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Up Front | Jul 2003

Surgery With a Shallow Anterior Chamber

The following letter refers to the special report on New Jersey Bill A3364 that appeared in our May 2003 issue. It specifically cites material from the article entitled “Politics and Ophthalmology” by Ralph Lanciano Jr, DO, FOCOO.

Thank you for the extensive coverage of the events surrounding New Jersey Assembly Bill A3364. While it was disheartening for New Jersey ophthalmologists like myself to see the circumstances by which the bill was proposed and subsequently passed by the Consumer Affairs Committee, there is also much inspiration to be gained from the events afterward.

The leadership of the New Jersey Academy of Ophthalmology was exemplary. Not only did they provide expert testimony before the Assembly committee, they also worked hard to mobilize ophthalmologists throughout the state to fight this issue. They provided “grassroots” materials for reproduction and distribution in offices. They communicated by e-mail in a timely and responsive manner so that all NJAO members were kept well informed.

As a result, our group of six ophthalmologists generated more than 800 letters signed by patients that we distributed to Assembly members. We spent time talking to patients about the dangers of the bill. Each of us called and wrote to our Assembly representatives about the issue. And, perhaps most importantly, we continued to strongly support our PAC.

The events surrounding the rise and fall of A3364 have galvanized many young ophthalmologists such as myself to work harder to protect against infringements on our patients' right to quality eye care. It is inevitable that our patients will continue to face such threats with the battles occurring in legislatures across this country. Dr. Ralph Lanciano, Jr, said it well: “We have learned that we must be politically proactive for the sake of our profession and our patients.” We can hope eye MDs everywhere will learn from these events and devote more of their time and money to defending our patients from nonphysicians who speak out of economic self-interest.

Samuel Liu, MD, PhD
Princeton, New Jersey

I'm simply a fan of your excellent magazine. I just believe that other publications pale in comparison to Cataract & Refractive Surgery Today in terms of timing, content, layout, writing, etc. It's all good. We read it from cover to cover. Publications like CRSToday set the standards of care in our medical industry. CRSToday is a resource for our entire refractive team: technicians, refractive coordinators, and the practice development/marketing manager. Dr. Grene routinely provides an overview of current literature during our weekly team meetings. Time and again, your publication is our primary resource for news and staff education.

Honestly, I have to “fight” to get each issue away from Dr. Grene so I can make copies of articles for our team!
Julie Martin
Director of Marketing and Practice Development for
R. Bruce Grene, MD
Grene Laser Center
Wichita, Kansas
The following reader/author exchange refers to an article written by James J. Salz, MD, entitled “Clear Lensectomy for High Hyperopes” that appeared in our May 2003 issue.

Recently, Dr. Salz commented that he had not observed interlenticular opacification where one lens lies in the sulcus and the other is in the capsular bag. When I advised him of the following patient, he suggested that I make this case known.

For this 67-year-old white non–insulin-dependent woman, I chose to replace her cataracts with the piggyback system based on unpublished observations that patients have experienced pseudoaccommodation. Because it was not clear to me which combination of lenses was the safest, I elected to put a different set of lenses in each eye. To calculate the powers, I used the Holladay II formula.

The patient underwent uncomplicated, near-clear, sutureless phacoemulsification with topical anesthesia. In addition to a sub-Tenon's injection of 40 mg of Kenalog (Bristol-Myers Squibb, Lakewood, NJ) in each eye, she received (1) a 16.50-D AR40e IOL (Advanced Medical Optics, Inc., Santa Clara, CA) in the bag and a 16.00-D AR40e IOL in the sulcus of her right eye on day 1 and (2) a 16.50-D AR40e IOL in the bag and a 16.00-D CLFLXB (Advanced Medical Optics, Inc.) in the sulcus of her left eye on day 34.

One week postoperatively for the first eye (day 8), her UCVA was 20/70 OD, and her BCVA was 20/40+2. At the 2-week postoperative visit for the second eye (day 49), she saw 20/50 UCVA OS and 20/40 BCVA OS. She had a history of mild amblyopia in her left eye.

Two months after surgery (day 72), no longer taking any drops, the patient complained of increased blurred vision and glare sensitivity. Her BCVA was 20/25 OD when she exerted a lot of effort. There was obvious interlenticular opacification consisting of globular clusters. She exhibited no macular edema.

With the YAG laser set at 0.4 to 0.6 mW and a zero offset, I treated the inferior interlenticular membrane in order to create bubbles between the lens.1 As the bubbles formed, I increased the power from 1.0 to 1.2 mW and dusted the surface of the lens, thereby creating a few minor pits. The patient took frequent doses of prednisolone acetate 1% after treatment for 2 weeks.

Two weeks after the YAG procedure (day 84), she reported that her vision was much better in her right eye, but she complained of more blurring in her left eye. Her BCVA was 20/30+4 OD when she exerted much effort and 20/50 OS. In her left eye, there was a subtle, white, fibrous interlenticular opacification best seen under indirect illumination.

Several weeks later, when I attempted to remove the film in her left eye (day 111), the bubbles skittered away from the site of impact. I could not achieve separation of the lenses without significant pitting, so I abandoned further attempts.

On my last examination (day 112) of this patient, she was satisfied with her vision, corrected now to 20/20-1 OD and 20/50 OS. We have elected to monitor the opacification and not exchange the lenses.
I concur with Dr. Salz, who said, “I now avoid using piggyback lenses whenever possible.” Donald Bodé, MD, PhD
Colorado Springs, Colorado
1. Rongé LJ. Preventing problems with piggyback IOLs. EyeNet. 2002 January;21-22.

Dr. Bodé,
I would like to thank you for describing this case report, and I would encourage you to publish it in a peer-reviewed journal so it will appear in a literature search on the subject. The patient you describe could have easily been implanted with a single foldable or single-piece lens. Your decision to implant piggyback lenses was based on anecdotal evidence of “pseudoaccommodation.” Since we know that interlenticular opacification can even occur with one lens in the bag and the other in the sulcus, we have further evidence that we should avoid piggyback lenses whenever possible. n

James J. Salz, MD
Los Angeles
Correction: The following correction refers to an error in the Chief Medical Editor's page published in the June 2003 issue of Cataract & Refractive Surgery Today.

The subjective patient responses for nighttime visual function after wavefront-driven ablations by VISX, Inc. (Santa Clara, CA), Baush & Lomb Surgical, Inc. (San Dimas, CA), and Alcon Laboratories, Inc. (Fort Worth, TX), and the optimized ablations of WaveLight Laser Technologie AG (Erlangen, Germany) and Carl Zeiss Meditec Inc. (Dublin, CA) have shown sensational results in comparison with preoperative values with glasses or contact lenses. I checked my own results for high contrast acuities in roughly the same refractive error as VISX's study, except for having slightly more mean astigmatism treatment with conventional ablation LASIK (a 6.5-mm treatment zone with a blend zone to 8 mm), and I achieved 20/20 or better UCVA in 89.7% of eyes. Not bad, but the most important point of the wavefront-driven and optimized ablations are that patients perceive better nighttime visual function after undergoing customized laser vision correction. Specifically, 75% of patients in the VISX FDA clinical trial of wavefront-driven ablations preoperatively reported marked satisfaction with their nighttime vision with glasses or contact lenses. After undergoing customized LASIK, 90% of patients reported marked satisfaction with their uncorrected nighttime vision. This subjective improvement in patient satisfaction is great news!

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