Demystifying Cataracts and

Cataract Surgery

Monica Khalil, MD

Summit Medical Group

June 28, 2017

What is a cataract?

A cataract is a clouding of the eye's lens,

which is normally clear.

Causes of cataracts

• ADVANCED AGE

• Ultraviolet radiation from sunlight and other sources

• Diabetes

• Hypertension

• Obesity

• Smoking

• Prolonged use of corticosteroid medications

• Previous eye injury or inflammation

• Previous eye surgery

• Significant alcohol consumption

• High myopia

• Family history

Cataract symptoms

• Hazy, cloudy vision

• Glare

• Seeing double (when you see two

images instead of one)

• Having trouble seeing well at night,

or needing more light when reading

• Seeing bright colors as faded or

yellow instead

Simulation of vision with

Cataracts

Examples of cataracts

Prevalence

• Nearly 25.7 million Americans over age

40 have cataracts. The number is

projected to increase to 45.6 million by

2050.

http://forecasting.preventblindness.org/

• Cataract surgery is the most common

elective surgery among Medicare

beneficiaries in the United States.

http://www.ncbi.nlm.nih.gov/pubmed/22978

526?dopt=Abstract

Benefits

Multiple studies have demonstrated its

association with improved quality of life,

reduced risk of falling and fewer car crashes.

• http://www.ncbi.nlm.nih.gov/pubmed/22851116

• http://www.ncbi.nlm.nih.gov/pubmed/22273356

• One study found that those who had cataract

surgery had a 40 % lower long-term mortality

risk than those who did not.

http://www.aaojournal.org/article/S0161-

64201300143-7/fulltext

How is a Cataract Detected?

• Visual Acuity Test: Determines how well

you can see at various distances.

• Dilated eye exam where drops are

placed in the eyes to dilate or widen the

pupils.

This will allow for evaluation of the

cataracts, optic nerve, and retina.

Are you Ready to have Cataract Surgery?

Are you Ready to have Cataract Surgery?

• Are your cataracts impacting your daily or

occupational activities?

• Are your cataracts affecting your ability to

drive safely at night?

• Are your cataracts interfering with the outdoor

activities you enjoy?

• Can you manage your cataracts in other

ways?

What Happens if you DON’T

have cataract surgery?

• Your vision will gradually get worse over time.

• Cataracts never stay the same

• Cataracts never get better

• Cataract surgery is not an emergency

• Cataracts that become very dense can

become:

Harder to remove

Associated with an increased risk of complications

About Surgery

• Same day procedure

• Done under sterile conditions

• Topical anesthetic +/-IV sedation

• Can be done with or without assistance of

laser

• Typically takes 15-20 minutes

• Cataract is broken up into pieces, and

removed

• Intraocular lens is inserted

• Incision is sealed, typically without stitches

Cataract Surgery animation surgery

Traditional Cataract Surgery

• Incision is created with a small blade

• The sac which holds the cataract is

opened up manually with handheld

instruments.

• Phacoemulsification (ultrasound power)

is used to break the lens up into pieces.

• Those pieces are then removed using

ultrasound power.

• An artificial lens is placed into the eye

Laser assisted cataract surgery

• In laser cataract surgery, a 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 (opening the sac which

holds the cataract)

Cataract fragmentation

• Removal of cataract pieces must still be done

using traditional ultrasound

• Implant must still be placed in the traditional

manner

Laser assisted cataract surgery

• Pros:

Can cut down on the amount of phaco

energy used to remove the cataract since

the laser has already broken the lens into

pieces.

Precision of placing incisions exactly as

planned pre-operatively

This can also be used to correct

astigmatism

Laser assisted cataract surgery

• Cons:

Not covered by insurance

Longer procedure time

Not everyone is a candidate

Laser can produce gas bubbles

within the sac that holds the

cataract. In rare cases, these can

rupture the sac.

Intraocular lenses (IOLs)

• An intraocular lens is a tiny,

artificial lens for the eye. It

replaces the eye’s natural lens

that is removed during cataract

surgery.

• IOLs come in different powers,

just like glasses or contact

lenses.

IOLs

• Monofocal: It has one focusing distance

It is set to focus on distance OR close up

OR intermediate range

Pros:

• covered by insurance

• Most commonly selected IOL

• Unlikely to get halos aftewards

Cons:

• Must wear glasses for the other distances

Monofocal IOL

IOL-monovision

• Monovision is where two different

monofocal IOLs are used in order to

minimize the need for glasses.

The dominant eye is used to correct the

distance vision.

The non-dominant eye is used to correct

the reading vision.

This is frequently done with contact lenses

IOL-monovision

• Pros:

Can minimize the need for glasses

Usually covered by insurance unless

astigmatism needs to be corrected.

• Cons:

Lack of binocular vision

There are truly three different distances

(far, intermediate, near), but only two eyes!

IOLs

• Multifocal: Provides both distance and

near focus at the same time. Designed

so that the brain learns to select the

correct focus automatically.• Pros: 75-80% of people who get these lenses

do not need to use glasses for anything

• Cons:

– Not covered by insurance

– Often associated with halos around lights at night.

– Not everyone is a candidate for this type of lens

Halos with multifocal IOLs

Multifocal IOL

IOLs

• Accommodative lens:

Lens that moves inside of the eye to allow

focusing at different distances

• Pros: May allow for some degree of

independence from glasses.

• Cons:

– Not covered by insurance

– Sometimes, with time and scarring, the movement of

the lens becomes limited, and it no longer functions

as intended

Accommodative IOL

IOLs

• Toric IOL (for astigmatism reduction):

Astigmatism is a refractive error caused by

an uneven curve in your cornea or lens.

• Astigmatism may be corrected by glasses or

contacts.

• It may be corrected by an astigmatism

correcting lens:

– Pros: Typically well tolerated.

– Cons:

» Not covered by insurance

» May move out of position in the early post

operative period and require re-positioning.

Astigmatism correction

Toric IOLs

IOLs

• Symfony:

Lens option that corrects distance and

intermediate vision, but still mandates the

need for reading glasses.

Pros:

• Less likely to induce halos than multifocal IOL

• Can also correct astigmatism

Cons:

• Not covered by insurance

• May also induce halos

Symfony IOL

Which IOL is right for YOU?

• This will involve discussion with your

ophthalmologist. It depends largely on:

Your pre-existing ocular/medical conditions

The measurements of your eye

Your feelings about glasses

Financial considerations

What things may limit your visual recovery?

• Pre-existing medical conditions

Diabetes that has already caused damage

to the retina

Hypertension that has already caused

damage to the retina

What things may limit your visual recovery?

• Pre-existing ocular conditions

Macular degeneration

Glaucoma

Other diseases or conditions which affect

the optic nerve and/or retinal health

Risks of Surgery

Overwhelmingly successful and well tolerated,

with a greater than 95% success rate.

Risks of Surgery

• Risks include:

• Infection:

Rate in the US is 6 or 7 out of 10,000 people

Can be devastating, and can result in loss of

vision and even loss of the eye itself.

How we try to prevent it:

• Topical antibiotic drops before surgery, morning or

surgery, during surgery, and after surgery

• Cleansing of the eye prior to surgery

• Sterile operative technique, and careful post operative

handling

Risks of Surgery

• Bleeding inside of the eye (<1%)

• Swelling of the retina (1-5%)

• Risk of need for additional surgery:

Retinal detachment (<1%)

Retained pieces of cataract inside of the

eye (<1%)

Wound leak (<1%)

Risks of Surgery

• Chronic inflammation (<1%)

• Development of glaucoma (<1%)

• Prescription error may not be

completely corrected with intraocular

lens.

There is a higher likelihood of this in very

near-sighted or very far sighted individuals

Restrictions after Surgery

• No swimming for 2 weeks

• No eye makeup or powder makeup for

at least 1 week.

• No heavy lifting, bending, or straining

for 2 weeks.

• Remain in an area where you have

access to quality medical care for at

least a month after surgery

Drops

• You will need to use drops before and

after cataract surgery. These will

include:

Antibiotic drops

Anti-inflammatory drops

Steroid eye drops

Drops after Surgery

Recovery

• The amount of time it takes for vision to

recover varies from one person to the next,

typically next day to a few days

• This also depends on how dense the cataract

is, and how much swelling resulted from

surgery

• Downtime from work is usually around 2

days, unless job is very demanding physically

A Few Thoughts

• Cataracts can never return. Ever.

• This is not considered a painful

procedure

Most people take nothing for pain

afterwards

Sometimes patients take Tylenol or Advil.

• You will not see the cataract surgery

happening to your eye. At most you will

see colors, lights and shadows.

Down the Road

• The intraocular lenses will last forever. It

would take major trauma to

dislocate/damage the lens

• Sometimes, people develop scar tissue

behind the lens, and complain of foggy

vision

This is called “after cataract” or “secondary

cataract”

This can be corrected with a laser

procedure in the office

QUESTIONS?