John C Hagan III, MD, FACS, FAAO  
Kansas City, MO

Specialties: Ophthalmology

Interests: Eye-Medical Blog

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General Information on "Premium" Multifocal & Accommodating IOLs

Dec 12, 2009 - 1 comments

A "mono-focal" intraocular implant (IOL) is the standard IOL used in most surgery. It has a fixed focal length. At the focal length things are generally quite clear (unless there is a large amount of astigmatism or severe eye disease).  Closer or farther than this focal length things are blurry and glasses (often progressive no-line bifocals) are used to help the eye see at those distances.  Many people with monofocal IOLs have excellent distant vision or excellent near vision or excellent mid-range vision without glasses. If one monofocal IOL has a focal length of infinitity (distance) and the other a focal length of 20 inches and the person uses one eye for distance and the other for reading and doesn't wear glasses that is "Mono-vision".

A multifocal IOL or Premium IOL or Accommodating IOL are new, used in a small number of cases and have variable focal lengths due to the way the implant is made (mutifocal or apodized IOLs) or the implant actually bends and moves in the eye and focus's light (accommodating IOL).  

Premium IOLs cost more, the costs are often not covered by insurance, the procedure is more difficult and complicated, complications are mor common, IOL exchanges and explants are much more common, night vision is often a problem and 20-30% of patients still require glasses for some or most visual tasks.

Our eye care forums are not a place where happy Premium IOL patients often come to crow about their successes, consequently unhappy premium IOL patients greatly outnumber "happy" premium patients.

I have said before that if I was going to have cataract surgery on myself at this time I would not choose a Premium IOL.

JCH III Eye Physician & Surgoen

General Information About Recurrent Corneal Erosions

Dec 12, 2009 - 1 comments

You have "recurrent corneal erosion syndrome". The condition is common and will not destroy your sight or cause serious loss of vision. It has been discussed in the past in the eye care forums. It usually starts after a scratched cornea that does not heal properly. In some instances it occurs due to a common disease of the outer layer of the cornea (basement membrane disorder). Use the search feature and type in "corneal erosions".

Here is part of a recent post on the problem:

Recurrent corneal erosions are the bane of the practice of ophthalmology for both the ophthalmologist (Eye MD) and the poor patient. I saw 2 of them in the office today. They can be very difficult and recalcitrant to treat. Not infrequently they are controlled with drops and ointments but reoccur if these medications are stopped. I'm sure you're well versed on the medical and preventive treatment of corneal erosions.

Treatment is to avoid anything that dries the eye. So keep it moist with artificial tears. At bedtime a lubricating drop with normal saline (Muro 128 ointment---available over the counter) is put in the eye.  Extreme care must be used in the morning on awakening as this is when the tissue usually tears. Avoid rubbing the eye. If the eye wants to stay shut from the ointment leave it shut, splash with warm water till it opens then put in an artificial tear or Muro 128 DROPS (available as 2% or 5% [which often stings] also available over the counter. If Muro 128 products are irritation try Refresh-PM ointment at bedtime and a good artificial tear on awakening and several times during the day (Systane, Opteve, Soothe, Refresh, Tears Naturale, etc).

Long plane and car trips are very stressing for corneal erosions. In the car, run the air conditioner or heater on the feet vents not into the face. Put artificial tears in the eye every couple of hours on a car trip and every hour on a plane trip.

You should go a minimum of 4 months without any pain from the erosion (usually during sleep or upon wakening) before trying to stop the ointment. Be aware that some people are never able to stop the medications and must use drops, ointments and precautions indefinitely (years and years).

The next step is often corneal stromal micro-punctures. This is an office procedure done with just eye drop anesthesia; a bandage contact lens is put in the eye for several days. You may return to normal physical activities immediately.  

If the problem persists then you may need to discuss these treatments with your ophthalmologist. He/she should be able to do the first method. The second he/she may or may not be able to do, sometimes referral to a cornea specialist is indicated.

1. There is a new method of treatment when all else fails. It involves taking oral tetracycline for a couple of weeks coupled with steroid eye drops. If your ophthalmologist is not familiar with the method he/she can do a literature search of the medical ophthalmology journals. The first time I read of it was in the journal "Ophthalmology". I have used this method on two patients that were "at their wits end and had tried everything else. In both cases it worked. I still have them use an ointment at bedtime such as Muro 128 or Genteal Gel but the severe pain has stopped.

2. The last technique would be to use the eximer laser to "resurface" the corneal epithelium and soft contact lens wear during the healing. This technique is most often used when the cornea has disease that keeps causing the erosions, the most common of these is corneal epithelial basement membrane disorder.

Keep trying and good luck.

General Information on Intraocular Lens Power Determination

Dec 11, 2009 - 2 comments

Hello Garrett,    Your mother's optical situation is not uncommon. Choosing an intraocular implant (IOL) power to give the best vision unaided by glasses is as JodieJ says not an exact science. It is much, much better than 5-10 years ago and it will be better 5-10 years from now. It will never be 100%. Like much of medicine we are sometimes a victim of our own success. There was a time in which patients were happy to go through a cataract operation without a major complications and wore regular glasses happily after surgery.

As we have been able to improve the vision without glasses some people expect to see perfect without glasses even though this is not possible for many people and something an ethical surgeon never promises or guarentees.  There are many variables (radius of curvature of the cornea, axial length of the eye, position of the IOL in the eye, etc) that can cause the actual result of surgery to differ from the "theoretical" values used in the pre-operative calculations. There is not even one forumula that surgeons agree is "best" to use for the calculations. As eyes become longer than normal or shorter than normal the possibility of under/over correction increases significantly.

Some eyes, because of astigmatism, are not correctable with the standard monofocal implants used in most surgeries. Even with the new multifocal "premium" IOLs that are used to try and get away from glasses completely for all distances often require glasses for certain tasks and certain distances (use the search feature and look at all the complaints).

Of course it is possible to have  gross miscalcuations due to error in data acquisition or data entry. These are rare compared to the normal "scatter".

Wearing progressive bifocal lens to achieve good vision is the expected and hoped for result of standard monofocal IOL surgery. Some people will see satisfactory at distance without glasses, others will see okay at near or mid range without glasses but this is a bonus not the expected result. We never tell our patients that they will be able to go without glasses. We tell them it often happens but we expect they will need glasses. Period.

There are certain circumstances in which if the difference is way to much to wear glasses (say a 4-5 diopter difference) that the information can be sent to a Medicare review or insurance review committee to authorize a LASIK procedure and have it paid for by insurance/Medicare (of course deductibles or co-payments would legally have to be collected). If glasses are feasible and wearable do not expect them to authorize the LASIK.

As to your physician's behavior, again Jodie J may be right. If you've gone to this ophthalmologist (Eye MD) for quite some time and he/she is generally even tempered and patient, I would cut them some slack. On the other hand if the physician is usually this way then I would seek not only a second opinion but a new ophthalmologist. I am a very patient physician and very even dispositioned but I have "lost it" on a few occassions with my patients. I always felt terrible afterwards and in most cases have called back to apologize the next day. More than one of these occured during a stretch where in addition to my professional responsibilities I was taking care of a sick parent and another member of my family was seriously ill.

Compared to some of the really serious sight threatening complications that are often posted here I think your mother has some really excellent options.


General Information on Fuchs' Corneal Dystrophy

Dec 11, 2009 - 1 comments

There is no exact definition of how many guttatta it takes to diagnosis Fuchs' Endothelial Corneal Dystrophy. Some guttatta are part of aging and do not ever become a problem. Two tests that are often helpful are corneal endothelial cell counts (the number decreases as the disease develops and progresses) and corneal pachymetry (corneal thickness) the thickness increasing as the disease develops and progresses. Family history is useful as many cases of Fuchs' are hereditary (affecting females more than males). Guttata are 'bumps' that develop on the back of the cornea when there are not enough endothelial cells to cover it. These cells are very important as they pump fluid out of the cornea and into the anterior chamber of the eye. The cornea is hydrophilic (water loving) like a sponge. When it swells and gets thicker it starts to become cloudy and blur the vision. When this happens and the impairment is severed than a corneal transplant is indicated. Recently a new operation for decompensated Fuchs' dystrophy called DSEAK (Descemet's membrane epithelial automated keratoplasty) has dramatically speeded the healing, safety and results over full thickness penetrating keratoplasty. Corneal endothelial cells do not multiply or replace themselves when damaged or cell death occurs.

Cataract surgery will not cause Fuchs' dystrophy but cataract surgery (or for that matter any surgery inside the eye) will stress the cornea and in severe Fuchs' could be the final straw that causes the cornea to compensate.

Your doctor is absolutely correct. In my patients with progressive Fuchs's dystrophy I recommend cataract surgery SOONER rather than later because the advanced, "hard" cataract will put much more stress and strain on the cornea endothelium than a moderately firm or softer cataract. Fuchs' dystrophy can decompensate on its own without any surgery taking place or any cataract in the eye.

It would be helpful to know if your mother's problem with her eye's was Fuchs' dystrophy. It is unusual for Fuchs' to cause an eye to be removed, so there's a good chance she had something else.

I would go ahead and have the cataract surgery when your vision starts to be a moderate problem for you and the cataract is the cause. By using the endothelial cell count and corneal thickness, your ophthalmologist can give you a reasonable risk of the cornea being able to stand your cataract surgery.

Good luck, new cataract surgical techniques are much, much more gentle on the eye than techniques used in the past.