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(upbeat music)
- So I'm gonna introduce myself.
I'm Cynthia Chiu.
I'm actually a comprehensive
ophthalmologist
and I've been on the
full-time faculty here
at UCF for eight years.
I also run the Division of
Comprehensive Ophthalmology
and Optometry here in our department.
And I was asked by Dr.
Lynn and Dr. Schwartz,
who are my colleagues and
the organizers of this course
to talk to you tonight about cataracts.
And I wanted to thank the Osher
Mini Medical School Program,
as well as the Bay Area Science Festival,
who is co-sponsoring this event tonight.
So, when you get a chance,
we have a representative
from the Bayer's Science Festival here.
So please send her your
greetings and your thanks.
I'm gonna get started.
So, I labeled my talk,
Cataracts: A Surgical Revolution,
because I really feel that
in the last half decade,
the rate at which cataract
surgery is evolving
is nearing an exponential pathway.
So, I wanna talk to you about
all of our new innovations,
as well as some of the history
of where cataract surgery has come from.
So to start off, since tonight
is a very important game.
I looked at the score before I came here,
we are doing very poorly.
So I'm hoping that things will turn around
by the end of our talk here,
but top five similarities
between baseball and ophthalmology.
(audience laughing)
Number five, baseballs are
round, eyeballs are round.
Number four, we both wear pajamas to work.
(audience laughing)
Number three, the baseball stitch.
And actually to be honest,
we don't really use the stitch
too much in ophthalmology,
but we do use it in other
medical specialties.
Number two, home runs.
So this one I think is fairly obvious.
This is actually an ophthalmic home run.
This is a man from Pakistan
who just had his cataract
taken out, and this is
the face of a happy man.
And number one,
both make for easy conversation
with strangers on MUNI.
(audience laughing)
He says, "I've been thinking
about getting LASIK."
And he says, "My sister just got LASIK."
All right, so now I've set the stage.
And I wanted to explain that I
have no financial disclosures
with any of the products
I speak about tonight.
I also wanna make the
disclaimer that I'll be showing
some short excerpts of eye surgery.
And if that makes anyone uncomfortable,
I just wanna let you know
from the get go, okay.
In terms of demographics of cataracts,
according to the World
Health Organization,
it is still the leading
cause of blindness worldwide.
It affects about 20 million people,
which is a 51% of the world's blindness.
Now in this country,
this has been a figure that's been stable
for about the last decade and a half.
We spend about 3.4 billion
medicare dollars a year
for the care of cataracts.
Risk factors for cataract
development include female gender.
So women tend to grow
cataracts younger than men.
Smoking, diabetes, radiation,
which involves a ultraviolet
as well as other types
of radiation and obesity.
What is a cataract?
So, a cataract is the
clouding of the natural lens
and it causes blurry vision,
which means difficulty with
reading, with driving, glare.
You can get double
vision or multiple images
coming from one eye.
You can get problems with
your color perception
and also difficulty in the dark.
Now I'm gonna show you
this diagram of the eye,
I know Dr. Ramanathan and Dr. Lynn,
have also showed this to you
before, but just to review,
this is the cornea.
This is the front clear window of the eye.
This is what people
wear contact lenses on.
This is the iris muscle with
the pupil in the middle.
Here's the lens, here's the
back of the eye with the retina,
which is a layer of
nerves and blood vessels,
like the film of a camera.
And then here is the optic nerve,
which takes all of this
information to the brain.
And so we're focusing today on the lens.
So now let's look at
the anatomy of the lens.
Here is a histologic specimen.
Here is the cornea,
so the front of the eye is this way.
Here's the iris and the lens.
And what you'll notice is
that the lens is suspended
to the ciliary muscle with
the suspensory ligaments.
And these are called zonular fibers.
And if we look at this drawing,
you'll see that these fibers
are joined to the lens capsule.
And what happens is, when you get a signal
for the ciliary muscle to contract,
the ciliary muscle is a sphincter.
And as it contracts, actually,
the diameter gets smaller.
And that actually loosens the tension
on the zonular fibers,
and that allows the lens to
get rounder more spherical.
And that allows you to focus up close.
So this is the process
called accommodation, okay.
So the rest of the lens anatomy.
So, right inside the lens capsule
is a single monolayer of cells,
a very important layer
called the lens epithelium.
This is the only actively
metabolic layer of a lens.
It regulates the chemical
metabolic medium of the lens.
It also replicates, and is the only layer
of the lens that proliferates.
And so the lens epithelial
cells, as they proliferate,
they move out towards the lens equator,
which is denotated here by
the junction of the zonules.
And then the lens epithelial cells
elongate to form lens fibers.
Now these lens fibers,
what happens is they lose all
of their internal organelles
and then they gain proteins.
And so, the lens fibers
then become responsible
for the optical properties of lens.
So, as new lens fibers get generated,
it pushes older lens
fibers towards the center.
So the lens is kind of like a tree.
If you look at cross-section of the lens,
you'll see lots and lots of layers,
the oldest layers being more central,
just like the rings of a tree trunk, okay.
And so, the oldest part of the
lens is called the nucleus.
And the other areas I'd like
you to look at are here,
the poles of the lens,
the anterior which is the front
and the posterior, which is the back.
This is the pathway of vision
through the pole of the lens, okay.
So, I'm gonna talk a little
bit about biochemistry.
And the lens is a special organ
because it is one of the only tissues
inside the body that does
not have a blood supply,
which means that to generate energy,
it doesn't have the ability
to use the traditional
oxidative pathway or the citric acid cycle
that other tissues in the body would use.
So instead it has to rely
on an oxygen, low process
called anaerobic glycolysis
to generate energy.
And glycolysis is a
pretty inefficient system,
but that's all that the lens has
because the lens is a transparent tissue.
There is another pathway
that is responsible
for a small percentage
of the use of glucose,
and that's called the Sorbitol Pathway.
However, in diabetic patients,
when there's too much glucose,
too much sugar in the environment,
then more glucose will be pushed
through the Sorbitol Pathway
generating sugars like
sorbitol and fructose.
These are large molecules
and they draw in water
by an osmotic radiant, and
they cause the lens to swell.
And then this leads to
disruption of the architecture
of the lens fibers, and it
leads to cataract development,
which is one of the reasons
why diabetic patients
can develop cataracts
younger than other patients.
Now, if we look also at this diagram,
it shows you that this
very important monolayer
of epithelial cells,
is where there's active pumping
of a certain molecules into the lens.
So potassium goes in,
sodium gets pumped out,
and then there's passive
diffusion of sodium back in,
but also amino acids and
other important molecules
that the lens uses gets
pumped in by the epithelium.
So, additional biochemistry of the lens.
We can talk a little bit
about the lens proteins.
The lens is about two thirds
water, and one third protein
and the proteins are
divided into two parts.
There's the water soluble
and the water insoluble.
Now of the water soluble,
these are the crystallins
the alpha beta gamma crystallins,
and one of the crystallin's
diagram for you here.
But these are the proteins of the lens
that help it retain its
optical properties, okay.
The rest of the proteins,
which are water insoluble
are responsible for the
cellular structure and
the alignment and
architecture of the lens.
So as someone ages,
the percentage of water
insoluble proteins increases,
and this also, you get oxidation
of these water insoluble
proteins and bonds,
permanent bonds that form
between the proteins.
And this leads to
precipitation of the proteins
and opacification of the lens
and the development of cataract.
So briefly on embryology,
I just wanted you to note that early on
in the gestational process,
which is right around 25 days.
So about three weeks into
gestation, the notochord,
the primitive notochord of the embryo
is starting to form the optic vesicle,
which then makes contact
with the surface ectoderm
and induces lens formation.
So you get formation of the lens plate,
which then invaginates
into a lens vesicle,
and then fills in to the adult
type of lens that we know.
And the reason I bring this up is,
it is pretty remarkable
how early in gestation
that the lens develops.
And this is oftentimes even before
a woman might know that she's pregnant.
And this might be one of
the reasons why we see
a large variety of congenital cataracts
or cataracts in young people.
It might be because the lens
developed so early on in life
and is prone to insults.
So, the adult lens has no vascular supply,
but as the embryo develops,
the initial lens, the primitive lens
actually does have a blood supply.
It comes from the hyaloid
artery from the back of the eye,
from the optic nerve, and it
actually envelops the lens.
And then it forms the
arterial circle of the iris.
As the fetus develops,
then there's regression of
all of these blood vessels,
so that eventually the lens
itself has no blood supply.
This structure is called
the Tunica Vasculosa Lentis.
So this now leads us to the question,
what causes congenital cataract?
And here's child, there's a baby.
And you can see that he
has a normal red reflex
in the left eye and an opacified
reflex in the right eye.
Now there's lots of reasons why babies
can have a white pupil or Luca chorea,
but congenital cataract is one of them.
So the majority of congenital cataracts
is from hereditary, genetic inheritance.
Majority of cataracts are from
an autosomal dominant inheritance,
which means if either of
your parents has a gene,
there's a 50% chance
that you could develop
a congenital cataract as well.
There are also a small
percentage of patients
who have autosomal recessive cataracts,
which are due to kind
of metabolic diseases,
such as galactosemia an
autosomal recessive condition
that causes bilateral
oil droplet cataracts.
As mentioned lenses
develop early on in life.
And so there's a risk for
a cataract development
if there's an intrauterine
infection or trauma.
Sometimes you can just
develop them sporadically.
And the most important thing to know
about congenital cataract
is that there is a risk of amblyopia.
Amblyopia means that the eye
does not develop full vision capacity.
So in order for vision
to develop appropriately,
there has to be a two-way communication.
The eye has to speak to the brain
and the brain has to speak to the eye.
And if there is some sort of
breakdown in the communication,
even if the eye has a normal anatomy,
it may never be able to reach 2020
or normal visual potential.
And so, if we don't remove cataracts
that cause blockage of the pupil,
then there's no light
signal coming into the eye.
And that eye may never
develop full visual potential.
I'd like to show you a few examples
of what congenital cataracts look like.
Remember we talked about
the poles of the lens.
Here are some cataracts
located along the pole
and anterior and a
posterior polar cataract.
When we use our microscope
light in the right way,
it can really stand out in
a red reflex orientation.
We also have opacification
of a suture line.
So what happens is those
lens fibers that develop
from the lens equatorial cells,
that lens epithelial cells,
they wrap around and then
when they meet in the middle,
they interdigitate and
they form these sutures.
And so, in the normal
lens, there's two sutures
a upright Y in the front and
an inverted Y in the back.
And so, sometimes some people
only have opacification
of the sutural lines.
Other types of congenital cataract
include a coronal cataract
and ophthalmologists
are very visual people.
So someone looked at this and thought
it reminded them of the
rays of the sun, the Corona.
So that's why it's called
a coronal cataract.
A cerulean cataract is when
some of these little flecks here
have a blue or turquoise color.
So they were named cerulean cataracts.
A lamellar cataract is
when you get opacification
of a certain layer of lens, a lamella.
So you can have a clear
portion inside the lamella
and a clear portion on the
outside of the lamellar.
But that particular layer is opacified.
You can get congenital cataracts
as a secondary complication
from a different process.
One of which we talked about
was an intrauterine infection.
So this is an example
of a Rubella cataract,
where you can have a very, very
dense nuclear opacification,
but the rest of the lens
is relatively clear.
Also, we talked about the
Tunica Vasculosa Lentis,
which was that primitive artery
that fed the embryologic lens.
So if that does not regress completely,
it actually forms this
fiber vascular membrane
that can cause a cataract
and also cause contraction
of ocular structures.
It can cause the tractional
detachment of the retina.
And it can also cause elongation,
pooling of the ciliary muscle,
which we saw from the initial diagram.
Both of these would be
visually significant
and amblyogenic if they were
not removed at an early age.
We can move on now to the
more common type of cataract,
which is, what we call
senile or adult cataract.
The risk factors for adult cataract.
Number one risk factor is just age.
I tell all of my patients,
if you live long enough,
you will develop some degree of cataract.
It's just a natural process of time.
Some patients have a family history
of early cataract development,
diabetes we've talked about.
Certain medications, such as steroids.
Radiation treatment,
radiation to the head and neck
for head and neck cancers.
You can get trauma that can cause cataract
and you can also get cataract
from other eye surgeries.
And so some of our referrals
are from our vitreal retinal
specialists and our glaucoma specialists
to remove cataracts after they've done
some other kind of
procedure inside the eye.
So the first type of senile cataract
I'd like to talk to you about
is this type called the nuclear cataract.
What this means is that
there is a hardening
of the lens material and
a generalized color change
from transparent to green,
to yellow, to Brown.
Okay.
And so, you can see in this picture here
that the lens has now become
this kind of greenish color.
And here are different lens specimens
from people in different age groups.
And you can see with the passage of time
that the lens is now becoming
more and more opacified
and more and more brown,
until you get to a very mature cataract,
which is down here, which is dark brown.
So symptoms of nuclear cataract,
all cataracts can cause blurry vision.
All cataracts can cause a
difficulty with multiple images,
nuclear cataracts, cause
difficulty in dark conditions,
everything becomes dimmer.
You can also get issues
with your color perception.
Because the lens itself has taken on
kind of a greenish, yellowish hue.
It filters out all of
the high frequency colors
like blue and violet,
and the only colors that pass through
are greens and yellows and tans.
So there's a famous story
of Vincent van Gogh,
when he was a young painter,
he was painting in purples and violet's,
and as he got older, his paintings
became more and more muted,
and the thought was because
he was also developing
cataract simultaneously
Other types of senile cataract,
one type is called cortical cataract.
So here's a diagram of it.
And this is just like,
you're looking at it face on.
But then here is a cross section,
a slice through the lens.
So cortical cataract tends
to affect the outer layers,
the cortex of the lens, not the nucleus,
which was what the nuclear
cataract was we just saw.
And it tends to form
these wedge like opacities
that come in from the periphery
and point towards the center.
And what happens is these opacities
they scatter light.
And so as a light tries to come in,
it gets scattered and then
it bounces around the eye
and it causes a lot of
comfort, it causes bad glare.
So these are patients
who have glare problems
in the sunlight or
actually driving at night.
Also as the pupil constricts,
if there's wedge opacification
through the center,
then patients as they're trying to read
and their pupil constricts,
it can disrupt reading.
This is another type of senile cataract
called the subcapsular.
So if we look at the cross-section here,
we see that there's just a
thin layer of opacification
along the inside of the posterior capsule.
To me, it looks like someone
took granulated sugar
and sprinkled it on the capsule, okay.
And this type of cataract
also causes glare.
And especially when the pupil constricts,
either in bright conditions
or when you're trying to read
and the pupil naturally constricts
it really disrupts reading.
So these different types
of cataracts are usually
found in some combination in patients
and can cause varying types of symptoms.
So, I can show you a few pictures
of what a mature cataract looks like.
When the cortex completely opacifies
you get this white cataract,
we call a mature cortical cataract.
When the nucleus completely hardens,
it turns dark brown, like
the color of root beer.
And we call this a
mature nuclear cataract.
And there's an interesting
cataract that happens
if you wait, you just,
you never take it out
and you just waiting.
The outer layers, the
cortical layers of the lens
actually liquefy, and they form this milk.
And then there's nothing
to hold the nuclears up.
And so this dense disc of nuclear material
ends up sinking down to the bottom,
surrounded by cortical milk,
and we call that a morgagnian cataract.
So, toxic insults can
also cause cataracts.
We talked about steroids
being the cause of cataracts,
primarily subcapsular cataracts.
Other drugs, these are phenothiazines,
these are antipsychotic medications.
They can leave pigmented
stellate cataracts
on the front part of the lens
and ocular foreign bodies, such as iron
can lead to pigmentation of the eye,
dysfunction of tissues like the retina
and also a pigmented cataract.
Trauma as mentioned, that's
another cause for cataract,
you can get these dense
stellate opacifications
from either blunt or penetrating trauma.
Here's an example of a fist injury.
And you can see all of these bubbles
that have been created, these vacuoles.
Here's an example of electric shock,
all of these thin linear opacities
that disrupt the architecture of the lens.
And then what happens when
the eye has a blunt injury
is you actually get compression of the eye
in the anteroposterior dimension.
So it presses from the front end.
And what happens is
temporarily you can get contact
between the iris and the lens surface
and the lens can make contact and stick.
And then eventually
when the iris releases,
then you actually can
leave behind a little ring
of pigment here called the Vossius ring.
So you can leave this ring
of pigment from the pupil,
from the iris margin
at where it had made contact to the lens.
We also get cataracts associated
with systemic disease.
We talked about diabetes and
how the accumulation of sugars
can cause osmotic swelling of the lens,
disruption of the architecture.
And that leads to opacification.
As we talked about, ophthalmologists
are very visual people.
And so, this one looks like a snowflake.
Sometimes we see this, we
call it a snowflake cataract.
Wilson's disease is a
disease of copper metabolism.
And you can get a pigmented cataract
along the anterior surface,
which to someone resembled a sunflower.
But one of the most beautiful cataracts
is found in a disease
called myotonic dystrophy.
Myotonic dystrophy is a disease
where patients have trouble
initiating motor movements,
and you get the deposition
of red and green
and gold crystals inside the lens.
And so someone called that
the Christmas tree cataract,
now that you have been exposed
to a wide variety of types of cataract,
I'd like to spend the rest of our time
talking about cataract surgery
and what we can do to improve vision
for patients with cataract.
The first thing to do
when we evaluate a patient
with cataract is to
take a very careful look
at all of the other ocular structures.
One of the most important
areas is looking at the cornea
because when we take out a cataract,
we are actually going through the cornea
and also working very
closely to the cornea.
And we don't wanna cause collateral damage
to the cornea while we work.
So conditions like this one
where you have lots of dimples
on the cornea, and endothelial
dystrophy would be a problem
for our current types of cataract surgery
and need to be specially managed.
Another condition which is very important
is a condition called pseudoexfoliation.
And those of you who went
to Dr. Shawn Lynn's talk
may remember some discussion about this.
This is a global condition
that leaves the deposition
of fibrillar material in
different organs of the body.
But the only organ that we know of
that has significant
trouble is actually the eye.
So when it deposits in the
drainage tissues of the eye,
it can cause the increase in
eye pressure and glaucoma,
it deposits along the iris
and the pupillary border,
and that can cause problems
with dilation of the pupil,
which can make cataract
surgery very difficult.
It can also deposit on
the lens zonular fibers,
which then de-stabilize
the suspensory ligaments.
And then the lens is not stable
when we try to take it out.
So, a lot of issues with this
condition pseudoexfoliation.
We also wanna take a very
careful look at the retina
and the optic nerve to see
if there's any other ocular diseases
that might affect vision.
There's really nothing more disappointing
than having a patient with
very high expectations
and then have cataract surgery
and still not be able to see
particularly well afterward.
So, we really wanna make
sure that we counsel patients
ahead of time, as to other eye conditions
that could limit their visual potential.
So, the first documented
types of cataract surgery
date all the way back to
the eighth century BC.
And there was a procedure called couching
that was documented in
the continent of India,
and then later on spread
to the Mediterranean
and then to Europe and
then Africa and Asia.
And basically, there is a
surgeon who in some cultures
was also the barber
and he had an assistant,
and the assistant was
supposed to hold the head
of the patient.
Now this is to remind you at this time,
there's no anesthesia, there's
no discovery of bacteria.
So these procedures were
done without anesthesia,
and without antibiotics.
But basically the surgeon
took a long curved needle,
went through the edge of the cornea,
went through the pupil
and just try to knock
the cataract out of sight.
So knock the whole cataract
out of the pupillary axis
and let it fall back
into the back of the eye.
So you can imagine that
this was problematic, right?
Because bless you, (laughs).
So the problems associated with this.
So number one, infection.
Number two, bleeding.
Number three, other
structures live near the lens.
And so, knocking the lens back
could potentially tear
the retina, tear the iris.
So the number of patients that actually
had a successful procedure
were pretty small.
But of those patients,
the other problem was
once you knocked the cataract out,
there was no lens to take its place.
And so, the patient could not focus
and they could see light
and they could see shadows,
but they could actually
not see anything more.
So, unfortunately this
was the state of things,
back in a long, long ago.
So, another type of surgery
developed in the 1800s,
and this was called the
intracapsular cataract extraction.
So, the surgeon made a large incision.
This is pretty much filleting
open half of the eye.
And they injected an enzyme to digest
all of those zonular fibers,
to make the lens free.
And then they took a
probe, a freezing probe.
We call it a cryoprobe that
would then attach to the lens,
form an ice ball,
and then you'd pull the whole thing out,
capsule and all, okay.
So the good thing was that,
the eye could be sewn back together.
The bad thing was that
you had a huge incision.
So again, risk of infection,
a risk that if the patient fell down,
that they would reopen the
incision and have an open globe.
Also at that time,
the intraocular lens
had not been developed,
therefore patients had to wear
these very, very thick glasses
called the Coke-bottle glasses
or aphakic glasses to
be able to see again.
And then in the around
1950, sir Harold Ridley,
who was a flight surgeon from the UK,
he was repairing injured eyes of pilots,
war pilots that had
fragments of a cockpit glass
embedded in their eyes,
which was cockpit glasses,
a material called polymethylmethacrylate.
And he noticed that this
material was very well tolerated
inside the eye, did not generate
a significant reaction by the eye.
So he thought about it and he said,
"Wouldn't this be wonderful,
"if we could create a
lens from this material,
"it would be well tolerated.
"And we could then put the
lens back into the eye."
So he is credited with the invention
of the interocular lens.
So I have a short video now,
this is the excuse for
anyone who can't watch
to cover their eyes.
And this procedure succeeds
the intracapsular cataract
extraction, because it actually,
we take out the cataract in total,
however, we leave the lens capsule behind
so that the artificial
lens can be placed inside.
However, you will notice
some similarities.
So I'm gonna go ahead
and activate the video
and I'll narrate through this.
So this is, I am teaching one
of our first year residents.
This was a procedure
that we did actually in,
I believe in the end of August this year.
And this procedure is still
done from time to time.
And it's because some
cataracts are just too dense
and too big to be taken out
via the more modern techniques
that I will show you.
So you can see that our resident here
is actually opening a large incision
at the edge of the cornea,
and the incision spans about 150 degrees.
It's a pretty sizable incision.
And then before this,
we have already opened
opening in the lens capsule.
And so now you're gonna see
that with two instruments here,
with gentle rocking pressure,
we're gonna be able to kind of express
the lens of the cataract all in one piece.
And this is just manual expression.
So the cataract comes out,
it's a very dense cataract,
pretty brown, pretty brunescent.
And now the eye has no lens,
but here's the artificial
lens being slid in
and positioned into the lens capsule,
which this first year
resident did an excellent job,
everything was intact.
And then finally we close
the eye with sutures
and the patient actually
is doing very well.
So this is the next
level of cataract surgery
still reserved for very
mature cataracts today--
- [Man] What material
is that lens made of?
- This particular lens is made of acrylic.
And we'll talk a little
bit about other lenses
in subsequent slides.
So a couple of important
innovations were made
after the popularization
of the extra cap surgery.
And one of which was the
small self-sealing incision.
So it was discovered that,
because the cornea is a dome,
if you make a small incision,
the physics of the dome are
that it wants to sit down.
And actually you can actually seal off
the incision on its own,
it does not necessarily need to be sutured
for it to be water tight.
And so, with good construction,
a clear corneal incision,
a small clear corneal incision
does not necessarily need to be sutured.
then came the invention of
what we call the phaco machine.
So the process of taking out the cataract
using a micro high frequency ultrasound
is to break the cataract into pieces
and take it out from the inside
so that we don't have
to make a giant incision
and express the whole
cataract in one piece.
So then was the invention of the machine,
the ultrasonic machine that would do that.
And here's an example of the handpiece.
So this emits a small high
frequency ultrasound pulse,
and then also has vacuums.
So once the material gets
emulsified into a mulch,
it then gets vacuumed out.
And here's an example of the
pump, the peristaltic pump
that pumps fluid through the hand piece.
So then the final invention
that led to what we consider
to be modern cataract surgery
is the foldable intraocular
lens and polymethylmethacrylate,
which is what Dr. Ridley used
is not a foldable material,
but with acrylic and silicone
and materials like that,
actually now the lens can be rolled up
into a tiny little scroll,
and it can be injected through an incision
as small as two millimeters,
which is less than a 10th of an inch.
So these pave the way
to the modern procedure,
what we consider to the gold standard,
which is called phacoemulsification.
And I'm gonna show you a video here too.
So,
most phaco surgeons use
a two-incision technique.
So the first incision was made
and I'm injecting some
anesthetic material,
as well as a liquid plastic.
This is called Visco elastic.
And what it does is it
creates space inside the eye
so that we can work.
Otherwise the eye is just full of fluid
and everything leaks out.
And so after the eye is stabilized,
we then create the second incision.
This happens to be a
2.8 millimeter incision.
I am now creating an open and
opening in the lens capsule
in a circular fashion.
And the reason it's a circle
is there's strength to the circle, okay.
There are no sharp points
where if I push on the capsule,
that that little point is
gonna tear off into a tear
that wraps around the lens.
Because it's actually the circle,
it keeps its own integrity.
Okay, so that's called a capsulorhexis.
And then you're gonna see me
injecting some saline material.
And what this does, is it
separates the lens material,
the cataract from the lens capsule.
So now the lens capsule, we
want it to stay in the eye.
We want to manipulate the lens material
so that we remove all of the cataract.
And here we are, there's two instruments.
This is the ultrasonic probe.
This is a second manipulating
instrument called the chopper.
And what I'm doing is I'm actually,
yeah, it's just like
chopping wood, the chopper.
So, I am fracturing the
lens into small fragments,
and then I'm using little
bursts of ultrasound
to pummel the cataract into a mulch.
And then I'm vacuuming out that mulch
through the hand piece, okay.
And I can't tell you how
satisfying this procedure is,
and that's my perspective.
And I'm sure as a patient,
patients feel that way too afterward.
But as you can see, now
we can work inside the eye
and we don't have to make
a large incision anymore.
And we are able to rotate this cataract
because we previously separated
it from the lens capsule
so that we can basically
even using only two ports,
I can take the entire cataract out.
Now I've switched instruments,
I'm using just a device
that only has vacuum
and no longer has ultrasound.
And I'm taking off at the outermost layer,
the thin cortex that lines the
inside of the lens capsule.
This is the final removal of the cataract.
Now I'm injecting some more
of that liquid plastic,
the viscoelastic, because I
have to refill the lens capsule
to receive the artificial lens.
So, I'm injecting the artificial lens.
You can see that it's scrolled
up into a little scroll.
And then as it warms up inside the body,
it starts to unfold.
And it has two arms,
the haptics which help hold it in place.
And then the central part,
the optic is what the eye uses to see.
Some of you may have noticed
these purple marks on the eye.
This is actually is a toric implant.
And these little dots show us
where the astigmatism correction is.
This is a patient with astigmatism
and I'm correcting the astigmatism
through the interocular lens.
So finally, we are removing
that liquid plastic,
we can't leave it behind
because it will clog up
all of the drainage tissues
and it will cause glaucoma.
So finally, I'm checking the incisions.
I'm making sure that everything is dry.
I'm pushing on the eye, no
water can escape and we're done.
So, this is a great procedure.
Patients have usually,
procedure takes less than 20
minutes in experienced hands.
And usually by the next day
or a couple of days later,
the vision's already pretty, pretty good.
So very different from the old days
where we had a lot of sutures
and had to remove sutures.
And it took a long time for
patients to get rehabilitated.
So, now on to the next generation,
we have been using in
the last several years,
a new technology for cataract surgery,
which is actually not new.
This is called the femtosecond laser.
We have been using this laser
for other types of eye surgery,
such as laser vision
correction like LASIK.
And so then some genius decided
to see if they could apply
the femtosecond laser to
taking out the cataract.
And so here's an example of
what the laser looks like.
And here's an example
of what the surgeon sees
and the surgeon programs a laser
to break down the cataract and
to make all of the incisions
on the surface of the eye.
So I have a little video to show you here.
So, first,
the laser is brought in close contact
with the patient's eye, and
then there's a contact lens.
And when the contact lens
makes contact with the eye,
then a little bit of suction is applied
and we have what's
called the eye is docked.
So that means that the eye
is now fixated by the laser
so that it can't move during
the laser procedure, okay.
And so, now the surgeon is
looking at all of the data
and we're gonna double
check where all of the cuts
are being made by the laser.
We're gonna move our incisions.
The patient has two primary incisions.
Also two incisions for
astigmatism correction,
also has an opening in the lens capsule
and a fragmentation pattern
for the cataract itself.
We're checking the parameters.
We're checking to make
sure that all the cuts
that we want the laser
to make are being made
in the right places.
And that the laser is only
being applied to the tissue
we want it to be applied
to, checking the incisions.
And then in a moment here,
you're gonna see that the laser is ready.
And so, once the laser is
ready, we activate the laser.
It starts to work.
And first thing that's gonna do
is cut the circular opening
called the capsulotomy.
And then the next thing that's gonna do
is it's gonna start to fractionate
the cataract into pieces.
And this pattern happens to
be a matrix or a Q pattern.
So you'll see that the cataract
is being broken down into cubes.
Now we have the creation of
the astigmatism incisions here.
And then finally we have
the main corneal incision
created right here.
And then the secondary
incision created right here,
and then we're done.
And this procedure, this was in real time,
this was about 30 seconds.
Now the cataract still in there,
and the lens is not in there yet.
So this is not all of the procedure,
but the laser has done
a lot of the components
of the procedure, very
quickly and very precisely.
And then the patient goes
into the operating room
and the surgeon will then
take out the cataract
and slide in the artificial lens, okay.
So this is called laser
assisted cataract surgery.
The surgery is not done
entirely with laser.
So this is kind of where
the cataract surgery
is currently moving
probably in our near future.
- [Man] What is femtosecond?
- Femtosecond means that
it's, I think it's a minus 12,
does anyone know?
Who's more sciency minded than me?
Is that 10 to the minus 12 second.
So just gives you an idea.
This is a particular type of laser
that has a short, burst period.
Okay, so now we're gonna
shift gears a little bit
and talk about the goals
of cataract surgery.
So the primary goal is to
remove the cataract, okay.
We wanna clear a pathway
for visual function,
and we also want to remove cataract
to assist in the treatment
of other eye diseases.
So, oftentimes I'll have a retina doctor
who's taking care of a patient
with macular degeneration
and can no longer see the macula very well
because of the cataract
and wants the cataract to be removed.
The secondary goal of cataract surgery
is to provide the best optical system
for the individual needs of the patient,
which is a combination of
the type of lens implant
that we use as well as
the shape of the cornea.
So to explain this,
I wanna show you a
diagram of the eye again.
And together, the cornea and the lens,
they will focus an image onto the retina,
and that image is then taken to the brain.
And most people assume that
the lens is responsible
for the majority of the
focusing power of the eye,
but actually that's not true.
The lens only accounts for about a third
of the focusing power of the eye,
the cornea actually is
responsible for two thirds.
So, together it's an optical system.
The mono-focal lens implant,
mono-focal means single focal point.
This is the most commonly used
lens implant that we have.
Most patients who get this lens, implant,
choose distance vision for their target.
That means that they would
like to be able to TV,
walk across the street, drive a car,
maybe not needing glasses for
those types of activities.
However, for things
that are closer to them
using a computer or reading
a book or using a smartphone,
those things have to be
done with glasses, okay.
Now, other patients who don't drive
and spend most of their
time reading, they say,
"Well, I would rather be able
to read without glasses."
So they ask to be corrected for near,
and that means that they're
reading without glasses,
but for all distance activities,
such as catching a bus,
going out for a walk,
they would need to wear
glasses for distance.
Now, there are some patients
who ask for a combination of
the two we call monovision,
which is one eye for far
and one eye for near,
so that they don't need to
wear glasses more of the time.
And this works great in some patients,
but usually in patients
with a pretty easy going personality.
(audience laughing)
So, because they're really
not using both eyes together
for most of their activities,
which means that
if they're, scientists that need to look
under the microscope and be in good focus,
and have depth perception,
this is not a good tactic for them, okay.
So the mono-focal lens is
currently the standard of care
and it is covered by
most medical insurances.
But then there were patients
who wanted to have more
and they didn't wanna be so dependent
on glasses all of the time.
And when I was thinking about,
why we develop this field
called Premium Lens Technology,
I was thinking about, well,
what do older patients want?
And, I just turned 40 and
of course, 40 is the new 20.
But I came across this picture and I said,
well, I know what they want.
They want exactly what
everybody wants, right?
I mean, they wanna be active,
they wanna be healthy.
They wanna go out and see friends.
They wanna do sports
activities, they wanna have fun.
They wanna be sexy.
I mean, check this guy out, right?
So, anyway, they wanted to
be less dependent on glasses
so that they could go out and do things
without needing to wear
glasses all the time.
So the first premium
lens I want to talk about
is called the multi-focal lens implant.
So multifocal means multiple focal points.
And our current generation
of multifocal lenses
use a technology called diffraction.
And what that means is
that there is a grading
on the surface of the lens,
and the wavelengths of light
that go through this grading.
They get bent, and they're
actually when they coalesce,
they coalesce at multiple focal points.
So you have a distance focal
point and a near focal point.
So the benefits of a multifocal lens,
you really can achieve far,
intermediate and near vision
without needing glasses.
It's pretty remarkable.
I remember the first couple of patients
that I put this technology into.
I was more astounded than they were.
And I said, wow, you can
really read that up close?
And you can really read that so far?
And they looked at me and they said,
"Doc, I thought you said, you
knew what you were doing."
(audience laughing)
And I said, Oh, but I did, I did.
I mean, I knew it, but this is amazing!
So, this is what the lens looks like.
This is the ring pattern on the surface,
And this is what it looks like
through a patient's pupil.
And like I said, this
technology does work.
And in terms of trying to read up-close
and have distance vision without glasses,
this is the best lens we have
currently on the market, okay.
But it's not for everybody,
there are some drawbacks.
So first of all, this lens
is not covered by insurance.
And there is a significant
out of pocket cost.
Sometimes upwards of
3000, $3500 per eye, okay.
Because of that, yes.
- [Woman] That's just for the lens?
- Usually that's what
the surgeon will charge
and that will encompass some
sort of package of care.
And the testing that you will get
in addition to the lens implant itself.
- [Woman] The procedure
becomes more difficult as well?
- So the procedure requires more precision
because this lens as you notice,
it's made of a, it has all of these rings.
Well, the center ring has to be
in the center of the patient's vision.
And so everything has to
be done more precisely.
Okay, good question.
And so, because of these rings,
patients may notice some rings and halos,
and this doesn't bother all patients.
And it does tend to get better
within the first six months,
but it does,
some patients may not like this.
And compared to a mono-focal lens,
the type of image quality you get
from a multi-focal lens
is a little different.
It's not quite as sharp,
but you're kind of trading
off the need for glasses
and the convenience for a little bit
of degradation in the quality of vision.
So maybe not so good for engineers,
but maybe pretty good for, someone like,
a bridge player or
something like that, right?
So also because of the light being shared
between different focal points,
there is a little bit
of loss of light overall
that reaches the retina.
We think it's around 18%, okay.
And so under good lighting
condition, there's no problem,
vision is pretty comfortable.
But in the dark that may
actually make everything
much dimmer for you.
And so, if patients drive occasionally,
maybe that's not such a big
deal, but for a truck driver,
if this patient is a truck
driver by occupation,
I would not recommend this kind of lens.
The last thing is,
in order to achieve comfortable
reading without glasses,
you really need to have
implantation in both eyes
because there is summation
between both eyes
and the brain to allow
that facility of reading.
So, there's another kind of lens implant
that hopes to achieve some
of this freedom from glasses.
And that's called the
Accommodative Lens Implant.
Accommodation we talked about
is the movement of the lens
to improve near vision.
And the only lens currently available
on the US market is called the crystalens.
And here's a diagram.
So the lens is supposed to be able to move
a little bit using the
same muscles of your eye,
as you used with your native lens
to accommodate a vision
at different distances.
So the benefits of the Crystalens
you can achieve excellent distance vision,
and intermediate or computer
vision without needing glasses.
Because it has no rings,
there are no rings or halos.
And also because there are no rings
and no diffraction grading,
you don't have difficulty
with night vision
like you do with the multifocal.
However, no technology is perfect.
So, the drawbacks of the crystalens,
again, a significant out of pocket cost.
Another lens that's not
covered by insurance
and pretty much the same
cost as a multifocal implant.
The crystalens is just not
able to achieve close vision.
It's just not strong enough
to allow you to read up close,
use your smartphone with a small
font without glasses, okay.
So patients who get the
Crystalens still have to,
in their minds, they have to resolve
that they will be willing to
wear glasses some of the time.
Because this lens is so
dependent on its position
and its orientation inside the eye,
that lens capsule, once
we take the cataract out
and we put the implant in,
that lens capsule has
its own healing process
and it normally kind of contracts
and wraps itself around the implant.
So if the capsule contracts in a way
that the lens is misfolded,
then that can cause a lot of
vision problems for the eye.
So, most patients who get a crystalens
will need a secondary laser procedure
to make an opening in the lens capsule
so that the capsule can not wrap tightly
around the lens and cause misfolding.
The last thing is, with other lenses,
there's always an option
if you're not happy.
Most of the time you can exchange it
to back to the standard
mono-focal implant.
The crystalens because of its design,
It's really designed to stay put
and to move with the lens capsule.
It's actually quite
difficult to get that lens
back out of the eye again.
And so, I would say that once
you commit to a crystalens
it's pretty difficult to exchange.
Okay, so moving on to another area
where patients would like
some freedom from glasses
is this topic of astigmatism.
And astigmatism is when the
cornea is not round in shape.
So a spherical cornea is
like a basketball, okay.
And then an astigmatic
cornea has a steep portion
and a flat portion, is shaped
more like a football, okay.
And what that means,
is that since the image
is being focused at different points,
there's really blurry
vision at all distances,
the vision can never be
focused to one point, okay.
So now, as we described in our video,
there are lenses that will
address the stigmatism.
And here's an example where you see
these little markings
here and this denotates
that it can correct
astigmatism along this axis.
Here is a topographic
map of someone's cornea,
which shows that there's
a lot of steepening
in this axis, which, this much astigmatism
probably would benefit from
having a toric implant.
So there's a couple of different
types of toric implants.
There's the toric monofocal,
and there's the toric Crystalens.
And both of them have
some out of pocket costs.
So even though you can't get
a correction of astigmatism
and the multifocality at this time,
at least some of these patients
who would otherwise be dependent
on glasses all the time
can have freedom from
glasses some of the times
such as for driving or
for playing golf, okay.
So, for patients with a
small amount of astigmatism
that doesn't necessarily
warrant a toric implant,
you can actually surgically
make small incisions on the cornea.
And because the cornea is a dome,
incisions by nature will
kind of relax the dome
in that meridian and cause
some relaxation of the astigmatism.
So it's an alternative, as I
mentioned to the toric implant,
and you saw in the laser video
that, that particular patient,
maybe because they
wanted a multifocal lens.
So multifocal lenses at this time
do not also correct for astigmatism,
that patient was getting a little bit
of astigmatism correction on their cornea.
Okay, the final lens
I'd like to talk about
is a lens and invention
by one of my colleagues,
Dr. Schwartz,
who actually is one of the
organizers of the series.
And he has a company that is testing out
a new kind of lens implant
called the light-adjustable lens.
And what happens for
most patients is that,
the surgeon gets measurements of the eye
and uses very sophisticated
computer programs
to try to identify what
the best lens power
is for that particular eye.
And then the patient has surgery
and the lens is implanted.
And then afterwards,
hopefully you're pretty close to what
we intended you to be,
but sometimes you're not.
And sometimes you're a
little bit nearsighted
and sometimes you're a
little bit farsighted.
Sometimes you have a little
residual astigmatism.
And so what Dr. Schwartz's invention is,
is that the lens is made of a material
of different types of polymers.
And after it's implanted,
these polymers still have the ability
to be kind of moved around.
And so the patient is
exposed to a type of laser,
which concentrates some of the polymers
to different portions of the lens,
to help change the shape of the lens.
And that will actually change
the focusing power of lens.
So, basically you implant the lens,
you see what the result is,
and then you customize it
to the patient's particular
outcome, visual outcome.
And then with a second
laser, you lock it in.
So that then the polymers
are locked in place and
can no longer move around.
And it's kind of a way to
get a customized outcome
from an off the shelf product.
So anyway, these lenses are in FDA trials
and he is designing new models
that can also correct for astigmatism,
and maybe some bifocal
types of lenses as well.
So no talk on surgery is complete
without talking about the
complications of surgery.
And I'm sorry, I was thinking
about putting this earlier,
but I think that,
I didn't wanna leave
this as the final slide,
but nevertheless,
I do think it's an important
thing to talk about.
So one of the risks of
surgery is an infection
inside the eye.
And luckily endophthalmitis
happens very rarely.
And I usually tell my
patients this happens
in about one in every 2000 patients, okay.
So it's a very rare phenomenon.
Surgeons who do cataract surgery,
usually give patients some antibiotics
to protect from a bacterial infection.
But once in a rare while
an infection will occur,
and this can be vision threatening.
And you see here that there
is this layer of material,
this is actually white blood cells
because there's so much
infection inside the eye
that the white blood
cells are floating around,
and now they've layered out.
So this is one of the
possible complications
of any kind of eye surgery,
but cataract surgery included.
Also, even though the
surgery happens in the lens,
which is in front of the retina,
sometimes either because of
a complication of surgery,
or sometimes even in
uncomplicated surgeries,
you can get a tear in the retina,
which can lead to a retinal detachment.
If caught early enough
these can usually be treated and fixed,
and patients can regain
some of their vision.
This happens about 1% of the time, okay.
And then for the more older
types of cataract surgery.
And some of the older
machines that, you know,
the machines keep getting better
and better with every generation.
But remember we talked
about how the cornea is,
we're working right under the cornea.
When we take out the lens
and injury to the cornea,
can also lead to complications.
So if we pummel the cornea
with too much ultrasound,
the cornea can lose some
of these vital cells
that pump fluid through the
cornea to keep the cornea clear.
And when those cells are lost,
the cornea doesn't stay
clear and it gets swollen.
And so you get corneal decompensation,
which then would require a
corneal transplant to treat.
So in cases where the cataract
surgery is complicated.
Now, I didn't really mention,
I didn't know if it was relevant,
but when we're taking out that cataract
and we're leaving that
lens capsule behind,
the lens capsule in the
back surface of the lens,
it is only four microns thick, okay.
Four microns thick.
So, I believe a human hair
is about nine to 10 microns thick.
So the lens capsule is extremely fragile.
So if you think about
the number of procedures
that we do annually, and,
most of these cases go
without a hitch.
We're preserving a very, very
diaphanous, fragile membrane.
So once in a while, a
small percentage of cases,
usually between,
the numbers are between 1% to 3%
in experienced surgeons.
Upwards in, surgeons in training.
But if you break the lens capsule,
then basically you can get
some of that vitreous jelly
that fills the back of the
eye and they can come forward.
And when the vitreous comes forward,
it can tug on the retina.
And that might be some of the reason
why some patients can
develop retinal detachments,
but you can get some vitreous loss,
and that's one of the complications.
Also, you can get inflammation
and swelling inside the eye,
and you can get swelling in
the center of the retina,
which we call the macula.
And when you get the fluid in the macula,
then the retina doesn't function well,
and you can get loss of vision.
This happens with both uncomplicated
as well as complicated procedures,
and usually has good prognosis
and is treated with medications.
Now, the very last thing
happens extremely rarely,
but there are situations
where during surgery,
you get unexpected bleeding,
and the bleeding can be limited,
or the bleeding can be diffused,
but that can also impact
the visual prognosis.
So, that's the end of my prepared talk.
I just wanted to
acknowledge my colleagues.
This is my division.
We have Dr. Michelle Bloomer
and Dr. Saras Ramanathan who
spoke earlier in the series.
And together we comprise
our comprehensive ophthalmology group.
These two surgeons are
excellent cataract surgeons,
excellent teachers.
Dr. Bloomer is also an ocular pathologist.
And so, if any of you are interested
in becoming patients in our department,
I left you some contact
information for us.
So thank you very much for being here
on a Giants game night.
And I will take questions.
So, I realized earlier,
I didn't actually repeat the question,
but I'm supposed to do that
since we're being videotaped today.
So the question is, that
both eyes are needed
for depth perception.
And if we do the monovision technique
where one eye is targeted for far,
and one eye is targeted for near,
what happens to depth perception?
So it's true that for
fine debt perception,
you actually need both eyes,
but believe it or not.
You get some idea of depth perception,
even just with one eye alone,
that's something that gets
trained during your development.
But you can tell by the
relative size of objects,
that object is closer than another.
You can tell by relative
to position to other things
and you know where those other things are.
If one thing is closer than another.
But you're right.
One of the problems with mono-vision
is that if patients do full mono-vision
where one eye is for distance
and the other one is all
the way up for reading,
that they will lose some
of their depth perception,
'cause they're actually not
using the two eyes together.
Sometimes we will use a modified technique
called mini mono-vision,
where we make the second eye,
not quite full strength for reading,
but maybe, like for computer distance.
And the closer, the two eyes are,
the better the depth perception will be.
So there's always,
we try to balance the
needs of the patient.
Excellent question.
Yes, let's go back to
that slide for a second.
So endophthalmitis, let me just
go through them in sequence.
The question was for the complications,
what is the treatment?
Okay,
so, endophthalmitis, the
treatment would be culturing,
the fluids or the eye to find
out what the organism is,
and then injecting antibiotics.
Sometimes if the vision has
dropped very significantly,
the patient will go back to surgery
and have a procedure to
clear out the vitreous jelly.
Because it's felt that the
vitreous is kind of like algae.
It's a nutritive substance
on which bacteria can live.
And so going back to clear out the jelly
allows the antibiotics
to have better penetration inside the eye.
So patients treated with antibiotics,
it depends on what type of organism
and at what stage patients
come back to see their doctor.
If they come back and their
symptoms are pretty early,
there's a pretty good chance
that they're gonna get
most of their vision back.
If they come back very late
or it's a very, very
virulent the organism,
then there's a bigger chance
of having permanent vision loss.
So that's for endophthalmitis.
Retinal detachment needs
to be corrected surgically.
So patients would need to
go to the operating room
and have retinal detachment repair.
Corneal decompensation is
treated with corneal transplant.
Vitreous loss, usually
when this is recognized,
the cataract surgeon tries
to clean up the vitreous
as much as he or she can
at that time to begin with,
because nobody wants to
have any residual vitreous
in the front of the eye.
The goal is to leave the
vitreous in the back, okay.
But if there is a single
strand, like this,
depends on whether it's
causing problems for the eye.
If the eye is otherwise functioning well,
healing well, no signs of infection.
Sometimes you might leave a
little vitreous and that's okay.
But if the vitreous is
causing other problems,
such as tugging on the retina
or inflammation inside the eye,
then another procedure
might need to be done
to clear out the vitreous.
And then macular edema, we
talked about out medications,
either eye drops, or injections
to try to calm down the inflammation.
And then for hemorrhage,
the way that we usually treat this,
is first to stabilize the eye.
And then to allow the eye,
if it's a small hemorrhage,
we allow the eye to reabsorb
that blood on its own.
And that works in small
hemorrhages very well.
If it's a very large hemorrhage,
then a surgeon will go in
and try to drain some
of that blood out, okay.
So before we jump to other questions,
I wanted to come back to you, sir.
Cause you had a question
that I jumped over.
- [Man] Oh you answered it.
- Oh, I did, okay, great.
Next question, you sir,
right in the front.
- [Man] Is the standard
of care that phaco machine
(speaking off mic)
- The standard of care
currently is the phaco machine.
The laser is considered relatively new.
It's not covered by insurance,
but it is an option for patients
who are interested in that technology.
- [Man] So facility that cataract surgery
would use the phacomachine
- Yes, and actually,
I would say the huge
majority of cataract surgeons
at this time use the phaco machine
as their primary method
of cataract removal.
Yes, ma'am.
- [Woman] In terms of cataract prevention,
what are your best advices?
- So the question is, how
do I prevent cataracts?
And actually the answer is nothing,
because you can't really do anything.
Cataracts will grow on their
own time table, no matter what.
Now, the things that you can avoid,
don't smoke, smoking makes cataract grow.
Second thing is, you know,
if you have diabetes,
keep your blood sugar as
controlled as possible.
Don't do space travel.
There was a study that,
when I was in Boston,
I heard a study by an ophthalmologist
who was researching astronauts.
And, we talked about
radiation causing cataracts.
So astronauts who go into space,
get exposed to a lot more
radiation than people do on earth.
And those people develop
cataracts at a much younger age.
- [Woman] What about wearing sunglasses?
- So, ultraviolet light.
Yeah, that was one of
the things we touched on.
So sunglasses may have a minor role
in protecting you from cataracts,
but ultimately you could change,
you can take some vitamins,
you can eat a healthy diet.
If you live long enough, you
will still have cataract.
And the question is, when
should you have surgery?
Surgery should happen when
you feel that your vision
is impaired and you can
no longer do the things
you would like to do, okay.
That's when to have surgeries.
For some people that's earlier
for some people that's later.
Yes, over here, sir.
(man speaking off mic)
So the question is, does cataract surgery
cause problems with depth perception?
I think when you meet your surgeon,
it's worth talking about
that particular issue.
However, I would say that cataract surgery
can restore vision that you had before.
It's not necessarily gonna augment vision
that you never had.
So if you didn't have
depth perception before,
I don't think cataract
surgery would necessarily
give you depth perception,
but you might be at a level that you were
before the cataracts developed.
So the question was the life
of these artificial lenses, the lifespan,
actually the answer is they
will outlive all of us.
(audience laughing)
Because they're made out of plastic
and they're acrylic and they're silicone
and there's polymethylmethacrylate
and these are all synthetic materials.
And so, they're supposed to last you
for the rest of your life.
Yes, ma'am.
- [Woman] Will the cataracts ever return?
- Very good question.
The question was do cataracts come back.
So cataract itself will never grow back,
once it's removed, it's gone.
However, remember I said
that the lens capsule
has its own healing process.
And we try to remove all of the cataract,
but there are microscopic
cells that are left behind
that we cannot see because they're smaller
than the resolution of
our surgical microscopes.
If those cells are still active,
sometimes they will proliferate
and form a little film behind the implant.
That is what we call an after cataract
or a capsular opacity.
And that can sometimes degrade the vision
and make you feel like your
cataract has grown back.
But what we do for that is,
we don't have to go back
to the operating room.
We use a different kind of laser
and we make a small opening
in the lens capsule.
So that through the center,
you can see clearly again.
question here, yes ma'am.
I see, so the question is
which kind of complication
would lead to a corneal
transplant and what is our supply?
So the one that would
most often necessitate
a corneal transplant is
bad corneal decompensation.
So when we lose the
corneal endothelial cells
and the corner accumulates fluid,
so it gets very swollen
and a swollen cornea does not allow
the passage of vision or light,
and that require a transplant
so that the cornea can be clear again.
Luckily, nowadays our
instrumentation is so good
that we very, we rarely need
to do corneal transplants
on patients who have cataract surgery.
It still happens once in a while,
but I would say if you looked
at the machine that I use,
when I started my training,
over a decade ago,
that older machine had a higher risk.
And with every successive
generation of machines,
the fluidics, the amount
of ultrasound that we use,
the materials that the
liquid plastics we use
to create space and protect the cornea,
those keep getting better.
And so the frequency of those procedures
is dropping quite a bit.
And in terms of the
supply of donated corneas,
that I don't know,
I actually don't
transplant corneas myself,
but we have an excellent
cornea division here
that would specialize in that.
And so the comment was that,
there's some patients who have
a bad experience in one eye
are scared to have
surgery in the second eye,
because they've had a bad experience.
So that is fully understandable.
Definitely surgeons do not
intend for bad things to happen.
I think that when someone
has a complication,
you do have to consider very carefully
what the needs of the other eye are.
Does the cataract need to come out sooner
or do you have time to wait?
There are situations where a
cataract needs to come out.
One example I gave you is if a patient
has macular degeneration
and they're bleeding in
the back of their eye,
the retina doctor can't
monitor that unless he can see.
And if there's a cataract there,
that cataract needs to come out.
So in other situations where
the cataract is not too bad
and the patient wants to wait,
waiting is the right thing to do.
And now that patient feels that
there's a need to have surgery.
Yes ma'am, go ahead.
Sure.
So the question is,
there are so many different
types of cataracts,
how does that influence treatment?
So, we first wanna divide
whether it's a cataract in a child
versus a cataract in an adult.
Cataracts in children, no
matter what type of cataract.
If they're blocking vision and
they could cause amblyopia,
those cataracts need to come out.
Children have that kind
of a window of time,
a window of opportunity.
If you miss that window,
then you develop amblyopia.
So cataract surgery in children,
there's, kind of a standard
technique that is performed.
And it doesn't really matter
what type of cataract is inside
because the technique can
kind of treat all of them.
Now, whether the cataract
was caused by an infection,
or there some other process.
Maybe additional ancillary
treatment needs to be done.
But at least the procedure
of removing the cataract
is fairly standardized.
Now, whether to put in an implant
is a different story for children,
because children who are very
small under two years of age
may not receive an implant
because their eyes are very small
and they're still growing,
and it may not be a,
how do you know what power of lens
this child is gonna
need when they grow up?
Not to mention the general size of the eye
cannot receive an adult size implant.
Now, shifting gears to the adult side,
all of those different
cataracts, with a few exception,
a few exceptions,
the rest of the cataracts
can all be taken out
with one standard technique as well,
which, for most surgeons,
as we talked about is the
phaco emulsification procedure.
Now surgeons do it differently.
Some fracture it into six pieces,
some fracture it into two
pieces, some do more chopping,
some do other types of techniques.
It doesn't matter,
ultimately we're taking the
cataract out from the inside.
And so whether you have
a nuclear, a cortical,
a subcapsular cataract,
it's all kind of encompassed
in the different techniques
we learn in our training.
Yes, ma'am here.
The question is,
can people develop
allergy to lens implants?
These lens implants are,
they are pretty inert.
Acrylic, silicone, polymethylmethacrylate.
To my knowledge, I'm sure
there are reported cases
of inflammation related to
certain types of implants.
It may not be the actual material.
It may be an imperfection
in the way that the lens
was manufactured or some
sort of residual material
that was left on the lens
when it was manufactured.
I will say that these lenses
are in general manufactured,
extremely with very rigorous guidelines.
So that the lens that we
implant into patients,
99.999% of the time, is
gonna be a perfect implant.
However, we do have situations
where patients have had
lenses removed from the eye.
Maybe not necessarily a material allergy,
but it might have something
to do with the way
that either the lens was made
or what the lens was in contact with
before it went into the eye.
(man speaking off mic)
Or the, I would be left without a lens
for a little while until
the inflammation calm down.
So the question was,
would the lens get exchanged?
Well, sometimes the eye would be left
without a lens for a little while.
Okay.
So the question was about the
health of the optic nerve.
So the optic nerve can be affected
by a lot of different diseases.
Dr. Lynn talked about glaucoma
a couple of weeks ago.
That's one of the most common
diseases of the optic nerve.
You can also have other
conditions, optic neuritis.
You can have blood vessel vascular
infractions of the optic nerve
So if you have an injured optic nerve,
would cataract surgery still benefit you?
So that depends on the severity
of your optic nerve injury.
If your optic nerve injury
is mild or moderate,
and the surgeon can do
some testing to show,
well, this portion of your vision
we think is, can not be recovered.
So even if we take the cataract out,
your vision will never be 2020,
but we might get you to 20,40 or 2050.
We can do tests like
that in the office, okay.
But then you can tell, well,
my vision is 2100 right now.
So part of it is from the cataract
and part of it's from the optic nerve,
is it worth doing the cataract surgery?
So you can make a qualified
decision like that.
But if you have severe glaucoma,
is it worth taking out the cataract?
Well, sometimes taking out the cataract
also improve the eye pressure,
and maybe that's a good thing
for the glaucoma
treatment after all, okay.
So I hope I've answered
your question on that.
Yes ma'am.
So the question is,
if you have glaucoma
and retinal detachment,
So I think we can
hypothesize many different eye conditions
that could be also present with a cataract
and how much vision improvement
would you get from a cataract
or is it safe to do cataract
surgery in those situations?
Like I said, for the previous question,
each particular situation has
to be individually evaluated
between yourself and your surgeon.
There's no way for me to
stand up here at the podium
and tell you, Oh, for sure,
all patients with this
kind of eye condition,
you'll definitely benefit from
cataract surgery, go do it.
No, you can't do that.
Because each person's vision,
each person's eye problems are individual,
just like we are all individuals.
So if someone has multiple eye conditions
and they also have cataract,
I think the way to address that
is to get evaluation
by a cataract surgeon.
And the surgeon will
try to do some testing
to find out how much of your
vision loss is due to cataract
and can be in theory improved with surgery
and how much of it can not be improved.
And you'll have to accept that
knowing that you won't
actually get full vision.
Now, whether you can do
cataract surgery safely
in the setting of a retinal detachment
or in the setting of
advanced glaucoma, you can.
The technique is modified
somewhat to account
for those other conditions.
In glaucoma, we might actually add on
glaucoma medications
around the time of surgery,
just so that your eye pressure
doesn't elevate after surgery.
In situations where you
have a retinal detachment.
Usually those are pretty
long near-sighted eyes.
So, certain adjustments
to the phaco technique
would be made to try to improve
the safety profile of
the cataract surgery.
- [Woman] Diabetes?
- Yes, it is.
So, is obesity a separate risk factor
from just having diabetes?
Yes.
It's not necessarily sugar dependent.
It may also have to do with other.
Obese patients have other risk factors,
such as, cholesterol,
difficulty with circulation,
high blood pressure.
All of those things may contribute
to the development of a cataract as well.
Ma'am you had a question right there.
So the question was
having cataract surgery
earlier or later, does it have
an impact on whether someone
has macular degeneration?
So macular degeneration
can also be worsened
by some of the same risk
factors as cataract.
So smoking can exacerbate it,
ultraviolet radiation can exacerbate it.
It doesn't mean that
having a cataract causes
or influences the progression
of macular degeneration.
So the lenses that we put
in, for the most part,
the implants are ultraviolet
protective, okay.
So your cataract has some
ultraviolet protection
because like I mentioned,
as cataract grows,
it filters out some of those
higher frequency wavelengths.
But the lens implants do that
just by the nature of the
material that they're made from.
Glasses will give you some
ultraviolet protection.
So, I don't think it's a known thing
that whether or not cataract
surgery done earlier
or later later would have any influence
on the progression of
macular degeneration.
And I only use that example
because we often get referred patients
who need to have frequent monitoring
and visualization of the macula,
but because of the cataract,
they might get pushed
into surgery earlier rather than later.
So the question was about
depth perception problems
and poor lighting.
So depth perception,
it's actually a very long and
like optical type of answer,
which I don't think we can
really get into in this format,
but, I'll just summarize by saying
you need to have the potential
for depth perception as a child
when the visual system is developing.
And if you do have,
depth perception that develops normally,
then it can be disrupted down the road
by diseases of the eye that
can impact the focal distance,
the quality of vision,
all of that can affect depth perception.
But to go into a lengthy discussion
on the optics of depth perception,
I'm afraid that we don't have time
for that for tonight, okay.
I wanna acknowledge back
there and then here.
Okay, go ahead ma'am.
Okay, so the question was about
a particular retinol condition
called macular pucker,
which means that there's a little membrane
growing on the retina
causing contraction of
the macular enfolds.
So my answer to this
question is kind of the same
as what I answered before
you can have any variety
of other eye problems.
You could have macular pucker,
you can have retinal detachment,
you can have glaucoma,
you can have hemorrhage,
you can have diabetes,
you can name any variety of eye problems.
And the question is, should
you have cataract surgery?
But the answer to that is, again,
you need to be evaluated
individually with your surgeon
to see how much of the vision loss
is due to the other eye condition?
How much of the vision loss can
be assigned to the cataract?
And then based on that, you
make an informed decision,
whether you should proceed with surgery,
of the cataract or not.
The second part of your question is
after you have cataract surgery,
can you then have repair
of the macular pucker?
And the answer to that is yes,
you can either repair the macular pucker
before, in conjunction with,
or after cataract surgery
if you'd like, okay.
Usually the surgeon who
fixes the macular pucker
is a retina specialist.
The surgeon who fixes the cataract,
is a cataract specialist.
And so it's usually a
team approach to care.
All right, sir, I didn't forget about you.
- [Man] Can dry eye (speaking off mic)
So the question is can dry
eyes affect cataract surgery
or cause complications
for cataract surgery?
The answer is absolutely,
on multiple levels.
Not that dry eye is the worst
thing that could happen.
And the brisk biggest risk
factor for cataract surgery.
'Cause we have a lot of other,
eye conditions that are
more dangerous for the eye.
But it is a relatively common condition
that can affect the outcome
of cataract surgery.
First of all, when your eye gets measured,
if you don't have, a well lubricated eye
the measurements might not be good,
and you might not get a
very precise measurement,
which then, if the surgeon
uses that information
to choose your lens implant,
maybe that's one of the
reasons why your lens implant
isn't right on target.
The second thing is, for
some of the premium lenses,
those lenses have a little bit
more delicate optical system,
especially like the multi-focal.
And for that, you don't wanna add
other optical problems into the mix
because that will in general degrade,
the quality of the vision
that you get afterwards.
So, if you have mild dry eye,
the goal is to kind of treat
that and get it healthy
before you have cataract surgery.
If you have more severe dry eye,
then you have to talk with your surgeon
about what needs to be done,
and what kind of implants would
be best in that situation.
Maybe not one of the fancier implants
and more of a standard,
kind of a less fragile
optical system, okay.
So the question is do we find it necessary
to use prophylactic antibiotics?
And the answer to that
is, from my perspective,
from the perspective of my colleagues
here in the department, we think so.
And we do it in a variety of ways
and we do usually more than
one way for each patient,
mainly because we are afraid
of a very rare complications,
but when it happens,
it can be devastating.
So we tend to use a lot of
resources in this regard.
So one way that we are doing now,
is we're injecting an
antibiotic into the eye
at the end of surgery.
This leads to a very
high cost concentration
of this antibiotic inside the eye.
Most cases of endophthalmitis happen
because of organisms
that live on your face.
There are bacteria that live
on your eyelashes, on your skin.
And they are either
inoculated into the eye
during the procedure or they
somehow make it into the eye
after the procedure,
if the incisions are not tightly sealed.
And so these are the big organisms
that cause endophthalmitis.
It's not some rare bugs that you get
from something exotic.
And so the antibiotic that we inject,
we leave a high
concentration after surgery.
The thinking is,
this is the time that the
eye is most vulnerable,
but once the corneal
incisions seal up tightly,
then the penetration of
organisms into the eye
drop significantly and then
you have much less risk.
Most ophthalmologists will also give you
an eye drop antibiotic
to use after surgery
in addition to the injection.
And that is for additional coverage.
So the question is
steroids being a risk factor
for cataract development.
What about injections of steroids
into joints for arthritis?
So we don't think that injectable steroids
actually make it so much
into the systemic circulation
to cause cataract growth.
We think that oral steroids, IV steroids,
and there's some hypothesis
about inhaled steroids,
like for asthma or for, rhinitis,
those might actually affect the eye.
But, I don't know of injectable steroids
being a risk factor for cataract growth.
So I'm looking at the time on the wall
and we're now at 8:30.
And so I don't wanna
hold anybody here longer
than you wanna stay,
but I'll stay around for a few minutes
to answer additional questions.
Thank you.
(audience applauding)
(upbeat music)
