Vision problems are a growing concern as our population ages. But baby boomers in bifocals may be an uncommon sight one day. Eye surgeon Dr. Guy Knolle answered our questions about the cutting edge of vision correction.
Moderator: Welcome to WebMD Live, Dr. Knolle. Please tell us about this new procedure to help all of us baby boomers ditch our bifocals.
Knolle: The new procedure is not really new, it’s exactly the same procedure as cataract surgery, and we’ve been using it since the early 1970s. It has been perfected over time, and now with the modern advances in technology, the outcomes are excellent, both for the cataract patients and the refractive patients.
The difference is that when we do refractive procedures, we’re correcting vision to make patients more free from glasses and contact lenses. With cataract surgery, we’re using lens replacement to remove a cloudy lens that prevents patients from seeing clearly, even with their glasses. In both cases we’re referring to a lens replacement, and with modern advances in technology the procedure is:
- Performed with topical eye drop anesthesia
- It doesn’t take long
- It’s essentially pain free
- There are no sutures required
- No eye patch is used
This results in patients being able to take advantage of their improved vision almost immediately.
The procedure consists of removing the lens material from inside of the patient’s eye using ultrasound fragmentation and aspiration, a procedure known as phacoemulsification. This was developed by Dr. Charles Kelman in the late 60s/early 70s in New York City. Now it’s the most widely used procedure for cataract removal in this country. That’s because the operation works extremely well and is reliable. It doesn’t work just most of the time, it works well almost every time.
Cataract surgery is the most common surgical procedure performed in the United States. Coupled with this procedure, a lens replacement is accomplished by injecting a foldable silicone intraocular lens through the 3-millimeter incision that was made in the cornea to remove the original lens, whether the lens was clear or clouded from cataract formation. The new lens spontaneously unfolds within the capsular bag, which is like a Saran Wrap that’s wrapped around the original fibers that were removed.
In my opinion the key to the success of this procedure for people over the age of 40, from a refractive standpoint, is that the array intraocular lens, developed by Advanced Medical Optics, is multifocal, and when this lens is placed in the eye it provides clear vision at all distances; it provides vision at the far distance, intermediate computer range, and the reading position.
If it’s placed in both eyes, then the patient has binocular vision; in other words they can use both eyes together simultaneously, unlike the monovision that is sometimes accomplished with contact lenses on the cornea, or LASIK surgery on the cornea, where one eye is focused for the distance and one is focused for near.
To summarize, the only real difference in cataract surgery and this clear lens replacement in presbyoptic patients, is the fact that the cataract patient has a cloudy lens that prevents them from seeing clearly even with glasses, whereas the refractive patient has a clear lens and they can see well with the appropriate glasses.
Member question: How often have you performed this surgery?
Knolle: I’ve performed this surgery on cataract patients since 1972. I began treating patients with clear lenses during the past year after three years of experience with this multifocal implant. During that time, I witnessed my patients having improved vision at all distances without glasses.
Moderator: Who is a good candidate for this surgery? What factors would rule out this procedure?
Knolle: A good candidate for the procedure is:
Any cataract patient that wants to see better with both eyes together at all distances without being dependent on glasses.
Any individuals without cataracts, who want to be less dependent on glasses and contact lenses, like bifocals and trifocals and monovision contact lenses, who are over 40 years of age.
The patient should have a healthy eye and they need to understand the use of the multifocal implant, the use of the intraocular lens.
The lens consists of circles of varying power in a bull’s eye fashion. Rings one, three, and five are for distance; two and four are for near. This provides the patient with multiple areas of vision at all distances.
By comparison, the monofocal intraocular lens or implant is a fixed focal length lens. It can be set for the distance or for near or for anywhere in between, but there’s not any depth of field with this lens. It’s a similar situation to focusing a camera on someone that’s sitting 3 feet from you and then moving towards the person or away from the person; they’ll be blurred. Then you move back to the focal plane and they’ll be sharp. When you mover further out they’ll be blurred again. So there’s one plane of sharp focus.
With a multifocal lens there’s more depth of field, there are multiple areas you can move into and the object or individual is still in sharp focus. The lens acts much like the lens in a normal eye in an individual younger than 40 years of age.
There’s always a trade-off with everything after the age of 40. To enjoy the use of this lens, patients need to realize that the circles of varying power put circles around lights at night. They don’t interfere with vision, but there are circles around lights at night and there is an adaptation period that lasts for a few weeks or months, although the vision is sharp almost immediately. I’ve had some patients tell me, after one, two or three years, their circles disappeared. The circles probably disappear because of the patient’s adaptation and the brain’s ability to suppress unwanted images on the retina.
My personal testimonial is that after witnessing the benefits of this surgical procedure, combined with this array multifocal intraocular lens during the past three years in my patients, I elected last May to have these lenses implanted in my eyes. I’ve been delighted with the results. I’m able to shave without glasses, read, see my computer, drive my car, and fly my airplane, without glasses of any kind.
Before the surgery my vision was better than 20/20 with no glare disability, but to achieve that vision I had to wear trifocals, and without the trifocals my vision was 20/60 in the distance and J 16 at near. Of course, now my vision is 20/20 plus, and J 1, which is 20/20 at near without glasses. I don’t find the circles around lights at night to be troubling; they were not a problem immediately after the surgery for me, and after each surgery my vision was 20/20 the next day in each eye without glasses.
Moderator: How long does this lens last? Does it deteriorate over time?
Knolle: The lens will last much longer than the patient. We’ve been implanting these lenses for over 30 years. The lenses are not biodegradable. They will withstand the test of time.
Member question: When and where is this procedure available, and is it covered by insurance or is it considered elective surgery?
Knolle: If you go to the web site prelex.com or if you go to the AMO web site, which is arraylens.com, they will, I believe, refer you to surgeons that do these lenses and do this procedure. It’s important to go to a surgeon that’s familiar with the lens and has been using it for some time, because the power calculations, the calculations to determine the power of the intraocular lens for each eye, must be done accurately. My web site is knolleyoung.com.
The operation, the refractive surgical procedure of lens replacement, is not covered by insurance. It costs about twice as much as traditional LASIK surgery. But once you have the lens replacement you’ll never have to have cataract surgery, and it will allow an individual, as I’ve said, to have binocular vision at all distances, rather than monovision using one eye in the distance and one at near, or having both eyes together in the distance and still having to wear reading glasses.
Moderator: So if you do have this procedure for cataracts, it is not considered elective surgery?
Knolle: If the lens replacement surgery is done in the presence of a cataract that’s interfering with vision, then the fee for the surgery will be covered by insurance and/or Medicare. But again, if the procedure is being done purely for refractive purposes, so the patient can be less dependent on glasses, like trifocals or contact lenses, then it’s not covered by insurance or Medicare.
Member question: I had 8 cut RK surgery approximately 8 years ago. A follow-up surgery was recommended, but vision never stabilized enough to do this and I now wear mild corrective glasses, three levels: distance, midrange, and especially required for reading. Not trifocals with lines but Varilux. Can the surgery that eliminates need for reading glasses be done after RK?
Knolle: The short answer is yes. The only concern that I have about your statement is the variable vision. If the vision is still varying, even eight years after the original surgery while wearing glasses, then it will still vary after the lens replacement, because the problem with the variance of vision will be in the cornea, not in the lens. The lens replacement should provide you with vision at least as good as you have currently with your Varilux lenses.
Member question: I’m unable to wear contact lenses because I can’t bring myself to touch my eyes like that. Yet you say the patient is awake during the procedure. I don’t think I could handle that. Can I be put under for the procedure?
Knolle: Yes. We can put patients to sleep, and normally when I do the surgery I have an MD anesthesiologist sit with the patient and give them intravenous medication so they are psychologically comfortable. It’s very rare that we cannot accomplish the surgery without general anesthesia, but general anesthesia is always an option. It’s not like when we’re performing LASIK on the cornea and the patient has to look at the flashing red light in the laser to center the treatment area. That’s not necessary with lens replacement.
Member question: If I still have good eyesight in my mid-30s (no glasses) is that any indication of future eyesight quality, barring injury?
Knolle: It’s normal, when an individual enters the fourth decade, to gradually lose the ability to accommodate with your natural crystalline lens, the same lens inside the eye that we have been discussing with respect to lens replacement. When we reach the fourth decade we lose the ability to round up this lens and bring our focal point from the distance to the near, and the near focal point gradually recedes. Suddenly our arms are too short and we have to hold the reading material or object of regard farther and farther from our eye to see it clearly. This is absolutely normal and occurs with everyone with time.
The average age of symptomatic presbyopia is about 42 to 45 years of age. I never wore glasses until I was 45. Then when I became 55 I couldn’t see in the distance without the glasses either, so I began to wear them all the time, instead of just for reading. That’s why I had lens replacement surgery.
Moderator: Do you have any final words on this procedure, Dr. Knolle?
Knolle: I appreciate your interest in this procedure. There are a variety of refractive surgical procedures, but because of the ability of this procedure to provide binocular vision over such a great range it is becoming more and more popular with patients and surgeons.
Also, I should mention we treat astigmatism at the same time we do the lens exchange by making peripheral incisions in the clear cornea in the steep axis of the astigmatism.
Moderator: Thanks to Dr. Guy E. Knolle Jr., for sharing his expertise with us today. For more information, please explore our many articles and archived Live Events on the subject of vision health.
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