A Letter To the Eye Surgeon

Dear Dr. B____,
We have known each other for perhaps twenty minutes total. Half exam and half short orientation. Three different technicians took ultrasound readings of the axial length of my eye because of conflicting results. Since the ultimate success of the surgery depends in part on the accuracy of these readings, I can only hope that the conflicting figures have not been averaged, which would of course incorporate error into the measurement.

I have looked at some of the less agreeable outcomes that some patients have reported (with other doctors). Some of them were due to unfortunate and perhaps unforeseeable complications. Others were perhaps caused by institutional, assembly-line practices.

But I kept noticing that many of these stories had a large factor in common. The patients themselves remained pretty oblivious about the details. They didn’t know what was happening and pretty much left all the details up to the doctor, just having hope and faith that everything was going to come out all right. I suppose that it is convenient for the various professionals and institutions involved, because most patients are not really well equipped to sort out many of the details, but such ignorance has to play a role in the results. I do not intend to be a party to anything going amiss here.

I did not have the opportunity to see the orientation videotape because the player was broken. I elected not to make another 140 mile roundtrip to see it. But I am not just leaving things up to fate. I am learning whatever I can even in our short time frame. Surgery is scheduled in two weeks. I will make sense of each enigma or potential problem that might arise before then, or we will reschedule if necessary.

Two things struck me about the sample implant that you showed me. It was very small in diameter, nowhere near the size of the clouded lens you are removing. This led me to wonder about the scattered unfocused light entering the eye around the smaller periphery of this lens and what effect that might have on such things as glare in night-vision after the procedure. And even though most lenses today filter the UV light that goes through them, what about the unfocused UV light that gets in around this smaller lens edge? It strikes me that scattered light could be playing a part in difficulties such as glare in night vision.

I presume that the central reason for the small size of the lens is the reduction of the size of the incision required for insertion. I am certainly in favor of that. But glare and haloes still seem to be quite a significant problem for some people and no one seems to know exactly why.

Another thing that I noticed is that there were two haptics, attached at 180 degree points of the model you showed me. This was counter-intuitive for me. From a stability standpoint, I would have thought that three haptics or even four would have been the number. I am also interested in knowing more about the interface between the haptics and the lens and how exactly the haptics anchor to the zonules and other tissues at the edge of the capsular cavity within the eye and what sort of changes occur in the tissue to accommodate the points of the haptics.
You mentioned the possibility of a secondary cataract developing after surgery which might need to be addressed later. If memory serves, you indicated a high probability that this would occur.

What we are dealing with now is a nuclear cataract of the lens itself. What we may have to deal with later would be a “posterior sub capsular “ cataract which develops frequently as a postoperative complication after the correction of the original problem, but can wind up being just as severe as the original. Do I understand that correctly?

The question occurs to me: Is there some clinically significant reason that the YAG laser procedure to correct this condition later, could not be done at the time of the original cataract surgery to prevent the problem from developing? It strikes me that you are already in the eye and removing the debris of the disintegrated lens. The debris of the laser procedure is also a consideration. But apparently the YAG lasering is usually done when there is no surgical procedure underway and therefore the resulting debris remains. Would it not be wise to do it when you are already in there slurping up the lens? This would certainly reduce the likelihood of this very common secondary cataract complication.

Another potential complication you touched upon had to do with the implant falling through a rupture in the posterior membrane and coming to rest on the retina. If memory serves, another specialist would quickly be called in to deal with this quite dangerous problem.

Indulge me for a moment while I brainstorm. Perhaps not too much can be done to prevent it but would it not make good sense if such a rupture were to occur, to prevent the lens from dropping through all the way down to the retina? It strikes me that such a falling lens must float down through a gel-like vitreous fluid until it reaches the retinal plane and comes to rest. I do not know how much time elapses, but it is not instantaneous. My guess is it takes ten seconds or more, and that the very worst spot for this fallen lens to come to rest is on the macula or on the fovea.

It also appears that the “natural” or “usual” or “conventional” or “accepted” position of the head during this operation is for the head to be pointing directly face up, placing the macula gravitationally directly under where the lens will fall if it breaks through the membrane. If there is even a short time between breaking through the membrane and the lens coming to rest, would it not be prudent to immediately reposition the patients head so that the lens would be more likely to come to rest in a peripheral area of the interior of the eyeball rather than the retinal surface?

You mentioned a brand or two and some materials which I did not write down or remember. We did not go into any detail about the actual structure of the lens, so I am going to take that up from the perspective of what would appear to have the greatest potential for success in my situation from my current perspective of limited knowledge.

If I refer to one particular brand or other, I do not mean to imply that I have “locked on” to that brand or even that it will be my preference when all facts are in. It just means that it seems from my perspective to have a lot of favorable things going for it. It is, after all, the critical component.

Another consideration is the corrective design of the intraocular lens. I am already monocular by habit and inclination, so I could easily live with it if the correction was very good at one extreme but less than perfect at the other. But lenses have improved markedly in the past few decades. I see no reason not to employ these improvements if possible. Both distant and close-up vision are important to me.

As I understand it, the choices I have are as follows. A single vision lens. A “bifocal” lens. A multi-focal lens. I am interested in a multi-focal accommodating lens.

I am interested in blue-blocking UV filtering as well.

Could you tell me more about the lenses that you currently use which meet these criteria?

As to stitches. Are they usually used in this operation? What is the usual length of the incision? If stitches are involved, are they self absorbing or do they need to be removed later?

Now as to anesthesia. I don’t recall our discussing it. It is my understanding that these operations can be done with topical anesthetic drops or with injections, which carry substantial additional risks, along with making the eyeball more fixed in position during the operation. What will be the game plan in this case?

And last, The manufacturer and the model and type of the lens in prospect may be of some interest from a financial standpoint. Some of the newer multi-focal accommodating lenses are not fully covered by insurers. Others are. I want to be sure that I am on the same page as my insurance provider before the operation.

Oh, and thank you for going out of your comfort zone on that prescription. I know I took you out of your specialty. You dealt with it and double checked what you were doing. That's one of the things I want in a doctor.

Cordially,


H.C.Benson