In today’s world, there isn’t just one way to achieve clearer vision.  If you are ready to move on from glasses and contact lenses, current refractive surgery options are better than ever.  So what is the right surgical option for you?  Short answer:  it depends.  So many factors play into which surgery will be most successful for your individual eyes, and your doctor will help you make the right choice based on your own needs.  Here’s a brief overview of the most popular surgery choices on the market today, and some of the key factors that make certain surgeries more ideal for certain patients.

LASIK (Laser Assisted Stromal In-Situ Keratomileusis)

When we think refractive surgery, most of us think of LASIK.  Laser eye surgery has the benefit of being quick, relatively painless, and has a very quick recovery time.  Today’s most accurate version of LASIK uses the laser for the entire procedure, both to cut a flap in the cornea that will act as a natural bandage as your eye heals and to perform the thinning of the cornea that “zeros out” your prescription.  This is often called bladeless LASIK or LASEK, and with its advent we’ve seen significantly better vision correction for both high prescriptions and astigmatism.  Studies suggest that LASIKcan routinely correct as high as -9.00D of nearsightedness (myopia), up to+2.50D of farsightedness (hyperopia) and up to 3.50D of astigmatism.  Today's Intralase procedures can accomplish as much as 6.00D of astigmstism.  This power range is based on an average corneal thickness; if you have thinner corneas there won’t be enough tissue to remove to correct for higher prescription ranges.  Corneal thickness is a measurement that all doctors will take to make sure you are a good candidate for surgery, and depending on the results your doctor will be better able to advise you as to whether you would still need glasses after surgery, or if surgery would be safe for you at all.

Who can’t get LASIK?  People with thin or irregular corneas (conditions like keratoconus for example) are unable to get LASIK surgery due to the risks of thinning their cornea to a point of prolapse.  People with corneal dystrophies, corneal scarring or a history of keloid scarring are not good candidates – if the cornea scars, you won’t be able to see clearly through it.  Inflammatory conditions are also a relative contraindication; people with rheumatoid arthritis, sarcoidosis, a history of herpes infections, Sjogren’s Syndrome, or significant dry eye will all heal poorly after surgery. Nearly everyone has dryness for the first 6 months after surgery, but many people that had dry eye complaints before surgery have severe dry eye problems after the surgery, sometimes requiring lifelong treatment.  Many doctors will recommend treating even mild dry eye before doing a surgical treatment to maximize the possibility for success.

What kind of vision can I expect?  Studies show that 94% ofpatients will achieve 20/40 or better (legal driving vision) after LASIK. As you can see from those numbers, not everyone achieves 20/20 vision after LASIK. You’ll be hard pressed to find a doctor that would guarantee such.   Vision won’t necessarily be as good as it is right now with your glasses or contact lenses after surgery, and some people will still wear night driving glasses after surgery to achieve that crystal sharp 20/20 vision if they desire it.  Even if your prescription isn’t corrected to zero, it will be very close.  Studies of LASIK surgeries since 2000 show 88% of eyes are within 1.00D of zeroprescription (emmetropia) after surgery, and 92 percent of eyes are within2.00D of emmtropia.  After age 40, everyone that has LASIK surgery to fully correct distance vision will still need reading glasses as they go through the normal aging condition called presbyopia where our eyes naturally lose the ability to focus up close.  So LASIK doesn’t mean no glasses ever again, but it does mean for most people that you will be glasses free for at least the majority of your day.

PRK (Photorefractive Keratectomy)

PRK is an older surgical procedure to correct vision that does not utilize a laser or a corneal flap as a natural bandage after the procedure.  As such it is significantly more painful – expect to miss around a week from work as you recover.  But the pro of PRK is that without a flap, you are fully regrowing a new cornea as the tissue heals, meaning less risk of scar tissue for people with thinner corneas or mild corneal changes that would prohibit them from LASIK.   PRK is typically around the same cost as LASIK, and studies show that visually patients that underwent LASIK or PRK achieve similar post-surgical results.

Phakic IOL

What if your prescription is too high for LASIK or PRK?  Your better option is to opt for an intraocular implant (IOL) that fully corrects your prescription– almost like having a contact lens implanted internally.  An IOL can correct very high prescriptions, as high as -20.00D and up to -6.00D of astigmatism. The IOL is placed either in front of your iris or behind your iris and in front of the lens (phakic means that they leave your lens in place).  The true perk of phakic IOLs is that nearly any prescription is possible, and if for some reason there is an issue, it is also possible to have it removed, unlike LASIK or PRK where the cornea is permanently changed.   The downside to phakic IOLs is that they require a much more invasive operation.  The lens has to be inserted into the eye, and since it is being placed much more internally than a LASIK or PRK procedure that only treats the cornea, there is an increased risk of cataract formation, glaucoma, or even retinal breaks or detachments.   The risks of these side effects is very low; studies show 1% of patients with phakic IOL develop acataract after the surgery.

A phakic IOL sits in front of the cornea acting like an internal contact lens via

Take Home:

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