Cataracts

Your eye’s natural lens plays an important role in focusing images clearly on the retina. When a cataract develops, the lens loses its clarity. When the lens becomes cloudy, light rays cannot pass easily through it, and the image you see becomes blurry. Cataracts usually develop as part of the aging process, but can also come from eye injuries, certain diseases (such as diabetes) medications (such as prednisone), and genetic inheritance.

How can a cataract be treated?

A cataract may need no treatment at all if the vision is only minimally affected. There are no medications, drops, exercises or glasses that will cause cataracts to disappear. If the cataract changes your vision enough to interfere with your daily activities, surgery should be considered. Surgery is the only way to remove a cataract.

In cataract surgery, the cloudy lens is removed. This is usually done through a small incision using an ultrasound procedure called phacoemulsification. In most cases, the focusing power of the natural lens is restored by replacing it with a permanent plastic intraocular lens implant. Most lens implants are flexible and can be folded and inserted into the eye through a small incision shortening recovery time. Lens implants are usually placed behind the iris and into the lens capsule which previously supported your natural lens. Lens implant design, material, and insertion techniques have made them a safe and effective way to restore normal vision after cataract surgery.

Are there lens implants that will allow me to see without glasses after surgery?

With improvements in lens technology, there are options available to minimize the need for glasses after cataract surgery. Multifocal lenses allow you to see both far away and up close without glasses. With multifocal lenses, most people do not need glasses for distance or near work under normal circumstances. You may need glasses in certain situations such as reading in low light, very fine print, or night driving. Not everyone is a candidate for multifocal lenses. The cost of these lenses and the additional testing and surgical care that go along with them are not covered by insurance.

Toric lenses are designed to correct astigmatism. Astigmatism is when the cornea is shaped more like a football than a basketball, and light rays are defocused as they pass through the cornea. If you have astigmatism and have a standard lens implanted, you will need glasses for distance and near viewing. A toric lens will significantly reduce your need for distance glasses, but you will still need glasses for near. Not everyone is a candidate for toric lenses. There is additional out of pocket expense for these lenses as well.

The standard lens implant is a high-quality monofocal lens. These lenses result in improved vision but they do not correct for astigmatism or focus at different distances. This means many people with a standard lens implant will need glasses for distance and near (bifocals) after cataract surgery to optimize their vision. It is usually best to wait one month after surgery to get a prescription for glasses. If we are operating on only one eye, it is often best to balance that eye with the glasses correction needed for the other eye.

Laser correction of astigmatism: In some patients with lower levels of astigmatism, femtosecond laser surgery can be performed to surgically correct astigmatism. This is done at the time of cataract surgery and is typically combined with a standard lens implant, usually to try to minimize the need for glasses correction at distance. Individuals who elect to have this part of the procedure still require glasses for near vision. The laser surgical correction of astigmatism and the testing required for it is not covered by health insurance and therefore is an out of pocket cost for those who opt for this correction.

When are lasers used?

The femtosecond laser can be used to perform the first steps of the cataract surgery. The eye is numbed with drops, and the laser treatment takes just a minute or two. There may be a feeling of pressure during the laser treatment, but it is not painful. The rest of the cataract surgery is performed, usually, using ultrasound and irrigation to remove the cataract followed by placement of the lens implant. The improvement in vision after cataract surgery is the same with or without the femtosecond laser. You should discuss with your surgeon whether laser-assisted cataract surgery is right for you.

What can I expect if I decide to have surgery?

Before surgery

When you and your ophthalmologist have decided that you will have your cataract removed, be sure to mention any special medical risks you may have. You will be asked to see your primary care physician for a preoperative medical evaluation. Sometimes, blood-thinning medications such as aspirin and warfarin are discontinued before surgery.

An appointment will be scheduled for your lens measurement before your surgery. This is to determine the best estimate of the proper power of the lens implant. To improve accuracy, it is necessary to stop wearing soft contact lenses one week before this appointment and soft toric lenses two weeks prior to this appointment. If you wear rigid gas permeable lenses check with your surgeon, but the average time out of RGP lenses is one month.

The day of surgery

Surgery is done on an outpatient basis. You must not eat for at least six hours prior to surgery, usually, this means skipping breakfast. Upon arrival for surgery, you will be given eye drops and perhaps medication to help you relax.

A local anesthetic should make the operation painless. Though you may see light and movement, you will not be able to see the surgery while it is happening and you will not have to worry about keeping your eye open or closed. The skin around your eye will be thoroughly cleansed and sterile coverings will be placed around your head. During surgery, the most important way you can help your surgeon is by lying still and not talking. However, if you experience any pain or discomfort please notify your surgeon. When the operation is over, a patch may be placed over your eye. After a short stay in the outpatient recovery area, you will be ready to go home. You should plan to have someone else drive you home.

Following surgery

• Use the eye drops as prescribed.
• Be careful not to rub or press on your eye.
• Use pain medication if necessary. Usually, over-the-counter medication such as Tylenol or ibuprofen is sufficient.
• Avoid strenuous activities until advised by your surgeon. Normal daily activities and moderate exercise such as walking are fine.
• Ask your surgeon when you can begin driving.
• Wear eyeglasses or a shield as advised by your surgeon.

Will cataract surgery improve my vision?

The goal of cataract surgery is to correct the decrease in vision that was caused by the cataract. Over 97% of cataract surgeries result in improved vision, but a small number of patients may experience problems during or after surgery where vision could be worse. Cataract surgery will not correct other causes of decreased vision, such as macular degeneration, glaucoma, corneal disease, or diabetic retinopathy.

Complications

The vast majority of cataract surgery is successful and the risk of complications is low, but as with any surgery, there is never zero risks. All operations and procedures have associated risks and can result in unsuccessful results, complications, injury, or even death. Possible risks of cataract surgery with implantation of an intraocular lens include but are not limited to:

1. Discomfort. Cataract surgery is usually quite comfortable. Severe pain is unusual and
   should be reported to your surgeon.
2. Failure to obtain the desired result. The goal of surgery is to improve your vision by
   improving the focusing ability of the eye. If a surgical or postoperative complication were to occur, or if there are other co-existing conditions affecting the vision such as macular degeneration, the vision may not improve as expected or could even become worse than before surgery.
3. Need for additional surgery. If a surgical complication occurs or there are unforeseen problems with the eye, further surgery may be needed. The reason and purpose of any such surgery would be explained by your physician.
4. Complications which can result in loss of vision or eye such as:
   1. Infection, either superficial or internal
   2. Bleeding in or around the eye
   3. Retinal Detachment, usually requiring surgical repair.
   4. Swelling in the retina (macular edema), usually treated with eye drops but can require an injection of medication.
   5. Glaucoma or increased eye pressure, which may require medication or rarely surgery
   6. Inflammation in the eye
   7. Corneal swelling or edema, which can rarely require surgery if it does not clear.
   8. Drooping of the eyelid; may require surgical repair
5. Complications associated with the lens implant include night glare and/or halo, double or ghost images, or dislocation of the lens. Multifocal lenses have an increased likelihood of glare, halo, or seeing circles around lights at night. If this does occur it is usually not overly bothersome, but if it were to be significantly bothersome the multifocal lens might have to be removed and exchanged for a monofocal lens. If you have decided to have a premium intraocular lens, it is possible that your surgeon may not be able to use that lens as planned. If this were to occur usually a monofocal lens would be used.
6. Unexpected refractive result. While the method used to calculate the lens power is very accurate in most patients, the result may be different from what you and your surgeon planned. As the eye heals, the intraocular lens can shift very slightly toward the front or the back of the eye. This amount of shift is not the same for everyone, and it may cause different vision than predicted. This means you may need glasses or contact lenses to focus your vision. If the eye’s visual power after surgery is considerably different than what was planned, surgical replacement of the intraocular lens or laser refractive surgery might be considered. Patients who are highly nearsighted or farsighted have the greatest risk of differences between planned and actual outcomes. Patients who have had previous LASIK or refractive surgery are especially difficult to measure precisely.
7. Complications associated with anesthesia used for cataract surgery include loss of vision from injury to the eye, injury to the optic nerve, interference with circulation to the eye, bleeding, bruising, or drooping of the eyelid. Serious medical complications such as low blood pressure, breathing problems, heart problems, brain damage, and death are possible with anesthesia.