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CataractPhiladelphia

Cataract Surgery Philadelphia

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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, PA 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.

Astigmatism Management

Toric

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.


Premium Implants

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.


Expectation Gap

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.


Poor Performance

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.


Myopia

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.


Monovision

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.


Pathology

Even with perfect cataract surgery and correct Implant selection and implantation patients can have late postoperative problems.


Retina

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.


Corneal Disease

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.

CALL FOR AN APPOINTMENT

(215) 886-9090

RxSight Light Adjustable Lens

Select uncompromised clarity with an IOL that matches your visual requirements

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PanOptix Trifocal dominates Cataract Philadelphia

Enjoy a glasses-free life, with the most advanced multifocal IOL.

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AcrySof IQ Vivity

Designed to deliver an extended focal range and a monofocal-like visual disturbance profile

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Dropless and Less Drops Cataract Surgery

Choose safer surgery and save $100 to $300 per eye

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Hydrus MicroStent: Cataracts and Glaucoma

Stop your glaucoma drops with the Hydrus MicroStent.

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Full compliance with all guidelines 😷 related to the Coronavirus crisis

Lewis LASIK
Our practice will start seeing patients again on M Our practice will start seeing patients again on Monday, May 11th in full compliance with all local, state, and federal guidelines. This includes masks, social distancing, and the disinfection of all common surfaces. Elective surgeries are also being rescheduled. Care will be taken to avoid office congestion and minimize exposure to COVID-19.

We require: ➡️ You do not have fever, chills, shaking, muscle pain, headache, sore throat, or a loss of taste or smell ➡️ You have not had exposure to anyone with a flu-like illness within the past two weeks ➡️ You wear a mask or equivalent facial covering over both your nose and mouth ➡️ You agree to maintain social distancing ➡️ You avoid touching your eyes, nose, mouth, and face ➡️ You enter the office alone if possible

Expect to hear from our staff shortly. You may contact us at your convenience from links at jameslewismd.com
Chorioretinal folds are a known finding following Chorioretinal folds are a known finding following penetrating glaucoma surgery, as in these two cases who underwent Ahmed valve tube shunt placement. Prevalence is estimated between 10-50% of incisional glaucoma surgeries.

Pic 1.) several linear chorioretinal folds throughout the posterior pole. Intraocular pressure was 4mmHg at the time of this photo. The fundus and visual acuity returned to baseline within a week as IOP leveled at 10mmHg.
Pic 2.) Small choroidal folds can be seen distributed temporal to the macula. This image also demonstrates a large hemorrhage consistent with ocular decompression retinopathy.
Pic 3.) shows complete resolution of the choroidal folds and hemorrhage after 4 weeks in patient 2.

#ophthalmology #ophthalmologist #ophthalmictech #ophthalmologyresident #ophthalmicphotography #ophthalmicsurgery #cornea #corneasurgery #eyesurgeon #eyesurgery #eye #oculardisease #optometry  #optometrystudent #optom #sunyoptometry #osuopt #salusuniversity #glaucoma #glaucomasurgery #retina #chorioretinalfolds
Inflammation of the anterior chamber can create fi Inflammation of the anterior chamber can create fibrin plaques that are readily seen within the pupil. The second and third images demonstrate an almost completely occluded pupil with synechia formation. The fourth image demonstrates an ultrasound biomicroscopy image of a patient in angle closure following complete pupil occlusion from fibrin (blue arrow). Aggressive corticosteroid therapy can ‘melt’ the fibrin and cycloplegics can mechanically disrupt it. Nd:YAG laser can also instantly disrupt total occlusion.

#ophthalmology #ophthalmologist #ophthalmictech #ophthalmologyresident #ophthalmicphotography #ophthalmicsurgery #cornea #corneasurgery #eyesurgeon #eyesurgery #eye #oculardisease #optometry #ocularinflammation #optometrystudent #optom #sunyoptometry #osuopt #salusuniversity
Descemet stripping endothelial keratoplasty (DSEK) Descemet stripping endothelial keratoplasty (DSEK) is a corneal transplant procedure that replaces only the innermost cells of the cornea. It is readily combined with cataract surgery to improve refractive outcomes. This is a one day post operative visit of a DSEK showing faint edema and remaining air bubble. The air bubble will typically dissolve over the first 48-72 hours.

#ophthalmology #ophthalmologist #ophthalmictech #ophthalmologyresident #ophthalmicphotography #ophthalmicsurgery #cornea #corneasurgery #eyesurgeon #eyesurgery #corneatransplant #dsek #fuchsdystrophy #endothelium #eye #oculardisease #optometry #optometrystudent #optom #sunyoptometry #osuopt #salusuniversity
Ocular surface disease is a complex state that rep Ocular surface disease is a complex state that represents a poorly performing pre-corneal tear film. It can frustrate many patients and can be challenging for clinicians. No two cases are alike.

In this case, a young patient without evidence of desiccation or inflammation had persistent physical symptoms. Biomicroscopy revealed clear lid margins, no conjunctival injection, and no corneal epitheliopathy. Meibography (imaging the meibomian glands) provides insight into the cause. A previous course of oral medication that acts on sebaceous glands has likely impacted his meibomian glands as well. The gland dropout is easily seen as truncation and atrophy. The final video demonstrates a noninvasive tear-breakup time where the red squares are regions with early loss of tear film stability.

#ophthalmology #ophthalmologist #ophthalmictech #ophthalmologyresident #ophthalmicphotography #ophthalmicsurgery #cornea #corneasurgery #eyesurgeon #eyesurgery #dryeye #ocularsurfacedisease #OSD #eye #oculardisease #optometry #optometrystudent #optom #sunyoptometry #osuopt #salusuniversity
Iris cysts are benign. If suspected, they should b Iris cysts are benign. If suspected, they should be imaged with ultrasound biomicroscopy (UBM) to confirm the diagnosis and rule out other causes of iris elevation.
#ophthalmology #ophthalmologist #ophthalmictech #ophthalmologyresident #ophthalmicphotography #ophthalmicsurgery #cornea #corneasurgery #eyesurgeon #eyesurgery #ubm #eye #oculardisease #optometry #optometrystudent #optom #sunyoptometry #osuopt #salusuniversity
There are various types of cornea transplantation There are various types of cornea transplantation procedures and each is best suited for different patients based on diagnosis and other factors. This is an MDALK (maximum depth anterior lamellar keratoplasty) that retains the innermost layer of cells and membrane, but replaces as much diseased tissue as possible. It has excellent clarity and comparatively good visual outcomes. 
#ophthalmology #ophthalmologist #ophthalmictech #ophthalmologyresident #ophthalmicphotography #ophthalmicsurgery #cornea #corneasurgery #eyesurgeon #eyesurgery #eye #oculardisease #optometry #optometrystudent #optom #sunyoptometry #osuopt #salusuniversity #mdalk #corneatransplant
Corneal infection! This series of images highlight Corneal infection! This series of images highlights a case of pseudomonas aeruginosa microbial keratitis (corneal infection) related to contact lens wear. Keep in mind the cornea is about 0.5 millimeters thick! Not much room to allow an infection to move deeper.
Pic 1. The resultant scar after the infection cleared.
Pic 2. At presentation, the eye is injected (red) with a large central infiltrate (immune response) and necrotic stromal tissue (dying cells). Pic 3. There was extensive inflammation in the anterior chamber including fibrin strands
Pic 4. Note the presence of a hypopyon (accumulation of white blood cells at the bottom of the anterior chamber).
Pic 5. This is two days after initiating treatment with fortified antibiotics. The pupil is intentionally dilated (for comfort) and anterior chamber inflammation is improving. There is a small unrelated fiber present that was subsequently removed.
Pic 6. A closer look at the scar and the shadow it casts. These scars disrupt the vision permanently. Fortunately this patient has achieved good acuity, yet blur, glare and haze can be persistent.
(Sorry for poor photo quality in pictures 2/3/4)

It is important to work quickly to identify the organism responsible for these infections to tailor treatment appropriately. If left untreated infection can spread to devastating results.

#ophthalmology #ophthalmologist #ophthalmictech #ophthalmologyresident #ophthalmicphotography #ophthalmicsurgery #cornea #corneasurgery #eyesurgeon #eyesurgery #microbialkeratitis #eye #oculardisease #optometry #optometrystudent #optom #sunyoptometry #osuopt #salusuniversity
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At the Philadelphia, Pennsylvania cataract surgery offices of Dr. James S. Lewis, patients are assured the highest quality treatments and impeccable care. Dr. Lewis and his team use the latest surgical technologies and techniques to deliver the best possible results. CataractPhiladelphia offers a wide range of premium IOLs, including PanOptix, Vivity, Toric and Light Adjustable Lens. Dr. Lewis also treats patients with both cataracts and glaucoma through an enhanced range of micro-invasive glaucoma surgical options.

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ASCRS
American Academy of Ophthalmology
ESCRS
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* currently only PanOptix, Vivity, Toric, and the Light Adjustable Lens patients qualify for ONCE AND DONE.

 
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CALL FOR AN APPOINTMENT

(215) 886-9090

8380 Old York Road
Suite 110
Elkins Park, PA 19027

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