Eyeworld

EW CATARACT 29 of the bag, the problem goes away," Dr. Masket said. Solutions Luckily, most cases of ND fade with time and rarely need surgical inter- vention. If ND is going to dissipate on its own, it will be in the first 6 months. But it doesn't always. A handful of patients will remain symptomatic a full year later. Why ND diminishes in some patients and continues to plague others is a mys- tery. Likewise, no one knows for sure why ND clears up in the first place. Some surgeons believe the pa- tient adapts to the phenomenon over time and stops noticing it as much. Dr. Miller, however, disagrees with that theory. "They don't just get used to it," he said. "It would be like trying to get used to having a ball and chain attached to your foot. You might learn to live with it, but you would- n't ever get used to it or act like it's not there. I don't think there are pa- tients getting used to it or neuroad- apting to it. I think it actually goes away." Dr. Miller believes ND disap- pears because lens epithelial cells begin to pack into the space be- tween the front and back capsule at the edge of the lens, reducing the difference in refractive index be- tween the inside lens and just out- side the lens. "They make the edge of the lens leaky to light," he said. "The light that leaks out illuminates the nasal retina and the shadow goes away." Because ND could simply go away, all surgeons interviewed rec- ommended waiting at minimum of 3 months, but ideally 6 months to a year, before trying anything surgi- cally. During that time period, hav- ing the patient wear thick-framed glasses might alleviate the symp- toms. "We always try to get patients out of glasses, but this is one case where glasses do help," said Dr. Davison. "Glasses can obscure the image so it makes it less distracting. It puts the shadow in the same cate- gory as a frame, and [the patient] doesn't notice it anymore." "Anything that will block a source of light on the temporal side, like a pair of spectacles, will reduce the symptoms," said Dr. Masket. "Unfortunately, that's not a satisfac- tory answer for many patients. If you can get thick-framed glasses, it's a good suggestion. It's worthy of a try." If a patient bucks at wearing glasses, it's time to consider surgery. Dr. Miller's preference is to do a full lens swap, taking out the offending IOL and replacing it with a rounded- edge or plate haptic lens in either the bag or the sulcus. "I'll put in a plate haptic lens like a STAAR Surgical collamer lens (Monrovia, Calif.) and will orientate the plate haptic in the 3 to 9 o'clock orientation," Dr. Miller said. "The optic is continuous with the haptic, so there's no lens edge to cause that problem anymore." Inserting a "piggyback" IOL, which was first reported by Paul H. Ernest, M.D., associate clinical pro- fessor, Kresge Eye Institute, Wayne State University, Detroit, is another surgical technique that's proven suc- cessful. Dr. Masket explained this technique in detail in the September 2011 issue of EyeWorld (page 16). A video of Dr. Masket's technique is available at www.eyeworld.org/ replay.php. "It's a simple surgery that brings with it a high degree of both techni- cal success and the alleviation of symptoms," said Dr. Masket. "I have heard reports where it hasn't helped 100% or even at all. Nothing is 100%, although in our research, we had either complete or significant reversal of symptoms. "The problem is you have a con- dition on which people don't have good facts, and they have a lot of emotions so you get a lot of opin- ions," Dr. Masket said. With so little clinical under- standing of ND, it's easy to see why the phenomenon both frustrates and captivates physicians. Even with a physical intervention, there will be the occasional patient who surgery won't help. In those cases, said Dr. Davison, it's up to the doctor to be a physician instead of a surgeon. "A surgeon repairs things, but a physician sits and listens to the pa- tient and councils him through problems," said Dr. Davison. "You can explain all the wonderful ad- vances we have, and there are mirac- ulous techniques and materials that we work with, but they are not like the good Lord's original equipment. There are limits to what we can do." EW Editors' note: The doctors interviewed have no financial interests related to this article. Contact information Davison: jdavison@wolfeclinic.com; via RN Carol Loney, cloney@wolfeclinic.com Masket: sammasket@aol.com; via assistant Ann McLean, avcweb@aol.com Miller: kmiller@ucla.edu November 2011 rePlay online content

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