consultation section

1. Do you recommend the use of intraocular lenses in cases of severe senile macular degeneration with all other parameters normal?

2. If loss of central vision from senile macular degeneration is a good condition for lens implan­tation, what is your opinion regarding implanta­tion of an intraocular lens in an eye that has become amblyopic for the same reason.

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1. It is logical to conclude that an intraocular lens would be most advantageous for those patients who will have complete loss of vision from senile macular degeneration after cataract extraction. Optically speaking, the patient who is unable to wear a contact lens and has senile macular degeneration and has 20/200 vision, or less, will certainly gain increased visual perspective by gaining their peripheral vision, which would be severely limited with the use of aphakic glasses. However, in my personal experience, in over 130 lens implants in the past 3Y2 years, my patients do not become particularly elated with the visual results after lens implantation with central visual acuity 20/200 or less. It may be that they do not realize what they have gained, and I have per­sonally not found it particularly satisfying as a surgical result.

2. Before this question was asked of me by Dr. Hecht, I had always considered an ambloypic eye a poor candidate for intraocular lens implanta­tion. If a patient gave a history of having poor vision in that eye for their entire life, I didn't consider this patient a candidate for cataract extraction. However, I must admit, in now analyzing this situation, that the logic should follow that if a lens implant is appropriate for senile macular degeneration of central visual acuity loss, it would also be so for loss of central vision from any other cause, including amblyopia. I would therefore entertain this concept in those patients with a strong motivation for an ex­tremely dense cataract in a previously amblyopic eye.

Kenneth J. Hoffer, M.D. Santa Monica, CA

1. I routinely recommend the use of intraocular lenses for cataract patients who have severe senile macular degeneration when the other parameters are normal. Cataract surgery without an intra­ocular lens for this type of patient is quite unsatisfactory since surgery and glasses give them neither side vision nor the potential for central vision. On the other hand, I have had a number of patients with senile macular degeneration who have been made quite happy by insertion of intraocular lenses in either one or both eyes after cataract surgery.

2. I would use the same rationale to treat a patient with amblyopia. I have one man of age 65 who was presumed to be amblyopic all his life who to our surprise and delight obtained an acuity of 20/30 following cataract surgery with an intra­ocular lens implantation.

John P. Beale, Jr., M.D. San Francisco, CA

1. Do I recommend the use of an implant in cases of severe macular degeneration. First I believe there must be an attempt made to correlate as ac­curately as possible how much of the visual loss is due to the cataract and how much due to the macular degeneration. If there is a severe macular degeneration and the patient has a useful other eye I could hardly see any justification for cataract surgery. If in fact the gaining of periph­eral vision as a probable result of the surgery would in someway enhance the individual's abil­ity to function then I could see a reason for surgery but I might add that I do not think that the availability of intraocular implants should loosen ones indication for cataract surgery to any sign i ficant degree.

2. I n reply to the use of an implant in an amblyopic eye the answer is essentially the same, that is, what is to be gained from improving the periph­eral vision in the amblyopic eye?

Murry K. Weber, M.D. Canoga Park, CA

1 &2. I do not recommend the use of intraocular lenses in cases of severe senile macular degeneration or amblyopia. The patient's peripheral vision is similar with or without intraocular lens implanta­tion. On a number of occasions where a mature cataract pre-operatively obscured the fact that the patient suffered from severe macular degeneration or amblyopia, I have implanted intraocular lenses. Post-operatively, I was able to ascribe the patient's poor vision to the maculopathy or amblyopia, however, I labor under the fear that the patient might blame the intraocular lens for his poor vision when in fact his central scotoma was due to a preceding pathologic condition.

Dennis D. Shepard, M.D. Santa Maria, CA

1. No - if there is no cataract I cannot see how an intraocular lens will be of any benefit to a case of senile macular degeneration. If, on the other hand, the question assumes that a cataract is present and is of severe enough density to reduce the patient's visual acuity enough that it restricts his peripheral visual acuity and makes it nearly impossible for the ophthalmologist to see the retina, then I believe an intraocular lens may be implanted with a substantial gain of peripheral visual acuity to the patient. The essence of the care in a patient with senile macular degeneration is do not be in too big of a hurry to remove the cataract.

Richard P. Kratz, M.D. Van Nuys, CA.

1. I n most cases of severe S.M.C.D. the condition is bilateral. In such a case if there is a mature or nearly mature cataract, I am fully in accord with the view that lens implantation associated with cataract extraction is the procedure of choice. I generally perform this only in one eye. If the cataract is not nearly mature the patient will benefit little from the procedure.

2. The situation with amblyopia is entirely different. This is usually a unilateral condition associated with suppression. Cataract extraction with lens implantation in such a case probably benefits the patient very little. It should be recalled that before the development of the cataract the patient had no binocularity or only a rudimentary form of it. Therefore this condition differs from that with senile macular degeneration.

Norman S. Jaffe, M.D. Miami, FLA

1. If the crystalline lens is a parameter, it must, of course, be cataractous. Severe senile macular degeneration means 20/400 or worse. I have heard it argued that aphakic spectacle correction gives these people an advantage because of the increased image size provided by a spectacle lens. Some surgeons, therefore, remove early immature senescent-type cataracts with the rationale that aphakic spectacle correction will be an improve­ment even if the cataract alone is of no particular significance. It would be interesting to know if these surgeons now are placing intraocular lenses after the cataract extraction, for that would certainly constitute a change in their reasoning. Yes, I think that lens implants are indicated in some people with macular degeneration but there are so many factors to consider in the individual case that short responses to a question such as this could be very misleading. Personally, I doubt that many eyes with 20/400 or worse (as a result of macular degeneration) deserve the added risk of an implant. An exception might be the first eye of an elderly, intelligent infirmed individual who is accessible for postoperative examinations.

2. That depends entirely upon the depth of the amblyopia. Some amblyopic eyes have 20/30 and others are best corrected at fingercounting two feet from the nose. Again, the patient's history, findings in the eye, acuity of the contralateral eye, etc. constitutes so many variables that a straightforward yes or no could be very mislead­ing. Surely, there are amblyopic eyes that are appropriate for consideration of an intraocular lens implant.

David Paton, M.D. Houston, TX

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1. One must ascertain whether or not a patient with senile macular degeneration requires lens extrac­tion. If this patient requires lens extraction, it is much wiser to use an implant than not to. Severe macular degeneration portends a very difficult low vision problem, since I infer the word "severe" means extensive central visual field loss. Certainly, a small central scotoma in the order of 5° is an ideal candidate for all forms of low vision assistance, which are greatly enhanced by the presence of an intraocular lens. A 10° to 15° field loss makes the problem very difficult for even the most meaningful low vision aid, and this diffi­culty is only minimally reduced with an intra­ocular lens.

2. I do not understand the second question, since I do not understand how an eye becomes ambly­opic. I should appreciate more details concerning this.

Miles A. Galin, M.D. New York, N.Y.

1. I have a few patients with truly "severe" senile macular degeneration, It is my impression that these patients have more than degeneration of the macula: they also have extensive degeneration of the entire posterior pole, and I am ready to believe some of the recent articles in the literature which suggest that these patients have depressed peripheral function as well.

These patients become functionally blind even in the presence of a clear lens. I suppose that If everything else were favorable and such a patient had developed nearly mature cataracts in both eyes so that I felt obliged to operate, I might put in a lens implant to give them as good vision as possible. Some of these patients however func­·tion just about as well without an aphakic correc­tion as with it.

On the other hand, ordinary macular de­generation patients with visual acuities of 20/200 or better certainly seem to benefit from lens implantation as far as overall visual function is concerned, and are good candidates for such surgery when the cataracts justify it.

2. I fail to see a connection between amblyopia and macular degeneration. The handicap of a condi­tion acquired late in life such as macular degen­eration, which in addition almost always effects both eyes to some degree, cannot be compared to a congenital amblyopia which has never bothered the patient in his entire life.

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The real question to be considered in doing lens implant surgery for an amblyopic eye is the status and future of the other eye. I n cases of deep amblyopia, the non amblyopic eye repre-

sents the patient's "only good eye," and most surgeons will not do lens implant surgery on such an eye. If in the future lens implantation is not to be performed in the non amblyopic eye, one certainly wouldn't want to do a lens implant on the amblyopic one. But then why remove a cataract from a deeply amblyopic eye anyway? If the lens is mature its removal may be advisable, but the failure to correct this eye optically poses no handicap to this patient with a deep am­blyopia anyway.

In mild degrees of amblyopia the arguments may be very different, and I have done lens implantation in such circumstances.

Robert C. Drews, M.D. Clayton, MO

1. Yes. 2. Same, if cataract.

Herbert Kaufman, M.D. Gainesville, Florida

1. SMD is an ideal indication for the use of intraocular lenses in cases where other parameters are normal. If a patient with SMD is fit with aphakic spectacles, the combination of the central scotoma from the SMD with the ring scotoma from the aphakic glasses leaves essentially no useful field and the patients are incapacitated because of their inability to ambulate. However, with an intraocular lens the patient ambulates quite well and is rehabilitated in all areas except for their reading.

2. Patients who have amblyopic eyes with cataracts can be helped in this eye providing the other eye is inadequate to meet their needs for ambulation. It is my opinion that the amblyopic eye need not be operated as long as the patient has been rehabilitated with the fellow eye in some manner.

Jerald L. Tennant, M.D. Dallas, Texas

1. I f the patient has a proliferative type of KhOnt­Junius discaform degeneration, I do not recom­mend intraocular lens implantation. I have exa­mined patients who have had intraocular lens implantations in such eyes, and they appear to subjectively and objectively offer little improve­ment over their pre-surgical condition. I n situa­tions where there is a non-proliferative maculo­pathy (of non-diabetic origin) providing this condition is known through previous history and if a cataract is present to the extent of 20/70 to 20/200 estimated visual disability by the cataract,

I would then consider lens extraction with simul­taneous intraocular lens implantation. This pre­supposes that I have been familiar with the appearance of this macula, having followed this patient for some time and that it is a "salt and pepper" type of pigmentary or apigmentary senile macular degenerative disease. These are usually older patients and I attempt to over plus them, making them artifically myopic. With the addi­tion of a moderate plus lens (+3.00) super­imposed on approximately a -3.00 refractive error, a very effective low vision aid has been satisfying these patient's needs for near vision.

2. To the best of my knowledge, I have never knowingly operated on an eye that is amblyopic with such a procedure. Wiesel, Hubel, and later von Noorden, et. al. demonstrated that in labora­tory animals (cats and monkeys) irreversible anatomic changes occur in the lateral geniculate body as a result of deprivation amblyopia. Physio­logically, this is not per se a loss of cone function in the macula which exhibits a cone bipolar cell ratio of 1: 1. This is a white matter loss, and I am of the opinion that this would not be ameliorated by intraocular lens implantation. This is, however, and opinion based on no experience but rather the statements of confreres whose honesty and integrity I do not question.

Donald L. Praeger, M.D. Poughkeepsie, N.Y.

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