Do you suffer from acne? Bumps on your eyelids can be a sign

21 01 2014

zitDo you suffer with zits or chronic acne on your face or elsewhere on your body?  Are you obsessed with having and maintaining clear skin?  If you don’t already know, a zit or a pimple on your skin happens when the oils in your pores are trapped, built up and harden.  Your ‘pores’ on your skin are actually called sebaceous glands and are oil producing glands that give your skin the glowing complexion.  Irregular production and secretion of these oils can be caused by dirt from your hands and makeup and lack of proper cleaning of your skin from dead tissue or built up debris.  When these glands, or pores, become obstructed the skin tissue becomes inflamed turning red swollen and sometimes painful.  This inflammation is the body’s response to local trauma.  Now this isn’t the trauma caused from a hit or a poke, but microtrauma induced by the trapped oil and debris pushing on the surrounding wall of the gland and skin.  Some people with certain skin types have a strong inflammatory response which in biology is known as the triple response (of Lewis) which consists of:

  1. Red spot: due to small capillary dilatation
  2. Flare: redness in the surrounding area due to arteriolar dilatation
  3. Wheal: due to leakage of fluid from capillaries and venules

Those with a stronger response will be more likely to have stubborn acne that has limited responses to commercial products.  These cases usually require a skin specialist (dermatologist) to treat it medically.  People with eczema, asthma, psoriasis and rosacea (to name a few) are known to have a hypersensitive triple response.

meibglandNow that you understand what causes a pimple, you should also know that those sebaceous glands found on your skin are also found in your eyelid and are slightly modified to secrete oils for the eye’s surface.  Each eyelid contains 20-40 of these glands and have a very specialized function.  These glands are called meibomian glands and react the same way the pores on your skin react to debris, dirt, bacteria and general trauma.  What’s different about this area of the body however is that your eyelid is constantly moving and wiping away environmental debris from the ocular surface.  If you are a contact lens wearer, then it is also rubbing the plastic of the contact as well causing friction on the inner eyelid.  Considering what we know about trauma and what it does to our glands, imagine that this microtrauma happens every time you blink, every time you apply make up, every time you wear a contact lens and every time your eye is exposed to environmental debris.  That is pretty much every minute of every day!   The average human blinks seven to ten thousand times a day and for those people that have a heightened inflammatory response are more susceptible to the meibomian glands becoming obstructed which can lead to an eyelid pimple otherwise known as a stye.  These styes can get very large if untreated and become chalazion or an eyelid cyst which can in some cases require surgery.  Interestingly, a stye only happens when the blockage has gotten large enough to become visible to the human eye.  The blockage usually starts long before it becomes visible externally.

Unfortunately though, these meibomian glands are few and once blocked or inflamed can quickly become dysfunctional and die off. happysad The eyelid surface is uniquely situated close to the eyelash follicles.  Naturally occurring bacteria often accumulate in high numbers in this area due to built up dead skin, makeup and environmental debris.  This surface cannot be cleaned by commercial products with the precision required without causing harm to the eye (cleanser in the eye, removal pads can abrade the cornea, etc.).  Also the inner eyelid tissue known as the wiper is too sensitive to touch or use retail cleaning agents on without causing pain and or damage.  Basically this tissue is never really cleaned and these glands are under constant burden.

Your eyelid glands are just like your skin glands and need clinical attention to keep them functional and prevent meibomian gland dysfunction which causes up to 86% of dry eye disease patients.  In many cases it is a preventable condition, but only recently has clinical periocular hygiene emerged as a new effective maintenance treatment.  Using special dyes and instruments, the eyelid surface and glands can be treated comfortably in your eye doctor’s office.   New advances in this area allow even the most hardened blockages to be melted using prescribed heat and pressure simultaneously (LipiFlow thermal pulsation) in non-surgical painless procedure.

Bumps on your eyelid are exactly the same as pimples on your face, however the consequence of not treating it or preventing it are potentially vision threatening.  If left untreated eventual gland death can occur decreasing the stability and vitality of your tearfilm.  This puts the entire surface of the eye at risk for infection, chronic inflammation and even scarring of the conjunctiva or cornea.

Experts from around the world have now recognized meibomian gland dysfunction as being perhaps the most pervasive cause of dry eye disease around the planet.  These tiny delicate pores have a huge impact on our visual health.  Talk to your eye doctor about your glands and be proactive.  Having dedicated my career to the ocular surface and spending the last 2 years specifically developing treatments in this area, my advice is:  don’t let the symptoms start!

In good health,

Dr. Richard Maharaj OD, FAAO

Cinical Director,

eyeLABS Optometry and Center for Ocular Surface Disease

www.eyelabs.ca

twitter: @eyelabsinc

info@eyelabs.ca

Advertisements




Think your eyelids are clean?….REALLY! Introducing Clinical Periocular Hygiene

16 01 2014

Beauty is in the eye of the beholder. Beauty is skin deep. It’s what’s inside that counts.   These phrases gets tossed around, yet people all over the world eyelidmascaraare investing billions into the cosmetic industry now more than ever.  Men and women paint our faces and in particular our eyes to create the smokey, butterfly lashes that magazines and TV tells us we need in order to be ‘current’.   But what is happening to the tissue underneath that paint – what happens after the smoke fades away?  I can tell you from my years of clinical experience and research that the eyes aren’t very forgiving and what you’re not seeing is the decline and deterioration of one of the most important organs in your body.  Your EYES!

So after years of piling pencil liner, mascara, shadow, concealer to and around your eyes, despite your best efforts to remove all of it from the area with cleansers and patented lotions and potions, the eyelid is unfortunately ends up carrying the burden of harboring microscopic bits of make-up debris and builds a breeding ground for bacterial growth which results in an aggressive inflammatory cascade that is so sneaky that the symptoms fail to present themselves until the disease is in full swing.  That disease is LID DISEASE – it encompasses blepharitis, meibomian gland dysfunction, lid wiper epitheliopathy and more generally dry eye disease.

When is the last time you visited your dentist or dental hygienist for a teeth cleaning?  Do you brush your teeth everyday?  This concept of oral debrishygiene is well accepted and widely known that the consequences of not cleaning your teeth can lead to gingivitis and several other oral issues.  The eyelid, both upper and lower, are complex structures that have hair follicles, 2 types of differentiated skin and several glands all that are responsible for keeping your cornea nourished, clear and comfortable;  the windshield wiper of your eye so to speak.  Yet  despite the importance of this structure in keeping your vision clear and protecting the eye from infection and damage, we plaster foreign material that is in some cases toxic to this sensitive tissue and still expect it to last a lifetime?  Well what actually happens is the eye lid skin and glands (known as meibomian glands) go through a process called keratinization and atrophy.  Basically the devitalized skin crusts and grows irregularly over the gland openings as well as within the glands themselves, eventually leading to gland death in the long term.  These glands are responsible for adding the much needed oil your tears need to prevent evaporation of the tears, buffer the friction between cornea and eyelid as well as balance inflammation at the surface of the eye.  When this surface isn’t properly cleared of debris, the keratinization process is started leading to breakdown of this gentle balance that keeps our eyes comfortable and clear.  Some studies have shown that as much as 60% of adults have incomplete eyelid closure when blinking, a process that is meant to assist proper clearance of debris and epithelium from the lid surface.

damageWashing your face and eye area is important to minimize the small particles of makeup debris that can and will transfer into the eye, however the lid margin is an area that without clinical instruments is near impossible to clear with causing damage.  In fact, without specific vital dyes, similar to the ones your dentist uses to highlight plaque on your teeth, damaged tissue is actually very difficult to see even under a microscope.  Don’t be fooled when you look at your lids under a magnifying mirror and think all the make-up is gone or if you cannot see any dead skin build up.

A new innovative area in eye care is emerging to manage this preventable problem.  Dry Eye Disease is reported in scientific literature in as much as 1 in 3 adults in North America.  The problem with that number is many cases of Dry Eye Disease can be prevented by clinical periocular hygiene.  At eyeLABS Center for Ocular Surface Disease, various techniques have been developed and adapted to clean and clear this area with clinical precision and effectiveness.  A comprehensive clinical periocular cleaning is the most effective way to keep this structure healthy and hygienic to date and is a non-surgical treatment for this surface.  As clinical director at eyeLABS, our patients have benefited from  hundreds of clinical hours spent refining our non-surgical periocular techniques as well as developing new ones making our center a first of its kind facility with specialty services in periocular hygeine and treatments.  Lid margin debridement/scaling is a technique used to clear keratinized tissue after being highlighted with specific ophthalmic dyes at the eyelid surface.  Obstructed glands can be cleared which give the oils a clear path to the tear film using various expression instruments with gentle pressure being applied.  In many cases, thermal pulsation is used if the obstruction is too hardened for routine expression to clear.  This 12-minute procedure is the only FDA approved therapy for non-surgical treatment of evaporative dry eye and eyeLABS was the first optometric center in the country to acquire this technology.  Eyelash follicles and roots are known areas where bacteria and mites (Demodex) make a home and can accumulate.  This can lead to inflammation at the eyelash base which worsens the nearby tissue inflammation and damage.  Loss of eyelashes can be a sign of bacterial or mite infestation.  Up to 80% of blepharitis patients have clinically documented Demodex infestation, depite good at home hygiene.  BlephEx is a new treatment method that allows clinical removal and cleaning of this area.

Clinical periocular hygiene is a growing area of non-surgical treatments for the eyelid and periocular region which is a proven effective means of keeping the delicate skin of the inner and outer eyelid healthy and vital to preventing lid disease and maintain good comfortable ocular health. Wear and tear to this area can and does happen without makeup application as well.  Incomplete blinking, contact lens wear, environmental debris, certain medications and health problems (diabetes, thyroid, arthritis) all increase the burden to this area.  Men are just as vulnerable as women to this problem.

Like every new area of medicine, many doctors don’t even know it exists and may prescribe artifical tears, antibiotic drops, lid scrubs or other at home warm compresses and baby shampoo however none of these at home solutions are able to clinically treat this area.  Like brushing your teeth daily (or twice daily), professional grade hygiene is required for proper oral health.  The most effective therapy is a combination of good home hygiene and regular clinical periocular hygiene.  The next time you book a facial to ‘clear your pores’, consider doing your eyes a favour and booking a comprehensive clinical cleaning for your eyes.  They’ll thank you for it!

In good health,

Dr. Richard Maharaj OD, FAAO

Cinical Director,

eyeLABS Optometry and Center for Ocular Surface Disease

www.eyelabs.ca

twitter: @eyelabsinc

info@eyelabs.ca





Counterknowledge: Is Dry Eye a Disease or a Syndrome?

5 08 2013

The answer:  IT IS A DISEASE!

Language is important and how we treat a medical ailment depends very much on what we call it.  Terminologies like disorders, syndromes and diseases get mixed up and misused and interchanged depending on the literature or even the medical professional you are speaking to.   Defining a condition correctly will change the attitude of the patient suffering from it and the doctor treating it.  Brampton-20130205-00310Dry eye is one such disease that has been misrepresented as a syndrome in many arenas but let’s take a look at the definition of a disease versus a syndrome.

Syndrome:  a collection of signs and symptoms known to frequently appear together but without a known cause.  This grouping generally characterizes a disease or disease process

Disease:  a morbid entity characterized usually by at least two of these criteria:

  1. Recognized etiologic agent (cause)
  2. Identifiable group of signs and symptoms
  3. Consistent anatomic alterations

Dry eye disease, also known as Keratoconjunctivitis Sicca, is the term used by the internationally recognized Tear Film and Ocular Surface Society (TFOS).  It has very clear and identifiable signs and symptoms, anatomical changes are both diagnostic and prognostic of the disease itself.  The cause, or etiology, of dry eye is an often debated subject but as a culmination of decades of scientific study, it is well agreed that it can be distilled into one or a combination of aqueous deficiency, lipid or oil deficiency and/or cicatricial (scarring).  It is also generally accepted that dry eye is an inflammatory disease, which is why the majority of pipeline drugs are targeting inhibition of specific inflammatory pathways.

Why is this conversation relevant?  Too often a ‘syndrome’ get’s swept under the rug or trivialized by medicine and pop culture.  We are swift to group symptoms together and call it a syndrome which may be reason enough to take this side-stepping approach.  However when a real and clearly defined condition affects over 25 million US adults and over 100 million people world wide, AND science has elicited cause and effect then it should become an imperative to give it ‘disease’ status; not to scare or induce fear, but to appropriately identify and manage the process.

The next time you meet someone that has dry eye disease (DED), don’t define that person by the disease but rather understand the impact that it has had on her/his life.  Ask them how many doctor’s have actually given it the attention it deserves.

In a survey of 100 patients at eyeLABS Center for Ocular Surface Diseases, the average number of eye physicians/doctors the patient had consulted for DED was 3 prior to seeing me.  I intend to be their last.

sidenoteSideNote: The Ocular Surface is Skin – Treat it that way

Dry Eye Disease is a skin condition, not unlike many dermatological conditions.  The lid surface, meibomian glands and corneal tissue are variations of epithelium and sebaceous glands which will age, like the dermis does.  The lengths of cosmetics, creams, lotions and potions for the skin can help to preserve our skin, but what about the eye?  The science at eyeLABS is founded in ocular surface skin preservation and sustenance.  Lid Margin Debridement (click here for related article) and clinical gland expression provides a basis for the spectrum of treatment options and maintenance procedures available at our clinic.  Contact lens wearers in particular should actively seek these types of treatments out as they are more likely to develop lid related inflammatory conditions (lid wiper epitheliopathy) that directly impact the glands, cornea and therefore dry eye disease progression.

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Inc.

www.eyelabs.ca

twitter: @eyelabsinc

rmaharaj@eyelabs.ca





eyeLABS featured on CTV: Dry Eye Clinic

19 07 2013

eyeLABS  was featured on CTV with Dr. Maharaj and fellow patients discussing the disease of dry eye and the merits of effective treatments focused on the eyelid.  LipiFlow, Lid Margin Debridement, and other therapies are found under one unique roof at eyeLABS center for ocular surface disease.  Click here or the image below to watch the CTV segment:  

CTVRMpic

Meibomian gland dysfunction is a commonly overlooked disease entity and can be inconspicuous even under microscopic examination.  Clinical expression by your optometrist or ophthalmologist is the only true way to identify blocked glands.  These glands, once blocked, will eventually atrophy or die which can lead to permanent scarring of the glands inner architecture.

The image below is a scale commonly used at eyeLABS to classify the severity of meibomian gland atrophy (Meibo-Scale).  It is important that patients and doctors intervene early enough in the disease to prevent natural progression, which is certain if left untreated.  Eye drops do little other than cover up the symptoms.  Clinical clearing of the gland is the most effective treatment and LipiFlow Thermal Pulsation is the only FDA approved therapy for MGD.

meiboscale

Dr. Maharaj has treated patients from across the country and has profoundly changed lives by offering ground breaking procedures like LipiFlow and creating new and innovative maintenance therapies like his signature Lid Debridement technique.  eyeLABS is an instruction facility for doctors in training and Dr. Maharaj has trained other LipiFlow doctors at other Toronto clinics in its use and advances in the treatment of Dry Eye Disease.

If you know someone who complains of even mild ocular discomfort with or without contacts, watery and or burning eyes then do them a favour and refer them for therapy they deserve.

eyeLABS center for ocular surface disease is a referral based clinic.  Call 905-456-9333 or Fax referrals to 905-456-9332 to book a consultation.

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Center for Ocular Surface Disease

www.eyelabs.ca

twitter: @eyelabsinc

rmaharaj@eyelabs.ca





25.8 Million US with Diabetes vs. 23 Million with Dry Eye Disease

16 05 2013

In June 2012, eyeLABS center for Ocular Surface Disease became the first optometry clinic in Canada to offer LipiFlow Thermal pulsation treatment – the only FDA approved treatment for evaporative dry eye.  eyeLABS is a unique facility because we don’t sell glasses – we manage the ocular surface of patients far and wide and we do so with an array of options that allows for a customized approach to managing a very complex disease – Dry Eye Disease.

eyeLABS year 1 clinical results:

Looking  just over 100 eyes treated using a combination of LipiFlow, lid management techniques, and medicine we have achieved a 90% rate of significant improvement in clinical signs and patient symptoms, 8% with mild to moderate improvement and 2% minimal to no change.  This was defined in our clinical study by validated patient symptom scores, gland scores, corneal staining, tear film break up time and visual acuity.  As a result we continue to educate as many physicians and patients as possible about the shift in approach of managing dry eye from exclusively cornea to the eyelids and glands.

Prevalence of DED vs. Diabetes

According to NDEP (National Diabetes Education Program) there are 25.8 million Americans living with diabetes.  According to a Marketscope 2011 Comprehensive Report on the Global Dry Eye Products, there are 23 million patients living with Dry Eye Disease.  Of course the comparison in the impact of two diseases on the body isn’t fair, but the impact on quality of life (QoL) is eerily similar.  A 2012 study examining 87 dry eye patients and 71 healthy volunteers found that vision-related QoL in dry eye patients was impaired and was correlated with anxiety and depression( Li, M Invest Ophthalmol Vis Sci. 2012 Aug 17).  Countless studies examining QoL within the diabetic subset show strong correlations to anxiety and depression due to the daily burden of medicine, monitoring and management.

Dry eye is too often dismissed by physicians as insignificant and ‘not as important’ as other ocular ailments like cataracts or glaucoma and patients have become embarrassed to mention it.  In fact, when eyeLABS Dry Eye Clinic patients were surveyed, the most common reason for not talking about dry eye with other doctor was embarrassment.  Embarrassment that their doctor wouldn’t think it was important.  Interestingly all patients reported social anxiety about the cosmetic appearance of their red eyes to colleagues, family, friends etc. and had sought out medical attention to treat the anxiety as a result.  eyepicture

The social impact of these two diseases are  far-reaching.  Given that the prevalence of the disease is near equivalent why is it that dry eye is swept under the rug?  It is possible that medical options of dry eye have been limited and expert agreement on the cause is divided has resulted in doctor’s complacency towards this growing epidemic.

Being in the position that I’m in seeing dry eye and ocular surface day in day out I can say that this condition does deserve attention and undivided attention at that.  My patients are physicians, teachers, celebrities, pilots, mothers, fathers and and they have all opened up about the anxiety that dry eye has caused them.  One might assume that those listed above are ‘professionals’ and would never leave the disease to take over their lives but many  patients have even considered suicide prior to having treatment because of how limited their lives had become.   For the first time they have had relief and I feel grateful for the opportunity to change their lives.

When one considers the impact of a disease on mental health, the mental health should be then considered a co-morbidity.  Diabetes, Dry Eye Disease and many other ailments all have the common denominator on reduction in quality of life and an increase in depressive and anxious tendencies.  Almost 50 million Americans share this common denominator between diabetes and dry eye, but those with dry eye don’t have nearly as many resources for dealing with their condition.  Considering the success I’ve had with my patients in this last year, I submit that we can do a better.

In good health,

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Inc.

www.eyelabs.ca

twitter: @eyelabsinc

rmaharaj@eyelabs.ca





Counterknowledge: “I only wear my contacts ‘once in a while’ so I usually replace them every 2 to 3 months”

20 02 2013

Do you drink milk past the expiration date?

Not likely, and if you do you’re probably not happy about it.  Contact lenses are tiny thin pieces of hydrated plastic that, like every other material in the world, are not impervious to getting dirty.  Despite pharmaceutical companies’ best efforts to create the perfect cleaning systems, even the best cleaning agent (hydrogen peroxide based systems) for both contact lens and ocular surface still doesn’t clean everything.  Protein sticks to the contact lens surface and over a period of days to weeks will denature or break down.  This denatured protein does not agree with the ocular surfaces  and can cause a host of complications that may not have immediate symptoms or signs.

17 million people in the US alone have Contact Lens Induce Dry Eye or CLIDE (Ramamoorthy P, 2008).  The peak age of contact lens wearers is in the mid-20’s and Brampton-20130205-00310

How often do you change your oil in your car?  How often do you and your eye doctor discuss  your eyes oil and how it relates to contact lens comfort and every day optical optimization?  Japan is home to the world’s highest number of LASIK surgeries performed at Shinigawa LASIK centers with over 1 million surgeries to date.  In order to optimize visual and surgical clarity each patient undergoes LipiFlow thermal pulsation, a new standard for treating ocular surface disease – specifically dry eye.  In December 2012, Shinigawa set a new standard in LASIK by treating 1000 patients with the LipiFlow system.   This precedent shouldn’t be isolated to those paying for premium refractive surgery.  The amount of money you invest in contact lenses over a lifetime is likely more then you would pay for lasik, so why does the ocular surface not matter as much?

Proper maintenance and therapies for you eyelids, cornea and contact lenses are crucial for comfortable clear vision but the wide and sometimes careless availability of contacts through online stores and big box environments have turned contacts into a commodity and with that comes this pitfall – ‘If I can shop around for the lowest price like a pack of gum then it must not be worth taking care of.  Right?’  But are your eyes a commodity that is as easily replaceable?  If you knew 10 years from now that you wouldn’t be able to tolerate your contact lenses would you do something different today?

Here’s what you can do:

1) Wear single use lenses otherwise known as daily disposables   Get rid of your case and solution and use it once and then toss it.  The healthiest contact lens is no lens at all.  The second healthiest is a daily disposable – sterile fresh lenses in the eye every day.

2) Treat your eyelids well – if you wear make-up, smoke, work in an office or use a computer for more then 4 hours a day then statistically your eyelids and blink are likely to be contributing to lid disease down the road.  Talk to your doctor about ocular surface health and options for maintaining it.  How often do you get a facial?   Your eyelids deserve the same!

3) Don’t shop downwards.  Consider your contact lenses and vision choices the way you would consider LASIK – you would make your decisions based on risk, doctor experience, equipment safety and statistical likelihoods first before looking at price.  Just because you can find them cheap online, does not mean they were created equal.

sidenote

SideNote: LipiFlow is available in Canada

LipiFlow is the only FDA approved in-office procedure that has demonstrated clinical effectiveness in treating the ocular surface, specifically meibomian gland dysfunction (MGD).  Although offerred to pre-operative patients going through lasik and cataract surgery in large refractive surgery centers, eyeLABS dry eye clinic is dedicated to the ocular surface  and is located in Brampton, Ontario.  A 12-minute non-surgical procedure has provided patients with relief of symptoms for up to 15 months as reported in clinical trials.  Making this available to everyone will make a difference to contact lens wearers and non wearers alike – Dr. Maharaj is the first optometric clinic in North America to acquire this technology.  Call 905-456-9333 to discuss your dry eye options.

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Inc.

www.eyelabs.ca

twitter: @eyelabsinc

rmaharaj@eyelabs.ca





Bladeless Cataract Surgery: “We have this ‘Laser’…”

13 02 2013

We are in the midst of a surgical evolution and many of us don’t even know it yet.  This is a ‘giant leap for mankind’ type of moment for eye surgeons globally, but more importantly for patients.  Femtosecond laser guided by optical coherence tomography is the newest innovation in modern cataract surgery.  Instead of  using a blade to create incisions, break up the lens and correct astigmatism, the femtosecond laser has leaped from being a purely refractive tool used in LASIK to a surgical sous-chef of sorts.   Currently OptiMedica Catalys (Optimedica Corp, CA, USA),  Alcon LenSx (Alcon Laboratories, Ft Worth, TX, USA),  LensAR (LensAR Inc, FL, USA) and Technolas (Technolas Perfect Vision GmbH, Germany) are the only commercially available cataract products.

Femto became popular in 2001 when it began to replace the microkeratome blade used to create the corneal flap during LASIK (Laser Assisted in-Situ Keratomileusis).  It was marketed to the masses as ‘bladeless lasik,’ winning the relief of patients fearing the blade traditionally associated with surgery.  It also became quickly adopted by many refractive surgeons due to its high repeatability and precision yielding a decrease in flap complications and an increase in visual outcomes.

Capsulorhexis 

Femtosecond cataract surgery has now emerged as a means of fragmenting the lens, creating the anterior capsulotomy and performing any corneal incisions required for the procedure including LRIs forastigmatic corneas.  Creating the capsulotomy in a highly precise and accurate manner allows for proper centration of premium toric or multifocal IOLs.  So far, several studies (Freidman,2011) have demonstrated that femto is at least as good as manual capsulorhexis and the incidence of capsular tears may in fact be lower when you factor in surgical teaching institutions.  Theoretically controlling the shape and size of the capsulotomy while minimizing complications (capsular tears) will allow the surgeon to achieve highly repeatable outcomes which greatly enhances his or her ability to fine tune the procedure to maximize visual outcomes.

Courtesy of Review of Ophthalmology

Phacofragmentation

Lens fragmentation is also improved in that the energy required to break up the lens is decreased anywhere from 50-96% (Naranjo-Tackman R, 2010 and  Edwards K,2011).  Less energy during phacofragmentation means less potential trauma during the surgery itself and therefore a lower incidence of post-surgical or peri-surgical complications.  To the after care doctor, this means a faster visual recover and less adverse events.  To the patient this means a happier healthier surgical experience.

Corneal Incisions

LRI or Limbal Relaxing Incisions are arcuate incisions made by the surgeon to correct corneal toricity.  This technique is considered a premium add-on to traditional cataract surgery and with femto this premium technique has made quite an impact.  The length, depth and angle are guided by anterior segment OCT.  This information is used in the femto-assisted astigmatic keratotomy to provide a very specific cut under the epithelium which can decrease astigmatism up to 1.5 diopters (Kymionis, 2010).

Is there a downside?  Yes.   Two.  Clinically, subconjuctival hemorrhages are reported due to the negative pressure applied to the eye during the procedure.  This typically resolves within a few weeks and doesn’t have any visual effects or pain associated.  The second, and the more obvious downside is the cost – both to the surgeon and to the patient.  With every new technology comes cost and somebody has to pay and with a half-million dollar price tag someone definitely is.  Being extremely new to the ophtalmic world, this premium will cost an average Canadian ~$3500 per eye so one needs to consider the pros and cons mentioned above.

From a clinical perspective the theoretical and real advantages to femto are currently developing but all evidence is pointing to reduced adverse events and better visual outcomes.  Patients will invariably ask – “How much better?” and there are varied statistics being reported by the various manufacturer sponsored studies most common being 60% of patients with traditional surgery achieving 20/20 while 90% with laser (Kránitz K, 2011).  However peer-reviewed scientific data is still lacking in general as to whether this is truly value added.  How will it change the landscape of next generation surgeons in training?

One could argue that the ‘hands-off’ approach to cataract surgery with femto will create a preference among younger surgeons to steer away from manual phaco.  Scleral incisions aren’t performed routinely anymore and a higher number of surgeons use clear corneal incisions (CCI) for good reason.  But as more surgeons become increasingly comfortable with laser cataract surgery and less so with manual, how effectively will complicated cases be managed where a manual intervention is required?   A natural inflation will create the demand for this technology by new surgeons which will invariably end up at cost to the patient and the added cost for 1-2% benefit has some surgeon’s hesitant to slide down this slippery slope.

There has also been some debate as to the role of optometry in this evolution.  In some high volume surgical practices, the added time of using the laser has decreased their caseloads and therefore efficiency.  The possibility of training optometrists in some US states has emerged, which would allow OD’s to perform the initial femto-guided portion of the surgery with the MD would take over for aspiration and implant positioning.  Of course significant training and mounds of legislative battles will hold this item in question for years, but think about how all changes in scope of practice began.  Regardless of the optometrist’s future role, currently it is critical to be aware of the ups and downs of femto cataract surgery and temper the marketing behind it.  Already there have been advances in this technology with real-time OCT guidance for next generation instruments.  Personally I see this as a great surgical step which needs to be managed judiciously by those providing  and managing it.  We did take an oath after all!

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Inc.

www.eyelabs.ca

twitter: @eyelabsinc

rmaharaj@eyelabs.ca