So what to do if you or a loved one has been diagnosed with cataracts that are in need of removal?  Firstly, know that cataract removal is very rarely an emergency.  If you decide that you would rather wait, in most cases there is no damage caused by leaving the cataract inside your eye for months to years longer.  An example: this past spring I spoke with a patient about removing his cataracts, and he told me that he had a lot of gardening to do over the next few months and would rather wait until winter.  As long as the cataract is not causing any urgent conditions like glaucoma or an acute inflammatory event,  any patient is free to wait until they are 100% ready for surgery.

Your cataracts will NOT get better.  I'm sure most of you already figured that, but cataracts do not regress with time because they are not a disease.  They may stabilize or they may get worse; it is hard to predict their exact rate of progression.   One very important point to remember: if your cataracts are bad enough to need surgical removal, glasses will NOT improve your vision.  This can be such a frustrating truth to patients. I feel very sympathetic to anyone that comes to me with a handful of glasses that they have purchased over the last few years trying to see clearly, but they just won’t work!  Glasses might be able to make a small improvement, but when a patient is referred for cataract surgery it is because their “best corrected visual acuity” meets removal criterion (typically worse than 20/40).  The “best corrected” is key; it means that even with the absolute perfect pair of glasses your vision is still worse than this 20/40 guideline.  For comparison, 20/20 is technically "perfect" vision; 20/40 is twice as bad as you are used to seeing if you had perfect vision before cataracts. Another point about 20/40 is that it is usually the cut-off for getting your driver’s license.  If the vision in both of your eyes is worse than this with glasses, you aren’t legally eligible to drive without special permissions granted by the DMV in your state!

If the cataract is getting denser and thicker and cloudier, this means that your vision will continue to deteriorate.  Typically the deterioration in vision is very slow and gradual so waiting months to a year will not make much of a difference to most people. There are some exceptions to this rule, however:

                -- If you have a posterior subcapsular cataract (commonly found in people with diabetes or cataracts secondary to steroid use), these cataracts progress much more quickly.  I have seen a patient with 20/50 vision reduced to 20/200 in a matter of 6 months, simply because his posterior subcapsular cataracts were right in the center of his vision.  He could no longer read and was having trouble recognizing faces in just 6 months’ time!

                --If you have a child diagnosed with cataracts, they do need to be removed as soon as your ophthalmologist deems it appropriate.  As stated in my previous post, children are developing their visual pathways even through age 8.  If the cataract is not removed in a timely fashion, the pathway will fail to develop normally and their vision will be permanently decreased. 

                --There is one other “false” exception to the concept that your vision will not get better with cataracts.  Some people early in their cataract progression experience a phenomenon called “second sight.”  These patients typically have nuclear cataracts (one of the most common types due to aging changes).  Nuclear cataracts are known to cause myopia, or decreased distance vision.  Because of the way the visual system is set up, an eye that can’t focus in the distance focuses more clearly up close.  This is why myopia is also called near-sightedness (we will discuss this more thoroughly in future posts).  Second sight occurs when patients experiencing normal, age-related decreased near vision develop cataracts causing myopic shift (or shift to clearer near vision).  They think they are seeing better all of a sudden when reading!  The problem is, the cataract will continue to worsen and the cloudiness and blur it creates will eventually wipe out this “second sight” improvement.   This is a difficult concept to grasp, and I am still learning how best to explain to my patient’s that they think they are seeing better when reading because their cataracts are getting worse!

One last issue if you choose to wait: it is possible that your surgery will be more difficult if you delay removal for years.  Remember, the cataract forms in the structure called the lens.  The lens is one of very few body parts that actually grows every year as long as you live.  That means that once cataracts begin to develop, they keep getting thicker and harder and denser.  They can get so hard that the surgical instruments actually have a hard time removing the cataract!  This leads to more inflammation and a higher risk of surgical complications.

To wrap our cataract discussion up, I like to tell me patients that their eyes are theirs, and all I am doing is making a recommendation.  It will always be their decision if the timing is right for surgery.  If you want to wait, and don’t have any risk factors that makes this a danger to your ocular health, I will be more than happy to assist you with whatever you decide.

With cataract extraction being such a quick and usually easy surgery, it is easy to forget that you just underwent a major procedure that requires close follow-up to ensure proper healing.  Your post-operative care generally begins one day after surgery, when you return to your ophthalmologist (surgeon) or co-managing optometrist and have the patch removed from your surgical eye for the first time. Here are some guidelines of what to expect:

Your vision: On Day One, your eye is just beginning its’ healing process, so don’t expect perfect vision from the start.  What most patients DO notice is that colors are much more distinct and crisp.  The clouding of the cataract causes whites to look more yellowed or brown, and once it is removed it appears “like the world has been dipped in bleach” to quote a happy patient.  As your eye continues to heals your visual acuity will improve, usually over the course of the next month.

The follow-up period can be daunting to some, and there are a lot of eye drops to instill at the beginning of your recovery process.  Don’t be discouraged, because with proper healing your post-surgical vision may be better than you imagined possible without glasses!

Surgery day; the day everyone has been anxiously waiting for!  Every cataract surgeon has their own individual protocol, so I won’t pretend to speak for exactly how your day will go.  I have been very fortunate to follow an ophthalmologist performing cataract extractions, so I have witnessed first-hand what the patient experiences.  Here are some general insights on what to expect:

1) Bring a driver.  You probably guessed that already, but you will need someone to take you to the appointment and (more importantly) drive you home after the surgery. 

2) Surgeries are typically performed on an out-patient basis, so you will only be in the hospital for a short time!  That is usually great news for my patients.  First you will be in a waiting area where the surgeon will likely come speak to you and go over which eye will be operated on today.  Then an attendant will come to give you a sedative to ensure that you are relaxed.  Most surgeries are NOT performed under anesthesia and you will be able to respond to the doctor, speak, and move throughout the procedure (though you should refrain from doing the latter).  Your heart rate will be monitored the entire time, and the doctor will continually remind you not to move if you are getting even the least bit fidgety. You will also be able to see what is going on during the entire procedure but don’t worry about seeing the instrumentation, everything will just look generally blurry to you.  Because you can talk during the procedure, it can be interesting to hear patients describe what they are seeing.  One woman kept talking about trees, and afterwards she told me that she could see the surgeon and his attendants while he was operating, but they were so blurry they looked like big trees.

3) Only ONE eye is operated on at a time.  I know it would seem so easy to get both of your cataracts removed in one fail swoop, but having a healing time between operations is very important.  As discussed in previous posts, the risk of complications from surgery are minimal, but if something were to happen that damages vision, it is better to have your other eye protected and undisturbed. Generally several weeks to 1 month passes between surgeries on each eye. 

4) Not only is cataract removal one of the most commonly performed surgeries in America, it is also one of the fastest.  The actual time of surgery is typically around 10 minutes!  It is incredible how quickly the process can be performed with today’s techniques.  Here is a little breakdown of the procedure:

                --A small incision is made into the cornea (no bleeding and no suture will be required afterwards) where the instruments to remove the lens are inserted.

                --The back surface (endothelium) of the cornea is protected with a material called viscoelastic that is inserted through the corneal entry point.  Viscoelastic greatly reduces the risk of swelling after surgery (and thus the immediate visual outcome).

                --The pupil is dilated prior to surgery so that the surgeon has good visibility of the cataractous lens.  If you are taking Flomax, this medication is typically discontinued several weeks before surgery to prevent the iris (colored part of the eye) from not retaining a good dilation and thus reducing visibility for the surgeon.   This is commonly called “Floppy Iris Syndrome”

                --The lens sits in a little sack (called the capsule or capsular bag) that is suspended behind the iris by string-like zonules.  To get to the lens, the surgeon peels away some of the anterior capsular bag, and then uses an instrument called a phacoemulsifier to break up the cataract into small pieces.   The phacoemulsifier also has a vacuum-like function that sucks up these cloudy cataract pieces, leaving a nice, clear, and empty capsular bag.

                --Once the entirety of the cataract is removed, the surgeon inserts the small intraocular lens implant that will act as your new lens.  The power has been carefully crafted to minimize your prescription or need for glasses post-surgically.  When it is inserted into the eye, the lens is rolled-up to make it as small as possible (which allows such a small incision in the cornea).  Once it enters the capsular bag, the lens implant will unfurl and the surgeon will rotate it into place via the arm-like haptics.  The lens implant is placed securely into the capsular bag that once held your natural lens, which ensures stability of the implant after surgery. 

After surgery antibiotic drops are instilled to prevent infection, and the eye is patched for protection.  Either later on that day or the following day (depending on your surgeon) you will return for the first of several post-op appointments.  We’ll address those in the next post of our series!

NOTE: All pictures today are from jirehdesign

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. 

            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). 

        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

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

Cataract extraction is one of the most commonly performed surgeries in the United States, but based on my experience in patient care, a large percentage of people are unsure of what a cataract actually is. To explore this topic further, let’s address some common misconceptions:

1) Cataracts are NOT a film over the surface of your eye.  This is a very common misconception, but cataracts actually develop inside your eye in a structure called the lens (see picture below).  The lens functions just like a lens on a camera – it changes shape to focus and create a clear image.  Over time this lens can harden and become cloudy, which is the development of a cataract.  Just as you would expect, clouding and yellowing of the structure responsible for focusing a clear image results in constant blurry vision. 

2) Cataracts are NOT a disease.   Most often they are a result of the normal aging process the lens.   While aging is the predominant factor for developing cataracts, certain medical conditions like diabetes can predispose someone to developing cataracts sooner than usual.  Prolonged use of steroids can also cause cataract formation.  It is also possible to born with cataracts which can cause substantial deficiencies in the development on the visual system, so having a comprehensive eye exam is important even for children!

3) I know it is a scary concept to some, but the ophthalmologist performing your cataract surgery will have to enter the eye to remove it.  Remember that the lens where the cataract forms is inside of your eye, behind the iris (the colored part of your eye).  The surgeon uses very small instruments to enter the eye and remove the cataractous lens.  With today’s technical advancements, you don't even have to be put to sleep to have this procedure performed.

4) Once a cataract is removed it can NOT grow back.  That’s a relief, right?  It is possible that a film can grow over the back of the intraocular implant (a small device that surgeons insert to replace your lens to allow you to focus a clear image again).  This film may reduce vision, but you will not have to have a second surgery to remove it.  All it takes is a quick laser procedure.  

5) Most people DO still need to wear glasses after cataract surgery.  While in most cases the goal of surgery is to fully correct your distance vision, the standard intraocular implant inserted to replace your lens is not able to focus for near distances.  That means that you will continue to need reading glasses.  Depending on your eyes and the surgical outcome, some people may also have left-over astigmatism (which causes blur at all distances) that must be corrected with glasses.  There are more expensive intraocular lens devices available that can help focus for both distance and near, but the technology has not been entirely perfected at this time.  Researchers are actively exploring this idea though, so expect future breakthroughs.

6) There is NOTHING you can do to entirely prevent yourself from getting cataracts.  Yes, that is 100% a true statement.  To use the words of a fellow optometrist, “ everyone will get cataracts if they live long enough.”  Some people get them younger; some people’s progress more rapidly to reduce vision; some people will never have the cataract bother them enough to want surgery.  There ARE some things you can do to slow down the onset and progression of your cataracts, however.  Some suggestions:

           
 A) DO wear sunglasses outside.  UV light can damage the lens and lead to cataract formation.  Studies show that more Americans are applying sunscreen because of the risk UV damage to the skin, but much fewer people responded to wearing sunglasses for UV protection.  Your eyes need protection too, and there are a lot of stylish options out there!

Wearing sunglasses is not just a fashion statement , but protects your ocular health and vision.  Choose 100% UVA/UVB blocking sunglasses for maximum protection.  Plus, there are so many stylish options out there like Gucci 3164 in tortoise above!

B)  DON’T smoke.  Like you needed any more reasons.  Smoking increases the rate and progression of cataracts.

C) DO have yearly eye exams.  Tell your doctor about medical conditions like diabetes, Wilson’s disease, and myotonic dystrophy that predispose you to cataracts.  Be aware that certain medications (especially steroids) also increase your risk.  If you are having blurry vision, it is always best to get it checked out.  Cataract surgery is a relatively easy procedure, but in conditions like diabetes, having the cataracts removed earlier may help decrease the surgical risk and improve the outcome of your vision!  You don’t want to wait until your vision is drastically impaired.

D) If you are a parent, your children DO need to have their eyes checked as well! Some children are born with vision-threatening conditions like cataracts, and the earlier these problems are caught, the better chance your child has for developing normal vision.  Because a child's eyes and visual pathway to the brain are still developing, a cataract in a child can cause permanent vision loss, even after the cataract is removed! Programs like InfantSEE allow free eye exams for children between 6 months and 1 year of age.  This is a great way to screen for blinding conditions, so please seek out local providers to see if they are participants! 

No one preparing to undergo surgery is entirely without apprehension, and for patients that are diagnosed with cataracts the decision to have them removed is sometimes a difficult choice.  A new study published in the June issue of Ophthalmology, however, delivers wonderful news concerning the safety of cataract surgery.  What was once an intimidating surgical procedure is now one of the most commonly performed surgeries in America (over 1.5 million are performed each year according to Eye Health Services!).  Due to the pairing of technological advancements and extensive training by ophthalmologists, there has been no safer time to explore cataract removal if your vision has been impaired.

The study performed in conjunction with the University of Michigan and Duke University followed Medicare-covered cataract extractions from 1994 to 2006, documenting the number of severe complications that arose from surgery.  These complications included endophthalmitis (a severe infection), suprachoroidal hemorrhage, and retinal detachment.  Compared to earlier years in the study, the risk of adverse complications in 2005 to 2006 reduced by 20%!  The study did find that the incidence of complications was much greater for people with underlying risk factors, such as diabetics with proliferative retinopathy.  Your eye doctor will be able to discuss any potential high risk factors with you, as well as if your cataracts are ready for surgery by performing a full dilated eye exam.

The amount of advancements that cataract surgery has undergone is truly remarkable.  In my next few posts I plan to detail what to expect if you or a loved one are facing the decision of having their cataracts removed.  Undergoing surgery is not an easy decision, but hopefully this information will help facilitate your decision making process!