The Gardener’s Challenge

April 25, 2015

In his latest blog, Mark Packer, MD, FACS, CPI, tells of a time a patient of his was left to only trust his judgment and nothing else, and why learning never ends for physicians.

Editor’s Note: Welcome to “Eye Catching: Let's Chat,” a blog series featuring contributions from members of the ophthalmic community. These blogs are an opportunity for ophthalmic bloggers to engage with readers with about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Mark Packer, MD, FACS, CPI. The views expressed in these blogs are those of their respective contributors and do not represent the views of Ophthalmology Times or UBM Advanstar.

 

 

The gardener’s challenge

A quiet, reflective woman in her mid-fifties with graying black hair, Mary was tall, with olive skin, overalls and work boots.  Her husband and brother sat to the side, listening to our conversation.

Previous blog: Sincerely, your lethargic colleague

Mary’s garden was famous in a town known for prize gardens.  She worked outside or in her greenhouse most days, pruning, planting, weeding, and thinning. 

“I can’t see the little buds anymore, or separate seeds without these,” she said, holding up a pair of fairly strong over-the-counter reading glasses.  “I have to get too close to what I’m working on to see it, and then the glasses get drops of sweat on them, and I can’t see at all.”

Mary started wearing glasses in the second grade, and got contact lenses when she was 10.  By the time she went to college, she was extremely nearsighted.  When she turned 45, she started to need reading glasses over her contacts.  Then, she tried monovision-under-correcting her non-dominant eye to leave it a little nearsighted-but she found this made her dizzy.  So she struggled along with the contacts and readers until they became so cumbersome that she decided to see me.

Next: Stepping in

 

“I love my garden,” she told me.  “I have to find a way to see.  I need to care for my flowers-it’s my favorite thing to do.  Plus, my contacts feel irritated sometimes-I think it’s allergies-and wearing my back-up glasses out there is just ridiculous.” 

Mary was worried that the deterioration in her vision was going to force her to give up her favorite activity.  For her, presbyopia and dry eye were the culprits-diseases of aging.  These degenerative changes were talismans of her mortality.

In case you missed it: Which patients deserve empathy

She had a small amount of astigmatism in addition to her nearsightedness, but her eyes were pretty healthy otherwise-a little dry on the surface, no cataracts yet.  Extremely nearsighted, her natural focal point was about two and a half inches in front of her face.

Mary had never been able to see a perfect 20/20 with her right eye.  The best she could see, even with a contact lens, was 20/30.  She had a slightly lazy eye–presumably due to refractive amblyopia.  Her left eye wasn’t quite as bad, and with correction she could read 20/20.  Her biometry measured as follows:

- 8.50 + 2.50 X 108   20/30 OD

AL 26.66

Ks 43.04 X 44.88 @ 85

- 7.00 + 1.25 X 90     20/20 OS

AL 26.35

Ks 43.60 X 45.24 @ 67

Mary asked whether there was a surgical option that might correct her vision so she wouldn’t have to wear glasses or contacts -ever.

I told her, “Refractive lens exchange is the only procedure that’s really an option for you.  Your eyes can be better than since you first got glasses.” 

“What are the chances she’ll never need glasses again?” asked her brother.

“That depends on whether we go with a multifocal or an accommodative lens.  For example, 88% of people who got the Tecnis Multifocal lens in the clinical study that won FDA approval never needed glasses for any activity.  On the other hand, many people who get an accommodative lens, the Crystalens, do wear reading glasses for fine print.  Both of these IOLs are considered to correct presbyopia, just to a different extent and in a different way.”

“Why would anyone choose a Crystalens?” her brother piped up. 

“Great question,” I admitted.  About a third of my patients decide to go with the accommodative lens because they don’t like the idea of halos around lights at night.  For them, quality of vision trumps freedom from glasses to that extent. 

Next: Crystalens experience

 

Seeing halos around lights at night is just part of the multifocal experience, and there is also a mild loss of contrast sensitivity, so that some objects just seem to fuzz out in relation to their background.  Even though night-driving simulation tests have shown that multifocal IOLs are safe, it’s still harder to see a bicyclist in the fog at dusk.    

Also, the Crystalens performs a little better than the multifocal IOLs at intermediate distance, which is roughly arm’s length.  That’s where a lot of people have their computer screen, or where someone might be doing crafts or sorting seeds.  So the Crystalens might be a better choice for a gardener.

Plus, the Crystalens does a little better in people who are very nearsighted.  These individuals have a better range of vision from near to far than people who were originally farsighted.  Mary was one of these, so I felt I could be a little more encouraging of the Crystalens in her situation.     

Her husband wanted to know, “Will she need another procedure in the future?”

“That’s always a great question,” I said.  The most common secondary procedure is the YAG laser for a cloudy or fibrotic lens capsule, which might be needed in a few months, a few years, or never.  It’s more likely with the Crystalens than with multifocals like the Tecnis and the ReSTOR, but in any case it is not a big deal.  Very safe, very quick, and very effective, the vision almost always returns to the same or better than it was before the capsule got cloudy.

“What about enhancements?”

“About 5% of the time the results of refractive lens surgery are too far off the mark, and there is enough left over nearsightedness, farsightedness, or astigmatism so that images are just too blurry.  In that case something has to be done to make up the difference-and that something is often LASIK or a piggyback IOL-a thin secondary lens we slip into the eye over the primary lens.”   

“What are the most common problems with this procedure?” Mary asked.

“Besides capsular opacification, which we talked about, and enhancements, which we also talked about, there are other complications that can occur.”

In the extremely nearsighted, the risk of retinal detachment always comes to mind.  People who are very nearsighted have a higher risk of retinal detachment than others even if they never have surgery.  The structure of their eyes is different – the eyes are actually bigger, and the retina is stretched thin and more prone to tearing.  A retinal detachment can almost always be repaired if caught early enough, and it usually isn’t subtle, so you’ll most likely know if you’re having one and you’ll get treatment in time to preserve your vision. 

Okay, I trust you not to damage my eye’

 

“What you’d like to know, of course, is how much the risk of retinal detachment increases if you have surgery.  Unfortunately, I can’t tell you precisely.  If your surgery is perfect, and your retina has no particular weak spots, then the risk may not change at all.  If there’s damage to your lens capsule during surgery, the risk could be high.”

“Okay, I trust you not to damage my eye. But which implant should I get?’

“Well, with gardening and your nearsightedness, I kind of like the Crystalens for you.”

“I also quilt in the winter when there’s nothing to do in the garden.”

“The Crystalens could work well for quilting.”

I asked Mary to show me where she held her hands when she was quilting.  Being tall, with long arms, she held her hands in her lap, easily two feet from her eyes.  This range tends to be crisp with the Crystalens.

“And for reading?”

“For reading, you’ll likely need to wear over-the-counter glasses.  Not everyone who has the Crystalens needs them, but most do.”

“How come some people need glasses and others don’t?”

“I wish I had the answer to that, because then I could predict who would do well with the Crystalens and who would not.  Unfortunately, it’s not possible to tell in advance.  I have seen, though, that people who are very nearsighted like you tend to do better with the Crystalens.

“There’s also something else you should know about the Crystalens.  It has a unique mechanism of action, bending inside the eye.  Sometimes the Crystalens can get stuck in a bent position, called a ‘Z Syndrome.’  In that case we have to use a YAG laser to open the capsule to let the Crystalens go back into its normal position.”

“What about my astigmatism?”

Mary had about a fair amount of astigmatism in her right eye-about 2.5 D.  In her left eye she had only half that-1.25 D. 

At that time, the toric Trulign IOL had not yet become available, so I told Mary that I would correct her astigmatism using Relaxing Incisions. 

“These are incisions I make in the edge of the cornea with a diamond blade.  They don’t go all the way through the cornea, but they make the curve of the cornea relax or sag along one axis, where it’s too steep.  One of the recent advances in astigmatism correction is the ability to take measurements during surgery and actually titrate the amount of correction based on the response.  The device that takes these measurements is called an aberrometer.  It improves the odds that you won’t need an enhancement about five-fold.”[1]

Next: Sailing through surgery

 

Mary sailed through surgery with no trouble at all, and her vision the first day astounded her.  She was all about how she could see leaves on trees, and find the soap in the shower.  She had uncorrected 20/30 vision in her right eye-as good as it had ever been-and uncorrected 20/20 vision in her left eye.  The near was about 20/50, and she could even read a bit without glasses. 

Everyone was smiling in the office on the first couple of days after her surgery (she had her right eye done on Wednesday and her left eye done on Thursday).  But a couple of weeks later the smiles had turned to doubt.

When Mary came back for her 2-week check up, her vision had gotten pretty blurry.  I measured her need for glasses at that point and discovered that most of her astigmatism had come back.  The relaxing incisions had, in technical terms, “regressed.”

20/80 OD

- 1.25 + 1.50 X 97     20/20

- 0.50 SEQ

20/60             OS

- 0.25 + 1.00 X 77     20/20

+ 0.25 SEQ

The fact that her best-corrected acuity in the right had actually improved to 20/20, which she had never before achieved, did not make matters any better.  Mary had tears welling up in her eyes.  “Things had been so clear,” she said.  I had to agree.  Her vision right after surgery was stellar, and now it was so-so.

Next: Rest assured

 

I knew my job was to reassure her, and I did.  I explained that she was now in the unlucky 5% who needed an enhancement procedure.  LASIK would correct her astigmatism very precisely and it wouldn’t come back.

“But I was told before I couldn’t have LASIK,” she said.

Of course, when Mary was extremely nearsighted, before her lens surgery, LASIK was not an option because correcting the full amount of that nearsightedness would be dangerous.  It would likely weaken her corneas and lead to progressive ectasia.  Now, however, the nearsightedness was gone.  Only a mild amount of astigmatism was left, and that could be corrected easily with LASIK or PRK.

It’s can be difficult to understand that a procedure once “too dangerous” for you is now “okay,” but Mary grasped the concept, fought back her tears and marched bravely out of the office.

I had asked her to come back in about a month because I wanted to be sure that her astigmatism had stabilized before doing LASIK.  In the meantime, she eked by without glasses, even though I had offered her a pair of prescription specs for free.

When she came back she had the feeling her vision had gotten worse, and she was right.  Only this time, not only did she still have the astigmatism, but also even with glasses, I couldn’t correct her vision to 20/30 and 20/20.  Something else was going on.

I examined her eyes carefully and discovered that the front of her lens capsule in each eye had shrunk around the implants.  The hazy border of each capsule was visible in her pupils.  For Mary it was like looking through wax paper.

- 0.75 + 1.50 X 95     20/40 OD

- 0.75 + 1.75 X 90     20/50 OS

Next: Betrayal

 

Although very unusual, capsular shrinkage like this is not unknown.  Other types of shrinkage can occur with the Crystalens, like the kind that causes a “Z Syndrome,” but this situation was not a “Z.”  I’d seen cases like Mary’s before, and knew what to do.  I explained to Mary that I would use the YAG laser to widen the opening in each of her capsules.

There’s always an odd moment of uncertainty when a complication has occurred that has never been mentioned before.  The problem is, it’s impossible to describe every possible complication during a discussion (and even though they are all listed on the informed consent document, it’s also impossible to remember all of them).  I discussed the common problems with Mary, but now that an uncommon problem had arisen I had to start from scratch and explain what was going on.  There’s always some head scratching and sometimes also a feeling of betrayal, as if I’ve just played a con: “But you never said this could happen!”

I was filled with tremendous compassion for Mary, who had to rely completely on my knowledge and judgment.  All my years of training and experience allowed me to understand the situation and act appropriately, but Mary did not have the benefit of all that study.  She had to trust me to know what to do.  I completely understood her anxiety and fear.  This was a situation she had not expected, and she was unprepared.

Fortunately, the treatment was straightforward and the result immediate.  I used the YAG laser to trim away the shrunken capsular edges, and her vision recovered by the next day.  Her relief was so complete, she had sort of forgotten about the left over astigmatism we still had to address.  That was nothing, because we had talked about it in advance, she knew what LASIK was, and the treatment made sense.  The frightening part – dealing with an unexpected complication she had never heard of before – was over.  It seemed like it was all going to be downhill from here.

- 0.75 + 1.25 X 92     20/20

 - 0.125 SEQ (pre YAG: Plano)

- 0.50 + 1.75 X 80     20/20

 + 0.375 SEQ (pre YAG: + 0.125)

One interesting occurrence with this procedure for capsular phimosis was the axial shift in the position of the IOL, which correlated with the shift in spherical equivalent.    

Next: Learning never ends

 

And it was.  Mary’s vision stabilized over the next couple of weeks, and she had very routine LASIK.  At the end she could see 20/25 with her right eye- better than she had ever seen in her life before-and 20/20 with her left eye, without glasses or contacts.   She could do her gardening, and quilting, without glasses, although she used over the counter readers for paperback books and the newspaper.

20/25, J 10  OD

+0.25 + 0.50 X 90 20/20

20/20, J 10  OS

Plano  20/20

 A year later everything remained the same, including best-corrected acuity of 20/20 with her right eye.  Conventional wisdom has said that a lazy eye cannot be corrected after childhood, but conventional wisdom is wrong.   One of the things we’ve learned from neuroscience is that learning never ends.  That’s true for patients-whether they adapt to multifocal IOLs or overcome a lazy eye-and it’s also true for physicians-who have to admit they are still learning, too.

 

Reference

 

[1] Packer M. Effect of intraoperative aberrometry on the rate of postoperative enhancement: retrospective study. J Cataract Refract Surg. 2010 May;36(5):747-55. doi: 10.1016/j.jcrs.2009.11.029.