Toric IOL for long axial length

[ValveJob]

Do you know if they even make toric IOLs for eyes with an axial length of over 30?  I was discussing cataract surgery with my retinal specialist, and he was not sure (I know he could find out, but I was wondering if you knew)?

[flossy93]

It sounds like you are on the exact right track to find the best possible surgeon to do a laser cataract procedure, if that works for you.  

In terms of the pupil diameter, the laser surgeon should be able to evaluate your eyes and determine if there is a risk to trying the LenSx process based on how much your pupils will dilate in response to the typical drugs.

  It's interesting that this is a factor; I hadn't heard about the small-pupil-size complication before.   Of course, I have whale-sized pupils, so I might have just ignored anything I read about small pupil size.  :-)

[ValveJob]

I read that exact article yesterday.  I know already that the ophthalmologist whom I mentioned and who is the head of this eye institute has been using the femtosecond laser for LASIK surgery for years.  He started doing the cataract surgery with the LenSx femtosecond laser in the summer of 2012.  Naturally, I will not only ask my RS about him, but if I see him for a consultation, I will ask how many he has done.

Oh, while I was searching scholarly articles yesterday, I found one that said that it might not be possible to use this method on people with small pupils (I realize the eye is dilated, but still).  I think I have small pupils, so that is worrying me.

[flossy93]

The LenSx platform is the one the cataract surgeon to whom I've been referred also uses.  I'm not having the surgery yet as I have some other eye issues to resolve first, and the cataract is livable at the moment.

One thing to be sure you do research is the experience level of the surgeon using the laser platform to do the cataract surgery specifically (vs how many laser vision corrections he/she has done).  Here is a link to a paper indicating that surgeon experience with the laser platform and laser cataract procedures is correlated with fewer complications:

http://www.ncbi.nlm.nih.gov/pubmed/22361311

I hope you can get enough information to be comfortable with whatever surgical platform and doctor you choose.  Good luck!

[John C Hagan III, MD, FACS, FAAO]

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[ValveJob]

I just found a place in Montreal - the Montreal Eye Institute - which uses a femtosecond laser, the registered trademark name being LenSx, to do cataract surgery!!  So, I will mention this to my RS as well as the surgeon whose name is Dr. Sam Fanous (I am mentioning the name in case Dr. Hagan has heard of him).

I will keep you informed of what eventually happens.

[ValveJob]

As a matter of fact, I just found last night the name of a private place in Toronto which does it.  I am located in Montreal which is about a 5-hour drive.  My husband said he would drive me back and forth if that is what I decide to do, but I first want to speak to my RS of course.  The doctors who work there seem to have very good credentials.

What is really frustrating is that the private places here in Montreal have the femtosecond laser for LASIK surgery (for doing the flap), but they don't yet use it for cataract surgery.  If I knew they would be using it in the next year, I would try to hold on and wait, but I don't know when they will be using it.

Thanks again for doing all that research when it is not even for yourself!!!

[John C Hagan III, MD, FACS, FAAO]

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[flossy93]

Not sure where you are located in Canada, but I did a quick search online and found there are at least 4 facilities in Canada (Toronto, Kingston and two others) who offer the femtosecond laser-based cataract procedure. This method of cataract surgery was first performed in Canada in mid-2012.  Just Google it and you can see where it is offered, in case any facilities are near you.

I understand that the public system may not pay for the procedure to be done at one of those facilities, but you might ask your RS if he/she feels any extra expense would be worth the reduced risk in your specific case.  Or, perhaps there is an appeal process to request a femtosecond-laser-based procedure based on your risk factors of extreme myopia and ultra-long axis?  Good luck, and try not to let it drive you crazy (I know it's difficult!)

[John C Hagan III, MD, FACS, FAAO]

laser is called "femtosecond" yag laser and used as outlined for parts of the cataract operation.
JCH MD

[ValveJob]

Thank you very much for that long post.  I remember reading something about the laser method on this forum.  I think someone commented that it is not used in Canada because we have a public system and it would cost too much!!!  Now, maybe at the private place I mentioned they would use it.  There is so much I have to check into.

I will see my RS at the beginning of December, and I will certainly bring this up.  I am going totally crazy with all the pros and cons I have to think about.

[John C Hagan III, MD, FACS, FAAO]

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[flossy93]

Hi ValveJob, just wanted to comment on your potential cataract surgery.

As a fellow myope who's axial lengths are also over 30mm, I've read a lot about the difficulty of cataract surgery for patients like us.

I can't remember if I've commented before on this, but wanted to make sure you are aware of the option in cataract surgery between 'traditional' methods of cataract extraction and the 'laser' method.  Of course, if you have a cataract surgeon selected already who uses the traditional method and is confident you will have a safe and successful surgery, feel free to ignore this post!

I've been told by two different retina specialists as well as my OD that given the fragile nature of retinas in patients with extremely long axial lengths, it would be preferable to have 'laser cataract surgery.'  

The name of the procedure is a bit misleading, as it's not 'laser eye surgery' like LASIK.  Rather, the laser is used to perform certain early steps of the cataract surgery, but it can be safer for high myopes and yield better results than the traditional surgery method - in the hands of a doctor who is experienced with the laser method of cataract surgery.

The improvement in retina safety derives from the use of laser energy to 'break up' or 'soften' the cataract before it is removed.  In a traditional cataract procedure, the surgeon uses an ultrasound probe to discharge energy into the cataract and break it up so it can be more easily removed through the tiny incision.  Generating ultrasound waves inside the eye can disturb the retina and lead to complications after surgery (increased risk of detachment, etc).  In contrast, the laser energy can be focused precisely at the depth and diameter of the clouded, hardened lens material, and does not 'migrate' elsewhere in the eye.  Not blasting the retina with ultrasound energy is a big benefit for those with tissue-thin retinas.

Another side benefit is that the laser cataract surgery also allows for limbal-relaxing incisions to be made precisely by the laser during computer mapping of the cornea.  This corrects for most astigmatism and can lead to better visual outcome after surgery.  

Lastly, using the laser allows the surgeon to more precisely create the 'pocket' in the capsule where he/she wants the replacement lens to sit.  For patients getting multifocal implants (this isn't us, obviously), it can give better outcomes through a more precisely-positioned lens.  I wonder if this could help improve your outcome if you end up having a toric implant?  It certainly seems like it couldn't hurt.

In reading several studies about the laser cataract surgery method, it was quite clear that doctors who have performed many of these procedures have the best outcomes.  If you choose the laser method, please be sure you find a surgeon who has done numerous cataract procedures with the equipment.  

It would be wonderful if you share your ultimate lens choice and surgical experience/outcome.  Best of luck with your research and the surgery!  

[John C Hagan III, MD, FACS, FAAO]

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[ValveJob]

Thanks for your reply.  I will make sure that my RS checks into this.  It depends on whether I go to the hospital to have the cataract surgery or whether I go to a private place that will then do a lasik a few months afterwards for the astigmatism.

[John C Hagan III, MD, FACS, FAAO]

It depends on what the calculations crank out. These calculations take into account also radius of curvature of cornea, K constant of IOL, surgeon adjustment constant and often anterior chamber depth. So your question cannot be answered.

JCH MD