Complicated Cataract Surgery Procedure Performed by Dr. Ralph Monnett, Jr. on Patty Moreno Saves Her Sight

Story Reprinted from Florida Health Care News, Fall, 1998

"I've been essentially blind since birth in my left eye," says 49-year-old charge nurse, Patty Moreno. "The zonules -tiny fibers in the eye that hold the human lenses in place did not develop properly before I was born with dislocated lenses.

"The dislocation was worse in my left eye, so I use only my right eye, with glasses, to correct for astigmatism," she continued. Two years ago, Patty started having vision problems even while wearing her eyeglasses. "Mostly, it was the glare," she explained. "When I drove at night, the headlights of oncoming cars and the street lights nearly blinded me. I could not see to drive safely, and I experienced difficulty with reading."

Patty assumed it was time for her eyeglass prescription to be changed again. "My optometrist had noted the beginnings of a cataract the previous year," she recalled. "When he checked my eye for my latest complaint, the cataract had grown significantly and was forming in the central part of my vision."

A cataract is the progressive clouding of the eye's natural lens, which impedes the passage of light, resulting in blurred images. Cataracts most often begin forming when people are in their forties as a normal part of the aging process, and typically become significant between the ages of fifty and seventy. In a few unusual cases, like Patty's, cataracts sometimes form earlier in life.

She and her optometrist considered her options. "Being a nurse, I know that complications can occur in even the simplest procedures," she acknowledges. "If I scheduled cataract surgery and anything went wrong, I'd be blind for life. Not addressing the cataract meant that my sight would continue to deteriorate anyway."

Patty had plenty of experience with serious eye problems, not only as a patient, but also as a former scrub tech and nurse in the Department of Ophthalmology at the University of South Carolina. Patty remembers wondering where her optometrist would send her for the challenging surgical procedure required to remove the cataract.

"He could have sent me anywhere in the country," says Patty, "and I would have gone, but he recommended Ralph B. Monnett, Jr., M.D., a board certified ophthalmologist at the Monnett Eye & Surgery Center, assuring me he felt strongly that Dr. Monnett is the best surgeon in the state.

SIMPLE PROCEDURE

"Normally No Needle/Instant Sight cataract surgery, and advanced technique that I introduced and have performed locally since 1994, takes only a few moments, and is accomplished for most patients without needle injections; eye drops are used to numb the eye," relates Dr. Monnett. This eliminates potential surgical complications, including blindness related to the use of needle injections.

The typical surgery is accomplished painlessly in about five minutes.

A tiny incision approximately one eight of an inch long is made where the clear cornea meets the white sclera. There are no blood vessels in the cornea, so bleeding is never a concern. Patients who are on blood thinners do not need to suspend their necessary medications in preparation for surgery.

Through the incision, a tiny probe introduces ultrasound waves that fragment the semi-hard cataract and vacuums it away in a procedure called "phacoemulsification."

Next, a tiny intraocular lens implant is inserted through the same incision. Because the incision is so small, it requires no stitches to heal. Patients should avoid swimming or strenuous activity for a few days, but some patients go out to dinner the evening of the surgery, and play golf the day after.

SPECIAL CHALLENGES

"Patty's case posed special concerns," acknowledges Dr. Monnett . "The dislocated lens weakened support for the usual procedure of placing the implant behind the iris. The other option was to place the implant in front of the iris, which I was reluctant to consider because this type of implant could, over many years, deteriorate the cornea. Patty's cornea was going to need to tolerate the implant for as many as fifty years, not the usual ten or thirty years of the average cataract patient. I felt we needed to pursue another option," he concluded.

Dr. Monnett has used an advanced technique to suture the implant into position behind the iris in the eyes that lacked adequate zonular support. "I felt that was the only option to preserve Patty's vision throughout her lifetime," Dr. Monnett relates. "I knew there was going to be more discussion of this technique at an upcoming national eye conference." Dr. Monnett advised Patty to postpone her surgery until after the conference to allow him to confer with colleagues.

"I felt very comfortable with Dr. Monnett," attest Patty. "He has a way of explaining things that puts you at ease, and he is very thorough, but when Dr. Monnett described his plan to suture an implant to the sclera behind the iris, I got a little scared."

Patty called her former employer, the chairman of the Department of Ophthalmology at the University of South Carolina, to ask his opinion. Her trusted colleague agreed that the procedure Dr. Monnett described was best and added that no one at the university facility was versed in the technique. Patty realized her fortune in having Dr. Monnett perform her surgery.

Dr. Monnett admits, "Patty's surgery is probably the toughest cataract surgery I've performed in all my years in practice." Instead of the usual five-minute procedure, Dr. Monnett labored nearly two and one-half hours. "Every aspect of Patty's surgery was especially complicated. I had to patiently deal with a number of challenges as the surgery unfolded, always remembering that every solution would need to last forty to fifty years for this younger patient."

Dr. Monnett suspected the zonules would not provide enough support for a typical implant, and he was right. "When I tried to place the implant, the zonules failed to hold, and I had to retrieve the implant," relates Dr. Monnett. "Some of the vitrous gel that fills the back of the eye came forward through the weak zonules, and was removed with specialized instruments."

It was apparent to Dr. Monnett that the option to suture the implant had to be exercised. "The eye was extremely soft after removal of the vitreous, making the placement of incisions on the sclera for suturing the implant extremely difficult," Dr. Monnett added. "Patience and precision were needed to place the incisions and suture the implant into place."

SEEING, BELIEVING

Patty recalls that Dr. Monnett was right there as she awakened, explaining how the procedure had to be changed to accommodate the weakened zonules in her eyes. "Dr. Monnett explained that my healing would take a little longer since my procedure required stitches," says Patty. "He told me what I should expect from the surgery, what complications there might be, and what he and I could do to offset them."

Patty wore a protective patch for the first 24 hours following surgery, and when Dr. Monnett removed the patch the next morning, Patty's vision was clearer, but not crisp.

"That was to be expected," reminds Dr. Monnett. "Patty's surgery was complicated, resulting in more swelling of the cornea and a longer period of healing than usual. I warned Patty that her vision would change and improve over a period of several weeks."

Patty returned to work just three days after her operation, with only a slight feeling of scratchiness caused by her stitches. After six weeks Patty's vision stabilized: "It's been two years since my surgery, and my visual acuity is 20/20 in my right eye. I never expected it to be that good!"

Now, Patty wears her eyeglasses, usually only at work, for fine reading, as is usual after cataract surgery. The implant provides acuity for distance vision.

She credits much of the quality of her life to Dr. Monnett's expertise.

"My experience as a nurse, especially with ophthalmology cases, makes me appreciate what Dr. Monnett accomplished for me," states Patty. "We did some difficult cases in South Carolina, and I saw some challenges, but I have to tell you: I THINK DR. MONNETT IS ONE OF THE BEST SURGEONS IN THE COUNTRY."