February 28, 2018 By Frances Foster NP
C. Stephen Foster, M.D.
CATARACT: a scum or a film or a growth on the eye: right? Wrong! A cataract is none of these. The word cataract simply means the development of an opacity in the crystalline lens inside the eye. We all have such a lens sitting just behind the pupil. And this lens does exactly the same job that the lens of a camera does: it focuses light rays into a clear picture onto the “film” (retina) in the back of the eye. If the crystalline lens becomes something other than perfectly clear (cataract), a clear view of the world will no longer be possible. And while there is no known effective medication to reverse cataract that has already developed, there are things that may be effective at stopping the development of cataract in the first place or at retarding the progression of cataract once it has begun. For example, protection of the eye from exposure to ultraviolet light may well provide some measure of protection from developing cataract. The use of antioxidants and of an aspirin once daily are other possible factors that might provide some protection against cataract development.
Once cataract does develop, however, and is distracting or disabling to the patient, the only effective known method of treatment is surgical removal of the cataract. Of all the surgeries known to man, this is without doubt the safest and the most effective surgery. And while this is extremely gratifying, it should also be realized that cataract surgery is not without potential risk of complication. The likelihood of a complication, which results in loss of vision, is quite small. The risk of developing a complication, which makes the outcome of the surgery less than perfect, is approximately 4%. This means then, that approximately 96% of patients who undergo cataract surgery are extremely pleased with the outcome, with improved vision and comfort in doing and seeing the things that they need to do and see.
Having difficulty doing and seeing the things that one needs to do and see, we believe is the primary indicator for proceeding to arrange for cataract surgery. The mere presence of a cataract is not in and of itself a sufficient reason to arrange for surgery. Many patients are able to see and do virtually everything that they need to see and do despite the presence of a small cataract. But once the cataract becomes annoying, or even progresses to the point of becoming disabling, it is appropriate for the patient to have a discussion with his or her ophthalmologist about proceeding with surgical removal of the cataract.
Surgical removal of cataract has undergone many developments over the past two decades. A common misconception is that “laser” is generally used to “take off” the cataract. This is virtually never the case, although we use lasers for many different indications in ophthalmology, and we use very sophisticated mechanical devices, which are sometimes confused with the role of laser (FemtoSecond Laser) to perform cataract surgery. The femtosecond laser replaces or assists use of a hand-held surgical tool for the following steps in cataract surgery: the corneal incision, the anterior capsulotomy, lens and cataract fragmentation, and can be used to correct astigmatism. Femto laser is not covered by insurance.
Cataract surgery itself is generally done on an outpatient basis, and typically takes anywhere from 15 to 30 minutes to perform. A small incision is made for removal of the cataract and, generally, an artificial lens (lens implant) is placed in the eye after the cataract has been removed. The patient is typically asked to return for re-evaluation the following day to make certain that everything is perfect, and to begin with the postoperative medications (drops) that are typically prescribed following cataract surgery. The patient may see extremely well the moment the patch is removed (the day after surgery); in some instances, it may take several weeks for the patient to enjoy the full benefits of improved vision following the surgery.
Restrictions in physical activity following surgery are generally minimal, and are limited to restrictions on activities which could dramatically raise the pressure in the eye (bending at the waist to lift something heavy), activities that could result in exertion of pressure on the outside of the eye (sleeping with the eye pressed against the hand or pillow), and extremely vigorous jarring activity (for example jogging).
Medications are generally tapered and discontinued within a relatively short period after surgery, and glasses for seeing the sharpest that the eye can possibly see, both at distance and at near, are then prescribed, unless the lens implant that has been chosen by the patient is one of the so-called premium lenses developed by new technology and requiring out of pocket premium payment by the patient, since insurers do not cover the additional costs associated with the care of patients requesting these special lenses, which are intended to enable patients to see well both at distance and at near without glasses or correct astigmatism. Approximately 85% of patients choosing such lenses achieve this goal of good vision without glasses.
Only one eye is generally operated upon at a time, though, assuming that things go extremely well with the surgery, the other eye may appropriately have surgery relatively soon after the first eye has been successfully rehabilitated.
April 26, 2016 By Dr Foster
Just like a camera, the eye has a lens inside which helps to focus light onto the retina forming a sharp image. The lens is made of various proteins arranged to allow light to clearly pass through. With age, the proteins in the lens change, and with this the shape, color, and clarity of the lens change. Any change in the lens clarity is defined as “cataract.”
There are many types of cataracts, or rather types of changes seen in the lens, and these may present in any combination. Each can occur with normal aging or secondary to another process. Some cataracts are present at birth. The type of cataract is not necessarily important, but how it affects vision for the patient, as all are dealt with in about the same way.
Cataracts will normally develop with time, inevitably, in everyone. There are some factors which may cause them to progress faster, such as diabetes, uveitis, infections, trauma, or long-term use of steroid eye drops or pills. There are some cataracts that characteristically develop from certain heritable and systemic diseases, but these are uncommon.
Unfortunately cataracts are inevitable; however there are some methods which may be of benefit to slowing their development. Protection from ultraviolet light with sunglasses may help, as may anti-oxidants or use of an aspirin daily. Once cataracts that are visually significant to the patient forms, they are not reversible.
The initial symptoms of cataract may only be a change in glass prescription; however later even new glasses will not correct for them. Patients often complain of blurry vision, requesting a check for new glasses. Most patients begin to develop symptoms and have no idea these are due to cataract formation. Common symptoms include haloes and glare with bright lights, especially while driving at night, or difficulty reading or seeing in dim light, or seeing the television clearly. Occasionally cataracts can cause double vision, which is very bothersome. Cataracts can become so severe as to decrease vision to only the ability to perceive light.
Cataracts are seen on examination at the slit lamp biomicroscope by the ophthalmologist. A careful history is reviewed to evaluate for potential causes, if any. Vision is checked; (it may worsen with challenge by bright light while reading the eye chart). Potential vision after cataract removal may be checked by special instruments. The quality of cataract is documented, which is important to the ophthalmologist to help determine the best approach to surgery.
Generally vision is well preserved behind the formed cataract, so that after removal of the cataract, the patient will be able to see quite clearly, potentially without the need for glasses for most of what they do. Cataract surgery is the safest and most effective of all surgeries, and the most common surgery done in the U.S. today. There are, however, risks to any surgery, and though they are rare, cataract surgery is not without these. Today 96% of patients who have cataract surgery have an excellent outcome, meaning 4% will have an outcome that is less than perfect. Unfortunately, cataract surgery can not improve vision lost due to other eye problems like glaucoma, diabetes, or macular degeneration.
There are usually different options available to patients for the types of lenses that are placed inside the eye during cataract surgery, which one may decide upon prior to surgery. Patients who choose the basic lens will usually see clearly after surgery in the distance, perhaps needing some fine tuning with glasses, definitely needing glasses to see up close. There are other lenses, so called “premium” lenses (insurance does not cover these) which offer further benefits such as great reduction in astigmatism or the ability to see both in the distance and up close well, with minimal use of glasses if they are needed at all. About 85% of people who ultimately choose a premium lens are extremely satisfied with the outcome. It should be noted that not every patient is a candidate for these lenses. As technology changes, newer and more sophisticated methods of cataract surgery will be developed, though outcomes have been excellent for some time.
The mere presence of a cataract is not an indication for surgery. There are patients with cataracts who actually see quite well and are happy with their vision. Others are bothered by even small cataracts. Surgery is considered when the patient is experiencing vision changes that affect activities in daily life – changes that are attributed to cataract, that are not treatable by more conservative therapy like glasses. Cataracts are also removed for medically necessary reasons, such as the need for the ophthalmologist to see inside the eye more clearly to treat vision threatening diseases of the retina. Only in rare instances is cataract surgery an emergency, so the procedure can usually be scheduled at the patient’s convenience.
Cataract surgery is usually performed as an outpatient procedure. The surgery itself is typically 15 to 30 minutes long and recovery is quick and normally without any discomfort, requiring only the use of drops for a few weeks after surgery. Small incisions are made by the surgeon and, with very sophisticated machinery, the cataract is removed and a new lens is placed inside the eye. There are some restrictions for a few weeks after surgery, which mostly involve limiting strenuous physical activity or anything else that may result in increasing pressure in the eye or tension in or around the eye; bending over, sleeping on the side of the surgery, or rubbing.
Laser Cataract Surgery
Femtosecond Laser now offers patients the new standard in precision cataract surgery with the CATALYS Precision Laser System. Using CATALYS, the surgeon can provide a gentle, highly customized cataract procedure with precision not achievable with traditional manual techniques. This allows patients the opportunity to receive tailored treatment with advanced technology multi-focal lenses, which may reduce the need for glasses or contacts after surgery.
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