Cataract surgery has changed over the past 20 years from large incisions with long recovery times to our current surgery with a 2.4mm incision, self sealing wound, and possible expectations of refractive benefits where glasses are not required for distance nor near. Some of the greatest difficulties with cataract surgery involve managing reasonable expectations.
This letter will review cataract surgery and its risks and benefits. It will focus on the new refractive options that are available because of new lens designs. Lastly, it will review unexpected benefits about glaucoma.
Cataract surgery involves the removal of a cloudy lens from the center of the eye and its replacement with a thin plastic lens that is designed to focus the light on the retina. The normal lens is optically clear but as we age, and occasionally in association trauma or illness, the lens becomes cloudy and discolored. It is no longer able to focus the light but rather causes the light to amplify or scatter in a random manner, what you might describe as glare or blurred vision. If these changes interfere with your daily activities and quality of life, it is reasonable to consider surgery. Your doctor will also consider other factors, beyond the scope of this letter, when considering your cataract.
While cataract surgery is one of the most successful and predictable surgeries, risks are still present. To each patient it remains a major surgery as there is the potential for vision loss and rarely actual loss of the eye from infection, bleeding or retinal detachment.
The excitement of cataract surgery comes from the refinements in instruments that allow a very small self sealing wound and the precise calculation of a monofocal lens implant that minimizes the need for glasses after surgery. Often, the residual refractive error, or need for glasses, is not significant and the patient is content with only reading glasses.
The special lens is also available to treat most astigmatism. These toric lenses are aligned with your eye to treat the moderate corneal irregular curvature that is not treated by a standard lens. The higher level of premium lens implant is a multifocal lens that is designed to minimize the need for distance and near vision glasses. There are multiple brands that utilize different technologies, but the goal is to have some light focused for near and some for far. This may limit contrast sensitivity and can be associated with a glare but for many patients, the benefits far exceed these issues. Not every patient is a candidate for the toric or the multifocal implant and for that reason, Medicare allows an out of pocket charge for the extra evaluation and services. Patients with dry eyes or other surface abnormalities do not tolerate these lenses well, and some consider macular degeneration to be a relative contraindication. Your doctor will take these factors into consideration if you are considering a premium lens implant.
Recent studies have highlighted other benefits of cataract surgery.
The Ocular Hypertension Treatment Study reported on the benefits of cataract surgery in patients with ocular hypertension in September 2012. The report had a better design and confirmed what other studies had reported, a reduction in postoperative intraocular pressure. There was an average 16.5% reduction in IOP and there was a greater reduction in eyes with the highest preoperative pressure. A lower intraocular pressure limits the potential for glaucoma damage and in some patients may make glaucoma drop therapy no longer necessary. This can be a considerable financial saving given the price of glaucoma medications.
In July 2012, a new study published in The Journal of the American Medical Association examined the incidence of hip fractures in the year after cataract surgery. The study showed 16% fewer hip fractures in the year after surgery. Interestingly, the patients between the ages of 65 and 69 had a slightly higher rate of hip fracture but the patients ages 80 to 84 experienced a 28% reduction in hip fractures compared to those Medicare beneficiaries who did not have cataract surgery.
Other studies have shown benefits in mental health and overall quality of life after cataract surgery. It is a very exciting time in ophthalmology and cataract care. It is amazing to think of the distance we have covered in the last 20 years. While all surgeries carry some risk, there is a lot more to be excited about than feared when you are told, “ You have cataracts and we need to consider surgery to make you see better.”
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