PGA Pro Tiger Woods, football star Troy Aikman, British racing driver Danny Watts, baseball pro Wade Boggs, Scottish snooker player, Stephen Macquire, NBA  pro Dwyane Wade, Norwegian rally driver Mads Ostberg…these are just a few of the famous sports professionals who’ve chosen to have laser eye surgery.

 Recently, a number of the US Olympic team competitors have joined the elite laser eye surgery club too, including a speed skater, bob sledder, cyclist, hockey player and a luge specialist.

 No doubt all of them would experience a real difference after the surgery, but the words of Danny Watts, a regular driver in the Le Mans 24 hour race and many other endurance events provides a real insight into his own experience. “When I was racing ( before surgery), I squinted a lot which gave me headaches over a period of time…now, the squinting is no longer, I can concentrate for longer and, above all, my lap times are a lot faster and I’m a lot safer”, he claimed.

 ”When I was back in the car (after treatment), I drove out onto the circuit and suddenly I could see all the sponsors boards, the marshals all waving their flags…it’s made a phenomenal difference to my eye sight,” said Danny.  

 While quality of vision is obviously absolutely critical for top sports stars, for many of them, the ability to avoid wearing glasses or contacts, is equally important. Whether you’re serious about sport, an amateur, or just enjoy an active lifestyle, the many advanced laser options now available are becoming an attractive alternative for people who are demanding high performance vision to enhance their abilities.

 If this sounds like a good option for you, it’s important to recognise that not everyone is suitable for laser vision correction. And, if you are a suitable candidate, it’s very important to allow the recommended time to fully recover after treatment before you start playing sport again. While your eyesight might be transformed almost immediately, it naturally takes time before you can enjoy the rough and tumble of really aggressive sports like martial arts, soccer, or rugby. So, make sure you ask your surgeon the allowable time before you can push 100% again. 

Science & Progress: Cataract Surgery in the 21st Century

Until intraocular lenses, 'coke bottle glasses' were needed to see.

It wasn’t up until the 1960s, when scientists developed a synthetic lens made of Perspex called the IOL (intraocular lens). The discovery was stumbled upon merely by chance, and is quite a fascinating story. Sir Harold Ridley, a British doctor, was on a mission to find a suitable material for a replacement lens, after being asked by one of his students as to why surgeons never replaced the extracted lens during cataract surgery. After trialling different materials, he found that all of them were being heavily rejected by the human body’s natural defence mechanisms.

He then began to pay attention to soldiers with eye injuries from shattered vehicle windshields. What he found was that  the soldier’s eyes were not rejecting the shattered perspex, hence making the material the perfect candidate for the manufacture of the very first IOL.

This became a medical milestone in the treatment of cataracts and is still one of the most common ways to have cataract surgery performed. With the help of the IOL, doctors were not only able to extract the cataract, but they now had the ability to completely replace the clouded-up layer with the plastic lens. This rendered those awful, thick-rimmed glasses obsolete, and the need for stitches was a thing of the past. In fact, since the advent of the IOL, cataract surgery has been reduced to a simple procedure that takes a professional ophthalmologist under 30 minutes to complete.

Ultrasound and Lasers

More recent technological advancements brought about the development of laser technology (femtosecond lasers, LASIK), and this has provided doctors with even more precision and accuracy in the extraction of cataracts.

Charles Kelman was directly responsible for pioneering a small-incision, cataract operation called phacoemulsification.  It works on the same premise as IOL, however the cataract is broken into tiny pieces using ultrasonic waves. This allows for a much smaller incision – reducing healing times and also patient discomfort. In the past, standard cataract surgery patients have had to spend around 10 days in the hospital, with a recovery period of up to several months.

Kelman’s discovery was an interesting one, as it was inspired by a trip to the dentist. As he was in his dentist chair having his teeth cleaned, he was intrigued by an instrument that his dentist was using. Kelman noticed a layer of mist emanating from what looked like a drill, except the tip of the instrument did not move. When applied to his teeth, it vibrated and made a high-pitched noise. Fascinated by it, he asked the doctor about the instrument – to which the doctor explained that it was an ultrasonic probe. Kelman knew immediately that this technology had the potential to revolutionize cataract surgery.

After years of extensive research, conducting phacoemulsification on cat eyes, the first patient was treated with it in 1967. Conventional doctors were astounded by the fact that Kelman was discharging his patients on the same day as the surgery and that they were fit to go to work the next day. Today, phacoemulsification is the most common and one of the safest options in ophthalmic surgery.

Overview

Cataract surgery has come a long way since its inception in India. In place of needles, butter and breast milk – today’s doctors are now equipped with intraocular lenses and advanced laser technology. Most would also be happy to know that the days of administering cocaine and blows to patients heads are long-gone. Due to the marvelous technology out there, we have seen the realm of ophthalmic surgery revolutionized – and is now as safe, quick and painless as it ever was. Providing the eye is healthy, an impressive 99% of cataract surgery patients will have a positive result with today’s professional doctors.

Butter, Breast Milk and Blunt Instruments: The Origins of Cataract Surgery

 It’s amazing how much as a society we take science and technology for granted. Given the state of medicine in the past, we are infinitely blessed to be living in an age which can grant us painless and guaranteed results. This two-part article will take you through a history of cataract surgery, from its shaky beginnings to the remarkably safe procedure that it is today.

Back to India

 The history of cataract surgery can be traced all the way back to 5th century BC in India, where they pioneered the procedure called ‘couching’.

The cataract would be dislodged into the back of the eye using a sharp object, such as a knife or needle – and was an excruciatingly painful process with poor results. Medicinal journals suggest that Indian doctors applied clarified butter and even breast milk to the patient’s eyes to speed up the recovery process.

 ”When in Rome”

 The earliest recorded mention of cataract treatment in Western medicine was found in 29AD in Ancient Rome. They were leading the way in advancements in eye care at the time, with remedies for not only cataracts, but also short-sightedness and conjunctivitis.

The Roman ophthalmic doctors would use a range of variously sized needles, which would be carefully inserted into the eye to break up the cataract into smaller particles. The sharp end of the needle would assist in the surgical process, whilst the blunt end would be used to cauterise the wound. Peculiarly, this was accompanied by administering blows to the patient’s head to assist the extraction process.

 The Birth of Modern Cataract Surgery

18th century France marked the beginning of modern cataract surgery. The Industrial Revolution brought radical developments in medicinal technology. Scientists were discovering vaccines for all sorts of deadly diseases from cholera to the plague, and various anaesthetics became available (nitrous oxide, cocaine).

The invention of hypodermic needles allowed doctors to extract and properly remove the cloudy cataract from the eye, and this formed the basis for many of the same procedures that doctors still use today. Unfortunately, the procedure still had its flaws. As the entire lens of the eye would be dislodged during the surgery, the eye would lose its ability to focus. As a result, the patient would have to wear thick and cumbersome ‘coke-bottle’ glasses.

In Hindsight

Without a shadow of a doubt, technology has vastly improved medicine and it is reassuring to know that it can only get better from here. In fact, the technology described here is still in its infancy compared to the exciting developments of the last twenty years . The next part of this article will highlight some of the more sophisticated technologies that have been developed, including the invention of highly-advanced synthetic lenses and laser technologies.

Although LASIK (Laser in Situ Keratomileusis) remains the technique of choice for the majority of refractive surgeons, PRK (Photorefractive Keratectomy) still plays an effective role in most laser practices, especially in patients with thin or borderline corneal thickness levels.  Postoperative discomfort and extended healing times have previously been hallmarks of the surgery and are seen as limitations to the procedure. Revision of surgical technique in combination with improvements in technology has improved both issues. We describe these changes and discuss where PRK is today in 2012.

PRK requires the removal of the outer layer (epithelium) prior to proceeding with the laser ablation. The preparation of the cornea has direct consequences for the patient and the postoperative result. Optimally the epithelial surface is removed completely in a smooth, consistent manner. Originally a surgical blade or brush was used to remove the outer surface. This prepared the eye adequately for laser ablation however the corneal bed was often irregular which could lead to delays in the return of the outer layer (re-epithelialization). The result may be an extended healing process which effectively prolongs the visual recovery.  The relatively harsh nature of the removal has also been shown to increase the inflammatory response of the cornea increasing the potential discomfort of the patient in the immediate postoperative period.

Recent technology has allowed the surgeon to provide for a significantly more consistent, gentle preparation of the outer surface.   These advances utilize the laser to remove precise, controlled areas of the epithelium leaving the corneal bed polished and perfectly prepared for the refractive laser ablation. This initial laser process is called PTK or Phototherapeutic Keratectomy. The improved corneal bed provides a considerably better platform for our patients allowing for potentially faster re-epithelialization in addition to less inflammation than previously. Patients are likely to see better earlier and with less overall discomfort. The precise nature of the technique is also likely to have a positive impact on the patients’ ultimate quality of vision.  

Understandably this is the preparation of choice Dr Hughes chooses for all his PRK patients in 2012. 

It may sound surprising, however a healthy, well balanced diet can help prevent the likelihood of you or your loved one developing macular degeneration.

Therefore, it’s worth considering what you eat, although it’s important to check with your doctor first to find out if the following suggestions are suitable for you, especially if you are suffering any medical conditions.

The good eye health menu 

• Try to eat fish regularly, ideally two or three times a week – the Omega-3 fatty acids are good for you.
• Eat dark green leafy vegetables and fruit everyday
• Eat a handful of nuts each week
• Try to cut down on fatty foods and oils
• Exercise regularly

 Other useful health tips

 For your eye health and a host of other very good reasons, it’s important not to smoke. Sorry smokers, but cigarettes can harm your eyesight as well as your lungs.

 Most important of all, don’t put off that eye check. There’s no substitute for routine eye examination which can detect the first signs of macular degeneration and other eye diseases.

Every year, eye institutes and vision centres around the world dedicate an entire week to raise global awareness about Glaucoma. So what is Glaucoma? It is a very serious eye condition that affects approximately 4% of the world’s population, and is the world’s second leading cause of blindness. In many African nations, it is sadly the leading cause of blindness. Many refer to it as the “sneak thief of sight”, as the onset of the disease carries no obvious symptoms – and as a result 50% of glaucoma-related cases remain undiagnosed. This means that 1 in 2 people could be gradually losing their sight without even noticing that there is anything wrong – until it is too late.

In Australia, glaucoma is an epidemic amongst our aging population, especially adults over the ages of 40. As there are no warning signs, Australians are strongly encouraged to book in an appointment regularly with their ophthalmologist for an eye check. Early diagnosis and treatment are essential to saving and restoring vision from glaucoma.

World Glaucoma Week aims to spread awareness about the importance of the early detection of glaucoma. It is predicted that the disease may affect as many as 80 million people by 2020. Thomas M. Brunner, GRF President and CEO states that “World Glaucoma Week is an opportunity for everyone to help spread the word by talking about glaucoma – either your own diagnosis or family history, or simply sharing information and encouraging eye examinations. In this way we can all help to prevent irreversible vision loss from this ‘silent thief of sight’.”

If we all helped to spread the word about the disease, we can drastically reduce the impact of glaucoma. Share it on Facebook, Tweet it, ask your nan if she’s had a check-up recently; do whatever you can to get the word out and make a difference – after all, knowing is half the battle! World Glaucoma Week 2012 ends this Saturday March 17th.

In an episode of the acclaimed series Downton Abbey, cook Mrs Patmore is having problems in the kitchen. She puts salt on a dessert instead of sugar. She burns herself regularly. All the while giving kitchen maid Daisy a difficult time.

 But Mrs Patmore has a secret – she is going blind. She has cataracts, and they are gradually taking away her sight.

These days, we take modern cataract surgery for granted – not only will cataract surgery renew the sight of the person, but leading-edge intraocular lenses will improve it.

So, as Mrs Patmore was sent to the famous Moorfield’s Eye by Lord Grantham, what would have been the approach towards cataract surgery?

The actual removal of the cloudy lens (the reason why, when untreated, cataracts can cause loss of vision) was first introduced in 1748. However, it wasn’t until the 1960s that technology made it easy not only to remove the cloudy cataract, but replace it with an intraocular lens.

 Although we don’t have records from Moorfields Hospital in 1914 (and Downton Abbey is, after all, a fictional television series), we can only make assumptions. *Mrs Patmore was most likely was given an anaesthesia (either cocaine or a nerve block called retrobulbar). Her cloudy lenses would have been removed through a wound, around 6mm (very different from today’s 2mm incision). Copious irrigation using saline or various syringes may have been used to remove the cortex. The wound would be sutured (not necessary today) and Mrs Patmore would remain at Moorfields and examined every day for any complications.  She would then be given ‘aphakic’ lenses (glasses), and told to expect a convalescing period of 6-8 weeks.

 In the episode  in whichMrs Patmore returns from Moorfields hospital with her ‘coke bottle’ glasses, she is able to do her job as before. Meanwhile, the rest of the staff are befuddled (and in awe) of a revolutionary new contraption – a telephone.

 “It’s not a toy!” Butler Carlson says, admonishing the younger staff. Little did he know that one day, it would have a thousand uses (including being a toy).

 Imagine what they would say if they knew that, one day, a laser could have been used for Mrs Patmore’s cataract surgery. But laser cataract surgery – that’s another story….

*Source: The History of Modern Cataract Surgery by Marvin L. Kwitko and Charles D Kelman

Academy Award winning actor, Judi Dench, has recently revealed that she has macular degeneration, also known as age related macular degeneration (ARMD).

 ”This condition is something that thousands and thousands of people all over the world are having to contend with.” she told Britain’s Daily Mirror.  

 ”I can’t read scripts any more because of the trouble with my eyes,” she said. “And so somebody comes in and reads them to me, like telling me a story.

“It’s usually my daughter or my agent or a friend and actually I like that, because I sit there and imagine the story in my mind.”

 Dench has wet macular degeneration in one eye, and the dry form in the other. She says she receives injections, which are used by retinal specialists to treat the wet form of ARMD.  

 The macula – a small area in the centre of the retina – is vital for reading.  Although neither wet nor dry macular degeneration is curable, injections and laser therapy can slow the progress of wet macular degeneration. At present, there is no form of treatment for dry macular degeneration, although some retinal doctors prescribe high doses of vitamins and minerals.

 Macular degeneration can be genetic – Dench’s mother lived with the condition. However, as ARMD is the leading cause of vision loss for people over the age of 60, regular eye tests are vital for everyone. Lifestyle factors such as eating leafy greens, oily fish and not smoking may slow both forms.

 As for Dame Judi, she has no plans to stop working. In fact, the sooner macular degeneration is diagnosed, the better the chances are that a person can seek appropriate treatments and, albeit with some minor changes to their lives, continue as per normal

Just like a Dame.

By Dr Michael Lawless

In 2012, 80% to 90% of corneal laser surgery is done using a LASIK technique.  Most surgeons use a femtosecond laser designed specifically to cut a flap of cornea and then using a different (excimer) laser to sculpt or change the shape of the underlying cornea, replacing the flap and improving the patient’s vision. 

 The good thing about LASIK is the accuracy, safety and speed of recovery.  Most patients work and drive the day after surgery. Some people however are not suitable for LASIK.  You need to have the right corneal thickness and the right corneal shape (anatomy).  10% to 20% of people do not meet the safety criteria and for these people the majority require surface laser (ASLA or PRK, LASEK etc…it goes under different names).  Surface laser for most ranges is just as accurate as LASIK, but it causes discomfort in the first few days and has a longer recovery time.  The discomfort can be controlled in most people, but occasionally people do get a lot more pain in the first seventy two hours than would be predicted.  Even more important is the speed of recovery.  The vision is fairly variable in the first week or two and can be quite disruptive in terms of returning to driving and work.

 Currently we use a type of bandage contact lens for 4 days and topical medication.  A lot of work is being done on two aspects to improve this.  One is impregnating a contact lens so that it can give a slow release of medication to make the procedure more comfortable. 

 More importantly, from my point of view, is an attempt by Nexis Vision.  (I’m on their Medical Advisory Board) to design a special type of contact lens which will allow good vision in the recovery period.  The contact lens would remain on for approximately one week and would only be removed once the epithelium was smooth and the vision had gone through its healing phase.  It has been tried in a small number of cases in the United States and needs much more work before it would be clinically useful, but if it can manage to speed the recovery of vision to mimic what is achievable with LASIK, it would make ASLA/PRK a much more patient friendly procedure.

 It sounds a simple idea, but is actually quite complex to design a style and type of contact lens which speeds visual recovery without causing harm, and which still allows the penetration of antibiotics and anti-inflammatory drops that are required in the recovery period.  Some bright minds are working on it and it will be very interesting to see how this progresses in the next one to two years, which is about the time line of it being available if the initial pilot studies are any indication.

 It was a pleasure to be asked to be part of the Medical Advisory Board and I am on it with many old friends and collaborators from the United States.

A key part of the technology behind laser vision correction was actually invented for etching silicone computer chips in 1970 in Russia.  The term ‘excimer’ is actually short for ‘excited dimer’ – a rather curious phrase for something that has allowed millions of people around the world to throw away their glasses.

 In fact, the excimer laser wasn’t employed for laser eye surgery until New York ophthalmologist Steven Trokel first used it in 1983. The technology was first used in Australia in 1991.

 Actually a form of ultraviolet laser, the excimer produces energy that can form temporarily-bound molecules (dimers). Called an ‘excited compound’, it gives up its excess energy by undergoing stimulated emission.

 In layman’s terms, the excimer laser is well absorbed, so, rather than burning or cutting, it simply disrupts the molecular bonds of tissue. This means that it can remove exceptionally fine layers of surface tissue.

 And so, while a femtosecond laser is responsible for creating the flap that allows a surgeon access to the surface of the cornea, the excimer laser then reshapes the surface with micron precision.

 And so, next time you hear someone say how excited they are to have been able to thrown away their glasses, remember that an ‘excited dimer’ was partially responsible for it.