Cataract Surgery
“I have a cataract, now what?”
Trey Bishop, MD and Scott Schultz, MD
In our daily patient exams, we frequently find ourselves saying “You have a cataract,” followed by “Don’t worry.” We then attempt to reassure you by discussing the benefits versus risks of proceeding with cataract surgery.
The truth is, once you understand what a cataract is, how it will be removed, and how your vision may be improved with modern day technology, your concern about your diagnosis could turn into excitement.
What is a cataract?
A cataract is a clouding of the natural lens inside your eye. This lens works much like the lens of a camera. It is located behind the colored part of the eye known as the iris. It focuses light images onto a “film” known as the retina. The retina in turn forwards the images to your brain via the optic nerve.
The human lens is made mostly of protein and water, and can become clouded. When it does, this is referred to as a cataract. A cataract prevents light images from clearly focusing onto the retina. While eye injuries, certain diseases, and some medications can cause the clouding, in over 90% of cases the clouding is simply caused by aging.
What are the symptoms of a cataract?
A cataract can cause sharp images to become blurred, bright colors to become dull, or seeing at night to become more difficult. You may have trouble seeing fine print even with reading glasses or you may have increased trouble driving at night secondary to glare.
Can cataracts be prevented?
Unfortunately, the answer is no. You cannot prevent a cataract. As mentioned above, the development of cataracts is typically due to aging.
Fortunately, removing the cloudy cataract and replacing it with a clear intraocular lens can restore your vision and significantly improve your quality of life. The time to consider cataract surgery is when the quality of your vision begins to place limits on your activities and enjoyment of life.
What is involved with cataract surgery?
Cataract surgery has evolved to become one of the safest and most successful procedures performed today. Most advanced surgeons use a “no shot, no stitch” technique that is performed in minutes with only mild sedation as an outpatient surgery.
Your eye is treated with an anesthetic drop prior to the procedure so you will feel little, if any, discomfort. A small incision is made in the clear part of the eye known as the cornea. An additional circular incision is made into the front outer capsule of the cataract. A small ultrasound-emitting instrument about the size of a pen tip is then manipulated to fragment and vacuum away the inner cloudy component of the cataract leaving behind a clear outer lens capsule. Finally, a new intraocular lens implant is inserted through the same small corneal incision and placed into its permanent position within the capsule.
The whole process from check-in to check-out usually takes a couple of hours. You will need a family member or friend to drive you home following surgery due to mild sedation. Most patients feel comfortable driving to the first post-operative exam the next day.
You will use prescription eye drops to guard against infection and assist with healing. These typically begin several days prior to your surgery and are tapered over several weeks. You will receive specific written instructions regarding these drops that will be reviewed with you both before and after surgery. You may need to wear a protective shield the first night to prevent you from inadvertently rubbing your eye. Of course, everyone heals differently, but you will most likely be able to return to your routine activities the next day.
Will I be able to see right away?
Yes, you will be able to see right away, but the vision is typically blurry the first 24 hours due to dilation and postoperative recovery. The vision typically improves over several days.
While many patients report excellent vision the first day after surgery, others may experience moderate or even severe blurriness or cloudiness due to swelling in the cornea, the front clear part of the eye through which the surgical incision is made. This is analogous to “fogging of your windshield.” The degree of swelling is dependent on the maturity of the operated cataract and the health of your cornea among other things. Fortunately, the swelling typically clears over a few days.
In addition, patients often report a shimmering sensation in their vision the first few days. This is normal and is due to tiny insignificant movements of the new lens implant in its proper position within the capsule. This typically resolves quickly as the capsule “shrink-wraps” around the lens.
Finally, patients often describe a shadow temporally early in their recovery. This is normal as you adapt to your new intraocular lens and typically resolves in a matter of a few days or weeks.
Does it hurt?
No, surgery is typically very comfortable. Of course, all patients are unique in their response to sedation and tolerance of pain. Many patients prefer to remain alert during their procedure, while others prefer to “remember nothing.” You will have an anesthesiologist and/or their assigned CRNA by your side to monitor your overall status and ensure your safety and comfort.
Immediately after surgery, some patients report a scratchy or foreign body sensation in their eye. This is normal and is typically due to the anesthetic drops used prior to surgery and/or the very small incision created during surgery. This usually resolves within 24 hours.
Some patients report the onset of these symptoms a week or so later. This is typically due to a condition known as dry eye often accompanied by inflammation of the eyelids known as blepharitis.
It is important to note that cataract surgery does not cause dry eye or blepharitis. Rather, they can be pre-existing and if previously unnoticed, were just asymptomatic. They can become symptomatic when challenged with the routine course of post-operative drops. If this occurs, artificial tears may help. Depending on the severity, specific treatment for dry eye and blepharitis may be needed.
Is there a chance something could go wrong?
Yes, cataract surgery is just that, surgery. As with any surgical procedure, there are inherent risks. These include but are not limited to infection, bleeding, chronic inflammation, detachment of the retina, and glaucoma to name a few. These complications can be serious leading to severe loss of vision or blindness. Fortunately, they are rare in an otherwise healthy patient in the hands of an experienced surgeon.
In addition, there are pre-existing conditions which may limit your vision even after “perfect” cataract surgery. These include but are not limited to conditions of the cornea such as Fuchs dystrophy; vitreous conditions such as “floaters;” retina conditions such as macular degeneration, diabetic retinopathy, and epimacular membranes; and optic nerve conditions such as glaucoma.
We will discuss with you your potential risks and benefits to help you decide whether cataract surgery is right for you.
Do cataracts come back?
No, your original cataract does not come back. However, your lens implant is held in place by a thin membrane known as the lens capsule. This capsule is the outermost lining of the original cataract. Furthermore, it may become cloudy with time. If it does, it is referred to as posterior capsule opacification or PCO. Fortunately, PCO is easily taken care of by “polishing” away the central cloudiness using a laser in the office. The procedure is known as a “YAG” Capsulotomy and is painless. In addition, while it is a procedure and has risks, they are minimal and rarely occur.
I’m guaranteed to see without glasses, right?
No. As stated above, cataract surgery is one of the safest and most successful procedures performed today. But while safety is the most important aspect, some have the false perspective that the procedure is not a success if they must wear glasses afterwards.
It is true that a large part of the success enjoyed by patients is owed to tremendous technological advances that afford us outstanding refractive results, thus allowing great visual freedom.
However, there is a stark difference between very successful traditional cataract surgery and cataract surgery that also enhances your vision by lessening your dependence on glasses and increasing your visual freedom. The latter is referred to as refractive cataract surgery. There are risks to any surgery, and while refractive cataract surgery is generally very successful, it is no exception. To better understand, it is important to first know about traditional cataract surgery.
What is traditional cataract surgery?
The objective of traditional cataract surgery is to simply restore your best-corrected vision to its pre-cataract status in a medically safe and effective manner. Best- corrected implies with glasses if needed.
Typically, most cataract patients selecting this approach have their vision improved with a monofocal lens focused at one point, usually distance. The power of the lens you require is traditionally determined by a keratometer to measure the curvature of the cornea and an ultrasound device to measure the length of the eye.
While the quality of your vision is generally excellent, any preexisting astigmatism and any postoperative farsightedness or nearsightedness you have is corrected with glasses.
In addition, your vision is limited in its range of focus because the lens implanted is monofocal. If focused at distance, you will need to wear reading glasses or bifocals for near vision and some intermediate vision.
In contrast, the goal of refractive cataract surgery is to not only restore your vision safely, but to also enhance your vision. Various advanced technologies and techniques are used to custom tailor your treatment to optimize your vision and minimize your dependence on glasses. The ultimate goal is to provide you the visual freedom to match your personal lifestyle.
What is involved with refractive cataract surgery?
Successful refractive cataract surgery is multifaceted.
First and foremost, we get to know you. We learn of your interests and hobbies. Do you play golf or tennis? Do you enjoy photography or bird watching? Do you paint or play a musical instrument? We also learn of your needs. Do you drive a great deal? Are you at the computer a lot? Do you read extensively? Lastly, we determine your expectations. Are they realistic? That is, are they too high? Or are they are too low?
Second, we get to know your eyes. We go way beyond the ordinary clinical eye exam by incorporating advanced technology such as corneal topography, corneal specular microscopy, and retinal macular optical coherence tomography to best ascertain your visual potential. In addition, we utilize the latest in optical biometry to make the most accurate and precise measurement of your eye’s parameters available. We then use numerous latest generation formulas like the Barrett Universal II and Hill-RBF to analyze these parameters and predict the best intraocular lens power suitable for your eye.
Lastly, we help you choose the refractive option that best meets your individual needs and preferences. This includes selecting the method with which the surgery is performed as well as the type of intraocular lens implanted.
Methods? Are there more than one?
Yes, we have two ways to access and remove the cataract from your eye and prepare it to receive your new clear lens implant.
Traditionally, we accomplish these tasks using delicate blades and forceps to manually incise the cornea and cataract followed by harnessing ultrasound energy to mechanically fragment and vacuum away the cataract as described above. Successful traditional cataract surgery is truly an art, and rest assured our traditional approach is “state-of-the-art.”
In 2012, we were among the very first to adopt the use of laser to help accomplish these tasks. In our opinion, Johnson & Johnson Vision’s CATALYS Laser is unquestionably the most technologically advanced option for cataract patients today. While still an art, the laser lends incredible accuracy and precision to the equation. The laser takes our “state-of-the-art” to a whole new level.
I have heard of the CATALYS laser. Why is laser accuracy and precision so important?
The CATALYS provides unparalleled accuracy and a truly custom-tailored surgery for your eyes. While all human eyes share the same basic anatomy, your eye is unique in its curvature, depth, width, and length. We measure these features prior to surgery, then use the CATALYS in surgery to capture incredibly detailed, high-resolution images of your eye. We then use the measurements and data these images provide to accurately plan and perform your surgery to exacting specifications not attainable with our traditional surgery.
CATALYS Precision Laser System
The CATALYS performs precise and extremely delicate surgery for your eyes. We use the CATALYS to produce femtosecond pulses of light and precisely deliver those pulses to the desired surgical targets via a computer controlled optical delivery system. This avoids the need for blades and conserves energy making the procedure as delicate as possible.
Impressive. So, what are my lens options?
Before grasping the options in detail, it is important to understand the primary purpose and general design common to most modern intraocular lenses (IOLs) used in cataract surgery today.
The main job of the IOL is to focus light onto the retina at the back of the eye just as a healthy natural lens would prior to cataract development. From here, the light rays are converted into electrical impulses that travel to the brain, where they are then converted into images. If the light is not focused correctly upon the retina, then the brain cannot process the images accurately.
Most IOLs share a similar construction comprised of a round, corrective central portion referred to as the optic connected to two “arms” known as haptics. The optic transmits and focuses light while the haptics keep the optic securely centered within the capsule where the natural lens used to be. Most of today's IOL optics are about a quarter of an inch or less in diameter and soft enough to be folded so they can be placed into the eye through a very small incision.
Beyond these shared characteristics, modern IOLs can vary widely in quality, design, material, and function. Rest assured that we use only the highest quality and best designed lenses on the market. Our personal favorites are the Johnson & Johnson TECNIS IOLs.
Tell me more about the lens options.
There are three main lens options that we use for our patients.
The most traditional is the Monofocal IOL. Though traditional, we elect to use the most modern “New Technology” Aspheric Monofocals designed to give patients without astigmatism the clearest, distortion free vision within a set range, usually distance. Our favorite model is the TECNIS Monofocal.
A variant of the “traditional” Monofocal is the premium Astigmatism Correcting Monofocal IOL referred to as a Toric. As the name implies, this variant is designed to give patients with astigmatism the clearest, distortion free vision, again within a set range, usually distance. Our favorite is the TECNIS Toric II.
Lastly, our most innovative lens is the premium Multifocal IOL. Using highly specialized optics, this variant is designed to give patients with or without astigmatism clear vision over a wide range of distances from near to far. Our favorites are the TECNIS Multifocal and Multifocal Toric II.
What if I want to read without glasses with either of the Monofocal IOLs?
For our monofocal patients who prefer to read without glasses, you have two options.
The most popular option is monovision, which we like to call blended vision, in order to distinguish it from the monofocal lens itself. This is where your dominant eye is focused at distance and your non-dominant eye is focused at near. While you may notice compromises in near depth perception and night driving without glasses, it is a very acceptable alternative for many, especially those of you experienced with blended vision in contact lenses.
A much less popular but occasionally chosen option is to place both of your eyes at near. This obviously requires you to wear glasses for all distance related visual tasks, but it is an option for those of you who are avid readers or hobby enthusiasts who work at near continuously.
What if I have astigmatism but not enough for a Toric lens?
If you have a low amount of astigmatism, your astigmatism may be treated with the CATALYS laser. Using the CATALYS, we create a simple extra incision or two, referred to as corneal relaxing incisions, to lessen your astigmatism.
Am I settling for less if I don’t choose the Toric or Multifocal lenses?
No, absolutely not.
First, if you have little to no astigmatism, the Toric is not indicated.
Second, you may not be an appropriate candidate for the Multifocal.
Third, you benefit from the technology and skills we use to perfect the premium lenses even if you do not choose the Toric or Multifocal.
Most importantly, as previously stated, all our lenses are state-of-the-art. The descriptive term “premium” simply denotes those lenses with features that are considered optional and above-and-beyond the standard set by insurance carriers.
Is there anything else that I should know about?
Yes, it is important to know that if you have previously undergone laser vision correction such as LASIK, PRK, or RK, these procedures decrease the accuracy of all our lens power formulas. As a result, your post-operative visual outcome without glasses is less predictable.
Fortunately, you’re not alone, and at Bishop Eye, we go to considerable additional effort to adjust our calculations to account for the effects of these previous procedures. We utilize proven methods to improve our calculations in these challenging situations so we can more accurately predict your post-operative outcome. We have become quite skilled in this regard and keep up to date with the very latest technology for this purpose.
All these technologies and options are somewhat overwhelming. Help!
We understand completely. That is why our extensive preoperative consultations are worlds apart from the ordinary.
We block an entire hour for each and every preoperative work up to ensure that we gather the information we need, and you garner the knowledge you need to make the very best decision possible.
While we ask that you prepare for the consultation by becoming familiar with our educational literature, we do not expect you to arrive with a decision. Only after a thorough discussion of the options suitable for you will you be asked to finalize our plan.
Of course, we will help guide your decision based on our experience and opinion if you so request.
How should I choose? Can I make a mistake?
In our opinion, the only way to truly make a mistake is to not take the time to learn of your options so that you can make a truly informed decision.
These options are conveniently summarized for you in two separate handouts describing our cataract surgery packages and their associated costs.
If you have a low to moderate amount of astigmatism and want the very best available independence from glasses at distance with over-the-counter readers, we recommend the LASER Astigmatism option. With this package we address your astigmatism with the laser to help you see in the distance without glasses, but you will need readers for close tasks. In appropriate patients, blended vision can be considered to reduce the use of glasses for reading. In both cases, you enjoy the added accuracy and precision of the laser.
If you have a moderate to a large amount of astigmatism and want the very best available independence from glasses at distance with over-the-counter readers, we highly recommend the LASER Toric option. Just like above, with this package you can also choose blended vision and you enjoy the added accuracy and precision of the laser.
If you are an appropriate candidate with or without astigmatism and want the very best available independence from glasses at distance and near, then we recommend the LASER Presbyopia option. This package allows the greatest visual freedom without glasses for the most active of lifestyles by implanting a multifocal lens.
If you are safety and technology conscious and don’t mind wearing glasses after surgery for distance, intermediate, or reading, we recommend the Advanced Technology option. With this package, depending on how much astigmatism you have, you may or may not prefer glasses to fine-tune your distance vision. You will typically need bifocals or reading glasses for intermediate and near tasks. Regardless, your corrected vision is expected to be much clearer with considerably improved contrast and color than prior to surgery since the cloudy cataract has been removed.
Of import, even if you prefer to wear glasses after surgery, at a minimum we recommend our Advanced Technology option. The diagnostic and refractive analyses included in the Advanced Technology package are very important and extremely cost efficient. Only through our use of these modern technologies are we able to truly advise you regarding your options to achieve your best vision.
To perform modern day cataract surgery without using these technologies dramatically compromises potential results in all but the most visually limited eyes. If cost is an issue, please let us know. We truly want the newest diagnostic technologies to be accessible to all.
When making a choice, keep in mind that one size does not fit all. There is no one choice that is perfect for everybody. The good thing is all of our refractive cataract surgery packages are excellent. It is just a matter of which option best serves your needs and lifestyle goals.
Is there an adaptation phase for my new IOLs?
Yes, it is important to understand that you must allow time to adapt to your new optics. Neuroadaptation is where the visual centers of your brain learn to utilize the images focused upon your retina by your new IOLs.
This process is particularly important for our multifocal and blended vision patients who must adapt to distance, intermediate, and near images provided by their new IOLs.
In our experience, neuroadaptation with multifocal and blended vision is typically accomplished fairly quickly over several days to weeks and continues to become more natural over a period of several months.
In addition, early on you may notice halos around point sources of light in dark surroundings. They are normal and are particularly noticeable in our multifocal patients due to the design of the optics and in our blended vison patients because one eye is focused at near. They typically diminish as neuroadaptation occurs.
However, they may persist in a small percentage of patients. If so, they can usually be improved with corrective lenses for night driving if needed.
Furthermore, your reading vision with multifocal and blended vision is best obtained with bright light and good print. Dim lighting and poor quality print can limit your ability to read as usual and may require over the counter or prescription reading glasses.
What happens if I never neuroadapt?
The inability for a patient to neuroadapt is rare. However, it can occur. If after a sufficient length of time we determine that a lens choice is incompatible with your vision, we can usually exchange the lens for another lens model utilizing different optics. Again, such a scenario is rare, but exchange is typically very successful.
What if I still need glasses after refractive cataract surgery?
First, we will provide every patient with a prescription for glasses after cataract surgery whether you choose to use the prescription or not.
The overwhelming majority of our refractive cataract patients are minimally dependent on glasses, but having a pair to fine tune your vision for special occasions is not out of the question.
Second, if you elect to have refractive cataract surgery and you feel your uncorrected vision does not meet your expectations, we will work with you to achieve your goals.
We offer extremely discounted or no cost laser vision correction to those patients who would benefit and are medically appropriate.
I don’t have cataracts. Can I still have an intraocular lens to gain freedom from glasses?
While the FDA approved the CATALYS laser and the TECNIS lenses for the primary implantation in cataract surgery patients, they may also be used off-label for refractive surgery, that is, surgery done to simply provide you freedom from glasses.
The multifocal is a particularly good option for those in their late 40’s or better who suffer from presbyopia. Presbyopia is the decreased ability of the natural lens to focus over a range of distances that occurs with aging. The condition eventually affects everyone, including those who are nearsighted, farsighted, have cataracts, or have had perfect vision most of their life.
The procedure for using an intraocular lens in a patient prior to the development of a cataract is essentially identical, except it is no longer referred to as cataract surgery. Rather, it is often referred to as a refractive lens exchange or clear lensectomy. If you are in this age range and have deferred laser vision correction because of the need for reading glasses, you may be interested in this potential new visual freedom.
Bottom line, what do you recommend Doc?
Bottom line, if you are considering cataract surgery or a refractive lens exchange, you are doing so at a time when lens-based surgery has taken a giant leap forward. The synergy of our laser precision and accuracy coupled with our premium lenses offers the opportunity to not only restore but truly enhance your vision.
