The Eye Doctor has Eye Surgery/ Multifocal Implant

Friday, May 8, 2009

I chose the Restor Implant.

I am an Ophthalmologist.

My first eye surgery is scheduled for Monday May 11th. The question that should be answered is Why the ReSTOR, Why any implant, and Why now.

I am a 63 year old full time Ophthalmologist with a busy cataract and ocular plastic and reconstructive practice. I have been contemplating this procedure for some time now, but was worried that I would be out of the office and or operating room for a prolonged period of time. I attempted to investigate what other eye doctors have experience, and how long they were unable to perform at 100%. Well, there is little information out there, and I could only find two ophthalmologists who had the ReSTOR lens implanted. One the latter was very helpful; he was able to operate within a week. Still, questions arise, so in an attempt to answer questions that others may have, I have agreed to write this blog. Patients, as well ophthalmologists, optometrists, any interested individual may be able to follow the course of my surgeries. I’m sure my patients will be interested, as well. I have prepped every surgical patient on my future operating schedule, that if I am not 100%, I will delay their surgery until I am. Everyone, of course, understands I have a great group of patients.Let’s get to the initial questions. Why the ReSTOR? There are 3 implants currently approved by the FDA for implantation in the US that allows distance, and near vision. These vary in design, function, ease of implantation, and patient acceptance. The ReSTOR implant has been out about 4 years. I have considerable experience implanting this particular lens in many patients, and have had great results. The third generation model is now out, the SN6AD1 and it has addressed some of the minor limitations of the first two. I tell all my patients that there is nothing like a 20 year old eye, which does not require glasses, but the AD1 is the next best thing. If I tell my patients that, then I should step up to the plate, if I have need for better vision, or simply wish to eliminate my glasses. (That would be called a clear lens exchange (CLE), removing a clear lens (no cataract) to eliminate glasses.) Have you ever wondered why you eye doctor is wearing glasses?

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I am a very active individual outside of medicine. I enjoy all types of outdoor activities. Glasses simply get in my way. Nothing is worse than climbing a mountain at 14,000 feet, jogging in the humidity of Texas, or on the water of your favorite lake, and glasses fogging up. Viewing the world through binoculars is much better without glasses. I have begun to notice visual problems. I am very critical of my vision, and being in the business, I know what to look for. I have begun to have halos around all point sources of light, more difficulty reading in dim light, seeing street signs at night, and clearly seeing some of the small 7-0, 10-0 sutures in surgery. Surgery could wait until this becomes a more serious visual problem, or I could elect to proceed with a procedure, to improve vision, and enjoy it while I can. I choose the latter.I have begun the pre-op process. A series of measurements were necessary to determine the exact lens power for my eye. With the current technology, this is now very accurate, however there are no guarantees. I am hopeful that my vision will be great, but I know that on occasion a secondary procedure may be indicated to fine-tune my vision. I have begun my preoperative eye drops, an antibiotic, and two types of anti-inflammatory meds. These will be used 3 days pre-operatively, and the antibiotic for a week post operatively. The anti-inflammatory meds may be used up to a month. I now can empathize with my patients. Getting that drop in the eye without wasting one on the forehead or nose is an art. I chose a surgeon who has more experience with the ReSTORE lens that anyone else I know. He was on the FDA medical panel that did the clinical trials, and therefore, has extensive experience with this particular lens. His name is Bob Lehman, and he lives 3 hours away in Nacogdoches, Texas.

Saturday, May 9, 2009

For those who are not in the medical field, a brief, non-scientific review of cataract and implant surgery may be indicated. The “Story of Tobit” may be the earliest documented surgical intervention for blindness. Various written texts mentioning this episode have been found, including mentions in the Dead Sea Scrolls. Scholars document that this could have been as early as 7th Century BC. The “Clinical history of Tobit, a man in later years who suffered a progressive loss of vision associated with whiteness of eyes leading to complete blindness,” pretty much establishes that this, indeed, was a cataract. Some type of “couching was performed.” Couching, from the French word Coucher, to lie down, is a surgical manipulation of a mature lens. This causes lens to fall backward and down into the Vitreous Gel of the eye, thereby allowing the patient to view the world. Now, viewing the world is not what most would describe the resultant vision. Without a lens the world was significantly unfocused, but better than nothing. Fast forward several thousand years, and spectacles became available, allowing those who did have surgery to see a bit better. (Still not very good) It is now generally accepted that spectacles were “invented” (more likely improvised) no later than the last quarter of the thirteenth century

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by the Italians (rather than the Dutch or even the Chinese) and their specific area of Origin centered possibly on the Veneto, Italy region. For those patients who ask if an intraocular implant is necessary (after cataract removal), I inquire whether they remember the 1977 movie “Oh God” starring John Denver and George Burns. (I know I’m dating myself) If they do remember, I point out the very thick glasses, (coke bottle glasses as laymen refer to), that George Burns was wearing, they were necessary because he had previous cataract surgery and implants were not common at that time. I was an active cataract surgeon and remember that era well. Although wearing these glasses were an improvement over cataracts, there was still significant problems associated with the optics and subsequent vision. In the technology era, new discoveries and techniques are adopted and refined very quickly. That was not always the case. The next huge innovation that occurred in Ophthalmology began to be developed during and immediately after WWII, in England, implant (lens), which led to superb post-operative vision. The story of Dr. Ridley in my next post

Sunday, May 10, 2009

The lens of the eye is normally transparent, but as people age the lens develop opacities and eventually becomes opaque. Vision, therefore, deteriorates. Previously, after cataract surgery, patients used very thick glasses as previously mentioned. Dr. Ridley was one of those innovative individuals that recognized a need, and found an answer. He noticed in a number of RAF pilots, pieces of “perspex,” the plastic used in fighter canopies. The plastic was inert, and caused no inflammatory reaction. He reasoned that an intraocular lens made of the same material would solve the age long problem of inadequate vision after cataract surgery. On November 29, 1949 he implanted his first lens. After a series of implants, he presented a paper to a UK ophthalmological society, and was summarily criticized and ostracized. The technique slowly caught on, actually faster in the US than in Britain. By 1980, the implant had been refined to the point where the majority of US surgeons were on board. I personally performed my first implant in 1978, and compared to the lens of today, they were primitive.Cataract Surgery has advanced tremendously since the late 70’s. A quick surgeon at that time took about 45 minutes and used 6-10 sutures. It was not uncommon to keep the patients in the hospital for a few days. Today, 8-10 minutes with no sutures as an outpatient. Healing is much quicker as well as vision. Most intra-ocular lenses are now made either of acrylic plastic or silicone. A small incision is created, the cataract emulsified, the implant rolled into a taco shape, and implanted.

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I have chosen the third generation ReSTOR implant, (SN60AD1) manufactured by Alcon. (Ft. Worth) I won’t get technical, but I believe it offers the best of distant, intermediate, and near vision. In addition, Dr. Lehman uses the “Infinity” phacoemulsification machine which I have extensive experience with. I believe it is the best on the market.I’m now off for Nacogdoches to spend the evening prior to my early am surgery. For my future patients, and ophthalmic surgeons who have not experienced eye surgery, I will attempt to describe my surgical experience and the immediate post-operative visual aberrations. I am particularly interested in seeing how it is with one implant and one natural lens. Some of my patients have no trouble, and some have considerable difficulties. Which camp will I be in?

Monday, May 11, 2009

I arrived at the Lehman Eye Center at 7:00am carrying 2 dozen donuts. (These guys work hard) Actually they had been at it for over an hour. I signed in and had a seat. Even though I am an eye surgeon, and had brought all my own measurements, Bob’s technicians repeated all the measurements necessary for selecting the most appropriate power for the implant. Notice I did not use the words correct or exact. There is not one implant power that is perfect; it often comes down to 2 choices that are near plano. (Neither farsighted or nearsighted) Bob came in re-evaluated all of the math, examined my cataract and retina, and I was ushered into the pre-operative holding area. Multiple consents to operate, insurance paperwork, etc. was signed, and IV placed. Great care was taken to ensure the correct eye was selected. A blue dot placed above my left brow, armband double checked, and the time arrived. I was ushered into the operating room. More topical anesthesia applied, my face was scrubbed and the nurse anesthetist introduced himself. Knowing I was a physician he let me know he was injecting 2mg of Versed IV. I am truly sorry that I cannot describe anything else. I was hoping I could walk you through the operation, but, alas the next thing I knew everything was over. I obviously did not feel a thing intra-operatively. For about two hours after surgery I could feel a “scratchy” sensation, which I believe was the incision site as the lid blinks across it. We hit the road about 20 minutes after surgery, my wife driving, of course. Things were blurry in the operative, Left eye. (My non dominant eye) We stopped to have something to eat, since I had nothing since midnight. No problems, but my wife says I was a bit loopy for a while. Took us about 2 hours + to drive home. About 5 hours after surgery, I was 20/50 at distance, getting better every hour. Near vision had not kicked in yet. Vision return is very variable, depending on your eye, the degree of density of your cataract, the health of the cornea, and any pre-existing disease such as Diabetes, Iritis (inflammation) etc. Many people see well the 1st day, buy many required several days. Some of my patients have complained of a lateral half-moon shape after surgery. I always felt it was the edge of the lens, but could never understand how that could be seen. I just assumed it was a reflection. Now I think I know what they see. I do not think it is the lens, but more probably the edema (swelling) at the incision site.

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At any rate, my vision is sharpening faster than I previously thought it would. Over the last 20 minutes my near vision has improved to the point where I am now typing without glasses. Not perfect, of course, but good. My pupil is still larger than normal and that while at work.

Tuesday, May 12, 20092nd Post Op Day

Everyday my vision has improved. My visual acuity is a clean 20/40 and sharpening every day. I have improved one line since yesterday. I could function to drive, and read more print if my operative eye was the only one I had. The most aggravating visual disturbance is the lateral “shadow” that I mentioned yesterday. That interfered with my vision significantly yesterday and early today. Now it is basically gone. We, ophthalmologists, are not sure exactly what causes it will fade with time. Indeed, it seems to have faded with me, and it has been my experience that it fades in all my patients. The other visual abnormality I experience today occurred when viewing the retina with my new eye. At a specific distance in front of the cornea I could see a reflection that looked like a small “placebo” disc. (For non-eye doctors, a series of concentric rings.) When I moved my instrument even 2-3 mm forward the rings disappeared. It would not interfere clinically. Testing my vision with a microscope revealed no problems what so ever. Since the microscope oculars can be focused individually, I dialed my refraction into the R ocular. There were no concentric rings, no glare, and the focus was excellent. I anticipate no problems having a full clinical schedule tomorrow, Wednesday, and operating on Friday.

Wednesday May 13, 2009

Wed. 20/30 J3A very interesting day. I kept my surgery schedule to a minimum, in case my vision wasn’t up to operate. As I mentioned in a previous blog, I prepared all my surgical patients for the next 2 weeks, just in case I wasn’t 100%. I performed a levator resection with blepharoplasty (elevated a droopy eyelid and removed excess skin), and a removal of a lid tumor. I had no trouble at all operating. I had a third schedule, a severe ectropion (lower eyelid turned outward causing chronic redness and pain.) I had no problem performing the first two, but my eye was a bit irritated and so we rescheduled the third for Saturday am. Patients so understand, as long as you explain things. I saw clinic patients all afternoon, no problems.

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I have never been a Contact Lens wearer! I really lacked the motivation, feeling glasses were just fine. For my non-medical friends, I wore no glasses until my 40th birthday. Within days, I required reading glasses, and within a few months, I could not see at distance. I was “far sighted”.I lived with bifocals for the next 23 years. Well, today I was motivated to become a CTL wearer. It was very difficult for me to function with an implant in one eye and being farsighted in the other. It may well be easier if you are “near sighted,” I don’t really know. Most of my patients do just fine, between the first and second eye. However, I will be more sensitive to those who are not retired and require better interim vision, (before the second eye surgery). I will offer more CTLs. Rings around lights at night? I do not know what deal is! Yes, I see a series of very fine rings around point sources of light with my new eye. Well, the other eye has a halo around the same lights, and I can truly say that neither bother me nor distorts my vision. Driving is just a not a vapor type of illumination seem to be worse….. but so are the halos in the other eye! I ask all my ReSTOR patients, at 6 months, if the rings bother their vision, or whether they have problems driving at night. All have to think about it before answering…. which means if they do see the rings, it does not bother them. My wife cautioned me to be patient!!!!!...... which, inherently, I am not. My Alcon reps remind me that there is a huge increase in binocular vision 2 weeks after the second eye is done and then again another bump in the vision at 2 months. It’s as if the brain must learn to use a new optical system. I have seen that also in my patients. The brain just does better interpreting images from the same optical system. I can hardly wait to have the second done, and begin to allow my brain to adapt to the new optics.

Thursday, May 14, 2009

A quick note to explain “rings” mentioned in my last entry. All eye doctors would immediately know I was talking about. All others would not have a clue. So, to clarify, to achieve the distant, intermediate, and near vision, the ReSTOR implant was created, by some very smart scientist, with a series of rings. Those rings segments have different powers and thereby focus light to different focal points. As physicians we hear a lot about the “ring” images that patients see at night with any point source of light. Now you know why the rings exist, but as I mentioned in my last entry, it doesn’t bother me and I anticipate that this particular reflex will either dissipate completely or my brain with its inherent plasticity, will ignore it. Bottom line, even 3 days after the implant, it is not a problem.

Friday May 15, 2009

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Vision 20/30+ at distance uncorrected; a +.25+.25 X 155 corrects vision to a sharp 20/20.

Worked a full day. Completed a full cataract schedule without any visual problems. Set my R. microscope ocular on +2.25, my refraction, and Plano in the left. That gave me excellent binocular vision with great depth perception. Of course, the new Zeiss microscope helped. My next case gave me a little challenge. A DCR (tear drainage operation), requires very good depth perception. I did not feel comfortable with one ReSTOR and one CTL. That gave me some near and intermediate vision, but the depth improvement, however the operating microscope was, again the best answer. No difficulty dissecting soft tissue, removing bone, or anastomosing mucosal flaps. I’m including these details for other active surgeons who may be considering eye surgery for themselves. I believe, that in most cases, a prompt return to a full operating schedule is possible. That, of course, depends on the surgical specialty. Everything will be much easier with a second ReSTOR to improve the depth perception problem. My drops are a pain to use, (but necessary) and for those doctors who have never used an ophthalmic steroid preparation: it blurs your vision significantly for 10-15 minutes. Plan ahead!

Saturday, May 16, 2009

Vision 20/25+ getting better every day. (Plano +50 X145 today)….. sharpens everything up. I am surprised how such little astigmatism gets in the way. On the other hand, it may just be my monocular (using one eye) vision.Getting prepped for my second eye on Monday. Had to start using my antibiotics and anti-inflammatory drops. To do so, I had to take my R CTL out, and leave it out. A big pain, to say the least. I can use my old glasses for my right eye, but then everything is blurred in my Left. Or just not wear my glasses and use my new, Left eye…. Which I can do, but I am Right eye dominant so that doesn’t work well. One other alternative; take the L lens out of my old glasses Well, at least for me, that is the worst alternative. Double vision, big time. When I finally get my vision together, then my R eye develops accommodative spasm. (for non-doctors, an involuntary focus) Bottom line, there is not best answer, and I will just have to muddle thru. Boy! Have I develop some healthy empathy for my patients. Of course, the majority of my cataract patients do not have immediate need for near perfect vision that I require. Time for more drops…..Later.

Monday, May 18, 2009

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Vision L 20/25 R 20/25+ (3 hours post op) at distance J2 at 16-18”

This is great for those not in the medical fields….especially for only 3 hours post operatively. Looking forward to everything settling down and sharpening up. Dr. Dan Voss, the only other active ophthalmologist who we have been able to find that has bilateral ReSTOR implants has been holding my hand via emails. He sent a particular insightful e mail last evening prior to my second surgery that I wish to share with you. It is below. The (…) are mine to explain medical comments to non-medical readers.

Tim,It’s exciting but I’m sure it has been a long week. With the anisokonia (different size in all images because of the farsighted refraction on the R) and a bifocal it’s more like triplopia. (triple vision) The contact lens was a really good idea. Anymore, I’m more likely to prescribe a CTL in the unoperated eye, even with a monofocal lens, for that week in limbo between surgeries with 2.5 D or more anisometropia. (Different prescriptions between the two eyes) Being a surgeon doesn’t make us a better patient, but being a patient does make us a better surgeon. A bifocal CTL in the unoperated eye is a good idea if the patient is already used it, but I’m not sure it’s worth trying to adapt to the glare from the contact lens for such a short time. You’re through the worst part. Two Restors are definitely better than one. I’ll be praying for you tomorrow, I’m sure you will do well.Dan

Dan was prophetic! Having 2 ReSTOR implants is so much better that having just one and an unoperated lens in the other. The Alcon reps have always mentioned that 1+1=¿2 when it comes to the results of the ReSTOR. There was an immediate (when I walked out form the surgical center) difference in vision and function, was remarkable. The brain just does much better, when using similar optical systems to input vision. I would have been able to drive without any visual checked my email, email, and did some paperwork and dictations… without any glasses.

Cannot say enough for all of Dr. Lehman’s employees. Very professional, very courteous, and organization is terrific. They truly believe in teamwork. I notice more than most (being in the business), and if one person was busy, the others pitched in to complete the task or make the patient comfortable. One could only wish that all clinics ran as well…I assure you they do not. My employees and I now have goals to achieve to even come close to this set up. I wish I could thank all the women who assisted me this morning, but you will have to blame Rusty, the CRNA (nurse anethtisist) who ensured I wouldn’t make any suggestions during the surgery. Versed is amnestic! (Make you forget most short term memories) Thanks Rusty. And congratulations to his son, who just graduated from

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Annaplois. He is on the way to F/18 training. I personally wish I could individually thank every member of the military. (My personal bias…forgive the editorial)Thanks again Dr. Lehman, for your expertise and your clinic personnel.

Wednesday, May 20, 2009

Vision 20/20- R, 20/30-L For the MD’s R-.25 + .25 X 005, L Pl. + .75 X 157

The L eye has been fluctuating between an astigmatism of +.50 and +.75 for the last few days. I knew from my past experience with implanting ReSTOR IOLs that astigmatism would decrease vision. For me, it is exquisitely so. If I correct the astigmatism incrementally, (by + .25 increments), vision improves dramatically. Under + .50 will be my target for any ReSTOR patient. I knew this intellectually, but having experienced the difference will make me more attuned to correcting it as much as feasible. It also depends on the patient. As you might expect, I know too much, know what to look for etc. Many of my patients post-operatively, have little problem with +.50 to + .75. However, every patient is an individual, and we must listen when they describe their vision post-operatively, if we want to provide the best possible outcome.The ring phenomenon is more evident when both eyes have a ReSTOR. Still doesn’t bother me, just a fact, it’s just there. As I mentioned before, I had significant ‘Halos” and now the halos just have fine rings inside of them. Interestingly, as I approach a traffic light the rings disappear at about 100-150 ft. Makes sense optically, the farther away from a point source of light, the more parallel the light waves, and the more ring phenomena. At least, that is my observation.I am blogging this without glasses, and doing just fine. I performed a Levator resection (raised a droopy eyelid), and a blepharoplasty (removed the excessive skin) this morning. I could have done so without glasses, but chose to wear an Over The Counter + 2.00. It just gave me more of the fine details I required. The intermediate is not fine, as I mentioned. Newspapers in the morning can be managed without glasses, but better with my + 2.00. Newspapers print is always bad. The decrease in vision may be a combination of having a little worse vision, early in the morning, (slight corneal swelling?) combined with the near taking longer to get better. All my ReSTORE patients tell me the near vision takes longer to sharpen.I had no shadow in the lateral portion of my vision in the R eye. If you remember I did report that in my Left… many of my patients have mentioned this shadow. My shadow took about 3 days to dissipate in the L. Why in one eye and not the other. Possibly the incision laterally, but I do not know for sure. No Pain! However, just using the drops are a pain!... using 3 separate drops 3x a day. I now realize that not all patients will use the drops as instructed.

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Saturday, May 23, 2009

I jokingly tell many of my patients after surgery; no bungee cord jumping, roller coaster riding, or jumping on a pogo stick (anything that will start and stop you quickly). They get a quick laugh, and then say something to the effect, “what can I really do?” That is a really great question, and I don’t know if it has really been studied. I don’t know that more activity a patient does, the more likely things will happen. For instance: After operating on a friend (back in the days before small incision surgery), he was doing minor chores at home. While he was shaking a kink out of an electrical cord, the end flipped up and hit him in the operated eye, opening his wound. A worst case scenario. I had to take him back to surgery, repair the wound. He did fine, but could have seriously injured/infected his eye. If he had been more sedate, perhaps it would not have happened. I routinely tell golfers, no golfing for a week. Do I really thing golfing will hurt the eye 48 hrs. – 72 hrs. after surgery? Probably not. It is the other possibilities that go along with increased activity. The 6 pack of beer, the golf cart accidents, the foreign debris… the unpredictable that can and will occur.So, what did I do? After the first eye, I limited my activity. Jogged 6 days later with no problems. After the second eye, I jogged 48 hours later. Now, I have no idea whether that was a factor, but later in the day, there was some definite pain in my most recently operated eye. Does jogging move the implant enough to cause a slightly increased inflammation? It seems unlikely. I don’t really know, but my eye did throb and hurt in a manner that the other didn’t. I increased my anti-inflammatory drops and decreased my activity and everything was fine. (To clarify, the implant becomes ‘shrink-wrapped’ in a clear capsule, and generally cannot move after the initial healing phase.) Jogging and other physical activities should not be a problem after that occurs. The most frequent question is concerning lifting objects. How much can I lift? Again, I’m not sure straining to lift a heavy object will hurt the eye; it’s the grandchild’s finger that accidently pokes the eye that may do the damage. (We no longer use sutures with cataract surgery, so sutures can’t break, but others damages could occur) I caution my patients.. Just be careful. Even though we are in a new era of eye surgery, “things happen.” Don’t mess it up. I should have taken my own advice!

Tuesday, May 26, 2009

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I asked Bob, if he would make a few comments concerning his technique, and on operating on a fellow ophthalmologist. Some of his comments are technical and I have explained them, following each item that a layman person may not be familiar; with (……..)

Tim, Yes! I would be happy to lend my two cents worth.

As for the basics, I always say that the softest cataracts can become the hardest and the most experienced surgeon still has to be compulsive about a thorough hydrodissection and in only the softer cases will I hydrodelineate. (Loosening the cataract with fluids) Before all that comes the proper incision and with premium IOLs, a 2.2.mm incision with torsional on the INFINITI can’t be beaten. (The machine we use to remove the cataract) I really find it helpful to mark the steep axis if I wish to make the incision on axis. (To reduce astigmatism) I routinely mark toric (astigmatism) patients as well in the preoperative holding room for the “next patient” ready to be brought back. Having a slit lamp in that room has greatly enhanced my ability to make toric IOLs, more accurate and to reduce pre-existing astigmatism for other patients as well. As you know, I rotate the slit beam to the axis for the incision in the case of premium IOLs, or to the axis for the final position for the toric IOLs and there I place a sterile ink on both sides of the limbus. (Edge of the eye) In addition to being more accurate and faster it eliminates all the goofy and none too well designed axis marking devices! (Boy, do I really agree with that!) I bet the cost of a portable slit lamp fixed to a table on wheels is less than the cost of the numerous making instruments some docs have in their ORs.I start and end my rhexis with the Utrata forceps and really try for an overlap on the IOL, meaning a 5.5mm rhexis. (A rhexis is creating a hole in the thin, transparent membrane covering the capsule)As for opening on a fellow eye surgeon, I suggest treating the doctor as the patient and doing all our own measurements and calculations. I suppose if it was a first time then a beta-blocker might be a good idea to control the tremor!!! (Some surgeons get very nervous, and have a tremor. A beta-blocker medication reduces tremors) Tim, it is much the same as doing live demonstration surgery or operating on a loved one/family member. You always want every patient to have the very best outcome possible…. Just in those close and personal patients, it is more foremost in the surgeon’s mind. (I agree, in is all psychological when operating on a relative, or friend)One final comment on my own situation is to point out that the Zeiss Lumera operating microscopes have really changed my operating day. I truly do more thru procedures with greater ease due to the enhanced red reflex compared to my former Leica scopes. (I also agree with that.. I previously had the old Zeiss scope, and the new Lumera is a technological leap, not just a small step.) I am confident that I would have had a capsular complication during my ASCRS surgery case from Tijuana a couple years ago if I had been able to use the Lumera (which was not even available them)

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Please keep me posted as to your progress,

Bob

Thanks for the excellent comments, Bob. The small things Bob and any excellent surgeon does, make the difference, and produces accuracy. The smaller incisions, good hydrodissection, making the axis of astigmatism, a 5.5mm rhexis, the Lumera microscope, just to name a few, are additive. Leave one out and it will decrease reproducibility, and accuracy. On the topic of, operating on surgeons, friends and relatives, there is one other situation that many surgeons shy away from, operating on a one-eye patient. Think about that one! No surgeon wants a complication, and in any patient it is difficult to swallow, but a one eye patient would be even worse. It is completely psychological. You have heard the term, “psyching yourself out.” That is exactly what can happen in any of those types of patients, if you allow it. I treat everyone exactly the same, and in the one eye patients, I often forget who they are. They are in the mix with rest of my schedule, and it is generally after the case when I tell them everything went fine, that they bring it up. I had the privilege of operating on tow active physicians, and a close family friend last Wed. I treated them just as Bob treated me….. No different than the next person, and everything went perfectly.

Friday, June 5, 2009

Haven’t posted for awhile… nothing to tell, other than thing were same. Vision today: 20/20 binocular (both eyes open) without correction. I can still tell it is not as good as with glasses before cataracts. However, it is much better than even 3-4 days ago. I am now almost 4 wks. and 3 wks. post op… vision improving every day. Let’s talk about the quality of vision the first few weeks. Although I could see, most written material seemed to be “washed out.” For those of you old enough to remember the old mimeograph machine, that is what it looked like. Type was not dark, it all appeared faded. Just in the lst few days, this has changed. Print is getting sharper and darker. I would have thought that would have been related to a residual glass prescription… but it is not! I have checked my refraction every day, and for the last 2 weeks, it has not changed at all. R,-50 +.50 X 05, & L, plano + .75 X 155. For non MDs, that is not much of a prescription. I’m not having a significant problem working, but still require a small reading aid in very dim light, such as in an ophthalmologic exam room. But that too, is getting better. Most of my patients have told me that vision gets better with time… only problem is being impatient.

Wednesday, June 10, 2009

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Vision 20/20 binocular, J 1 at near with good light. Refraction R- .50+50x180, L Plano +.75x155 R eye 20/20, L 20/25- without glasses.Below are a few comments from Dan, another ophthalmologist who has a ReSTOR IOL (Some aspects of Dan’s comments below are fairly technical are meant for eye surgeons. Don’t worry if everything is not perfectly clear….) I liked your description of the circles around lights at night. Yes they are a visible artifact but it certainly does not limit function. It’s not a problem for night driving. It’s certainly less of a problem than a 20/20 distance and 20/50 glare cataract. Patients need to be told to expect it, especially if it is a refractive lens exchange, but it is transient and increasingly intermittent over 2-4 weeks. I wouldn’t hesitate to use the lens in truck drivers. As ophthalmologists we are rightly worried every time we hear the words glare or halo but with the ReSTOR lens it is a fine line artifact that is easily worked around until visual adaptation makes it go away.The “mimeograph paper” effect on near vision is visual confusion between the near focal and the far focal. Usually one is clear and the other is so blurred to seem more like a smudge than a recognizable letter. That effect will go away. This is more noticeable in dim lights and with the object of regard midway between the ideal near focal point and the distance focal point (Circle of most Confusion). So adjust the lighting when you can and the distance you’re holding your work. It also gets rapidly better with practice. Go without the readers as much as you can. That does short circuit the adaptation process. You mentioned that your near vision varies at different times of day. I actually retained about a diopter of accommodations. I’m not a morning person, so it shouldn’t come as too much of a surprise that my near point moved out 3-4 inches in the morning during the first few months. Now it’s little less. Having some residual accommodation makes it even more of a learning experience that’s improved by practice. The odometer falls right in between where I would see it best with the near focal and the distance focal. Even a diopter of accommodation becomes a wild card. My brain is facing the choice of A) use the near focal and relax accommodation or B) use the distance focal and accommodate. Less satisfying but equally possible choices would be to C) use the near focal and accommodate or D) use the distance focal and relax accommodation. So it is equally likely to choose the wrong option until it is experienced a few times. Practice going without glasses. Practice makes perfect.DanTim, I’m +.25 OD and +0.75 OS. Early on I felt the same way you did, that the trial lens correction was noticeably better. But after a month or so I didn’t notice as much difference. I also talked to another surgeon who is liberal with contact lens correction during early adaptation and he said that a lot of patients stop wearing the contact lens before 3 months because they don’t need it anymore. He uses it as a test to see if they really need a Lasik enhancement. Believe it or not the quality of your vision will “up convert” significantly

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with adaptation alone. I definitely would wait 3 months to consider Lasik. I really don’t think that you will be interested in more surgery especially for the right eye. I did enhancement on 10% of my first 100 ReSTOR 4’s. Mostly for -0.50 Sph or cylinder, but I wish I hadn’t because a little anisometropia like what you have can help with adaptation. 0.75 cylinder is a little marginal, but wait, your vision will improve significantly in 3-6 months. How many people with your refractive error do you put in glasses? Your surgeons did a nice job, be patient, your brain is still processing the changes.Dan

Sunday, August 23, 2009

It has been since June 10th, since I posted a note. The reason is simple. There really has been little change. I am still doing very well. My distant vision is no problem, 20/20 binocular. (With both eyes) Near vision is also 20/20 but the near vision is better with good lighting. My intermediate vision (computer distance) has never been a problem. Night time ‘rings’ are still present, but as I mentioned before not a problem. Only a distraction if you perseverate about them. A small majority of patients may do that.

I was asked by Alcon to be a part of a speakers forum, along with Dr. Voss (who also has the ReSTOR lens), and our individual surgeons, at our national meeting on Oct 24th. Would have loved to participate, however I will be in Kyrgyzstan, at about 16,000 ft. (FYI: That’s north of Afghanistan and a very isolated part of the world) this planned trip was a major reason for having the surgery in the first place. Not good to fog up at that altitude! You have enough problems to deal with. I’m sure the forum will be informative, and I’m looking forward to read a transcript.

Below is a series of refractions that show I have been very stable after the first month. This is a variable with each patient, but more importantly, I believe variable with each surgeon. (For a series of technical reasons) Each surgeon should know when the majority of his patients become stable……. In case an enhancement is necessary. Enhancement? If a patient’s vision is not acceptable then the surgeon may elect to reduce any residual astigmatism, near or far sightedness. I tell every patient that I operate on, whether they choose a ReSTOR or not, that I am not perfect, the science is not perfect, the pre-op measurements may not be perfect, and the patient’s eye may not be perfect. If all these variable are additive, it could leave the patient with some small residual prescription…. Just as I have below. The question is always: is the vision as is, acceptable, and whether the secondary surgery would reliably improve day to day function with enhancements, there are risks, and benefits, all of which needs to be discussed fully with each patient. Currently, I have a small residual prescription which sharpens my vision dramatically in my examining room. However, when I wear

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that same prescription, which sharpens my vision glasses, I see no significant changes with my driving, reading or any other activity. That’s what counts! Every surgeon will need to preform enhancements, but with more experience the numbers decrease. (Find a compulsive surgeon) with these small prescriptions I am a sharp 20/20, without these I am 20/20, but just a bit blurred

6/2………-.50+.50 x 015…………..Right Eye…………..plano + .75 x 165……….Left Eye6/16………-.50+ .25 x 005…………..plano + .50 x 1576/22………No Change7/7……….-.50+ .50 x 180…………..+.25 + .25 x 1557/17………No Change7/25……...-.50 +.25 x 003…………..+ .25 + .25 x1657/31………No Change8/07……...-.50+ .50 x 015…………..+.25+ .50 x 1658/22……..-.50+ .50 x170…………..+.25+ .50 x 157

Wednesday, September 16, 2009

About a week ago, I noticed that the vision in my right eye was slightly worse. Since that time my visual acuity dropped from 20/20 uncorrected to 20/30, uncorrected. Interestingly, when I use my phoropter (lenses), I could correct my vision to 20/20. The problem was my posterior capsule. For non-doctors: that is a membrane in which we secure the implant, and ‘shrink wrap’ it into place. This membrane may develop spots, striae, or turn completely white, thereby decreasing the patient’s vision. My capsule changes were subtle, but noticeable. I underwent a YAG capsulotomy today. (A specialized laser which actually cuts open this membrane without making an incision in the eye) Takes about 15 seconds. My vision improved to 20/20 within an hour. I am still amazed at how small a

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change in the capsule decreased my vision without glasses, and also that with a small prescription it improved….. even in the presence of my capsular changes. This experience has reminded me to look more critically at the capsule in all pts. Post-operatively and laser those ReSTOR pts. Early, who notice changes in their vision? Until next time…….

Sunday, January 31, 2010

I must apologize for being so slow to post an update in recent months. Lots of things to update you on: First of all: the main reason for me to have surgery and the ReSTOR implant was to free myself of spectacles and see well. I am a very active individual, and had a constant ‘fogging’ with my glasses etc. I had planned, for several years, an excursion to Kyrgyzstan, which ultimately took me to 16,500 ft. with weather at 0 degree F. I knew from previous experiences that the fogging of my glasses on this trip was not acceptable, and could be dangerous. I can report that I had no problems (with my eyes) on that trip! My reasons for surgery was justified, and my results of surgery effective for the perceived tasks! I was very happy.Let’s talk about a couple of technical things. I first started noticing a little blurring in my R. eye in early November. As an eye surgeon, I assume that I may have noticed this decrease earlier than most of my patients. My vision decreased fairly rapidly, which surprised even me. In the span of 1 week my vision decreased from 20/20 to 20/30. That is not a huge change, but it was dramatic for me. I remind everyone that an eye surgeon or a commercial pilot may have different criteria for their vision. I am not saying that each and every one of my patients doesn’t deserve perfect vision, but the bottom line is that if a given patient is not performing extremely detailed tasks, then less than perfect vision will not even be noticed. My “capsule” had opacified. To review: after cataract surgery a clear membrane is purposely left behind the implant, and may become cloudy with time. My capsule changed quickly, causing decreased vision. A 15 second laser treatment ( in the office) cleared this problem. I was again 20/20. The same problem occurred in my L. eye in late Nov. I again had a laser procedure. The results were a bit different, and I will explain. My R. eye was a bit nearsighted and my L. eye was a bit farsighted. With a bit of farsightedness, the capsular material and the cilliary muscle contract and compensate for this small amount of farsightedness. Prior to the capsular opacification my vision could be corrected with accommodation. After, the laser, my accommodation ability (ability to compensate) changed dramatically and I could no longer compensate for the farsightedness. My vision did not return to 20/20. With both eyes open, I am still 20/20, and happy. However, not only do I know the difference, but I have requirements for the vision that most do not have, and I am thinking about having an “enhancement” to the L eye. An enhancement would be a ‘Lasik: type of procedure to reduce that farsightedness in the L eye. For my future patients knowledge, enhancement requirements a rare occurrence, but may be required. Anyone having a ReSTOR implant, or

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for that matter, any implant may require additional surgery/expense if they require or wish to have near ‘perfect vision’. I tell each and every potential implant patient that fact. I also tell my patients that there is nothing in the current medical technology that matches a 20 year old eye that does not require spectacles. I will repeat that I am very happy with my vision.More later

Friday, March 12, 2010

Back to 20/20Time may change many things. My vision decreased, in both eyes, worse on the L, over the last 3 months. My vision was 20/30+, in both eyes with the following Rx: R-.50 +.50 x 005,L +.50 +.75 X 180. In normal daily activity, I had no visual problems, but operating with smaller sutures required reading glasses. I also had a fair amount of glare at night, due to the slight blur.

On May 4th, Dr. Lehmann performed an ‘enhancement’, a laser treatment, in both eyes. I am now 20/20 and have no visual problems at any distance, far or near. In addition, I no longer have significant glare, and see no ‘rings’ around lights at night.

Enhancements are a fact of life; it is not a failure of surgeon, or your eye. Even the most experienced surgeons, using the latest technology will have an enhancement rate between 5-15%. Not everyone requires or even wishes an enhancement.

All things considered: I now can do anything I wish to do, day and night, at all distances

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