The Truth About Cataracts and Surgery

My Eye Doctor Said My Cataract is Going to Explode in My Eye! Really!!!

Unfortunately, cataract surgery has become one of the most unnecessary surgeries performed in the United States. Patients are told all kinds of crazy stories about why their cataracts need to be removed.  Many are told that if the cataract remains in their eye any longer, the cataract is going to damage their eyes. If the cataract isn’t removed now it will be much more difficult later with many more complications. Patients are sometimes told that the cataract is going to explode inside their eye and ruin their eye. What an outrageous statement by a supposedly caring eye physician that took the Hippocratic oath to help people and to do no harm. There are other stories that the cataract isn’t that bad now but it should be removed now as it is easier to do the surgery now. Or that their cataracts are going to go from a level 1 cataract to a level 4 cataract within 6 months and the surgery will be very difficult with more complications.  Unfortunately, there are too many of these doctors who are more interesting in making money than providing proper and compassionate care of their patients.

What is the Truth About Cataracts and Surgery?

What is a Cataract?

Nearly 100 percent of people believe that a cataract is a film or growth that is grows over the eye. A cataract is actually not a film or piece of tissue that grows over the eye that blurs people’s vision. How does the eye see? There is a lens inside of the eye that is positioned behind the pupil and colored portion of the eye (iris) that focuses light as it passes through the pupil to be focused onto the retina (the retina is similar to the film of a camera as its receives the object that you are looking at).

This image that the retina sees is transmitted from the retina through the optic nerve. The optic nerve transmits the image to the back portion of the brain called the occipital lobe. The occipital lobe is the vision center inside the brain. As the human body ages, this lens behind the pupil loses its clarity over time. The lens becomes hazy or cloudy. As the lens becomes progressively hazy or cloudy, it causes the vision to blur. It is similar to the windshield of your car fogging and diminishing your ability to see through the windshield. As the fogging of the windshield progresses, it becomes more difficult it is to see through it. So, now you know the truth about what a cataract is. Let’s take a look at why people get cataracts.

What Causes Cataracts to Develop in the Eye?

In nearly all cases, a cataract develops in the lens over time secondary to just simple aging. There are many genetic factors related to cataracts that can lead to the development of different types of cataracts. In some families, they develop cataracts at a younger age due to these genetic factors. On a rare occasion, a child will be born with cataracts. What other risk or factors contribute to the development of cataracts. There is very good scientific evidence that ultraviolet light or sun exposure can increase the risk of developing cataracts and at a faster rate. Also, Smoking leads to the development of cataracts at a younger age. People with diabetes develop cataracts at a younger age.

Cataracts develop slowly over years of time in most cases. Many times,  a person with cataracts just needs to get a new prescription for glasses to clear their vision. Cataracts can cause the eye to become more nearsighted from the eye’s original state as the lens becomes denser. The human lens is comprised of several different structures which can become cloudy which means there can be different types of cataracts. Here is a list of some of the different types of cataracts:

• Nuclear sclerosis
• Cortical cataracts
• Posterior subcapsular cataracts

 

• Traumatic cataracts
• Anterior subcapsular
• Mature or hypermature cataracts
• Combination of the different types of cataracts

Ripe or Mature Cataracts

A ripe cataract is a term used to describe a mature or hypermature cataract. The term cataract comes from the word originally used for describing the appearance of rapids or water falls where the water turns from clear to white which are also cataracts in the river. A ripe cataract occurs when the lens in the eye becomes white. Also, the tissues of the lens start to degenerate, liquefy, or melt. The lens melts in a way like when a fruit becomes over ripe and begins to soften. You can see a ripe cataract without any special equipment as the pupil of the eye is white. The vision with a ripe or hypermature cataract is horrible. The person can only see light out of the eye. They are only able to see light when a bright light in shown into the eye. The term ripe cataract was used years ago by eye surgeons or rarely today when the cataract had advanced to a stage when cataract surgery would be indicated. It is very rare in the United States to see a mature cataract. Ripe or hypermature cataracts are very common in third world countries due to limited access to health care. Eye surgeons used this term in the past as it was an easy way to tell someone that the cataracts had advanced to a stage where cataract surgery would be indicated. You waited until the cataract had advanced to a significant stage. This was due to the fact the patient had to be admitted to the hospital for up to 2 weeks following cataract surgery with sand bags by their heads to keep them from moving. Before today’s modern techniques, there were many more complications related to cataract surgery as well. In the United States, very few people let their vision or cataract advance to a ripe stage today. Hypermature or ripe cataracts are a leading cause of blindness in third world countries where access to health care is limited. If you are able to see out of your eyes and your eye doctor is telling you that you have a ripe cataract, ask them to explain what they mean.

You Need to have Cataract Surgery???

This is absolutely one of the most important things you need to know about cataracts. There is almost never ever a medical reason or emergency for cataract surgery. In very rare circumstances, are there medical indications for you to have your cataract removed. Cataract surgery is an elective eye operation not a requirement. Unfortunately, there are many people who are being told that they must have cataract surgery or need cataract surgery. Many are told they need to have the cataract surgery right away, as there will be more complications that can harm their eye. Many people complain that they don’t see any better after the surgery. The surgery may have been performed well and their vision may be good, but these people probably had minimal cataracts or none before the surgery. Many people are being told to have cataract surgery with only a minimal cataract or no cataract present in their eyes.

Why or When Should You Consider Cataract Surgery?

First thing that you need is thorough eye exam. You may need only a new eyeglass prescription to see better. Only after seeing with your best corrected vision with glasses or contacts, should you consider having cataract surgery if the vision with that correction is not sufficient. The only reason for cataract surgery is if your blurred vision is interfering with your lifestyle. That is, if you are having trouble reading books which your passion, the distance vision is blurred to the point that you are not happy with what you can see, you are having trouble driving at night or you are difficulty seeing well enough at work. The only real reason to have cataract surgery is that you are unhappy with your vision not that the eye doctor tells you it is time. Also, the eye doctor tells you that your eye is healthy and it is their opinion that cataract surgery should make a significant difference in your vision. The role of the eye surgeon is to your assistant in your making the decision that is right for you. People with eye diseases such as macular degeneration present more of a dilemma as it may be difficult to determine the amount of improved vision after cataract surgery. Sometimes, it can be a challenge to determine if a person’s blurred vision is related to their macular degeneration or the cataract. This is when your eye surgeon can be of help in making the best decision. Otherwise, the decision of the most appropriate time for cataract surgery is yours. You know better than anyone else how your blurred vision is affecting your daily life. Cataract surgery is an elective operation. It is your choice of the right time for you to decide that you need better vision, and not that an eye doctor wants to perform more surgery, period.

You have Decided to have Cataract Surgery – What’s Next?

The eye doctor has told you that you have cataracts and you are unhappy with your vision, what is your next? The eye doctor is unable to change your glass prescription to improve your vision. Therefore, you have decided to have surgery.

What is Involved with Cataract Surgery?

As you read earlier, a cataract is the lens inside of your eye behind your pupil loses becomes cloudy and/or hazy. The cloudy or hazy lens inside your eye needs to be removed to restore your vision. If the only thing that was done was to remove your cloudy lens, your vision is going to be still very blurred as there is no lens in your eye to focus the light onto the retina. Once the cataract or lens has been removed, the natural human lens needs to be replaced with an artificial lens so that your eye can see again. A significant portion of the focusing system for the eye has been removed. Before your surgery, the eyes are tested and measured with special instruments that provide the eye surgeon with the correct strength of artificial lens to correct your vision. The lens strength or power is calculated by computers inside of instruments used to measure your eye.  The eye surgeon will choose the strength of lens that will best correct your vision. So, the great news is that no matter if you are far-sighted, near-sighted, or have astigmatism, your vision can be corrected with the insertion of an IOL that has been calculated to correct your vision.

What Happens Prior to Surgery?

Prior to cataract surgery, the eye doctor needs to make sure that you don’t have any other eye diseases that could affect the outcome of your surgery such as diabetic retinopathy, macular degeneration, glaucoma, or other eye diseases. There will be a series of tests on your eyes to give guidance on the best surgery for you. The testing may include a visual field test, Lenstar, IOL master, Pentacam, i-Trace, specular endothelial microscopy, eye dominance, dry eye testing, and corneal topography.

iTrace Technologies Instrument

The iTrace technologies instrument is a great instrument that gives a significant amount of information about the vision system of your eyes. It measures the aberrations in your vision.  The amount of aberrations of the eye can provide very important information that the eye doctor uses to guide you with your decision. Every animal and human has aberrations in their vision. Some animals see better than others depending on the optical system of their eyes. Even if you have better than 20/20 vision and no eyeglass prescription, there are still aberrations in your vision. Mankind would have much better than 20/20 vision if our eyes did not have these aberrations. The iTrace gives the eye surgeon information about aberrations of the eye due to the shape of your cornea (clear front portion of the eye) and aberrations inside the eye secondary to your cataract and/or lens inside your eye. The iTrace also provides information about the asphericity of your cornea and the alignment of your visual axis. It compares the visual axis of your vision to the center of your pupil. All this information is extremely important if you are considering a multi-focal intraocular lens with your surgery. Many people are not good candidates for a multifocal IOLs. If there are too many aberrations in the eye and/or the alignment of the visual axis and center of the pupil are not close together, you may be happy with your vision after surgery.

Determining the Power of the IOL

The Lenstar and IOL Master are the two most common instruments used in the United States to measure the eye for determining the strength of the intraocular lens that is going to be used to correct the vision during the surgery. These two instruments take a variety of measurements of the eye.  A computer in the instrument uses an algorithm to determine the strength of the lens that is going to be used. These instruments are very accurate but not perfect. Even though the results are great, there is no guarantee that the instrument will be perfect in every case.

LenStar

The Lenstar features a unique dual zone keratometer with a total of 32 marker points on two concentric rings at 1.65 and 2.3 mm in diameter for improved power calculations of IOL powers to be used to correct vision after surgery. The Lenstar provides a variety of measurements of the eye which are used in the calculation of the IOL power. These include:

Keratometry/Topography

Lenstar’s unique dual zone keratotomy with 32 marker points provides great data for IOL calculations.

White-to-White

The white-to-white measurement is the measurement across the cornea from the sclera to the sclera. This measurement is used in advanced IOL calculations.

Pupillometry

The Lenstar measures the size of the pupil which can used in providing information for suitability with multifocal IOLs.

Lens Thickness

Accurate measurement of the lens thickness is key to precise optimal IOL power calculation when using the latest advance formulas.

Anterior Chamber Depth

The depth of the anterior chamber is very important in IOL power calculations. The Lenstar uses optical coherence biometry to precisely measure the anterior chamber depth.

Axial Length

The size or length of the eye is the most important measurement in calculating the IOL power. The Lenstar uses OLCR technology using a superluminescent diode as a laser source to measure the axial length of the eye.

IOP Power Calculations

The Lenstar provides numerous IOL formulas. These include:

Olsen, Barrett, Hill-RBF, and standard formulas are provided. People with a history of LASIK or other refractive procedures need special formulas or calculations. The Lenstar has the Barrett True-K and Shammas formulas for these patients.

The Lenstar provides very precise calculations and a variety of formulas for the eye surgeon use in providing the best IOL correction for your eye.

IOL Master

The IOL Master 700 is the next generation in biometry from Zeiss that gives very accurate measurements for IOL calculations. The SWEPT Source Biometry from the IOL Master 700 provides a full-length OCT image showing the anatomical details of the eye on a longitudinal cut through the eye. The SWEPT Source Biometry scans the eye 2,000 times a second. The IOL Master 700 is the only instrument with a biometer that has telecentric keratometry with is distance independent. All measurement calipers are shown on full-length OCT images. The unique Fixation Check provides the eye surgeon with more confidence in that a proper measurement was taken. The IOL Master 700 has the three Barrett IOL formulas which are Barrett Universal II, Barrett Toric, and Barrett True K. Depending on the eye status, the system automatically choses the appropriate formula.

Ultrasound

In some advanced cataracts or ripe cataracts, the previous instruments discussed may not be able to measure the eye. An ultrasound is capable of measuring the eye with advanced stages of cataracts and may be used if one of the other instruments are unable to penetrate the cataract.

Once all the testing has been performed, the eye surgeon will be able to guide you with the decision-making process with the cataract surgery. The type of cataract procedure and the type of IOL will be decided by you with the help of your eye doctor.

A staff member or surgical coordinator will go over all the details involved with cataract surgery. There are many papers and different forms that you will have to read and sign. You will be given an informed consent to read over about your cataract surgery. Write down any questions that you may have concerning your surgery. The eye surgeon will go over the informed consent and that is the time to ask your questions. In most cases, you will be prescribed eye drop medications for use before and after the surgery. Some doctors may inject the medications inside the eye during the surgery. The staff will cover all the pre-op and post-op instructions with you. You will be given a copy for your records and as a guide to follow.

How is the Cataract Removed?

In basic simple terms, the cloudy lens or cataract inside your eye is removed. After the cataract is removed, a new artificial intraocular lens is placed back inside the eye to correct the vision. The power or strength of the IOL was determined by the testing and instruments in the office prior to the surgery. The natural lens behind the pupil has a certain amount of focusing strength and this needs to be replaced. The eye would not see very well if all that you had as cataract removal and the lens was not replaced. The good thing about the intraocular lens is that it can correct any prior refractive error that was present before the surgery. So, no matter if you are near-sighted or far-sighted, the strength of the new IOL can correct the vision in most cases.

What Steps are Involved with Cataract Surgery?

In most instances throughout the United States, the eye surgery will take place in an out-patient ambulatory surgery center. There are a few places in the United States where the surgery may still be performed in a hospital on an out-patient basis. On your arrival to the surgery center, you will be admitted and taken to the pre-op holding area. You will sign more papers and meet with the anesthesia department. You will be asked to lie down on a stretcher and an IV will be started. In most cases, the IV will be only the tubing. There will no IV bottle. The anesthesia department will give medications in the IV to relax you. You will not be put to sleep or have general anesthesia except in very rare circumstances. In some cases, you will get a short acting drug to put you to sleep for a minute or so. This is so the anesthesia personnel can inject numbing medication behind the eye while you are asleep. Most eye surgeons are using topical anesthesia and are not doing any injections. A variety of eye drop medications will be instilled onto the eye to numb it and to dilate your pupil as the cataract is behind your pupil.

When everything is ready, you will be taken to the operating room and placed under a microscope used during the eye surgery. The eye will be prepped and draped to sterilize the area around the eye prior to surgery. There are very small incisions made in the cornea near the sclera. These micro-incisions are so small that sutures seldom necessary to close the tiny incisions. A gel-like substance is instilled into the anterior chamber or portion of the eye between the iris and the cornea. This viscoelastic material keeps the eye formed during the portions of the surgery. There is a thin cellophane-like capsule that surrounds the lens of the eye that has the consistency of Saran wrap. A 5mm circular opening or capsulorhexis is made in the anterior capsule to gain access to the cataract.

A syringe with balanced salt solution is attached to a cannula. The fluid is used to loosen the lens material from the surrounding capsule. A phacoemulsification tip that vibrates approximately 45,000 times a second is used to dissolve or emulsify the nuclear or center portion of the lens. During this time fluid is delivered inside the eye with this tip to keep the eye formed and the center of the tip is hollow. A computerized pump is connected to the phaco tip so that the liquid and emulsified cataract material can be aspirated from the eye. Another type of cannula or tip is used to remove the softer cortical material of the cataract. The viscoelastic material is injected into the eye again to keep the eye formed and open the capsule to receive the IOL.

The IOL to correct your vision is placed inside an injector device that rolls the lens up like a pancake or soft taco.

The intraocular lens is inserted inside of the same capsular bag that held your natural lens. Once the lens is inside the eye, the IOL unfolds back to its original shape. The intraocular lens is held in place inside the eye by the same capsule that held the eye’s natural lens. In almost all cases, sutures are not needed to closed the incisions. The incisions are checked to make sure they are closed. Some eye doctors will have the patched after the surgery. In many cases there are no eye patches applied after the surgery.

You are transported to the recovery area in the surgery center. Once you are doing well, the IV will be removed. You will be given something to drink. Your vital signs will be checked and you will be discharged in about 30 minutes after the surgery. The actual surgery only takes a few minutes to perform with no shots around the eye, stitches, or patches. The whole process takes approximately 2 hours.

Femto Laser Cataract Surgery Or Bladeless Laser Cataract Surgery

Some eye surgeons are advertising femtosecond laser cataract surgery as bladeless laser cataract surgery.

If you have decided to have a femtosecond laser used during your cataract surgery, there is another step in the surgery that you have to go through. The femtosecond laser is usually located in another room in the surgery center. What is the benefit of having a laser perform a portion of the cataract surgery?  The femtosecond laser performs several of the surgical procedures in cataract surgery in an extremely precise manner. The laser cuts the microincisions in the cornea. If you have less than 1.25 to 1.5 diopters of astigmatism, the laser will make limbal relaxing incisions on the cornea to correct the astigmatism or irregular shape of the cornea. Astigmatism means that your cornea is shaped more like a football slice in half length-wise versus a round basketball. The femtosecond laser will change the corneal shape back to a basketball providing you better vision without glasses. Another of the critical delicate steps of the cataract surgery is the capsulorhexis.  The laser creates 5-mm circular capsulorhexis or opening in the anterior capsule which is precisely placed centrally and in perfect circle.  The femtosecond laser further helps with the cataract procedure by dividing the nucleus of the lens into pieces. The laser is also able to soften the lens which makes the removal of the nucleus more efficient. The femtosecond laser completes all these steps in approximately 30 seconds. After the femtosecond laser is completed, you will be taken to a different operating room where the cataract surgery and IOL insertion is performed. The femtosecond laser provides a more precise surgical cataract procedure, more consistent results with less dependence on glasses, and fewer complications.

FDA Approved Femtosecond Lasers

The Alcon LenSx laser system is the most commonly used femtosecond laser used for cataract surgery. The LenSx laser’s OCT technology provides high resolution cross-sectional images for every cut at the location where the incisions are being performed. The laser has excellent scanning processes and image management. The combination of scans provides precise placement of all the laser applications by accurate positioning of the line scan following the axis of maximum tilt.

The one-piece design of the LenSx Laser SoftFit Patient Interface is an excellently designed interface of the connection of the laser to the patient’s eye. The interface design produces a 66 percent in the laser energy needed to perform the procedure and a minimal rise in the IOP just 16mmHg above the baseline of the patient’s IOP. The interface minimizes corneal distortion compared to solid interfaces and form a solid fixation to the patient’s eye. The laser takes only about 30 seconds to perform its procedure.

The Bausch and Lomb Victus Laser Workstation is an innovative laser the high technology, multi-mode versatility, and comprehensive capabilities in a single laser workstation. The laser uses fast impulses and small spot sizes at 80 kHz for cataract surgery. It has detailed precision and control. The Victus uses REALEYEZ swept-source OCT which is delivered in real-time, high-resolution visualization, and image guided cataract surgery planning. Auto-recognition automatically recognizes important landmarks of the cornea, pupil, lens or cataract, anterior and posterior capsule of the lens for precise centering and incision placements. The laser allows for independent adjustment of incision depth, diameter, and axis. The Victus Verafit patient interface provides a stable and comfortable connection to the patient’s eye. Intelligent Pressure Sensors monitor the sheer forces on the eye from the docking interface to prevent any undesired corneal distortion.

Streamline III is the latest LENSAR laser system upgrade platform. The laser provides the eye surgeon with the most advanced technology for managing astigmatism and optimizing patient outcomes. The LENSAR Streamline III is focused on correcting astigmatism to improve the visual outcomes of patients. A new wireless total astigmatism data transfer is now available. The total corneal astigmatism measurements can be transferred wirelessly from the Cassini Corneal Analyzer to the LENSAR laser system. Postoperative data analysis can help the eye surgeon refine pre-, post-, and intraoperative data which allows the surgeon to improve outcomes. IntelliAxis accurately determines the steep axis landmarks on the cornea. The laser has iris registration and automatic cyclorotation adjustment providing accurate corneal incision placement by comparing the pre-op image to the images during surgery. Accurate incision planning allows for better patient outcomes. Intelligent incisions employs localized imaging to monitor the cornea immediately before each incision is made for precise location.

The Catalyst laser combines a <600 femtosecond laser with gentle LIQUID OPTICS interface, and integrated 3D Full Volume OCT image guidance to create a precise laser cataract procedure. Liquid optics interface provides gentle docking or connection of the laser to the eye with minimal IOP rise and clear optics for excellent imaging and laser delivery. The Integral Guidance System provides 3D Full Volume Optical Coherence Tomography and automated surface mapping algorithms. The laser performs precise capsulotomies with an accuracy within 30um. The laser performs complete segmentation and softening of the nucleus of the lens with adjustable grid sizing. Multiple corneal incision centration options are based on the anatomical landmarks of the eye. The eye surgeon’s cataract surgery treatment plan is customized based of the patient’s anatomy of their eye.

All the FDA approved femtosecond lasers have passed the government’s testing for being safe, reliable, and do an excellent job.

Post-Op Cataract Surgery

In most cases, you will be placed on an antibiotic eye drop before surgery. There are some eye doctors start their patients on a NSAID or anti-inflammatory medication eye drop before the surgery. Most of the time, your eye doctor will start you on a corticosteroid, cortisone, or prednisone eye drop after the surgery. Typically, the antibiotic and corticosteroid eye drops are used 4 times a day for the first week. The eye medications are tapered off over the next 2 or 3 weeks. In most cases, you can resume normal activity very soon after cataract surgery. You eye doctor will provide you with their specific post-operative instructions.

Complications

Since there nearly 4 million cataract surgeries performed in the United States a year, there is a long list of possible complications related to cataract surgery. Still, cataract surgery is one of the safest, reliable, and most beneficial surgeries performed today. More than 95% of people have excellent results from their cataract surgery. The short list of the more common complications are hemorrhages, infection, swelling in your cornea, retinal detachment, macular edema, and mechanical difficulties during the surgery. You eye surgeon will go over the risks, benefits, procedures, alternatives, and complications with you.

Summary

Cataract surgery is the most common operation that Medicare or CMS cover. Since the advancement of new technologies, cataract surgery has very safe and reliable over the years. Cataract surgery is one of the most cost effective, beneficial, and successful operations performed in the United States. Some of the important keys to a great result is proper testing prior to surgery, picking the right surgery for you, strategic planning, finding the right eye doctor, and following the instructions given by your eye doctor. Following these steps can help maximize your surgical outcome.

How do You Know Which Cataract Operation for You?

In order for you to know what is the right cataract procedure for you, you first need a complete thorough eye exam and proper testing of your eyes. There is a possibility that you don’t even need cataract surgery, you may only need a new eyeglass prescription to correct your vision. As stated before, there is never a requirement or need for cataract surgery except in very rare circumstances. You only need to consider cataract surgery when your vision is blurred to a level that limits your lifestyle or ability to work. You should never have cataract surgery because some eye doctor says that is time for your cataract surgery, they need a new car, it needs to be done now or it will harm your eye, or that you need cataract surgery just because they say so. The bottom line is that cataract surgery is an elective operation except in a rare circumstance, it is always your choice of when to have surgery. So, if you have decided that you are unhappy with the quality of your vision and need to see better, what are the next steps?

What is Your Goal with Your Cataract Surgery?

Since you have decided to have surgery, what goals do you have concerning how you will see after your cataracts are removed? Is it that you just want to see better? Or, is it that you have always hated wearing glasses and would like to reduce or eliminate wearing glasses after the cataract surgery? Do you want to see well at distance without glasses and only wear reading glasses for near? Or, you hate glasses period and don’t want wear any glasses for distance or reading? There are many options related with cataract surgery.

Intraocular Lens Options for Cataract Surgery

There are 6 basic types of intraocular lenses, IOLs, or implants which are basic spherical lenses, aspheric or high definition lenses, toric lenses, multifocal lenses, accommodating lenses, and extended depth of focus lenses.

Monocular IOLs

A monocular lens has one specific strength or power to correct vision after cataract surgery. There are three types of monocular lenses which have a single power of focus which are traditional monocular lenses, aspheric monocular lenses, and accommodating lenses.

Traditional monofocal spherical IOLs have been available since the 1040s and provide very good vision after cataract surgery. Through the years the designs of the IOLs have been dramatically improved. In the late 1970s, the lenses started providing excellent results. These IOLs are round or spherical in shape just like a magnifying lens. Traditional monofocal IOLs are covered by Medicare and insurance companies. Many eye surgeons refer to aspheric IOLs as high definition monocular lenses. Accommodating IOLs move inside the eye to focus objects at near.

Multifocal IOLs

Multifocal lenses provide you with vision at distance and near similar to the way a bifocal works. There are two types of multifocal lenses which are diffractive IOLs and extended-depth of focus IOLs. Diffractive IOLs create two separate images in the eye. One image is focused at distance and the other image at near. You do not need to look down as with bifocal glasses. When your eye is looking at distance, the only image the eye can see is the distance image and when you use your eyes to look at near, the only image that the eye can see is the near image. Extended-depth-of-focus lenses (EDOF) work differently as the IOL provides distance and near vision by expanding the range or depth of focus of the lens.

Cataract Surgery Vision Option 1

This option is considered traditional cataract surgery with a monofocal IOL.  The goal of this type of surgery is to see well at distance without glasses if your eye does not have significant astigmatism. After the surgery, you will most likely need reading glasses to see up close.

Vision 2

Aspheric or High Definition Monofocal IOLs

Until recently, all lenses for eyeglasses and IOLs were spherical or round like a ball. A major refractive component of the vision system is the curvature or shape of the cornea which is not round. The cornea is aspheric in shape. The cornea is steeper in the center and flatter in the peripheral portion of the cornea. A spherical lens does not bend or focus light in the same manner as the cornea of the eye. Traditional round or spherical lenses can cause high order aberrations in the vision of a person. These aberrations can cause problems with the overall quality of your vision especially in low light conditions. Part of the pre-op testing should include measurements of sphericity and aberrations of your eye. Aspheric IOLs focus light in a manner that more closely matches the way the eye focuses light. Aspheric IOLs can be used to provide sharper vision with better contrast, and less problems with night vision. A good example would be the difference the clarity of the picture between a regular TV and a high definition TV. These aspheric IOLs can be used to focus your eyes for distance, intermediate, and near vision. Some of the more common aspheric IOLs are Alcon (AcrySof IQ), Lenstec (Softec HD), Abbott Medical Optics (Tecnis Aspheric), and Bausch and Lomb (SofPost AO).

 

Vision Option 3

Monovision surgery with monofocal IOLs is another option. With monovision, the dominant eye is focused at distance and the non-dominant eye focused at near with the IOLs. The best candidate for monovision surgery is a person who has worn contact lenses with monovision correction. Monovision can cause many people to feel disoriented or dizzy wearing monovision contacts. You need to be sure about cataract surgery in this manner as it is permanent. If you are interested in monovision and have never tried monovision, your eye doctor can have try wearing contact lenses with monovision for a period of time before deciding to have your cataract surgery with monovision correction.

Vision Option 4

A modified-monovision option with monofocal IOLs is another option. The dominant eye focused at distance and the non-dominant eye is focused at near with a mild amount of monovision. A slight amount of monovision will not cause any of the problems associated with regular monovision which are disorientation, unstable feeling, dizziness, and loss of depth perception. This level of modified monovision correction provides people with the ability to see prices at the grocery store, see a menu in a restaurant, and perform their daily routine activities without wearing glasses. Some people are able to read a book without glasses but looking at any fine print will require reading glasses.

Vision Option 5

Toric Monofocal IOLs (Astigmatism Correcting IOLs)

The toric IOL is a great choice for people who have significant astigmatism. Toric IOLs are able to correct astigmatism from 1.25 diopters or more of astigmatism due to the irregular shape of the eye. As described previously, astigmatism occurs when the cornea is shaped like a football cut length-wise. The cornea is more curved in one direction verses the other. A round eye shaped like a basketball does not have any astigmatism. Light that goes through a cornea with astigmatism is focused to a point on the retina but a line on the retina. People with astigmatism see ghost images or streaks around lights at night without their glasses on.

A toric IOL is designed in a manner so that it corrects the astigmatism just like glasses are designed to correct astigmatism. The IOL is stronger or has stronger power in one axis or meridian and is weaker or has less power 90 degrees in the opposite axis or meridian. The IOL manufactures place indicator marks on the IOL to show the axis or direction of the astigmatism. The eye surgeon uses these marks on the IOL to align the IOL to match the astigmatism of the eye. Prior to surgery, the surgeon places marks on the cornea to provide reference points to the axis of the astigmatism. Some eye surgeons may use an image of the eye that is taken in the pre-op workup to show the axis of the astigmatism. During the surgery, the toric IOL is placed inside the eye and aligned with the astigmatism of the eye. Common toric IOLs are Alcon (AcrySof IQ Toric), Bausch and Lomb (Trulign Toric), and Star Toric IOL.

Vision Option 6

Multifocal IOLs

The option of multifocal IOLs is for people who hate wearing glasses or want to drastically reduce their reliance on glasses. Presbyopic or multifocal IOLs are designed to give distance and near vision through the intraocular lens. The lenses work in a similar manner to bifocal glasses but use a completely different technology. IOLs that are design to provide distance and near vision are multifocal IOLs, accommodating IOLs and extended-depth-of-focus IOLs.

How Do Multifocal IOLs Work?

 

Multifocal IOLs are designed to provide vision at distance and near. They are also known as bifocal IOLs. The IOLs are designed in a way that split the light coming into the eye and going through the IOLs into two images. One image is focused at distance and one image is focused at near. The IOLs are designed with circular diffractive ridges, edges, or steps on the surface of the lens. The light is split or separated as it passes through these ridges resulting in two separate images. A bifocal lens in glasses has two different strengths of lenses and you have to look down through the bifocal to see up close. The IOL is fixed inside the eye and you can’t look down into the bifocal portion of the IOL. The multifocal IOL produces two separate images for distance and near. The vision is based on distance not direction. When you look at distance, the only image that the eye sees is the distance image. When you look up close, the only image that the eye sees is the near image. Therefore, it does not matter if you are looking up, down, or to the side, the image the eye sees is based on distance from the eye.

Proper Testing Prior to Surgery is Paramount with Multifocal IOLs

With multifocal IOLs, one of the most important steps prior to your cataract surgery is thorough testing of your eyes. The tests provide your eye surgeon valuable information essential in guiding you in choosing the best type of IOL based on how you wish to see after the cataract surgery. For multifocal IOLs, it is very important to have a completely normal eye and vision system. The correct power of lens needs to be chosen as any deviation can have a significant effect on how you see. Everything needs to be right on point for a good result. Multifocal lenses are not the best choice for everyone. It is much better to choose the proper type of surgery and IOL before your cataract surgery than have the wrong type of IOL placed in the eye. The surgery to remove an IOL and insert a new IOL can be much more difficult than the initial surgery. Also, you are putting the eye through another operation with its risks and complications. Be wise and make the proper choice for you. Do not just go along with some type of surgery the eye surgeon is pushing you to do. A second opinion is always a great idea.

Are You an Excellent Candidate for a Multifocal IOL???

1. You need to have a completely healthy eye

No significant dry eye disease

Normal cornea and especially no Fuchs dystrophy

No macular degeneration

No diabetic retinopathy

 

2. Very little aberrations in your visual system

 

3. The visual axis and the center of the pupil need to be very close to the same (small angle kappa)

 

4. Astigmatism is minimal or the astigmatism is correctable with femto laser or toric multifocal IOL

The Pros and Cons of Multifocal IOLs

Pros

For people who are good candidates, the IOLs provide very good distance and near vision

Multifocal IOLs provide the best IOL option for total relief from wearing glasses

Cons

• Decreased contrast sensitivity
• You will see halos or rings around lights at night. In good candidates, this diminishes over time
• You need good light to read

A brain process called neural adaptation helps you learn how to see with these IOLs. The brain is able to adjust to the new manner in which light is being focused in your eyes. Over time, neural adaptation minimizes the rings, halos, and contrast sensitivity issues.  If prior testing shows that you are an excellent candidate for multifocal IOLs, you can have a great result. Companies that make these types of IOLs are Alcon (AcrySof IQ ReStor) and Abbott Medical Optics (Tecnis Multifocal).

 

Accommodating Monofocal IOLs

Accommodating IOLs are designed focus moving inside the eye when you look at near or up close. The accommodating IOL moves forward inside the eye as you focus up close as the focusing muscles inside the eye contract. The forward motion increases the effective power of the IOL to help you see at near.  Just like moving a magnifying lens closer or further away from an object changes the focus of the magnifying lens.  The lens is designed with flexible haptics or appendages attached to the IOL which allows the IOL to move inside the eye. This IOL design has some limitations in that this movement can be minimal in some cases limiting the amount of clear near vision and the amount of movement may reduce over time. Accommodation IOLs are Bausch and Lomb (Crystalens AO and Trulign Toric).

Extended Depth of Focus IOLs (EDOF IOLs)

An extended depth of focus or extended range of focus is a new IOL design. Th EDOF IOLs or multifocal-like lens does not split the light into two separate images like the other multifocal IOLs. The EDOF IOLs provide near vision by extending the depth of focus allowing for near vision. The advantage of EDOF IOLs is that they do not reduce contrast sensitivity and form rings or halos around lights like regular multifocal IOLs. Another benefit of EDOF lenses is that they do not reduce reading vision in low levels of light as do multifocal IOLs. The disadvantage of EDOF IOLs is that they do not provide as good near vision as true multifocal IOLs. The EDOF lenses do allow people to see reasonable size print, restaurant menus, and prices at the grocery store. If you need to look at very fine print, you may need a weak reading glass. The extended-depth-of-focus IOL is made by Abbott Medical Optics (Symfony IOL).

Astigmatism or Toric Multifocal IOLs

If your goal is to not wear glasses and you have significant astigmatism, there are now new options. If the eye has 1 to 1.25 diopters of astigmatism or less, the Femtosecond Laser can correct the astigmatism and you can still have a multifocal IOL to correct your vision.

If you have greater than 1.25 diopters of astigmatism, then there is one multifocal IOL and one extended depth of focus IOL available that will correct the eye for distance and near vision. These are the multifocal Alcon (AcrySof ReStor Multifocal Toric IOL) and the extended depth of focus Abbott Medical Optics (Tecnis Symfony Toric IOL). There is also the accommodating toric IOL made by Bausch and Lomb (Trulign Toric IOL).

Option of Different IOLs in Each Eye

There are people that have only have astigmatism in one eye or different amounts of astigmatism in each eye.  You can choose to have different types of cataract surgery in each eye or different types of IOLs in each eye to maximize your vision and decrease the need for wearing glasses after cataract surgery. Your eye surgeon will go over the different all the different options that you may have  based on the health of your eye and your goals of how you wish to see after the surgery.

Summary

As you can see from all the options listed, there are many different options for cataract surgery. Traditional monofocal IOLs are covered by Medicare and insurance companies. The other types of surgeries and IOLs discussed are not covered by Medicare or insurance companies. These IOLs are designed to decrease your need of wearing glasses not just regular cataract surgery. These lenses are not covered by Medicare and insurance companies as they do not consider it medically necessary to decrease your need of wearing glasses. These new IOLs are designed to correct your vision such as for astigmatism or reading vision. Since you are choosing to have a newer technology IOL that is designed to decrease or eliminate the need for glasses, they are not covered. Medicare and insurance companies do not believe that they need to correct your vision. They only pay for routine surgery with monocular IOLs.

Once you have decided for yourself that you are unhappy with your vision and need to see better, the next question is how do you want to see after cataract surgery. Are you OK with wearing glasses after surgery or do you want to decrease your need for wearing glasses completely?

The next step is to find the right eye surgeon for you. As covered in the beginning, there are many eye surgeons who first priority is only about doing as many surgeries as possible. Many eye surgeons will try to tell you that it is necessary for you to have surgery right away. That if you wait, it is going to harm your eye. Many eye doctors’ offices will also push you toward the more expensive new technologies even if you are not the best candidate for that type of IOL. How do you know what to do? How do you choose your eye surgeon? One option is that you can ask your family physician for recommendation or ask who do they go to? Other things that you can do is to make sure that your eye surgeon is board certified, is a member of their state ophthalmology society, local societies, and has a clean record. You can always get a second opinion.

You need thorough eye testing of your eyes to help you determine the best cataract surgery procedure and IOL for your specific needs and goals. Your eye surgeon should be your guide and help you make the best decision. If the eye surgeon is pushing you into surgery or a specific type of surgery or IOL, then get a second opinion.

Cataract surgery is an extremely successful operation. One of the most successful operations performed in the United States. Most people are thrilled with their vision after surgery. It is important to follow the right steps in order to get the best result.