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Michael J Kutryb, MD  
Male

Specialties: Ophthalmology, Cataract Surgery, glaucoma

Interests: Ophthalmology

Kutryb Eye Institute - Titusville
321-267-2020
Titusville, FL
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Cataract Surgery After Lasik - Choosing the Best IOL

Feb 23, 2011 - 14 comments

     The baby boomers have loved having Lasik and PRK surgery for the past 16 years since initial FDA approval in the U.S. in 1995.  I call the baby boomers the "I want it all and I want it now" generation so you could see how they would gravitate to the remarkably fast and accurate results of refractive surgery.  Now many boomers are approaching their 60's and, not surprisingly, they are developing cataracts.  Picking the best IOLs for these cataract surgery cases, however, is quite challenging and is an underappreciated science.  

     10 years ago I did cataract surgery after refractive surgery about once a year, but now it has increased to about twice a week.  I have, necessarily, invested a great amount of time and money into the proper training and equipment in order to maximize the results.  You see, picking the proper IOL for these cases is fraught with possible errors.  The excimer laser used in Lasik and PRK creates changes in the curvature of the cornea, sometimes major, sometimes sublte.  But the changes are not what you would see in a typical human eye.  In a very basic way, I tell patients that the new cornea takes on a slightly non-human shape and thus the typical devices and mathematical formulas used to pick IOLs for cataract surgery will usually give innacurate results.

     The solution is to use a corneal mapping device such as a Zeiss Atlas Corneal Topography system.  This system can pick up the subltle changes in curvature and give average corneal power readings at different optical zones.  Importantly, the results from the Atlas can be entered into the ASCRS Post-Refractive IOL Calculator computer application.  This is a critical step that cannot be overlooked, in my opinoin.  The Atlas also measures corneal spherical aberration which can be hugely affected by previous Lasik or PRK surgery.  Some of the most expensive apheric IOLs such as the Tecnis or Acrysof may need to be avoided in patients with high levels of negative spherical aberration - namely those who have had hyperopic Lasik or PRK.  On the other hand, patients with with previous myopic Lasik or PRK often have high levels of positive spherical aberration and can benefit greatly from an aspheric IOL.

     One more thing that is commonly overlooked is knowing whether myopic or hyperopic lasik was done and, in my experience, most patients don't have a clue.  Old records are helpful but are usually unavailable.  Some properly worded questions about their visual history will usually help.  Completely different IOL mathematical formulas are used depending on the type of previous Lasik/PRK treatment. The good news is that the Zeiss Atlas has a program which can usually tell you what type of surgery was done. Another good reason to choose that machine.

     In the end, four things are crucial:  1.  Determine whether the patient had myopic or hyperopic Lasik/PRK surgery.  2. Accurately measure corneal power with a very good corneal topographer.  3.  Measure corneal spherical aberration and pick IOL model accordingly. 4.  Use the ASCRS Post-Refractive IOL Calculator to pick IOL power. accordingly.
    
     Don't hesitate to post questions if you have them.  This is one situation where it pays to be obsessive-compulsive.  Little things can make a big difference!

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by cejas, Mar 02, 2011
I'm in Austin TX
Would appreciate advice on implant or if there exists any kind of diference (materials,quality or kind) on IMPLANTS
at the time on a cataract surgery. May the cost of surgery influence or maximace 'quality' on that especific 'implant'
QUALITY? or is it a STANDAR and only option for 'implant' and are there any more conveniences or 'bennefits' on new
'LENCE' or implant after cataract surgery?
I'm a Truck driver and would appreciate info or mail in reference or related best if apply on materials' or diferences if any.
Are Implants all the same?
Thanks for your concern
***@****

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by Michael J Kutryb, MDBlank, Mar 07, 2011
If you are truck driver, I would advise against any multifocal implants such as tecnis multifocal or rezoom.  What you really need is quality of distance vision particularly at night so I would consider getting an appropriately matched aspheric, monofocal implant such as Alcon Acrysof IQ, or standard Tecnis or Bausch and Lomb ashperic monofocal lens.  You should not  have to pay extra for any of these lenses buy may be required to pay for some special tests at some offices.

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by walkietalkie, Apr 12, 2011
Had lasik 12 yrs ago. Was -8, now -2. It regressed over time from the initial -0.5 post lasik. Which is fine, as it gives me good reading vision.In mid-forties now and have early cataract. Am wondering if technology will be more precise when I eventually need cataract surgery, which I reckon in 10 years time. The clinic that did my lasik is still around, though I wonder if they still keep records after 12 years, and whether I should request for my old record now for future use.

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by Michael J Kutryb, MDBlank, Apr 25, 2011
Old records are always helpful and yes technology will continue to improve.  Even now we have intra-operative wavefront scanners available that can show real-time if the implant power is off and there is much more to come.

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by markhu, May 17, 2011
I am only 42 and had nuclear cataracts removed earlier this year.  Presumably they were caused from prednisone and/or other steroids prescribed to me for eczema over the years.  I don't remember this being listed as a side effect, but maybe it was and I ignored it since most side effects don't happen.  But I digress.  The reason I am replying here is that when I learned I had cataracts in 2010, one my of first thoughts was that I barely got my money's worth for the LASIK I got in 1998 to treat my myopia+astigmatism. I was 20/400 before LASIK and 20/15 for about 10 years afterward, so I can're really say I regret LASIK.

The first cataract surgeon I consulted with said that my previous LASIK had flattened my cornea such that one of the few IOL options that was "steep enough" was an aspheric Tecnis IOL which he only offered as part of a "premium" package which more expensive, in part due to the fact that it included "touch-up LASIK if needed."

I didn't like the idea of being sold a package that involved me pre-paying for a follow-up procedure that might not be needed.  Sounded like what you hear about gambling: the odds are always in the house's favor.

So I kept researching, and finally found a surgeon I was more comfortable with.  He did not agree with the first doctor's claim that the "steep Tecnis" was my only choice, but he was willing to install the Tecnis ZCB00 1-Piece Acrylic IOL with no additional charge or premium package requirements.  He did suggest to "back off" the correction by about .5 diopter to allow room for LASIK later in case it was needed.  I followed his suggestion and am very happy with the results: I have "intermediate" range vision in one eye and distance in the other.  I understand that there is some variability in calculations vs. actual outcomes, and that "perfect balance" is not guaranteed.

So far I just use "drug store" reading glasses for computer work and reading and don't really need any glasses for distance.  I might get prescription glasses to give me more distance in the left eye, or some bifocals which would have stronger reading-strength by about 1 diopter for the right eye.

The one side-effect from LASIK is that I see halos at night around certain bright points of light.  My theory is that this is the edge of the LASIK-corrected zone that only enters the field of vision when the pupil is wide open.

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by markhu, May 17, 2011
One other thing I wanted to mention was that my cataract was too-far progressed for the IOL-Master device to get an accurate diagnosis, so the doctor hauled out an old A-scanner.  I don't think he had any intra-operative devices at hand.

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by afox48, Jun 01, 2011
I had Lasik in 2000 in Memphis.  My eyes were severely Myopic with astigmatism. The Lasik has been very sucessful with exception of some problems with night vision.  I am developing cataracts now and trying to find the best opthamologist to do my cataract surgery when it is needed.  I want someone who will take the time and have the knowledge/expertise to do the type of testing you described in your article to find the best IOL for my post-Lasik eyes.  Do you have any advice on how to find the best opthamologist to meet my needs?  Any colleagues you know personally and could recommend ?

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by Michael J Kutryb, MDBlank, Jun 02, 2011
To markhu,

the a-scan can be very accurate if used with an immersion tip where you have to lie back and tip is immersed in a water bath device.  othewise, it takes an incredibly steady hand to get decent readings but they can still be pretty good.

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by Gabrielle99, Jun 07, 2011
Dr. Kutryb,

Can LASIK be used to remove a conjunctival cyst?  My 9yr old has had one for 2 years.  We have been diligently watching it - depending upon the weather/dust/wind it gets higher/lower (does not change in surface area).  He has seen 3 optomologists - 1 wanted to do surgery immediatly - the other 2 (pediatric optomologists) said we can "watch" it.  Now one suggested that it has been there "too long" and should be removed.  It is clear other than for a few blood vessels around it and if he rubs his eye/it's windy/dry it will increase in redness.  We have been told we can wait but also that it could be eroding from within.  I am hesistant for any type of surgery to his eye especially due to his age.  We have used steriod drops and the height lessens - but were scared with the warning it will cause glaucoma. Any suggestions?


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by Michael J Kutryb, MDBlank, Jun 10, 2011
If it is simply a conjuctival cyst then there is generally no harm in leaving it alone - except some occasional irritation.  Laser surgery has absolutely no place in this situation and when he gets a little older it could be easly treated in the office or a surgery center.  The key is to wait until he is older so surgery is not as big a deal for him.  If it is not hurting anything just leave it alone.  Sometimes I will just take a quick sterile needle in the office to open the cyst up and hope it doesn't reform.  That is an extremely easy thing to do but a 9 year old likely wouldn't like it.

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by Gabrielle99, Jun 22, 2011
Thank you very much for your reply!  We (my husband and I) agree with the old addage - first, do no harm. The first optomologist wanted to schedule surgery within the same week he was seen because he said he didn't know what it was and all he could say is it shouldn't be there so we should have it removed.   I guess the big question is - how do we know if it isn't hurting anything?  We were told it could be a tumor(same surgeon), that it could be eroding from the underside into the eyeball (pediatric surgeon)... all types of wonderful possibilities.  And all three doctors said they could not be sure what it was unless they cut it off.  I find this a bit hard to swallow that they are not definite what it is - I have done extensive research, looked at photos, read reports and based on all I have found can find no other answer - of course I am not an optomologist. Of course none of the 3 doctors we saw ever indicated it could reform, or come back larger as I have found in the literature.  I think the fact that it has a very small blood vessel next to/under it is causing the most concern for us.  It seems as though I might have to venture out of NV to CA, or take a trip down to see you! Thank you very much again for taking the time to answer my questions.  It is nice to know that there are doctors out there willing to take the time to help.

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by sheila9962, Mar 02, 2012
I had bilateral July Lasik 2001 and Lasek in Sept 2010.  Currently March 2012, I'm recovering from severe dry eye. I would classify my dry eye as mild now.  I take Bio Tears (4 capsules per day) and Gentle Gel at night and that regimen works for me. I'm comfortable most of the day.  I'll be 50 yrs old May 2012.  I anticipate cataracts will come within 10 years or so.  My question:  Will it be even harder to fit me with IOL's because I had 2 separate laser surgeries?  My right eye is better than my right due to returning astigmatism.  I know having laser surgery permanently changes the shape of the cornea making it harder to be fitted with IOL's but did I make it even harder for myself by have 2 surgeries?  Thanks in advance if you read this question and are still available to answer.

Sheila

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by jbkortho, Apr 21, 2013
Have you used ORA  (http://getorasystem.com) for real time measurements on previous Lasik patients needing IOL because of cataract? Has your research involved use of crystalens after Lasik - perhaps focusing on monovision?
Thank you for your time and consideration


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by ale22169, May 30, 2013
Assuming there is no history or patient recollection of what type of lasik was done.
What should I look for in the pentacam to determine if the patient had hyperopic or myopic laser surgery?

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