Cataract on eye with detached retina

Hello,

My mom underwent a surgery in 1990 for retinal detachment with multiple
retinal tear. The surgery could only restore about 20-30% of her vision. She
is 62 years now, and is undergoing regular examinations of the retina.
Recently, while diagnosing, it was found that she is developing cataract in
both the eyes. The doctor said that she could wait for a cataract surgery
for 6-8 months or even more in her right eye. Her left eye might also take
the same time, but he was not sure whether an IOL implant on the eye with
almost dead retina would really help.

Could the elite give their views about the prons and cons on a cataract
surgery to the left eye? Also please let me know about the laser assisted
sutureless foldable IOL implants for the right eye. How is it better than a
conventional IOL implant? As she has to rely only on the right eye, I would
like to get her the best medical treatment.

Best regards,
BKR.

 

I must say, I have never heard of a
"laser assisted sutureless foldable IOL implant". There is no "laser assist"
in cataract surgery.

Most surgeries are done with foldable lenses, placed through sutureless
clear corneal incisions, using topical anesthesia, these days. (I just did 6
today.) However many doctors still do scleral tunnel incisions with 1 or
more sutures. Either they don't want to change, or they believe in some
studies that have shown a higher incidence of endophthalmitis (devastating
infection) in sutureless incision surgery.

If the retina is really damaged, the cataract surgery will have little, if
any, impact on the vision, unless it is a totally white cataract, and this
were the only eye.

Unless she is relatively handicapped by the vision in the good eye, don't
operate. There is some risk involved, and as long as she can do what she
needs to, leave it alone. She alone will know when she HAS to have it, not
the doctor. (If she has to ask him, "Do I need surgery?", then she really
doesn't need it, in general.) Cataracts do not hurt or damage the eye,
whereas surgery can. Leaving a cataract does not make one blind, either.


David Robins, MD
Board certified Ophthalmologist
Pediatric and strabismus subspecialty
Member of AAPOS
(American Academy of Pediatric Ophthalmology and Strabismus)

 

I'm not sure who you mean when you ask "the elite" giving their
views? My own view (non-elite) is that is a conservative approach
is best with cataract surgery when dealing with basically a
monocular situation (one eye with reduced,low, or no vision).

The left eye would likely benefit very little unless the cataract was
fully mature and even then , the outcome wouldn't help much.
For the right (sighted) eye, there's always a chance of post-operative
complications that can be unforseen so surgery ,IMO, should
be delayed until necessary . Cataract surgery is usually very
successful but I have seen bad and poor outcomes- cataract
surgery cannot be guaranteed 100%.

frank

 

I was told by the surgeon's assistant that laser would be used to
disintegrate the natural lens (cataract infected) and suck off. May be he
was not so competent as the surgeon.

This brings me to another question. What are the risks involved in
sutureless surgeries?

Just to add: With the retina affected eye alone, she can walk independently
and only recognize objects which are close.

-BKR.

 

I've had a couple of cataract surgeries. They have a little vacuum
cleaner device that dissolves and removes the stuff inside the lens. It's
not a laser, though. Note that cataract isn't an infection. The stuff
inside the lens is what lets you focus. Cataract simply means that the
stuff becomes opaque. It's usually not a big deal to take away the
focussing, since cataract surgery usually happens at an age when people
have mostly lost the ability to focus anyway.

I'm not a medical person, but I believe that the risks are the same either
way. Furthermore, it probably doesn't make a difference. The doctor will
do the surgery the way that they think best. You can tell a professional
what to do, but they get a little testy if you try to tell them how to do
it. At least I do.

As David posted, you may get a surgery with sutures if the doctor is
older. You will get a surgery without sutures if the doctor is younger,
or has switched to that method. For my first cataract surgery, my doctor
was almost at retirement. He put two stitches in my eye. For my second
surgery, I asked about stitches and my doctor said there was no reason to
put them in. No stitches seems better to me in that you don't have to
worry about getting them out.

 

For peace of mind, your mother should consult another ophthalmologist and get a
second opinion. In my humble layman's opinion, after having two cataract
surgeries, no one should have the surgery until they think they need it. (My
surgeries both went fine; the principle is that, if a person is functional and
happy without the surgery then there's no need to take even a small risk.)

 

Well, "you've never heard of a thing" is not equal to "the thing does
not exist". Be sure in your statements.

The principle of laser cataract extraction is almost the same as with
phaco, but the cataractous lens is emulsified not with ultrasound but
with special YAG laser through the similar handpiece (even thinner than
phaco one). Doctor Dodick invented such an instrument in the West. Here
in Russia we have our own machine ("Racot") developed at the Fyodorov's
Institute. It consisted of two handpieces - laser/irrigation and
aspiration (with silicone posterior capsule protector). The separate
aspiration has the advantage - it decreases the size of laser probe
(extraction can be done through two paracenteses and it can be done in
endocapsular fashion - inside the almost intact capsule through the
small opening in it). And you doesn't have to move the handpieces inside
the eye - you just put the aspiration tip near the capsular opening, put
the laser tip near the aspiration probe, turn on suction, and when the
lens material is on its way to the aspiration line you help it with the
laser, emulsifying it just at the aspiration orifice.

A.B.Durasov, MD
Samara, Russia

 

Sorry, I've never heard the term: laser-assisted ....IOL implant.
We all know about laser phakoemulsification - but not generally called laser
assisted ...

Lasers don¹t ASSIST with anything, they may drive the instruemnt, however.

They should call it what it is: laser handpiece phakoemulsification.
Otherwise, you create all this nonsense of marketing terms.

By the way, I have yet to see lens material move on its way to the
aspiration port - hard lenses do not do that - yet very soft (ie: mature
liquified lenses or pediatric lenses. Most adult lenses have to be carved
out with the phako - doesn't matter if its electronic phako ultrasound or
laser-created phakoemulsifiation. At this point, most laser systems are not
used much, since they are not very powerful and can't handle harder lenes.
Most of the people I see using them are doing so for the advertising value
of "laser". Right now the money is with the standard phakoemulsifiers
(Alcon, AMO, etc.)

At this pint there is no real advantage to the laser instruments. They are
VERY expensive. Most foldable implant technology has not yet caught up with
the tiny opening used for the surgery.

 

Actually, the nylon sutures usually don't have to be taken out, anyway. They
are buried, and if not affecting astigmatism (1-2 sutures placed away form
the wound usually won't) then they can be left in for many years. The thin
sutures gradually are broken down.

As I said, the jury is still out as to whether sutures reduce the risk of
infection.

 

No, he is right. Most surgeons, at least in the US, are not yet using laser
phako. What I meant was the there is no such thing as a laser assisted
implant lens, which is what the statement sounded like!

Well, yes, some people are using laser phako machines, where the end of the
probe is vibrated by a laser rather than an electronic crystal, or even
where the laser strikes the cataract chunk that has been aspirated into the
port. These tend to be weaker instruments, need a very soft cataract for
them to work right now.

Not much use yet - the advantage is smaller incisions, but IOL technology
for the most part still requires opening the smaller incisions to ~2.5 -
2.8mm to inject them. The 1.5mm foldables are rare.

 

however.

Here I agree with you, laser doesn't assist. But it doesn't DRIVE the
instrument. Laser beam itself IS the instrument, it is just transported
to the working space by some means (handpiece in case of laser cataract
extraction or lenses/mirrors system in case of posterior capsulotomy).

lenes.

Right opposite! Laser can break nuclei too hard for phaco (requiring too
much ultrasound power). And one more difference is that in
phaco-machines ultrasound is combined with the aspiration (it
counteracts with aspiration; suction pulls fragments in - ultrasound
pushes them out) but in laser system aspiration is on its own, it is the
independent working unit, it pulls fragments in, and if they are soft
enough they are aspirated, if they are hard they stuck, and laser breaks
them down to the size that can be aspirated).

Which lasers do they use? You may want to visit the site of Fyodorov's
institute (IRTC Eye Microsurgery) at www.irtcem.ru (they have english
pages) or contact Boris Malyugin, MD, PhD (Vice Director (science) of
the institute - the laser technique is well developed there, and from
the reports on various conferences and meetings (of course, you may
consider them advertising) the results are superior to the western
machines.

A.B.Durasov, MD
Samara, Russia
I'm not in any way affiliated with IRTC EM.
There are no IRTC branches in our city.

 

There are 2 kinds of laser phako instruments:
In one, a YAG laser hits a target in the end of the tip, vibrating it - no
laser energy leaves the tip

In the other, yes, laser energy is exposed to the lens material. This kind I
thought was the less-used technology.

Regarding the power: the latest I have read is that the laser energy is far
less than that of traditional phako.

No idea what some people are using in the USA.

Regarding the issue of the irrigation: yes, microphako using bimanual
technique for irrigation on a separate handpiece is getting some press -
smaller incisions as well as the claim that it reducing pushing of material
off the end of the instrument. However, unless the lens material is chopped
first, or is broken up by some other methods, it is not attracted to the
port. You are talking about free chunks that have been mechanically
liberated from the cataract first.