Kevin Prendiville, MD, FACS
Certified, American Board of Ophthalmology
CATARACT/LENS IMPLANT SURGERY
Cataract/Lens Implant Surgery
Cataract/lens implant surgery is Dr. Prendiville’s main specialty and he has performed about 15,000 “no-needle and no stitch” cataract/lens implant surgeries. In 1997, he was chosen by Staar Surgical to be the first ophthalmologist in Arizona to implant a toric intraocular lens for the correction of astigmatism.
What Are Cataracts?
OPHTHALMOLOGY SERVICES OFFERED
CATARACT/LENS IMPLANT SURGERY
Cataract/lens implant surgery is Dr. Prendiville’s main specialty and he has performed over 15,000 “no-needle and no stitch” cataract/lens implant surgeries. In 1997, he was chosen by Staar Surgical to be the first ophthalmologist in Arizona to implant a toric intraocular lens for the correction of astigmatism.
[What are Cataracts video]
A cataract is a significant degree of opacification or cloudiness in the crystalline lens of the eye which occurs naturally as a result of aging. Also, many cataracts occur naturally at a young age and occasionally result from corticosteroid medication or trauma, etc. Cataracts can lead to cloudy or blurry vision for driving and watching tv or reading, or glare with night driving, etc. Cataract surgery is usually considered when a person experiences adverse visual effects from the cataract in the course of daily living. Occasionally, cataract/lens implant surgery is performed for refractive purposes, only. Prior to cataract surgery, we perform measurements in our office and utilize advanced intraocular lens implant calculation formulas to ensure accuracy in the selection of power of the intraocular lens to be implanted. Utilization of advanced intraocular lens implant calculation formulas are especially helpful in ascertaining the correct power of intraocular lens to be implanted in long, short, and post-refractive surgery eyes. Cataract surgery is typically performed under intravenous sedation with monitored anesthesia care and with powerful anesthetic eye drops and other agents to ensure comfort, and takes about an average 11 to 12 minutes or a little longer when combined with ORA and/or implantation of a glaucoma drainage device for pressure lowering in glaucoma patients. The incision is self-sealing and very small at 2.4 mm thus resulting in no need for stitches.
We enjoy and look forward to taking the necessary amount of time discussing the visual needs and desires of each of our cataract surgery patients and understanding their lifestyles. It is helpful for us to know your hobbies including activities such as golfing, computer use, and reading, etc, how much you drive at night, and how spectacle independent you may wish to become. We apprise each patient of the various options for refractive vision correction which is integrated into each cataract surgery. These options include, but are not limited to, excellent distance vision for each eye resulting in a requirement for reading glasses postoperatively or vice versa for near vision, various degrees of monovision including blended vision, etc, and multifocal vision (seeing both distance and near without glasses). Many of our happiest postoperative patients simply have a very small amount of near-sightedness in one or both eyes resulting in very good distance vision in each eye, ability to see the computer screen very well, along with some functional reading vision, all without glasses or premium services. We, also, advise you of how much astigmatism is present and whether or not it would require correction in order to achieve more spectacle independence, and the best method of correcting it. In many cases, excellent vision and freedom from glasses for many activities can be achieved without having to purchase any premium services whatsoever. After a thorough discussion of visual desires and expectations, and understanding whether the patient has an interest in purchasing premium services, we can make recommendations for a treatment plan that will be the most cost-effective and in the best interest of the patient.
Regarding intraocular lens implants, there are 2 broad categories: monofocal and multifocal/EDOF (extended depth of focus). Monofocal lenses include the basic or standard IOL that insurance pays for, the toric IOL that corrects astigmatism, the Light Adjustable Lens, and Eyhance. These lenses tend to provide excellent vision and the latter two provide some extended depth of focus. Multifocal/EDOF IOLs include PanOptix (trifocal), AciveFocus, Symfony, Synergy (combined multifocal and EDOF), Vivity and others, and they enable vision for both distance and near to varying degrees. But, the quality of vision may not quite as good as monofocal IOLs due to potential optical aberrations such as halos, glare, decreased contrast sensitivity, and needing more light to read. As people are different, the best lens for me may not be the best lens for you. My job is to learn and understand your goals and expectations, and then recommend what I consider are the best IOL options for you taking everything into consideration, and then the decision is made.
Our goal is to continue communicating and taking the extra steps necessary to ensure that we are providing the best and most appropriate care for each of our patients in order to achieve the best and most satisfying outcomes. As with any surgery, there are possible complications which we will apprise you of; fortunately, serious complications are rare.
Dr. Prendiville recognizes and strives for three components of highly successful cataract surgery and high patient satisfaction:
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Achieving excellent vision on the first postoperative day after cataract surgery by having crystal clear corneas. This is achieved by minimizing corneal endothelial cell trauma during surgery which tends to result in corneal edema and delayed visual recovery.
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Performing cost effective surgery by recommending only the premium services, if any, that have a reasonably high likelihood of positively impacting the outcome of the surgery.
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Willingness to go the extra mile to achieve high patient satisfaction. Occasionally, when indicated in order to achieve the best refractive result, we will recommend IOL exchange or laser vision correction to fine tune the refractive outcome. Also, we are pleased to now be offering the Light Adjustable Lens which is extremely accurate and adjustable and requires post-operative light adjustments. Cataract surgery is refractive surgery and we wish for patients to be very happy with their refractive outcome.
The vast majority of our cataract/lens implant surgeries are performed at El Mirador Surgery Center in Palm Springs, CA in very close proximity to Desert Regional Medical Center. El Mirador Surgery Center is dedicated mostly to eye surgery and has excellent eye surgery equipment and staff. Also, Dr. Prendiville has surgical privileges at Rancho Mirage Outpatient Surgery Center and performs blepharoplasties and other eyelid surgeries there.
For our patients who may benefit from premium services and advanced technology intraocular lenses, we are pleased to be able to offer a comprehensive array of premium services. All of these following premium services are entirely optional, are not paid for by any health insurances, and therefore require out-of-pocket patient expenditures:
1. FEMTOSECOND LASER ASSISTED CATARACT SURGERY (“FLACS”)
FLACS, available at El Mirador Surgery Center, is a more accurate and more controlled way of performing certain essential parts of the cataract surgery and assists in the following ways: a) performs a perfect anterior capsulorrhexis which is an essential step in cataract surgery and which the surgeon does manually otherwise, b) softens up the nucleus of the cataract and divides it into 4 or 6 sections to make it a little easier, safer, and gentler to remove, and c) in some cases, performs peripheral arcuate corneal incisions for astigmatism reduction/elimination to achieve clearer vision without glasses after cataract surgery. By fragmenting the cataract prior to removal by phacoemulsification, FLACS tends to decrease the amount of “cumulative dissipated energy” (CDE) used during phacoemulsification removal of the cataract which may result in a gentler and safer surgery. Also, the perfectly round and centered capsulorrhexis may help to optimize “effective (intraocular) lens position” (ELP) which may confer visual benefits in some cases compared to manual capsulorrhexises. The actual time for the laser to perform FLACS is only about 13 to 20 seconds. We tend to correct smaller amounts of astigmatism, from 0.50 up to about 0.75 diopter, with FLACS; over that amount, we tend to recommend toric intraocular lenses for it’s elegance and accuracy. Additionally, FLACS may be extremely helpful in cases of complex cataract surgery posed by white, intumescent, and traumatic cataracts, in eyes with corneal endothelial dystrophy, shallow anterior chambers, and in eyes with weak and/or torn zonules which are microscopic fibers which attach to and stabilize the capsular bag of the cataract.
In summary, the advantages of FLACS include reduction in ultrasound power and time needed to remove the cataract, high precision/accuracy, improved arcuate incisions for astigmatism correction compared to manual incisions, reproducibility/computer controlled, benefits in complex cases, and overall improved safety and efficacy of the procedure. If I or a member of my family was to have cataract surgery, I would opt for/recommend FLACS.
2. TORIC INTRAOCULAR LENSES
[Acrysof Lens Images Toric]
Toric intraocular lenses are recommended for patients who desire better vision without glasses and contact lenses, and need corrections of about 1.0 or more diopters of corneal astigmatism. These lens implants, including Tecnis toric and Alcon toric, are available to us in various strengths to correct the precise amount of astigmatism present in any given patient. We perform several various measurements of astigmatism in every cataract surgery patient prior to surgery to accurately determine the precise magnitude and direction of corneal astigmatism. Toric intraocular lenses are not indicated for all types of astigmatism. Astigmatism refers to a corneal shape that is not perfectly round like a basketball; rather, the cornea is shaped a little like a football. Most of us have at least a little corneal astigmatism. A very small amount of astigmatism is usually not visually significant. However, more than a little contributes to blurred vision when not wearing corrective glasses or contact lenses. When toric lenses are implanted, the goal is almost always excellent vision primarily for distance without glasses and contact lenses. However, it is anticipated that reading glasses would oftentimes be needed postoperatively, especially for small print. Toric lenses can also be targeted for excellent unaided near vision in which case glasses would be needed for distance vision. Toric lenses obviate the need for, and use of, corneal and limbal relaxing incisions, and are thus a more elegant way of correcting astigmatism. Moreover, when combined with ORA, they tend to be very accurate resulting in an increased chance of excellent distance (or, near) vision without glasses. Also, toric multifocal lenses are available for implantation which can provide excellent vision in patients with astigmatism for both distance and near.
IOL - Astigmatism
3. OPTIWAVE REFRACTIVE ANALYSIS
Optiwave Refractive Analysis (“ORA”), available at El Mirador surgery Center, is an ”in-surgery” adjunctive diagnostic device which provides the following information and guidance during surgery:
a) correct power of intraocular lens to be implanted
b) correct magnitude of toric intraocular lens to be implanted to fully correct the patient’s astigmatism
c) proper meridional alignment of the toric intraocular lens after implantation
d) additional analysis on peripheral arcuate relaxing incisions made at the time of FLACS
We use ORA to perform at least three refractive analyses on the eye prior to intraocular lens implantation, and again immediately after toric intraocular lens implantation to ascertain correct meridional alignment of the lens. Although ORA is generally recommended for many cataract surgery patients who can comfortably afford it, we especially recommend it for patients who have undergone prior refractive corneal surgery such as PRK, LASIK, or radial keratotomy, etc due to the higher degree of difficulty in ascertaining true corneal dioptric power in some of these eyes preoperatively. Also, use of the Ora System is highly recommended for any patient receiving a toric or multifocal intraocular lens. Using the ORA only adds a few minutes to the surgical procedure. In a 2017 survey of 150 Ora System users, surgeons reported a 27 % incidence of changing the IOL power due to the ORA measurements, 79% agreed that the ORA System reduced their need for enhancements postoperatively, and 88% viewed the ORA System as a valuable tool for implantation of toric IOL’s. If I were to have cataract surgery myself, I would opt for both FLACS and ORA at a minimum for their accuracy, predictability, and facilitating an easier surgery, in addition to a toric IOL if needed for astigmatism correction.
ORA Animation (Short)
4. MULTIFOCAL/EXTENDED DEPTH OF FOCUS INTRAOCULAR LENSES [Restor Toric 3.0 IOL Image]
These lenses, including Alcon ActiveFocus (shown above), Tecnis Symfony and multifocals, and others, provide both distance and near vision and are most suited to our cataract surgery patients who prefer to be as spectacle independent as possible. The newer multifocal lenses, ActiveFocus and Symfony, provide excellent distance vision due to both their contrast sensitivity and optical image quality for distance being equivalent to monofocal lenses. Additionally, they are available in a variety of toric powers for correction for astigmatism which markedly increases their effectiveness. These extended depth of focus lenses correct both distance and near vision and can be tailored to the patient’s visual needs including computer versus up-close reading or both. It is important for us to work together and communicate fully through the process of performing surgery on the 1st, and then the 2nd eye, to achieve the desired outcome for that particular patient. We aggressively pursue problem solving for any unusual issues that need to be addressed in order to have each patient be fully satisfied. Certain optical aberrations such as minimal halos around headlights may result from implantation of these lenses. Due to the superior design of the newest multifocal lens implants, these halos are generally mild and insignificant, if noticed at all. However, these symptoms may be bothersome enough to avoid night driving or even to warrant removal and replacement with a monofocal lens implant. Also, some patients who were previously not very good candidates for multifocal lens implants, such as those with those with mild epiretinal membranes, mild drusen degeneration, a monofocal IOL in the contralateral eye, and in those with more discriminating visual needs, can now be considered good candidates for these lenses. However, we fully apprise and counsel patients who may be interested in multifocal lenses to ascertain their appropriateness and suitability. The vast majority of patients who have multifocal lenses implanted in both eyes can function spectacle free either all the time or most of the time. Some patients will find a need for low power non-prescription readers for small print such as on a medicine bottle, reading a novel for an extended time, and reading in dim illumination.
5. Laser Vision Correction or Intraocular Lens Replacement Surgery
Following cataract surgery, in occasional cases where the patient does not achieve their desired refractive outcome or objectives, or just desires more “fine-tuning” of their refractive result, we offer and can easily perform either intraocular lens replacement surgery or laser vision correction. Our preferred methods of laser vision correction are “PRK” (photorefractive keratectomy) and LASEK which gently and very precisely reshapes the cornea to correct any postoperative cataract surgery ametropia. Typically, in these cases after cataract surgery, the amount of correction required is small which leads to a very precise refractive outcome and a highly satisfactory result. Dr. Prendiville is very experienced in PRK and LASEK and these procedures can be performed at a local laser vision correction facility. Following most premium cataract surgeries, we do not charge for either intraocular lens replacement surgery or PRK; however, facility fees may apply. Our experience is that patients are very satisfied and appreciative when we take this extra step, when needed, to achieve an excellent outcome.
6. Light Adjustable Lens
The Light Adjustable Lens (LAL) from RxSight, Inc in Aliso Viejo, CA is the world’s most accurate and technologically advanced lens implant in the world. Cataract surgery with this lens is typically very quick and easy as it tends to be a standalone premium offering. The lens contains photoreactive material which allows for adjusting the lens implant power post-operatively with ultraviolet light from a Light Delivery Device to eliminate any residual refractive errors including myopia, hyperopia, and astigmatism, and then “locking in” the final result after any necessary adjustments. The light adjustments are performed about 3 weeks after surgery to allow time for post-operative stabilization of the refractive error. Light treatments are painless, non-invasive, and last approximately 90 seconds. You may need 2 to 4 total light treatments over a period of 1 to 2 weeks to reach your vision goals. This fine tuning delivers the world’s best clinical outcomes for cataract patients, overcomes limitations of both pre-operative and intra-operative prediction processes, and provides us the unique ability to preview and adjust your vision until it meets your personal desires and lifestyle requirements. The result of this customization process is the best and highest chance of achieving excellent vision at the distance(s) you desire.
The Light Adjustable Lens delivers superior vision outcomes that non-adjustable IOLs cannot match. In a clinical study, the majority of patients who received the Light Adjustable Lens achieved 20/20 or better vision at 6 months without glasses. In comparative studies, the chance of obtaining 20/20 or better vision without correction postoperatively with the LAL was about twice as high compared to other lenses and the chance of an outlier (visual acuity less than 20/32) was 10x less. When doing light adjustments, we tend to adjust from plus to minus which results in negative spherical aberration and extended depth of focus. In one study, 80% of patients were able to see 20/20 for distance and near without correction. Moreover, unlike multifocal lenses, there is much less chance of any halos, glare, and decreased contrast sensitivity.
This lens is especially well suited to the following patients: 1) past history of any corneal refractive surgery such as lasik, PRK, or radial keratotomy (due to potential decreased reliability of pre-operative and intra-operative IOL calculations in these patients), 2) anyone who wants to optimize their unaided visual acuity after cataract surgery, 3) willing and able to pay the extra cost for the procedure, 4) wishing to preview at least a small amount of monovision, and 5) able to return for additional postoperative visits for the light treatments.
Patients who are not candidates for this lens implant include those with pupils which dilate to less than around 6.5 mm, history of herpes simplex keratitis, inability to return for post-operative light adjustments, and those taking certain mediations associated with increased photosensitivity.
Because of the unrivaled accuracy and excellent quality of vision which it affords, along with it’s ability to preview and adjust, this is the lens that I would opt for if I was having cataract surgery, and would recommend it for family members, also. We are pleased to be the first and only ophthalmology practice in the Coachella Valley to offer the Light Adjustable Lens.
