"Could flowers change in color over time?" asked Wallace Janssen at a garden club meeting. "Azaleas, which I remembered as pink when first planted, seemed to have turned to a deeper, scarlet color. Bronze chrysanthemums seemed a darker red."
"No one had observed this," says Janssen, 78. "I knew it was my vision that was changing."
Janssen had cataracts, a diagnosis he was informed of at least 20 years earlier. But until recently and even though he had difficulty driving at night, he was able to delay cataract surgery with the aid of frequent eyeglass prescription changes.
"In my case, waiting had paid off," he says. "Years of technological progress had provided a superior solution to an age-old problem."
Janssen, who is the Food and Drug Administration historian, is one of an increasing number of patients and physicians responding enthusiastically to the effects of medical technology on cataract surgery. Advances in diagnostic equipment, surgical techniques and implants have made surgery simpler, quicker and more effective. Some operations are now done in the physician's office under a local anesthetic. The result: dramatically restored vision for most patients.
"When I started in cataract surgery, patients were staying in the hospital, immobile, 10 days waiting for their 180-degree incisions to heal," says Dr. Charles Kelman, clinical professor of ophthalmology at New York Medical College. "Now they come up to my office, have their operation, go out for lunch and go home."
Kelman, 52, attributes the change to the use of the phaeco-emulsifier, an ultrasonic needle he developed, which is now used in some cataract surgery.
"Instead of opening the eye half-way around, you make a small needle puncture and the cataract is dissolved with this ultrasonic needle."
A relatively new method of cataract extraction ("extracapsular") leaves the back part of the lens capsule intact, thus requiring a much smaller incision. "A week after extracapsular," says Arlington ophthalmologist Dr. Maurice Gaspar, "they don't even look like they've had an operation."
While the laser has also contributed to less invasive surgery, it is not, as many people believe, used to remove the cataract, but to remove the remaining membrane that sometimes clouds up after cataract surgery.
"Instead of having to stick a needle in and open the membrane," says Kelman, "we can now open it with the YAG laser. That is the only use of the laser for cataract surgery. Patients think they can come to the office and get their cataract out with a laser. There is no such thing."
Whatever the procedure, cataract surgery involves two parts, removing the cloudy lens of the eye and replacing it with one of three alternatives: "cataract" glasses, contact lenses or an intraoccular lens (IOL).
Twenty-five years ago, the only way useful vision could be restored was with extra-thick cataract glasses. Particularly for people with one "bad eye," the glasses can cause problems with focusing. For others, there may be poor peripheral vision and depth perception, and what is called a jack-in-the-box effect.
Extended-wear contact lenses, because they can be worn by cataract patients for two to three months at a time, have been convenient for some post-operative patients. But their disadvantages include fragility, possible infection, intolerance by some people for long periods and the necessity of regular visits to remove, clean and reinsert the lenses.
"The lens is very thin and does not correct the astigmatism perfectly," says Dr. Robert Ralph, Rockville cornea specialist and clinical associate professor at Georgetown University. "Protein combines chemically with the lens, so they cloud faster. It's expensive in the long run."
So far as daily-wear contacts, many older people don't have the dexterity, says Gaspar, who is on the George Washington University and Arlington Hospital staffs. "And often the eye gets drier as it ages, making contacts uncomfortable."
He estimates that 75-80 percent of his patients choose the IOL, a tiny piece of clear plastic, three-sixteenths of an inch in diameter, with plastic loops on both sides. "Some look," notes one physician, "as if they were conceived as doodles of feverish imagination and others look surprisingly like the last initials of their innovators."
"It the IOL is just such a superior way of treating a patient who no longer has a lens," claims Kelman, designer of five different types.
The intraocular lens is implanted surgically in the eye to replace the old lens removed during cataract surgery. It is maintenance-free and involves only a slightly higher risk than cataract surgery.
The A-scan machine, which the physician uses first, sends a high-frequency sound wave through the eye, providing, ultimately, a measurement of its length to determine the necessary optical strength of the implant.
The IOL, says Ralph, " "sits in approximately the same anatomical position as the lens that was removed so it distorts the rays the least."
Dr. Frederick Davidorf, professor of ophthalmology at Ohio State and editor of Ophthalmic Forum, says the implants have "truly revolutionized management of the cataract patient." Minneapolis ophthalmologist Dr. Malcolm McCannel, who returned to his normal surgical schedule three weeks after his own IOL surgery, believes the IOL "will be the rule, rather than the exception in cataract surgery."
"It works like a charm," says Kathleen Price, 69, who is now seeing 20/20 without glasses after Gaspar implanted an IOL in her right eye last December. She wears a temporary extended-wear contact in the left eye. A three- to six-month interim between IOL implants is customary.
"If my left eye can take it, I'll get one in there, too," says Price, who is retired from the Electronics Trade Association, "I can see better now than I have in a long time."
IOLs were discovered during World War II when Dr. Harold Ridley observed that the shattered fragments of plastic cockpits did not cause the usual inflammatory reaction in the eyes of pilots. Ridley implanted the first IOL in 1949 in England.
The early history of lens implantation involved, according to the American Academy of Ophthalmology (AAO ), "unacceptably high complication rates." Between 1975 and 1980 there were more than 20 IOL recalls, involving thousands of lenses with rough edges, lens warp and improper sterilization.
IOLs, along with pacemakers and IUD's, were the impetus for the 1976 FDA Medical Device Amendment. Since 1978, FDA has monitored a series of 300,000 implants through 13 manufacturers and reports from physicians.
Ralph Nader's Health Research Group called the initial FDA studies "seriously flawed," contending lack of uniformity in reporting methods, lack of long-term follow-up and insufficient basis for "any conclusion that a particular lens is safe and effective for general use."
However, most of the group's earlier complaints have now been addressed, says Allen Greenberg, staff attorney of the Health Research Group.
"IOLs are a very important innovation which can be useful to many people. Our main concern has been that 1) the people being fitted for them are the proper candidates 2) the physicians using them are qualified to fit them and 3) the lenses are made to high-quality specifications."
"Newer lens designs," points out the AAO, "have reduced the complication rate to only very slightly more than cataract surgery alone."
"Over the years I've been very cautious about the use of IOLs," says Robert Ralph. "For me it has only been in the last few years that I've felt much more comfortable with them. Now there is much better design and very good tolerance. I have not seen any dramatic complications from these lenses in the last two years."
In the seven years since the first list of contraindications--which recommended against implanting IOLs in both eyes--many ophthalmologists now feel safe in doing both eyes.
Although the enthusiasm is largely warranted by the number of patients whose vision has been successfully restored, some ophthalmologists are concerned that, as the AAO recommends, "the superior optical results . . . be weighed against the risks involved."
Certain patients are unable to tolerate IOLs and, occasionally, an IOL will have to be removed. IOLs require frequent follow-up, and although cataract glasses are unnecessary, patients usually will need some minor spectacle correction for reading or distance.
While some ophthalmologists are optimistic about long-term use (IOLs have been tolerated for 20 years and the plastic will last 40 years), the AAO does not recommend the lenses for children and young adults, and the FDA recommends "under 60."
Other specialists are concerned that long-term effects are still unknown.
"FDA says they are committed to doing the studies," says Greenberg, "but we haven't seen any protocols and no indication that they're moving forward. If people are going to have trouble five to 10 years down the road, we should start finding out about it."
According to FDA spokesman Chris Smith, all manufacturers have set up toll-free numbers to which physicians can report defects. Although the manufacturers have agreed to the studies, he concedes that FDA has not gone forward in demanding any.
But perhaps caution is in order for another reason.
Davidorf tells of one ophthalmologist's patient, an 82-year-old woman with slowly vanishing eyesight whose vision was restored to 20/30 after an IOL implant. Soon after the operation, she came into the office with a picture of herself at age 21.
"This is what I looked like before the cataract extraction," she wailed. "You have made my face look like a baked apple."
Says Davidorf with a grin: "I urge restraint lest we allow the success of IOL surgery to go to our heads!"