Why its important your eye surgeon also does laser eye surgery if you're having a multifocal or #trifocal lens implant

I am  about to perform laser surgery on a patient of mine who had uncomplicated refractive lens exchange surgery with trifocal lens implants. The patient feels that her vision is blurred for distance and is much clearer when the small residual prescription in each eye (-0.5 dioptre) is corrected. To give her the best possible result and clearest vision from her expensive new lenses she needs correction of this small prescription which would probably go unnoticed in an eye without a multifocal lens.

During cataract or lens replacement surgery the lens implant power is based on a predictive formula. This is accurate in most cases, but in roughly 1 in 100 patients the predicted prescription may be different to the end result. The commonest cause of unsatisfactory or blurred vision in patients with multifocal or trifocal lenses is due to residual uncorrected prescription. This is even more so if there is a high level of residual astigmatism. 

If your surgeon is unable to correct this by laser eye surgery you may be referred to another surgeon to have your prescription corrected. Worse still, nothing further may be done and the patient may simply be asked to accept their visual outcome. There may be further costs if another surgeon is required and patients should clarify from the outset what actions will be taken in the event of blurred vision after multifocal or trifocal lens implants. Residual prescriptions only require correction if it leads to unsatisfactory results. There may be other causes of reduced vision such as cystoid macular edema or early posterior capsular opacification which your surgeon should exclude.

Posted on March 28, 2017 .

Disposable eye mascara applicators for patients with blepharitis

I see and treat a lot of patients with blepharitis and meibomian gland dysfunction. Blepharitis is an inflammatory condition of the lid margin where there is typically a sensitivity to normal skin bacteria such as Staphylococcus Aureus. Due to it's close contact with the eye's surface blepharitis typically causes dry eye, irritation and redness of the eye.  Part of the treatment regime for blepharitis includes regular lid cleaning to remove build up of oil and skin flakes from the lid margin and to reduce bacterial load. One recent useful tip from a female patient who wanted to wear occasional mascara was to use disposable mascara brushes to avoid harbouring staphylococcus and other bugs in the make brush. These are available through amazon and are very reasonably priced for hundreds of brushes. Great idea!

Posted on March 10, 2017 .

Swap over corneal transplant

Left to right switch over corneal auto-transplant

How do you restore sight in a patient who is blind in one eye due to end stage glaucoma (this eye has a healthy cornea) and is almost blind in the fellow eye due to a dense corneal scar after infection? The fellow eye has less advanced glaucoma and some macular degeneration but was the only eye with visual potential. The patient has not been able to see for 6 years and is dependent on others and needs to be led. The patient also comes from a country with standards of healthcare that are variable and hence long term survival of any treatment was another concern.

My approach to this case was to swap the healthy cornea from the right eye with the scarred cornea in the left eye. At the end of the surgery the patient had their own clear cornea and new lens implant on the left and their own scarred cornea on the right.

At the next day review both eyes were healing well with minimal inflammation. The patient was for the first time able to read letters from the vision chart and could walk unaided. He was incredibly emotional that after 6 years some sight had been restored. Vision wont be perfect due to glaucoma and macular degeneration, but some vision will improve his quality of life and help him regain his confidence and independence. An added bonus is the fact that he cannot reject his own tissue and hence rejection in the long term wont be an issue once things have healed. A rewarding case for me and him.

#Corneatransplant #CornealScarring

corneal transplant Moorfields eye hospital
Posted on March 8, 2017 .

New lens may be good news for RK radial keratotomy patients with cataracts

IMG_3784.JPG
Patients with RK surgery typically have aberrations in corneal shape due to multiple incisions. This typically degrades image quality causing glare, haloes and distorted vision, particularly at night when the pupil may be dilated.   RK patients having cataract surgery are faced with two issues;  1. Lens predictive formulae are less accurate in RK eyes even when using post RK adjustments.  2. Corneal distortion still leads to decreased visual quality.   A new small aperture lens - the IC8 lens by Acufocus - may be very useful in RK patients, offering a pinhole effect that largely eliminates corneal distortion whilst increasing depth of focus.   Lens prediction may still be a problem, but can be refined by laser surgery after lens insertion. One limitation is that the IC8 can only be used in one eye at the present time. This may change with time and more experience of the lens by surgeons. The lens can be removed if found to be poorly tolerated.  

Patients with RK surgery typically have aberrations in corneal shape due to multiple incisions. This typically degrades image quality causing glare, haloes and distorted vision, particularly at night when the pupil may be dilated.  

RK patients having cataract surgery are faced with two issues; 

1. Lens predictive formulae are less accurate in RK eyes even when using post RK adjustments. 

2. Corneal distortion still leads to decreased visual quality.  

A new small aperture lens - the IC8 lens by Acufocus - may be very useful in RK patients, offering a pinhole effect that largely eliminates corneal distortion whilst increasing depth of focus.  

Lens prediction may still be a problem, but can be refined by laser surgery after lens insertion. One limitation is that the IC8 can only be used in one eye at the present time. This may change with time and more experience of the lens by surgeons. The lens can be removed if found to be poorly tolerated.  

IC8 intraocular lens visible with full pupil dilation and retro illumination. The lens is not normally visible externally.  

IC8 intraocular lens visible with full pupil dilation and retro illumination. The lens is not normally visible externally.  

For more information please contact the clinic 

Posted on January 4, 2017 .

What is a YAG laser treatment and why might you need it after cataract or lens surgery?

Frosting of the lens capsule causing posterior capsular opacification or after-cataract

Frosting of the lens capsule causing posterior capsular opacification or after-cataract

A cataract is much like a smartie or M&M. It has an outer coating (capsule) and an inner nucleus (the chocolate in the smartie). When an eye surgeon performs cataract/lens surgery the surgeon makes a circular opening in the front facing capsule of the lens and then removes the inner nucleus. The remaining capsular envelope supports the new artificial lens which is typically injected in through the opening in the capsule. Over time the capsule shrinks and wraps around the new lens much like shrink wrap or cling film. As the capsule contains live cells some capsule can develop a layer of new cells that form a frosting on the back surface of the lens. This is called posterior capsular opacification (PCO) or an after-cataract and can occur in up to 10% of patients after lens/cataract surgery. The frosted layer is much like the frosting on a window which can blur the view through the window and similarly through the new lens. PCO can occur at any time after surgery including a few weeks to months later. In some surgeries an adherent plaque may be present on the capsule and a surgeon may prefer to leave this rather than risk tearing the capsule. In these cases early treatment to clear the frosting may be necessary.

The YAG laser is the laser used to clear the frosting from the back surface of an intraocular lens. YAG laser treatment is painless and is completed from outside the eye in a few minutes. During YAG laser treatment your eye doctor may use a magnifying contact lens to help with aiming the YAG laser at the layer of frosting. During the treatment patients will see flashes of light and hear a clicking sound. The pupil needs to be dilated before YAG laser can be performed to allow a good view of the lens surface. After the treatment your doctor will prescribe a short course of anti-inflammatory and pressure drops. Most patients will noticed an improvement in clarity and vision within a day. YAG laser treatments are typically only needed once as the capsule does not regrow after it is vaporised by the YAG.

Complications after YAG laser are very rare but can in rare cases include vitreous floaters, raised eye pressure, retinal swelling, lens damage and very rarely retinal detachment.

Posted on January 1, 2017 .

Artificial iris for traumatic iris pupil damage

Iris damage
artificial iris

Artificial iris technologies to repair aniridia or traumatic iris damage has evolved significantly. Current technologies such as the Human Optics artificial iris can be colour matched to the patient's eye. These are the before and after images of a recent case treated by Mr Angunawela. The patient's eye was damaged by a cricket ball causing severe iris and pupil disruption with a cataract. The Human Optics artificial iris was colour matched to the patient's healthy eye. The cosmetic result is a significant improvement.

* Please note that it is necessary to combine the procedure in phakic eyes with lens removal and lens implantation, even if no cataract is apparent. 

** This type of artificial iris is not intended simply for cosmetic use. Mr Angunawela does not perform cosmetic eye colour changing surgery. Please do not contact the clinic for cosmetic only surgery. Devices such as the BrightOcular cosmetic iris implant are not available or recommended within the EU or USA.

Posted on December 25, 2016 .

Free consultations for laser eye surgery

How is it that some clinics offer free consultations for laser eye surgery whilst others dont? The simple rule that you get what you pay for applies to laser eye surgery as it does to other aspects of life. Clinics that offer free consultations do so through cutting costs by employing opticians rather than eye surgeons to assess potential patients for surgery, with those undergoing surgery meeting their surgeon once and only on the day of surgery. Opticians play an important role in eye care, but when it comes to surgery in your eyes a trained eye surgeon is the best person to assess you for laser eye surgery or any other sort of eye surgery including cataract surgery or multifocal lens surgery.

The best standard of care is to see your eye surgeon at your first consultation and at every visit from surgery to post-operative care. Your surgeon should personally examine your eyes, explain the available options personal to your eyes, potential issues and should answer any questions that you have. You should also have time to ask questions from your surgeon and should not feel under pressure to have surgery because of some last minute discount offer that might be ending soon.

For an objective unbiased review of laser eye surgery clinics consider reading the Which report

Posted on December 7, 2016 .

Symfony or trifocal intraocular lens? Which is better? Which should you have? Which is the best multifocal lens?

Trifocal intraocular lens

Which multifocal lens is best? A question I am often asked by patients. With different eye clinics advertising and claiming that the lens they offer is better than anything else, potential patients wishing to have cataract surgery or refractive lens exchange (RLE) surgery can be faced with a confusion of choice.

 

Multifocal lenses are a type of intraocular lens implanted at the time of lens surgery (cataract or RLE). They differ from standard monofocal lenses, which generally give good distance vision in that they offer the opportunity for patients to enjoy a range of vision from distance, intermediate and near without the need for glasses. This is achieved by an lens optical design which typically consists of concentric rings of increasing power separated into seamless zones for vision at a range of distance. This is an attractive proposition for someone who wants to be independent of glasses for distance and in particular reading vision. My patients often say they feel younger after multifocal lens surgery because they aren’t shackled to reading glasses any longer.

 

To understand what some of the different lenses offer it is important to understand the very basics of optics. Someone wishing to read at 40cm ( a typical distance of a book or newspaper) would usually require additional optical power of +3.0 dioptres (unit of power). On the other hand if the text was held at arm's length (intermediate distance) the optical power required would be roughly +1.5 D. Seeing in the distance doesn’t require any additional optical power over what is required to correct distance vision in that individual. Having understood these basics it is possible to explain what the current lenses offer and move closer to the answer to the question on which multifocal is better.

multifocal lens implants
Symfony lens implant

Amongst the current crops of multifocal lenses the predominantly used lenses are the Physiol Finevision Trifocal lens, Zeiss AT-LISA trifocal lens and the AMO Symfony lens. Both the Physiol Trifocal and the Zeiss Trifocal have built in powers of 1.75D for intermediate and 3.5D for near, giving a full range of vision at all distances. The Symfony lens has an intermediate only power of +1.75D. Other lenses such as the Oculentis Mplus Comfort or Mplus MF20 have powers of +1.5 and +2.0D respectively. Surgeons using Symfony or Mplus lenses typically ‘extend’ the range of focus of these lenses by targeting the patient’s non-dominant eye for a small amount of added prescription (0.5 to 0.75D) to boost the range of focus in one eye (technically called micro-monovision).

 

In term of post-operative results, a higher proportion of patients are completely independent of glasses after trifocal lenses than they are with other types of lenses. This is down to the simple fact that the optics of these lenses (the +3.5D part) allow reading at 40cm. Having said that, this doesn't mean the other lens designs aren’t as good. The right lens depends on each patients lifestyle and visual needs. The person who likes playing golf, doesn’t read that much and doesn’t mind the possibility of occasional glasses would be very happy with a Symfony or Mplus lens. A bookworm who loves reading or someone who loves sewing would probably prefer a trifocal lens. 

 

Patients should be aware of some other factors with multifocals. All multifocals can cause glare and haloes around bright point sources of light such as headlights when driving at night. This tends to be more common with trifocal type lenses and occur less often with the Symfony or Mplus lenses. In the majority of cases even where there are haloes around headlights when driving at night patients are so delighted with their new independence from glasses that they don’t find the haloes particularly troublesome. Personally I haven’t had to remove any lenses in patients due to night time haloes. Some patient may just never like the quality of vision they achieve with a multifocal lens and roughly 0.5% of my own patients require an exchange of lens implants due to dissatisfaction. This can be with any type of lens. The final thing to mention is that multifocal lenses of all types work best in good lighting. Hence a patient with a mutlifocal trying to read the program at the theatre or opera with the lights down can struggle.

 

Which is the best type of mutlifocal lens? Trifocal or Symfony? The answer depends on your lifestyle and needs. If you’re an outdoor sportsman who reads on an Ipad and doesn’t mind the possibility of occasional reading glasses, the Symfony lens may suit you. Alternatively, if you're a book worm and hate the idea of reading glasses, one of the Trifocal lenses may be best for you. If your’e a taxi driver that drives at night for work the Symfony or Mplus lens may be the best option for you with occasional use of reading glasses.  

 

I would also advise you to follow the advice of your eye surgeon. Surgeons like me that do this type of lens surgery tend to stick with lenses we know work and keep our patients happy. Each surgeon will have their own preferences, but be assured that these preferences are based on the knowledge of satisfaction from past patients. I personally use the Finevision, Zeiss and Symfony lenses.

 

Finally, my old mum just had lens surgery. She’s 72, a retired psychiatrist who reads a lot, sews for her grand kids and plays golf twice a week. She had the Zeiss trifocal lens. She’s over the moon!

 

To arrange a consultation with Mr Angunawela for laser assisted lens surgery at Moorfields Private Eye Hospital or for more information please fill in the contact form below. You will be contacted by one of the team. 

*please note that the clinic is open Monday to Friday and you will only receive a response during the week.

 

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Posted on November 20, 2016 .