When We Advise Against Surgery
by David A. Wallace MD
In the modern era, the practice of medicine has become a very complicated business. Interestingly, most practitioners can be sorted into two simple categories. Some practice medicine as a profession, embracing the spirit of the Hippocratic Oath, offering care in the best interest of their patient's well-being. This group assumes that necessary or appropriate care will generate enough revenue to support the office. Others, particularly those that are fiscally quite shrewd, practice another brand of medicine. They operate their practices first and foremost as a business, with profit motive driving most decisions and recommendations. These are basically revenue-seeking professionals who happen to have a medical degree. I submit that most people have an instinctive ability to detect the difference between these two doctor types, and when they sense they are in the presence of the latter type of professional, they are well-advised to promptly leave.
At LA Sight, while we are extremely proud of the great results we help our clients achieve, we are also mindful that surgical care is not for everyone. We offer herewith a few stories about people for whom we have not supported an interest in surgery.
Dr. Wallace
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From: Douglas P.
Sent: Wednesday, August 12, 2009
Hello Dr Wallace.
I have grade 2 ROP (that's shorthand for retinopathy of prematurity, an eye condition that afflicts some premature babies) in my right eye, causing at least -11Ds of myopia, and anisometropic amblyopia (left eye is -2.75D of myopia, and no ROP). My ophthalmologist (Dr H.) has told me that I'm not a candidate for laser surgery. I'd like to know whether I could be a candidate for a pseudophakic or phakic intraocular lens implant for my right eye. I know this won't correct the amblyopia, but my right eye provides all of my peripheral vision on that side (left eye provides all my central vision). I cannot see over my right shoulder, which causes many problems; driving reverse would be very difficult, if not impossible. Please advise on whether this procedure would serve my purposes.
Sincerely, Douglas P.
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On Aug 12, 2009 Dr. Wallace wrote:
Greetings, Douglas,
Thank you for your inquiry about vision correction care. Your history and current situation are complex, to be sure. If you are able to achieve decent (reasonably functional) vision with the right eye using a contact lens, then it would be possible to consider a phakic lens implant. However, I probably would not advise lens replacement care (pseudophakic intraocular lens, as you put it), as this does increase the future risk for retinal detachment in any eye that is highly nearsighted (and -11.00 is in that range). Obviously, all this is speculation and it’s impossible in a situation as delicately balanced and nuanced as yours without seeing you in person and doing our usual comprehensive consultation. I’d suggest that as a good next step.
I will ask Ms. Karen Mrosko, my senior vision correction coordinator, to follow up with you by phone tomorrow. She can answer any questions you may have, and help schedule a consultation at a time convenient for you.
I look forward to seeing you soon!
Regards,
David A. Wallace, M.D.
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Douglas,
See comments in bold, below. I can’t continue to offer thoughts on your situation without seeing you and examining your eyes.
>Dr. Wallace
From: Douglas P.
Sent: Wednesday, August 12, 2009 8:28 PM
My optometrist (Dr R.) implied that refractive correction is possible, but he declined to put the required strength of lens in my right eyeglass, b/c it would be very unwieldy, and cause my glasses to become slightly lopsided (or something to that effect). I do not wish to try contact lenses, as I am not very good w/ manipulating tiny transparent objects. I would strongly encourage you to try contacts first, even though you don’t love the idea. If you’re only 18, your eyes are not done growing, and your prescription may change over time. Where it’s very easy to upgrade or change a contact lens, that is not the case with an implanted phakic lens.
I am also wondering whether adding a prismatic component to the implant could reduce the amblyopia slightly by improving convergence, as the area of overlap is very slight; Not possible; no lens implants (Phakic or pseudophakic) are manufactured with prism.
I can literally look at the chair across my living room (at my far left) and my TV (currently to my near right) at the same time. This creates depth perception problems, which are compounded by my slight ataxia due to the periventricular leukomalacia caused by my 16 weeks prematurity. Perhaps this could force my brain to attempt to merge the images? Not a chance, sorry to say. Or would this just give me massive headaches and double vision? Moot point as this is not possible now, but if it were, these symptoms would be likely consequences.
Also, since a phakic IOL prevents my eye from accomodating, should I consider a Crystalens? A phakic IOL does not prevent the eye from accommodating. A lens replacement (lens implant) would eliminate natural accommodation, though. Very unwise in a young person unless there is a significant cataract that needs to be removed.
If it turns out that my right eye cannot be fully corrected, I'll still wear my eyeglasses (I need to anyway, for my left eye). They look super-cool; I don't get why people don't want to wear them. I wouldn’t argue with you on that point – it’s personal preference and a million other factors.
I suppose most of my problems in my right eye were caused by me not wearing my patch when I was two years old I would disagree. (I'm 18 now, and my vision in my right eye is stable according to Dr R.; my left eye is actually improving). One of my ophthalmologists I had during that age yelled at my Mom for me not wearing the patch; I once threw the patch (and glasses!) in the gutter, and my Mom fished them out just before the street sweeper got it! Why in your case has it happened that only your right eye has ROP, but the left is normal? That is a question worth contemplating. But it’s absurd to assert that patching at age 2 would have had much constructive benefit if there was very substantial disparity in prescription between the two eyes at that young age. I don’t think any of the problems were caused by not wearing a patch, frankly; and I don’t blame you for throwing it in the gutter. Your Mom just wants you to be normal and healthy, and probably did everything in her power to help you as much as possible. Yelling at her? Personally, I’d like to yell at the ophthalmologist who yelled at her; in my opinion he’s an insensitive moron.
I have an appointment w/ both Drs. R. and H. at the end of the month, and will print out our conversation to show them. If Dr H. agrees that a refractive lens exchange is right for me, I will make my decision on whether to have you or him perform the surgery. Please have Karen contact me between 11pm and 12pm. I know of Dr. H.; we both were residents in ophthalmology at the Doheny Eye Institute back in the ‘80s. I haven’t kept up with him but I believe him to be an excellent eye specialist and surgeon. Now that I know you are 18, I would NOT recommend refractive lens exchange or Visian ICL at this point – I would strongly encourage you to give soft contact lenses a serious try first.
Douglas, it’s clear from reading your email that you are an exceptionally bright, articulate 18-year old. You write better than most adults, and even some ophthalmologists! I appreciate that the prematurity-related consequences (PVL, ROP if you like acronyms) must be very tough for you. I understand you desire a ‘quick fix’ and hope that surgery will do that for the eye problems. I beg you to let Dr. R. try fitting you with a (very comfortable) soft contact lens in the right eye. If the contact strength is about -7.50, you will need about -2.75 additional correction in glasses (it’s not exactly additive, as correction at the spectacle plane changes when converted to the corneal plane). So the correction in glasses will be symmetric on both sides.
Thank you for your prompt reply. If you'd like my ophthalmological records to review, feel free to contact Dr H.
Funny, my grandma just had cataract surgery, and now I may be getting the same procedure, but for different reasons. Also, the only reason I heard about this procedure was by watching "Style by Jury" (the candidate was a prospective policewoman who was ineligible for Lasik) during a late night of studying. Please don’t have lens replacement surgery at your age! Bad idea unless absolutely necessary. But keep studying and burning the midnight oil! Your intellect and curiosity, combined with good problem-solving skills, will carry you very far indeed.
Regards,
Dr. Wallace
Sincerely,
Douglas P
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Dr Wallace,
I would just like to thank you for steering me away from getting as-of-yet unnecessary refractive lens surgery in your very helpful and illuminating emails. Me and my mom would both like to thank you for both informing us that the problems in my right eye could not have been prevented in any way by patching, and that a mere contact lens could restore the peripheral vision provided solely by my right eye. My mom felt vindicated that she was right after all, and the ophthalmologist I saw at age 2 did not know what she was talking about. I have taken your advice, and have scheduled a contact lens fitting during my appointment with Dr. R. Hopefully, I will finally have my peripheral visual field back in my right eye, and finally be able to see over my right shoulder! And all without resorting to expensive and somewhat risky eye surgery! And I may be able to even change my eye color from a drab, boring brown, to a striking vivid violet (unless I choose the Synergeyes hybrid lenses, which I probably will, as I need the high acuity of rigid lenses, but the comfort of soft lenses). If you would like to post a summary of my story on the website as a reason why NOT to get refractive lens exchange or a phakic IOL, that would be great! It would be very useful to your future prospective patients like me, who could be served fully by simply wearing contacts alongside their eyeglasses. My Mom would really like to speak with you over the phone, as she would like to thank you for the wonderful advice you gave me in our "mini-consult". I will be giving Dr H. your warm regards!
Sincerely,
Douglas P.
PS: Although I will definitely consider consulting you for a Visian ICL implantation once my eyes have fully matured and my prescription stabilizes, and I get enough money.
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Hi, Douglas,
I’m glad you have decided to give contact lenses a try. I think a soft lens is very likely to work well for you.
Interestingly, I have thought for a couple years that I should put up a page on our site discussing people, and conditions, for which I would not advise surgical care. Your encouragement has given me the impetus to get this done.
Thanks. Take good care and give your mom a big hug! She has every right to be very proud of you.
Dr. Wallace
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Dear Dr Wallace,
Thanks for the phone call! What did you and my Mom talk about? I understand that trying to patch me at 2 was "arcane". Patching can work to strengthen an amblyopic eye in certain (mild) cases if detected early enough in life, but when the two eyes are so different in prescription (one being -11.00 and the other being near zero prescription measurement) then patching alone is IMO a waste of time. Then again, I'm not a pediatric ophthalmologist and I'm sure there are situations where patching and other therapy may be helpful in combination. So patching is not necessarily always 'arcane' but it seemed, given your complex situation, to be inadequate at least, and obviously ineffective in reality.
I now know that the specific Visian ICL implant I require (my exact prescription is -11.25 -2.50x178, do I have with-the-rule or against-the-rule astigmatism?), the Visian Toric ICL, isn't approved in the US yet, so I wouldn't be able to get it even if you did recommend it and I could pay for it. You are correct there. The astigmatism-correcting Visian ICL (toric ICL) is not yet available in the US. What we do currently for clients with prescriptions in this range is to advise ICL for the nearsightedness correction, and then LASIK for the remaining astigmatism. This two-step approach is called "bioptics" -- if you Google that term you will see that it is a fairly widely-accepted approach among vision correction surgeons (at least among those comfortable doing both procedures).
Here's an interesting story: one time, I was debarking a 747 in India. Now, there was no jetway, but a large, steep flight of stairs from the plane to the ground. I had quite a bit of hesitation in starting my descent, and kept staying close to the rails, holding on to them. When I reached the ground, a fellow passenger ran up to me, saying "Hi! I'm an ophthalmologist from UCI, and I noticed you have an eye problem; do you need any assistance?" It was amazing he knew I had an eye problem just by watching me go down the stairs!
I have mild CP on my right side due to my PVL, which is unnoticeable to non-neurologists, and I'm wondering if this could be affecting my ciliary muscles in my right eye, causing my extreme myopia. Probably not, but very difficult if not impossible to prove. Neurologists will remind us that motor nerves in the right brain influence muscles on the left half of the body (this is referred to as contralateral -- other side -- innervation) and vice versa, whereas ciliary body innervation is 'ipsilateral' (same side). Again, very curious why the PVL and ROP affected one side of your developing nervous system so much more profoundly than the other. Have you asked any neurologist why this might have occurred, and whether they have seen this amount of right-left disparity in others?
Why would a pseudophakic IOL cause detachment of the retina in patients w/ extreme myopia; the anterior segment is no where near the posterior segment of the eye. Fabulous question. We think it's because the natural lens of the eye occupies more volume inside the eye than any current-generation artificial lens. When the natural lens is removed, even if an IOL is placed, the vitreous has slightly more space to occupy, and so expands. The vitreous expansion can then place secondary (sub-microscopic) mechanical stress on the peripheral retina. In a highly nearsighted eye, the peripheral retina is already thin, and stretched, due to enlargement of the anatomy. You are closer to high school geometry than I am so hopefully you recall that the volume of a sphere varies as the cube of the radius (sphere volume is 4/3 pi times the radius cubed, to be specific). The 'normal' eye has an axial length (diameter) of about 24.3 mm so just over 12 mm radius. An eye that is 11 diopters nearsighted will have a diameter of about 28mm or radius of 14mm. If you do the math, it works out like this:
Volume of a normal eye = 4/3 pi x (12) cubed = 7,238 cu. mm. (just over 7 cc)
Volume of a -11.00 eye = 4/3 pi x (14) cubed = 11,493 cu. mm (just over 11 cc)
So now you know why nearsighted eyes are at so much higher risk for retinal problems, and also why it's important to retain certain (seemingly pointless at the time) lessons from high school math. If a nearsighted eye, precariously balanced to begin with, has lens replacement surgery, the small volume changes between natural lens and IOL can be enough to tip it over into a state where a retinal tear, followed by detachment, can occur.
Have you ever had a patient similar to me? In your opinion, on a sclae from 1 to 10, w/ 1 being least complex, and 10 being so complex you doubt your skills as a surgeon, where would my problem rate? Yours is right up there in the 9 - point - something range by any standard, Douglas. The surgical skill is not the limiting factor here, it is more the underlying biologic situation (ROP, profound nearsightedness, retinal risks) that make your care challenging.
It would be a great testament to your skills as a refractive surgeon if when I consult you for eye surgery, you got my right eye from legally blind to 20/20; I know you've managed to accomplish that several times from your patient testimonials, but probably never in a patient with such a highly complex problem in your opinion as me. Refractive surgery can't help an eye recover vision better than it's best-corrected state with best glasses or contact lenses. So if the definition of amblyopia is that "one eye can't correct to 20/20" due to one of several causes, it's quite unrealistic to hope that any surgical procedure could achieve that goal
I'll be telling Drs H. and R. all about the excellent advice you've been giving me.
You're an excellent eye surgeon, both in your knowledge (I never knew my amblyopia was untreatable an inevitable) and in your wonderful bedside manner (you've made me and my Mom crack up laughing w/ your comments on that ophthalmologist who yelled at my Mom). I now understand why you've been voted one of LA's Best Doctors. We can't believe you're willing to do so much for someone who isn't even your patient!
Doug
Amblyopia is not in all cases untreatable and inevitable. Your case is very dramatic due to the fact that one eye has stage 2 ROP and is -11.0 nearsighted; while the other eye has no ROP and is not nearsighted at all. Other more mild cases or causes of amblypia can be treated and amblyopia (if detected and treated appropriately) in those cases is not inevitable. The art here is in appreciating the subtleties and being able to tease out the differences, to know who can be helped (by patching, for instance, or optical correction, or eye exercises, or other surgical care) and who cannot be so helped.
Please allow this to be our final email exchange. While I enjoy the back-and-forth, it does take a lot of time and I must attend to my own patients, and my own practice. Additionally, I do not wish to undermine your relationship with Drs. H. or R. in any way. I trust you (and your Mom) recognize that I have donated a lot of time to your thirst for answers. In the process I think you have learned a lot and have been dissuaded from contemplating any surgical type of vision correction in the imminent future. I hope I have also helped you learn much about the underlying ocular conditions and have in some small way made up for certain care you received many years ago that seems in retrospect both inadequate and stressful for you and your Mom.
Dr. Wallace
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On September 3, 2009, Douglas wrote:
Dear Dr Wallace,
Dr R. just fit me with my trial contact lens. The improvement is amazing; I went from 20/400 to 20/40, a major improvement (can you tell me how many lines I've gained?) I can read so many things in my right eye that I never could before! And Dr R. says I've passed the DMV test now! Thank you so much! This would've never happened without your advice! I now definitely plan on consulting you for a Visian Toric ICL in my right eye when my eyes stop growing! God bless you and your practice,
Douglas
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Way to go, Douglas! And tell Dr. R. he has done great work for you, too! I'm thrilled to hear this good news. Take great care, wear the contact lenses responsibly, and we'll talk to you down the road a few years. As you have now learned, sometimes the best surgery to have is ... no surgery at all (at least for the mean time) !
Kind regards,
Dr. Wallace
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Sent: Wednesday, December 16, 2009
To: David Wallace MD
Subject: Is arcuate keratotomy an option to correct my astigmatism?
Dr Wallace,
Are you proficient in the technique of arcuate keratotomy for the correction of astigmatism? Or would wavefront custom Epi-LASIK/LASEK/PRK , with mitomycin C to prevent corneal haze, be the best option, as I will not risk a corneal flap coming undone if I suffer some sort of eye trauma.
My dilemma is that wavefront custom laser eye surgery will more precisely correct my severe astigmatism of -2.50, but arcuate keratotomy will most likely be cheaper, due to the fact it only involves placing curved incisions on the the corneal surface, and not a complex computer-guided laser ablation.
I guess my exam and consult will determine all of this. I have a whole list of questions to ask you on the 7th.
I'm sorry for bothering you again, it's just that I'm so excited to see whether I can stop spending $150/quarter for contacts. Drs Ryan and Hertzog have no objections, so now it's up to you to determine whether or not my right eye is a candidate for a Visian ICL. Well, it's also up to my Mom to finance this.
Mom'll be coming along (as she's my primary transportation); perhaps you can evaluate her for monovision, as I am getting sick of her wearing her prescription progressive driving sunglasses in the house because she doesn't want to buy a pair of distance eyeglasses. Before she had her progressive driving glasses, she'd wear TWO pairs of glasses together, one pair was for reading, the other pair was for distance.
Can't wait to see you,
Doug
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Doug,
Arcuate keratotomy is virtually obsolete; I haven’t done it for over 15 years. This is because it is far less predictable, and post-op refraction is at least 1,000 times less stable over time compared to laser methods of treating astigmatism.
Your 2.5 diopters of astigmatism is not the issue. Driving factors are your young age, high myopia, corneal thickness, corneal health (keratoconus?) and other factors (including your own inability to be financially responsible for the cost of the right kind of care, due to your youth).
A toric (astigmatism correcting) version of the Visian ICL should be available in the US early next year, so the whole discussion of corneal surgery for astigmatism correction may become moot or irrelevant anyway.
You have clearly learned how to ‘sling the lingo’ of refractive surgery as well as some who practice in this industry. However, that is not in itself a substitute for life experience and perspective. Asking bright-sounding questions with fancy terminology should not be a goal in itself; the better goal for you (in classes you take as well as exchanges with professionals and others who offer you advice of any kind) is to think past the ‘good question’ and allow yourself the option to derive the answer on your own.
Let’s answer all remaining questions at time of your consultation. Until then, Happy Holidays,
Dr. Wallace