Today's Visionaries

Rhode Island is on the cutting edge of a revolution in eye surgery, says Dr. Paul E. Koch, chief medical officer of Claris Vision. It’s laser-assisted refractive cataract surgery, which builds on two previous innovations in eye surgery: the development of cataract surgery with small incisions in the 1980s, and the invention of LASIK (laser in-situ keratomileusis) surgery to improve vision in the 1990s. Designed to provide better visual outcomes and reduce the overall risk to the patient during surgery, the LenSx is an evolution of laser technology that brings an exciting possibility of a new level of precision in cataract surgery.

“We’ve taken the laser technology that gave people such wonderful vision with LASIK and modified it to assist in cataract surgery. It makes cataract surgery much more precise, with much less inflammation than ever before. I’m really excited about it,” Koch explains.

The laser technology itself has been maturing for more than ten years, regularly being adapted for new applications. It was approved for use in cataract surgery in the United States by the FDA in 2012, a long-anticipated development, and the procedure has become popular.

Claris Vision’s Saint James Surgery Center in Warwick was the first in the area to invest in the technology. Already an experienced laser surgeon, Koch just started performing the laser-assisted cataract surgery with the LenSx laser there in October.

Using the laser removes some of the challenges that traditional cataract surgery presents. Those include the need to make reproducible and accurate incisions with a microscopic scalpel, then opening the cataract and breaking it apart using high-frequency ultrasound pulses. But each ultrasound punch adds to the inflammation within the eye.

“The laser makes all the incisions with incredible precision, a perfectly circular opening every time, in a predictable diameter that is reproducible from patient to patient. Next comes the part of the operation that is the most difficult: breaking apart the cataract and removing it in tiny pieces. Instead of ultrasound, the laser dances around the cataract, breaking it into tiny pieces. That reduces the amount of ultrasound energy I have to use by more than half, and we believe that this reduces the risks of inflammation, swelling and other complications. There is less trauma to the eye and patients heal quicker,” Koch explains.

Patients who have had traditional surgery in one eye, then the laser surgery in the second, have a good basis for apples-to-apples comparison. Koch says they report good results, less inflammation and a faster recovery.

Another revolutionary aspect is that the laser-assisted cataract surgery is also used to correct vision.

“We combine the cataract removal with laser etchings to reduce the astigmatism and correct sight permanently. For people who wear bifocals or who wear reading glasses, we can also correct that permanently by using a lens implant that’s modeled on a bifocal, called a presbyopia correcting lens. These patients will have reduced dependence on glasses for driving and reading with these special implants,” Koch says.

Koch also reports advancements in LASIK surgery. LASIK software has become more sophisticated, giving the laser expanded range for treating astigmatism and farsightedness. The result is surgeons can now operate on people who would have been turned down for LASIK just five years ago. Advancements have also eliminated a previous roadblock to performing LASIK: having a cornea that was too thin.

“We now have a new range of surface ablations that don’t take away too much tissue. It’s very elegant, we essentially etch your contact lens prescription onto the surface of your eye,” Koch explains.
Those are revolutions worth looking into.

Corrective or cosmetic surgery?  

Botox, brow lifts, eyelid lifts — you might think these cosmetic procedures are just for looks, but they also address a wide array of functional vision problems, says Dr. R. Jeffrey Hofmann. He is a board certified ophthalmologist who specializes in ophthalmic plastic and reconstructive surgery, including laser and cosmetic surgery, at the Rhode Island Eye Institute.

For instance, a procedure called blepharoplasty, or eyelid correction, is a small-incision surgical procedure that corrects excessive skin and fat pockets of the upper and lower eyelids. Sometimes it’s performed for purely cosmetic reasons, but there can also be an issue of function when patients lose peripheral vision due to upper lids drooping over their eyes.

“I’ve had some patients come in after a car accident because they literally didn’t see the car coming from the side, and sure enough the lid is drooping,” he explains. A quick lid lift and they’re not only looking better, they’re seeing better.

“Another common patient complaint is tearing or discomfort in the eye. A lot of times it’s because the lower lid is lax, and if it’s not functioning properly then it affects the surface of the eye itself. So we tighten the tendon in the lower lid,” he says.

Cosmetic treatments such as Botox and other neurotoxin injectables are also very popular. Hoffman estimates he does twenty of the five-to-seven-minute procedures each week. They not only restore a more youthful appearance, but for more than half of his patients, they fill a functional role as well.

“For example, many people have a problem with spasms, twitching of the eyelids and they can’t stop it. Injectables like Botox work by relaxing the muscle.”

Other injectables, such as Restylane, act as fillers that address what patients call “bags” under their eyes. “It’s not really puffiness. It’s a loss of volume in the tear trough we all experience as we age. It used to be we’d go in there and remove fat, but that actually tends to age you even more as everyone gets more sunken in as they age. So the newest concept is to address that by injecting a filler to make the lid look a lot better. It’s very effective and has become quite popular, so much so that the number of lower lid blepharoplasties that I do has decreased because we’re doing more of the injectables instead.”

Fillers are also being used in reconstructive surgeries.
“I had a patient with a very large squamous cell carcinoma inside the corner of her eye. The tumor went quite deep so a large amount of tissue was removed, requiring a lot of skin grafts on the side of the nose right up to the corner of the eye. She was left with a little hollowing out, which was difficult to repair surgically. We filled it with Restylane so she has an even contour with no caving in.”

Another tumor patient lost her eye, requiring a prosthetic. But because proton beam therapy had destroyed surrounding tissue, it was difficult to keep it in place. Restalayne used as a filler helped support her prosthetic eye.

Hofmann treats a lot of cancers, and he’s excited about another new procedure in this field: Reconstruction of the ocular surface using amniotic membrane grafts.

“I remove a lot of tumors on the surface of the eyeball such as squamous cell carcinomas and melanomas. Reconstruction has always been problematic. We used to replace that tissue with grafts from the other eye, sometimes from the inside of your mouth, but neither one was very appealing. Amniotic membrane grafts have been very helpful. It’s very inert, it heals well, there’s no rejection and it has anti-inflammatory properties.”