Friday, March 12, 2010

Back to 20/20

Time 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 x180. 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 your surgeon, or your eye. Even the most experienced surgeon, 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.

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 problem of '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 accomodation. 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 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 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. The rate of additional surgery is very low, (2-10 %), in my hands, but a 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

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 still am amazed at how small a 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, 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 Afganistan 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 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 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 preop measurements may not be perfect, and the patient's eye may not be perfect. If all these varibles 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 need 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 that same prescription in glasses, I see no significant changes with driving, reading or any other activity. That's what counts! Every surgeon will need to perform enhancements, but with more experience the numbers decrease. (Find a compulsive surgeon)

with these small prescription's 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 eye
6/16...............-.50 + .25 x 005
......................plano + .50 x 157
6/ change
6/ change
7/7................-.50 + .50 x 180
.....................+.25 + .25 x 155
7/17 change
7/25..............-.50 +.25 x 003
.....................+.25 +.50 x 165
7/31 change
8/07.............-.50 + .50 x 015
....................+.25 + .50 x 165
8/22.............-.50 + .50 x 170
....................+.25 + .50 157

Wednesday, June 10, 2009

Vision 20/20 binocular, J 1 at near with good light. Refraction R -.50+50 x 180, L Plano +.75 x 155 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 and 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 noticable 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 dioppter of accomadation. 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 a little less. Having some residual accomadation 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 accomadation becomes a wild card. My brain is facing the choice of A) use the near focal and relax accomadation or B) use the distance focal and accomadate. Less satisfying but equally possible choices would be to C) use the near focal and accomadate or D) use the distance focal and relax accomadation. So it is equally likely to choose the wrong option until it is experienced a few times. Practice going without glasses. Practice makes perfect.
I'm +0.25 OD and +0.75 OS. Early on I felt the same way you did, that the trial lens correction was noticably 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. Beleive it or not the quality of your vision will "upconvert" significantly 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 enhancements 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 surgeon did a nice job, be patient, your brain is still processing the changes.

Friday, June 5, 2009

Haven't posted for awhile....nothing to tell, other than things were about the 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 improving every day. Let's talk a minute 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 memeograph machines, that is what it looked like. Type was not dark, it all appeared faded. Just in the last few days, this has changed. Print is getting sharper and darker. I would have thought that would have been related to a residual glass perscription.....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 perscription.
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....the only problem is being impatient.

Tuesday, May 26, 2009

I asked Bob, if he would make a few comments concerning his technique, and operating on a fellow ophthalmologists. Some of his comments are technical and I have explained them, following each item that a lay 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 also hydrodelineate. (Loosening the cataract with fluid) Before all that comes the proper incision and with premium IOLs, a 2.2mm 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 mark 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 instuments 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 operating on a fellow eye surgeon, I suggest treating the doctor as the patient and doing all your 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 even 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 move 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 not 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).

Please keep me posted as to your progress,


Thanks for the excellent comments, Bob. The small things Bob, and any excellent surgeon does, makes the difference, and produces accuracy. The smaller incisions, good hydrodissection, marking the axis of astigmatism, a 5.5 mm 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-eyed patient. Think about that one! No surgeons 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 eyed patients, I often forget who they are. They are in the mix with the 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 privilige of operating on two active physicians, and a close family friend last Wed. I treated them just as Bob treated different that the next person, and everything went perfectly.