A Patient’s Guide to Cataract Surgery Part 1: The Referral

If you, a family member, or a loved one has made the decision to pursue cataract surgery, I’m sure there are a multitude of questions dominating your thoughts.  In the following post I will discuss the most common questions that my patients pose to me (as a referring optometrist), and hopefully I can help clarify topics that may be causing some confusion.

1) Your Referring Doctor

                Most of the time patients see an optometrist as their primary eye care provider, which means that they will need to be referred to a cataract surgeon, who is an ophthalmologist.  A question that commonly arises concerning your referral doctor is how do they decide you are ready for cataract surgery?  I have many patients tell me that their doctor was waiting on surgery until their cataracts were "ripe," but they aren't sure what ripe means.  Some of the guidelines that I use to make the recommendation for surgery:

               Is the best corrected vision (which means the best the patient can see wearing the absolute best prescription glasses) worse than 20/40? 

                   Note about visual requirements: different surgeons have different cut-offs for vision, but usually it is around the 20/40-20/50 mark.  If you are pursuing surgery in the Veterans Administration system, however, the vision cut-offs are much higher.  Typically 20/60 or worse is consideration for referral there.  What does 20/40 vision mean to you?  Perfect vision is 20/20, so that means that you are seeing twice as bad as someone with perfect vision!

                Are the patient’s quality of life or activities of daily living affected?  This is the MOST important question in deciding if the patient is ready for surgery.  The decision to have cataract surgery is entirely up to the patient, and even if your vision qualifies you for referral, you do NOT have to have surgery.  Cataract extraction is a non-urgent procedure (except for in a very few, rare cases where there is a risk of permanent damage from inflammation or glaucoma).  If the patient has reduced vision, but is perfectly happy and experiencing no problems doing the activities they want to do, then I would be less likely to refer the patient for surgery.  As a side note, remember the cut-off in most states for driving without a restricted license is 20/40!

                Does the patient have a compounding condition that would increase the risk of cataract surgery?  Certain conditions can make it beneficial for a patient to wait longer for cataract surgery, or conversely to consider surgery sooner.  For example: a patient has diabetes and a history of retinopathy (bleeding in the back of the eye); I would be more likely to recommend earlier cataract surgery.  Cataracts can block the doctor’s view of the retina, and make it much harder to see if there is damage from the diabetes.  Conversely, if the patient has a history of retinal detachment, I would be more inclined to wait for cataract surgery until it is absolutely necessary due to the increased risk of another detachment with surgery.   Your doctor will be able to tell you of any secondary influences that may impact your need for cataract surgery.

2) Your Pre-Surgical Consult with Your Ophthalmologist/Cataract Surgeon

                The ophthalmologist performing your surgery will want to meet with you typically once before the day of your surgery.  For your first appointment you do not need to bring a driver because NO surgery will be done that day.  Think of it as an information gathering session.  In this appointment many of the same tests performed by your referring doctor will be repeated, but this is not a waste of your time, I promise!  The measurements the surgeon takes are very important to ensure a great visual outcome post-surgery. 

                Be prepared for your surgeon to ask you again whether your cataracts are bothering your quality of life.   I always warn my patients that they need to be truthful.  Some people don’t like to be viewed as “complaining” so they will downplay how much they are being affected.  This is not the time to be meek; make sure your give the surgeon the same information you gave your primary eye care provider.  If the surgeon thinks the cataracts aren’t bothering you, then he or she will recommend not having surgery in some cases!

                Again, there will be a lot of machines used and measurements taken.  The surgeon is going to remove your cloudy, cataractous lens and replace it with an intraocular lens implant on the day of surgery.  To have clear post-surgical vision, this implant must have a precisely calculated power.  If you typically wear hard or rigid gas permeable contact lenses, you may have to stop wearing them for several weeks before getting these measurements taken to ensure that the surgeon obtains an accurate reading from the front surface of your eye. 

This machine is an A Scan; an ultrasound instrument helpful in determining the power of your lens implant

            You will also have several choices of intraocular lens implants when you meet with your surgeon.  The most commonly used (and the one covered by most insurances and Medicare) is a design whose goal is to fully correct your distance power.  This means that after surgery you will continue to need reading glasses or bifocals for your near vision.  There are some people who choose to do a “monovision” technique where one eye’s implant is made for distance and the other eye is corrected for near vision.  The most successful patients with this monovision technique are those who have been wearing monovision contact lenses happily for many years.  There are also a few “multifocal” intraocular lenses on the market.  Designs vary, but commonly they have numerous rings inside the design of the lens implant to give you areas of distance and near vision. Some patients are very happy with the vision this type of lens provides, while others are very disappointed.  The cataract surgeon will discuss these options with you and make recommendations based on your visual demands (what you spend most of your time looking at) and your expectations for visual quality after surgery (for example, the multifocal lens implants will give you passable near vision, but not perfect 20/20 near vision in most cases, so the doctor makes sure you are aware of the limitations). 

This is an intraocular lens implant that will be inserted behind your iris (the colored part of your eye) after surgical removal of the cataract.  It is a small device often made of silicone.  Because of the advanced technology of these implants, many patients only need glasses part time after surgery!

This is the Restor lens design, a multifocal intraocular lens imlpant.  Note the subtle rings in the center of the lens that provide both distance and near vision.  In some patients the effect is such that no glasses are needed for distance or near.  In other patients, reading glasses may still be needed, and halos around lights may be induced by the rings.  It is best to discuss with your surgeon whether upgrading to a multi-focal design would be ideal for your desired surgical outcome and visual needs!

        At the end of the appointment, the surgeon will hand you a packet of information detailing their surgical treatment plan.  They will discuss what to expect on surgery day, where to go, when to be there, and when your first follow-up appointment will be.  You will also be given prescriptions for several ocular medications, and generally you will start some of these drops before your surgery day.  Different surgeons have different recommendations, but typically you are prescribed these 3 medications:

1) An antibiotic: usually Zymar, Vigamox, or newer generation Zymaxid.  TAN CAP

2) A steroid anti-inflammatory drop: usually Pred Acetate / Pred Forte. PINK CAP, shake well

3) A non-steroidal anti-inflammatory drop: examples are Acular, Nevonnac.  GRAY CAP

These are some of the most commonly prescribed ophthalmic drops for cataract surgery.  Note the different cap colors with the different classification of medicine to help remind you which drop is which!  You will be dosing all of these on different schedules so it can be hard to keep track.  

You may need to start taking one or two of these eye drops before your surgery; this varies based on your surgeon’s protocol.  Make sure you have all of the medications filled prior to your surgery to make your surgery day easier! 

Coming up next: what to expect on surgery day