LRI: Try Before You Buy

If you’re a surgeon who is reluctant to start using premium lens implants, why not try doing limbal relaxing incisions (LRI’s) as a first step in getting into refractive cataract surgery?

When I first went into practice over ten years ago, my confidence in my cataract surgery skills was still growing. Though my refractive outcomes were predictable and consistent, I was reluctant to adopt LRI’s as a value-added service for patients, even though my more senior colleagues encouraged me to offer them. Not until I was in practice for about two years did I start doing LRI’s routinely.

Now I look back on those two years and wonder why I took so long. How many patients did I leave with astigmatism who could have had a spherical result? How many of them would have been that much happier?

Astigmatism correction with LRI’s is truly a simple procedure that adds a great deal of value for patients. Consider the two pictures shown below, taken moments apart here in Laguna Beach. With the left hand picture, my camera was trying to autofocus through a -1.0 diopter cylindrical lens placed in front of the camera’s lens. The right-hand picture was taken with a plano sphere lens. The difference in clarity is significant and shows what a difference we can make for patients by simply correcting their astigmatism.

There are a number of good courses to teach astigmatism correction, and I’ve produced a brief video, which can be viewed in two parts below, that explains the process step-by-step.

I’d welcome comments from readers on how doing LRI’s has affected your practice.

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Visual Questionnaire Efficiently Collects Information/Guides Implant Discussion

A simple form used in our office gives us a wealth of information about patients’ visual needs and complaints. It helps us understand who is ready for cataract surgery, what type of implant might be best, who might just be happy with a couple of new pairs of glasses, and who is interested in LASIK. You too might find this form a useful way to learn about your patients.

Download it here: Visual Questionaire – Word document

The form consists of three sections. At the top (in the boxes) is an update of demographic and medical information necessary for updating our charts.

Lasik interest question: besides the obvious use of this information for non-cataract patients, we find it a strong indicator of interest in premium implants among cataract patients who answer “yes”.

How old are your glasses? Notice we ask about multiple types of glasses? This introduces patients to the concept of activity-specific lenses. It gives our optometrists and opticians valuable information about the types of lenses a patient already employs and might want in the future.

Visual difficulties section: this is adapted from well-established visual function questionnaires validated and used by the National Eye Institute objectively to assess visual impairment. It records each patient’s visual complaints in his/her own handwriting, providing irrefutable evidence that there were symptoms of disability before surgery. One never knows (Medicare audit, malpractice case) where this might be useful later. Mostly, it helps us understand how bothered a patient is by symptoms. I have found that patients who respond with 3′s and 4′s are fairly consistently ready for cataract surgery, assuming no other condition accounts for their visual complaint.

The last section is derived from Steven Dell’s pre-implant survey. It asks about the three activities  that best guide us toward implant choice: driving after dark, computer use, and close detail work. Those who spend much time with the first two might be best for an accommodating implant, especially if they have had a good experience with monovision and don’t mind wearing glassed for fine print. Those who do not drive after dark, do a lot of near work, and don’t mind glasses for the computer might do better with a multifocal.

Naturally, every patient questionnaire has its limitations and can’t serve as a substitute for a thorough discussion. However, this form saves us valuable time and directs this discussion toward the finer details needed to help patients make the right decision during their always-too-brief time with the doctor.

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Finishing the Job Happens Months After Premium IOL Surgery

Looking back on seven years experience with premium IOLs I’ve come to learn that the most important exam we perform is the one that should come several months after surgery. It’s at this time our premium implant patients feel they’ve reached their “final” result. It’s at this time they tell their friends how well they are seeing and how much they’d recommend their surgeon. And it’s at this time we surgeons really prove our commitment to the patient.

Beware the patient who has mild residual refractive error or mild posterior capsule opacity (or both) and is only marginally happy with his or her vision. The patient who says, “I’m doing ok, doctor. I guess it all right,” is not raving to her friends about your surgical skill. Rather, she’s probably telling them, “I paid over $4000 dollars extra, and I still can’t see well.”

You can turn this minus into a plus, and you owe it to your patient and your practice to do so.

Those of us with LASIK experience know it’s in the patients’ best interest to discourage unnecessary enhancements when patients are marginally happy after surgery. With minor ametropia after LASIK, enhancement doesn’t improve satisfaction. In many cases it only only prolongs postop dry eye.

In premium IOL patients, though, most marginally happy (or unhappy) patients get great symptomatic improvement with a yag capsulotomy, a refractive enhancement, or both.

For this reason it’s become our practice at Harvard Eye Associates (www.harvardeye.com) to see all patients four to six months after premium IOL surgery to gauge both their refractive outcome and their satisfaction with surgery. Those who are doing well are always a pleasure to see, and the visit reinforces to our doctors and staff why we offer premium IOLs. Those who are doing marginally well get the royal treatment: we suggest a yag, or we do an enhancement at no charge. In either case, the patient becomes our greatest advocate and enthusiastic ambassador, and we know that we have finished a job well done.

Dr. Hovanesian’s educational videos and other materials can be found at www.bettereyesurgery.com.

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Going Back to Monovision Cataract Surgery
Surgeons are Going Back to Monovision Cataract Surgery, and It’s Working

Several colleagues of mine have recently informed me how happy they and their cataract patients have been with monovision. I credit Jay McDonald of Fayateville, Arkansas for reintroducing me to this approach.  Look for an upcoming article in The Premier Surgeon where I interview Jay for his take on this topic.

In a time when we have an expanding line of presbyopia-correcting implants to offer, why would they consider such an old-fashioned approach?  Because it’s simple and it works.  Despite perceptions about this age-old approach, monovision with an IOL:

• does not require a contact lens trial.  In fact, a trial should probably be avoided.  Cataract patients who have never before worn contacts tend to become more bothered by the experience of wearing CTLs than the monovision itself.  They are more likely to reject the concept on the basis of the CTL’s unfamiliarity rather than the anisometropia.
• does not require significant anisometropia.  Targeting plano in the dominant and -1.25 to -1.5 diopters in the non-dominant will yield high-grade intermediate and near vision.  Some patients may need to increase their working distance for some tasks like needlepoint.  Naturally, they can also resort to readers that balance both eyes for very near.
• does not reduce stereopsis significantly.  Patients who enjoy playing tennis, for example, do not complain of inability to function on the court. Postop patients typically can be measured to have high-grade stereo acuity.
• does not reduce contrast sensitivity significantly.  While some reduction in high spatial frequency contrast sensitivity occurs during distant tasks in the non-dominant eye, the patient can compensate.  The brain “shifts” its attention during these tasks to the dominant eye, which has perfect contrast sensitivity.  You won’t find “perfect” contrast sensitivity in an eye with a multifocal.

Additional advantages of monovision cataract surgery:

• Unlike multifocal implants, the very mild loss of contrast sensitivity at distance is completely reversible.  Many of my patients would much rather spend their day without glasses, even if they have to put on a pair of specs to drive at night.
• Monovision can be offered with a variety of implants.  My personal preference is to use a monofocal implant with either negative asphericity like Tecnis (AMO, Santa Ana, CA) or the AcrySof IQ (Alcon, Ft. Worth, TX), or a neutrally aspheric lens like the Softport AO (Bausch & Lomb, Aliso Viejo, CA).
• Monovision allows the surgeon to offer a refractive procedure without the added cost of a multifocal or accommodating implant.  This saves the patient thousands of dollars.  Note it is appropriate to bill for refractive services incident to this procedure, including all non-covered services, such as refractive evaluation, topography, pachymetry, limbal relaxing incision, and refractive enhancements.  The Corcoran Consulting Group (www.corcoranccg.com) has developed audit-proof guidelines for the financial aspects of this procedure, which are beyond the scope of this blog.

To be sure, there is a fair bit of work involved for the surgeon, just as with a high-tech IOL.  Getting the postop refraction to be perfectly spherical and nailing emmetropi in the dominant eye are essential elements of success; enhancements are occasionally necessary, and patients do have the same demands as the higher-paying customers who have PC-IOLs.  But there’s something elegant about using nature’s gift (the brain’s plasticity) to give patients spectacle freedom, and in the future I’m going to be doing more monovision.

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Pterygium Eye Surgery Techniques By Dr. John Hovanesian

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Cataract and Fuchs: DSEK has Changed the Equation

Since the widespread availability of DSEK, have you noticed how much simpler the discussion of cataract surgery has become for patients with Fuchs Dystrophy? Before DSEK, most of us cataract surgeons have probably spent many hours explaining to Fuchs patients how their upcoming cataract surgery might make their vision worse. To be sure, corneal decompensation still happens after cataract surgery, despite newer viscoelastics and phacoemulsification technology. But the significance of a decompensated corneal is now a much simpler matter to correct, thanks to DSEK.

Over five years ago I started doing DLEK (the precursor procedure to DSEK) for endothelial replacement. It was not a pretty procedure. None of the eye banks even knew what DLEK was, let alone could provide pre-cut donor tissue. The femtosecond laser was not yet approved for cutting corneas for this procedure. We had to manually cut the tissue on an artificial anterior chamber. Trauma to the endothelial graft, perforations, and inconsistency of the graft tissue were extremely common. Naturally, this very much affected the results of surgery. Donor dislocations happened in nearly 50% of cases and recovery of vision took months and yielded results that were really no better than PKP. Nevertheless, the procedure had merits. The idea of not needing sutures and not creating irregular astigmatism was very appealing.

Now, DSEK has become a truly simple procedure. High quality, properly pre-cut tissue is routinely available from nearly any eye bank, and we’ve learned enough lessons about surgical technique that we can consistently provide somewhat rapid and predictable visual recovery. No more repetitive topographies and selective suture removal sessions. No more broken sutures on the weekend. And no more apologies to patients about their bizarre corneal irregularity despite what seemed like great surgery.

This procedure has really been a gift to both patients and corneal surgeons, and let me take a moment to recognize Gerrit Melles, Frank Price, and Mark Terry and others who tireless efforts helped make DSEK the procedure it is today.

Nowadays, my cataract conversation with Fuchs patients, while still long, is much simpler. I like to give patients a percentage chance that their cornea will decompensate based on all the data available. Of course there is some guesswork in coming up with a number, but patients do seem to find it comforting to think in terms of numerical odds. More importantly, I explain that the subsequent procedure of replacing the defective endothelial cells is a fairly simple one that takes no more than 20 minutes. The healing is fairly painless, steadily progressive, and generally allows very satisfactory vision (20/25 to 20/30 with minor correction is not unusual).

I welcome readers to comment on what preoperative parameters you use to assess risk in cataract patients with Fuchs Dystrophy.

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Diamond Burr Polishing Combined with phototherapeutic keratectomy (PTK) for Recurrent Erosion Syndrome.

Sometimes the combination of two or more well-established technologies yield a new and better treatment for an old problem. So I’ve found with PTK combined with a diamond burr for the treatment of anterior basement membrane dystrophy.

Anterior basement membrane dystrophy (ABMD), also called map-dot-fingerprint or Cogan’s microcystic dystrophy is the most common corneal epithelial dystrophy, occurring in up to 2% of the general population. This condition’s presence makes itself known when patients have painful recurrent corneal erosions, but quite frequently it’s missed as a cause of painless visual symptoms.

The best way to detect this condition is not with a fine slit beam and indirect illumination. Instead, use broad, direct slit lamp illumination directed from the patient’s side to bring out the lines, map areas, and microcysts that characterize ABMD.

Loss of acuity with ABMD happens when the basement membrane beneath the central corneal epithelium is thrown into folds. This may cause surface irregularity that the tear film simply can’t smooth out, or it’s possible that the basement membrane folds cause diffraction and light scatter that becomes symptomatic. Whatever the cause, the best way to eliminate the problem is to remove the offending basement membrane and epithelium.

Simple epithelial scraping can provide very satisfactory results after epithelial healing, but in my experience many of these patients have a recurrence of aberrant basement membrane (with a return of erosions or visual symptoms or both) within months or years. Scraping plus PTK yields still less recurrence, but more recently I’ve employed a combined approach using both PTK and “polishing” of bowman’s membrane with a diamond burr.

In this procedure, after proparacaine drops are placed I remove the epithelium with a blunt PRK spatula, then use a 3 mm diamond burr, polishing the entire surface of the stroma for a few seconds. PTK is then applied for 20-30 pulses, and a bandage contact lens is placed over Zymar, Xibrom, and prednisolone acetate drops. The postoperative regimen includes these same three drops, discontinuing the first two when the epithelium has healed and continuing the prednisolone for about four weeks.

Over the past two years I’ve used this regimen on nearly 30 patients with various manifestations of ABMD, some with painful erosions and some with visual symptoms. To date none have recurred.

I invite readers to comment on any other pearls or suggestions for diagnosing and treating ABMD.

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BID Postoperative Drops = Better Compliance = Better Outcomes?

How many of our patients take eyedrops as prescribed for QID use faithfully four times a day? According to studies of patient compliance, less than 50% of patients do. So how compliant are our postoperative cataract patients with a QID regimen of three medications: steroid, non-steroidal, and antibiotic?

With this question in mind, my practice partners and I switched our routine postoperative cataract regimen to three drops, all taken BID. Looking at pharmacokinetic data on available drugs, Ista’s Xibrom is a non-steroidal that is already indicated for BID dosing. Sirion’s (soon to be Alcon’s) Durezol has shown steroid potency nearly twice that of prednisolone acetate as well as dose consistency data that far exceeds the familiar suspension, so we felt comfortable using Durezol BID after surgery. As to an antibiotic the best candidate seemed to be Vistakon’s Iquix (levofloxacin 1.5%). Levofloxacin is a highly respected antibiotic among infectious disease specialists, and Iquix’s concentratio is three times higher than Vigamox’s moxifloxacin 0.5% and five times more concentrated than Zymar’s gatifloxacin 0.3%.

We are now three months and several hundred patients into our new BID postop regimen, and we have yet to see (knocking wood) any complications related to our postoperative regimen. Furthermore, we feel much more confident that our patients are actually getting the drops we’re prescribing. Patients love the new regimen too, since it allows them the freedom to go about their day without having to drag along eyedrops.

I encourage readers to comment on their own spproaches to simplify postoperative management.

Dr. Hovanesian is a consultant to Allergan, Bausch & Lomb, Inspire, Ista, and Sirion and has no financial interest in Vistakon.

Says John A. Hovanesian, MD, “The financial impact of the abuse of lubricant eye drops  by patients exceeds the cost of alternative treatments that would, in many cases, provide greater relief to patients.”

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Azithromycin–is it Mother’s Milk for Blepharitis?
Note this article discusses an off-label use of azithromycin.

Inspire’s Pharmaceutical’s Azasite has changed the way I think about blepharitis.

For years, like every other ophthalmologist I’ve taken great effort to instruct patients with blepharitis about the benefits of eyelid hygeine/warm compresses and how to use them. I’ve also prescribed erythromycin ointment for use at night. Patients seem to do well for a short while, then symptoms slowly return, prompting a visit back to the office. After reviewing their treatment plan, I’ve most frequently found these folks are compliant with taking the erythromycin but have slowly phased out the use of warm compresses–the most effective part of the regimen. It has became fairly clear that busy people have the discipline to put in a medication, but even with repeated instruction, they fall off the wagon of using time-consuming eyelid hygeine and warm compresses.

Then a colleague suggested I try topical azithromycin instead of erythromycin for these patients.

My first reaction to this was that azithromycin was an unnecessarily expensive and high-tech solution to a very low-tech problem. If warm compresses could treat blepharitis, patients darn well ought to use them. But the reality seemed to be that most of my patients would only make the effort to use warm compresses if and when they became highly symptomatic, by which time the vicious cycle of meibomian inspissation-bacterial colonization-more inspissation had spiraled out of control.

These patients need maintenance therapy they can live with that will keep their blepharitis controlled. So why would I consider azithromycin instead of the freely available and less expensive erythromycin?

Azithromycin–well known to primary care physicians as the cure-all Z-pack–has been made available in eyedrop form by Inspire for about two years under under the trade name Azasite. Though it’s official indication is for bacterial conjunctivitis, more and more ophthalmologists have used it off-label for chronic therapy of posterior blepharitis (meibomian gland dysfunction).

Like doxycycine, an antibiotic that is used in blepharitis to thin meibomian secretions rather than for its antimicrobial properties, azithromycin has effects on local tissues (conjunctiva) that go beyond the usual effect of an antibiotic. Azithromycin seems to have anti-inflammatory effects because of actions of its effects on matrix metalloproteinases. Within about a day of use, patients seem to notice less inflammation.

Naturally, azithromycin’s antibiotic properties too are important to its functioning as a blepharitis treatment. In fact, this is where the drug really seems to excel. Azithromycin has not only high potency against the gram positive organisms responsible for MGD, it also has conjunctival tissue penetration that is off the charts compared to other topicals. That suggests it may reside in tissues for a much longer time allowing effective therapy with very infrequent dosing.

In treating blepharitis (again off-label), I instruct patients to use the drop once a day for a week, then stop for three weeks, then start again for a week and repeat the cycle. Many patients mark their calendars to remind them to take drops for one week each month.

The major complaint patients seem to have with Azasite is stinging. It can be uncomfortable to use initially. Some of my patients tell me that refrigerating the drop reduces considerably these symptoms.

Another concern is that the drop is so viscous that it can be difficult to dispense; when the bottle is inverted the patient has to shake down the contents or just wait for the liquid to roll down to the tip. (Remember the Heinz ketchup “Anticipation” commercials?) Some of our patients have worked around this by storing the bottle upside down, just as we do with gonioscopy gel.

I hope never to give up the crusade for warm compresses and eyelid hygeine, which are the real “mother’s milk” we can offer people with blepharitis, but until human nature allows our patients to continue these time-consuming treatments faithfully, we will continue to need other treatments like azithromycin that come out of a box.

Dr. Hovanesian is a consultant to Allergan, Bausch & Lomb, Inspire, Ista Pharmaceuticals, Sirion Therapeutics, and Vistakon.

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An oldie but a goodie — Corneal Tattooing
Please note the following is a description of a procedure that is not consistent with FDA labeling.

About once a year, I encounter a patient who helps me rediscover an old but great technology — keratopigmentation, or corneal tattooing. This procedure fell out of fashion for a number of years but has re-emerged among a few cornea specialists because it’s a near-perfect solution for defects in the iris or for corneal leukomas.

One example is a patient referred to me with visual disturbances after previous cataract surgery. The patient had best corrected visual acuity of 20/30 with halos, even under photopic conditions. She had a peripheral iris defect caused by trauma during surgery. This allowed light to enter her eye without passing through her IOL. Several treatment options were possible: iridoplasty with a suture, placement of a Morcher artificial iris, placement of a therapeutic (peripherally opaque) contact lens and, of course, corneal tattooing. After discussing the options with the patient, I recommended corneal tattooing.

Tattoo dye for corneal use is an off-label procedure, as there are no approvals of tattoo inks for use on the eye. However, many surgeons have used commercially available tattoo dye, using a steam sterilizer to prepare it for surgery. Naturally, only a few cc’s are necessary for the procedure.

In the procedure, I debride epithelium from the area of interest. I dip the tip of a 15° paracentesis knife into a small amount of sterilized dye and approach the corneal surface tangentially. This minimizes the chance of entering the anterior chamber while maximizing the visibility of the pigment when viewed externally.

It’s important to intentionally “overdo it” or put about three times much more pigment spots than appear necessary at the time of surgery. That’s because much of the dye accumulating on the surface of the stroma makes the cornea appear adequately pigmented. However, this will disappear within a few days, leaving behind only what was injected intrastromally.

One downside to this procedure: Some patients experience significant pain for a few days afterwards. To minimize this, I perform this procedure under a peribulbar anesthetic using bupivacaine because it keeps patients comfortable for at least 12 hours after surgery, by which time some of the corneal epithelial defect has healed. To further reduce pain, I use an NSAID drop — I typically use Xibrom (bromfenac, Ista) twice a day, but Acular (ketorolac, Allergan) four times a day or Nevanac (nepafenac, Alcon) three times a day work also — in addition to four times a day dosing of prednisolone acetate and a broad spectrum antibiotic. A bandage contact lens is also a must during healing.

This patient’s BCVA improved to 20/25 after tattooing. Moreover, her complaints of halos disappeared, and she much appreciated having a noninvasive procedure with little risk to solve her problem.

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