Thank your for taking the time to review Pacific Cataract and Laser Institute’s quarterly electronic newsletter. In this issue, Dr. Bob Ford discusses cataract surgery options and the thinking behind our surgical preferences. Please be assured that in everything we do, the quality of your patients’ care is our highest priority.

Ben Stoebner, OD
Editor

It is hard to believe that PCLI has been in operation for 18 years. Time sure flies! But what a delight it has been to work in close cooperation with the optometric community. It really is a privilege to be invited to provide care for your patients. Our entire team thoroughly enjoys the opportunity to be at your service.

Over the years, innovation and change in the realm of surgery have been invigorating. Yet often, to insure that referred patients receive the kind of care we would want for ourselves, we find ourselves taking a road less traveled.

On a regular basis, our surgeons get together to discuss the pros and cons of advances in techniques and technology. We evaluate all sorts of variables and are in constant discussion amongst ourselves as to what we believe is best for patients. It affords a wonderful opportunity to gain input from 6 colleagues who each have a high volume of surgical cases to draw from.

Having personally performed more than 30,000 cataract surgeries over the last twenty years, I very much enjoy observing and participating in the continuing evolution of the procedure. Subjects of specific interest have been—the type of anesthesia, the type and location of incision, and the style and material of lens implants. Following are some of my thoughts on these options.

Anesthesia
Anesthesia can be done with various combinations of topical, systemic and injection methods—each with pros and cons. I have eagerly switched to topical anesthesia at multiple points in my career. However, each time I have concluded that even though it works well for the majority of patients, approximately one in twenty is so uncomfortable that it is a bad experience for them and the surgeon. In my opinion the only way to provide topical anesthesia on a large scale is to combine it with IV sedation. Yet when we weigh the disadvantages of starting IVs on everyone and the added risk of systemic cardiovascular complications, we conclude that retrobulbar injection is a better alternative—and more closely fits the low-stress atmosphere and calming experience patients enjoy. We are able to perform this injection in such a way that it minimizes discomfort. However, even though retrobulbar injection is our preference, exceptions can always be made. If a particular referring doctor or patient has a special need or desire for topical anesthesia, we are always happy to comply.

Incisions
The configuration and placement of the cataract surgery incision is another interesting subject. The allure of bloodless surgery beckoned me to a trial of clear corneal incisions when foldable lens implants first became available more than ten years ago. I loved the way the eyes looked so white one day post-op and found the procedure to be quicker and simpler to do. If the joy of surgery was the only consideration, I would do most cases this way. However, we have discovered higher incidences of induced astigmatism and patient discomfort.

Published studies also indicate a higher rate of endophthalmitis, presumably due to the fact that the incision is exposed rather than being covered by conjunctiva. Our conclusion is that it is best to avoid making incisions in the cornea whenever possible—except in glaucoma cases where the conjunctiva needs to be left undisturbed. The scleral tunnel incision we use instead is also required for PMMA (non-foldable) lens implants.

While this incision is more difficult to make and leaves the eye a little more red the first few days, the wound is actually more comfortable and in the long run heals better than a clear corneal incision.

Lens Implants
A wide selection of intraocular lens types and materials gives us lots of choices these days.

• PMMA (non-foldable) is the gold standard, and many doctors whose patients we treat have come to appreciate its superior optical qualities and reduced reflections and glare. For this and other reasons, after trying nearly every available material over the years, we keep returning to PMMA as our first choice of lens material.
• Silicone (foldable) lenses were developed to be inserted through a small clear corneal incision but have been associated with a higher incidence of inflammation—both in published studies and in our own experience. We have noticed this even with newer generation silicone materials.
• Acrylic (foldable) is an excellent, relatively new lens material that may be associated with decreased incidence of posterior capsular opacification compared to PMMA. We are in the process of comparing our results of a large series of acrylic vs. PMMA lens cases to draw a conclusion on this issue.

In a related matter, we are gathering data on YAG capsulotomy complications. If the incidence of post-YAG complications justifies concerted effort to reduce this procedure, and acrylic foldable lenses prove to be helpful, we may use them more uniformly. However, we would still prefer a scleral tunnel incision. One interesting possibility that may arise is a “mini scleral tunnel” approach where a folded acrylic lens is inserted through a 3 mm incision in the limbus with an extremely small conjunctival flap. This might produce the best of both worlds resulting in an essentially white eye one day post-op, but without the disadvantages of a clear cornea incision.

Your Input
Although our current preference is to use retrobulbar anesthesia with scleral tunnel incisions and non-foldable PMMA lens implants, we are here to serve you. We are comfortable providing all of the options discussed, so please let us know if you would like us to make changes for you or a specific patient. We always factor your wishes into our overall decisions and will make exceptions as you request them.

On behalf of our entire team, thank you for allowing us to help you provide first-quality care to your patients.

Bob Ford, MD

Staff Profile

Jayne Bailey plays a key role in our Professional Relations department. Over 900 ODs throughout the Northwest regularly use PCLI education brochures, booklets and videos in their practices. As orders roll into our Chehalis office via fax, mail, phone and email, Jayne is the one who cheerfully takes them all.  Every day she carefully packages stacks of boxes for shipping—often including hand-written notes to doctors or staff.

Jayne also manages the assembly of personalized photo albums that we send to each cataract surgery patient as a keepsake of their surgery experience.  In addition, she is involved with our participation in optometric conventions throughout the Northwest.

A native of Chehalis, Jayne has worked at PCLI for 11 years.  She enjoys interacting with optometric offices and loves her job.

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