Michael J Kutryb, MD  

Specialties: Ophthalmology, Cataract Surgery, glaucoma

Interests: Ophthalmology
Kutryb Eye Institute - Titusville
Titusville, FL
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Laser to Change Eye Color Could Face Tough Road to Approval

Nov 03, 2011 - 5 comments

     The Headline from yesterday's MailOnline article states that Dr. Gregg Homer from Stroma Medical in California, has developed a laser procedure to make brown eyes blue.  It makes sense that a laser could be developed to target melanin containin cells in the iris and potentially help to break them up, but significant side might be a stumbling block to approval of the technology.  
     Melanin targeting lasers are already in use for other procedures.  In fact, a laser I use frequently, the Lumenis Selecta II laser, is used to reduce intraocular pressure in patients with glaucoma. The procedure is called SLT or Selective Laser Trabeculoplasty. It uses a special wavelengh of 532 of nanometers, to selectively be absorbed by melanin containing cells in the trabecular meshwork of the eye, the outflow channels that control the eye's pressure.  This laser is effective in improving fluid outflow through the meshwork but it does not lighten the pigmentation of the meshwork due to its lower power.   If a laser could be made to affect those specific cells, it seems possible that a laser could also be made to affect the melanin containing cells of the iris.
     Using currently available  lasers in the eye, we generally use extremely low power levels and ultrashort pulses of energy (3 nanoseconds for the Selecta II laser.)  We do this because, too much laser power can cause significant inflammation.  It is  the quick recovery, limited inflammation and superior safety that make the SLT procedure so popular.  A surgeon might use 100 pulses with a laser spot size of 400 micron.  The total area hit by a treatment would be less than 40 square millimeters with total duration of 300 nanonseconds.  
     Now, contrast using a new iris laser over the intire iris, and you might be looking at roughly a 92 square millimeter treatment area, double the area of a typical SLT treatment.  The amount of power needed to break up the melanin granules, however, might  have to be significantly higher.  This in turn could create inflammation and possibly dangerous elevations in the eye pressure, as all the liberated pigment would tend to clog up the trabecular meshwork.  Perhaps, multiple, low power sessions, could lessen inflammation.   Also, the eye's crystalline lens is located directly behind the iris, so could there be concern that excess laser energy would affect the lens, leading to cataract formation?  Finally, it should be remembered that the melanin pigment does have a purpose in absorbing visible light to improve visual performance and protect the retina from excess light.  Could there be atrophy or thinning of the iris after a prolonged laser treatment, leading to potential loss of vision? These are the type of questions that will have to be answered.
     In summary, while I am certainly no fan of anyone trying to change his or her eye color, it seems plausible that low power, targeted laser energy could, in theory, be used to at least lighten the color of brown eyes. Whether or not a desirable cosmetic result could be obtained, is at present, still unknown.  The treatment would likely have to broken up into multipe sessions and the relative risk of side effects, including glaucoma, cataracts and decreased vision would have to be determined.  

Femtosecond Laser Cataract Machines Create More Questions Than Answers

Oct 28, 2011 - 0 comments

     I had a chance to personally view the femtosecond cataract laser systems at the American Academy of Ophthalmology meeting this week in Orlando and I have to say that these systems are quite impressive.  Unfortunately, I have already been wowed in the past by the excimer laser systems that are used for Lasik and PRK surgery.  The new "femto" laser systems look like a small SmartCar in size with large touchscreen LCD monitors for the surgeon and technician to control and view the surgery.  A 3-D computer model of the eye is obtained and a computer-driven laser program has the ability to perform the incisions, the capsulorhexis (the opening into the cataract capsule) and fragment the cataract into segments.
     The femto lasers can do the same steps that a cataract surgeon usually does by hand, but they can do it more precisely.  For example, the surgical incision is typically done with a steel or diamond scalpel precisely sized at anywhere from 1.8 to 3.0 mm.  It takes the surgeon about 3 seconds to make the incision manually, while the femto laser takes around a minute, but it is a perfect incision essentially every time.  Opening up the cataract capsule is a step called capsulorhexis, and it is this step where the femto lasers have claimed clear dominance, demonstrating a superior ability to create a consistently nearly perfect opening in size and shape.  
     Experienced surgeons can still do a very good job at the capsulorhexis, but can't compete in consistancy over hundreds and hundreds of cases.  Questions start to pop up however, because early studies have shown that the improved opening made by the laser makes only a smallish improvement in overall refractive outcomes after cataract surgery and no clear improvement in safety.   Note that a surgeon can make the opening in a minute or less while the laser adds at least 15 minutes to the overall cataract surgery time. Is it worth the extra cost and increasing surgery times up to fourfold?  Remember, the femto laser procedure still requires the surgeon to use traditional phacoemulsification (a finely tuned ultrasonic handpiece) to remove the actual cataract.
     Lasers have so many possible applications but at what cost?  At what point do we go for our bagels being sliced by a laser or laser haircuts or manicures.  We could even have our lawns cut by a laser (maybe at Pebble Beach.)  At present, it is still too early to find consensus that the femto procedure is any better or safer than traditional cataract surgery.  There are some hints that it might be, but as they say, the jury is still out.  From a purely cost/benefit analysis, the extra cost may not be worth it for the average patient. Insurance plans and medicare, clearly are not going to cover any of the cost of the procedure, so patients will have to fork over one or two thousand dollars per eye for the upgrade.  In fact, one of the ironies of the possible femto revolution, is that the patients with the very advanced, complicated cataracts that might benefit most by the surgery, are likely to be the ones least able to afford a large cash-pay upgrade.  Stay tuned for a blitz of marketing from the few very wealthy or ambitious cataract centers that jump on the bandwagon early.  The pricing structure still remains murky.
     I just read an article about how retailers like Sears work very hard to create a tiered pricing structure for products with "Good", "Better", and "Best" products.  They find that a consistent number of customers will generally pick the certain percentage of each.  Often the Best (and most expensive) product serves another purpose, and that is to create interest in the Better (medium cost) product.  I'm sure you will see femto centers  will also have a lower priced, yet attractive non-laser alternative, so they are able to appeal to more patients.

Laser Cataract Surgery:  Five Things You Should Know

Jun 19, 2011 - 2 comments

1.  The new Lensx and Lensar femtosecond lasers can only perform certain parts of the cataract surgery procedure.  The laser can make the incision into the eye, the opening into the lens capsule (capsulorhexis) and soften the central part of the cataract into smaller pieces.  Unfortunately, the standard ultrasound hand piece is still needed to remove the cataract from the eye and the irrigation/aspiration hand piece will still be needed to remove the lens cortex, as before.

2. It remains unclear if the lasers will actually improve visual outcomes.  Early studies have shown that the lasers can make a statistically more precise capsulorhexis and that this might in turn lead to a slightly more consistent IOL position in the eye.

3.  The laser will make the surgery significantly longer, probably about 10 to 15 minutes extra, but that might come down a little with experience.

4.  Expect to pay a large fee out of pocket for laser cataract surgery, above and beyond what insurance will pay.  This will be considered a custom upgrade.

5.  Other than the laser making the incisions and pre-chopping the cataract, the recovery and postoperative course will be mostly unchanged.

Trust me when I tell you that you are going to be hearing much, much more about this subject.  I just wanted to get the conversation started and try to be as unbiased as possible.  There is already a big controversy among cataract surgeons as to whether the lasers will improve results or just make the surgery longer, more complicated, and much more expensive in a time when soaring healthcare costs are a major concern.  More to come.

Tennis Eye Injuries Are Totally Preventable

Mar 30, 2011 - 0 comments

     Tennis season is in full gear and it's a good time to remind you about the importance of proper eye protection.  With three girls playing competitive tennis in our family, balls are flying around constantly and I know that it is just a matter of time before someone gets a serious eye injury.  It very well might be me since I'm the one always picking up balls out on our court.  I have seen it firsthand, already.  An ophthalmologist I know very well, nearly lost one eye from a serious retinal detachment from a tennis ball injury.  One of our coaches at the tennis club, lost all the central vision in one eye and another had a bad retinal detachment, again from a serious tennis ball injuries.  

     Tennis balls can come at you at over 100 mph and can cause a tremendous amount of damage at impact.  At tennis clubs, balls can fly over from the next court or from your court when you're not paying attention.  Even a slow moving ball that your friend bounces to you can cause a corneal abrasion putting you out of commission for several days.

   My best advice is to wear a nice pair of sunglasses that are specifically made for tennis.  Bolle and Oakley are two excellent examples.  The lens are made of polycarbonate material which is virtually shatterproof.  It is essential that you get a pair that is ANSI (American National Standards Institute) approved for proper impact protection.

     One final note, these sunglasses will usually offer excellent UV protection for your eyes and eyelids as well.  Down the road, this could help reduce progression of cataracts and macular degeneration.  In addition, skin cancers are quite common on the lower eyelids especially.  This area of the face is absolutely bombarded with UV sunglight when outdoors and there is a reason why athletes wear eye black paint there to reduce the reflections off the skin.  Proper sunglasses will greatly reduce the amount of sun damage for the eyelids and should reduce skin cancers down the road.

     I just got back from the Sony Ericsson Tennis Open in Miami where I wathched Federer, Nadal and Sharipova practice and play.  None of them wear sunglasses on the court (but always wear them when styling around town.)Stay tuned, for my next blog which will discuss why professional tennis players hardlly ever wear sunglasse.  Elite players are so quick, they could probably deflect flying bullets, but if they wore sunglasses, they would encourage the average club to protect his or her eyes.