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Cataract Surgery Philadelphia

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Cataract Surgery Risks – James S. Lewis, MD

Also Serving Philadelphia, Bucks County, King of Prussia, Delaware Valley, Warminster, Conshohocken and Phoenixville


Virtually all surgeries have some degree of risk. You and your surgeon must balance the risks against the benefits. The surgeon should describe the risks from surgery in general as well as the special risks you might have following a complete and detailed ocular examination.

Prior to making this decision you should consider what problems you are experiencing visually and how they impact your life. The onset of cataract development is not a reason to have surgery. In fact, most patients over 60 have some degree of cataract development and in many of these cases the signs and symptoms are sub-clinical. Your surgeon should dissuade you from surgery if your cataract is not effecting your activities of daily living. Similarly your surgeon should make sure you are not simply rationalizing your symptoms and avoiding surgery because you are scared, you don’t want to complain, or you think you are too old.

Cataract surgery is one of the most successful procedures in modern medicine. Well over 99% of patients are very happy with the results or can at least recognize significant visual functional improvement. Approximately .5% have problems after surgery that will be described below. Most of this small grou_p will recover through additional therapy and sometimes additional surgery. Most of the common and uncommon risks are listed below.

Retinal Detachment

Rarely the retina, the neuro-ocular tissue that lines the inside back of the eye, can become separated from its blood supply at the time of surgery or soon thereafter. Retinal detachment also occurs without surgery particularly in those with significant myopia (nearsightedness), trauma, or a family history. When patients are at a high risk of retinal detachment Dr. Lewis asks a retinal specialist to evaluate your risks and perform any prophylactic treatment to minimize the chances of a detachment. Because post-operative patients are followed immediately after surgery and for a few months thereafter these detachments are caught early. The signs and symptoms of retinal detachment are described to all surgical patients to facilitate their recognition and prompt a quick response. Over 90% of patients who alert their doctor to symptoms of flashes, floaters, and a curtain crossing the vision will recover all or almost all of their vision.


Macular Edema

Cystoid macular edema is usually a self-limited phenomenon that can go unrecognized in many patients. The use of topical non-steroidal anti-inflammatory medications routinely is theorized to reduce this complication. In some patients with diabetes, uveitis, or pre-existing macular disorders (epi-retinal membrane, partial lamellar hole) cystoid macular edema is anticipated and treated aggressively with topical medications. If this is exacerbated after cataract surgery, more aggressive and effective drug treatment has become available recently. If this condition does not resolve promptly or if your a recalcitrant to standard therapy, Dr. Lewis will refer you to a retinal specialist who will administer these newer agents.


Macular Degeneration

Stable macular degeneration is rarely exacerbated by cataract surgery. If a patient has active hemorrhagic macular degeneration (wet), Dr. Lewis will ask a retinal specialist to treat this condition and to clear you for subsequent cataract surgery when your ocular health has stabilized.


Other Retinal Problems

Rarely other retinal problems can occur. While most are not caused or do not appear to be caused by cataract and related surgeries, it is worthwhile mentioning them here. Retinal vascular occlusion, epi-retinal membrane development, initiation or progression of a macular hole, retinal hemorrhage, vitreous hemorrhage, and other extremely rare retinal anomalies.


Vitreous Floaters

Almost all patients experience a change in the amount and frequency of “floaters” . This is the result of additional movement of the partially liquified vitreous humor that composes the vast majority of the ocular volume. Shadows are cast by the more condensed portions of the vitreous and they are interpreted as flies or clouds that move. Because this is a virtual image (existing entirely within the eye) there are really no flies or clouds. In almost all cases these floaters resolve over days, weeks, or months. Very rarely, additional laser treatment and sometimes a pars plana vitrectomy is required. Dr. Lewis has referred two patients in his career for this kind of vitrectomy.

Endophthalmitis

Infection of the intraocular contents is an extremely rare phenomenon. It occurs in as few as 1 out of every 5000 to 10,000 surgeries. It is almost always recognized during the early post-operative visits and if treated resolves with recovery of all or almost all vision in 95% of cases. Cataract surgeons worldwide have endeavored to reduce the occurrence of endopthalmitis through the use of topical betadine (iodine-like antiseptic) applied to both the lids and the surface of the eye as well as advanced topical antibiotics both before surgery, during surgery, and following surgery. Care must be taken to maintain excellent incision construction. This has become a simpler tasks now that Dr. Lewis’s incision size has been reduced to 2.2 millimeters.


Capsular Disruption

Very rarely the support structure of the natural crystalline lens do not survive surgery. This is slightly more common in those patients with severe pre-existing trauma (including surgical trauma), unusual ocular development issues, or systemic metabolic disorders. In most of these cases the advances in capsular support technologies (endocapsular rings, scleral sutured rings, capsular retraction devices) allow the surgery to progress without incident. If the capsule can not be retained the implant can be sutured to the iris or more physiologically to the scleral using the Lewis Suture Technique. In the rare instance in which some lens material can not be removed at the time of surgery a pars plana vitrectomy is planned in the next few days by a retinal surgeon. In the extremely rare case the intraocular lens implantation is simply scheduled for another day.

IOL Power Surprise

The accuracy of intraocular lens power calculations have helped make cataract surgery on par with LASIK surgery. In fact, most post-operative cataract patients can pass the Pennsylvania driver’s test without glasses (95% in Dr Lewis’s Study). In patients with unusual corneal topography as is present in corneal ectasia (Keratoconus, Pellucid Marginal Degeneration, Keratoglobus), irregular astigmatism (trauma, previous surgery, Peripheral Marginal Degeneration, resolved microbial keratitis, Salzmann’s Nodules, Severe Dry Eye), or previous LASIK, Epi-LASIK, Penetrating Keratoplasty, Lamellar Keratoplasty, RK, AK, Intacs, or ALTK the formulas are less effective. The formulas are also less successful in patient who have had retinal detachment surgery, posterior staphaloma, silicone oil treatment, and coloboma. While the implant power determination can be accomplished using advanced techniques sometimes the results are not perfect. In these cases patients elect to wear glasses, or to have an intraocular lens exchange, intraocular lens piggyback, or corneal refractive correction (LASIK). Dr. Lewis does this at no cost to the patient. The practice has developed a number of special techniques to minimize these IOL Power issues.


Iris Damage

Floppy iris syndrome is usually the results from the use of Flomax for urinary retention. Thanks to innovative surgical appliances these cases have gone from extremely difficult to routine. Iris damage is extremely rare because of the improvements in viscoelastics, iris retractors (Graether Pupillary Ring, Malyugin Ring) and improved fluidics. Iris repair techniques are used to ameliorate pupillary issues the pre-dated cataract surgery or developed during the procedure.


Retained Lens Material

On occasion a small portion of cataract can escape detection and be found at some time postoperatively. If it is small enough this resolves naturally, when it is larger or primarily composed of lens nucleus a 2 minute return trip to the operating room is required. This is a rare event and usually results in complete recovery.


Corneal Changes

When larger incisions were prevalent the corneal shape was changed during cataract surgery and vision did not recover completely until the sutures were removed. Because incisions today have been reduced to 2.2 millimeters and are self-sealing this residual astigmatism is extremely rare. Sometimes limbal relaxing incisions (LRI, RLI) are performed to correct pre-existing corneal astigmatism. Sometimes it does not completely eliminate the patient’s astigmatism, only rarely is the astigmatism made worse. This can be resolved by suturing or removing sutures from the cornea. Sometimes procedures like LASIK are required. With the improvement in phacoemulsification instrumentation corneal burns, a feared complication of cataract surgery which induces corneal damage and irregular astigmatism, has been virtually eliminated from Dr. Lewis’s practice.


Corneal Decompensation

Following surgery for a very dense cataract, or in an eye with a small anterior chamber (hyperopia), the cornea can remain less than crystal clear for a few days and sometimes even weeks. This can also occur when patients have a reduced number of endothelial cells either from previous surgery, trauma, or a condition knowns as Endothelial Dystrophy (Fuchs). In the rare instance the cornea does not recover these cells are replaced using a new and very successful procedure called DSEK. Rarely, Dr. Lewis will recommend performing the DSEK (endothelial corneal transplantation) at the same time as the cataract and intraocular lens procedure. This “triple procedure” results in rapid and dramatic visual rehabilitation.

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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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* currently only PanOptix, Vivity, Toric, and the Light Adjustable Lens patients qualify for ONCE AND DONE.

 
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(215) 886-9090

8380 Old York Road
Suite 110
Elkins Park, PA 19027

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