Cataracts & Cataract Surgery
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More than half of all Americans will have dealt with cataracts by the time they are 80, yet many people still do not know what they are or what causes them. Cataracts are common among those over the age of 50 and are characterized by a clouding of the eye's natural lens, resulting in blurry vision.
Currently, the surgical removal of the lenses and subsequent replacement with artificial intraocular lenses (IOLs) is the only cure for cataracts. Fortunately, cataract surgery is a low-risk procedure with an excellent record of safety and success.
Cataracts form when proteins begin to clump together in the lens, clouding a small area of the eye. This cloud will continue to grow and interfere with vision. Cataracts can occur in one or both eyes. While the most common cause of cataracts is age, they can also be caused by eye trauma, certain medications, and various environmental and lifestyle factors. Additionally, some cataracts are congenital.
Your eye is composed of protein and water. If the protein cells separate from your eye, they will eventually drift onto the natural lens located behind your pupil. This will prevent light from passing completely through the lens and focus properly on your retina, resulting in obscured vision. As light passes through your eye, the lens refracts the light, focusing it on the retina. As the cataract grows, vision becomes progressively worse.
In part, cataracts develop because of the process of oxidation. Free radicals roam throughout the body. These oxygen molecules stabilize themselves by taking electrons from nearby molecules. In response, these molecules will attempt to self-stabilize by taking an electron from another molecule, and the cycle continues until it affects more and more cells. As this process, known as oxidation, occurs in the eye, it can lead to the development of cataracts.
Types of Cataracts
There are three types of cataracts, each defined by its location on the lens:
- Nuclear cataracts, which form in the lens' nucleus, are the most common type of cataracts. Because opacity develops in the center of the lens, known as the central nucleus, nuclear cataracts interfere with a person's ability to see objects in the distance. Usually the result of advancing age, nuclear cataracts can take years to develop and often give the nucleus a yellow tint.
- Cortical cataracts begin at the outer rim of the lens and gradually work toward the central core. Thus, this type of cataract resembles spokes of a wheel. Patients with cortical cataracts often notice problems with glare, or a "halo" effect around lights. They may also experience a disruption of both near and distance vision.
- Subcapsular cataracts progress the most rapidly. While nuclear cataracts take years to develop, subcapsular cataracts reach an advanced stage within a matter of months. Posterior subcapsular cataracts affect the back of the lens, causing glare and blurriness. This type of cataract is usually seen in patients who suffer from diabetes, extreme nearsightedness or retinitus pigmentosa, as well as among those who take steroid medication.
Congenital cataracts refer to cataracts that are present from birth, as well as to those that develop in early childhood. These cataracts can be nuclear, cortical, or subcapsular. Congenital cataracts may be linked to an infection contracted by the mother during pregnancy or to a genetic condition such as Fabry disease, Alport syndrome, or galactosemia. Because clear vision is essential to the development of the child's eyes and brain, it is important to diagnose congenital cataracts as early as possible.
Because each of these cataract types affects vision in a distinct manner, it is possible for a patient to have more than one type of cataract at the same time.
Most cataracts form as a result of advancing age. Other possible causes of cataracts include environmental factors and certain medications, such as antidepressants. If your medical history or lifestyle increases your risk of developing cataracts, it is important to have your eye health monitored regularly by a qualified ophthalmologist.
Over 50 percent of Americans over the age of 80 have cataracts
Age is the main reason cataracts form. According to the American Academy of Ophthalmology, the eye disease appears in over 22 million Americans over the age of 40. Over 50 percent of Americans over the age of 80 have cataracts. In fact, if we live long enough, nearly all of us will eventually develop this condition. Because the lens of the eye cannot shed old cells naturally, protein that accumulates on the lens gradually builds up over time, progressively obscuring vision by preventing light from reaching the retina.
Ultraviolet Radiation (UVA or UVB)
According to the U.S. Environmental Protection Agency, long-term exposure to ultraviolet radiation, especially UVB rays, can cause changes in pigment that lead to the formation of cataracts. This is especially common in tropical climates, where high concentrations of UV exposure occur year-round. To protect the eyes from sun damage, it is important to wear sunglasses with a high level of UVA/UVB protection.
Certain medications are well-known causes of cataracts, and some drugs can also accelerate their development. Steroid medications - whether pills, injections, or eye drops - are most frequently associated with cataract formation. If you are taking steroid medications to manage a long-term condition, it is important to note any visual changes and to have your ocular health managed by a qualified ophthalmologist. The medications that can cause cataracts include:
- Eye drops containing steroids
- Glaucoma medications
- Certain antipsychotics and antidepressants
- Certain medications for autoimmune conditions
- Medication to control heart arrhythmia
High levels of blood sugar cause the lens of the eye to swell with excess fluid, making diabetic patients more susceptible to cataracts and glaucoma. People who have diabetes are more likely to develop cataracts at a younger age, and experience rapid cataract progression. Careful monitoring of blood sugar levels helps to minimize the risk of developing cataracts.
Obesity is most commonly linked to the development of posterior subcapsular cataracts. According to researchers at Harvard University, individuals with a BMI of 33 had at least a 30 percent greater likelihood of developing cataracts, compared to subjects with a BMI of 23 or below.
Injury, Inflammation, or Trauma to the Eye
Injury or trauma to the eye increases a patient's risk of developing cataracts. Individuals who have experienced inflammation in the eye, either post-operatively or as the result of another eye disease, are also more likely to eventually develop cataracts. For instance, iritis is an ocular condition that causes chronic inflammation inside the eye, and is commonly linked to early and rapid cataract formation.
Lifestyle habits such as smoking or consuming alcohol are often considered causes of cataracts. In 2012, the Investigative Ophthalmology & Visual Science published a study performed by Chinese researchers on the correlation between smoking and cataracts. The scientists found that smokers were at a significantly higher risk for cataracts, with current smokers showing the highest rate of cataracts development. These individuals were most at risk for nuclear and subcapsular cataracts. Some doctors attribute the connection to the high level of free radicals present in the bodies of smokers, placing them at particular risk of developing nuclear cataracts.
Alcohol is responsible for a slight increase in the likelihood of cataract development, and the level of risk directly correlates to the amount of alcohol consumed. For both eye and overall health, it is recommended that drinking be limited to moderate amounts.
Maintaining healthy eating habits can help to prevent cataracts in two ways. First, a good diet will control your weight, thus eliminating one of the significant risk factors. Second, increasing your antioxidant intake can also inhibit the oxidation process. In a 2013 Swedish, researchers observed 30,000 women over age 49, and found that those who consumed the highest amounts of antioxidants had a 13 percent lower chance of developing cataracts than those who consumed the least amounts.
To reduce your risk for cataracts, be sure to eat plenty of foods high in antioxidants. These could include:
- Colorful fruits and vegetables
- Whole grains
- Red wine
- Poultry and red meat
- Sunflower seed
In addition to changes in diet, there are several other modifications you can make to protect your eye health:
- Stop smoking: As stated above, current smokers have a significantly higher chance of developing cataracts.
- Wear sunglasses: Be sure to look for lenses with 100-percent UV protection. To ensure that you are receiving quality lenses, purchase sunglasses from your ophthalmologist. If you purchase them elsewhere, don't assume that just because the label says they offer complete UVA/UVB protection, they actually do so. Ask you eye doctor to check the percentage before you wear them.
- Protect your health: If you have another health condition, such as diabetes, that increases your risk for cataracts, seek treatment for these concerns. If you have diabetes, keeping your blood sugar under control is one of the most important things you can do to protect your eye health.
- Exercise: Although workouts themselves will not affect your eyes, an active lifestyle will help to manage your weight. Of course, if you choose outdoor activities, be sure to wear your sunglasses.
Routine Eye Exams
When you make regular visits to your ophthalmologist, he or she can monitor your eye health and look for cataracts in the early stages. With early diagnosis, your doctor can treat the condition before it begins to impinge upon your quality of life. Typically, you should have an eye exam once a year, although if you are at a higher risk for cataracts, you should make biannual visits.
There are a number of signs that may indicate that you are suffering from cataracts. Common cataract symptoms include:
- Blurred vision: When cataracts cloud your lens, light cannot focus on the retina properly, and your brain will register a distorted image.
- Difficulties with night vision: With cataracts, your retina is already receiving less light, and therefore, in dim light your sight is compromised even further. This can be especially problematic when you are driving at night.
- Halos and light sensitivity: Cataracts cause the light passing through your eye to scatter, so that it hits your retina in several different places. This can cause discomfort and vision difficulties in bright light.
- Difficulty distinguishing colors: If you have cataracts, you may have problems perceiving hues on the blue end of the color spectrum. As a result, objects may appear yellow or simply dull and faded.
- Rapid changes in vision: If you experience swift and repeated changes in your glasses or contacts prescription, this can be an early sign of cataracts.
- White spots on the pupil: On occasion, your cataracts may be visible to an observer, especially when viewed at certain angles or under specific lighting conditions.
Progression of Cataracts
Of course, the frequency and degree of your symptoms will depend on the severity of your cataracts. Symptoms and treatment will vary, depending on whether your cataracts are in the early or advanced stage of development.
In the early stages, indications include changes in vision, such as glares, halos, difficulties with night vision, etc. Often, these symptoms are so slight and progress so slowly that people don't even realize they are present. It is not unusual for cataracts patients to seek treatment only because family members have pointed out that they seem to be having difficulties. In some instance of early stage cataracts, you may develop what is known as "second sight," in which your close up vision will actually improve before your eyesight starts to decline over all.
Advanced cataracts will cause more severe changes in your eyesight. Without treatment, you may have difficulty distinguishing facial features and completing daily tasks. The rate at which your cataracts develop will depend on several factors. Typically, if you are at a higher risk for cataracts, for any of the reasons described above, your cataracts will develop more quickly.
Cataracts are fairly easy to diagnose. Nevertheless, for the most accurate diagnosis, there are a number of advanced tests that your doctor may use. Utilizing these diagnostic tools, your doctor can also check for an additional eye disease, such as glaucoma or macular degeneration.
Visual Acuity Test
When you think of a routine eye exam, this test is probably what you picture. Your doctor will ask you to read a series of letters off of a Snellen eye chart posted 20 feet away from you. This test allows him or her to detect any significant changes in your vision.
If you have already been diagnosed with cataracts, and your vision has degenerated to 20/40 or below, your doctor may recommend surgery. In some cases, you may have a good score on this test, but you still present with other cataract symptoms, such as light sensitivity or blurred vision. When this occurs, your ophthalmologist will likely recommend more tests to determine whether cataracts are, in fact, responsible for your symptoms.
Slit Lamp Exam
Your doctor will give you eye drops to dilate your pupil. By shining a light on the front of your eye, he or she can usually detect any white spots on your lens, even if they are very minute. The slit lamp exam often allows for extremely early diagnosis, so that your ophthalmologist can detect cataracts before they begin to affect your vision. During the test, your doctor will likely use a magnifying lens to examine your retina and optic nerve. Although this step is not necessary for cataracts detection, it enables your doctor to check for other serious eye conditions.
Glare and Contrast Sensitivity Tests
These two tests are similar to a traditional visual acuity test.
During a glare test, you will be asked to read the Snellen chart under various lighting conditions. If you have difficulty discerning the letters under very bright light, this could be a good indication of cataracts.
Contrast sensitivity tests use different kinds of charts; instead of the letters getting smaller as they go down the chart, they "fade," or contrast less with the white background. If you are unable to read all but the most defined rows of letters, this, too, could be an indication of cataracts.
Ishihara Color Test
Named after its designer, Dr. Shinobu Ishihara, this test uses a series of plates covered with colored dots. The dots vary in color, forming a number in the center of the plate. Those with an inability to distinguish hues on the blue-green end of the spectrum will not be able to see the numbers. If you have not been previously diagnosed as color blind, and you do not pass the Ishihara color test, you may be suffering from advanced cataracts.
Your ophthalmologist will direct a puff of air towards your eye, and it will measure the intraocular pressure (IOP), determined by the amount of vitreous fluid inside your eye. Although tonometry tests are most commonly used to diagnose glaucoma, it is important that your doctor be as thorough as possible during cataract diagnosis. When left undiagnosed and untreated, glaucoma, macular degeneration, and similar eye diseases can have dramatic consequences for your vision and ocular health.
When to Consider Surgery
During cataract surgery, your doctor will remove the old, clouded lens and replace it with an artificial intraocular lens, or IOL. Fortunately, cataracts only affect your lens, and therefore, there is no rush to undergo cataract surgery.
Typically, doctors will recommend surgical treatment when your condition has started to affect your daily life. If you find that it is difficult to complete certain daily tasks, or if you are no longer able to see objects or faces clearly, it may be time for surgery. If you frequently drive at night, you should undergo surgery sooner, as the nighttime glare can pose a serious risk for accidents. (In the meantime, you should avoid night driving, resuming it only when you have recovered from your cataract surgery.)
Alternatively, your ophthalmologist may recommend surgery if you do not receive a good score on your visual acuity, glare, contrast sensitivity, or Ishihara color tests. Ultimately, the decision to undergo surgery is your own, but your doctor can help you decide when it would be most beneficial to your health and quality of life.
Treatment for Early Stage Cataracts
Before surgery becomes necessary, there are a number of methods that your doctor may employ in the treatment of your cataracts. In the early phases, he or she may recommend new glasses or contacts, anti-glare lenses, and magnification devices. In most cases, however, these treatments will only work for a time. As your cataracts grow, surgery will typically be in your best interests.
Fortunately, virtually all insurance companies cover the cost of cataract surgery, as it is necessary to restore your vision and quality of life. However, the final cost of your procedure can vary significantly, depending on several factors, and there may be some costs you will need to cover out of pocket.
The Type of IOL
Typically insurance companies will only cover the cost of standard cataract surgery, which includes placement of a basic monofocal IOL. These lenses only correct vision at one distance. Premium lenses provide vision correction at varying distances, but these lenses typically cost more. If you choose to receive a premium lens, your insurance will usually cover the cost of basic surgery, and you will be responsible for any additional fees.
Astigmatism occurs when your iris is irregularly shaped, and therefore your vision is blurred at all distances. If you suffer from this condition, as well as cataracts, you may benefit from limbal relaxing incisions (LRI) before your procedure. After your doctor makes tiny incisions in the limbus (the tissue that connects the cornea and the white of your eye), your iris may relax and become more rounded as it heals. LRIs typically cost about $500 per eye, and they are not covered by insurance. Astigmatic keratotomy (AK) is a similar procedure, in which your surgeon will make two incisions at the steepest portion of your cornea. Insurance companies also do not typically cover AK.
You may also benefit from a toric IOL, the only type of intraocular lens proven to correct astigmatism. Again, these premium lenses do cost more than traditional monofocal lenses, and the extra cost is not covered by insurance.
As stated above, most insurance companies, as well as Medicaid, cover the full cost of basic cataract surgery. However, it is important to be fully informed about your insurance coverage and to make certain that you are getting the maximum benefits that your plan provides. Before undergoing cataract surgery, be sure to ask about your deductible and co-pay. You should also inquire about the cost of glasses or contacts. Even after cataract surgery, you may still require corrective lenses, so you will need to budget for this, as well.
In most cases, your surgeon's administrative staff will work as a liaison with your insurance company, making sure that you receive the full amount of your rightful coverage. They will usually file your claim for you, as well. However, you will be directly responsible for any fees not covered by insurance.
Paying for Additional Costs
If you need help covering additional charges, there are several options available to you:
- In-house financing: Many doctors offer flexible repayment plans, designed around your budget. Some may even provide significant discounts if you pay for your procedure in full before treatment. Be sure to inquire about any financing options at your initial appointment.
- Medical financing: Most eye surgeons accept medical credit cards, as well as medical financing through companies such as Compassionate Finance®. These companies offer fixed-interest plans with approved credit. Many offer no-interest plans when costs are paid in full within a certain time frame.
- Third-party financing: Sometimes, banks and other lenders will also finance medical procedures. These loans work much like any other loan that you would take out for a house, car, and other important purchases.
How to Choose a Cataract Surgeon
Your eyesight is invaluable to your quality of life. Therefore, when you are preparing for cataract surgery, it is essential that you choose a surgeon with outstanding training and expertise. The ideal doctor will have performed hundreds, if not thousands, of cataract surgeries with success.
You can inquire with your state's medical board to find out if the doctor you are considering has a good history. Each state is legally required to make these records public, and they will show malpractice suits, as well as complaints lodged against a doctor. In many areas, these records are accessible online, but in other states, you may have to request paper copies through the mail.
Type of Lenses and Surgery
If you are considering a premium IOL, you should look for a surgeon with experience using these advanced lenses. While all cataract surgeries involve technical skill, certain lenses require extremely precise placement for optimal vision enhancement. Additionally, if you are interested in advanced technology, such as laser cataract surgery, find a doctor who has been using these advanced tools on a regular basis for several years.
Cataract surgery is typically performed on an outpatient basis, and therefore it is important that you choose a doctor with hospital privileges. Although this procedure is renowned for its low complication rate, in the unlikely event that something goes wrong, you will be assured of a place to go for emergency treatment.
Additionally, doctors must pass rigorous standards and inspections in order to be granted privileges. When you select a surgeon who has passed these tests, you can rest assured that you will be treated with the highest degree of safety and ethical consideration.
While your safety and the outcome of your surgery are the most important considerations, you are far more likely to enjoy good results, if you choose a doctor who truly takes the time to listen to your concerns. A good eye surgeon will answer your questions and help you feel comfortable about your treatment.
In general, a doctor should make premium IOLs available, but he or she should not pressure you to choose these lenses. Additionally, a surgeon should encourage you to have realistic expectations for the procedure. If he or she promises that you will no longer need glasses or assures 20/20 vision, know that this doctor is making unrealistic guarantees.
The Initial Consultation
Once you have decided that it is time to undergo cataract surgery, you will have a complete consultation with your doctor. This will give you a chance to discuss your goals for surgery, and your surgeon can begin planning out your personal treatment plan. He or she will typically begin by taking your medical history, including a list of current medications. In some cases, the doctor may perform an additional eye exam. If you wear contacts, you should not wear them for about two weeks before your consultation, as they can affect the accuracy of measurements and tests.
Choosing Your Lens
After gathering all relevant information, your doctor will explain the various types of IOLs, including the benefits and disadvantages of both standard and premium lenses. He or she will help you select the right one for your needs. If you want to reduce or eliminate your reliance on glasses or contacts, then premium IOLs may be your best option. However, if finances are your biggest concern, you may want to consider standard monofocal IOLs.
Choosing Your Anesthetic
When you undergo cataract surgery, you will have two sedation options: general and local. Local sedation is the most common choice. However, if you are feeling particularly anxious, you may benefit from general anesthesia. Many doctors also have strong preferences about the type of sedation they use, but a good surgeon will listen to your concerns, putting your safety and comfort above everything else.
Types of Cataract Surgery
There are three basic types of cataract surgery: extracapsular surgery, intracapsular surgery, and laser-assisted surgery. Each offers its own unique benefits and risks.
Extracapsular cataract extraction is the most commonly performed type of cataract surgery. There are actually two types of extracapsular procedures:
- Standard Extracapsular Cataract Extraction (ECCE): Your doctor will make a small incision, about 8 mm to 10 mm wide where the cornea and the white of the eye come together. He or she will make another incision in the lens capsule, the membrane surrounding the entire lens. Then the surgeon will remove the old lens, place the IOL behind the iris, and close the incision in the lens capsule.
- Phacoemulsification: This newer procedure is far more common than ECCE. During this treatment, also known as small-incision surgery, your doctor will create two tiny incisions between the cornea and the white of the eye. Then he or she will insert a phaco probe in these incisions. The probe emits ultrasound waves to break apart the clouded lens. Then the pieces can be gently suctioned out without damage to the surrounding tissues. After the old lens has been completely removed, the doctor will place a new lens behind the iris, and the incisions should heal on their own.
Intracapsular cataract surgery was invented in the 1980s, but it is rarely performed today. During this procedure, which involves a much larger incision, a doctor will inject the eye with a special medication, which causes the fibers holding the lens in place to dissolve. Then the doctor will freeze the clouded lens by applying liquid nitrogen with a specially designed probe. As he or she removes the probe from the eye, the natural lens will come away with it, enabling the surgeon to place the new IOL. In contrast to extracapsular surgery, in which the artificial lens is placed behind the iris, during intracapsular surgery, the doctor will position the new lens in front of the iris.
As with many other areas of medicine, advanced lasers are rapidly changing how cataract surgery is performed. In contrast to traditional surgery, in which the doctor creates an incision by hand using a small blade, during a laser procedure, he or she will make these incisions using highly precise femtosecond lasers.
The high power lasers offer even greater accuracy because they are carefully calibrated, based on a three-dimensional digital map of your eye. Although traditional cataract surgery is still quite safe, lasers allow your doctor to place the IOLs even more precisely, and they can also minimize discomfort and recovery time.
The Surgical Procedure
Cataract surgery is an outpatient procedure, which typically takes about 15 minutes. However, you should plan to be at the surgical center at least an hour and a half to allow time for anesthesia and post-surgical instruction. If you have cataracts in both eyes, your doctor can treat both eyes. However, this will nearly always take place during two separate surgeries.
At your pre-surgery consultation, you and your doctor will already have determined the type of sedation best suited to your needs. You will be able to choose from two types:
- Under general anesthesia, you will be completely asleep throughout the process.
- Under local anesthesia, your doctor will apply numbing drops to your eye. Alternatively, he may use an anesthetic injection to numb the surrounding tissues. With either type, you will remain awake, but you should not feel any discomfort.
When you are comfortable, the doctor will remove your clouded lens using one of the techniques described above. In most cases, he or she will use phacoemulsification to minimize recovery time and the risk of retinal tears.
After removing the natural lens, your doctor will carefully place your new IOL, made from silicone, acrylic, or plastic. The surgeon will use extreme precision to ensure the best vision correction possible. If you are undergoing laser-assisted cataract surgery, he or she will situate the lens using the digital map of your eye.
After your doctor has placed the IOL, in most cases, the incisions will heal on their own. However, in rare cases, the surgeon may need to position an interior chamber lens in front of the iris. When doctors use these lenses, they will need to close the incisions using tiny sutures.
Although limbal relaxing incisions are typically performed prior to cataract surgery, if your doctor recommends astigmatic keratotomy, he or she will often perform this procedure at the same time. Astigmatic keratotomy, also known as AK, functions according to similar principles as LRI, but the incision are located more in the central portion of the cornea, rather than in the limbus.
Types of IOLs
Cataract surgery is not a one-size-fits-all procedure. Rather, it is completely customized to meet your needs, and one of the most important considerations is the type of IOL you choose. Your doctor will explain the benefits and disadvantages of each type and help you select the one that is most suitable for you.
Monofocal IOLs were the first type of intraocular lenses to be developed, and they provide vision correction at one distance only. Typically patients choose monofocal lenses adjusted for distance vision, and they will continue to wear reading glasses. However, if you work a lot with fine details, you may benefit from monofocal lenses set for close-up vision. In this case, you would continue to rely on glasses for distant objects.
If you are undergoing cataract surgery on both eyes, you may want to ask your doctor about monovision. Using this technique, your doctor will place a distance-adjusted IOL in one eye and a near vision IOL in the other. Your brain will register both distances and adjust the images accordingly. Most patients are able to acclimate themselves to this new way of seeing after a few weeks; if you are considering monovision, however, you may want to try it with removable contacts before your doctor places the IOLs. The technique can be especially beneficial if you work with computers, but if you rely on very sharp, clear vision for your work or hobbies, this may not be the optimal choice for you.
Multifocal and accommodative IOLs provide vision correction at multiple distances. The two names are sometimes used interchangeably. However, they are actually two lens types that work differently but achieve similar results. Multifocal lenses have a series of visual zones that provide vision correction at varying distances. Your brain automatically learns to use the visual zone that is suited to the task at hand. For a better understanding of these IOLs, you could compare them to bifocals or trifocals. There are three brands of multifocal IOLs available in the US:
Like your natural lenses, accommodative IOLs are flexible; they can move and adapt to adjust to varying distances. Currently, Crystalens® is the only FDA-approved accommodative IOL, and this brand comes in various strengths. Your eye surgeon will determine the right strength for you, using a highly precise mathematical formula. Although these IOLs can dramatically enhance your vision and reduce your dependence on glasses or contacts, you should have reasonable expectations following your cataract surgery.
Your eyesight will not be as crystal clear as it may have been in your twenties, and you will still need corrective lenses for prolonged reading or detailed work. If you have had previous laser vision correction, or if you have extreme nearsightedness, farsightedness, or astigmatism, accommodative lenses may not be the right choice for you. These conditions can complicate the mathematical formula, leaving you with lenses that are not the right strength for your eyes. Nevertheless, for the right patients, accommodative lenses can be a great choice, giving you better vision than you may have enjoyed in years.
Toric IOLs are the only type of lens that can treat astigmatism. This condition occurs when your cornea changes shape, making both near and far objects appear blurry. Toric IOLs are fixed focus lenses, but they correct light refraction at varying distances, making all objects appear sharper. If your life has been dogged by the burden of astigmatism for many years, toric IOLs can give you greater freedom and better vision than you may even have enjoyed in your entire adult life.
However, because these lenses must be placed with absolute precision, there is a greater risk for surgical error. There is also a chance that your lens could rotate after placement, distorting your eyesight. Fortunately, these conditions can be corrected with revision surgery. You should also be aware that you are likely to need glasses for prolonged distance vision. FDA-approved toric IOLs include:
Blue-Light Filtering IOLs
Your natural lenses have a slight yellow tint, and, thus, they can filter out some of the blue light and UV rays that prove so detrimental to your ocular health. AcrySof® Natural IOLs are designed to mimic this affect, and like natural lenses, they have a yellowish hue. However, these lenses should not affect your color perception.
Some doctors believe that these lenses may inhibit your contrast sensitivity. Others hail their ability to protect against macular degeneration and other conditions that may arise from exposure to UV rays. If you are interested in these specialized lenses, talk to your doctor to learn more and to find out if they may be right for you.
Aspheric IOLs are flatter on the edges than traditional IOLs. With this advanced design, they can reduce vision aberrations and increase contrast sensitivity, especially at night or in dim light. Some doctors believe that the increased contrast sensitivity will not last for older patients, meaning these premium lenses would have no added benefit. However, for younger patients, they can be a great option, enabling them to live full, uninhibited lives for years to come. Aspheric IOL brands include:
- SofPort® AO
- AcrySof® SN60WF
- AcrySof® IQ ReSTOR
Your natural lens is surrounded by a soft lining called a capsule. There are three ways in which your surgeon may place your IOL in relation to these tissues:
- Inside the capsule: The doctor will fold the IOL so that it can fit through a tiny incision. Once the lens is in place, it will unfold to its full size. This is the most common type of IOL placement.
- In front of the capsule: The IOL will lean against the capsule for support. This position is also known as sulcus fixated, and it offers great stability.
- In front of the iris: Phakic IOLs rely on the sclera (the white of the eye) for support. These lenses are primarily used for vision correction, as an alternative to LASIK or PRK. However, in rare instances, a doctor may use this placement for cataract surgery.
All three positions are safe and effective, but one may be more suited to your needs than another. At your initial consultation, your doctor will discuss your options and select the right placement for optimal vision enhancement.
Placement during Laser-Assisted Surgery
One of the benefits of laser-assisted cataract surgery is that it allows for highly precise IOL placement, using optical coherence tomography (OCT). To obtain these images, your doctor will dilate your eyes. By shining light through your eye, your doctor can create a three-dimensional map that shows the depth and length of your eye using cross section images. This will enable your doctor to create a personalized treatment plan, and it reduces the risk of a misplaced lens.
Cataract surgery is a low-risk procedure that involves little to no discomfort for the patient. The recovery time is relatively brief, and you can typically return to your normal activities within a few days. Immediately after your surgery, your vision may be a bit blurry. This will significantly improve over the next few days, although it could take up to six weeks for your vision to completely stabilize. However, according to the American Optometric Association, approximately 90 percent of patients who undergo cataract surgery report better vision the day after their procedure.
The Day of Your Surgery
Cataract surgery is an outpatient procedure, so you will be allowed to go home soon afterwards. Because of the anesthesia and blurred vision, you will not be able to drive home, so you should arrange for a ride in advance of your treatment. You will have a protective shield over your eyes, and you may be allowed to remove it when you arrive home. In some instances, you may need to leave it on for longer, and you will often continue wearing it while you sleep. Be sure to follow your doctor's instructions regarding this device.
Caring for Your Eyes
In most cases, you will have a follow-up appointment with your surgeon 24 hours after your procedure, and you will have another check-up several weeks after that. In between your appointments, there are several things you should do to protect your eyes and encourage faster healing:
- Use eye drops: Your doctor will prescribe medicated eye drops to control inflammation and intraocular pressure. You should apply these eye drops several times a day for the next two to four weeks, following the precise instructions set out by your surgeon.
- Watch your activity level: For the first two to three days after your cataract surgery, you should rest and avoid strenuous activity. Within a few days, however, you should be able to resume most of your routine activities, including exercise. Avoid heavy lifting until otherwise instructed, as this can increase your intraocular pressure. Reading and watching TV are generally permitted immediately after surgery, although you may find that your vision is too blurred for the first day or two.
- Wear sunglasses: After cataract surgery, your eyes may be extremely sensitive to bright light and glare. Whenever you go outside, you should wear sunglasses with high UVA/UVB protection. If your eyes are particularly sensitive, you may even find that sunglasses prove helpful indoors. Continue to wear sunglasses, even after you have completely recovered. The lenses can help prevent cataracts in your other eye, as well as conditions such as macular degeneration and pterygia.
- Protect your eyes: You should avoid touching or rubbing your eye for the first few days after your cataract surgery. You can wash your hair and shower, but you should be careful to avoid getting soap or shampoo in your eyes. You should not wear eye makeup for a week after your surgery, and you should not go swimming or play contact sports for two to four weeks.
Right after your surgery, your eyesight will typically be a bit blurred. In some instances, you may notice an almost instant improvement in your vision, particularly if you had advanced cataracts. As your recovery progresses, your vision will continue to improve.
Following surgery, the vast majority of patients experience dramatically improved eyesight in comparison to their vision with cataract-clouded eyes. Most people enjoy at least 20/40 vision, which means that they are legally permitted to drive without glasses. Many patients rely far less on glasses or contacts, and a number of people no longer need corrective lenses at all.
Following surgery...most people enjoy at least 20/40 vision
However, before your surgery, it is important that you have realistic expectations as to what cataract surgery can and cannot accomplish. The procedure does remove cataracts and greatly enhance your vision. However, you should not expect a full restoration of your youthful sight, particularly if you are in your later years.
Of course, the most obvious benefit of cataract surgery is that enhances your vision, and gives you clearer, sharper sight. Even if you continue to wear glasses or contacts your vision will be much better than it was when your lens was covered in cataracts. Additionally, following surgery, you are likely to be less troubled by glares and halos, and you will typically have better night vision.
Enhanced Quality of Life
With improved vision comes improved quality of life. Cataracts can take a huge toll on your daily routine. After surgery, however, you will be able to see your loved ones' faces clearly, and you can fully participate in the hobbies and activities you love. For example, reading, golfing, crafts, and travel will all be much easier and more enjoyable. If you work with computers or engage in manual labor, you may find that your professional performance improves after your treatment.
Finally, cataract surgery can protect your safety as well. With sharp, unobscured vision, you are less likely to fall or have some other type of accident.
If you suffer from advanced cataracts, you may rely on others to help you complete daily tasks. You may have stopped driving, either depending on loved ones for rides or rarely going out at all. Following cataract surgery, the vast majority of patients are able to drive, so you should enjoy increased independence. With greater freedom, mobility, and the ability to engage in the activities you love, you could enjoy a dramatic improvement in your mood and self-esteem.
Cataract surgery is an incredibly safe, low-risk procedure. However, this treatment, like all surgeries, does have some chance for complications. Choosing a highly experienced and well-regarded eye surgeon, according to the guidelines listed above, can further minimize risks.
Secondary cataracts are one of the most common complications of cataract surgery. Once removed, cataracts cannot come back. Therefore, this appellation is actually the colloquial name for posterior capsule opacity (PCO), a condition that occurs when corneal cells grow on the posterior lens capsule. These cells can cause vision to become hazy, and in some cases, PCO can make eyesight worse than it was with cataracts.
Secondary cataracts have nothing to do with a surgeon's skill, and they can affect patients of all ages. Fortunately, the condition is easy to treat with a YAG laser capsulotomy. A highly precise surgical laser can remove the clouded capsule with no need for incisions. The procedure is quick and discomfort-free.
Eye infection, or endophthalmitis, is another possible risk of cataract surgery. Fortunately, with proper safety protocol, this complication is quite rare. Doctors should apply antibacterial eye drops before cataract surgery. He or she should also disinfect the tissues around the eye and use antiseptic drapes to protect the entire face. Of course, all surgical instruments should be properly sanitized.
Even following proper safety procedures, it is possible for infection to develop. If patients experience severe discomfort, inflammation, worsening vision, or sensitivity to light, they should contact their surgeons immediately. Doctors may treat infection with antibiotic injections, and in severe cases, further surgery may be required.
In some cases, an IOL could move out of place, making a patient's eyesight blurry or giving him or her double vision. In extreme cases, it can even cause legal blindness. Fortunately, no matter how severe the results of IOL dislocation, the condition is easily treatable. Doctors typically perform a vitrectomy, removing the vitreous from inside your eye so that they can more easily reposition the IOL. Surgeons will replace the fluid with a gas bubble, which will eventually dissipate as the vitreous repairs itself.
In some cases, small pieces of the IOL may fall to the back of the eye. A vitrectomy is also used to treat this problem, as well.
Want to know more about risks associated with IOLs? IOL Risks
Retinal detachment occurs when the jelly-like vitreous inside the eye pulls on the retina, separating it from the underlying cells. When the retina completely tears away, it can cause swift, irreparable vision loss. While the condition can affect anyone, patients who have had cataract surgery are at a higher risk for retinal detachment.
Fortunately, detachment rarely comes on without warning, and it is usually preceded by a retinal tear. If a patient notices sudden flashes of light, floaters, or a curtain-like effect drifting across the visual field, he or she should alert a doctor immediately, as these can be signs of a retinal tear. Laser treatments can often repair these tears quickly and effectively.
In rare instances, bleeding can occur in the complex web of blood vessels at the back of the eye (choroid). While scientists are not sure what causes this condition, it is known to affect older patients more than younger individuals. Often, bleeding can be controlled. However, in rare cases, unrestrained bleeding can lead to significantly impaired vision.
Cystoid Macular Edema
If the eye is particularly inflamed after cataract surgery, the tiny blood vessels at the back of the eye may begin to leak. The excess fluid will then swell the macula, the central portion of the retina. Often, this condition will clear up on its own, and doctors can also treat this problem with anti-inflammatory eye drops or steroid injections. In rare instances, vitrectomy may be the only treatment option.
Temporary Side Effects
Cataract surgery has a very short recovery time and involves minimal discomfort. Nevertheless, you may experience a few minor side effects, which will typically go away within a few days of your surgery. These may include:
- Bruising: If your doctor injected local anesthetic around your eye, this can cause some bruising, much like a black eye.
- Discomfort: This will primarily consist of itching, stickiness, or a feeling of something in the eye. Cataract surgery rarely causes significant pain. If you experience severe discomfort or a sudden increase in pain, you should alert your doctor immediately.
- Blurred vision: Your eyesight will typically improve within a few days, if not a few hours, after your surgery. Even with blurred vision, you may find that you see better than you did before your cataract surgery.
- Mild headache: This can typically be controlled with over-the-counter pain medication.
When your doctor replaces your cataract-clouded lens with an IOL, it can greatly enhance your vision. However, cataract surgery is primarily designed to remove cataracts and restore unclouded sight. Therefore, it may not provide complete correction for nearsightedness, farsightedness, and astigmatism. LASIK (Laser-Assisted in Situ Keratomileusis) corrects the way your eye refracts light. Thus, it may reduce or even completely end your dependence on corrective lenses.
How Is LASIK Performed?
During LASIK, your eye surgeon will create a thin flap in the surface of your cornea. The doctor may do this manually or using a precise femtosecond laser. Gently lifting the flap, the surgeon will then reshape your cornea. By removing a few corneal cells, he or she can correct the path of light through your eye, allowing it to focus properly on your retina. Your optic nerve will then be able to send a clear signal to your brain. When the procedure is finished, your doctor will lay the flap back down over your eye, and it will heal on its own, usually within a few days.
Does LASIK after Cataract Surgery Involve Extra Risks?
The vast majority of patients who have undergone cataract surgery are good candidates for LASIK. However, because your intraocular pressure can increase after cataract surgery, most doctors advise waiting several months before undergoing laser vision correction.
If you are not a candidate for LASIK, due to thin corneas, past LASIK surgery, or other factors, you may still be a good candidate for PRK (photorefractive keratectomy). This procedure is similar to LASIK, but it does not involve the creation of a corneal flap. Of course, the only way to know if you are a candidate for laser vision correction is to schedule a consultation with your eye surgeon.
If you are preparing for cataract surgery and are still feeling anxious, a look at the following statistics may prove reassuring.
David F. Chang, a contributor to the seminal work Textbook of Refractive Laser Assisted Cataract Surgery, complied data from multiple studies to examine the overall rate of post-surgical complications. The numbers proved consistently low. He reported:
- Between a 0.8 and 5.6 percent incidence of anterior capsule tears in 4 studies between 2004 and 2007
- A rate of vitreous loss between 2 and 4 percent
Cataract Surgery Can Improve Your Overall Safety
Several recent studies published by the American Academy of Ophthalmology show that cataract surgery can significantly reduce the risk of hip fractures and car crashes among senior patients. The study tracked 1.1 million Medicare beneficiaries, including 410,000 recipients of cataract surgery. Researchers found that there was a 16 percent lower chance of hip fractures within the first year of cataract surgery. Among patients with severe cataracts the reduction was even greater - 23 percent.
An Australian study followed 30,000 recipients of cataract surgery, and linked their records to police accident reports in Perth. The researchers found a 13-percent reduction in police-reported car crashes among the subjects. In addition to the preservation of the subjects' lives and health, researchers estimated that the reduced number of accidents saved $4.3 billion Australian dollars.
This study corresponded with a similar American investigation. Dr. Cynthia Owsley, a professor of ophthalmology at the University of Alabama at Birmingham, followed 277 patients who were considering cataract surgery. Those who chose to undergo surgery were involved in 50 percent fewer car accidents over the next four to six years than those who did not. Although the two analyses show dramatically different numerical results, they both reinforce the idea that cataract surgery can significantly increase patients' safety.
According to the American Academy of Ophthalmology, cataracts affect over 70 percent of adults over the age of 75. Further research shows that 24.4 million Americans age 40 and over are affected by cataracts. The Center for Disease Control and Prevention (CDC) estimates that this number will rise to 30.1 million by the year 2020.
Compiling data from the World Health Organization and other sources, the International Centre for Eye Health reports that, in developed countries, there are between 4,000 and 6,000 cataract surgeries performed each year per 100,000 inhabitants. Sadly, however, there are an estimated 19.84 million people in the world who are blind because of cataracts. Most of these cases are operable, yet, due to lack of doctors, poor education, and/or poverty, individuals around the world continue to suffer from obscured vision. The World Health Organization also reports that untreated cataracts lead to 33 percent of the world's vision problems.
Age, Race, Gender, and Cataracts
Cataracts are more likely to affect white women over the age of 80. According 2010 data from the National Eye Institute:
- 68.3 percent of all cataract sufferers were 80 or older. In contrast, only 2.51 percent were between ages 40 and 49.
- 80 percent of all reported cataract patients were white, 8 percent were black, and 7 percent were Hispanic.
- 61 percent of cataract suffers are female.
Frequently Asked Questions
Can my doctor correct my nearsightedness, farsightedness, or astigmatism during my cataract surgery?
Yes. When you choose a premium IOL, your doctor can often treat your other vision concerns. You should remember that, while cataract surgery can enhance your vision, you may still need glasses or contacts. Many patients, however, are much less dependent on corrective lenses.
How long do IOLs last?
Both standard and premium intraocular lenses are designed to last for life.
Is there an age limit for cataract surgery?
No. Patients of all ages can undergo the procedure. If you have significant health concerns, your doctor will typically recommend local anesthesia, rather than general sedation.
How soon can I drive after cataract surgery?
The answer is different for each patient. Your eyes may take several days to adjust after surgery, or you may be able to drive the next day. As a general rule, you should only do so when you feel comfortable. If there is any doubt in your mind, you should wait to drive for another day or two.
When can I get my new glasses prescription after my cataract surgery?
Again, it can take a while for your eyes to adjust after the procedure. To save time and money, you should typically wait at least a few weeks before getting new glasses.
What causes congenital cataracts?
There are a number of reasons congenital cataracts can occur:
- Certain medications, such as tetracycline medications
- Infections or diseases that a mother contracts during pregnancy
Sometimes, older children can develop cataracts for the same reasons or because of a blow to the eye.
Should my child receive an IOL?
There are varying opinions on this matter. Some surgeons believe a child will benefit from immediate placement of an intraocular lens. Others feel that a child should rely on contact lenses and have their IOL placed at a later date. To make the best determination for your child, you should consult with a pediatric ophthalmologist.
Is there a rush to receive cataract surgery?
For adults, there is no rush to undergo surgery. No matter how long you wait, cataracts will only affect your lens, and once the clouded lens has been removed, your vision will be unaffected. However, children born with cataracts will need to have surgery soon; if their brains do not learn how to see in the first months, their sight will not be restored, even after the cataracts are removed.
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