Michael J Kutryb, MD  

Specialties: Ophthalmology, Cataract Surgery, glaucoma

Interests: Ophthalmology
Kutryb Eye Institute - Titusville
Titusville, FL
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Cataract Surgery After Lasik - Choosing the Best IOL

Feb 23, 2011 - 17 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!

Toric IOLs for Cataract Surgery

Jan 28, 2011 - 22 comments

Of all the new "Premium IOLs" for cataract surgery it has been the Acrysoft Toric IOL that has been the most widely accepted and praised by cataract surgeons like myself.  I personally have been very pleased with this IOL, because it delivers better results for patients with significant levels of astigmatism and with very little downside.  Also, the cost for the patient is less that half of the cost for a multifocal IOL.

Patients who are good candidates are those with:
1. Amounts of astigmatism in the 1.50 to 4.00 diopter range.
2. Regular astigmatism that measures the same on a consistant basis.
3. Patients with minimal other eye problems such as macular degeneration, retinal disease, or corneal diseases.
4. Patients with an understanding that glasses may still be needed for the very best possible vision

Going forward, it is very important to talk about the patients that are not good toric IOL candidates.  These include:
1.  Keratoconus patients, since their astigmatism is usually quite irregular.  Results are generally disappointing.
2.  Patients with signifincant map dot fingerprint dystrophy - again they often have irregular astigmatism.
3.  Previous radial keratotomy patients.
4.  Some patients with previous lasik - these cases can go either way but they are not optimum cases in general.

Finally, regarding toric IOLs, there is an expectation from patients that they will see fairly well without glasses, so it is of the utmost importance for the surgeon to get excellent measurments of the eye before surgery.  This means using an IOL Master or Lenstar unit, and multiple manual and automated readings of the corneal astigmatism making sure that the reading are clear and consistant.  A corneal topography reading is also needed.  Using Holladay IOL Consultant software and personally adjusted A-constants are very helpful as well.

If you have any specific questions about toric IOL's, don't hesitate to ask.  A very common question is when are limbal relaxing incisions (LRI's) a better choice?  We can get into that next time, but in general, LRI's may be better for lesser levels of astigmatism in the 1.00 to 1.50 diopter range as long as the patients don't have corneal surface problems like bad dry eyes.

Beware of Super Glue "Drops" in the Eye

Oct 24, 2010 - 27 comments

Yes, it sounds crazy, and repulsive but it really happens.  Super glue, that nasty, but useful agent found in he supermarket checkout aisle, has a dark side too.  Being a firm believer in Murphy's Law, I completely understand how super glue would find its way into the eyes of unsupsecting people.  It's quite simple, if you think about it.  There are many manufacturers of super glue type products and some of the containers are about the same size and shape as a bottle of eye drops.  Often, people who need eye drops may have bad vision and would have to take their glasses off to put in the eyedrops.  They reach into the kitchen junk drawer and grab the wrong little bottle and a very bad day begins.

I have personally seen 4 such cases of super glue products in the eye and I'm sorry to admit one was an aunt (yes, it runs in my DNA.)  Yesterday, I was called about a grandmother who accidentally put super glue "drops" in both eyes of a 1 month old infant.  You can stop cringing now.  The baby was taken to a childrens eye clinic and should be fine.

The good news is that, almost always, a full recovery can be made in less than a week.  Lots of lubricating ointment is placed on the eye and eyelids and lashes and the hardened glue can carefully be removed over the next few days.  The glue itself is not terribly toxic to the tissues but rather it becomes hardened, glues the eyelids and lashes together and can scratch the cornea and conjuctiva if not removed within a few days.

Now that I have you thinking, remember that other similar products can inadvertantly be dropped in the eye by accicdent.  One of my well known patients put fresh breath drops in her eye last week, and she recovered completely. Other culprits include ear drops and fingernail antifungal drops.

Multifocal IOL Decisions Should be Made Very Carefully

Oct 05, 2010 - 6 comments

     Some of the most common comments I hear on the forums here at Medhelp are patients worried and upset after multifocal Intraocular lenses (IOL's) such as the Restor and Rezoom.  (The Crystalens is a different type of IOL and I will discuss that another time.)   Now I'm not here to bash either lens because countless thousands of hours of research and millions of dollars have been expended to develop them with a legitimate goal of reducing dependance on glasses after cataract surgery.  They have their pluses and minuses.
     Talking about Multifocal IOL's is sort of like talking about big SUV's like Hummers or Suburbans..  They're not all bad, not all good, just very different.  Perfect for some people but terribly wrong for others.  I dislike the label "Premium Lenses" that are used for multifocal IOL's because that gives the impression that these IOL's are "better."  The premium price tag also lends itselft to the thought that these lenses must be "better" in some way.  "Of course they must be much better or why would they cost so much more" one might say.

     My final take home message is that if you are thinking about selecting a multifocal IOL for your cataract surgery, you need to do your due diligence.  You cannot try out these IOL's before surgery.  Remember that.  If you had to buy a new SUV, without being allowed to look it over or test drive it, you would be very cautious, right.  Be cautious with your IOL selection.  Make sure you get feedback from real patients, who have already had the IOL you are considering.  Preferably get feedback from friends, family or neigbors.  People you trust.  If you can't get the type of recommendations you were looking for, please don't feel ashamed to have a standard monofocal implant.  You could call standard monofocal IOL's the Toyota Camrys or Honda Accords of implants.  There is a reason why millions and millions of people are very safisfied with them.