Performing Cataract Surgery
For Over 35 Years
Cataract surgery is the most common surgery performed in the U.S. today. It is performed on an out-patient basis and can offer significant improvements to vision. In cataract surgery, the clouded lens of your eye is replaced with a plastic lens, an intraocular lens (IOL).
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Cataracts are a slowly-progressing discoloration of the lens of the eye that probably actually starts the day we are born. The lens is crystal clear at birth but slowly turns brown with age, mostly due to UV-induced changes in the proteins of the lens. Everybody’s lens discolors with age but not everybody needs cataract surgery. Eventually, the brown discoloration of the lens may interfere with vision and that’s when you need cataract surgery.
Cataract surgery is elective. You have cataract surgery when your lens has discolored to the point that you are having difficulty seeing to perform your daily activities. Typical cataract-induced vision complaints are glare in bright light or at night from headlights, blurred, dim or distorted vision. The cataract does not physically damage the eye but it sure can blur the vision. When you are having difficulty seeing to do your daily activities, like driving, especially at night, reading, seeing to walk safely, etc., then you need to consider cataract surgery.
Obviously, if you are having difficulty seeing to perform your daily activities, you need to have your eyes examined. Cataracts aren’t the only cause of blurred vision. You may just need your glasses prescription updated, or you may have other problems with your eyes, like glaucoma, macular degeneration, dry eye, etc.
During cataract surgery, a small, self-sealing 1/8 inch incision is made in your eye’s cornea – the clear, outer layer of your eye. The wound is so small it does not even usually require a suture to close. The lens of your eye is removed and an intraocular lens (IOL) is inserted in its place. The IOL is not susceptible to discoloring like your original lens. You may feel pressure during your cataract surgery, but the majority of patients do not describe the procedure as painful. Anesthetic eye drops are administered to numb your eye.
There are many different IOL options available. Traditionally, monofocal IOLs have been used in cataract surgery. Monofocal IOLs focus the eye at one distance only and do not correct astigmatism. These lenses are usually covered by insurance and, depending on the lens selected, will allow you, without glasses, to see distance and/or near objects. With monofocal IOLs, you may have to use eyeglasses to read, see the computer and/or see clearly in the distance for driving or TV.
However, if you are interested in decreasing your dependence on glasses, we do have an opportunity, with Multifocal intraocular lens implants, to significantly decrease your dependence on glasses after cataract surgery, permitting you to see to read, see the computer and drive without glasses.
1. Toric IOLs to correct astigmatism.
Toric IOLs correct astigmatism. Toric IOLs are not covered by insurance and cost the patient out-of-pocket about $1000 per eye. The standard monofocal IOL does not correct astigmatism, thus requiring the patient with astigmatism to wear glasses to see clearly. However, with the toric IOL correcting the patient’s astigmatism, patients can expect to significantly decrease their astigmatism. Toric IOLs are not perfect; they typically correct 60-90% of the astigmatism, which is usually adequate for permitting patients with astigmatism to function without the need for glasses to correct their astigmatism. Most patients do not have enough astigmatism to require a toric IOL.
2. Multifocal IOLs
If you are interested in being able to see without glasses after cataract surgery, consider multifocal intraocular lenses (IOL). Multifocal intraocular lens implants are designed to let you see simultaneously at near (reading), intermediate (computer) and far (driving, movies, TV), without glasses. Multifocal intraocular lens implants function by having multiple concentric rings that focus at variable distances. Multifocal IOL’s technology has been available for at least twenty years. The first generation multifocal IOL’s did not work particularly well. The first generation multifocal IOL’s were not capable of giving an adequate range of clear vision at distance, intermediate and near. They also had significant problems with glare from the concentric rings, especially at night while driving. However, over the last 20 years, the multifocal lens technology has slowly but significantly improved with the introduction of multiple generations of new multifocal IOL technologies from numerous lens manufacturers. Modern multifocal intraocular lens implants are much more successful now at accomplishing the goal of achieving simultaneous clear distance, intermediate and near vision. The multiple ring design of the newer multifocal IOLs causes significantly less glare at distance for night driving. I am presently implanting the Alcon PanOptix multifocal IOL and the Alcon Vivity, which have been successful in giving patients good distance, intermediate and near vision, without significant night glare or need for glasses. There is a $2195 charge per eye for the PanOptix or Vivity Multifocal IOL. Insurance does not cover this charge. I have actually been successfully monofitting patients with the PanOptix or Vivity multifocal IOL. I insert a traditional monofocal IOL for distance in the dominant eye (no additional out-of-pocket charge) and insert the PanOptix or Vivity multifocal IOL ($2195 out-of-pocket charge) in the non-dominant eye. This is usually very well-tolerated and gives the patient good distance, intermediate and near vision with minimal night glare, and without the need for glasses. Multifocal lens implants are not perfect and will not completely restore your range-of-focus to normal, like when you were 16 years old, but they are very successful at giving patients a good range of vision and permitting patients after cataract surgery to significantly decrease their dependence on glasses.
If you would like to be able to see at distance and near, but not intermediate, without needing glasses, and without the additional $2195 out-of-pocket charge for the PanOptix or Vivity multifocal IOL, I recommend monovision. With monovision, a traditional monofocal IOL is inserted at the time of cataract surgery. The dominant eye is set to focus at distance and the non-dominant eye is set to focus at near. With monovision, patients can usually see to drive and to read without glasses. After an initial adjustment period, the visual system usually adapts to monovision and transitions the vision from near and distance. The intermediate computer vision will be blurry with monovision, requiring glasses correction for computer use, or requiring the patient to sit closer to the computer than they are used to. The near vision is usually very good with monovision but distance vision is compromised in the non-dominant eye. This will affect the patient’s distance vision but the patient can always wear a mild pair of glasses to correct the distance vision, if needed, for night driving, for instance. There are no additional fees for monovision. Understandably, patients may be concerned they will not be able to tolerate monovision. In my experience, most patients adjust, with few complaints, and with a high satisfaction rate, to monovision. And if monovision is not well tolerated, you can wear a glasses correction to equalize the vision in both eyes. Monovision will not give you perfect vision in every situation but it will significantly decrease your dependence on glasses and allow you to perform most daily activities without glasses.
If you have further questions about the various lens options available in cataract surgery, we invite you make an appointment with my office to see me and my staff so we can talk you about which lens option would work best for you.
4. What to Expect from Cataract Surgery
Cataract surgery is the most commonly performed surgery in the US. Cataract surgery has an extensive safety record, and serious complications are rare and usually treatable. In my practice, 97% of cataract surgeries are without complication.
After your surgery, you may experience:
• Itchy eyes
• Dry eyes
• Blurry vision
• Mild discomfort
• Discharge from your eyes
Most patients can return to normal daily activities within 24 hours after cataract surgery with only minimal restrictions. Your vision may continue to adjust to the IOL for a month or so, and you may want to use reading glasses during this time. After about a month, your eyes and vision should adapt to the IOLs. If you need glasses to fine tune your vision, the glasses are typically prescribed 3-4 weeks after surgery.
The blurriness and poor vision caused by a cataract can be devastating and can interfere with your day-to-day activities. If a cataract is affecting your ability to drive, read and enjoy life, cataract surgery may be right for you.
The human lens is mostly made of protein and water. With aging, the proteins in the lens discolor, turning the lens brown, causing what we call a cataract. Diabetes and chronic steroid usage can further increase cataract formation. The increasing discoloration of the lens is similar to a dirty windshield on your car, especially in the winter when slush drys on the windshield. With increasing “dry slush on your windshield”, light entering the eye is scattered by the cataractous lens, causing the patient to experience haze, glare and distortion, ie blurred vision. Changing your glasses prescription will not improve blurry vision caused by cataracts. Cataracts tend to progress but at an unpredictable rate. There is no known, scientifically verified treatment or supplement that prevents cataract formation. Everybody develops cataracts with aging and about 75% of people eventually have cataract surgery.
If your cataract is affecting everyday tasks like walking, driving and reading, or if it is interfering with your quality of life, you should have the cataract removed. Cataract surgery is the only effective way to eliminate cataracts. Cataract surgery removes the clouded eye lens and replaces it with an intraocular lens.
Cataract surgery is one of the most common surgeries performed today. It does carry the risk of certain complications, but it also has an excellent record of safety and a low rate of complications. Most estimates say that less than 5 percent of patients will experience serious complications. Most of those complications are treatable. Certain factors increase the risk of serious complications, such as the presence of other eye diseases. Dr. Levinson will discuss all the risks of cataract surgery with you during your pre-op examination.
First, a tiny incision is made in the cornea – the clear, curved outer portion of your eye. The lens is dissolved with ultrasound energy, called phacoemulsification, and the residual small lens fragments are removed from the eye with suction. An intraocular lens (IOL) is then inserted in the eye. The IOL is held in position by the same lens capsular that held your previously removed cataractous lens. There are no sutures involved in fixating the IOL.
Good question. In 2013, FDA-approved Lasers became available for cataract surgery. These Lasers, called femtosecond lasers, can make the incisions involved in cataract surgery but they DO NOT remove the cataract. They do:
Make the small corneal incision for entering the eye.
Make the opening into the lens of the eye, called the capsulorhexhis.
They soften the lens, making it slightly easier to remove the lens with suction from the eye.
They can partially, but not precisely, make small incisions in the cornea to decrease astigmatism.
With Laser Cataract Surgery, the lens is still removed with phacoemulsification, ie breaking the lens into small fragments and using suction to remove the fragments from the eye. The Laser DOES NOT remove the cataract from the eye, and this is the most difficult step in cataract surgery. The Laser does make more precise, reproducible incisions than the incisions made by the surgeon manually, but the advantage is very minimal, especially in the hands of an experienced cataract surgeon.
The Laser is a small technological advance in cataract surgery, but at what cost? Presently, the femtosecond laser for cataract surgery adds $1000-$1500 to the cost of the procedure. This is an out-of-pocket expense not covered by insurance. There are some theoretical advantages to the more precise incisions made by the femtosecond Laser, but there is scant evidence that Laser-assisted cataract surgery is safer or provides better visual outcomes than traditional cataract surgery, in the hands of an experienced cataract surgeon. The femtosecond laser has limitations that compromise its efficacy in removing the cataract in the more difficult cases, such as when the patient has a small pupil that won’t dilate. And there are some complications associated with the Laser that are not present with non-Laser cataract surgery.
Less than 5% of cataract surgery in the U.S. today is performed with Lasers. I am not offering Laser cataract surgery to my patients, yet. There is no obvious advantage to the Laser, especially at the present cost. However, I think that the technological achievements of the Laser are impressive and will probably become more available as the price, hopefully, drops in the future and the technology continues to improve.
Intraoperative Aberrometry, brand-name ORA, is a new technology to measure, calculate and verify the accuracy of the intraocular lens, IOL, during cataract surgery. Once, again, this is an out-of-pocket expense, about $250 per eye and is not covered by insurance. In every cataract surgery today, the IOL power is always calculated pre-operatively with very accurate, laser-scanning measurements that are extremely precise, except in patients that have prior LASIK or PRK. The ORA probably offers little advantage in routine cataract surgery but its much more accurate in calculating IOL power in patients that have had prior Laser Vision Correction or Radial Keratotomy. At this time, I use the ORA in all cataract surgery patients that have prior LASIK or PRK.
About 97% of patients have better vision after cataract surgery. Your vision may fluctuate for a month or so after surgery. After 3-4 weeks, you will be given a glasses prescription, if needed. If you need cataract surgery in both eyes, the second eye can be done within 1-2 weeks after the first eye, assuming the first eye is healing without problem.
No and yes. No, the cataract itself will not recur. However, when we remove your cataract, we leave the back capsular membrane of your old lens in place to support the new intraocular lens implant. If we didn’t leave this capsular membrane in place, there would be nothing to support the lens implant and it would fall back into the vitreous cavity, the back part of the eye. In approximately 50% of eyes following cataract surgery this capsular membrane will become hazy and interfere with vision. This opacified membrane, or “secondary cataract”, can easily be opened with a procedure called a YAG Capsulotomy. A YAG capsulotomy is a simple, painless, safe procedure that takes just a few minutes to perform. When we perform the YAG capsulotomy, we dilate the eye with an eye drop, that is all you will feel. The YAG Laser is then used to make a small, central opening in the hazy capsular membrane. You won’t feel anything during the YAG capsulotomy procedure. The vision will improve within hours after the YAG capsulotomy.
For the curious, YAG is an abbreviation for Yttrium, Aluminum and Garnet, the 3 metals used in producing the Laser energy. Actually, there is a fourth metal, neodymiun, that is also used, and the full name of the Laser is Nd:YAG Laser.
No. The lens implants are made of inert plastics that are extremely well-tolerated within the eye. They do not wear out and do not need to be periodically replaced.
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