Cataract Awareness (cont.)

Beginning in the 1970s, small-incision cataract surgery became gradually more and more popular as a result of the late Dr. Charles Kelman from New York City. Currently, almost every good cataract surgeon in the world uses this small-incision technique called phacoemulcification. During this operation, parts of the lens are selectively removed and a part of the lens is left behind to support an intraocular lens. A 3-millimeter or less incision is required. The anterior capsule of the lens is opened and removed through the dilated pupil and ultrasound, in association with irrigation of balanced salt solution and aspiration, is used to soften and emulsify the lens material so that it can be aspirated through this small incision.

We now use foldable injectable intraocular lenses that can then be delivered into the remaining lens capsule supported by the zonules. The injected, foldable intraocular lens spontaneously unfolds and the incision can be closed by injecting balanced salt solution into the margins of the incision without the use of sutures that can create unwanted astigmatisms. If corneal astigmatism is present, it can be treated with relaxing corneal incisions in the periphery of the cornea at the same time cataract surgery is performed.

MEMBER QUESTION:
Does the cataract surgery also fix other vision problems such as farsightedness or near sightedness? Will I be able to get rid of my glasses after cataract surgery?

KNOLLE:
The intraocular lens replacement can consist of a monofocal lens, like we've used since the 1970s and before, or it can consist of a multifocal intraocular lens that has been used in recent years. If a monofocal lens is used, the lens can be adjusted to be in focus in the distance, at near, or somewhere in between, but there is a single focal point. It is monofocal, and areas that are not in the focal plane will not be clearly seen.

If a multifocal intraocular lens is selected, the power is calculated appropriately, and the lens resides within the capsular framework as calculated, the patient's vision should be good in the far distance, at intermediate distance, and at near. In other words, the vision should be good throughout the range of vision at all distances.

The Array intraocular lens, manufactured by Advanced Medical Optics, was approved for cataract patients over the age of 60 in September of 1997. I personally have a great deal of experience with this lens, and have used it in essentially all of my cataract patients since the year 2000.

In fact, I had such good experience with my patients that after I had used the lens for two years, I made plans to have the lens implanted in both of my eyes. This was done last year and I've been very happy with my vision and with the fact I no longer have to wear trifocals. I did not have cataracts and my vision was corrected with my spectacles to 20/15 with no glare disability, and now I can see 20/20 with no glare disability without glasses.

In my experience, more and more patients are looking to clear-lens exchange as a refractive surgical correction, because it can provide good vision using both eyes together as compared with monovision at all distances.

There are other accommodative or multifocal lenses now coming available, and over time we may see that they offer advantages that are better than the Array. But in my opinion, this remains to be seen. The only significant criticism that I'm aware of with the Array lens is that since it has concentric circles of varying power, to provide clear vision at all distances, or through a wide range of distances these circles in the lens put circles around lights at night. They don't cause glare, they only put a circle around the light that makes it appear larger in diameter than it would without the circle. There is no interference with visualization of the roadbeds or road markings.

I had a patient that was a truck driver. He drove an 18-wheeler day and night in all kinds of weather and he developed cataracts at an early age, in his 50s. The first time I did surgery on him before I was using the multifocal implant and I implanted a monofocal lens that was calculated to correct his distance vision. He felt like he could see so well that he delayed surgery in the second eye for two or three years.

When he came back for the second surgery, I explained to him that I had now the use of a multifocal implant and there was some question in some surgeons' minds about whether or not the two would work well together. But I told him that from my previous experience with a multifocal lens in 1989 (that had never been approved by the FDA and "went away"), I felt the multifocal lens would fill in the gaps and work well with his monofocal lens in the first eye. It made sense to the patient, and he elected to have the multifocal lens implanted in his eye.

About two months after his surgery the patient was so delighted in his depth of field and his ability to see so many distances with his two eyes working together that he went to the drugstore and bought a thank you card to send to me. That confirmed what I had thought about the lens filling in the gaps that a monofocal lens leaves, and the usefulness of this multifocal lens day and night on the highway.

MODERATOR:
Why is the lens approved just in patients over 60? What about those who have cataracts and are not yet 60?

KNOLLE:
The lens is used as an off-label device in people other than those that are over 60 years of age. When we use the Array lens in cataract patients or to do clear lensectomies in patients without cataracts, these are all off-label uses as LASIK surgery once was. It's done at the discretion of the surgeon and the patient.

MEMBER QUESTION:
I have mild cataracts. My eyes HURT in bright light and most outside light unless it is raining. This light doesn't seem to bother the people around me. At night oncoming headlights cause the same pain. Is it normal to have PAIN with cataracts? Also, I have been told that sunglasses don't help because the pupils enlarge allowing more light to enter (I wear them anyway).

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