Advancements in technique, technology and training have resulted in major improvements in the field of medicine, and the area of ophthalmology is no exception.

Such advancements as the use of tiny implantable devices, 3D operating systems and new microsurgery approaches have led to shorter recovery times and improved outcomes for those needing medical attention to address vision-related problems.

Butler County is home to several providers who stand ready to address those problems, but some area residents might not be aware that such providers exist. That’s why those providers are happy to share the latest developments in the realm of eye surgery and overall eye health.

Dr. Joshua Paul, a cataract and glaucoma specialist with Associates in Ophthalmology, said rural medicine can be very challenging because some people might not know the best way to get help for a certain condition or even what types of help might be available to them.

Paul said his group, which has an office at Pullman Center Business Park in Butler and locations throughout the East, has subspecialists who treat the three most common causes of blindness in elderly patients — glaucoma, cataracts and age-related macular degeneration — and they’re all available in the Butler area.

“We strive to make it as easy for patients as possible, and doing that helps people care for their eyes and makes a good outcome more attainable for them,” he said. “That’s something we really pride ourselves on.”

Paul said in many rural parts of the country, patients must travel for hours to see such specialists, “but we’ve picked this location to make it easy for that population.”

In layman’s terms, a cataract can be viewed as a fogging or clouding of the eye’s lens. In the past, once corrective lenses no longer proved effective, surgeons would manually remove the entire lens with surgical tools. Over time, however, practitioners began using ultrasound to break up the cataract into small pieces, which then could be removed via a vacuum-type instrument.

That advancement resulted in smaller incisions, less trauma to the eye and improved recovery.

Dr. Chris Spearman, of Scott & Christie Eyecare Associates in Cranberry Township, said today’s approaches also have reduced the length of the average surgical procedure considerably, and that’s not the only benefit.

“If you go back to the early 1990s, surgeries routinely took about a half-hour, and vision recovery could have taken a week to a month to start getting better,” he said. “And if you go back to the ‘80s, it was an inpatient procedure and people would be hospitalized for a couple days after surgery.”

Now, Spearman said, most cataract surgeries are completed in 10 to 15 minutes and even complex procedures can be completed in less than 30 minutes.

“Times are getting shorter and recovery is getting quicker,” he said. “And other than being faster and easier, the outcomes are more predictable or improved.

“It’s completely painless, and people usually get good vision within one to two days after surgery. It’s really quick gratification, which is good for me and good for the patient.”

Spearman said incision sizes have been reduced along with the length of cataract surgical procedures. In the late ‘80s and early ‘90s, the average incision might have been 5 millimeters, which created astigmatism that required a stronger prescription after surgery. Now, those incisions are more like 2.2 to 2.4 millimeters, which allows for faster healing and less of a prescription change after surgery.

Years ago, when it was determined that cataract surgery was necessary, the goal was to remove the cloudy lens and replace it with a clear lens, but in those cases the patient would need glasses to see properly. But over the past decade or so, many patients who have undergone cataract surgery have been able to do away with glasses following their procedures.

That’s because rather than inserting a clear lens, doctors can insert a prescription lens, thus often negating the need for corrective lenses. Some of those lenses, known as monofocal lenses, provide the same type of vision that one would get with standard distance-only glasses. But multifocal lenses can act similarly to a progressive bifocal lens, giving your entire vision a better depth of focus.

Spearman said that not everyone can become independent from glasses following cataract surgery, but it’s becoming more common.

“When I do patient visits to prep for surgery, half or more expect to be relatively glasses-free after surgery,” Spearman said. “That’s our goal. We can tell if that’s a reasonable expectation, and for a lot of people, it is.”

For some, however, it’s not. For example, some patients may have another eye disease that would preclude that from happening. Either way, Spearman said, it’s important for patients to discuss their needs and expectations with their surgeon to determine the best course of action before having cataract surgery.

“Some people get used to wearing glasses and don’t mind them,” he said.

Another new approach being used today to address cataract issues involves the use of 3D technology. Dr. Brian Jewart, a retina surgeon also with Associates in Ophthalmology, said 100% of the surgical procedures he performs involve the use of such equipment.

“I literally put on a pair of 3D goggles and use a 65-inch monitor,” he said, “and all the surgery is done through the 3D system.”

The system, known as the NGenuity Digital 3D Visualization System, allows Jewart to see things in-depth — an important advantage when dealing with such tiny elements. “We’re peeling microns of tissues sometimes,” Jewart said. “It helps to see that in 3D.”

The other advantage to using such equipment is that it’s physically less demanding. “It’s completely changed how we operate,” Jewart said. “We don’t have to be hunched over a microscope, and it allows us to operate on things we couldn’t operate on before. It’ll help us extend our careers because when you’re hunched over a microscope for 30 years, it can cause neck and back problems.”

Jewart said like anything else, there’s a learning curve when it comes to using such new equipment. “It’s hand-eye coordination,” he said. “Typically, you’re looking through a microscope straight into people’s eyes. Now, you have both feet on pedals and both hands on surgical instruments and you’re looking at a screen. It took about six months to get comfortable. But if you’re an eye surgeon, you tend to have good hand-eye coordination to begin with, so it’s not so hard to adapt.”

Jewart said another innovation that doesn’t involve new instrumentation or equipment has great promise in battling another leading cause of blindness — age-related macular degeneration, or AMD. He said that about six months ago, the Food and Drug Administration approved medication designed to slow the progression of what’s known as dry AMD, a form of the disease which until this year had not been treatable. Dry AMD is one of two forms of AMD — the other is wet AMD — and according to the Cleveland Clinic, 90% of all age-related macular degeneration is the dry variety.

“It’s revolutionary — it’s a game changer,” Jewart said. “With the dry kind, people lose 5% of their central vision every year. But studies show the new medication slows it down significantly. It’s a way to maintain your vision. Dry macular degeneration is really aggressive, but now we can treat it.”

Another issue related to eye health that affects many people is glaucoma, a group of conditions that damage the optic nerve. According to Dr. Andrew Williams, a glaucoma and cataract specialist and faculty member at UPMC, glaucoma is a chronic disease that cannot be cured. But it can be treated, and one of the most beneficial advances in that treatment is what’s known as microinvasive glaucoma surgery, or MIGS.

Prior to the advent of MIGS, doctors would use eyedrops and laser treatments to address glaucoma-related issues. And if those did not prove effective, doctors would create new drainage patterns to allow fluid to leave the eye and help maintain the proper pressure.

But more recently, surgeons began turning toward MIGS, which involves the implantation of tiny metallic devices called microstents that can help improve the eye’s drainage system, thus lowering one’s eye pressure and therefore slowing down the disease’s progression. The latest approach utilizes the existing drainage areas, rather than creating new ones.

“That’s really made a big difference, either as a standalone to treat glaucoma or in conjunction with cataract surgery for those who have glaucoma and cataracts,” Williams said.

Associates in Ophthalmology’s Paul said the new MIGS approach has allowed him and others in his field to treat a larger number of patients in a safer way that allows them to recover more quickly. Just about all glaucoma-related surgery and most cataract procedures other than those that involve advanced technology lens replacements are covered by most medical insurance plans.

Paul compared the old approach to glaucoma surgery to old open-heart surgical procedures in that they were much more invasive, required more incisions and sutures and resulted in a longer recovery time for patients — as well as more complications.

“Now we have more options,” he said.

Some of the microstents used in the procedures are so small they are dwarfed in size by things such as coins. One stent is 8 mm long, or roughly one-third of an inch, and some are even smaller. “You have to look at 8X on the microscope to see the structure,” Williams said.

While glaucoma and cataracts generally affect the elderly, children also are impacted by vision-related issues. Dr. Jane Hughes, a pediatric ophthalmologist, said strabismus surgery — a procedure to treat a misalignment of the eyes — is common among children. Common types of strabismus are esotropia, exotropia and hypertropia. Esotropia is a crossing of the eyes, exotropia is a drifting out of the eyes and hypertropia is an upward or vertical deviation of an eye.

Hughes said among the noteworthy advancements in pediatric ophthalmology in recent decades has been the growing use of optical coherence tomography, an instrument that uses light waves to take cross-section pictures of the retina. Hughes said it’s especially useful in following optic nerve and retinal pathology. Another advancement is the use of intraocular lens implants and small-incision surgery in children who require cataract surgery.

Doctors also are using adjustable sutures for certain types of procedures, which allows the patient to help determine if the eyes are aligned correctly after strabismus surgery.

Hughes, who graduated from medical school 30 years ago and practices at Pediatric Ophthalmology & Strabismus Surgical Associates, which has a location in Cranberry Township, said certain things she sees in children, such as more crossing issues or an increase in nearsightedness — or myopia — might be related to more time spent on their devices.

“We’re seeing that more and more in children, and there is some thought that it’s related to excessive screen time,” she said. “We’re definitely noticing a bit more crossing as the world has become more screen-based.”

Regardless of age, it’s important for people to be vigilant about their eye health before problems surface.

“I’d say the most important thing is having routine eye exams,” Paul said. “We work very closely with our optometry colleagues in Butler to care for patients, and they do an outstanding job of monitoring those patients and treating those with glaucoma and cataracts. So, seeing them is crucial.”

— Article by Frank Garland, photos by Shane Potter