The topic is Advanced Technology Intraocular Lenses.

Whenever I take out a cataract I have to put in an intraocular lens because a cataract is a cloudiness in the patient’s natural lens.  If you don’t replace it, everything is out of focus.

Fifteen years ago there was one type and style of lens and now there are a multitude of choices; multifocals, accommodative, toric, combinations of toric and multifocal, aspheric and others, and the list goes on.  How does an ophthalmologist decide and is this just too bewildering for a patient? It comes down to three things;

1.  Surgeons need to be familiar with what lenses are available and be confident about how to measure the eye to get the best results for the lenses and how to safely and efficiently place the lens inside the eye.  You would think ophthalmologists would do all this naturally, but it is not easy.  What is easy is to continue doing what you did last year.  It’s difficult to embrace change and eye surgeons are no different to anybody else.
2.  You have to assess the patient’s anatomy.  The anatomy will dictate the choice of lens because some eyes are unsuitable for example for a multifocal lens.  A patient who has loose attachments around their natural lens, some with retinal disease that would preclude good quality vision – these people probably should not have a multifocal lens as they would not be able to be placed with certainty in the correct position, nor would they get the visual results that go with the multifocal lens.  The surgeon has to work out which lens is suitable for that particular patient’s anatomy.
3.  The surgeon and patient need a conversation.  If the patient’s anatomy would allow any available lens to be placed, it comes down to what matters most to the patient.  If what matters is true independence from glasses for all activities then this will require an aspheric multifocal lens in both eyes.  The good reading that comes with this lens means that the patients will have some halos when driving at night, but these diminish with time, and this lens requires adaptation on the patient’s part, so patience is required.  If a person is driving a taxi cab on the night shift, it is not the sort of lens that would be ideal as they would be faced with halos constantly in their work environment.

For a person more interested in excellent quality distance vision with no fuss, no halos, quick adaptation and who doesn’t mind reading glasses, you would use an aspheric lens with or without astigmatism correction.

Sometimes there are subtleties between these two options, such as a form of blended vision aiming for slightly better intermediate vision with less than perfect distance, or using an accommodative lens for good distance vision and reasonable intermediate, but accepting the need for reading glasses. The conversation is essential to work out what best to do.

The accompanying slides show the range of lenses that I put in at present; from phakic intraocular lenses in people with high myopia, multifocal intraocular lenses which make up just over 50%, aspheric lenses, toric lenses and accommodative lenses.  These are choices for both patients and surgeons and it is a time consuming but beneficial process to get it right.

 Dr Michael Lawless

From March 2009 until mid 2010 I placed a large number of accommodative Crystalens in both cataract and refractive lens patients.  We analysed the results carefully. The safety criteria were excellent, as expected.  The reading ability however was disappointing.  In order to have reasonable intermediate and near vision, a blended or monovision effect was required aiming for deliberate short sightedness in one eye.  This is a compromise that was acceptable to some, but not the majority of patients.  Even with blended vision 50% of patients with the accommodative Crystalens required reading glasses for some activities.  All other metrics were good.  The YAG capsulotomy rate was reasonably high and needed to be performed early to get the best performance from the lens, and this would have been the only other unusual feature of this lens.

Because of the disappointing near vision with the accommodative lens I relooked at the aspheric 3+ ReSTOR^® lens.  This is an apodized multifocal lens and I had first used the previous version with a stronger reading add in 2004 and studied and lectured on it extensively.

My hesitation in returning to the ReSTOR^® multifocal lens was that in the earlier version with the stronger reading add patients had a fair degree of halo and flare at night and took a long time to adapt to this.  Patients who were unhappy at six or twelve months did adapt with time and I have never had to remove a ReSTOR^® +4 multifocal lens.  Indeed what happened in 2010 is that I started to see some of the patients who I operated upon five to six years before and they were universally happy with their visual quality and free of glasses for all activities.

I relooked at the new aspheric version (ie +3 not the +4) and started using this lens.  The safety profile is excellent because it is made of the most biocompatible material.  It is very safely injected into the eye and stable once placed in the capsular bag.  You can see from my use of the lens (figure one) that it is now the dominant lens that I use.  Just over 50% of lenses I implant now are either ReSTOR^® +3 multifocal or the multifocal toric.

If patients achieve a plano endpoint; that is they have no remaining astigmatism, long- sightedness or short-sightedness, they are fairly certain of being free of glasses for all activities.  There is still an adaption period and patients need to understand that in order to get reading and intermediate vision they will have some flare and halo at night for a period, and their brain and eye will need to use the lens in an appropriate way.  It is also a lens that needs to be implanted in both eyes for its best effect.  Since the toric version (ie a version that is able to treat astigmatism) became available in early 2011, that has added to the usefulness of the lens as well.

It has been quite a  transition in the last three years in understanding how best to use these lenses, which patients are best suited to which individual lens and how to get the best from the lens; a difficult transition in some ways as a surgeon, but at all times improving the options for patients.

Dr Michael Lawless 

Everyone knows that LASIK decreases tear production.  It is related to the fact that LASIK (even all laser LASIK, which is the best way to do it) cuts through corneal nerves and they regenerate slowly over weeks to months.  The nerve supply is in a very complex way linked to tear volume.  After LASIK one of the things you can guarantee is that your tear production will be decreased probably by about 25%.  Most people have a good tear reserve so that they may be aware of mild dry eye, or sometimes nothing at all.

It can become a problem though if the tear volume or quality is compromised ahead of refractive surgery.  It is important to recognise this by looking at the quality of the tear film break-up time and analysing the tear volume, but there are no perfect tests to determine this and it is in some ways a subjective assessment by the surgeon.

Without making the issue too confusing, there is an element of tear production that is not just the amount of tears you produce, but the quality of tears, which  is important and can be disturbed by a poor blink response if you are sitting in front of the computer for long periods and compounded by air conditioning or heating.  It can also be impacted by inflammation in the lids oil glands that produce oil for the tears, and this is something to recognise ahead of surgery and deal with.

In the last twelve months, I’ve started to more aggressively target the tear film peri-operatively.  Simply it comes down to recognising that there is a problem and deciding whether it is due to low tear volume or whether it is a tear film disturbance for other reasons.  I deal with it by using weak topical corticosteroids (FML or Fluoromethalone drops) for a few days before LASIK, sometimes using punctal plugs, either temporary or permanent at the time of LASIK. What has made a great difference is getting prospective patients to take oral flaxseed oil 2000mg per day for a week before and about a month after LASIK.  Flaxseed oil is one of the few things known to increase tear volume and quality.  It is a very safe thing to take and is available from health food stores.

The combination of these things has led to not just more comfortable patients, but there is a link between tear volume and quality and the accuracy of corneal refractive surgery.  A good tear quality film will help you see well.  The tear film is not just a wetting agent coating the surface; it is linked to how the eye behaves optically, so for a whole range of reasons attention to the tear film is just as important as getting the laser accurately calibrated and the surgery performed well.  It makes a difference.

The cost of  laser correction surgery will vary depending on the procedure you have. During your initial consultation Dr Michael Lawless will discuss the options and fee’s with you.

As a stand guide to the cost of laser eye surgery,fees range from $3,000 per eye to $3,400 per eye.
Please consult  Dr Lawless and your Vision Laser clinic for full details.

The laser eye surgery fee includes:

• Surgeon’s fees
• Optometrist’s fees
• Post operative medications
• 4 post-operative visits at 1 week, 1 month, 3 months and 6 months
• Enhancements (if required) for at least the first 24 months (see clinic for details)

The cost of laser Surgery cannot be claimed from Medicare or from most Private Health Funds. However, you may be eligible for a Medical Expenses rebate on your tax return.
Please check with your tax accountant for more details and information regarding any tax rebates.

Please note: The initial assessment is not part of the surgery fee, please contact your clinic for details.

Payment Plans

At  the Vision Eye Institute, we understand that the decision to have laser eye surgery is a big one. The financial cost of the procedure needs careful consideration and needs to be balanced with the real benefits that can be obtained with laser eye surgery. Many Australians who believe that laser eye surgery is outside of their budget are missing out on the wonderful benefits that freedom from glasses or contact lenses provides.

We offer a range of realistic and affordable financing options to help you experience the freedom of clear vision:

• Interest-free payment plans
• Extended payment plans

Both of these plans are provided by GE CareCredit, which is a credit facility offered by GE Finance Australasia Pty Ltd, trading as GE Money.

12 month interest-free payment plan available*

Click the calculator below to estimate your monthly payments
CareCredit Repayment Estimate Calculator

Call 1800 601 747 or email your clinic for further details about this offer or the extended payment plan.

*Available to approved applicants only. Fees and charges apply. Minimum amount financed $500.

Net medical expenses tax offset

The Australian Tax Office (ATO) allows Australian taxpayers to claim a tax offset on the out-of-pocket expenses they incur on certain medical expenses.

On the ATO website, Net medical expenses are defined as the medical expenses you have paid less any refunds you received, or could get, from Medicare or a private health insurer.

You can claim a tax offset of 20% – 20 cents in the dollar – of your net medical expenses over $1,500. There is no upper limit on the amount you can claim.

Most procedures performed at Southline fall under the definition of Claimable Medical Expenses.  According to the ATO, “You can claim expenses relating to an illness or operation paid to legally qualifieddoctors, nurses or chemists and public or private hospitals”.

Laser eye surgery is specifically listed as a procedure that qualifies for the tax offset.

You can read more about the Net Medical Expenses Tax Offset on the ATO website.

The 2010 Commonwealth Budget provided for an increase in the threshold from $1,500 to $2,000, effective from July 1, 2010.

This information is provided as general assistance only and does not take into account your personal financial or medical circumstances, nor does it guarantee that surgical procedures performed at Vision Laser with qualify for the tax offset.  Before making a decision about your eligibility to claim the tax offset, please consult your accountant or other tax professional

Cataract surgery is currently one of the most successful surgical procedures, So now imagine, if the same medical procedure took a pain free 60 seconds.

A revolutionary, state of the art machine has just arrived in Australia.

With the help of Dr Michael Lawless and a hand full of expert surgeons at the vision eye institute, is ready to restore vision for many Australians suffering from cataracts.

Laser Cataract Surgery offers a non-invasive procedure and remarkable results and all with no pain attached.

If you would like to watch Dr Michael Lawless on Channel 9, ACA, please follow this link for the full story. Sixty-second surgery

For more information about this revolution in Cataract treatment, please visit Laser Lens SMA

Intralase is the most current development in laser eye surgery, it is a type of LASIK, and is usually referred to as Intralase LASIK. Intralase LASIK is considered the gold standard in laser eye surgery and this is because of the various benefits it has over common LASIK. Intralase is different to standard LASIK in the way in which the flap is formed. In the course of common Lasik the flap (outer layer of cornea) is made using a microkeratome (surgical blade) whereas with Intralase it is constructed with a laser. The development of the flap becomes necessary so that the surgeon can access the inner layers of a person’s cornea which are to be lasered during the particular process. Intralase is referred to as a bladeless treament and is becoming increasing popular. Let’s look at the benefits and find out if it is well worth the additional cost:

Identified Risks/complications: generally there tend to be fewer complications when in comparison with standard LASIK as the flap that is produced is much more precise and cleaner. The vast majority of complications with LASIK tend to be flap related.

Dry Eyes: There is less of a chance of acquiring dry eyes if you have Intralase.

Recovery Time: Recovery time is normally faster than compared with standard LASIK and eyesight stabilises far sooner as well.

Results: Having Intralase gives people a greater platform of achieving 20:20 vision following surgery. It not only improves the quantity of your vision (how far you can see down the test chart) but it also improves the quality of your vision, meaning you are less likely to have night vision problems following surgery.

The previously mentioned information and facts is meant for educational purpose exclusively, please contact vision eye institute in the event that you have any kind of concerns concerning your own eyesight. Information and facts offered were not necessarily constructed by Dr Michael Lawless and is created simply to distribute knowledge concerning Intrase LASIK.

It uses a femtosecond laser, of the same type used to create the flap in LASIK to make lens and cataract surgery safer, more accurate and more predictable. Cataract surgery is the commonest eye operation in the world. Over 200,000 procedures are performed in Australia per year, about 3.4 million in the United States and about 18 million worldwide. Increasingly lens removal and replacement with an intraocular lens is seen as a way of vision correction for those people who have refractive errors and a desire to be free of glasses.

As a general rule anyone below the age of fifty would like to retain their own crystalline lens because it retains some elasticity to help with the range of focus. It is a gradual process which begins in the early forties, but after fifty the lens has lost much of its elastic property and this is why normal people need reading glasses at age forty five plus. If you are aged fifty five plus and want to be free of glasses, then one way of achieving this is to remove the now non-elastic lens and replace it with an intraocular lens.

These come in different types and are a discussion for another day. Back to the point of laser lens surgery; there are three critical elements that could be make better both in safety and accuracy terms;

1. The incision is currently done with a blade, sometimes metal, sometimes diamond, and to create the incision with a laser will add to the level of safety. The most feared complication of lens surgery is infection and it is believed that slight leakage of the wound in the first few days is one possible cause for infection. If the wound could be made more secure and more certain in its structure, which is what can be done with a laser, then it may decrease this feared risk of lens surgery. If you create the incision in a precise manner it also means that you have less induced astigmatism and a better quality visual result.

2. The capsulotomy, that is the removal of the front part of the lens, is currently done with a needle and forceps directed by the surgeon’s hand. You have to make approximately a 5mm opening in the front of the human lens in order to then be able to extract the body of the lens. Around 1% of the time this capsular rhexus tears and this can lead to problems of lens stability. Sometimes it is not possible to remove all of the lens and sometimes other problems arise following this such as not being able to place the desired lens or not being able to fix it safely in place. So the series of problems cascade, like many issues in surgery, if the capsulotomy is not done perfectly.This has already been shown in at least one published series to be better when performed with a femtosecond laser. That addresses the safety side of the capsulotomy. On the accuracy side, if you have a round properly centred capsulotomy, it means that the synthetic lens you place in the eye will be more accurately positioned and lead to a better visual outcome. Again this has been shown in a paper by Zoltan Nagy to be achievable. If, for example, you want to have a consistent size within 0.25mm you can achieve this every time with a femtosecond laser, and you achieve it about 10% of the time with a skilled surgeon.

3. The third aspect of surgery that can be improved is the softening of the lens. Currently this is done with an ultrasound and is called phacoemulsification. This began in the 1970’s and continues to this day as the preferred method of softening the lens so that it can be aspirated through a fine cannula, the reason being that you want to keep the wound small. If you enlarge the wound it adds to the risk and decreases the accuracy, but to keep the wound small you need to be able to soften the crystalline lens or cataract and remove it. The femtosecond laser allows either reduction in the amount or sometimes elimination of the need for phacoemulsification. Phacoemulsification is a controlled process but it does have potential and real risks inside the eye that can lead to problems with lens placement and corneal endothelial damage. A reduction or elimination of phacoemulsification will also lead to better wound integrity.

On all three aspects incision, capsulotomy and lens removal, laser lens surgery appears to be superior in safety and accuracy. My best estimate is that this will be available in Australia in 2011 and I would dearly love to have the first instrument in Australia. There will be a number of competing technologies but at this stage the Alcon LensX certainly has the edge in both USA Government approvals and the best of the research and development teams behind it, along with the service and high quality reliability of a company like Alcon. It has gained approvals for all the essential elements; that is the incision, capsulotomy and lens softening as regulated by the USA FDA. It will probably be used by those surgeons who are currently performing refractive lens surgery on the population who wish to be free of glasses and for whom LASIK is not appropriate. These are the people who are relatively risk averse and would like a safer more certain procedure in order to proceed with surgery, and in my estimation, over a few years it will become the standard of care for cataract and lens surgery generally. It has many implications for patients, the profession of ophthalmology and government regulators.

These machines are expensive to purchase and service and it is not a bad thing that the surgery will be concentrated in certain facilities. A small facility doing less, for example, than 1,000 procedures per year, will probably not be able to afford this technology. The concentration that will result does allow for a build up of expertise in nursing staff and the team that is involved these days in modern lens surgery. This will be the technology at the right time because demographics drive many things, and 65 year olds who are the first of the baby boomers who turn 65 in 2011, and after them a demographic bulge of population in all western countries, will be at an age where lens surgery is appropriate for them, and it is just as well that a safer, more accurate technology has come along at the right time.Laser lens surgery is truly the right technology for the right time. It uses a femtosecond laser, of the same type used to create the flap in LASIK to make lens and cataract surgery safer, more accurate and more predictable.