Cataracts by Rochelle Steinhaus

   Stitches. eye patches and a long road to recovery are, usually to be expected after cataract surgery. But for some patients, watching television and reading the newspaper are activities they are able to resume -- from the minute they leave the hospital.

   "I had a patient go play golf the same day," said Dr John S Kung, an Eltingville ophthalmologist.

   Although activities requiring visual attention may be dificult at best and impossible at worst after a traditional cataract operation, new technologies gaining popularity over the past two years are enablinng some patients to recover faster.

   "They are amazed that they could go home and read and watch television," said Eltingville ophthalmologist Dr David Gerstenfeld, an eye surgeon at Staten Island University Hospital, Prince's Bay.

   A faster recovery, however, is only one of the benefits resulting from the latest breakthroughs in cataract removal techniques, lens replacement, and anesthesia, which have also paved the way for surgeries involving no stitches. no patches and no needles.

   "There's faster visual recovery and no patch, so they can begin to see immediately after surgery. The goal is to restore them to normal state as fast as possible" said Dr Kung. who has performed hundreds of surgeries using the new procedure, technically known as phacoemulsification.

   Cataracts, the yellow or brown discoloration of the eye's lens located behind the iris (the colored part of the eye), result from a natural aging process, and most often affect those over age 65.

   "Since the eye's lens is similar in function to the lens of a camera. if the lens of the eye is cloudy, then so is our vision." said Dr. William C. Boozan, a Casleton Corners eye physician, and eye surgeon with Bayley Seton Hospital and St. Vincent's Medical Center. "The only way to remove cataracts is with surgery," he said.

   Cataract surgery is the most commonly performed operation in the United States, with over a million a year, according to Dr. Kung, who is also an eye surgeon at Staten Island University Hospital.

   But since the new procedures have only begun to garner popularity among doctors over the past two years, the vast majority of ophthalmologists still utilize the traditional procedure, technically known as extracapsular cataract extraction, which involves an injection of local anesthetic to the muscles behind the eye, prohibiting its movement and numbing pain. The surgeon then makes an incision into the white part of the eye, large enough to remove the lens in one whole piece, and then proceeds to replace the lens with an artificial one.

   Since the incision is large, stitches are necessary, to seal the wound, and a patch is placed upon the patient's eye to prevent it from drying out as a result of not blinking since the surrounding area is still numb from anesthesia.

   The patient can see a few days later when the patch is removed. and it generally takes up to two months to reach optimal vision.

   The new no-stitch technique, phacoemulsification, allows the cataract to be removed through a one-millimeter incision, a fraction of the size required during the extracapsular procedure, eliminating the need for stitches.

   Instead of local anesthesia. a topical anesthetic has been developed in the form of eye drops which wears off in a lot less time.

   "It takes an average of 20 minutes to wear off. You don't even need a needle now." said Dr. Kung.

   "Topical anesthesia cannot be used in the traditional cataract surgery. You can't numb the white part with eyedrops. The nerve endings that are there are not susceptible to the eyedrops." said Dr. Gerstenfeld.

   This technique. which is performed as the surgeon looks through a microscope. allows for the incision to be made into the cornea, rather than the white part of the eye, preventing any blood loss. "In the cornea there's no blood vessels," said Dr. Gerstenfeld, adding that eliminating blood loss decreases the risk for people with serious medical conditions, such as diabetes.

   The incision Itself is made in a beveled manner, allowing the eye to literally seal the wound by itself. "The cornea has natural healing properties that the white [part of the eye doesn't," said Dr. Gerstenfeld.

   According to doctors. a widely-held misconception among patients is that phacoemulsification involves laser technology. "Laser became the buzz word of the '80s and '90s. There's no such thing as laser cataract surgery," said Dr. Boozan

   To extract the yellowed lens through the tiny hole, an ultrasound probe is inserted through the incision, and generates sound waves to break up the cataract into small pieces. The other parts of the eye are shielded from the ultrasound with a protective coating.

   "The machine put in the eye emits a high-frequency sound wave, disrupts the molecules and breaks them up," said Dr. Gerstenfeld.

   After the ultrasound breaks up the cataract, the probe then vacuums the pieces out of the eye.

   Next. the surgeon must replace the lens through an incision that is much smaller than the lens. To address this problem, foldable lenses made of soft plastic have been developed to squeeze through the incision and unfold in place.

   "You begin to get vision back the day of surgery, normal vision [within two weeks of] surgery." said Dr. Gerstenfeld.

   Besides doctors and patient the new procedure is also being lauded by insurance cmpanies, since faster recovery periods and fewer complications are cost-effective. Both cataract procedures have the same billing code, according to Dr. Gerstenfeld. so there is no cost difference to patients.

   "There is no cost comparison. Insurance companies nowadays are encouraging doctors to do these procedures because they lead to fewer post-op visits, and there tend to be fewer complications. Insurance companies are happy and reimbursement is the same." said Dr. Gerstenfeld.

   But since this is a relatively new procedure, few doctors are trained to perform it. For example, local anesthetic is still used by 95 percent of ophthalmologists, according to Dr. Gestenfeld.

   "The experience of the surgeon is very important in this procedure." he said.

   "It's a very sophisticated, technically demanding operation," said Dr. Boozan.

   Even if one's doctor has undergone training with the American Academy of Ophthalmolgy to perform phacoemulsification not all patients are good candidates for the procedure.

   Patients whose pupils do not dilate properly, which comprise about 10 percent of the populalion are not eligible for this type of surgery.
People wtth cataracts in advanced stages also are not suited for the operation, since the ultrasound won't be able to break up such a thick cataract.

   But for those who are not good candidates or whose doctor of choice does not yet perform this type of surgery do not despair. The traditonal methods, which are still the most widely used, are just as effective, according Dr. Boozan

   "One is not necessarily better than the other. Advertizing about 'no stitch' techniques imply stitches are a backward technique. It's simply not true," said Dr. Boozan, who performs both types of operations regularly.

   But in terms of its immediate effects and patient comfort, doctors are very excited about the medical innovation.

   "Nationwide its becoming more and more adopted," said an enthusiastic Dr. Kung, who has performed the procedure hundreds of times and teaches it to new doctors at Columbia Presbyterian Hospital, Manhattan.

   "I found it to be amazingly beneficial to patients. The patient satisfaction is tremendously high," said Dr. Gerstenfeld who says he recommends phacoemulsification to his eligible patients. "I'm convinced of it's effacy and I'm very enthusiastic."


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