My first patient this morning at Miami Eye Center was a 50 year old executive who was “tired of wearing my glasses and I would like to be evaluated for LASIK.” Seemed like he was in the right place until I asked him what he wanted to accomplish. “I would like to be able to see far objects without my glasses.” I then preceded to ask him what he did for his near work. He told me that he took his glasses off to read. This gentleman was telling me that he is nearsighted and has presbyopia. I asked him what happens when he wears his glasses and attempts to read; answer: “I can’t see a thing.” Major caution lights go off! So if I do a LASIK procedure on this patient and correct his distance vision, he will have to wear glasses all of the time to read. As it turned out, he did not see this as a reasonable alternative to his present condition. I went on to tell him that the only other option was to apply the laser to his dominant eye and correct it for distance and leave untouched the fellow eye for near work. This was also unacceptable at which time we shook hands and went on to other things.
If the above tale sounds like it’s you then save yourself a LASIK evaluation. I have written this blog because this scenerio plays out quite often in my office and hopefully this will help someone understand one of the LASIK dilemmas and be resigned to eyeglasses or faking it.
Many of my Miami patients who return sometime following their LASIK/PRK will enthusiastically relate their life experience as it pertains to their surgery. Here I want to tell my story which basically charts the entire history of LASIK as I was there at the beginning and have grown with the advancements and re-directions.
In 1986, I was introduced to the excimer laser which had been developed at IBM in New York. It was a precision cutting device which was only used to demonstrate how you could cut a square in a strand of human hair; a party trick. Eventually some researcers at Columbia University came up with the idea of aiming the laser at the cornea with the hope of reshaping it and eliminating nearsightedness. The device which had been developed in New York could not be used in the USA thanks to the FDA so I traveled to London and on to Berlin where the procedures were being done. The trips were fun and the technology was spectacular.
My first opportunity to actually use the laser was in 1996, when it finally received FDA approval. Tne LASIK procedure at that time was not in existance. We were aiming the laser at the surface of the cornea without creating a flap; this was PRK, Photorefractive Keratoplasty. We could only treat myopia as there was no algorithm for farsightedness or astigmatism. The procedure worked very nicely for the limited number of patients that were treatable. The down side was that it was a painful postoperative coarse. Because of the pain created by lasering the front of the cornea, the notion of cutting a flap and lasering the interior gained popularity. There turned out to be much less pain with this approach and so began LASIK.
The process of cutting an extremely thin section of cornea became the challenge. One of the earliest and most popular devices was actually developed in Hialeah. These cutting devices are called keratomes. In the early days of LASIK the application and successful use of the various keratomes was a tricky undertaking as the equipment was unforgiving if the operator made the slightest error. There were dislocated flaps, irregular cuts and partial cuts. But since the vast majority of folks did very well without pain we forged on. Ultimately, the keratomes became automated and complications became rare. Surgeons still had in the back of their minds the ultimate safety of the PRK as there is no flap and therefore no flap related problems. At the same time there emerged a class of eye drops known as NSAIDS (non-steroidal anti-inflammatory drugs). These drugs eliminated the postoperative pain following the PRK. Thus began the swing back to the old days of PRK. Ofcoarse by now we were treating myopia, hyperopia and astigmatism.
While I watched the excimer laser go through four generational changes, the newest kid on the block is the femtosecond laser. This laser is used to cut a precise flap with minimal complications.
All of this brings us to the present. In my consultations with refractive surgery candidates we discuss these options. Many people want to reduce the risk factor to as close to zero as is possible and elect PRK. Some need to have an immediate visual result and short term recovery period and elect LASIK (the return of vision following PRK can be five to six days). Others have thin corneas wherein PRK is the only option. So it all comes down to fitting the procedure to the patient and not visa versa. In the end, personalized care and attention to detail leads to a happy patient and a happy doc and we all sleep well at night.
“I had cataract surgery 6 months ago but I’m still having blurry vision.” I see patients here at Miami Eye Center who come to see me for a second opinion totally distraught over the issue and in many instances their degree of concern is unwarranted. This could be you, if so there are several things to consider. Firstly, what is the cause of the blurriness and secondly, can it be fixed?”
We can start analyzing the problem from the front of the eye (cornea) and working to the back (retina). Some of the issues are simple yet overlooked while others are complex. If you have had a multifocal lens implant there is no margin of error as these lenses are unforgiving. If your tear film is not good you could be losing vision. I have many patients complain of poor acuity only to find that by putting a drop of artificial tears on their eye they recover substantial vision. A long term program of tear film enhancement leads to continued excellent vision.
There could be residual nearsightedness, farsightedness and or astigmatism. If this is the case and you have had a multifocal lens implant it is incumbent upon the surgeon to correct this. If you have opted for a generic lens implant, eyeglasses is the answer. However, with multifocals you should be offered LASIK correction which has the potential to completely correct the blurry vision.
The intraocular lens is placed into the eye on a clear membrane (like Saran wrap) called the posterior capsule. On occassion this clear membrane becomes cloudy and impacts the vision potential. This is easily treated with a Nd:YAG laser procedure which vaporizes the membrane and thus clears the vision.
Moving to the back of the eye there is the retina. If there is a problem with the retina it is the same as taking a photograph with bad film in the camera. In a small percentage of surgeries there could be swelling of the retina known as cystoid macular edema. This has a profound effect in reducing the vision. Fortunately, it is self limited to several weeks to months and often responds to therapeutic eye drops.
While the point of this discussion is to inform the reader that all is not lost if at first glance the outcome of cataract surgery appears to be less than optimum, however, there are a number of complications which require extensive evaluation and complex repair. One must keep in mind that if you lump all of the possible complications of cataract surgery into one, the risk is about 3%, one of the safest major surgical procedures performed today.
Here in Miami and probably elsewhere, about half of my patients having cataract surgery also have dry eyes or eye allergies or various types of inflammation of the eyelids. It is amazing to me how this problem can reduce the good results of well done cataract surgery (LASIK surgery as well). In many cases the condition is only slightly bothersome prior to surgery, however, when you have cataract surgery with one of these ocular surface diseases present, there appears to be a surprising diminusion of the visual outcome. If you have chosen to make a significant “lifestyle enhancement” with a multifocal lens insertion at the time of cataract surgery you want to maximize the result and achieve the ultimate potential of this new technology.
During the preoperative examination at Miami Eye Center, we look at the tear film using new technology and are able to determine if you have a deficiency in the water component of the tear film or if your tears are evaporating too fast. When found, patients are treated with artificial tears preoperatively and the surgery itself is performed in a way which protects the surface of the cornea. If we find an inflammatory problem causing a tear film deficiency we treat that with a course of cortisone eye drops before the surgery. We might also use Restasis to decrease inflammation. In cases of eyelid inflammation a round of oral antibiotics as well as antibiotic eyedrops over a period of several weeks can improve the tear film.
The take home message here is that there are subtle issues which can impact the outcome of your eye surgery that are beyond just having a good procedure and your surgeon needs to evaluate these factors and discuss them with you.
Most of my patients think that astigmatism is a disease; it is not and it’s time to clear the air. Astigmatism is a normal condition effecting 80 percent of the population. Astigmatism is caused by an irregular shape of the cornea; the clear window on the front of the eye is the cornea. In a non-astigmatic eye it has a round curve in all directions, like a basketball. In the case of astigmatism, it is shaped like a spoon. In one direction there is a steep curve and in the other there is a gentle curve. This is called “regular astigmatism.” When light passes into the eye it must pass through the cornea. When there is no astigmatism the light comes to a perfect focus on the retina and the vision is excellent. When light passes through an astigmatic cornea light from different directions is focused differently and there is a blurry image projected onto the retina.
Regular astigmatism is easily corrected with eyeglasses or contact lenses. If you hold your glasses out in front of you and look at a picture on the wall while rotating the glasses you might see some changing distortion; this is the lens correcting your astigmatism. Rigid gas permeable (hard) contacts are excellent at correcting astigmatism while soft lenses are less effective.
There are excellent surgical techniques for the correction of astigmatism. The oldest method that I began using in 1982 is astigmatic keratotomy. Here small straight incisions are made on the cornea across the steeper curve (meridian). This tends to flatten that meridian and steepen the flatter meridian, ultimately making the cornea more spherical. Along came LASIK where after several years there emerged an algorithm for the correction of astigmatism along with nearsightedness and eventually along with farsightedness. Very substantial amounts of astigmatism can be corrected with LASIK. More recently, we have added a variation of astigmatic keratotomy (AK), known as limbal relaxing incision (LRI). Here the corneal incision is moved to the outer edge of the cornea and is curved rather than straight. It is more predictable than AK.
When patients come for cataract surgery we always evaluate their astigmatism. This is done so that we can calculate the power of the lens to be implanted at surgery and also to be in the position to offer them an opportunity to have the astigmatism corrected with LRI at the same time. The purpose is to enable patients to achieve excellent vision without glasses when the cataract surgery is done. We usually reserve the LRI for small amounts of astigmatism because there now is available the toric lens. This is an intraocular lens with optics designed to neutralize the astigmatism along with the correction of myopia or hyperopia. This lens is implanted just as any lens might be then it is rotated into a position to match the steep meridian on the cornea, thus neutralizing the astigmatism.
So don’t be concerned when you learn that you have astigmatism; it could be a lot worse.
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.
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.
