Practising as I do in a practice that began fitting contact lenses in 1961, it follows that many of the forty year veterans of CL wear are now at the stage where cataracts are an issue. Of course their best option is to consider refractive cataract surgery. The question then becomes how best to stabilise their corneal topography and achieve the best possible outcomes. It’s also necessary to decide on the best option.
By definition many of these wearers are long term hard lens wearers. Very few ever want to swap to soft lenses with their added cost, hassle, potentially lesser quality vision and increased risk of infections.
Why would they?
As practically every PMMA wearer has converted to RGPs over the past few decades hypoxia is rarely an issue, however the long term affect of RGP ‘moulding’ of the cornea is. Most RGP practitioners will be well aware of how, in many cases refractive astigmatism is reduced as a result of this ‘asti-keratology’ effect. On cessation of wear we may see increasing astigmatism coming to the fore over hours, weeks or even months in some cases. Of course many of these CL veterans flatly refuse to obtain a pair of often expensive hi-index spectacles for just a few weeks. Thus the best option is to refit them into high Dk low modulus lenses. Many need astigmatic corrections. Many have high prescriptions.
For those soft lens wearers with cataracts we also need to refit any low Dk soft lenses due to oedema effects on Rx and corneal topography. Similarly high modulus si-hy lenses and in particular torics, also need refitting into low modulus high-Dk lenses to minimise any topographic effects. With soft lenses we also see other hyperkeratology and orthokeratology effects due to modulus issues, particularly in higher plus and minus powers.
Once the surgeon is satisfied that they have two stable topographies over a period of time [usually a few weeks], then they will usually terminate any CL wear for a week or two and proceed to surgery. Some people like to use a rule of thumb of one month off lenses for every decade of lens wear however if the patients have been well fitted with high Dk lenses for the past decade or more, this is probably overkill. Most of my patients are done and dusted after two or three months. A good history of refractive and topographic data help us determine how much change to expect.
As to the refractive solution targeted, we often aim for emmetropia [or as near as possible] for both eyes. Reading spectacles are then necessary, or we can consider multifocal IOLs.
In many of the cases I deal with patients choose their habitual monovision.
Most of these long term wearers developed presbyopia on the way to cataracts so are au fait with the options. Few are habitual multifocal CL wearers.
Toric IOLs are often used.
I generally work closely with a handful of specialist cataract surgeons who in general achieve amazing outcomes. I know how they work and they know how I work and this helps to enhance the experience and minimise hassle for the patient. This collegiality and interaction helps enhance outcomes. I’ve had a few myopes in the range of -13.00D to -17.00D [with and without astigmatism] who have achieved near plano results with impressive levels of vision - as have most of the rest of a wide range of refractive states. One recent case was a patient who was diagnosed as ‘amblyopic’ for as long as the records show, who now miraculously achieves near normal vision with an IOL. I assume she must have had some form of congenitally abnormal lens or possibly even lenticonus.
The one thing all these patients have in common is a smile from ear to ear. They rave about being able to see without correction, often for the first time since a young age. They love their new found visual freedom.
In many cases we prescribe post op reading or driving glasses to balance monovision and enhance visual results. For others decent sunglasses are an option, or simple reading or occupational spectacles for those who opted for distance-only IOLs.
I’ve previously written about modern cataract surgery outcomes, particularly in the hands of dedicated and passionate surgeons with a penchant for perfectionism.
These surgeons obtain excellent biometrics with the advanced instruments we have these days. Algorithms are fine tuned. Some of these programs even allow for the individual nuances of a particular surgeon to be inputted to obtain ever more perfect outcomes.
One thing I find amusing is the absolute silence and the emptiness of my Inbox when the Springboks trash the ABs. It was little like that when the Boks won the world cup in 1995 but became a deafening silence in 2007.
So-called ‘mates’ simply disappear off the radar. Some have never been heard from since. I am also owed a few bottles of wine from people who were dead keen to place a wager on the past two RWCs and numerous games in between. Funny how they only remember when they win.
The Four Seasons’ song ‘Silence is Golden’ comes to mind after a good win by the Boks against the ABs. The lyrics take on an even more comical tone when one considers the references to eyes, ‘cheap talk’, tears, and sheep.
Oh, don't it hurt deep inside,
Oh, don't it pain to see someone cry
Silence is golden, but my eyes still see
Silence is golden, golden, but my eyes still see
Talking is cheap people follow like sheep
Ha ha…
Let’s see now. The Boks have two Rugby World cup wins, are top of the IRB ratings and should take out the Tri Nations, but it ain’t over till it’s over. The Bulls also took the Super 14 this year. The trophy cabinet is almost full. The ABs have never won a World Cup with the Boks competing and Lomu never scored against the Boks.
So the record shows.
So for all the hot air and abuse I’ve had to put up with these past 16 years, one could only say that talk is cheap but money buys the whisky.
The silence was the same this year after the first Bok vs AB encounter in the Tri Nations however by the second match a few of my Kiwi mates were grudgingly prepared to admit that the ABs were simply outclassed, if not lousy. Some however have taken it so badly that they resorted to supporting the Wobblies against the Boks. It seems some people never learn as the Boks dealt to Oz clinically and effectively.
I remain hopeful that the Boks meet the ABs in the RWC final at Eden Park on Sunday October 23rd 2011. Pool play certainly makes it a possible option; provided the ABs lift their game and assuming that the Boks can stay up there for the next two years. I hope I am one of the lucky few who can be there.
A Springbok win will mean there’s absolutely no argument as to who the best team in the world really is.
Until next time, cheers.