.D. (UCSF) who is one of the most impressive cataract surgeons alive today. It uses a unique two-lens approach to providing a range of vision (distance and near) after cataract surgery. Once inserted into the eye these two lenses would move relative to each other resulting in a variable range of vision.

Unlike most presently available presbyopia-correcting IOLs this lens does not result in halos or glare after surgery. The initial results are very impressive and I am looking forward to offering this IOL to my patients as soon as it becomes available in the US.

As it is such an unusual type of IOL (two lenses instead of one) many surgeons will not be comfortable implanting this IOL when it first becomes available. Nevertheless, this may be worth searching out as the initial results are quite impressive. I'll keep this blog posted when new results are available as I'm very bullish on this IOL.

Exciting new IOL technology on the horizon

This weekend was the joint American Society of Cataract and Refractive Surgery (ASCRS) / University of California, Los Angeles (UCLA) conference in Century City. Some of the most impressive cataract surgeons from North America presented their findings on the latest advancements in cataract and refractive surgery.

The new intraocular lens study results created quite a buzz among the attendees. None of these IOLs will be available in the USA for at least another year or so. Nevertheless, anyone who is on the fence about their cataract surgery might consider waiting as their options will only get better as these new IOLs become available.

Today I will discuss the most revolutionary design change in IOL technology, the Calhoun light-adjustable IOL. Over this next week, I will write about the exciting IOLs that were presented at this meeting.

Calhoun light-adjustable IOL
Although this lens is not a presbyopia-correcting IOL (more on that in my later posts), this lens embodies what is probably the most exciting and revolutionary technology on the horizon for cataract surgery.

Presently, when someone needs cataract surgery the surgeon chooses the IOL based on measurements taken of the cornea and size of the eye. However, the calculations used to choose the IOL are "best estimates" of what that particular patient will need. They don't work for everyone. Additionally, IOLs come in 1/2 diopter increments meaning that the best we can possibly hope for is that the post-surgical refractive error will be plus or minus 1/4 diopter. It's like buying shoes: if you have a 10 1/4 foot it will be a bit too large for a size 10 shoe and too small for a 10 1/2.

Unlike buying shoes, however, your don't get to try on an IOL before buying. It's a lot like having a shoe salesman measure your foot and forcing you to buy the shoe he thinks will fit without trying it on. Oh, and there is a no return policy. Would this make you uncomfortable buying a shoe? Welcome to the life of a cataract surgeon - present IOL technology forces us to choose the IOL for the patient without really knowing (beyond what the measurements suggest) what they will finally need.

Enter the light-adjustable IOL. This amazing technology allow the surgeon to adjust the strength of the IOL after surgery using an ultraviolet light. Even astigmatism can be corrected. Once the post-operative refractive error has been minimized, the strength of the IOL can be "locked-in." After this is done there would be no need for distance glasses. Reading, however, would still require "cheaters."

Of course, this technology will probably be quite expensive so don't expect Medicare or most insurances to pick up the cost of these adjustments. How much will it cost? That's unknown at this time. Since the IOL and the equipment to adjust the strength of the IOL has not been approved yet the company has not released pricing information. Although this is a shot in the dark, I would expect it to be at least $1,000 extra just for the IOL and another $1,000-2,000 for the surgeon's fee.

Tomorrow I'll discuss what I think is the most exciting advancement in "presbyopia-correcting" IOL technology.

Introduction to About Eyes

I’m just shy of a decade of practicing ophthalmology. In ten years time I’ve listened to a lot of questions from my patients and learned that many of these questions are asked again and again (only by different people). It occurred to me that if my patients are asking these questions, so are the three million other patients in the US that have cataract surgery every year.

So I created a website http://www.sgveye.com (or rather, my web designer did) that would function both as a forum to allow questions and answers about cataract surgery or general eye disease and as an online brochure for my medical practice, the San Gabriel Valley Eye Associates, Inc. However, despite the best efforts of my web designer, I have found that the website is just not the best format for what I would like to do.

My hope is that the blog format will allow me to provide real-time updates to those questions my patients are asking. As a secondary benefit, I hope that this blog will be informative to anyone with cataracts or eye disease who shares similar questions about the eyes.

In the spirit of a blog (and at the request of my patients) I will also be somewhat indulgent in the following manner: the single most common question I hear is not about eye disease, but about my daughter, Arden.

To those who are internally moaning “Oh no, not another ‘Isn’t my child cute’ site,” I have the following to say: I understand your reaction; I was there. Prior to Arden’s birth I thought most parent’s gushing about their kids was about as bearable as fingernails on a chalkboard. All that changed with her birth. If you’re not a patient and don’t get it, you won’t until you are. And, I promise that the primary focus of this blog will be on eye disease.

I look forward to what I hope will be an interactive and educational experience for my patients, other readers of this blog, and myself.

Sincerely,

David D. Richardson, M.D.
Medical Director

San Gabriel Valley Eye Associates, Inc.
207 S. Santa Anita Street, Suite P-25
San Gabriel, CA 91776
626.289.7856