>> Sometimes you don't know what you're not seeing until you can finally see it.

Stay with us as we talk with ophthalmologist doctor David Strickland about cataract lens replacement surgery.

Next on Kentucky Health.

>> Kentucky Health is funded in part by a grant from the Foundation for a Healthy Kentucky.

>> Johnny Nash sang the song.

I can see clearly now the rain has gone.

Well, the same thing can be said about the clarity of vision.

After the fog of cataracts are removed and new lenses are inserted.

One day everything is clear and then the next day we see halos around.

Lights have cloudy or blurred vision, and or an increased difficulty in driving at night.

For me, it was that and the difficulty I was having in locating birds so that I could photograph them.

These and other problems have led over 3 million people to undergo cataract and lens replacement surgery.

The most patients who undergo lens replacement procedures have it as part of a cataract removal.

There are some who have lens replacement surgery alone or as treatment for other visual problems.

To tell us more about the indications, types and benefits of lens replacement surgery, we have as our guest today, Doctor David Strickland.

Doctor Strickland earned his medical degree from the University of Louisville School of Medicine and then completed a residency in ophthalmology at the Naval Medical Center in San Diego.

He then, as an active duty naval officer, was a staff physician and department head of ophthalmology and refractive surgery at the Naval Medical Center at Camp Lejeune in base in North Carolina.

Doctor Strickland is currently in practice at Middletown Eye Care in Middletown, Kentucky, where he specializes in refractive surgery.

If you, I should say, refractive eye surgery.

And if you notice that I have difficulty seeing he's the guy that operated on my eyes, so don't blame me.

We can all blame him.

David, thank you very much for taking time out.

No problem with us today.

And by the way, thank you again for operating on me.

I can't actually see.

I just can't read.

I see.

So tell me, what are cataracts?

>> Well, cataracts are our natural lens, so we all have a natural lens in the front part of our eye.

And as we age, usually that's the main type of cataract.

Those that lens starts to change its different proteins.

So the lens is composed of proteins.

And those proteins start to change as we get older.

It's just the fact of life.

So everyone gets cataracts as we get older.

Now there's different types, age related types of cataracts.

There's also types like from trauma, varying medical conditions, inherited conditions, genetic conditions, different metabolic conditions that can cause cataracts as well.

But your general type of cataracts, the one we all get when we get a little bit older, are just changes in those proteins that exist in the natural lens.

>> So what happens.

>> Is they're okay.

Obviously some medications that we're taking.

You said you said trauma, but what is going on is sunlight a factor or what are some of these things that give rise to some.

>> There's different risk factors UV exposures one, you know, actually ladies have a little bit higher risk of cataracts.

Strangely in clinical practice I don't really see that.

I think it's pretty much 5050 split.

But basically those proteins start to denature and change.

And there's different types that are important for me.

But for the general public, cataracts is just denaturing, changing of those proteins that cause a clouding of that natural lens.

So when you look at it, it just it changes colors.

And that's what you're looking through.

You're looking through a cloudy lens and that's what becomes a problem.

>> Does the person who has a cataract realize that they have cataracts early on, or is it something that they themselves may not recognize till late, and therefore we're depending upon someone like you looking at our eyes and saying, hey, you got something here?

>> I think I can look at most people.

You know, once you get hit about 50, I can say, yeah, you've got some cataracts starting to form just because of that color change.

But for the most part, people aren't going to really notice cataracts are forming until it gets a little bit later.

You know, the lens really becomes cloudy.

And then they have some visual symptoms from that, some type of cataracts though.

Yeah.

It's acute.

And and you notice a change in vision almost immediately like after trauma or something like that.

>> So what's going on.

>> Within the trauma.

Because you mentioned it twice now.

So what's going on with trauma and medications that can give rise to cataract formation medications?

>> Well, specifically, I think you might be alluding to like steroid use.

A lot of us are on steroids for various medical conditions, and that can cause a particular type of cataract where those lens cells, those proteins can start to migrate along the backside of our natural lens or the cataract and kind of form an acute change in vision.

So and then trauma, same, same thing.

Trauma can cause changes acutely in the lens composition that you might notice a lot quicker.

>> So once.

>> You start developing a cataract can we halt the progression of this or even reverse the cataract formation?

>> I think that would be the, the Holy grail to, to use a drop or take a medicine to kind of reverse that.

But right now, no, you prevent UV exposure, you know, be healthy, don't smoke.

Tobacco use is associated with early formation.

Yep.

Smokeless and smoke.

You know, any type of smoking can can lead to cataract formation or progression of it.

So you know modifiable risk factors just be healthy, you know.

Wear sunglasses outside, but the rest is kind of in the cards.

We all we all get there at some point.

>> So so.

>> Other than the those things is is there a family history of cataracts.

>> You can yeah.

Family history.

You know some people familial they get they get cataracts a little bit earlier on and need need intervention.

But for the most part, you know, like I said, all of us, once you're on the planet long enough, you kind of join the club.

You know.

>> Everybody's going to get it.

>> Everyone's going to get it.

>> What are.

>> The things or are there things that we can confuse as cataracts, we as patients, or maybe even a non-ophthalmologist specialist taking care of someone?

>> Well, there might be conditions.

You know, that eye has all types of medical conditions and you might think, hey, it's just cataracts that are causing me to not see so well.

But, you know, common things like macular degeneration and glaucoma, things in the back part of the eye that you might not really be able to see clinically.

Someone like me would have to take a look and see that.

That's why you're not seeing so well.

It's not just your cataracts.

Everyone just assumes it's your cataracts.

Because that's what happens when we get older.

But it might not be the case.

>> So when we talk about someone needing, I guess, glasses, and we go in there and our prescriptions are changing, is that because of the cataracts or is that a primary other lens dysfunction that's going on?

>> Once we get to young adulthood?

The eye has done the majority of its changing, you know, the changing in shape.

You know, the cornea has for the most part stabilized, which is the front windshield of the eye.

So the main element inside the eye as we age that changes is your natural lens or your cataract.

So once that starts to change, it can change your prescription.

And once that starts to happen, it's kind of cluing us in.

Hey, you know, things might be changing.

It might be time to do something about cataracts.

If change around the glasses isn't satisfactory for your for your visual needs.

>> I don't care what store you go into nowadays, there's always the ophthalmology or the optician center.

Or I shouldn't even say that.

The place where you go buy glasses and or and should we be using those little kiosks just to fit ourselves with glasses?

I guess I should hide these.

Or should we be seeing somebody as we have to keep changing these things?

Because are we masking a potential problem?

>> You're not hurting yourself.

Getting over-the-counter readers and the vast majority of people, if you don't have a need for actual prescription glasses, then over-the-counter readers are fine.

You know they're necessary because as we age, we can't see up close.

That's also, you know, a natural part of aging and the natural part of the front, part of the eye.

The muscles don't function as well.

They can't flex and relax our natural lens so we can see up close.

So wearing over-the-counter things is fine.

It's okay.

Yeah.

>> I'm sure your optician friends are glad to hear.

>> You say that.

>> Yeah.

Is surgery the only treatment for cataracts right now?

>> Cataracts.

Surgical treatment is the only.

Yes, that is the only management.

But before you get to that point, like I said, changing around glasses is reasonable.

I mean, definitely doing the most conservative thing before you jump into surgery is the best.

So if if you can change around those glasses a little bit and still be able to do the things you enjoy, then that's usually what I recommend before we jump into doing surgery.

But surgery surgery is the only answer to.

>> What is that point where when you're talking to the patient?

And let's face it, I think a lot of us are saying, I don't want somebody poking on my eyes or doing all this stuff.

It's kind of a creepy thing.

So when do you sit down and say, you know, you really need to have this done?

>> There's only a few cases medically where we say, hey, you really need to do this right now.

You know, the actual the cataract can leak protein, leak those proteins out can cause glaucoma.

There's all kinds of other reasons medically where we say, hey, we need to do this now.

But for the most part, the patient has to kind of tell us, hey, I'm having a problem with my vision.

I'm not able to do the things I enjoy doing.

You know, it's affecting their quality of life.

That's when we say surgery is the answer and we'll help you out.

>> Cataracts can cause some other problems.

>> Cataracts can cause.

Cataracts can cause.

Cataracts can cause problems.

>> Like what?

I did not know that I really did not know.

>> Yeah.

So again, coming back to trauma, it seems like that's that's the hot topic.

But, you know, say you dislocate your lens, dislocate the actual natural lens into the front part of the eye, it can cause glaucoma.

Like I said, those those lens proteins, if they start to leak into the front part of the eye, they can clog the natural drain that exists there cause glaucoma.

So, you know, there's there's some things that can happen from cataracts that are not so good.

>> How has cataract surgery changed in your lifetime as an ophthalmologist?

>> Well, I mean, I've been doing it for ten plus years.

The advancements in the technology, how we do the surgery is always getting better.

But going back, you know, the modern way of we we take out cataracts now is through Phacoemulsification, where we use an ultrasound to actually kind of break apart the cataract and remove it.

And it's really cool technology.

You know, a lot of smart people figured these things out, but that's only been around since the 80s or so.

Before that, they had advancements in how they would manually take out the cataract.

So it was a lot bigger deal.

You know, a lot of folks, parents, they probably remember them.

And you got to be admitted to the hospital.

It's a whole thing.

You got to keep your head down.

You know, it was a it was a big process.

You know, the surgery itself would take, you know, 30 an hour, 30 minutes, an hour.

You know, it was it was a big deal.

But now, you know, through advancements in technology and, and the, the way we do things, I mean, surgery can be done very quickly.

I mean, about five minutes.

>> Really all outpatient, relatively safe.

>> Yeah.

And it's safe.

It's effective.

The complication rates have gone way down with these these new procedures that we do.

>> So so at the same time you remove the bad lens, the cataract, are you always putting in a new lens.

>> Yes.

So when we take out the cataract and I like to use the analogy of an M&M because it makes sense.

It's easy.

So chocolate kind not the not.

>> The peanut.

>> Not the.

>> Peanut kind.

Okay.

>> So there's a shell and a, you know, and a chocolaty center.

So I remove the chocolaty center.

Yeah.

And inside the shell goes a new lens.

Always.

So we always put a new lens that we manufacture inside that shell or capsule is what it's called.

And that's what holds the new lens in place.

And that new lens shrink wraps or the new lenses shrink wrapped in place by our capsule that we all have.

So that's kind of how it works.

>> So there are few, if any, indications for just taking out a cataract and not putting in another lens.

>> Then you if you have to do that, sometimes you'll do a staged procedure where you take out the natural lens and leave it, and then put you can put a secondary lens in later.

And for the most, for the most part, for most people, that's that's not going to be the case.

You're going to take the cataract out and put the put a new lens in place at the same time.

>> So when you're putting in a lens other than just getting rid of the old, putting in the new, what are you actually doing?

What are you trying to do for that patient?

>> We're trying to remove that opacity.

So that's what a cataract is.

It's just a cloudy opacity you're looking through.

So by removing that, removing the chocolate, putting in the new lens, it's restoring the clarity of vision amongst many other things that cataract surgery can offer.

>> So but is this lens that you're putting in one size fits all?

And is it going to be as good as my old lens or my regular new lens?

>> They haven't figured out how to make everyone age 20 again.

They haven't figured that one out.

They're trying to replicate the natural human lens.

And that's really that's that's the end goal.

If they can figure out an implant that replicates our natural lens, then that that's the answer.

But they have a lot of great technology lenses.

Now, the main companies are always trying to figure out the next the next lens that is the best product.

And they have all engineers, material science folks working on these things.

>> So what's the trade off?

What am I in terms of the types of lenses?

What am I getting and what am I sacrificing?

>> So you know before we pick an actual so we have patients come in, we do a bunch of measurements.

So we really study the eye.

Because when you talk about deciding on a lens, you have to take a bunch of pictures and measurements of the eye, really study and in detail to be able to determine what the best lens is for patients.

And the great news is there's all different types of lenses, great technology out there to accomplish what you want out of your surgery.

So, you know, a lot of folks, as we get older, you know, again, we need reading glasses.

We can see at a distance and we can accomplish that with cataract surgery.

We can have, you see, great at a distance and wear reading glasses.

Or the alternative, we can focus you for up close.

If you are nearsighted, your life and you want to keep it that way, we can do that as well.

And you can wear glasses for distance.

So those are the main options.

And then you can get into other types of lenses where there's astigmatism.

A lot of folks have probably heard of that, which is the way your cornea is shaped.

We have lens technologies where we can neutralize that and fix your astigmatism.

>> Really?

>> Or we can use lasers during surgery to neutralize your astigmatism by making incisions in the cornea as well.

So there's different ways to go about fixing astigmatism, which is great.

>> So you have basically what, three different types of lenses that you can put in.

>> So there's there's different types.

There's a monofocal lens, which is what I was talking about setting you for distance or up close.

So meaning one focal point there's lenses that can accomplish that same thing and fix astigmatism.

So monofocal we call them toric lenses.

There's extended depth of focus lens, which is, you know, a lot of words, but basically there's different types of lenses in that category that their function is to give you good distance up to intermediate vision.

So there's different types of implants that accomplish that and fall into that category.

So that's another type of lens.

And then we get into multifocal lenses which are lenses that basically manipulate light.

How it enters the eye really.

And it can change that and allow the eye to be focused at different points.

So the goal is to you want to let as much light in as possible, but then you want to be able to change that focal point.

So you can see up close, you can see intermediate and you can see distance.

So they're coming out with a lot of great new lenses that let more light in and still accomplish that same thing.

Whereas in the past, you know, those lenses did really reduce your contrast because they had to change how much light entered the eye.

So and then the final option that's, that's come out pretty recently is a light adjustable lens, which is a newer technology where we put a lens inside the eye and then after the surgery.

So after the fact, you can go and change that lens to fix any residual prescription that folks might have.

So wow.

>> So it's a tune up.

>> Kind of.

Exactly.

Yeah.

And you can do several tune ups before you get your final your final product.

Interesting.

So which is pretty cool.

>> Now when one is operating on somebody for a cataract or even lens refractive surgery, people have halos and little blurred vision or trouble at night once you get the replacement done, are all these things gone?

Or do one or any of the various types of lenses you just told us about may still have a little bit of those components going on?

>> Yeah.

So, you know, glare and halos at night are common complaints with cataract surgery.

Some of the lenses, you know, getting into the multifocal lenses, you might have some element of glare halo at nighttime.

But again the lens technologies are advancing and those symptoms aren't as bothersome to patients.

And you know, when you actually question them like, yeah, I might notice it sometimes if I really pay attention to it.

But for the most part, you know, your brain gets used to the, the new technology that's, that's inside your eye.

But certainly, you know, nothing is perfect.

Nothing's nothing.

Nothing is the age 20 natural lens.

So but for the most part, yeah, those symptoms should be resolved with cataract surgery.

If the cataracts are causing those problems.

>> So take me through what is going on when you're doing the surgery.

>> So.

>> I mean, you operate on me.

Yeah, I was asleep.

You didn't ask for my opinion.

So.

>> Yeah, I mean, so so people, you know, it's a quick procedure.

Like I said, it's several minutes.

We don't put people to sleep.

Or at least I don't.

You know, you're getting some feel goods through the IV and you're relaxed.

I like people to be aware so that they're not looking around the room.

They can pay attention to to what we're saying to them.

And, you know, after you've you've had the sedation, you're you're able to follow that.

And after a few minutes it's done.

And then you, you basically go home.

We do surgery for the most part outpatient and surgery in a surgery center.

So it's a lot more convenient.

It's a more efficient process than having to get admitted to the hospital and doing all those types of things.

So it makes it overall a more pleasant experience for folks.

But in and out, I mean, usually it just takes a couple hours from start to, from getting there to to leaving and going home.

>> So you mentioned about a laser and early on you talked about I got the feeling that you actually were cutting things up.

So is the laser doing some cutting or is it laser just burning things away?

And how do you control I'm sitting there trying to figure out how you got this laser and this little tiny space.

So how are you controlling all this, how far you go and all that?

>> So.

So the laser.

Yes.

There's a femtosecond laser that we can use during cataract surgery.

And there's also femtosecond.

It's called femtosecond laser.

Yes.

It's just the the wavelength of light.

Yeah, yeah.

So but basically the laser is a tool.

And that's what I like to tell people.

And I utilize that tool not all the time but but a lot of times.

And what it does, the laser helps to make a precise opening on the cataract or your natural lens.

So then we can access the nucleus or the chocolate when I take out the chocolate.

Yeah.

It also helps us kind of break apart the cataract.

And then again, it can make little incisions in the cornea to help fix astigmatism or even make incisions that we use during to access the cataract and do the procedure.

So it's a cool technology, and it uses a lot of different things to be able to tell how, how deep in the eye and make very precise cuts and measurements and all these things.

So, you know, it's yeah, it's it's a neat technology.

>> You're working on such a finite area.

And I would imagine any minute movements.

Not by you.

Well, hopefully not by you but by the patient.

How do you control keeping the patient's eye from moving around?

>> So you know, initially before we, you know, start the surgery.

Yeah.

If someone's looking around it can make it a lot more challenging the surgery.

But after we get going and you make your, you know, very small, very small incisions, you know, the main incision that we use is like 2.4mm.

>> So 3.4mm, 2.5mm.

>> So very small.

So we're able to kind of control the eye and kind of take that take that away from them so that they don't have to worry about looking around or those types of things.

So it makes it you know, we're in more control in that situation.

So but yeah, looking around in general, it's not that it's not that big of a deal.

>> How do you get the lens in.

>> So there's different ways to do it.

But for the most part we have a little injector that the lens, they're made of acrylic for the most part silicone lenses are still on the market as well.

But those lenses were able to kind of fold up into an injector that we can then put through that 2.4, or even some folks use a 2.2mm incision, and we can inject the lens inside the eye.

>> So you're just slipping this thing in?

>> Yep.

You just kind of inject it in there.

>> How do you secure it?

>> Say that again.

>> How do you secure it in place.

>> So the lens goes inside of of the the shell that that everyone has or the capsule and it goes inside there.

And the natural capsule fibrosis or shrink wraps around the new lens and holds it in place.

So that's that's how.

>> How long does that take for it to be secured?

>> Usually, you know, you start to see some fibrosis or shrink wrapping around a month.

And then it continues to do that throughout the next several months.

And then it's really, you know, fixed in place.

>> So at that point, does one have to worry about dislodging the lens from any activity that they may do?

>> No.

Not necessarily.

I mean, if someone obtains really blunt trauma to the eye, certainly a lens could dislocate, your natural lens could dislocate as well.

So that's always a risk.

But for the most part, no, I mean, that thing is it's solid.

>> It's solid, it's solid.

And it stays in there.

>> It stays in there.

It's not going to go anywhere.

>> What does follow up look like following having this type of surgery.

>> So I think anything with the eyes, you know, we're very you know, we want to be on top of things.

So we see folks a lot.

We usually see folks the next day.

And then in between most folks get both eyes done, but some people only get one.

It depends on if they're having issues with both eyes.

So we'll see someone in between.

And then again kind of following that.

So again after the second eye.

And then normally we just do kind of a one month checkup to make sure everything's okay.

So it's a lot of visits a lot of it's a lot of, you know, you get to hang out with me a lot during the process.

But, you know, we just want to make sure when we get to the finish line, you know, we have a everyone's happy.

>> If you know you're going to do two eyes, why not do them both at the same time?

Why not?

Why do one then come back and do another?

>> They've done a lot of you know, they've done studies on bilateral sequential cataract surgery and it's safe and effective.

They do it a lot in managed care settings.

But I think in the real world, you know, insurance companies just don't pay for you to have them both done at the same time.

That's what it boils down to.

But also, you know, you want to see how the first I did, if you want to, you know, make a change or do something for the second eye, you know, it's nice to have that information.

But yes, they've they've studied it and it's, it's safe.

>> What is the biggest misconception that people have about what you do?

>> I think they think it's a lot more invasive than it is.

And I think a lot of folks just have a fear of someone messing with their eye.

You know, they think if I move or what, you know, they're going down a what if scenario.

And I think it's my job to just kind of, you know, relax, folks and make sure their set their expectations, but also make them feel more comfortable about everything.

But I think that's the most it's just the fear of having someone do something.

>> Are our expectations about the results?

Are they reasonable and are they usually met.

>> I think expectations you need to set the expectations.

Like I said, nothing is going to.

We're not setting back the clock, so we're trying to help you see better.

And again, that's my job to set the expectations.

You know, you want to make sure people are happy, but you want to make sure they're educated about what type of lens they're choosing, what the outcome should be.

And, you know, if we have to do other things after the fact to make folks happy, then we do.

>> So last thing, you mentioned that there are several different types of lenses.

Who gets to make that choice.

Is that a choice made by the patient?

Is that made by you or is that made paid?

That choice made by the person who's paying for all this stuff?

>> Yeah.

So not everyone is a candidate for all the lenses that we talked about.

So if you have underlying conditions in the eye, you know, maybe those multifocal lenses or those extended depth of focus lenses aren't a great idea if you have glaucoma or macular degeneration.

You know some of those things.

I'm really a stickler for those.

You know, the eye really needs to be perfect from front to back.

So to some extent I'm helping guide that discussion or saying this is off the table.

But for the most part, you know, if if you're a candidate for everything I tell you about all the risks and benefits of each lens, and then you pick which one you want that fits your lifestyle and.

Sounds good, you want to go.

>> With it sounds good.

Thank you for being with us today.

And thank you for doing my surgery too, by the way, and thank you for being with us today.

I hope that you have an appreciation of the indications and the benefits of cataract and lens refractive surgery, as well as the type of lenses that are used for replacement.

If you wish to watch this show again or watch an archived version of past shows, please go to ket.org Frost Brown Todd.

If you have a question or comment about this or other shows, we can be reached at KY at ket.org.

I look forward to seeing you and I will be able to see you now on the next Kentucky Health.

And if you've got any questions or concerns, please talk to your eye care health professional and please get somebody to get things done if you have a problem.

Thank you for being with us.

>> See you.

>> Kentucky Health is funded in part by a grant from the Foundation for a Healthy Kentucky.