ORA

Posted on by DrVish

ORA stands for Optiwave Refractive Analysis. It is the only means of intraoperative aberrometry approved in the country.

Purpose

ORA is designed to deliver superior refractive outcome to patients undergoing cataract surgery. This means treating nearsightedness (Myopia), farsightedness (Hyperopia), and astigmatism at the time of your procedure. For some basic information on these, please refer to the section on Lasik.

How it works

Before understanding how ORA works, we must first understand how myopia and hyperopia are typically treated. Before a patient has cataract surgery, the anterior curvature of their cornea and the anterior-posterior diameter of their eye are measured. This information is entered into equations that allow us to predict the IOL (intraocular lens) power that would suit them best.

ORA adds an additional safety net by taking a refractive measurement of the eye during the course of surgery using infrared light (completely safe for your eye in this context). In less than a minute, ORA takes 40 measurements which allow for a much more reliable measurement of predicted myopia, hyperopia, and astigmatism.

Why Use it?

Well, to put it simply it delivers superior refractive outcomes without being invasive or adding any risk to the procedure

Unlike the traditional methods of simply measuring the corneal curvature and axial length of an eye, ORA factors in posterior corneal astigmatism. And as we’re learning, posterior corneal astigmatism is becoming increasingly recognized as a factor that must be considered for delivering good outcomes.

Lastly, there are some cases in which ORA is particularly useful and consistently offers a clear advantage.

Eyes that have had LASIK or PRK.

These eyes are notoriously unpredictable in terms of refractive outcomes. Traditional formulas that are used cannot reliably account for refractive changes in the structure of the cornea. ORA lets us bypass these formulas and offer patients the best chance of an ideal outcome.

Premium IOLs (intraocular lenses)

It is vital that the correct lens power is chosen for any of these lenses to function properly. ORA maximizes this chance and greatly increases patient satisfaction along the way. In astigmatism correcting lenses, there’s another fold to this. ORA not only helps predict the best lens power but also helps guide positioning to treat the maximum amount of astigmatism. Here are some pictures of ORA guiding lens positioning.

In the top picture, ORA suggests rotating the lens clockwise to maximize astigmatism. The bottom picture was taken after the lens was rotated successfully. NRR just means “No Rotation Recommended” or “Good job”.

toric-positioning-monitor-1

toric-positioning-monitor-2

 

 

Dry Eye Syndrome

Posted on by DrVish

What does Dry Eye look & feel like?

  • Blurred Vision
  • Eye redness
  • Tired eyes
  • Burning
  • Grittiness
  • Irritation
  • Watery Eyes
  • Foreign body sensation

What causes Dry Eye?

Here are some of the major causes of Dry Eye:

  • Exposure (i.e. poor closure of the eyelids)
  • Poor production of your natural tears
  • Decreased lipid content of tears (which may be related to blocked or inflamed glands of the eyelid)
  • Certain prescription medications
Here is a magnified picture of blocked Meibomian glands of the eyelid taken from dryeeyezone.com.

Blocked meibomian glands

Dry Eye Testing

Before starting treatment, it is important to understand what is causing your Dry Eye. This information will allow a more focused approach to your dry eye treatment.

Appropriate dry eye testing entails a full exam with your Ophthalmologist and may involve certain in-office tests to determine the cause.

Dry Eye Treatment

There are various modes of Dry Eye treatment. Common therapies include the following:

  • Artificial tears or lubricant drops
  • Tear gels/ointments
  • Lid Scrubs
  • Fire and ice mask
  • Hydroeye
  • MiBo
  • LipiFlow
  • IPL

New treatment options

There are a lot of new and exciting treatments for Dry Eye. MiBo and LipiFlow have both shown very promising results in recent studies. However, these therapies are not suited for every type of patient. They work especially well for patients whose Dry Eye is related to blocked glands of the eyelid (pictured above). Ask your eye doctor if you fit into this category.

 

Saying Goodbye to Glasses

Posted on by DrVish

There are many reasons why patients are dissatisfied with eyeglasses.

  • Eyeglasses distort or block peripheral vision.
  • They may become scratched, smudged, or foggy.
  • They can exert pressure on your nose and ears.
  • They can fall off during sports or activities.
  • Adjusting to the bifocal or progressive segment can be very difficult.

Recently, I have had a lot of patients express their frustration with eyeglasses. Usually, the problems involves a problem with the bifocal or progressive segment. Often, these patients ask if they are candidates for LASIK or if there is any way they can reduce or eliminate their need for glasses.  With this in mind, I decided to summarize some basic options for patients who are looking to see the world clearly without any glasses.

LASIK

LASIK is a great option for patients who are looking to correct their distance vision. In this process, a laser is used to re-shape the Cornea (front part of the eye). This allows perfectly clear vision and can eliminate the need for glasses or contacts.

In patients who need some additional reading help such as a bifocal or progressive segment, the LASIK measurements can be set for “mono-vision” which allows patients to see clearly up close and in the distance.

There is much more information about “How it works”, “Pro’s and Con’s” and “Cost” in the LASIK section. Feel free to check it out.

Lens Exchange

In eyes that are Myopic (nearsighted) or Hyperopic (farsighted), the eye’s natural lens has either too much or too little power relative to its size. The result of this is blurred vision. In “Lens Exchange”, the eye’s natural lens is replaced with a synthetic lens which is designed specifically for your eye. As a result, patients have clear vision after a lens exchange without the need for contact lenses or glasses. All of this is done through a self-sealing micro-incision that is often created with a laser.

An added benefit of Lens exchange is that clear vision at distance and up-close may be obtained with a Premium implant. In addition, cataract surgery will never be required in the future since your natural, aging lens has already been replaced!

There are risks and benefits to every procedure. If you are interested in saying ‘Goodbye’ to glasses, please see an Ophthalmologist who will do a thorough exam and complete the necessary testing to see if you are an appropriate candidate for either of these procedures.

Frequently Asked Questions

Posted on by DrVish

What is the right age to get LASIK?

Patients must be older than 18 years of age to have LASIK. In addition, they must have a stable refraction (the number that is used to measure the power of glasses or contacts). If both of these criteria are met, there is no “wrong” age to have Lasik. Reports have indicated that a growing number of people age 45 and older are having Lasik and other refractive procedures to reduce the need for reading glasses.

What causes Cataracts?

Most cataracts are simply due to age-related changes in the Lens of an eye. However, there are a number of other conditions/factors that contribute to the development of cataracts.

Diabetes– Unfortunately, individuals with diabetes develop cataracts more frequently and earlier in life.

Medications– Certain medications are known to cause cataracts. One of the biggest culprits here is corticosteroids. While many of us have never taken corticosteroids, they are used heavily in patients with Chronic Obstructive Pulmonary Disease (COPD), Rheumatoid arthritis, and various other inflammatory and infectious conditions.
Other medications that lead to the formation of cataracts include chlorpromazine and other phenothiazine medications.

Ultraviolet (UV) radiation– Unprotected exposure to UV radiation can lead to cataracts. It’s a good idea to always keep those eyes protected!

Trauma– Sharp trauma (entry into the eye) and blunt trauma can both lead to cataracts. Even something as seemingly harmless as “eye rubbing” has been shown to cause the early development of certain cataracts.

Smoking– There is a significant association between smoking and the development of cataracts. Just more reason to quit.

Alcohol– Studies have shown that patients with higher alcohol consumption have an increase in cataract formation compared with patients with lower or no alcohol consumption.

What will happen if I don’t get my Cataracts removed?

It is important to understand that every Cataract is different. Some cataracts are very severe and lead to blindness if they are left alone. Other cataracts may simply cause permanently blurred vision but never significantly impair the functions of daily living. Still others can cause increased glare, double vision, or lead to forms of Glaucoma. With this in mind, it is important to see a trusted eye-care provider who can counsel you on the best decision to make regarding cataract removal.

Do I need to discontinue blood thinners or anticoagulants (example: Coumadin, Plavix, Aspirin) for Cataract surgery?

Standard Cataract surgery does NOT require the patient to discontinue anticoagulants (blood thinners). You may continue taking these as prescribed by your primary care doctor. However, it is important to note that sometimes Cataract surgery is combined with Glaucoma surgery (or less frequently with Retina surgery). In these cases, it may be beneficial to temporarily discontinue blood thinners for the surgery. Please consult with your doctor before the procedure to find out.

When will I know if I need glasses after Cataract surgery/When can I get them?

1 month. Although recovery from Cataract surgery is incredibly fast and patients often see an improvement within days, it takes a month for the lens implant to settle into position and the eye to heal. All of this impacts the power of glasses. Therefore, it is important to check patients for glasses at 1 month to avoid giving a premature prescription.

Most surgeons also check patients at 1 day and 1 week after surgery to make sure the eye is healing well.

LASIK

Posted on by DrVish

LASIK has been around for decades. Thankfully, like some of the other procedures we’ll discuss, the technique has been improved thanks to advancements in technology and our understanding of the eye.

Now, the key steps of the procedure can be performed entirely by laser. This allows for a degree of accuracy and precision that was never possible before.

How it works

To fully understand how LASIK works, it helps to first understand Myopia (nearsightedness) and Hyperopia (farsightedness) as well as Astigmatism and Presbyopia.

In a “Normal” eye, a beam of light is focused by the Cornea (front part of the eye) and Lens to a single point on the Retina (back part of the eye). This allows clear vision. However, if a patient has Myopia, Hyperopia, or Astigmatism, light is not focused onto the Retina.

Here is a diagram from eyeglassguide.com illustrating this concept. Here we’ll use Myopia as an example.

Light entering the eye is focused by the Lens and Cornea to a single point in front of the Retina

As you can see from the diagram, a light beam is focused to a single point in front of the Retina in Myopia. This causes blurred vision in patients with Myopia.

I won’t include diagrams for Hyperopia and Astigmatism here, but you can read more about these conditions and view helpful diagrams in their respective sections.

The take home message here is that all of these conditions interfere with the ideal condition of light being focused to a single point on the Retina instead of in front or behind it.

LASIK (and a few other refractive procedures) fix this problem by re-shaping the cornea so that light can be focused onto the Retina, as it should in a “Normal” eye. Thus, LASIK returns the eye to full functionality and eliminates the need for glasses or contact lenses!

Process

The key steps in LASIK can now be performed exclusively by laser. This allows for improved precision and even better results.

Before it begins, patients are counselled on exactly what to expect so there are no surprises. First, a femtosecond laser is used to create the LASIK flap. Afterwards, an excimer laser re-shapes the cornea based on precise calculations. Both of these lasers were developed specifically for LASIK and help us achieve the best results.

Pro’s and Con’s

Pros: Patients notice improved vision immediately after having LASIK. This effect only gets better as the eye heals. Many people describe LASIK as “life-altering” once they are able to see the world in perfect clarity without assistance for the very first time.

Patients may then say good-bye to the negative aspects of wearing eyeglasses. These include blocked or distorted peripheral vision, scratched lenses, and difficult bifocal/progressive segments.

Contacts provide better peripheral vision, but come with their own set of problems. Contact lenses decrease the amount of oxygen that reaches the surface of the eye. On top of that, they interfere with the ability of our own tears to naturally remove toxins, allergens, and bacteria from the eye. Partly because of this, contact lenses cause higher rates of potentially blinding eye infections, allergic reactions, and dry eye.

Refractive procedures (such as LASIK and PRK) help decrease if not eliminate the need for glasses and contacts, which can mean a major difference in satisfaction

Cons: Every procedure has risks. While LASIK is very safe, it should not be performed in patients with specific eye diseases. Therefore, it is very important to see an Ophthalmologist who will do a thorough examination and various screening tests to ensure a patient’s eyes are healthy enough to have LASIK.

Once the examination and tests are complete, it is also important for patients to listen to the risks and details of the procedure so they can make an informed decision.

Cost analysis

While there are many reasons why patients want LASIK, the most common reason for holding off is cost. I recently attended a lecture which talked about the cost savings from refractive surgery and thought it would be helpful to share.

Cost of refractive surgery

Varies by provider but is approximately $2000 per eye or $4000 for both eyes.

Cost of contacts (with backup set of glasses)

Initial eye exam with lenses: $225
Contact Lenses: $200 every year
Annual eye exam to check prescription: $75 every year
Contact Lens solution: $150 every year
Glasses Frames: $190 every 2 years
Over the course of 15 yrs this adds up to $7875

Cost of glasses alone

Eye exams to check prescription: $150 every 2 years
Glasses Frames: $250 every two years
Over the course of 15 years this adds up to $3000. Over the course of 25 yrs, the cost has already exceeded the price of LASIK.

With this incredibly basic cost analysis, it is obvious that LASIK may actually save money in the long run. With that said, no decision that could potentially affect your eye health (or any health for that matter) should be made on the basis of cost. While LASIK is a wonderful procedure, it is imperative that you have a thorough eye examination with a trusted Ophthalmologist to ensure that you are a good candidate.

Cataract Removal

Posted on by DrVish

Thanks to advancements in technology, an improved understanding of the eye, and ground breaking surgical techniques, cataract removal is now safer than it has ever been!

How it works

To understand how cataract extraction benefits patients, it is important to understand what a cataract is. A cataract is a cloudy lens, which prevents patients from seeing clearly. Please check out the Cataract section under Quicklinks for a more detailed explanation and some interesting facts. Cataract extraction involves removing the cloudy part of the lens and (usually) replacing it with a clear lens which is developed specifically for your eye.

Process

Like any well designed procedure, Cataract extraction involves a series of steps that are performed one after the other. I will describe these steps below.

The first and most important step of cataract removal is making sure the patient is comfortable. Patients are laid on a bed with pillows and cushions which are positioned according to the desires of the patient and the doctor. Light medications are used to ensure the patient is relaxed and pain-free. Dilating drops are used to help dilate the pupil so the cataract can be taken out as easily as possible. Numbing eye drops are used until the patient’s eye is completely numb. This is supplemented with numbing medications during the procedure to make sure that the entire procedure is absolutely painless. To give you an idea of how effective this is, many patients are surprised to hear I’ve finished (or even started) the procedure since they could not feel us working on their eye.

Once the patient is comfortable, the patient’s eye is carefully cleaned and a drape is used to make sure it stays clean and the field is “sterile”, or free of any bacteria.

A microscope is brought into position and the remaining steps are performed under the magnified view which allows incredible visualization. The microscope also provides target lights for the patients to look at during the procedure.

The next steps of the procedure vary depending on whether you and your physician have decided on “laser” or “conventional” cataract surgery. Keep in mind that not all facilities offer “laser” cataract surgery and if you are interested in it, you may want to check with your doctor’s office before making an appointment.

I offer both “laser” and  “conventional” cataract surgery. I will go into the specifics of each before getting back to the steps of the procedure that are common to both. As far as which one is right for you, I tailor my treatment plans for each individual patient as any doctor should. With that in mind, I recommend every patient discusses any questions they have with their eye care provider.

Conventional Cataract Surgery

A “microkeratome” is used to create a cataract incision. Other microscopic instruments are used to create a “capsulorhexis”, or circular opening in the lens capsule through which the cataract can be taken out and a new clear lens can be inserted. While some of these terms may sound unfamiliar, the take home message is that special instruments designed for micro-surgery are used to gain access to the cataract. You will see how this differs from Laser Cataract Surgery just below.

Laser Cataract Surgery

A femtosecond laser (an incredibly precise laser designed specifically for eye procedures) is used to create a cataract incision. At the same time, the laser creates a “capsulorhexis”, the circular opening through which the cataract is removed and new lens is inserted. The laser can also break up the cataract to make it easier to remove and create “limbal relaxing incisons” , which are a wonderful way to treat astigmatism. All of this is done in less than a couple minutes. It’s safe to say the laser is a great multi-tasker!

The remaining steps of the procedure are common to both conventional and laser cataract surgery. Now that there is clear access to the cataract, ultrasound energy is used to break up the cataract and take it out. This process is called phacoemulsification.

With the cataract out of the way, a carefully selected intraocular lens or IOL is inserted into the anatomical position that will provide the patient with the best visual and functional outcome. The idea of a lens inside your eye may seem unusual to some patients. However, intraocular lenses have been in used for decades, with the first one implanted in 1949. Over the years, the technology of IOLs have grown by leaps and bounds as the material used and designs have been perfected. Each lens is custom selected for the patient based on a variety of measurements and careful discussions at the time of your visit. In addition to restoring 20/20 vision or better, IOLs are also designed to reduce (or possibly eliminate) your need for glasses and treat astigmatism. There are many options to choose from, which is why I’ll write more about them in the Premium Lens section.

Getting back to the last steps of the Cataract procedure, once the lens is in the place, they eye is carefully flushed out and the eye is inspected to make sure it is in great condition. Additional drops are given to help the eye heal and protect it from infection. This concludes the procedure and the patient is then to the recovery area for check out. They can then spend the remainder of the day in the leisure of their own home.

Pros

The obvious benefit of this procedure is permanent relief from the symptoms induced by your cataract. Classic symptoms of cataracts include vision that is blurred or foggy vision, washed our color perception, and severe glare among other things. Cataract removal can improve clarity of vision, increase contrast sensitivity and color perception and reduce symptoms of glare. To help understand how one procedure can accomplish all this, imagine that you’ve been looking through a dirty, stained window for years. Now imagine that window is replaced with a brand new window that is completely stain resistant. This analogy might help you visualize how much of a difference cataract extraction can make.

An added benefit to cataract extraction is treatment of refractive errors (Myopia, hyperopia, and astigmatism). The surgeon can chose a specific lens to treat whatever refractive error your eye has. As a result, many patients no longer need distance glasses after cataract removal, even if they have worn them their entire life! Some lenses even allow for distance vision and near vision. These are especially helpful for patients that wish to say goodbye to reading glasses. Please consult the Premium Lens sections for more detailed information about specialty lenses.

Cons

As with any other procedure under the sun, it is important to fully understand the risks before deciding on cataract surgery. These include infection, inflammation, and (in the worst case) loss of vision. With that said, cataract removal is one of the safest procedures in the world and most complications can be effectively treated.

Another disadvantage for younger patients requiring cataract removal is the need for reading glasses after the procedure. However, there are many solutions to this problem including Monovision and Premium IOLs, which allow patient to see clearly far away and up-close.

Cataracts

Posted on by DrVish

Fun facts

Cataracts are the leading cause of blindness across the globe.

They affect people of all races and ethnicities and occur in men and women equally.

To give you a glimpse of how universal cataracts are, here are some interesting figures:

  • In 2002, the World Health Organization estimated that cataracts cause reversible blindness in a staggering 17 million people. This number is projected to reach 40 million by year 2020!
  • In the United States, more than 20 million Americans over the age of 40 are affected by cataracts.

How Do I Know If I Have Cataracts?

Classic symptoms of cataract include vision that is blurry, cloudy, or foggy. You may also notice a film over your line of sight that prevents clear vision. Colors are often less vivid and may appear washed out. One of the most debilitating aspects of early cataract formation is its effect on driving. Cataracts can cause severe glare from oncoming headlights which can make night driving very dangerous. They can also cause a refractive shift (nearsightedness or farsightedness) which makes viewing signs, traffic, and turns in the road more difficult.

Cataracts typically start out very small and often progress slowly. Partly because of this, they often go undiagnosed for years until they begin to impair functions of daily living.

What Can I Do About My Cataracts?

Removal or “extraction” of the cataract is the only effective treatment. Luckily, advances in surgical equipment and technique have rendered cataract extraction one of the safest procedures in the world today. Ultrasound and laser technology have been mastered to painlessly and effectively remove cataracts and restore patient’s vision. Many patients are able to achieve 20/20 vision or better after cataract surgery and resume the activities they have neglected because of worsening vision. Facilitating this improvement in quality of life is one of the most gratifying aspects of the procedure and my job in general.

Cataract surgery is an outpatient procedure, which means that there are no overnight stays in a hospital. Patients arrive the morning of the procedure and go home afterwards to spend the rest of the day in the leisure of their own home.

For more on the details of cataract surgery and different options, please visit the section on Cataract Removal. This section provides some basic information on technique and different options for the procedure.