Scientists are beginning to unlock the mystery of aging. In 1900 average life expectancy was 47 years. We are now pushing the average toward 80 years. But there is far more to just racking up the years, in my view it is about quality of life; we want to live well for as long as we can. I see myself as dying at 94 while standing on the bow of my fishing skiff wrestling a 110 pound tarpon.
Part of feeling well is looking good. As we age, it takes an extra effort to accomplish that goal. Gravity is at work, body fat is relocating, collagen (the scaffold supporting our skin) is degenerating and our genetic predisposition begins to play out. If you are in your forties, just look at the quality of the skin of your parents and get a glimpse into your future. All of these factors have an effect on the appearance of our face. Perhaps the most important feature of the face is the eyelid area. Upon meeting a person, this is the first region that is considered and we are programmed to make numerous decisions about that person at the instant of “the first encounter.” By creating small alterations in the appearance of the eye area, one can send a whole new set of information at the moment of the encounter.
62 year old prior to upper eyelid surgery
Following surgery
The only thing that was done in this case was to create a lid crease by removing skin. You have a more youthful appearance and you notice the sparkle in the eye. The key to surgical success is to do the minimum necessary to create the desired effect.
This procedure, known as blepharoplasty or cosmetic eyelid surgery is a 20 minute outpatient procedure which we do in our adjacent ambulatory surgery center. It is done with local intravenous anesthesia from which the patient awakes immediately and leaves the operating room under their own power. For reasons that remain unclear to me, there is no pain following the surgery. Folks can be up and about on the next day provided that they make an effort to apply ice to the surgical area. The issue of bruising always comes up. If you tend to bruise then expect that with the surgery, otherwise localized swelling is the norm. The sutures are removed in one week.
In many instances, health insurance companies including Medicare and Medicaid provide full coverage for this surgery. When a patient meets the criteria, we take photographs preoperatively and submit them for review by the insurance companies. Many people are surprised to learn that they are covered.
Age alone is not a factor; your state of health and your motivation to look as good as you can are the driving forces. Call the office and I will meet personally with you and review your candidacy for blepharoplasty.
I performed my first cataract surgery in 1973, while a resident in training at the Medical College of Virginia. The patient was admitted to the hospital on the evening prior to the day of surgery. The surgery took about an hour and the patient was returned to the hospital bed. On the patient’s second hospital day, she inhaled an orange peel and had a respiratory arrest which resulted in brain damage. It was my belief that had she been at home in familiar surroundings that this never would have occurred.
As chief resident in Virginia, I began a crusade to shorten the length of hospital stay for cataract surgery. The best that I could do was to reduce it to two days. From Virginia, I moved on to Bascom Palmer Eye Institute. In the mid-seventies the same policy was adhered to; in-patient hospitalization for cataract surgery. I was able to get folks home on the day following surgery but still not good enough. Ultimately, I went into private practice at the old Victoria Hospital. This was the infancy of the HMO movement in Miami. One of my early patients was in AvMed HMO and on the first day following cataract surgery I got a phone call from the president of the HMO advising me that it would be a good idea to discharge the patient that day. That was the incentive that I needed and I sent the patient home on day one much to the chagrin of my colleagues.
Fast forward to this week. I operated ten cataract patients at Miami Eye Center which does not even have a postoperative bed in which to put patients; there are lounge chairs. The surgery takes ten minutes, there are no preoperative shots, no stitches, no patches and the patient is on his/her way home after a fifteen minute recovery. How is all this possible? In 1973, I was operating with magnifying glasses to see the surgery. The wound was 3cm and it was closed with silk suture. The entire cataract was frozen (intracapsular cataract surgery) and removed in a large piece through this large wound. Occasionally the sutures broke and the wound opened leading to serious complications. In general, the trauma to the eye left it quite inflamed. Today the surgery is performed with the aid of an operating microscope which allows for microscopic management of the details of the surgery. The wound is 2.6mm long and no stitches are necessary. The cataract is removed via this tiny bloodless incision by breaking the lens into a soupy material and aspirating from the eye (phacoemulsification). The wound is secure so folks can become quite active on the next day. Very sophisticated antibiotics and anti-inflammatory drugs reduce inflammation to the point that patients rarely feel any discomfort. And most importantly, patients have the opportunity to come away from the surgery with little or no need for eyeglasses.
If you are in need of cataract surgery, step up to the twenty-first century advances. The experience will amaze you.
Patients of all ages ask me what they must do to be free of eyeglasses. The answer lies in their age and their vision requirements.
The first group of folks are the younger aged. These are people who are nearsighted or farsighted with or without astigmatism and who when they have their contacts or glasses on, can read without the need for additional reading glasses. This group is “pre-presbyopic.” The approach to getting this group out of glasses or contacts is straight forward. We must correct the refractive error (nearsightedness, farsightedness or astigmatism) and they are set. In most cases this is done with LASIK or PRK in individuals who have a refractive error which has stopped changing with age and meet the other criteria for safe refractive surgery.
Eliminating the need for glasses gets a little more involved in the next group; the presbyopic group. These people need reading glasses in addition to their contacts or distance glasses correction; this is the group that wears bifocals. There are several theories as to the mechanism of this progressive need for reading glasses but the bottom line is that the lens of the eye losses its ability to focus at near. This inability is superimposed upon ones nearsighted or farsighted condition. This gets confusing because a 48 year old nearsighted individual can see well at near without glasses but once the glasses go on they no longer can see close. A younger nearsighted person will see well at near with the distance correction. So what must we do to eliminate glasses? In my surgical ophthalmology practice there are two ways to do this. The first is to do LASIK or PRK with the dominant eye corrected for distance and the non-dominant eye for near (monofocal). While this may sound “wild and crazy,” about 20%-30% of the population is capable of doing this. When patients inquire about this approach, we fit them with trial contact lenses for the day which simulates the monofocal condition. In general, people who are not suited for the monofocal correction know immediately after putting the lenses on. For those who are comfortable we go to LASIK or PRK and permanently correct the refractive error.
The other 80% used to have no option but to wear bifocals. Now there is an excellent second option; multifocal lenses. These are acrylic lenses which can be permanently placed inside the eye which give good distance and near vision in each eye. The lenses create two images at the retina, one for near and one for far. Depending upon which image your brain wants to see will determine which image it recognizes. This works similarly to being in a room where there are several conversations going on simultaneously. Your brain will direct your attention to one of these conversations and you will hear it at the exclusion of the others and in an instant you can switch to another conversation and not hear the first.
In multifocal lens surgery your clear lens is surgically removed and replaced with an acrylic lens which has been calculated to neutralize your refractive error and at the same time correct for near vision. I prefer the Restor Lens manufactured by Alcon Labs. The surgery takes about 15 minutes and one eye is operated at a time. The second eye is operated about 2 weeks later. There is very little down time as people feel good the next day.
This surgery is available for those of any age as long as they are presbyopic. In younger presbyopes we remove the clear lens and instill the multifocal lens. In those older presbyopes requiring cataract surgery, the same lens is placed with the same benefits.
I or one of the surgery counselors will be pleased to discuss these options with you. Give a call.
I am asked this question on a regular basis, “are my cataracts ready for surgery?” The answer to this question is not a “one size fits all.” Since cataracts develop slowly in most cases, the change in vision is subtle. Very often, the only way to know that you have developing cataracts is to be told by your ophthalmologist during a routine examination. In any case, the earliest symptoms are often glare while driving at night, glare during the day, dim vision in low light or double vision. In all cases this is a painless process. The symptoms will be different depending on the location of the cataract change in the lens of the eye.
Cataracts which are found in young individuals are often associated with using steroids (cortisone) for extended periods or following eye trauma. This type of cataract is located in the back of the lens (posterior subcapsular cataract). Because it is closest to the retina, the impact on vision is most profound; a small cataract can cause substantial loss of vision. These cataracts tend to develop quickly. The more common type of cataract is called a nuclear cataract and is the typical age related lens change. This cataract grows slowly sometimes taking ten or twenty years to become a problem. There is also an anteriorly located cataract known as an anterior cortical cataract seen quite often in diabetics. Because it is further forward in the eye and away from the retina, it has less of an impact on vision.
The over-riding factor that determines when it is appropriate to intervene with surgery is the lifestyle of the individual. Depending upon your line of work or your recreational interests, you will have different visual needs. I have performed cataract surgery on commercial airline pilots who had only a slight loss of vision with only a small amount of glare. Their complaints would probably not bother most of us. But when attempting a landing at night there is an exquisite need for sharp vision and these young pilots were in need of help. I have operated a number of recreational fisherman whose complaints were not being able to see into the water or see the markers at night. Golfers ofter complain that their friends can follow the ball and they can not. At the other end of the spectrum is an elderly inactive person whose only interest is to sit in front of the T.V. This individual can just move closer to the screen and defer surgery indefinitely. I hasten to add that I have seen amazing changes come over debilitated folks (who might also have hearing problems and possibly Alzheimers Disease) following cataract surgery and the resumption of good vision.
Most of us are somewhere between the pilot and the elderly infirmed T.V. watcher. It is for that reason that routine exams are recommended and once cataracts are diagnosed, continued followup is important. Cataracts are not a disease, they are a normal part of having birthdays. These days we are all hoping to live well as long as we can and often early intervention with cataract surgery can put spring back in your step.
It is my pleasure to open the BLOG section of this website. I hope to give the reader an opportunity to obtain up to the minute information about the newest technologies offered at MIAMI EYE CENTER as well as the greater ophthalmic community. I encourage those with an interest to become involved with questions or comments.
This evening, I was reviewing the chart of patient C.B. who is a very young 72 years. He had R.K. (radial keratotomy) surgery in Columbia 15 years ago. He was quite pleased with the outcom of that surgery until recently when became bothered by nighttime glare while driving. He consulted an optometrist who diagnosed cataracts and referred him to this office.
I began performing radial keratotomy surgery for myopia in 1982, PRK in 1996 and LASIK in 2000. Now that many of my patients from those days have “grown up” they are developing cataracts. Cataract surgery in folks who have had prior RK, PRK or LASIK presents a unique challenge to ophthalmic surgeons but one which I have managed incorporating the newest technology. The challenge facing the surgeon is in selecting the proper intraocular lens to place in the eye at the time of surgery. For patients who have not had prior refractive procedures, the selection process is routine. However, the standard computer programs used for the average patient do not work for people who have had prior RK, PRK or LASIK. If the incorrect lens is utilized, the patient will be nearsighted or farsighted following the surgery.
In the clinic today, I measured the power of C.B’s eye as one would for making eyeglasses. I then inserted a special diagnostic contact lens and repeated the process. This yielded the true power of the cornea and that data was used in two additional programs to yield the power of the intraocular lens to be inserted at surgery. These mathematical manipulations have been evolving over the past several years and I have found them to be quite accurate.
The goal of modern cataract surgery is not only to achieve excellent vision for the patient but excellent vision without glasses. This goal can be achieved for many patients even in complex cases as outlined here.
