Lady from the Audience: I just wanted to ask a question…
Dr Croley: Sure…
Lady from the Audience: I went to get Lasik, I came under one and I wear contacts but I went to get Lasik a couple of years ago and they said, ‘Your cornea is too thin, so, they said, ‘We can’t implant the lens on’. Maybe this is ten years ago when we first started just implanting lenses and I don’t want to do that yet. I’m ‘waiting’ for my Cataracts. I’m just anxious to get my lenses implant. So now does it have any problem if my cornea is too thin?
Dr Croley: Alright with Lasik this is a different procedure so it has nothing to do with Cataract. When you have Lasik, you’re cutting a portion of your cornea off to make you non-nearsighted. Someone who’s nearsighted, your cornea is too round and your eyes too large, okay, so therefore, lights focus in front of your retina so you’re nearsighted so in order for the light to be focused on your retina you gotta hold something close. So we think and we do know that if we don’t leave enough of the corneal tissue thickness thereafter the laser, your cornea will start working and not have enough of that structure to stay normal.
So if you had so much nearsightedness and then compared to the thickness of your cornea, then therefore you’re not a good candidate for Lasik because you would be at risk of that happening to your cornea. Now there’s another way of getting around that because when you do Lasik, you’re making a flap on the cornea. So you’re cutting a hundred and twenty microns, that means we’re talking tiny pieces but hundred and twenty microns across your cornea. (I’ll just switch over to a different computer if I may turn that on. So I just need to switch it on. )
So you got a hundred and twenty microns so then you’ve already lost some structure by cutting through that. The old original way of doing, it wasn’t Lasik, the first thing was called PRK. So PRK was, you took the epithelial cells off, which have no real structure and then you did a laser on top so there wasn’t a cut. So you can’t have it done to people with Lasik Cataracts but we could do them without redoing the flap and do the surface the old way and you have enough plenty of tissue to do it that way.
So that could be bad, you might not have enough tissue for that either I just don’t know.
Lady from the Audience: My question is if I don’t go get my Cataracts done that won’t be a problem? Because I’d never had anything done.
Dr. Crowley: It’s not a problem.
So, but Cataract surgery, we’re not slicing through the cornea, that doesn’t really matter. Okay, so now the newest thing. This is Laser Cataract Surgery and we did just actually a few cases this morning.
So basically what is happening is, younger and younger people are having Cataract surgery because of active lifestyles, low vision or because either you wanna be doing all these things so in England now they don’t do Cataract surgery anymore. So if you live in England and you’re already 65, you’re no longer a good citizen, and not paying any taxes so you don’t get Cataract surgery over 65. If you’re under age 65 and you still can work and you’re still paying some taxes then they’ll give you the Cataract surgery because you’re still a tax-paying citizen. But stay tuned ‘coz that’s coming here in years.
So like I said everything’s changing. So now there’s lasers. The baby boomers and everyone who’s now getting towards the Cataract age were all, with your iphones, are now changing our technology, so now this another step of the technology of doing Cataract surgery.
And so what are we doing with this laser? So this femtosecond laser that we use for Cataract surgery was also being used for making the flap and lasering. That’s where it first started about 7 or 8 years ago. Before you make a flap with the machine now it’s been done with the laser. And what’s Femtosecond? That’s ten to the tenth of a second. So a lot of zeros of a second that the laser is on. So it’s multiple short little blasters, trillions and millions of a second, and that’s a femtosecond laser. And it’s extremely precise because it’s isolated just exactly where it’s aimed and it’s of extremely short duration so it doesn’t disrupt other tissues.
So there’s different kinds of lasers. Everyone thinks of a laser that it’s gonna burn something. Well, there are lasers that do that. When a company designing…that do a particular procedure, then different wavelengths of light have different properties. So a laser is a focused beam of light of one single wavelength. You choose different wavelengths that do different things. The first lasers were chosen because they would cauterize or burn something and they were at certain end of wavelengths with certain light properties.
This laser that is on this wavelength is a cold laser, so it doesn’t create any heat. It is a precise cutting machine with no heat. And so a laser is just a focused beam of light of a specific wavelength and each wavelength has different properties. Basically what we’re trying to do is, is by adding the laser to the procedure, the theory is, is we’re gonna get more consistent results and where people who wanna see well without glasses, where we’re gonna predict exactly a better result every time we do this. And so that’s where the company who’s making these lasers promoting consistency and safety in the procedure.
So the biggest part is, is these are the things that the laser will do. We’ll go over that, but it will make a corneal incision and it will do a Capsulorhexis and then it also softens the lens inside that has become a Cataract to soften it so it’s easier to get it out. So basically, this is going to be reduced by the laser and those things. The incision part is really something they’re sort of capping for most, because the incision is easy, I mean, any average surgeon can do the incision, there’s nothing special about that. Capsulorhexis is a lot more difficult to do well. And so when a resident is doing this or had to do it, the thing is, the study that I looked at, up to 20 -25 percent of the cases they messed up on training, so, if someone wanted to go to the DA and let a resident work on their eye, they’re free to do that if that’s what they want to do.
So what does this do? Basically we’re able to..our knowledge on laser and this machine but there’s also sort of like, what you would know like a CT Scan, that’s not a CT Scan that’s an OCT, but you got to understand, a CT Scan of your eye. So this, the scan you can see up here. So this is your lens inside your eye behind, here’s your iris that’s been dilated and here’s the lens. And this is the area in yellow bit, the laser says it’s gonna treat because it’s gonna stay inside of this capsule so it wouldn’t tear that capsule. This is where the corneal incision is made and it’s a three-plane incision. When you do incisions typically it must have a plane, so this is a single plane but it’s making a three-plane incision which is more water tight. So we don’t put stitches into these incisions, they’re 2.2 millimeters in size and they don’t require any sutures. And also this is centering the opening that’s made in the capsule right in the middle, so this is precise control by the laser. And this is what the machine looks like. So there’s actually two monitors. This is pretty much a controlled monitor that goes into the computer. This is what I see through the microscope and the machine, and then the laser is inside here and there’s a light pathway and then the laser goes down right there.
So this is what I see on that screen when we do the surgery. So we’re lining up all these things on your eye. This is the incision that’s made by the laser and this is 2.2 millimeters in size. There’s also a little tiny side incision that’s made as a second instrument is in the eye during the surgery and then all these different things, these are incisions for Astigmatism. So if you have some Astigmatism, like I said before, Astigmatism is your eye, the cornea is shaped more like a football than a basketball so on the steep side of the football, you can make these little incisions to let the cornea relax to make it round like a basketball if you have near-sighted Astigmatism. So these can be placed anywhere I choose to place them around the eye. So the Astigmatism is over here so I put the incisions there. So that can be moved.
So this is the cornea, so the clear part of your eye. This is a OCT of your cornea. So we’re making sure that your lens is surrounded by a capsule, that’s sort of like a cellophane or ceramic. It’s that sort of thing that’s fragile so we manually put a 5 millimeter opening by hand, most of the time I’ do it manually. We now have a machine that does it, exactly followed. So this laser, saying we’re gonna cut, we’re gonna start cutting this far below the capsule and that far above, so we cut all the way from the capsule so that’s the plan. So I make sure that everything’s within inside these two lines, same thing with the laser doing the cutting inside the lens. I make sure that it’s far enough away from the posterior capsules… and far enough away from the end of the capsule. Once this all acceptable, then that’s when the laser’s actually turned on.
And this is an electron micrograph of what the incision looks like after it’s healed. So there’s no stitches needed to heal the incision.
So this is the other thing that we’re putting a lot of emphasis on and why this is a better way to have your Cataract surgery done is Effective Lens Position. So what that means is, is that a little circle that’s made in that capsule in the front that’s 5 millimeters in size, the laser makes it identically the same every, every time. A good surgeon’s pretty good in doing it. Any other surgeon’s sort of average of doing it. And so by doing that, where the lens sits in your eye determines the result of what you see. So if you put your glasses out you don’t see well, right. So if your glasses are in the right place, when we make glasses it needs to be some millimeters from your eye for you to see right. So if that lens moves out and back, it blurs your vision. So inside the eye it seemed more magnified because this is a strong lens inside your eye so if that lens moves a hundredth of a millimeter frontwards or backwards, it changes the result of how well you see without glasses. So the theory is, is thereby having everything always the same size and everything centered perfectly then that will be consistently sitting on the same place every time. And so that’s, like I said, where they’re putting emphasis. And this is just a diagram showing that.
So consistent Capsulorhexis opening in that capsule is an important part of the operation. This is still early on so we don’t know what exactly the number’s are gonna be and to be quite frank about things, is that the doctors who’ve done the first thirties on this are being consultants to the laser man so anything that study says xyz you gotta know know who’s writing the article and what the background is. So I think what they’re saying about this is true. We just don’t know how big of effect when there’s a lot of doctors who start doing this as time goes on ‘coz they’re still very few of these lasers around.
So, also, the laser, your lens, the center part of the lens is somewhat dense, it’s not like a concrete, but it’s somewhat dense and so the laser is able to make patterns in this lens of different kinds and I get to choose what that pattern is and by the laser doing this, that means there’s less ultrasound time I’m using to remove your lens.
And so the power reduction, in one study, is fifty percent ultrasound power, we still, as what I’m saying, this laser and then poof then it goes away, it does these in different parts of the procedure but we still had to put an instrument in the eye that is an ultrasound that dissolves the lens up and aspirates it out of the eye. By using a laser prior to that, it reduces the amount of ultrasound time which can damage the cells in the eye by half.
And the other part is you can treat the Astigmatism. When you make an incision for Astigmatism by hand, it’s not gonna be as good as this laser making an exact of the size and depth as you manually do them. So it’s more consistent on correcting the Astigmatism.
So, I can probably show you just a little bit of what it looks like before we start the surgery… We don’t want people passing out.
So, this a doctor doing a procedure in Chicago. We’re gonna turn it off before it gets to the surgery. If someone wants to watch it, you stay over and I’ll be happy to play it.
So this is the machine, this is the globe device that attaches to the eye. So if you has Lasik procedure, the laser so precise we can’t have your eye moving around while it’s doing microscopic little things. So this little device is actually little suction … that it attaches to your eye so that so your eye can’t move while the laser’s doing what it does. But you can see up here that this attaches to the eye..
Lady from the Audience: Is the patient awake?
Dr Croley: Yes. You see the eye move.. You don’t really see much. You only see the lights in there. Now this is measuring the eye. So you can see here’s the eye, this is the sectioning of the light, and so now this is our visual incision, so he may change or move around, he’s centering everything. So he can even move the incision anywhere he wants to move it, and he can center where the Capsulorhexis is gonna happen. And then we’ll just watch the laser and then turn it off. So now we’re doing the scan. This is like the OCT just like the CT of the eye. This is your cornea, he’s gonna make sure this all falls within the line, that this is all within what he’s comfortable with or where he’s gonna do the chopping of the lens…
Gentleman from the Audience: You’re taking out sections of it?
Dr Croley: You’re taking the whole lens out . You’re taking out pieces and you’re emulsifying those pieces So this is gonna chop it up into pieces so you can take it out by piece because the lens is bigger the opening is 9 millimeters and your lens is ten to twelve millimeters in size you have to take it out in pieces. And an ultrasound does it. There still has to be an ultrasound that goes in to do that.
Lady from the Audience: What’s the amount of pain during those…
Dr Croley: No. So here’s the laser cutting the capsule in a circle. There’s bubbles that come from the laser. This is making the cuts in the lens and it’s gonna make the incisions. So the bubbles are the result of where the laser’s going off. You’ll see it make the lens cuts here, just a second and we’ll turn it off. So all these cuts inside the lens soften it up so the ultrasound time is less. Here’s the incision, here’s the incision. This is the primary incision and then the secondary incision. And that’s it. So we’ll turn it off as you don’t need to watch the rest of it.. unless someone wants to.
Lady from the Audience: Excuse me, then you’re operating on the other lens?
Dr Croley: Yes. So then, that’s in one room. then you get wheeled out to the regular operating room where the other equipment machines are and then actually do the removal. So an ultrasound tip, that is, because that is a 2.2 millimeter incision is then put in the eye, and the tip vibrates 45,000 times a second. It emulsifies the lens that’s already been chopped up a little bit with the laser and then there’s a tube so then there’s a machine that has ___ fluid behind the end that aspirates the lens through it and then all the lens material is removed and then the lens is put back in the same capsule that held your own lens. And so the implants, are like, you can roll them up like a pancake, so then through an injector that’s a tube, you put that in the eye, it opens up inside the capsule and then that’s done. There’s no stitches, you’re done.The next day you wake up and it’s like, ‘Okay, this is good’. So, that’s what the laser is. Yeah?
Lady from the Audience: You said that’s why it’s called ‘Fragmentation’ because you take bit by bit out?
Dr Croley: Well, it’s called Fragmentation because you cut it into pieces. The machine is actually called Phacoemulsification, so it’s emulsifying your lens with ultrasound. The laser can’t remove anything, it’s fragmenting the lens into sections, so then when we go in with the ultrasound, those pieces can be removed one at a time.
Gentleman from the Audience: When were these type of machines approved?
Dr Croley: This laser just got approved… four months ago…
Gentleman from the Audience: Sounds like it’s real new…
Dr Croley: Yeah, brand new. Four months ago there’s… There may be a hundred of them in the United States now.
Lady from the Audience: How many have you done?
Dr Croley: We just did three this morning.
Well, the surgery just went great. I can’t tell you that this is gonna make exactly the prediction of the same… We.. There’s a lot of measurements we did get into. So before you have surgery, there’s lots of equipment that examines your eye and it comes up with a lens power that all these equipment says it’s gonna give you the least amount of glasses prescription. And so then, the machines we have are very accurate but there’s still a little play, I mean, you’re not gonna know it’s gonna be exactly zero prescription, you can be one or two off of being zero, but I would say and Ronnie here is my technician and does all the surgery scheduling and she assists me in surgery… probably seventy five percent of people are 20/20 the next morning.
And when they say they had Astigmatism that they chose not to correct because, what I told you about a regular plain set of lenses covered by Medicare insurance. The Astigmatism lenses, the laser, all these other special eye things, the bifocal lenses are not covered by Medicare or insurance, so you are choosing, just like you chose the Lasik to correct your vision, you are choosing to change how you see and to be quite honest about it, this is a one time deal. You don’t go back and change your lens out so this is a one-time choice. So this is vision for the rest of your life that you’re choosing. A hearing aid, they break, you gotta replace them and that costs three to four grand and you’re changing and yes, this is a one-time thing. So when you make this decision, you wanna make sure that you get all the information that can get, and you make the best decision for you and we have equipment that measures how many aberrations you have in your vision system. We want someone with 20/20 vision and no glasses as aberrations in their visions. If we didn’t, we have 20/0 then we have unbelievable vision but everyone’s cornea, system, lens, everyone obviously, is not perfect. And so 20/20 will be considered normal but you could be super normal if all those aberrations are gone. So the machines can measure that. Yeah?
Gentleman from the Audience: So does Medicare pay for the laser part?
Dr Croley: No, so they don’t pay for that because Medicare, and you’re gonna get the true part here, because you’re not gonna get the story, but Medicare will not pay for the laser because the code for doing your Cataract surgery says ‘removing your Cataract by any means’, it doesn’t say with the laser, with this, with that, so by law I cannot charge you for doing the laser that costs 500,000 dollars. So the only thing I can charge you for, so you can have it done with the laser, is tweaking your Astigmatism and try to get you the best solution without glasses. So if you’re someone who says, ‘I want to have the least dependence on glasses and I want to get the best result I can have a chance of getting, then you can have that done because we can put the little spots in your cornea to make sure the cornea is round as we can get it and that’s what you’re paying for; you get the benefit of having a laser do that. But there’s no code for using a laser that insurance has. Yup?
Gentleman from the Audience: Does the surgeon’s correcting Astigmatism complicate this ability to have to see up close and far away with glasses?
Dr Croley: So if you have a lot of Astigmatism, then you’re probably not the best candidate for that ReStor or one Tecnis Multifocal because you’ll have a lot of difficulty getting rid of a lot of Astigmatism. So my definition of a lot of Astigmatism may be different from your definition because I have people come and say ‘I have a lot of Astigmatism’, and when we checked them there was none. So if we get told by people that ‘we got Astigmatism, we really don’t know how much you have, so someone really examines you and tells you. But yes, a lot of Astigmatism with their bifocal lenses are a problem. I have done people with a lot of Astigmatism but I’ve told them upfront, ‘this is our problem, you are not gonna see good right that time, and we’re gonna have to tweak around and do some procedures in the office to try to straighten out your Astigmatism. As long as you understand that and you’re willing to know that this is what the process is, then I have done people with a lot of Astigmatism and we gotten them happy but it’s taken sometimes two or three procedures in the office to get them.
Now in Europe, the ReStor lens comes with an Astigmatism correction in it, it’s not approved in the US but it is overseas that they have that. I don’t know how well it’s working ‘coz ReStor Lens has been around a long time and Astigmatism lenses without the bifocal have been around a pretty good while now so there must be something with the Astigmatism and the bifocal that the FDA is still not happy about ‘coz they haven’t approved it yet. Yeah?
Lady from the Audience: You said by the next day, we’d be able to get back to work and do whatever. Are there eyedrops or something?…
Dr Croley: Yes, you’re on eye drops four times a day for a week typically then a couple of times a day for a couple of weeks…Yeah?
Lady from the Audience: You said the ReStor lens isnt’ perfect. Is there something in the pipeline we can choose from over the other?
Dr Croley: There’s probably thirty lenses in the FDA studies and trials and some will make it through and some won’t. There’s another one coming out that at least the company thinks, it might be available in six months that is more like a Crystalens that moves and focuses. They’re saying they’re getting more movement than the Crystalens got so the focusing is a lot better, so theoretically, they would give you a little better distance because there’s only one power, there would be clear distance vision not the rims but the company will tell you anything because they want you to use their lens so I don’t know.
There are some other lenses that do slightly different things or similar to ReStor. They’re still doing studies ‘coz other companies want to have a product to compete against them and so, but there’s nothing I can tell you there’s gonna come out tomorrow or the next few months that’s gonna be any different or dramatically better. I haven’t heard any research that says we have the lens of the century and this is coming out, I’ve not heard of that. Finally, anybody, friends or anyone who’s doing research and I’ve done research on lenses, I mean, I’ve done studies for the FDA on new lenses and I haven’t heard anything special. There is one that’s coming out that might be a little interesting; it’s not a bifocal though, because those ridges would be removed but there is one lens that you can apply..not a cutting laser light but a light beam and change the power of the lens once it’s inside the eye. So if you’re slightly a little nearsighted or slightly a little farsighted, after surgery, it could tweak that a little for you, so that’s interesting.. but we’re still good with the equipment that we have, I don’t know how it’s supposed to be coz we’re pretty close already.
Gentleman from the Audience: So what can you do with that? Do monovision?
Dr Croley: You can do monovision ‘coz it’s just a lens. So you can do monovision. So I wouldn’t recommend monovision if you start wearing contacts that way or unhappy with them. But you can do monovision. Yup?
Lady from the Audience: How does the emulsified lens material removed?
Dr Croley: The tip is a tool. So there’s an opening in the metal so there’s a machine that has a suction device that aspirates once it’s emulsified, that aspirates it out of the eye. So the biggest thing is, is that, don’t let anybody tell you that you have to have Cataract surgery. I bet several people from this church here have been scheduled for Cataract surgery even if you don’t have any. Actually I won’t say who but one of the pastors was totally have had Cataract surgery but didn’t have Cataracts. So, it happens. And so if you’re not having any trouble with your vision, you shouldn’t be having surgery, that’s it.
Lady from the Audience: So the first step is to have an appointment…you come in and you gotta weigh whether you really need Cataracts surgery?
Dr Croley: I almost tell no one they need it, you gotta tell me, “I want it because I’m not happy with what I see.”
Lady from the Audience: What’s the difference between the lens that you have one lens for distance and one lens up close?
Dr Croley: Nothing, it’s just the strength.
Lady from the Audience: Up close? Well, two different lenses? Can anybody wear those or how do they compare to the bifocal lenses? If you have a choice, would you…
Dr Croley: If people have worn monovision with their contacts and they’re happy, there’s no problem with doing monovision with the implants. It’s the same thing. But when you’re wearing contacts it’s a strong contact in one eye and not so strong in the other, you can do the same thing with the implants, it’s the same process. And so you have to decide when you have monovision, you lose…