Cataracts

[Ms. Kathy]

Gift of sight for only $20
Source Link: Wisconsin State Journal www.madison.com/wsj/topstories/index.php?ntid=205691&ntpid=1

CHRIS MARTELL
608-252-6179
August 15, 2007

Cataracts, a clouding of the lens of the eye that begins as a vague blurriness and can lead to blindness, is a common affliction of aging. For insured Americans, cataract surgery is a routine procedure that restores vision completely.

Despite the simplicity of cataract surgery, about 20 million people worldwide are blind because of cataracts, and 90 percent of them live in developing countries.

Dr. Suresh Chandra, an ophthalmologist at the UW School of Medicine and Public Health, has been working to eliminate preventable blindness through the Combat Blindness Foundation he started in Madison in 1984. Since then, the CBF has supported more than 100,000 free cataract surgeries.

Now, he has far more ambitious plans to expand that mission in collaboration with other organizations, including the World Health Organization. The plan is to perform 1 million cataract surgeries in the next 10 years. That's $20 per patient, which means $20 million would have to be raised. In addition, the CBF plans to raise an additional $4 million to $5 million to build an eye hospital in India and train medical personnel there.

Giving back
After finishing Harvard Medical School, Chandra established himself at UW-Madison as a specialist in relatively rare diseases of the retina. By the early 1980s, he began feeling compelled to do something more than just enjoy his successful career. "I was settled, and I thought it was time to start giving back."


Chandra's native country, India, seemed the easiest place to launch his mission because friends and family there could help him. He went to India originally to perform free retinal surgeries and teach his Indian peers high-tech techniques.

Quickly, Chandra realized that wasn't the best way to help people.

"One day I was going in to do surgery on a man who was already blind in one eye because of diabetes, and almost blind in the other eye because it was filled with blood and scarring," he said.

"On the way into that surgery, I saw 40 patients sitting there, like they were in an assembly line, waiting for cataract surgery. When I came out of my surgery on the man with diabetes, which had taken four hours, all the cataract patients were gone. They had been completely cured and they were recovering. That sent my mind spinning. In the four hours I'd spent on the man with diabetes, all I'd done was restore him to walking vision, at best.

"That was a trigger moment for me," he said. "I realized that the way to make a difference in a lot of lives was go after the common causes of blindness that were easy to fix: cataracts and vitamin A deficiencies."

Chandra's fundraising and search for volunteers began in the Madison area, with ophthalmologists, residents, medical students other volunteers paying their own way to join him on trips to perform cataract procedures. Chandra spends four to six weeks, once or twice a year, making sure CBF projects are going well and moving on to the next level, and he also makes arrangements for other medical professionals to visit CBF projects on their own.

In the CBF's early years, post-surgical patients were given glasses with thick, Coke-bottle lenses after cataracts were surgically removed.

"The problem was that people would lose their glasses, or they'd break, and they'd be blind again," said Chandra, at the CBF office on Odana Road.

A better alternative to glasses was intraocular lenses, which are lenses that are put into a slit in the eye after the cataract is removed. But intraocular lenses were expensive, costing $200 to $300 each into the 1990s.

"That was cost-prohibitive, so we joined hands to start a factory in India for producing high-quality lenses at low cost, about $3 to $4 a lens," he said.

As a result, it's now possible to perform cataract surgery and insert intraocular lenses for $20 a patient, which includes lens, sutures, bandages, medicines and transportation for patients.

Another preventable form of blindness the CBF addresses is xerophthalmia, an eye disease of children caused by vitamin A deficiency. After a diagnosis is made, high-dose vitamins are provided and mothers may be given seeds so they can grow vegetables rich in vitamin A in their gardens. So far, more than 25,000 children have been treated for the disease.

Working with others

"There is one ophthalmologist for 3,000 people in the United States. In India its one eye doctor for 100,000 people, and in Africa it's one ophthalmologist per million people," he said. "For a lot of people who are poor and illiterate, they think blindness is God's will. Africa is a neglected continent. It needs lots of everything."

Chandra adds that developing nations are also disproportionately afflicted with avoidable blindness not just because they lack ophthalmologic care.

"There are much larger populations of the blind in developing countries because they're developing cataracts earlier," he said.

In the United States, people usually start getting cataracts when they're over 60, while in developing nations, people are getting cataracts in their 40s and 50s. Malnutrition is believed to be part of the cause of early onset cataracts. Ultraviolet exposure has also been suspected as being a contributing factor, but studies have not yet borne that out.

The CBF is also working to help the uninsured in the Madison area, via free eye clinics offered regularly at UW Hospital for people with appointments who've been referred by clinics and social service agencies.

"We have a very big problem here in the U.S. as well, because there are 43 million people who are uninsured or underinsured," Chandra said. "Sometimes I think doing the surgeries is selfish in a way, because I get so much happiness and pleasure seeing people who are blind one day be able to see the next morning. I can't exactly tell you the feeling, but it's better than anything. But now, the most important work I can do is getting money. If I raise $100 here, it means eyesight for five people."

Making a difference

Chandra says everyone, even those without eye problems, has a stake in preventing avoidable blindness.

"If the current situation is allowed to continue, there will be between 100 to 150 billion dollars (internationally) in lost productivity over the next 10 years, according to the World Health Organization,'' he said.

Increased efforts to fight blindness will be launched both on the grand scale and internationally, as well as at the grassroots levels.

"There are people like Warren Buffett who can afford to give $30 billion to Bill Gates' foundation," he said, "but this is also a grassroots effort and individuals can give $20 to pay for one person's cataract surgery."

A recent recruit to the cause is Dr. Stephen Sauer, who specializes in cataract surgery at the Veteran's Hospital in Madison and at UW Hospital and accompanied Chandra to India last fall, where he taught and performed surgeries.

"I wasn't really prepared for what I saw — the phenomenal poverty and the sheer numbers of humanity," he said. "It was like going right into the fire, and it really opened my eyes to how great the need for this mission is."

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[Ms. Kathy]

Cataract surgery
Surgeons explain how to approach reconstruction of the iris, pupil
Source Link: OSN SuperSite www.osnsupersite.com/view.asp?rID=23421

Tips and techniques are given for handling iris stromal loss, iris root disinsertion, pupil abnormalities and iris functional loss.

By Michael E. Snyder, MD; Christopher Khng, MD; Scott E. Burk, MD, PhD; Robert H. Osher, MD
September 1, 2007


Introduction

Amar Agarwal
Iris reconstructive surgery is among the most difficult operations performed by the anterior segment surgeon, especially in cases after ocular trauma. Patients in need of such reconstructive efforts, either in cases of congenital, traumatic or other causes of iris loss, often are significantly debilitated by glare and other visual disturbances resulting from a compromised iris diaphragm. My guests in this column, Robert H. Osher, MD, Michael E. Snyder, MD Christopher Khng, MD, and Scott E. Burk, MD, PhD, of the Cincinnati Eye Institute, explain how to deal with iris dysfunction or loss.

Amar Agarwal, MS, FRCS, FRCOphth



Patients with partial or total iris loss, whether from congenital, traumatic or other causes, suffer from varying amounts of visual disability. The visual dysfunction may vary from mild to severe and includes glare, photophobia, reduced visual acuity and contrast sensitivity loss. In addition, significant cosmetic issues may also be present, especially when the patient has a light-colored iris. Abnormalities of pupil size, shape and location may also be reasons for pupil reconstruction.

The following considerations for loss of iris tissue are:

Suture repair is preferable to the use of an iris prosthesis whenever possible, although poor quality iris stroma may not be repairable.
Create and maintain a pupil size to alleviate symptoms, yet allow adequate visualization of the fundus.
Small-incision surgery is desirable whenever possible.
Detailed informed consent and observation of regulatory protocol are necessary because the iris devices are not approved by the U.S. Food and Drug Administration.
Iris stromal loss
The repair options available to the surgeon depend upon the extent of iris tissue loss. This can conveniently be described in terms of clock hours or quadrants of loss.

One quadrant or less. With less than 3 clock hours of loss, the management options are straightforward. Examples of such an iris defect are iatrogenic iris atrophy with a transillumination defect adjacent to the corneal tunnel post-phaco in which iris prolapse has occurred repeatedly, a congenital iris coloboma or an excessively large surgical iridectomy. The primary repair option is with imbricating sutures to the iris leaflets or edges of the defect using Prolene 10-0 sutures with a modification of the McCannel or Siepser technique. If the operation is going to be combined with cataract surgery, implantation of both a single sector iris prosthesis such as the Morcher 96 (or single fin Ophtec Iris Prosthetic System element) and a foldable IOL, each placed into the capsular bag, may be chosen if the remaining iris stroma cannot be adequately closed. Although the sector implant affords good functional results, the cosmetic result may be suboptimal because the 96 series of implants is available only in black PMMA and the Ophtec device colors may not be an exact match at the present time. Therefore, in addition to the implant, we will often place an imbricating suture through the iris defect for cosmesis.

Between one and two quadrants. Between 3 and 6 clock hours, for example, in a case after iridocyclectomy for an iris tumor or post-traumatic iris loss, two pieces of either the partial aniridia ring (Model 96, Morcher) or the Ophtec single-element Iris Prosthetic System (IPS) may be placed into the capsular bag. If the capsular bag is absent, a full-sized prosthetic iris device may be sutured with scleral fixation. Alternately, if the iris defect is only marginally beyond 3 clock hours, imbricating sutures may be attempted depending on the elasticity or friability of the iris tissue. In the situation with iris sutures, an additional McCannel type suture may need to be placed to attach the newly created iris root to the sclera in the area of the repair.

Beyond two quadrants. Beyond 6 clock hours of iris loss, there are several good surgical options. If a small incision is possible, two multiple-fin endocapsular rings (Morcher type 50C, D or E with respective apertures of 6 mm, 5 mm, 4 mm or 3.5 mm, respectively) may be placed in the capsular bag combined with phacoemulsification and implantation of a foldable IOL.


Traumatic iridodialysis with iris loss and aphakia. Iris loss between 2 o’clock and 7 o’clock and zonular dialysis between 4 o’clock and 5 o’clock and intact posterior capsule.

Final result of Figure 1 patient after lens implantation into the sulcus, pupilloplasty and repair of iridodialysis with mattress sutures.


Cerclage suture being placed using a long curved needle on a Prolene 10-0 suture.

Oculocutaneous albinism with cataract and disabling glare. Appearance after paired Morcher 50C prosthetic iris rings after rotation.

Images: Osher RH, and colleagues


Iris root disinsertion
The surgical options for repair of iridodialysis (Figure 1) are relatively straightforward. Mattress sutures are used to reattach the iris to the sclera, the number and placement of which would depend on the extent and location of disinsertion (Figure 2).

Abnormalities of pupil size, location and shape
Abnormalities of pupil size range from an absent pupil to a large unresponsive pupil. Pupils obliterated by posterior synechiae may be abnormal in position (eccentric, corectopia) as well as in size. In this situation, synechiolysis alone or the peeling of the peripupillary membrane may restore adequate pupil size and centration. A severely displaced pupil may require the creation of a new central pupil with either a vitrector or fine intraocular scissors, followed by imbricating sutures to close the previous pupil.

A pupil may be either too small or too large. Bound-down pupils from previous anterior uveitis or long-standing pilocarpine usage may be the cause of fixed miosis. Our approach is to first attempt to lyse the posterior synechiae with a cohesive viscoelastic agent injected at the pupil edge. Any separation of tissue will allow insertion of the injection cannula, as viscodissection is highly effective. If the membrane cannot be penetrated, a flat blunt instrument such as a cyclodialysis spatula may prove more helpful in dissecting the iris edge off the lens capsule followed by viscoelastic injection. While sharp dissection is possible, care must be taken to avoid inadvertent puncture of the anterior lens capsule. A safer option is to create a small iridectomy midway between the pupil edge and the iris root through which the viscoelastic agent is injected, which by itself may lyse the posterior synechiae. Recalcitrant synechiae can be severed by either blunt or sharp dissection using the iridectomy for entry. Alternatively, 20- or 25-gauge vitreoretinal scissors can be helpful instrumentation. The iris defect can be closed by sutures. Once the pupil edge has been elevated off the lens capsule, a peripupillary membranectomy technique, as described by Dr. Osher, may prove successful in peeling the discrete ribbon-like membrane off the iris border. This often permits a significant enlargement of the pupil, once the restrictive membrane is removed. If, however, the pupil is still not an adequate size, a pupil-stretching technique may be performed with two blunt manipulating instruments followed by viscomydriasis. Other options include multiple sphincterotomies or pupil “sculpting” with either a vitrector or intraocular scissors.

At the other end of the spectrum is the dilated atonic pupil. Common causes include previous traumatic mydriasis or herpetic iris atrophy. The easiest surgical approach, as described by Dr. Osher, is to use a McCannel-like imbricating suture of 10-0 Prolene passed in each quadrant. A more elegant solution, although more technically demanding, is to use the Ogawa pupil cerclage (Figure 3 on page 61) suture. We prefer to use Prolene 10-0 on a CTC-6L needle, and the suture is placed with the needle passing just inside the

pupil margin. With this technique, the more bites of the iris the better, as too few bites cause scalloping of the pupil margin. Typically, around 20 to 24 bites are taken before the suture is tied to itself. The pupil size may be adjusted by tightening the cerclage. Once an adequate pupil size is attained, the suture is locked. The final option in a case with a fixed dilated pupil is to use two Morcher 50 series prosthetic iris rings placed into the capsular bag, an Ophtec IPS, a model 311 diaphragm prosthesis (fixated or not-fixated) or a model 67 sulcus-fixated prosthetic iris device. However, in view of the small incision, the cosmetic benefit and the regulatory availability issues, suture repair is our first choice before considering an artificial iris. A pupil that is either eccentric or severely oval can be improved by either extending the pupil into the visual axis or by creating a new centered pupil. The previous eccentric pupil can be closed by placing imbricating iris sutures.

Iris functional loss
This group of iris conditions has neither lost nor missing iris tissue, but the iris present is poorly functional. Examples include the diaphanous irides of the albino, which have missing pigment within the iris pigment epithelium, cases of chronic uveitis in which the iris tissue is poor or nonfunctional from inflammation, and the iridocorneal endothelial syndromes in which spontaneous iris holes develop as the iris tissue pulls apart, even though no actual tissue is lost. With severe transillumination defects in the albino, the functional loss may be little better than congenital aniridics. Fortunately, the same capsular fragility problems that are associated with congenital aniridia are absent. We have had mixed responses in terms of glare reduction in albinoid patients undergoing phacoemulsification and foldable lens implantation with placement of paired Morcher 50C or 50E rings or an IPS into the capsular bag (Figure 4). In the absence of adequate capsular support, an iris diaphragm IOL prosthesis such as the Morcher 67 or Ophtec 311 may be sutured to the sclera. For both the uveitic iris and cases of iridocorneal endothelial syndrome, repair of the iris using sutures may be unsuccessful because of the poor quality of iris tissue. Our patients with either uveitis or iridocorneal endothelial syndrome have enjoyed a significant reduction in glare with a prosthetic iris device.

For More Information:
Amar Agarwal, MS, FRCS, FRCOphth is director of Dr. Agarwal’s Group of Eye Hospitals. Prof. Agarwal is author of several books published by SLACK, Incorporated, publisher of Ocular Surgery News, including Phaco Nightmares: Conquering Cataract Catastrophes, Bimanual Phaco: Mastering the Phakonit/MICS Technique, Dry Eye: A Practical Guide to Ocular Surface Disorders and Stem Cell Surgery, and Presbyopia: A Surgical Textbook. He can be reached at 19 Cathedral Road, Chennai 600 086, India; fax: [phone]; e-mail: [e-mail]; Web site: www.dragarwal.com.
Michael E. Snyder, MD, can be reached at [e-mail].
Christopher Khng, MD, can be reached at [e-mail].
Scott E. Burk, MD, PhD, can be reached at [e-mail].
Robert H. Osher, MD, can be reached at Cincinnati Eye Institute, 10494 Montgomery Road, Cincinnati, OH 45242; 513-984-5133; fax: [phone]; e-mail: [e-mail].
References:
Agarwal A. Handbook of Ophthalmology. Thorofare, NJ: SLACK Incorporated; 2005.
Agarwal A. Phaco Nightmares: Conquering Cataract Catastrophes. Thorofare, NJ: SLACK Incorporated; 2006.
Agarwal A, et al. Two Volume Textbook on Phacoemulsification. New Delhi, India: Jaypee Brothers; 2004.
Agarwal A, Agarwal A, Agarwal S. Four Volume Textbook of Ophthalmology. New Delhi, India: Jaypee Brothers; 2000.
Ogawa GS. The iris cerclage suture for permanent mydriasis: a running suture technique. Ophthalmic Surg Lasers. 1998;29(12):1001-1009.
Osher RH. Peripupillary membranectomy. Video J Cataract Refract Surg. 1991;Volume VII, Issue 4.
Osher RH. Surgical repair of the fixed, dilated pupil. Consultation Section. J Cat Refract Surg. 1994;20(6):665-666.



.

[Ms. Kathy]

News from the Phillipines:
Group to help eliminate cataract blindness formed
Source Link: Sun.Star Bacolod www.sunstar.com.ph/static/bac/2007/10/03/life/group.to.help.eliminate.cataract.blindness.formed.html

THE Provincial Health Office and the Center for Health Development Western Visayas organized a local committee on sight preservation.


The committee was organized following the national government's program, Vision 2020, that aims to eliminate cataract blindness, screen and manage visual loss in children, and provision of services for and correction of refractive error, specifically the control of eye infection (trachoma and onchocerciasis).

The program also unites opthalmologists’ and optometrists' associations, community organizations, non-government units, and hospitals in setting up and managing cataract intervention and eye care programs, school screening, and community screening programs.

Named chairman of the committee is Dr. Ricardo Gallaga Jr., Dr. Eduardo Galon is vice-chairman, and Teresita Jingco is secretary.

The committee heads are Dr. Rolando Lee and Luisito Escalona, awareness campaign and advocacy; Dr. Eduardo Galon and Marissa Santiago, fund raising; Dr. Ma. Cristina Eusebio, basic training, screening and referral; Dr. Nonito Avecilla, cataract surgeries; and Dr. Ray Valencia and Dr. Susan Sioco, spectacle distribution.

[Ms. Kathy]

What Is Cataract Surgery?
Source: About.com

Cataracts cause the lenses of the eye to become cloudy. Cataract surgery restores vision in eyes that have been affected by cataracts. Learn more about this surgical procedure.

Watch the video at this link: Cataract Surgery - What Is Cataract Surgery - Do You Need Ocular Implants Video - About.com
video.about.com/vision/Cataract-Surgery.htm

[Ms. Kathy]

Gift of vision for poor
Avis MacIntyre


As many as 40 hopefuls are waiting in line for the chance to undergo the nearly miraculous cataract operation offered by a public spirited alliance of medical professionals, the local Medi-Clinic and the Hermanus Rotary Club.

In the last few months ten patients have benefited from the unique Rotary Cataract Project that was initiated four months ago. They walked away from the 30 minute procedure with the precious gift of sight, completely free of charge all thanks to a few philanthropic men who came together to help the helpless.

As a result of the symbiotic relationship between opthalmologist Anton van Biljon, optometrists, the Hermanus Medi-Clinic, the pharmaceutical company Alcon Laboratories and the Hermanus Rotary Club, indigent cataract victims, who fit the criteria of the project, no longer have to face a bleak future of certain blindness.

Of the approximately 250 000 blind people in South Africa, 160 000's blindness is caused by cataracts and the waiting period at state hospitals for a cataract operation can be anything up to 18 months.

Under this project the hospital theatre time is donated, as is the expertise of the opthalmologist, the opticians and the intra ocular lenses from Alcon Laboratories while the Hermanus Rotary Club raises funds through various functions to cover the cost of medical supplies such as eye drops, swabs and other consumables.

Screening of potential patients has to be meticulous so as not to jeopardise this pilot project and strict regulations are in place to ensure that only indigent patients benefit from it. For patients to qualify for the Hermanus Cataract Project they need to be South African citizens, earn less than R2 000 a month with no medical aid and have best corrected vision of less than 6/60. Anyone who falls into this category should call Rotarian Johan Pretorius for a detailed screening on 028-312 1277. Public donations are warmly welcomed and can be made to: Rotary Club of Hermanus, Standard Bank Hermanus, current account 082261385.

Source Link: HermanusTimes www.news24.com/Regional_Papers/Components/Category_Article_Text_Template/0,2430,486_2195585~E,00.html#top