Cataract Surgery Concerns – Dr. James Lewis
Serving Philadelphia, Bucks County, Delaware Valley, Conshohocken, Warminster, Montgomery County, King of Prussia and Phoenixville
Nearly 3 million cataract surgeries are performed in the United States each year. Most patients enjoy a substantive improvement in their central and peripheral vision, their color sense, their contrast sensitivity, their performance in low light scenarios, their quality of life, and a reduction of their dependence on glasses and contacts.
Sometimes patients have significant complications. That will be addressed below. Cataract failure is an inability to achieve the expectations of the Philadelphia cataract patient or the expectations of the surgeon.
IOL (Intraocular Lens) Power Errors
Choosing the power of the implant to use for each patient is a complex process. This begins in our offices with multiple measurements of corneal curvature (K-readings) using automated, manual, and topographic systems. Next the axial length and anterior chamber depth are measured with both laser interferometry (IOLMaster) and non-contact immersion ultrasound. This along with measurement of the horizontal white to white distance is applied to a number of equations including Holladay I, Holladay II, Hoffer-Q, SRK-T, and Haigis. Dr. Lewis and Dr. Devlin make the final determination of the exact power. If this is a second eye, the results of the first surgery are also taken into consideration.
Sometimes, these calculations are not perfect despite the measurement redundancy and safety protocols present in our electronic medical record. For our practice this is usually the result of inherent weakness of the equations for very nearsighted and very farsighted patients.
In other practices, this can be the result of transcription errors, failure to use redundant measurements of corneal curvature and axial length, failure to recognize irregular astigmatism, failure to use multiple predictive equations, failure to consider the special calculations needed for post LASIK, PRK, Epi-LASIK, Corneal Transplantation, DSEK, and RK eyes.
Dr. Lewis sends the patient’s intraocular lens power calculations to the surgery center electronically so that no miscommunication occurs. Only physicians are involved in generating and communicating the IOL Powers for each patient.
For patients experiencing IOL Power problems elsewhere we rectify this problem with a variety of modalities. In consultation with the patient we s_elect either lens exchange, piggy-back IOL placement, and sometimes excimer laser corrective surgery like LASIK, PRK, or Epi-LASIK. Our success rate in resolving these problems is excellent.
For nearly two decades IOLs have been able to reduce or eliminate astigmatism. These lenses are called Torics. Sometimes these lenses are inserted correctly but a few days or weeks after surgery they rotate. This rotation can degrade your best post-operative visual acuity.
It is important to address this issue with the operative surgeon or our practice as quickly as possible. Often, Dr. Lewis can simply rotate the Toric back into the proper position. Other times a lens exchange is required.
Corneal Methods of Astigmatism Management
Dr. Lewis has been using Toric implants for more than 15 years. Corneal methods of astigmatism control can take the place of Toric implants in some cases and can supplement Toric implants in others.
Relaxing Limbal Incision (RLI) or more commonly Limbal Relaxing Incisions (LRI) are used to correct smaller degrees of astigmatism. Our practice sometimes uses both Toric implants and LRI’s to achieve superior astigmatism control. Unfortunately, these methods are limited both in terms of the amount of astigmatism correction and the predictability. Dr. Lewis will use the Excimer Laser (PRK, Epi-LASIK, or LASIK) to control larger degrees of astigmatism. In fact, he has pioneered the use of excimer photoablation on patients with Excesssive Regular Astigmatism including those who have had corneal transplantation (ERAPK). Our practice has used LRI’s to correct astigmatism at no cost for 15 years.
Second opinions are frequent for disappointed Philadelphia / Bucks County Crystalens AO or multifocal IOLs (ReSTOR and ReZoom) patients. Sometimes this is nothing more than a lens power miscalculation or the result of residual astigmatism. Both of these scenarios are easily addressed. Dr. Lewis has two on-site Excimer Lasers to address these issues. In some cases lens exchange or piggy-back implants are necessary. These results are usually excellent.
Unfortunately, despite proper pre-operative counseling, patients hopes for the Premium Implant may not match the lenses capabilities. It is safe to say that no Premium Implant and no Premium Surgeon or Premium Surgery can replace the outstanding near, far, and intermediate acuity we enjoyed in our youth. In fact, today’s technology is excellent but nowhere close to what the future will hold. These improvements are too distant to delay your cataract surgery.
Some patient simply need to reset their expectations and recognize that the performance of today’s Premium Implants is significantly better than monofocal lenses and Multifocal lenses of the past (Array). In fact, Dr. Lewis was one of the most successful Array Lens Surgeons on the East Coast implanting over 3000 of these implants successfully.
Some patients can be disappointed because they still can’t read comfortably after surgery yet they paid as much as $5000 dollars more for the Premium Implant. Buyers remorse is understandable but it is hard for the patient to recognize how the Premium Implant compares to a Standard Implant. Usually these patients do not need additional surgery.
On occasion, the vision from the Premium Implant is unsatisfactory. This can be the result of glare, halos, poor contrast sensitivity, or ocular health changes like maculopathy or corneal edema. In these cases lens exchange as well as other interventions are necessary. Rarely all that is needed is a Premium Implant replacement or repositioning. Sometimes it is nothing more than an opacification of the posterior capsule. This is easily accomplished in our offices with a YAG laser.
End Point Failures
Patients who have worn glasses for distance their entire life often jump at the chance of having excellent uncorrected visual acuity. The dream of watching TV, driving, swimming, and seeing the alarm clock without glasses is tempting.
These patients are thrilled with their distance vision but soon recognize that their near vision without glasses is suboptimal. Sometimes patients adjust well to their “new vision”, other times therapeutic intervention is required. Preoperative counseling can decrease but can not entirely eliminate this problem. It is important to remember that the natural crystalline lens of youth is the only device that provides near perfect distance, near, and intermediate vision.
Despite the excellence of Premium Implants, patients who have successfully tolerated with contact lens or LASIK- based monovision (one eye near, one eye far) are usually best left with post-operative monovision. This mistake is made by many novice surgeons. Dr. Lewis is reluctant to disrupt the excellent near and distance acuity in the successful monovision patient.
Similarly, some surgeons will suggest monovision as an option for the cataract patient. This is rarely a successful strategy because almost 75% of patients can not tolerate monovision. Therefore, our policy is to encourage monovision cataract surgery for patients who have succeeded with pre-operative monovision and to avoid offering monovision as an intraocular lens power end point to those inexperienced with this vision correction strategy.
Even with perfect cataract surgery and correct Implant selection and implantation patients can have late postoperative problems.
Diabetic retinopathy, age related macular degeneration, vascular occlusion, and retinal detachment can occur following perfect cataract surgery. It is always worthwhile to contact your surgeon if vision degrades following a successful procedure. This may require intervention by a retinal specialist.
Dr. Lewis is frequently consulted by retinal surgeons when implants are damaged during retinal procedures. Replacing the implant is often all that is required. Unfortunately, most of these retinal conditions are not-reversible.
Optic Nerve and Glaucoma
Progressive damage to the optic nerve from glaucoma can convert a perfect cataract surgery to a complete failure. Optic nerve damage from glaucoma or Ischemic Optic Neuropathy can not be reversed. Dr. Lewis is extremely conscientious in the treatment of glaucoma prior, during and after cataract surgery. We have used the SLT (Selective Laser Trabeculoplasty) before almost every other practice in Pennsylvania and New Jersey. This helps control glaucoma without drops or with fewer drops than before laser.
Dr. Lewis has performed more non-penetrating deep sclerectomies (AquaFlow) than any other surgeon in the United States and is considered an expert in combined cataract and glaucoma procedures. In more severe cases Dr. Lewis will perform a variety of shunts (Molteno, Ahmed, and Mini-Express). On occasion Dr. Lewis will combine cataract surgery with EndoCycloPhotocoagulation (ECP), a laser based glaucoma procedure done at the time of cataract surgery.
Careful management with the latest imaging and visual field techniques is vital in order to maximize the health of glaucoma patients. Our practice has the most advanced Optical Coherence Tomographers as well as prototype devices to recognize problems before they occur.
Patients with Fuchs Endothelial Dystrophy can have decompensation before, during, or after cataract surgery. Dr. Lewis is a fellowship trained corneal subspecialists who has one of the strongest corneal practices in the area. Dr. Lewis performs all corneal surgeries for The Pennsylvania College of Optometry at Salus University and has recently been asked to collaborate with Michael Aronsky, MD at Kremer Eye Center in the surgical management of Corneal Diseases. Twenty years ago he was Director of Corneal Surgery at Hahnemann University in Philadelphia.
Patients with reduced endothelial cell counts and clinical and optical evidence of pending corneal decompensation are treated with simultaneous endothelial replacement surgery (DSEK or DMEK) and cataract and implant surgery, the so called “triple procedure”. Our practice performs this procedure with considerable frequency. Knowing that a patient requires a triple procedure changes the power of the implant used.
Sometimes patients have irregular astigmatism, corneal scarring, Keratoconus, or Pellucid Marginal Degeneration. Dr. Lewis will often perform a simultaneous “Big Bubble” procedure as first described by Dr. Anwar. This technique is called MDALK or Maximum Deep Anterior Lamellar Keratoplasty. This allows faster rehabilitation than standard full thickness keratoplasty with earlier suture removal and far less corneal astigmatism.
Patients with corneal surface disease are treated in our practice with Excimer surface ablation or chelation therapy prior to cataract surgery. This optimizes the visual results and makes the surgery easier and safer for the patient.
Absence of Capsular Support
On rare occasions complications occur in the operating room preventing surgeons from implanting an intraocular lens. Sometimes surgeons will place an anterior chamber implant but they can be fraught with complications including UGH Syndrome (Uveitis, Glaucoma, Hyphema). In some cases this can lead to soreness, light sensitivity, decreased vision and corneal decompensation.
In 1991, Dr. Lewis described a technique of placing a posterior chamber Implant (the preferred IOL) in these complicated cases. This procedure is still the standard of care and is taught in all ophthalmology residency programs. When patients have exfoliation syndrome or trauma Dr. Lewis is always prepared to implant a posterior chamber intraocular lens. Thirty years after the development of this technique, Dr. Lewis is still referred patients requiring this procedure.