Every day in the office I hear stories told to me from patients who have told all kinds of wild stories about their eyes and cataracts. I have been told many times that they were told by their eye doctor that they needed cataract surgery immediately as the cataract is going to explode inside their eye. If the cataract remains in their eye any longer, it is going to cause their eye great harm. What a ridiculous statement by a supposedly caring eye doctor that took an oath to help people and to do no harm. Or other stories that the cataract is just starting but it should come out now as it is easier to do the surgery now. Or that the cataract is going to go from a level 1 cataract to a level 4 cataract within 6 months and the surgery will be very difficult then. Unfortunately, there are too many doctors who are more interesting in making money than taking care of their patients.
What is a Cataract?
Nearly 100 percent of people that I see in the office believe that a cataract is a film or growth that is growing over their eye. A cataract is not a film or piece of tissue that grows over the eye which is causing your vision to be blurred. How do you see? The lens inside of the eye behind the pupil and iris (colored portion of the eye) focuses light that passes through the pupil to be focused onto the retina (retina is like the film of a camera as its receives the image that you are looking at).
The image that the retina receives is transmitted through the optic nerve and to the back portion of the brain. This is called the occipital lobe and this is the vision center inside the brain. This lens behind the pupil loses its clarity over time and becomes hazy or cloudy. The lens becomes progressively cloudier, which causes the vision to blur. It is like the windshield of your car fogs up. The denser the fog of the windshield, the more difficult it is to see through the windshield. You now know that a cataract is not a growth or film growing over the eye.
Light Passes Through Lens (Cataract) Scatters the Light
In almost all cases, a cataract is just that the lens loses its clarity over time secondary to aging. There are genetic factors related to cataracts that can lead to the development of cataracts. There are families that develop cataracts at a younger age. On a rare occasion, a child is born with cataracts. There is very good evidence that ultraviolet light or sun exposure increases the risk of developing cataracts at a faster rate. Smoking also leads to the development of cataracts at a younger age. Diabetes causes the eye to develop cataracts at a younger age as well.
In most cases, cataracts develop slowly over years of time. There are many times that a person just needs to get a new prescription for glasses. Some cataracts can cause the eye to become more nearsighted from the eye’s original state as it progresses. There are several different types of cataracts as there are different portions of the lens that can become cloudy. Here is a list of some of the different types of cataracts:
Cloudy Vision from a Cataract
- Nuclear sclerosis
- Posterior subcapsular cataracts
- Cortical cataracts
- Anterior subcapsular
- Traumatic cataracts
- Combination of the different types of cataracts
- Mature or hypermature cataracts
Bottom Lens Brown and Cloudy (Nuclear Sclerosis)
Central Blurred Vision from Posterior Subcapsular Cataract
A ripe cataract is an old term used to describe a mature or hypermature cataract. The term cataract comes from the word used for rapids or waterfalls where the water turns from clear to white in waters, rapids, or cataracts. A ripe cataract is when the lens in the eye becomes white and the tissues of the lens start to liquefy or degenerate. The lens melts like when a fruit becomes overripe and begins to liquefy. You can see the cataract as the pupil of the eye is white. The term ripe cataract was used as far back as Aristotle’s time. The vision with a ripe or hypermature cataract is usually that the person can only see light out of the eye. That is the person can only see light when a bright light is 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. It is very common in third world countries. The eye surgeon used this term as it was an easy way to tell someone about the status of their cataracts. This was before there were more advanced surgical techniques when people had to be admitted to the hospital for several days or as long as 2 weeks following cataract surgery. There are very few people who let their vision and cataract advance to that level in the United States 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.
Color Changes that Commonly Occur with Cataracts
If you remember nothing else, you need to remember this. This is absolutely the most important thing you need to know about having cataracts. There is almost never a medical reason or emergency for cataract surgery. There are very few medical indications for needing to have your cataract removed. Cataract surgery is an elective eye operation. Unfortunately, I see people in my office nearly every week who have been told that they have to have cataract surgery or need cataract surgery. They are told they need to have the cataract surgery right away, it is going to harm their eye. Or I see people who come in for a second opinion after their surgery because they are not happy with their result or don’t see any difference in their vision after the surgery. The surgery was done well and their vision is actually good. It is my opinion that these people probably didn’t have any cataract at all or a very small amount of cataract present before the surgery. A very large number of people are being told to have cataract surgery with no cataract or only a minimal cataract present in their eyes. I have been told story after story about the eye surgeon telling them that their cataract was at a level 1 presently but would advance to a level 4 within six months and harm their eye. I am not sure what the doctor means by a level 1 or 4 as I have never seen cataracts referred to in this manner except by eye doctors wanting to do surgery to everyone that they can.
So, Why or When Should you have Cataract Surgery?
First, you need a thorough eye exam and see if just changing your glasses will improve your vision. If with your best possible corrected vision with glasses or contacts, you are having blurred vision, then you should consider having cataract surgery. There is almost never, ever a medical reason that your cataracts are required or needed to be removed. You only need to have cataract surgery if your blurred vision is interfering with your lifestyle. You are having trouble, reading books which you love to do, you are having trouble driving at night, the distance vision is blurred so much that you are not happy with the quality of your vision, or you are having trouble seeing the things you need to see at work. The real reason to make the decision on having cataract surgery is that you are unhappy with your vision. The eye doctor says that your eye is healthy and it is the opinion of your eye surgeon that cataract surgery would improve your vision. The eye surgeon should be an assistant in your making the best decision that is right for you. People with macular degeneration are more difficult to know when to have the surgery. Sometimes it can be challenging to know if a person’s vision trouble is related to their macular degeneration or the cataract. This is where you need to depend on your doctor’s opinion. Otherwise, the decision of when you are going to have surgery is up to you. You know better than anyone else how much trouble you are having with your vision. Cataract surgery is an elective operation that you choose to have performed because you decide that you need better vision, and not that the eye doctor wants to do more surgery, period.
Cataracts Causing You Blurred Vision- What’s Next?
Now that you have found out that you have cataracts and you are unhappy with your vision, what is next? Your eye doctor cannot change your glass prescription to improve your vision. Therefore, surgery is next.
As discussed earlier, a cataract is the lens inside of your eye behind your pupil loses its clarity and becomes cloudy. The cloudy or hazy lens needs to be removed in order to clear your vision. If all that is done is to remove the lens, your vision is going to be very blurred as you have no lens in your eye to focus the light onto the retina. After the cataract or lens has been removed, it needs to be replaced with an artificial lens so that you can see again. If you don’t replace the lens that was extracted from your eye, the vision is going to be very blurred. A significant part of the focusing system for your eye has been removed and the lens needs to be replaced. Before your surgery, the eyes are tested and measured so that the eye surgeon can choose the proper lens power to replace your lens. The lens power is calculated by computers inside of instruments used to measure your eye and the eye surgeon will choose the strength of lens that will correct your vision. So, no matter if you are near-sighted, far-sighted, or have astigmatism, your vision can be corrected with the insertion of an intraocular lens that has been calculated to correct your vision.
Prior to cataract surgery, you need a thorough complete eye examination. The eye doctor needs to make sure that you don’t have any other eye disease that could affect the outcome of your surgery such as macular degeneration, glaucoma, diabetic retinopathy, or other eye diseases. You will have a series of tests on your eyes so that the eye doctor can give you guidance on the best surgery for you. Some of these tests may include a visual field test, Pentacam, IOL master, Lenstar, specular endothelial microscopy, eye dominance, corneal topography, dry eye testing, and i-Trace.The i-Trace instrument is a fantastic instrument that gives a significant amount of information about your eyes. It measures the aberrations in your vision which provides very important data that the eye doctor can use to guide you with your decision. Everyone has aberrations in their vision even if you have better than 20/20 vision and no eyeglass prescription. We would have much better than 20/20 vision if our eyes did not have these aberrations. The i-Trace gives the eye surgeon the data about aberrations due to then shape of your cornea (clear front portion of the eye) and aberrations secondary to your cataract and lens inside your eye. The i-Trace also provides the asphericity of your cornea and the alignment of your visual axis compared to the center of your pupil. All this information is very important if you are considering a multi-focal intraocular lens. Many people are not good candidates for this type of lens if there are too many aberrations and/or the alignment of the visual axis is not optimum.
The Lenstar and IOL master are the two most common instruments used to measure the eye for determining the power of the intraocular lens that is going to be used to correct your vision during the surgery. These instruments take a variety of measurements of the eye and a computer in the instrument determines the strength of the lens that is going to correct your vision. These instruments are very accurate but not perfect. There is no guarantee that the instrument will be perfect in your particular case.
Once the eye surgeon has the information they need to help you with the decision-making process on the variety of options you have with your cataract surgery, you will make the decision on the type of surgery you are going to have performed on your eye and the type of intraocular lens that will be inserted into the eye.
A surgical coordinator or staff member will go over all the details of having cataract surgery. There will be numerous forms and papers that you will need to sign. You will read over the informed consent for having cataract surgery which the surgeon will go over. In most cases, you will be using eye drop medications before and after the surgery. The staff will go over the pre-op and post-op instructions and give you a written copy for you to follow.
In simple terms, the cloudy lens or cataract inside your eye is removed and a new artificial intraocular lens is placed back inside the eye to help correct your vision. The power or strength of the lens was determined by the instruments in the office prior to the surgery. The natural lens has a certain amount of focusing power that needs to be replaced. You would have very poor vision if you only had the cataract removed and no lens replacement in almost all cases. The great news is that the intraocular lens can correct any prior refractive error that you had prior to the surgery. Again, if you are near-sighted or far-sighted, the strength of the new artificial lens can correct it in most cases.
Common Steps of Cataract Surgery
In most cases, eye surgery will be performed in an ambulatory surgery center. There are some places in the United States where the surgery is still performed in a hospital on an out-patient basis. Once you arrive at the surgery center, you will be admitted to the surgery center and taken to the pre-op area. You will lie down on a stretcher and an IV will be started. In most cases, the IV will just be the tubing without any 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. A variety of eye drop medications will be instilled into your eye numb and to dilate your pupil as your cloudy lens is behind your pupil.
You are taken to the operating room and placed under a microscope used during the operation. The eye will be prepped and draped prior to surgery. Very tiny incisions are made in the cornea (clear portion of the eye) near the sclera (white portion of the eye). These micro-incisions are so small that are sutures are very rarely necessary to close the incision. There is a thin cellophane-like capsule that surrounds your lens that has the consistency of Saran wrap. A 5mm circular opening is made on the anterior surface of the lens capsule to gain access to the cloudy lens material.
Capsule can be Stained with Blue Dye for Visualization
Phacoemulsification Probe Dissolving the Cataract
A cannula on a syringe with balanced salt solution is used to loosen the lens material from the surrounding capsule. A phacoemulsification tip that vibrates approximately 45,000 beats per second is used to dissolve or emulsify the nuclear or center portion of the lens. Fluid is delivered inside the eye with this tip and the center of the tip is hollow so that the liquid and emulsified cataract material is aspirated from the eye. Another cannula is used to remove the softer cortical material of the lens.
The lens chosen to correct your vision is inserted into an injector device that rolls the lens up like a pancake or soft taco.
Intraocular Lens Inside the Eye. Anterior Capsule Opening Visible
The intraocular lens is inserted back inside of the same capsular bag that had your natural lens. Once the lens is inside the eye, the lens unfolds back to its original state. The intraocular lens is held in place inside the eye by the same capsule that held your natural lens. Most of the time, sutures are not needed to closed the incisions. There are no eye patches applied after the surgery in many cases.
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.
If you are having a femto laser used during your cataract surgery, you have another step to go through. The femto laser may be in the same operating room or in another room near the main operating room. The femto laser performs several of the steps in cataract surgery in a very precise manner. It makes the incisions in the cornea. If you have a small amount of astigmatism, the laser will perform a limbal relaxing incision on the cornea to correct your astigmatism. Astigmatism means that your cornea is shaped more like a football versus a basketball. The femto laser will help restore your corneal shape back to a basketball providing you better vision without glasses. The laser also makes the 5-mm circular capsulorhexis or opening in the anterior capsule centrally located and in a precise circular shape. The femto laser then divides the nucleus of the lens into pieces and can soften the lens as well to facilitate the removal of the cataract. The femto laser performs these steps in 30 seconds or so after the laser is in position. After the femto laser, the cataract surgery and intraocular lens insertion are performed in a routine manner. The femto laser provides a more precise surgery, more consistent results with less glass prescription after the surgery, and fewer complications.
Alcon LenSx Femto Laser
You will have started an antibiotic eye drop before surgery. Some eye doctors start their patients on a NSAID or anti-inflammatory medication eye drop prior to surgery as well. Most of the time you will start a corticosteroid eye drop after the surgery. Typically, you are antibiotic and corticosteroid 4 times a day for a week. The eye drops are tapered off over the next 2 or 3 weeks. You can resume normal activity very soon after surgery. You eye doctor will provide you with their post-operative instructions.
There is a long list of complications as there are nearly 4 million cataract surgeries performed in the United States last year. The great news is that cataract surgery is one of the safest and most beneficial surgeries performed today. Better than 95% of people do very well after their cataract surgery. The short list of complications are hemorrhages, infection, swelling in your cornea, retinal detachment, macular edema, and mechanical difficulties during the surgery. You eye surgeon will cover the complications with you.
Cataract surgery is the most common operation that Medicare or CMS pays for. With the advancement of technology, cataract surgery is one of the most successful operations performed in the United States. The key to great results is proper testing prior to surgery, strategic planning, and following instructions given by you eye doctor are essential for maximizing your surgical outcome.