Written by: Dr. Stephanie Mulick, O.D.
👁️🔍 Decoding the Ocular Landscape: A Prelude to Cataracts
Before we dive into the world of cataracts, let’s illuminate the intricate realm of ocular anatomy. Picture light pirouetting through the clear cornea, waltzing past the pupil, and gracefully wending its way through the crystalline lens. This journey continues, meandering through the vitreous body until it reaches the retina—a visual masterpiece decoded by our brain.
Typically, the crystalline lens is an avascular transparent structure enclosed by a thin capsular membrane. The lens continues to grow throughout life. Eventually leading to presbyopia, loss of accommodation/focus, time for some reading glasses.
A cataract occurs when the crystalline lens of the eye becomes cloudy or opaque causing light to scatter or blur when it passes through similarly to frosted glass. With time this opacity will cause progressive blurry vision and if left untreated eventually visual impairment.
🔍 Spotting the Cataract Culprit: Unmasking the Cloudy Lens
Enter cataracts, the stealthy villains clouding our crystalline lens. Like a mysterious fog on a glass pane, cataracts scatter light, casting a blurry spell on our vision. The first whispers of their presence include frequent glasses changes, halos dancing around headlights, and a yearning for more light during reading sessions.
First symptoms of Cataracts
- Frequent glasses prescription changes
- Glare especially at night
- Halos around headlights
- Need for more light when reading
- An overall decrease in vision
- Decreased contrast sensitivity
- Color vision changes
- Unable to pass the DMV vision test
Most cataracts are a normal result of aging affecting more than 20.5 million Americans over the age of 40. I always say if you’re lucky enough to live a long life you will eventually get cataracts. And really, cataracts aren’t so bad. It turns out that after Cataract surgery most of my patients tell me that they see better than they have in years.
Most cataracts develop slowly and usually in both eyes but can be unilateral. Over half of Americans over the age of 80 will develop cataracts according to the National Eye Institute.
🔍 Cataract Varieties: A Theatrical Lineup
Picture your eye doctor as the discerning critic, evaluating cataracts with a keen eye. The playbill includes Nuclear Sclerosis, Cortical, Anterior Subcapsular, and Posterior Subcapsular—each a character in the unfolding drama of ocular health.
Some common types of cataracts include:
- Nuclear Sclerosis: a central yellowing of the crystalline lens
- Cortical: peripheral radial opacities of the crystalline lens
- Anterior Subcapsular: opacities on the anterior surface of the lens.
- Posterior Subcapsular: opacities on the posterior surface of the lens
🕵️ Detective Work: The Cataract Evaluation
As you step into the eye doctor’s theater, expect a thorough evaluation. Eyes dilated, measurements taken—your eyes become the stars of this show. Vision-threatening diseases lurk in the shadows, impacting the choice of Multifocal intraocular lens implants (IOL). The plot thickens as cataracts are graded, and insurance steps onto the stage.
Vision-threatening ocular diseases can have a negative impact on the outcome of cataract surgery. During the cataract evaluation, your doctor will examine your eyes thoroughly for any signs of ocular disease that could prohibit you from having Multifocal intraocular lens implants (IOL).
👴 Aging Tales and Cataract Chronicles
Cataracts, often considered the badges of a life well-lived, are more common than you might think. Over 20.5 million Americans, gracefully aging past 40, find themselves in the company of cataracts. But fear not, for the tale takes a turn after cataract surgery—a transformation many describe as seeing the world with newfound clarity.
Most cataracts are a result of living a long life; however, there are some factors that can speed up the process of cataract development such as:
- Smoking
- UV/Sun exposure
- Blue-light exposure from electronic devices
- Family history
- Diabetes
- Steroids: oral, injected or nasal sprays
- Eye surgeries
- Eye injuries
- Radiation treatment
- Eye diseases
- Excessive alcohol consumption
⚒️ Crafting Vision: Tools of the Cataract Surgeon
Enter the cataract surgeon, armed with tools that rival a magician’s wand. Cataract surgery, once a grand spectacle, is now a swift outpatient procedure. The advent of LenSx® femtosecond laser adds a touch of wizardry, promising faster recovery and more precise outcomes.
Cataract surgery is one of the most common surgeries performed in the U.S. Cataract surgery is a painless outpatient procedure that usually takes 10-20 minutes (not including preparation), usually performed on one eye at a time. It consists of removing the natural crystalline lens by breaking it up into small removable fragments and replacing it with an artificial intraocular lens.
Cataract surgery can now be done bladeless with the LenSx® femtosecond laser. It used to be common for patients to need glasses after cataract surgery, but now with technological advances, many patients do not require glasses after cataract surgery. The advent of multifocal intraocular lens (IOL) implants allow for improved vision and quality of life. There are even IOL’s that can correct Astigmatism.
When a cataract is affecting your quality of life and daily activities it is time to consider cataract surgery.
Your eye doctor will monitor your cataract with annual dilated eye exams and let you know when it is time for cataract surgery.
Refractive lens exchange/clear lens extraction:
Presbyopia is a term used for patients over the age of 40 when the natural crystalline lens of the eye becomes less able to accommodate/focus and patients become more dependant on reading glasses. Because of this, some patients over the age of 40 choose cataract surgery before they have a cataract over LASIK because of the advanced technology (multifocal IOL) that allows patients to see multiple distances in both eyes without the need for monovision (one eye that is corrected for distance and one eye for reading).
LASIK surgery is still a great option; however, if the presbyopic patient over 40 years old wants to be free from glasses and contact lenses the LASIK surgeon may recommend monovision, where the dominant eye is corrected for viewing distant objects and the non-dominant eye is set for reading up close. When considering monovision LASIK, I personally recommend trying it first with a trial contact lens to determine if that is the right option for you. Many people do just fine with monovision; however, some people experience blurred vision or decreased depth perception.
👓 IOL Options: Crafting Vision’s Final Act
The first documented cataract surgery was in Paris in 1748 according to the article in Geriatrics and Aging. 2008;11(6):328-332 titled The Evolution of Cataract Surgery: The Most Common Eye Procedure in Older Adults. Since this time cataract surgery has evolved from the removal of the entire opacified lens to now breaking up the lens into small fragments that are aspirated out of a small self-sealing incision less than 3mm in length. The technique to break up the opacified crystalline lens is called phacoemulsification which was introduced by Dr. Charles Keman in 1967.
Current Intraocular lens implants (IOL’s) are made of biocompatible acrylic or silicone material which can be folded and inserted into incisions as small as 2mm in length.
The chart below explains the different types of IOL’s and the need for glasses following cataract surgery.
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With advanced IOL’s came advanced techniques for improving cataract surgery. The newest cataract surgery procedure can be done bladeless with the use of a femtosecond laser. The femtosecond laser makes the incision and cuts in the crystalline lens creating less force and trauma on the eye during surgery. The use of femtosecond laser results in faster patient recovery and more precise visual outcomes.
Cost of Cataract Surgery:
In 2019 the average cost of cataract surgery on the U.S. was approximately $3,783 to $6,898 per eye. This amount is dependant upon which IOL you choose, if you need astigmatism correction and if you have the procedure with a femtosecond laser. Most patients who need cataract surgery in the U.S. have Medicare or private medical insurance, which usually cover the cost of a standard monofocal IOL without the use of femtosecond laser (excluding insurance deductibles and copayments).
Post-operative Care:
You will be required to use eye drops at least 4 times per day. An antibiotic eye drop is required 2 days prior to surgery and for the first week following surgery. Steroid and non-steroidal anti-inflammatory (NSAID) drops will also be necessary for about 4 weeks after surgery. Make sure to follow the post-op instructions that have been given to you. It is extremely important to follow up as directed with your eye doctor to ensure proper healing of the eye.
Cataract surgery requires the use of strong dilating agents that can cause your pupil to be dilated for several days. Normal swelling after cataract surgery and pupil dilation can cause blurry vision. Do not be alarmed if your vision is blurry for the first few days or even the first month. You can expect vision improvements just about every day following cataract surgery especially for the first week. If you experience a decrease in your vision, floaters or flashes of lights make sure to contact your eye doctor.
Postoperative Complications:
Cataract surgery is one of the safest and most effective vision-correcting procedures, which is why more than 3 million cataract surgeries are performed each year in the U.S.
Complications following cataract surgery are very rare and usually not serious.
Making sure that you follow up with your eye doctor and use the required eye drops will ensure proper healing of your eyes after cataract surgery.
Some postoperative complications are:
- Posterior capsular opacification (PCO): This is very common and easily treated with a quick Yag Laser. A posterior capsular opacification occurs when your natural posterior capsule of the eye that is located behind the new IOL becomes cloudy. The Yag laser is a quick and effective treatment for removing the cloudy capsule allowing for improved vision. Many patients with Posterior capsular opacifications experience a decrease in vision similar to the effects of the original cataract. A PCO can develop any time after Cataract surgery from immediately to several years later.
- Ocular infection: After cataract surgery, it is very important to follow up with your eye doctor as directed. Ocular infection after cataract surgery is extremely rare with an incidence of 0.13%-7% as stated in the Current opinion of Ophthalmology journal.
- Retinal detachment: When the sensory retina is pulled away from its normal location, patients can experience flashes of lights, floaters or shadows in their vision or even a curtain coming over their vision. If you experience any of these symptoms please see your nearest eye doctor immediately.
- Lens Fragments: Some complicated cataract surgeries result in pieces of cataract left behind. If the pieces are small there is usually no concern, large pieces of lens fragments may require additional surgery.
- Inflammation: it is normal to have inflammation after surgery, which is why you will be required to use steroid and anti-inflammatory eye drops. Excessive inflammation may require more aggressive treatment.
- Dislocated IOL: In extremely rare cases, if the IOL falls out of position and into the back of the eye another surgery would be necessary.
- Floaters: you may see dark spots in your vision that move around. This is usually not serious but should be addressed with your eye doctor.
- Retinal fluid or macular edema: the use of NSAID eye drops postoperatively has reduced this risk. If your vision becomes blurry or wavy please see your doctor for evaluation.
- Ocular hypertension (High intraocular pressure)
- Photophobia: it is not uncommon to become light-sensitive after cataract surgery due to more light entering the eye. It is recommended to always use sunglasses (preferably polarized) outside.
- Dysphotopsia: some patients see a dark or light area in their peripheral vision which usually goes away in a few weeks.
- Temporary ptosis (lid droop): this is a rare side effect of cataract surgery that usually improves with time.
Conclusion:
Cataract surgery is a safe and painless procedure that can improve vision and quality of life.
I never knew that someone with cataracts would have trouble reading and looking at things clearly. My uncle mentioned that this has happened to him a couple of times especially when watching TV. I think we should try to consult an eye doctor that can determine his case before going into surgery.