A cataract is a clouding of the lens in the eye that impedes the passage of light and affects vision. When the clouding blocks enough light and impairs vision to the point where glasses won’t even help, the lens is generally considered to have become a cataract.

A cataract will get worse if not removed. Cataract surgery is the only way to do so.   It involves removing an aging, cloudy eye lens and replacing it with an artificial one, called Intraocular Lens (IOL). The surgery only takes on the average, twenty minutes, and full recovery a month after surgery has been performed. However, integral to the whole process is the accurate measurement of your eye made by the surgeon prior to surgery.

What is an Optical Biometer?

The device used to perform necessary ocular measurements before refractive or cataract surgery is called an Optical Biometer. An Optical Biometer measures the length of the eye, curve and width of the cornea, and anterior chamber depth. The device is intended to acquire ocular measurements as well as perform calculations to determine the appropriate intraocular lens (IOL) power and type for implantation during intraocular lens placement, ultimately providing the accurate information a surgeon would need prior to surgery in order to ensure clarity of vision after the procedure.

How Is Argos Different Compared to Conventional Biometry

When compared to conventional biometry, ARGOS demonstrates faster, more accurate biometry, while providing a unique live 2D OCT image of the whole eye from cornea to retina, limbus to limbus. In addition, ARGOS is able to successfully measure axial length in denser cataracts that are beyond the capability of other non contact biometers. It guarantees precise ocular biometry for accurate selection of IOLs by way of its contact-free measurement using SS-OCT – Swept-Source Optical Coherence Tomography. Compared to traditional OCT techniques such as SD-OCT or TD-OCT, ARGOS delivers a more streamlined process of acquiring biometric parameters—reducing procedure times and minimizing patient discomfort.

References:

1. Biometry measurements using a new large-coherence–length swept-source optical coherence tomographer. Shammas, H. John et al. Journal of Cataract & Refractive Surgery , Volume 42 , Issue 1 , 50 – 61
2. Movu [Internet]. Movu-inc.com. Available from: http://movu-inc.com

When someone with a cataract makes the decision to undergo modern cataract surgery, there is yet one more decision that must be made: what type of intraocular lens (IOL) to have placed in the eye. Most eye surgeons (or their surgical schedulers) will discuss the various options available. These may include monofocal, toric, multifocal, pseudo-accommodating, and extended depth of focus (EDOF) IOLs. Such a broad range of choices can be a bit overwhelming. It was not always so.

As recently as the turn of the millennia patients were not given a choice as to what type of IOL to have implanted as there was no choice to be made. Only one type of IOL, “monofocal” was used. A half century prior even that option was not available.

That all changed with the pioneering work of Sir Harold Ridley, who first implanted an IOL in 1949. Although he is now considered a hero in the field of ophthalmology, he was initially demonized by many of his contemporary surgeons for placing a foreign object into the eye. Sir Harold Ridley’s early critics, however, had reason to be concerned. At that time it was simply not known what would happen to a foreign material implanted in the eye.

Today an intraocular lens (IOL) is almost always placed in the eye at the time of surgery. They are generally considered to be both safe and effective as all IOLs implanted in the USA undergo a rigorous process of evaluation by the FDA. Nonetheless, modern eye surgeons know that not all material choices have proven to be long-lasting. It is possible for the IOL material to degrade after it has been implanted in the eye.

Photo: Glistenings on IOL  | Photos 1 & 3 Credit: www.iolsafety.com | Photo 2 Credit: crstoday.com

One of the most commonly chosen IOLs by surgeons in both Canada and the USA is the Alcon AcrySof® IOL. This IOL is made of a soft acrylic material that allows it to be injected into the eye through a small (less than 3mm) incision. Recently, however, reports of significant “sub-surface nano-glistenings” have been observed in AcrySof® IOLs years after they have been implanted in the eye.

Glistenings (or nano-glistenings) are microscopic fluid-filled bubbles that can form in synthetic lens material. A small number of glistenings may be observed in any IOL that has been in the eye over a period of time. If these glistenings were only visible to the eye surgeon under the microscope and caused no problems with vision then they would be an interesting footnote in some journal of material science. However, there is now evidence that large amounts of these glistenings may indeed degrade the quality of vision¹. Night vision, in particular, is reduced by glistenings as they can result in glare around lights.

The material used in the AcrySof® IOL has a tendency to develop more of these glistenings than is seen in IOLs made of other materials. Indeed, by only a few years after cataract surgery the majority of AcrySof® IOLs will likely have developed these glistenings². Over time it appears that these glistenings only get worse³.

In a review of the Alcon AcrySof® lens by the US Department of Health and Human Services⁴:

• We conclude that the AcrySof® Natural IOLs do not demonstrate substantial clinical benefit in comparison with currently available IOLs [emphasis mine] (p. 1010)
• Moreover, in our review…regarding the blue light filtering optic, we found evidence suggesting that the blue-filtering lenses could decrease best possible vision. (p. 1006)
• the glistenings associated with AcrySof® Natural lenses that develops overtime causes disability glare rather than reduces it. [emphasis mine] (p. 1009)

The International Society for Intraocular Lens Safety has published a very succinct review of the literature concerning these glistenings. Here is the conclusion of this document:

“The evidence is overwhelming that glistenings in AcrySof® intraocular lenses have an adverse influence on vision [emphasis is mine]…the use of these lenses in cataract surgery patients should be reconsidered.”

Photo: Simulation of effect of glistenings on night time vision. | Photo Credit: www.iolsafety.com

To my way of thinking, the above statements are so compelling as to warrant serious reflection about whether Alcon AcrySof® IOLs should be implanted at all (or at least in younger patients) if there is a same-diopter IOL option available in another material. When choosing an IOL (as with every treatment recommended by a physician), “primum non nocere” (above all, do no harm) should be a guiding principal. Given what we now know about the Alcon AcrySof® IOL, it is my opinion that choosing the Alcon AcrySof® IOL (when a same-diopter IOL is available in another material) violates this fundamental principal of practicing medicine.

When choosing an IOL (as with every treatment recommended by a physician), “primum non nocere” (above all, do no harm) should be a guiding principal.

To be fair, not all cataract surgeons are aware of the issue of glistenings. There is a never-ending stream of announcements, articles, and studies related to eye disease that no human could reasonably be expected to keep up with. Even those with knowledge of glistenings may be under the impression that they do not have a noticeable impact on the quality of vision.

Patients, however, entrust their eye surgeons to make the best decision in the hopes that they will enjoy many years of excellent vision. We now know that the AcrySof® material may result in decreased vision over time. As such, the case against implanting the AcrySof® IOL is especially strong in younger patients who are more likely to suffer from glistenings during their lifetime. Furthermore, given that “AcrySof® Natural IOLs do not demonstrate substantial clinical benefit in comparison with currently available IOLs” there seems to be no compelling reason to implant the AcrySof® IOL in patients of any age.

Ultimately, it is the patient who must live with whatever material is implanted. Unlike with “premium” IOLs (e.g., multifocal, toric, etc.) patients are not routinely informed about the brand and model of the IOL when they elect to have an insurance-covered monofocal IOL implanted. This choice is generally made by the surgeon (or occasionally even the surgery center or HMO) without any discussion beyond “at the time of cataract surgery your cataract will be removed and replaced with a plastic lens”.

There is a lot of information that must be conveyed prior to cataract surgery. Often the surgeon will demonstrate how surgery is done, warn of the risks, and discuss the type of IOL to be used. By that time many patient’s eyes are glazing over with information overload.

It’s understandable why this would be the case. There is a lot of information that must be conveyed prior to cataract surgery. Often the surgeon will demonstrate how surgery is done, warn of the risks, and discuss the type of IOL to be used. By that time many patient’s eyes are glazing over with information overload. Reviewing the nuances of IOL material choice just doesn’t seem necessary or prudent at that point. After all, most IOL materials don’t have definite clinical benefits or downsides. However, for surgeons whose “go to” IOL is the AcrySof® IOL a simple handout could be offered to the patient to be read at his or her leisure.

References:

1. Matsushima H, Nagata M, Katsuki Y, et al. Decreased visual acuity resulting from glistening and sub-surface nano-glistening formation in intraocular lenses: A retrospective analysis of 5 cases. Saudi Journal of Ophthalmology. 2015;29(4):259-263. doi:10.1016/j.sjopt.2015.07.001.
2. Christiansen G, Durcan FJ, Olson RJ, Christiansen K. Glistenings in the AcrySof® intraocular lens: pilot study. J Cataract Refract Surg. 2001;27(5):728-33.
3. Behndig A, Monestam E. Quantification of glistenings in intraocular lenses using Scheimpflug photography. J Cat Refract Surg 2009;35:7-14.
4. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services, 42 CFR Parts 410, 411, 412, 413, 416, 419, and 489 [CMS-1504-FC and CMS-1498-IFC2], RIN 0938-AP82 and RIN 0938-AP80, published Nov 2010; available at http://www.ofr.gov/OFRUpload/OFRData/2010-27926_PI.pdf

Talk Details:

Resource Speaker: Dr. David Richardson
When: Friday, October 23, 2016
Where: Embassy Suites – 211 E Huntington Dr, Arcadia, CA 91006, United States

Event:  Joint University of Southern California (USC) – San Gabriel Valley Optometric Society (SGVOS) Annual CE Symposium.

FULL TRANSCRIPT

Femtosecond Laser Assisted Cataract Surgery

How Do The Marketing Promises Compare To Reality?

So today’s topic is going to be on Femtosecond Laser Cataract Surgery also known as FLACS. In particular, we’re going to be discussing whether or not the literature supports the marketing. First of all, can I have a show of hands how many are familiar with FLACS? Ok, very good. How many of you have been to a presentation on it already? Ok, so just a few.

David D. Richardson, MD

So, first, just a couple statements about me; So you’ll understand a little bit about me and my practice. As well as why I’m here talking about this particular conversation or topic… Cataract surgery is actually one of the focuses of (not only my practice but) my career and not just in terms of performing it but also in terms of educating those [patients] about it.

• Author, So, You’ve Got a Cataract – For example, I wrote a book about cataracts surgery. It was focused specifically for patients addressing their needs, their concerns, and helping them to choose among the numerous options that are now available. Because it’s not like it used to be decades ago, as we know, where you just have a cataract, put in your lens, you’re done! He gets new glasses. Now, we know we have a lot of different lens options. And now, there’s this type of surgery option available: Laser-Assisted Cataract Surgery (we’ll talk about that).
• Medical Director, San Marino Eye – As a doctor who’s in private practice, I also spend, on average, between 45 and 60 minutes with my new cataract surgery consultations. And that’s because, I think, it’s really important to actually communicate all of these very, very confusing topics to patients and that just cannot be done in a short period of time.
• Adjunct Assistant Professor of Clinical Ophthalmologys, USC Roski Eye Institue, Keck School of Medicine  – And finally, as Adjunct Assistant Professor of Clinical Ophthalmology of USC [University of Southern California]. My primary role there is teaching residents how to communicate these things to their patients in the clinic as well as developing the skill sets they need in the operating room.

Confict of Interest

I have no conflicts of interest. This is important to be aware of. With each presentation that you get on something that’s going to cost your patients hard-earned money. This will not be your typical industry-sponsored dinner talk which just glosses over the side effects and counts all of the benefits. I want you to have a clear understanding of what the literature states.

What Is Laser Cataract Surgery?

What is laser cataract surgery? Well that’s a misnomer and we do not perform cataract surgery with a laser. It’s not been done and it’s still not. What it is, in fact, is Femto Laser Cataract Surgery also known as FLACS.

Femto Laser-Assisted Cataract Surgery

The “Femto” is short for “Femtosecond”. This is the same laser that’s used very successfully with lasik. Instead of using the microkeratome, you use a laser. It cuts to clear tissues such as the cornea very, very well; and very precisely. And that particular term is one that you will be exposed to (if you’ve not already been exposed to)

Precision. One of the things that the marketing pushes about the femto laser-assisted cataract surgery (I’m just going to call it FLACS from now on) is that it’s more precise than manual or the traditional, ultrasound-only phacoemulsification. Precision is a term that, you have to recognize, comes with a lot of assumed promises. And we’re going to discuss whether or not assumed promises are actually born out.

Can I just get an idea, when you hear the word, “precise” when discussing cataract surgery, what are some of the things that you think that might be describing? Any ideas? Capsulorhexis – precision in creating the Capsulorhexis. What other things do we look for with precision? What the patients’ ultimately want after surgery? Better vision – closer to 20/20; closer to 20/20 uncorrected. So, if we can get something that could accurately get somebody there that would be very desirable. So precision is being used very loosely in marketing and advertising to make us feel like we’re going to get our patients closer to 20/20. That’s the assumed promise. So let’s see whether or not that’s actually the case.

Other marketing terms you’ll hear: Safer. When you hear, “safer” what do you think? What do your patients think when they hear “safer”? Less side effects. Less risks. Let’s see whether that’s the case.

The other thing you’re going to see: Gentler. “Laser is gentler than ultrasound”. Again, “gentler”, one would think, is safer. Fewer risks.

What Does the Laser Do?

So let’s take a look. Just briefly for those who aren’t aware. What does this laser do?

• Create Corneal Incisions – It makes incisions. Corneal incisions – the side port incision, the main incision. You can also make arcuate incisions. So limbal relaxing incisions to correct for astigmatism. Now, traditionally we do these with metal or diamond keratomes but they can be done with a laser now.
• Create an opening in the Capsular Bag – You mentioned creation of the capsulorhexis. The laser can create a perfectly round capsulorhexis and it is beautiful. When you watch this laser performing capsulorhexis, it is perfectly round. The question is, “does it matter?” Now, traditionally we perform the capsulorhexis with either forceps or *** bent needle cystotome.
• Soften the Cataract – The other thing you can do is soften the cataract. Well softening the cataract makes sense because you can soften the cataract before using ultrasound energy. You’ll use less ultrasound energy. Less ultrasound energy should protect the corneal endothelium, should result in less inflammation, faster healing and just generally a gentler procedure. So this is where the term, “gentler” comes from. Now, you can also soften the cataract using certain phacoemulsification techniques, such as “chopping”, which is a newer technique; it’s more challenging technique but it’s one that most surgeons should be capable of performing and chopping essentially does the same thing as the laser softening.

So, what does the laser do? The summary is, “nothing that can’t be done already hasn’t been done already”. So, the real question is, “is using a laser to perform these things truly superior to the ultrasound only” And the marketing tells you that it is. And indeed (if I was to present the industry supported marketing) it looks pretty slick. But, we only have about 20 minutes today so rather than show you all of that, which you can find very easily and I personally don’t believe it because it’s industry-supported (he who pays the piper chooses the song /chooses the outcome of what’s going to be published). I find that literature to be very questionable. So, I’ve chosen instead to present to you the literature that you’re not going to get presented at any industry-supported evening dinner show; the peer-reviewed large studies that were performed by non-industry-supported groups.

This is an expression of my disappointment (as well as others disappointments) when we realized that, “Wow! There’s really nothing that the laser does that we can’t do already. It just does it in a way that sounds a lot cooler.”

FLACS ESCRS Study

So let’s take a look here. This is a Peter Barry, MD († 2016) who presented the preliminary results of a study performed by the European Society of Cataract and Refractive Surgery. And I’d like to thank my colleague Dr. Steven Safran in New Jersey who brought many of these studies to my attention as I was investigating whether or not this was something that I wanted to provide to my patients.

So this study was not a small study there are 16 centers in 10 European countries throughout Europe. This involved almost 3,000 patients.

So what were the results?

• Worse post-operative visual acuity – Unfortunately, the visual acuity, which we were hoping precision would result in better acuity, (it) turns out that in this study those who had FLACS actually ended up with worse visual acuity on average than those who had phacoemulsification only. Now it was small but still it was worse and whole point is we believe the marketing that it should be better but it was not.
• More post-operative complications – It gets gets worse. there were more postoperative complications among those who underwent FLACS than those who underwent standard phacoemulsification.
• Were more likely to have post-op visual acuity worse than pre-op – Take a look at this. This requires that we spend a moment and think about it. Those who underwent FLACS were more likely to have post-op visual acuity that was worse than pre-op. Why do we submit our patients to the risk of surgery? To make their vision better. Any new technique or technology has to, at the very least, not make patients worse more often than the gold standard. So FLACS fails there.

A Closer Look

Let’s take a closer look and because these these results are really unintuitive right?

Post-Operative Biometry Prediction Error

So let’s first take a look at the idea of accuracy. Again, what is being loosely referred to with the marketing term, “precision”. One would think that if you’re targeting plano refractive error or minus one-half (whatever it is you’re targeting), that this more advanced technology is going to get you closer to your target. Well, indeed, that’s not the case. At least not based on the preliminary results of this very, very large study.

Postoperative Surgical Complications

I think it’s important to look at the types of complications that are more common.

Corneal Edema, Posterior Capsule Opacification, and uveitis (so anterior chamber reaction) ***. These are not small differences. In fact, corneal edema is five times more likely among those who had FLACS; Posterior Capsule Opacification, six times more likely.

Now you may say, “Okay that’s not a big deal. We take them back to the the yag laser. Good to go!” The yag laser is not without risk. Specially in high myopes. Three times the risk of anterior chamber reaction. “Ok”, you say “but that’s just one study”. Albeit a very large study – almost 3,000 patients. Well it’s not the only study.

There’s another study that looked at almost 2,000 patients enrolled and what this one found and I’ll read the conclusions because it’s a little difficult for you see,

“femtosecond laser cataract surgery did not demonstrate clinically, meaningful improvement in visual outcomes over conventional phacoemulsification cataract surgery.”

If you look up a little bit higher it gets even more concerning.

“Phacoemulsification cataract surgery cases had more letters gained compared with laser cataract surgery.”

[Reference: Ewe S, Abell R, Oakley C, Lim C, Allen P, McPherson Z, Rao A, Davies P, Vote B. A Comparative Cohort Study of Visual Outcomes in Femtosecond Laser-Assisted versus Phacoemulsification Cataract Surgery. Ophthalmology. 2016;123(1):178-182.]

So conventional, actually, did better. And why that might have been the case? Well let’s look again at risks and complications.

Perioperative Complications – laser cataract surgery and phacoemulsification only. If you take a look at those ring in the red you’ll see that there are some significant differences but not just your usual, just barely, less than P (P-Value) or P is less than 0.05 these are really statistically significant. But more important than statistically significant they are clinically significant. Ocular hypertension, cystoid macular edema – these are things that can result in loss of vision. It should be noted that these are not the first studies to show this cystoid macular edema is an increased risk in FLACS.

Cystoid Macular Edema

This study is from 2014 and showed an increased risk of cystoid macular edema in cataract surgery patients who underwent FLACS. So why might this be? What could be going on during the laser portion of FLACS that results in (more likely) corneal edema, increased anterior chamber reaction, iop elevation, cystoid macular edema and posterior capsule opacification.

[Reference: Ewe S, Oakley C, Abell R, Allen P, Vote B. Cystoid macular edema after femtosecond laser–assisted versus phacoemulsification cataract surgery. Journal of Cataract & Refractive Surgery. 2015;41(11):2373-2378. ]

What could be the the unifying factor here?

Well, let’s take a look at some of the studies that have actually looked at the changes that occur during and after the femto laser portion of the cataract surgery.

Corneal Edema – So with corneal edema, what could be going on? Well it turns out that the bubbles that occur (the cavitation bubbles that occur) from the femtosecond laser change the pH in the aqueous. It shifts it to more acidic aqueous. And we know that the corneal endothelium is exceptionally sensitive to changes in pH.

[Reference: Rossi M, Di Censo F, Di Censo M, Al Oum M. Changes in Aqueous Humor pH After Femtosecond Laser-Assisted Cataract Surgery. Journal of Refractive Surgery. 2015;31(7):462-465.]

Anterior Chamber Reaction – Prostaglandins have been shown to rise immediately after femtosecond laser treatment. Prostaglandins are part of the pro-inflammatory cascade. But that’s not it. It’s not just the prostaglandins. There are, in addition, other inflammatary mediators that have been shown to increase after the femto portion of the cataract surgery (Increase inflammatory Cytokines after Femto treatment).

[Reference: Schultz T, Joachim S, Kuehn M, Dick H. Changes in Prostaglandin Levels in Patients Undergoing Femtosecond Laser-Assisted Cataract Surgery. Journal of Refractive Surgery. 2013;29(11):742-747.]

Posterior Capsular Opacification (PCO) – How about Posterior Capsular Opacification? Well, It turns out that femto is association with a higher concentration of fibroblast growth factor (FGF-2) as well as other pro fibrotic factors.

The conclusion from that particular paper was

“femtosecond laser pretreatment in cataract surgery significantly induces altered levels of pro-fibrotic intraocular cytokines which are involved in the development PCO…Increased levels of these cytokines and growth factors in aqueous humor in the early phase after cataract surgery could induce lens epithelial cell proliferation, migration and transdifferentiation.”

So this is a a posited mechanism by which Posterior Capsule Opacification (PCO) could actually be more likely after Femto. It’s a reasonable hypothesis.

[Reference:  Chen H, Lin H, Zheng D, Liu Y, Chen W, Liu Y. Expression of Cytokines, Chmokines and Growth Factors in Patients Undergoing Cataract Surgery with Femtosecond Laser Pretreatment. PLOS ONE. 2015;10(9):e0137227.] 

So Where Does That Leave Us?

So then where does this leave us with regard to FLACS versus traditional, ultrasound-only phacoemulsification? Well, first of all, let’s take a look at the benefits. I mean, the marketing benefits don’t seem to have a lot of support in the literature. At least not in the non-industry supported, large-scale population studies.

Benefits of FLACS

It’s cool

You have to admit it’s cool. I mean, it is a really cool technology. Anytime you have laser and you put it with anything it just makes things cooler. And this is very much true with patients they hear laser cataract surgery and they want it.

It’s fun for the surgeon

And it is a lot of fun for the surgeon. Okay, Ophthalmologists, in general, are kind of geeky. We like our Star Wars and most of us have seen Logan’s Run and there’s something about doing surgery with a laser – it just…it feels cool. And I will say – having performed FLACS, it is fun. There’s just something about watching that video screen…it turns surgery into a video game. And so from the surgeons perspective, it’s a lot of fun.

Bragging Rights for the patient

It does give bragging rights to the patient. The patients get to tell their friends at the golf course/at cocktail parties that they had laser cataract surgery. Right? And that really does sound impressive. Even more so when you find out that in general we have to pay extra for it. So, it’s kind of like “anything that have to pay extra for – whether it be a nice bag or a really nice car, whatever it is, you get bragging rights for it

But,…

To date there’s no strong evidence from (this is key to recognize) independent (non-industry supported), peer-reviewed (published and represented in major conferences). So, no strong evidence from independent, peer-reviewed studies, supporting an objective benefit. Not just a cool sounding marketing term benefit, like “precision”, which basically means “nothing clinically”. But, an objective benefit to patients of FLACS over conventional phacoemulsification.

Worse,…

But it gets worse. FLACS appears to actually be associated with greater pro-inflammatory changes in the aqueous humor that can lead to increased risks of vision-threatening postoperative complications including:

• corneal edema,
• anterior chamber reaction,
• cystoid macular edema,
• posterior capsule opacification, and
• intraocular pressure elevation.

And I’ve not spoken about any of the other risks that were common in the early studies of Femto; such as capsular tags, increased risk of posterior capsule rupture, and things that were largely associated with learning curves of the surgeon or with improvements in technology. We’ve not talked about those because, I think that for the most part, those were related to learning curves and technology issues that have, for the most part, been solved. So, what I wanted to focus on today was just what (objectively) appears to be going on when you look at a large number of patients who’ve had surgery by experienced surgeons with the modern equipment that’s available. All of the FLACS have been modern, but [I mean] the most recent.

Still, …

Still despite everything that I said today, FLACS is very much in its infancy. There’s a very, very good possibility that with tweaks to the technology – perhaps the hardware, perhaps the software, or perhaps changes in the way we treat patients pharmacologically (so either with with drops or injections before or during surgery), that it may be possible (we may be able to) reduce or even eliminate the rise inflammatory mediators and with that the added risks of FLACS. So that FLACS could potentially – not only be “equivalent” to ultrasound-only phacoemulsification, but “better than”.

Summary

To summarize, at the moment…

• FLACS is not all it’s stouted to be. Not by any objective criteria
• At the moment there is no strong evidence that FLACS is superior to conventional phacoemulsification, and may actually be a step back at least with regard to intraocular inflammation and its associated risks and complications.
• But (I do think that there’s the real possibility that) with advances in technology, it may have the potential to make good on at least some of its promises. That’s just not the case yet.

My argument is that until that’s the case it’s very very difficult for me, as a surgeon, to justify strongly recommending FLACS to my patients over traditional phacoemulsification-only surgery because I don’t think that the coolness factor and that the bragging rights really justifies the risks that I just went over.

Anyway, that’s my view. You will definitely hear alternative views but I want to thank you for attending this and then now it’s off to lunch. Any questions that anyone has?

All right, thank you.

Rosacea is a condition that affects many people. While it’s more common in fair-skinned women of any age, anyone can actually develop it. It’s generally characterized by a reddened face, and sometimes causes small red bumps, and can be often mistaken for acne, an allergic reaction, or other skin conditions.

Over time, the condition can become worse, if it isn’t given medical attention, as it tends to flare up for weeks, or even months, at a time, only to lessen again. There is no known cure, but treatment can certainly mitigate the effects.

Ocular rosacea is a condition that often develops in people who suffer from rosacea, causing burning, red, itchy eyes. On occasion, ocular rosacea is a sign of developing the other kind. As with all rosacea, it most often develops in people between the ages of 30 and 50, who have fair skin prone to blushing and redness. Medication can control the symptoms, but not cure them. It’s usual for the condition to return after a period of remission.

Ocular rosacea can develop slowly over time, with symptoms that can belong to a number of other eye conditions, like dry eyes, the feeling of grittiness or a foreign object in the eye, blurry vision, red eyes, or excessive tearing. It may happen when the skin condition is apparent, or may happen all on its own.

Parkinson’s disease is a much different disorder. Instead of the skin, it affects the nervous system, in particularly the ability to move. It often starts with minor tremors or stiffness in a hand. A loss of facial expressiveness, soft or slurred speech, and other symptoms may also develop. All these symptoms become worse as the condition continues.

There is no cure for Parkinson’s disease, but medical science has progressed to the point where the symptoms can be significantly reduced. It is known that the disease causes neurons in the brain to die, causing neurological degeneration, but no one really knows what the ultimate cause is. Researchers believe there may be genetic factors or certain triggers in the environment, much like any disorder with no known direct cause.

Parkinson’s tends to develop in older people, most commonly over 60, and most of these are men. As stated before, there are also genetic factors. Some researchers believe they have found another link.

The Link Between Parkinson’s and Ocular Rosacea

A Danish study published in JAMA Neurology suggests there may be some correlation between ocular rosacea and Parkinson’s disease. This is not cause for anyone with ocular rosacea to be unduly worried – instead it may be a step toward finding new ways to treat both disorders by coming to terms with whatever their ultimate causes might be.

The subjects of the study were every Danish adult over the age of eighteen, nearly five-and-a-half million people, with information tracked over more than a decade from 1997 to 2011. Information was taken from the Danish National Patient Registry, in order to find those with Parkinson’s, rosacea, or both. According to the findings, there was a lower age of onset as well as an increased risk of Parkinson’s in patients who were also living with rosacea.

An analysis of the data showed those with rosacea were about 1.7 times more likely to develop Parkinson’s disease than those without rosacea. Patients with ocular rosacea were just over twice as likely to show symptoms of Parkinson’s. Rosacea patients who developed Parkinson’s also tended to develop symptoms about two-and-a-half years earlier than those without rosacea.

While there seems to be a link of some kind, the researchers are not quite sure what the link is. One theory is the level of matrix metalloproteinase (MMP) in the patient’s system. Normally, MMPs are created to activate aspects of the immune system and help the body fight off infections. In rosacea patients, it is believed an over-production of MMPs create anti-bodies which can attack healthy cells, causing rosacea. Patients with rosacea and Parkinson’s or other disorders similar to Parkinson’s show they have extra production of MMPs.

It has been proven that additional activation of MMPs, anti-bacterial elements in the body, and rosacea are all linked; these peptides induce inflammation of the skin. The link to Parkinson’s implies MMPs also have a part to play in neurodegenerative diseases, including Parkinson’s disease. While the researchers have stated further studies are needed to confirm these findings, in the future they may lead not only to a way to stop outbreaks and recurrences of ocular rosacea, but to a means of arresting the development of Parkinson’s disease before it becomes debilitating.

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Guest Author: Laura O’Donnell | EyeCare 20/20

It’s quite common for those who have had cataract surgery to notice tearing, foreign body sensation, mild soreness, “scratchy eye”, or a “tired eye” for a period of time after surgery^1,2,3. Although not entirely understood there are a few likely suspects including, (1) the preservative contained within the many drops used before and after surgery, (2) drying out of the ocular surface during cataract surgery, and (3) decreased blink rate secondary to a “numb” cornea.

Femto laser-assisted cataract surgery has been touted by many as a “gentler” method of cataract surgery. In fact, there is little objective evidence to suggest that laser-assisted cataract surgery is any gentler than ultrasound-only cataract surgery. However, there is now reason to believe that dry eye syndrome could be worse after laser-assisted cataract surgery.

In December 2015 a study comparing dry eye after laser-assisted cataract surgery to ultrasound-only cataract surgery was published in the Journal of Cataract and Refractive Surgery⁴. Although both types of cataract surgery resulted in temporary worsening of dry eye symptoms, those who had undergone laser-assisted cataract surgery experienced more severe symptoms. This difference between surgical groups was both modest and short-lived (one week). By one month after surgery both groups had similar dry eye symptoms. However, evidence of dry eye syndrome continued to be more pronounced in the laser-assisted cataract surgery group even one month after surgery.

If you have cataracts and have been Googling cataract surgery options then you’ve seen advertisements for “laser cataract surgery.” It’s been touted as “safer”, “gentler”, and even “more precise”. Sounds pretty good. Why wouldn’t you want that?

Most everyone with cataracts is old enough to have gained some basic wisdom regarding advertising: “Don’t believe everything you’re told.” With regard to “laser cataract surgery” that wisdom could serve you quite well indeed.

Millions of dollars have been spent by the manufacturers of cataract surgery lasers to convince both doctors and their patients that “laser cataract surgery” is superior to cataract surgery performed without a laser. The industry has tried everything from intimate dinners at expensive restaurants to rock concert like presentations with laser light shows and loud music (I’m not kidding) to sway the views of eye doctors. Many have been impressed enough by these presentations to spend up to a half million dollars to purchase one of these laser units. Yes, that’s up to $500,000 just to purchase the laser. On top of that the laser companies charge another $300-800 each time the laser is used on a patient.

Think someone who has spent a half million dollars might be just a little incentivized to recommend laser cataract surgery to his or her patients? Think some might even bend the truth just a wee bit?

But,…doctors would not outright lie about laser cataract surgery, would they?

“Founded on a mistaken impression”, “false impression”. I’m going to show you how the typical online statements about “laser cataract surgery” rely on “false impressions” to produce wildly incorrect beliefs based on what may be technically true statements.

Let’s take a look at just some of the many lies about “laser cataract surgery” that can be found with a quick Google search:

Resource Speaker: Dr. David Richardson
When: Friday, January 8, 2016 from 11:00 AM to 12:00 PM
Where: Crowell Public Library – 1890 Huntington Drive, San Marino, CA 91108, United States

Dr. David Richardson talks about cataracts, cataract surgery, types of intraocular lenses, and laser cataract surgery or laser-assisted cataract surgery.

TRANSCRIPTION:

Very good. So, we’ll go head and start the program. I want to thank everyone for coming here today. On this beautiful day without rain. hidden inside. Room that has the shades down’s not exactly the ideal place to be but I’m hoping to make it worth your time.

So what we’re going to be talking about today is the topic of the book that I wrote that’s available here in the library for your borrowing. You can also get it online at Amazon. And for those who want to purchase it directly from us today, we’ll give it to you at our cost, which is $10 and any revenue that we get today will go to the library’s donation. So, basically if you wanted it, it’s available.

Now I’m going to give you information that, for the most part, is not in this book. This is information that’s relatively new but I will start with an introduction to what cataracts are and how cataract surgery is performed.

Before I do so, just to introduce myself and justify the reason why I’m giving the talk…

My name is David Richardson. I grew up in Southern California; went to USC for undergraduate and I’m an ophthalmologist, which means that I had to go to medical school before training to perform surgery on the eye. Presently, I’m an Assistant Professor of Clinical Ophthalmology at USC Keck School of Medicine. The adjunct just means that I’m also in private practice. My role there is primarily to train young surgeons on how to perform cataract surgery. I also have a private practice which is just down the street here at 2020 Huntington Drive.

Now, before we get to cataracts, it’s important to understand the eye itself. This is an image of the eye and just briefly the very front of the eye, which is the clear window of the eye, is the cornea. The cornea focuses light through the pupil, which is the opening and the colored part of the eye which is the iris through the lens. This here is the lens that sits behind the iris and it focuses light unto the retina which then sends the signal back through the optic nerve to the brain. Now, the lens in the eye is actually what becomes the cataract. So the lens, essentially, becomes less clear and as it loses its clarity, so do you.

So I find it’s helpful to think of the eyes is a bit like a camera for those who remember cameras. An object would essentially reflect light it would then be focused through the lens onto the film in the back of the camera and you can think of the eyes being quite similar.

So essentially the image is focused by the cornea – the front of the eye, through the lens which does additional work focusing the light on to the retina and then out through the optic nerve so what then really is a cataract?

What is Cataract?

Well, cataract is a term that actually means waterfall and back in the day, not so long ago, just a few decades ago, your cataract would actually have to get bad enough that anyone could see it and it would look at bit like a waterfall through the pupil. The natural pupil with a clear lens should be dark but with a significant cataract here, it actually reflects light back and looks a bit like water that’s being churned up. Looking again at the anatomical image in the eye you can see that the normal lens should be clear and focus light very well . Whereas as the lens in the eye (again it’s the actual lens) becomes more opaque it’s not able to focus light as well.

Here are some images of actual lenses as they become more cataractous with time. And this is pretty severe. We generally don’t let them get to this point anymore (this step) beyond that is actually the white cataract you saw the other image.

What are the symptoms of cataracts?

Well there are many symptoms and they range from just blurred vision, to cloudy or hazy vision. You can also have double vision or ghosting and glare or sensitivity to light especially with oncoming headlights or traffic lights at night. And then another common thing that tends to be an earlier occurrence, so it’s a bit more subtle, is yellowing vision. So blues become more green. Whites become more yellow.

When to consider cataract surgery?

If we don’t allow cataracts to get to that kind of brown or white tint stage, when should somebody consider cataract surgery? Well, in general we recommend that you consider it when what you call your activities of daily living are being impacted by the cataract. Now fortunate thing is that I don’t define activities of daily living. You get to define that. So what are the things that you need to do, want to do, enjoy doing that you’re no longer able to do even with a new pair of spectacles – that could be reading driving computer work but it could even be hobbies. You know if you’re a golfer and you don’t have to be a scratch golfer. If you enjoy it but you can no longer see your ball and it’s not because you’re looking at it but just because you can’t see where it’s going then it’s time to consider cataract surgery.

How is Cataract Surgery done?

So then let me show you and animation of how cataract surgery is actually done. So essentially a small incision is made in the cornea and then the bag that holds the lens with the cataract is opened up (that’s called creating a capsulorhexis) An ultrasound device, which is very, very small little tubes that’s used to emulsify the cataract itself and then a new lens is placed through that small incision and allowed to unfold in the eye. So the surgery itself, on average, can take less than 20 minutes.

Now you’re generally in the surgery center for longer than that because it’s done under sterile conditions. You’ll probably have a little IV or something that will get you…just say that you’re relaxed you don’t care about what’s going on.

Types of Intraocular Lenses

Now you saw in that video that the lens was placed in the eye so it’s not just that your cataract or natural lens is removed it actually has to be replaced because if we didn’t replace it with a new lens you really still wouldn’t see well. You’d need coke bottle glasses.

Back in the day, about forty years ago, cataracts were just removed and everyone had these – what were called, “aphakic spectacles”, which looks kind of like Mr. McHugh spectacles. You don’t need that anymore. And as a matter of fact, it’s now possible with cataract surgery to actually achieve a level of vision without spectacles or contact lens correction. We’ll talk about that in a second.

So the actual lenses that are used – these are synthetic lenses so they’re not donated from other humans they’re not from animals. The common materials that are used here in the US are acrylic, silicon and collamer. The reason these materials are used is because they’re clear, they’re bio-compatible so the body doesn’t reject them and they’re flexible. The flexibility is important because the incision that’s used ** created in time of cataract surgery tends to be on the order of two to three millimeters. Very, very small incision.

In addition to different materials being used there are actual different types or functions of intraocular lens – also known as IOLs.

Different types or functions of intraocular lens

So let’s talk about some of these different functions. Roughly you can divide them into four groups Monofocal intraocular lenses, then toic and multifocal and what’s called pseudo-accommodative.

Monofocal Lens

Now the monofocal lenses have been around since Sir Harold Ridley in the UK first discovered the Royal Air Force pilots who had pieces of the windshield stock in their eye – clear pieces of this windshield, show their eyes were not rejecting these pieces of windshield. Amazingly the canopies just sat in the eye without inflammation. So Sir Herald Ridley, who was not a sir at that time, thought, “well this is this is really interesting. I wonder whether we could make lenses, actually, put in in the eyes of people who had cataracts.” And he did that and just about lost his license because at that time, putting anything in the body let alone in the eye was considered to be just absolutely hearsay. Fortunately for all of us his foresight turned out to be accepted by even the stodgy academic institutions and we now are all benefiting from that – that wonderful work of Sir Harold Ridley.

So these monofocal lenses replace the natural lens, they’re clear and they do focus light pretty well but they don’t focus it quite as well as you might need for all of your activities and we’ll get into why that is the main reason is that they don’t correct astigmatism and there are other aberrations in the cornea that can affect vision and that’s where spectacles and contact lenses can be of benefit. Now these lenses are covered by Medicare and all insurances but after cataract surgery with monofocal lens, unless your cornea has no astigmatism and is otherwise in perfect condition, you will likely need spectacles for most if not all of your activities. So again, these are well made high quality lenses. They just don’t do anything to limit your need for spectacles. So the next set of lenses I’m going to talk about is the set of toric intraocular lenses.

Toric Lens

Toric lenses correct astigmatism. Astigmatism is you can think of it as an irregularity of the cornea the front and the window of the eye the first surfaced that reflect -that refracts light so bends light rays to focus on the back of the eye and whereas a normal cornea is round kind of like a softball, astigmatic corneas are shaped a bit more like a football. Not enough that you could tell just by looking but if we measure, using very well (I’d say, we can measure using) very sophisticated equipment now. But it could be measured decades ago with with less sophisticated equipment you can tell that there’s some distortion there. Well what toric lenses do is they essentially balance out that cornial distortion so with a toric lens for those who have astigmatism end up with excellent, crisp vision at a particular distance.

So if you wanted to see well at distance, so far away, after cataract surgery and you had a astigmatism, a toric lens would allow you to have excellent vision at distance without spectacles or contacts. Now, it doesn’t give you a range of vision however so you wouldn’t be able to see necessarily at near but you could choose to set your focus it near and then you’d need spectacles for distance so the benefits of the toric lens provides excellent quality vision at a particular distance.

Limitations: It doesn’t provide a range of vision so you may still need cheaters if you choose to have it set for distance and it’s considered either a premium or refractive lens by Medicare and most insurances so the cost of the lens as well as all of the testing and surgical maneuvers and other things that are required to place or position the lens are not covered by Medicare and most insurance.

Multifocal Lens

Then there’s multifocal lenses. Now multifocal lenses, here in the united states have these little concentric rings you can probably see here now what these rings do is they actually focus distance images and near images on the retina at the same time. Now I don’t know who first thought of this because it’s a bit on intuitive to think that you could have two images focused on the retina at the same time and the brain would be able to choose which image is the image you should be looking at but amazingly most people who have these lenses implanted in their eyes do quite well and end up with a nice range of daytime vision.

The downside however is that not everyone adapts to the lens. The process is called neuro adaptation where as some cynical ophthalmologist had said neuro resignation because you do have these two images and you will always have either a small ghosts or a halo around the main image that you’re focusing on now that’s not usually an issue during the day but at night it’s particularly with driving people do notice little halos around lights.

Again, most people that have this, who have otherwise healthy eyes, really enjoy their range of vision but it’s important to know before choosing any particular lens what the strengths and weaknesses are. And again, this is not a lens that’s covered by Medicare or insurance. Then we have what are called the pseudo accommodating lens.

Pseudo-Accomodating Lens

Accommodation is the natural ability of your lens before you turn forty or fifty to be able to change focus from far away up to very close and actually as infants and toddlers we can focus very very close up with that ability to change the focus reflects the lens in the eye decreases with time until slowly it feels like our arms aren’t quite long enough and that’s what we need to start using the cheaters. We lose that accommodative effect.

Well pseudo accommodating IOL or intraocular lenses are quite flexible and as such they they seem to have some – we don’t really know whether its just movement or just some wild distortion or what it might be but they do you have more of a range of vision than the other lenses than the standard monofocal lens and because it’s not a multifocal lens so it’s not focusing two images on the retina at the same time there are no halos to be expected.

Now, the main pseudo accommodating intraocular lenses that are available in the United States are the crystalens, the star nanoflex and the Softec HDO. Europe has a number of others that we don’t yet have. We’re hoping that the FDA will approve them sometime over the next decade or so. Now, what are the limitations of pseudo-accommodating lenses? Well they don’t get quite the range that some of the multifocals do.

Generally, the pseudo accommodating lenses will focus from distance to about arms-length. Sometimes, you can get up to about 16 or 18 inches but if you want to have a fuller range of vision with the pseudo accommodating lens, you really have to have both eyes done so that when the eye is set for distance and it blends to intermediate the other eye, you can set a bit closer. So you get more of a near range. Between the two eyes you do end up with an outstanding range of uncorrected, that spectacle-free vision during the day. You may still need cheaters or readers for real small prints, conditions such as low light conditions. But in general for those who think that they might not be good candidates for the multifocal lens because they’re worried about the Halos at night or if you have other conditions in the eyes such as some mild macular degeneration, glaucoma, dry eye, blepharitis – none of those conditions play very well with the multifocal lens, you can still have a pseudo accommodating lens and achieve some spectacle independence. And again the procedure itself for implanting and testing and all of that for pseudo- accommodating intraocular lens is generally not covered by insurance or Medicare. Now it’s worth noting, since I’ve been talking about the limitations because I consider it very important with my patients that they understand what the limitations are. I do not want the surgery to go perfectly well and have someone disappointed because he or she was expecting that the current technology was capable of providing more than it is.

There is currently no lens available on the market either here or in Europe or you know some other country that doesn’t have this strict regulation that can provide the full range of uncorrected vision, in all lighting conditions without the need for spectacular contacts and that’s true of the lenses that we put in the eyes. it’s true of the cameras that we have – the camera phone or 4d high-definition you know cinema quality video camera. The way our eyes are able to adjust almost instantaneously when we’re young, younger than say you know thirty or forty to any light condition and almost any distances is absolutely phenomenal and we just don’t have the technology , material technology or digital technology to to recreate that. But we’ve we’ve managed when it comes to intraocular lenses to provide a pretty good functional range in the right lighting conditions. But you have to understand that we as humans expect a lot of our eyes and so what can you expect?

If you decide to go with one of those lenses that I just spoke about whether it’s a multifocal, Toric or pseudo-accommodating lens, you will still need to have spectacles for what we consider to be the extremes of vision. Extremes of vision meaning very low light or conditions where you’ve got low light and then suddenly there’s bright light. Think about nigh-time driving for instance.. And then certain extremes of reading so if you’re gonna try to read something… like if you’re a cartographer there’s no lens that we have available to provide that kind of ability to see tiny little subtle markings on a map four inches from your eyes but for most of our activities when it comes to reading iPads or your iPhone or computer or your dashboard driving during the day, we can provide a nice range available for those activities.

So those are the lenses that are available today, here in the US. Kind of general categorization of them but of late, there’s been something else that’s created quite a bit of buzz among those who are considering cataract surgery and that is laser cataract surgery. So if you’ve heard anything about laser cataract surgery you’ve probably heard some pretty amazing things about it that it’s more precise, its gentler, it’s safer – just all of these these terms that make you feel that this is just, you know, so much better than cataract surgery has been for decades and you know it should be because I have laser cataract surgery means that in addition to the cost of cataract surgery which may be covered by insurance in addition to the cost of the premium lens package if you choose that you’re going to have to pay for the use of a laser, which could be as much as $1,500 and in general surgeons are charging somewhere between 800 and $1,500 per eye to use the laser. Now here’s the interesting thing you might not even have the option to pay for the laser it turns out that medicare does not allow the surgeon or the surgery center to charge extra for using the laser if you’re going with the standard lens and don’t have some kind of refractive issues such as astigmatism. You may think this is not fair there’s a lot of things that that medicare does that’s unfair but medicare actually restricts the ability to have it so is that an issue should you be upset if you are thinking that you’re just gonna go with the monofocal lens but you want the laser? Is that something that you should feel that you’re getting second-rate treatment for? Well, let’s take a look.

What is Laser Cataract Surgery

First of all, in order to answer that question we have to look at, “What is this laser cataract surgery?

Well laser cataract surgery is really a misnomer because those surgery is not done by a laser. Its laser assisted cataract surgery. The laser performs certain parts of the surgery but you still have to use ultrasound which is called phacoemulsification in order to take the lens out. So why then is there all of this haballo about laser cataract surgery or laser assisted cataract surgery – also known as FLACS which stands for femtosecond laser assisted cataract surgery because it’s a particular type of laser called the femtosecond laser and a particularly expensive type of laser.

There are currently four companies that make femtosecond lasers that are available here in the US. Each one of these lasers has a price tag of approximately a half a million dollars. On top of that the laser company charges either the surgeon or this surgery center between $300 and $900 per use. So every time it’s used on an eye, they charge what’s called a click fee. Well you can imagine that if you’ve got this device sitting around using up a room you not gonna want it to be a half a million dollar paperweight. So so you’re going to tell people that this is the absolute best thing around since sliced bread and the question is, is it?It could be. Let’s take a look.

What does the laser do?

So what does the laser do in order to figure out whether or not it’s worth this we have to look at what it does. Well it creates corneal incision so that that two to three millimeter incision the cornea that you have to make in order to get to the lens will traditionally we make with what’s called a keartone – a handheld instrument it’s made of either metal or gym quality blades – sapphire, diamond things like that and these blades are disposable and they’re very sharp. If they’re metal you use it at once. You toss it. If it’s a diamond, it’s sharp and like diamonds, it stays sharp. And it makes a wonderfully, wonderfully just precise incision that seals on its own. So it’s a great incision and the laser does the same thing and it’s really cool to watch it make the incision.

Does it make a better incision? Unfortunately there’s no objective evidence that the incision is a better incision. What else does it do? Now this is actually interesting the incision is is is kind of an extra but in order to get to the cataract, you have to make an opening in the capsular bag. The capsular bag is a very very delicate transparent membrane and it’s very very thin it’s on the order of microns, right, thousands of a millimeter. It’s incredibly delicate and this is the part of surgery that gives most cataract surgeons early in their career coronaries. So to residents that I trained this is the most difficult part of the surgery and if it’s not done well the whole rest of the surgery is impacted. I can tell you that isn’t attending when I’m watching the residents I can feel my coronary state. But once you’ve done a few hundred cataracts, this should not be an issue anymore and most capable surgeons are not fearful of making a round capsulorhexis.

So, what’s new about the laser? Well it makes a perfectly round capsulorhexis. I mean it’s perfectly round and so in terms of precision it’s beautiful to watch does it matter whether capsulorhexis is perfectly round? Well, when these lasers first came out there was a lot of of talk about it it should but it turns out it doesn’t. So it’s really pretty but it doesn’t make any difference in terms of final visual outcome. Now if I knew that my surgeon was uncomfortable making a capsulorhexis, then I might choose to have the laser instead of the surgeon make the capsulorhexis manually. Just like you know if you got somebody is not very good driving a stick best to have them drive the automatic but would rather just find somebody who knows how to drive the stick?

So we’ll talk about that. It can offer also soften the cataract. This is important because we know that the more energy that’s absorbed by the cornea, the more inflammation there is in the eye, and the longer it takes the eye to heal. Now the older techniques of ultrasound, called phacoemulsification – the other techniques such as divide and conquer where you make a couple of grooves then you split up the cataract took a lot of energy. The newer techniques, which are a bit more advanced and have a steep learning curve such as a chop, use a fraction of the energy of divide and conquer. So for the surgeons who still use divide and conquer, breaking up the cataract with a laser makes a lot of sense. Because they don’t have to use as much **** but for those surgeons who use the more advanced techniques you’re really not saving much energy in terms of ultrasound and recent evidence suggests that the eye doesn’t care what form of energy is used whether it’s ultrasound or whether it’s Electromatic magnetic laser energy it’s still energy and the eye responds to both the same. So it’s kind of like are you gonna pay for something in dollars or Euros.Well if it’s the same price does it really matter and it doesn’t seem to matter to the eye.

Now, there is one other thing that that the laser does. I mentioned earlier that it makes incisions in the cornea. Well it can make what are called Arcuate incisions that can correct astigmatism and this is how many surgeons are getting around the medicare issue of not using this laser and charging for it if you’re using a monofocal lens. Well, you have a little bit of astigmatism, let’s correct that. Well it turns out you can correct astigmatism with a diamond knife or a metal knife in the office or any operating room or you can use something you’ve all heard of before PRK photorefractive keratectomy or LASIK.

So ultimately what does the laser do? And the answer is nothing that couldn’t already be done without the laser. But you say what about this more precise, is safer, is gentler? All marketing terms with little evidence based on facts.

Now precise just means that as I said that capsulorrhexis is perfectly round. Yes, the laser can make a capsulorrhexis that is more round. You know, if you could get tiny little compass in the eye and drive the laser would do a better job than I can by hand just like any one of us is not an artist he tries to draw a circle is not going to draw as perfect circle as you would using a compass on paper. But it doesn’t matter or at least we don’t have any evidence to suggest that it matters. Gentler? What does that mean?That’s a term that has no meaning in surgery and one could argue actually it’s not as as gentle because in order to use the laser you have to dock it onto the eye and that provides quite a bit of pressure and when the dock comes off, most people have eyes look kind of bloody. It doesn’t look gentler to me. How about safer? Oh, this is a term that we can actually address. Because something that’s safer should have fewer complications. Right?

So, it turns out that FLACs may actually be less safe than cataract surgery performed with only an ultrasound. So, the Europeans – The European Society of Cataract and Refractive Surgery actually ran a study called the FLACS ESCRS study and what they found after performing this study in 16 centers, 10 European countries and almost 3,000 laser cataract surgery so it wasn’t a small little study. This was a big study, they found that when compared to ultrasound only cataract surgery (the kind of cataract surgery that’s been done for decades without a laser) those who had laser-assisted cataract surgery actually had worse vision after surgery compared to those who had ultrasound only.

But in terms of this safety issue it was quite clear that those who had a laser assisted cataract surgery had more postoperative complications. So by definition it’s less safe and here’s the interesting thing the whole point of having cataract surgery is to improve your vision but it turns out it with any surgery. Whether you’re exchanging a joint or a lens, not all surgeries work and occasionally people will end up worse off than before surgery. That’s something you absolutely want to avoid or minimize. Well it turns out that those who had laser assisted cataract surgery were actually more likely to have vision after surgery that was worse than the vision they had before surgery. Again this is a very very small number but doesn’t have to be a very large for it to be something that you want to avoid.

What Do I Recommend?

So what do you do when it comes to time to think about cataract surgery?

What do I recommend first of all I recommend that you find a skilled cataract surgeon. How do you find a skilled cataract surgeon? Well if you look at page 69 in the back of my book which again is available here at the library tomorrow I’ve actually created a section on how to choose a cataract surgeon. If you don’t want to borrow the book or buy it then I believe that I have that information available on my website online too. So that’s the most important thing – It’s finding a skilled cataract surgeon.

Two, choose an intraocular lens that meets your needs. All surgeons including myself have their preferences in terms of what lens they’re most comfortable with. But you now have the basic information necessary and you can find more online through more research as to which lens would best meet your needs and only you know what your needs are. For example, somebody who doesn’t drive at night much you know multifocal lens could be a very good option for you but if you’re in airline pilot that’s probably not going to be a great choice.

And then don’t fret about the tools that your cataract surgeon uses When you take your car in to get it fixed, you find a good mechanic. Do you care what particular brand of tool that mechanic is using so long as your car is reliable and working well afterwards No. And so the same thing should be true of your cataract surgeon and this also goes for other surgeons also and then most importantly, is after you’ve had that surgery, enjoy the vibrant, crisp beauty of the world around you because that’s ultimately what you’re doing this for.

Thank you

Downsides to the Multifocal IOL

A multifocal intraocular lens (IOL) focuses both distance and near images onto the retina at the same time. Amazingly, our retinas and brains are generally able to “see” both images clearly. This results in a greater range of clear vision with a reduced need for spectacles after cataract surgery. There are, however, some downsides to the multifocal IOL:

Decreased Contrast Sensitivity

Every edge, shadow, and non-moving object depends on our ability to detect contrast for it to be seen. Unfortunately, multifocal intraocular lenses (IOLs) decrease our sensitivity to contrast. This is seldom an issue during the day when strong illumination from the sun tends to create a high contrast environment. However, during dawn, dusk, or night the ability to distinguish between low-contrast objects becomes critical (think of a grey hooded child at the edge of a road). Some hobbies such as hunting also rely on the ability to detect objects that blend into (have very low contrast with) their environment.

Halos Around Lights

After cataract surgery with a multifocal intraocular lens (IOL), two images of everything in one’s visual field are focused onto the retina: both clear and blurred near images as well as clear and blurred distance images. The retina and brain are pretty good at distinguishing which image should be ignored. There is one main exception: point sources of light. With multifocal IOLs, headlights, traffic lights, dashboard indicators, etc. will all have noticeable halos around them at night. Many people do get used to these a few months after cataract surgery, but they never entirely disappear.

My practice is located in greater Los Angeles which has woefully inadequate public transportation. As such, almost all of my patients need to drive at night and would find night-time halos around oncoming headlights unacceptable.

Not Everyone Can Tolerate the Multifocal Images

Many people are able to adapt to the halos and “ghosting” of images that are present after cataract surgery with use of a multifocal intraocular lens (IOL). This process of getting used to the unusual dual images created by a multifocal IOL is called “neuro-adaptation”. Frankly, we have no idea how the retina and brain adapt to these dual images. What is amazing is that most people are able to tolerate having a focused and blurred image of everything simultaneously projected onto their retinas.

“Most people”…but not everyone.

Unfortunately, there is no test that can be performed prior to cataract surgery that can accurately predict who is likely to tolerate the dual images generated by multifocal IOLs. If neuro-adaptation does not kick in within a few months of cataract surgery then the multifocal IOL may have to be surgically removed and replaced by a monofocal or pseudo-accommodating IOL.

Multifocal IOLs Are Not a Good Choice for Most People Considering Cataract Surgery

When multifocal intraocular lenses (IOLs) work they really can provide an outstanding range of daytime vision. Additionally, not everyone needs to drive at night or is bothered by rings around point sources of light after cataract surgery with a multifocal IOL. Even so, a large percentage of people with cataracts simply are not good candidates for placement of a multifocal IOL at the time of cataract surgery due to the presence of other eye disease. Following is a short list of eye conditions that would limit the benefit of a multifocal IOL:

Eye Conditions That Would Limit the Benefit of a Multifocal IOL

Ocular Surface Disease (Dry Eye Syndrome)

In order for a multifocal IOL to work well the cornea must be smooth and without astigmatism. Ocular Surface Disease (of which Dry Eye Syndrome is the most common) results in an irregular tear film on the corneal surface. Without a healthy tear film the cornea cannot finely focus light onto the lens. My practice is located in Southern California which is an arid (dry) environment. This results in evaporative tear loss. As such, almost all of my patients have at least some evidence of ocular surface disease and may not be appropriate candidates for the multifocal IOL.

Glaucoma

Many people think of glaucoma as a disease that limits peripheral vision. In the latter stages, however, glaucoma can impact central vision. Even with only moderate glaucoma contrast sensitivity can be decreased. Multifocal IOLs also reduce contrast sensitivity (see above). As such, implanting a multifocal IOL during cataract surgery in a glaucoma patient is potentially unwise.

Macular Disease

In order for a multifocal IOL to provide both distance and near vision the central retina (“macula”) must be in excellent condition. Any eye disease that limits central vision will degrade the range of vision possible with a multifocal IOL. Most everyone with significant macular disease should avoid implantation of a multifocal IOL at the time of cataract surgery.

Diabetic Eye Disease

Diabetes can limit central vision due to swelling in the macula. In the earliest stages this might not even be noted with the natural lens or monofocal intraocular lens (IOL). However, even mild amounts of macular swelling can severely limit the quality of vision when a multifocal IOL is placed during cataract surgery. Those with diabetes (especially if uncontrolled or with known retinopathy) should generally avoid placement of a multifocal IOL during cataract surgery.

Dry eye, glaucoma, macular degeneration, and diabetic eye disease all have one thing in common with cataracts: they are more likely to occur as we age. As such, most anyone considering cataract surgery is at risk of either already having or eventually developing one or more of these conditions. My personal philosophy is that I would like the lens implanted at the time of cataract surgery to work well for the life of the individual having cataract surgery. As most eye diseases get worse as we age, I generally recommend against the use of multifocal IOLs in my patients who already have other significant eye diseases.

Fortunately, the Staar nanoFLEX^® IOL does not share any of the above concerns. Its use is not limited by the presence of other eye diseases, halos are rarely seen, and it provides for excellent contrast sensitivity.