Cataracts Surgery

[EyeFitWell]

To remove, or not to remove, and more importantly, why?

I had a patient in today who complained in conversation of poor VA in general (no new specs) and said he has cataracts that his OD assessed as not ripe enough to remove. I talked to him about it for a while and explained that WHILE I AM NOT AN OD, I thought he might be sure the OD understood how he found the cataracts to be problematic in his vision. My understanding is that most OD's will wait until it's a significant problem to go through the trouble of surgery, but when it bugs the patient enough, the surgery is recommended.
It got me thinking...he said that he heard from friends of similar age they would reform if they were removed too early. I explained that the natural lens is removed and replaced with an artificial one, so I didn't think the cataracts could reform.
Then I remembered the different types of cataract surgery as loosely glossed over in Opticianry class, some of which leave the back surface of the natural lens (partial encapsulation?).
So, my questions are:
What is the most common type of Cataract surgery used today? Do secondary cataracts form in most cases? How long after the first surgery are these likely to form? Does the pt have to live to be 110? Is there truly a draw-back to performing surgery too quickly? And if not, why do most OD's and OMD's let the cataract form before removing it? Just to play Devil's Advocate, hypothetically, what would be wrong with removing it even before cataracts form at all? I could see cost and inconvenience as reasons to wait, but if a pt is already retired and his insurance covers it, is there a benefit to waiting?

Thanks in advance, Optigeniuses!

[nickrock]

...So, my questions are:
What is the most common type of Cataract surgery used today? Do secondary cataracts form in most cases? How long after the first surgery are these likely to form? Does the pt have to live to be 110? Is there truly a draw-back to performing surgery too quickly? And if not, why do most OD's and OMD's let the cataract form before removing it? Just to play Devil's Advocate, hypothetically, what would be wrong with removing it even before cataracts form at all? I could see cost and inconvenience as reasons to wait, but if a pt is already retired and his insurance covers it, is there a benefit to waiting?

So, almost ALL cataracts today are removed by phacoemulsification, an ultrasonic probe that crushes/splits/destroyes the lens cortex and nucleus. The same phaco probe irrigates, aspirates and removes the "chopped" up lens fragments. The posterior lens capsule is almost always left intact, which acts as a "bag" for the Intraocular lens (IOL) implant to sit in. The term secondary cataracts refers to posterior capsule opacification of the "bag," which occurs roughly in 5-10% of all cataract cases. Although the treatment for that opacification is very easy, quick, and yields very good results.
The downside and contraindication of cataract surgery before it is necessary is endothelial decompensation which leads to stromal edema and bullous keratopathy which could require a corneal transplant to fix. Lots of surgeons are on the bandwagon of clear lens extraction (CLE) which is a great refractive option for high myopes that are not good LASIK or PRK candidates, but the risk is high with endothelial failure in the future.
There are also insurance requirements for cataract surgery. Usually, it has to be proved that the cataract is decreasing BCVA and/or decreasing BCVA with glare as demonstrated with a Brightness Acuity Test.
I hope that helps.

[EyeFitWell]

The downside and contraindication of cataract surgery before it is necessary is endothelial decompensation which leads to stromal edema and bullous keratopathy which could require a corneal transplant to fix.

Wow, Nick, great answer! But on the above part, "huh, in english?"
:-)

[nickrock]

Talk to a community doc and see if they would let you observe a surgery in the OR. It is definately worth watching.

[EyeFitWell]

Stromal edema=swelling of the Stroma, but bullous keratopathy I don't know.

[OHPNTZ]

The question to ask is, is the surgery worth the risk?

Vision usually has to be limited to 20/40 or worse, or a problem with glare...however this varies from surgeon to surgeon. Many complications can happen after surgery, endophthalmitis, cystoid macular edema, corneal changes such as worsening of fuch's endothelial dystrophy, etc., etc.


Some patients do end up with complications, so that is why 20/25 to 20/30 is still "acceptable". Hope that helps...

[peregrinerose]

I hate the 'ripe cataract' thing. I always assure patients that there is no fruit growing in their eyes, so there's nothing that can possibly ripen. It's time for cataract surgery when the patient can no longer see what they need to see WITH best possible glasses or contacts. That is different for every patient. If your patient is not happy with his vision, and there is no other pathology besides cataracts decreasing the vision, then it's time to at least get a surgical consult.

For some patients, 20/25 can be truly debilitating... they may work nights, so driving at night with the headlight glare can be functionally blinding. They may be avid fly fishermen that tie their own flies, so the poor contrast and detail vision, even at that acuity, can hinder them. They may be artists, and the effects of color distortion cause very real issues. The line they read on the chart is pretty meaningless, it's real life that counts. On the flip side, I have patients that see 20/400 and are perfectly happy with their vision, and don't feel they need surgery. As long as they are no longer driving, I educate them regarding their options, and let them make the choice.

[Dave Nelson]

In other words...quality of life.

[npdr]

Quality life should always be balanced by the risk and to say that the procedure is innocuous would be misleading.

1. 1/10,000 experience endophthalmitis
2. 2% of retinal detachment 1 yr after the surgery
3. 10-12% chance of PCO
4. Associated risk of aggravation of AMD

Sample references

1. Bockelbrink A, Roll S, Ruether K, Rasch A, Greiner W, Willich SN. Cataract surgery and the development or progression of age-related macular degeneration: a systematic review. Surv Ophthalmol. 2008 Jul-Aug;53(4):359-67. Review.
2. Tsai CY, Chang TJ, Kuo LL, Chou P, Woung LC. Visual outcomes and associated risk factors of cataract surgeries in highly myopic Taiwanese. Ophthalmologica. 2008;222(2):130-5. Epub 2008 Feb 22.
3. Cugati S, de Loryn T, Pham T, Arnold J, Mitchell P, Wang JJ. Australian prospective study of cataract surgery and age-related macular degeneration: rationale and methodology. Ophthalmic Epidemiol. 2007 Nov-Dec;14(6):408-14.

[peregrinerose]

I don't recall anyone saying that the procedure is inocuous. However, it's the PATIENT's call as to the risk/benefit ratio, as it is their quality of life that's at stake. Calling a cataract 'ripe' (or not) is unfair to the patient, grossly misleading, and completely ignorant of the effects cataracts can have on functional vision.

Quality life should always be balanced by the risk and to say that the procedure is innocuous would be misleading.

1. 1/10,000 experience endophthalmitis
2. 2% of retinal detachment 1 yr after the surgery
3. 10-12% chance of PCO
4. Associated risk of aggravation of AMD

Sample references

1. Bockelbrink A, Roll S, Ruether K, Rasch A, Greiner W, Willich SN. Cataract surgery and the development or progression of age-related macular degeneration: a systematic review. Surv Ophthalmol. 2008 Jul-Aug;53(4):359-67. Review.
2. Tsai CY, Chang TJ, Kuo LL, Chou P, Woung LC. Visual outcomes and associated risk factors of cataract surgeries in highly myopic Taiwanese. Ophthalmologica. 2008;222(2):130-5. Epub 2008 Feb 22.
3. Cugati S, de Loryn T, Pham T, Arnold J, Mitchell P, Wang JJ. Australian prospective study of cataract surgery and age-related macular degeneration: rationale and methodology. Ophthalmic Epidemiol. 2007 Nov-Dec;14(6):408-14.

[npdr]

I personally use the concept because its concept is that you wait until it is bad enough before you operate. I don't imply that the advancing opacification has to be some threshold value, but that the functional limitation or interference is so bad that only extraction would help.

To me I see few too many surgeries being done and not enough being done to coach patients to wait for the appropriate time for extraction.

[peregrinerose]

Who determines 'appropriate time'? I don't see through my patients' eyes, I don't walk in their footsteps, do their jobs, participate in their hobbies.... truly only they can determine if their vision is impacted or not. If they can't do the things they need to due to their vision, it's time. The number on the chart, what it looks like through a slit lamp, is irrelavent, as patients don't live in my happy little exam room bubble.

10+ years of low vision rehab taught me a great deal about making calls like that (regarding functional vision and visual goals) for my patients... usually very humbling lessons by patients not afraid to put me in my place (deservedly)

[npdr]

There is no doubt that diminished vision that is something that no one should wish on anyone else any longer than it needs to be. But alas, functional outcomes, surgical complications, and unmet expectations are factors in determining what is the "appropriate' time.

Because optometrists don't do cataract surgery but only evaluate the patient pre and post operatively, we really do not have any insight whether the surgery would go well, did go well, should have gone well. I must assume, as you would in the same circumstance, that leaving someone far worse off than blurry vision is to be avoided at all costs.

[sharonm516]

***Pops popcorn and watches doctors discussion***

[peregrinerose]

***Pops popcorn and watches doctors discussion***

LOL!!!!!!!:bbg:

That's the problem with us docs, we all are aware that there are more than one valid way to address an issue, but we still all think that our way is the right/best one :)

[DragonLensmanWV]

My first cataract surgery is scheduled for August 26. I gotta say my acuity is really low. All fine detail is lost, I have trouble laying out jobs, I get dazzled easily with lights and computer screens (playing heck with my Crysis playing),and I haven't driven at night in months because of the circular rainbows, now filled with milky haze.
We're shooting at going from a current -14.25 to a -1.50 to -2.00 at my request, not opting for monovision implants.

[sharonm516]

LOL!!!!!!!:bbg:

That's the problem with us docs, we all are aware that there are more than one valid way to address an issue, but we still all think that our way is the right/best one :)

Yes....I remember watching my 4 docs "duke it out" over cataract surgery co-management. :D I literally popped popcorn and all of us techs would just sit and watch.

[Chris Ryser]

My first cataract surgery is scheduled for August 26. I gotta say my acuity is really low. All fine detail is lost, I have trouble laying out jobs, I get dazzled easily with lights and computer screens.........

Just had my second eye done 3 weeks ago. Left eye slightly amblyoptic was done last fall and I had 100% better vision with that one.

When walking out into the bright daylight all colors looked so fresh, but when I closed the freshly done eye everything looked like through slightly brownish sun glasses.

Now that both eyes are done I got perfect vision on my right eye and I have the feeling that I have not seen that well in many years. However it is important to continue using the prescribed drops for quite while to prevent any infections.

As for the procedure, it lasted about 15 minutes,and 2 hours from check in to leave again without any eye patch, only pair of sunglasses.

What a difference when we used to go service cataract patients with glasses at the hospital/ They had to rest on their back for 6-7 days with as little movement as possible and then got prescriptions + 12.00 to + 18.0 and all in glass lenses.

One funny thing.............when waking up at night with open curtains a street light shines at me at a certain angle that lets me see the edges of the implant as a very clear hairline circle.

[DragonLensmanWV]

Just had my second eye done 3 weeks ago. Left eye slightly amblyoptic was done last fall and I had 100% better vision with that one.

When walking out into the bright daylight all colors looked so fresh, but when I closed the freshly done eye everything looked like through slightly brownish sun glasses.

Now that both eyes are done I got perfect vision on my right eye and I have the feeling that I have not seen that well in many years. However it is important to continue using the prescribed drops for quite while to prevent any infections.

As for the procedure, it lasted about 15 minutes,and 2 hours from check in to leave again without any eye patch, only pair of sunglasses.

What a difference when we used to go service cataract patients with glasses at the hospital/ They had to rest on their back for 6-7 days with as little movement as possible and then got prescriptions + 12.00 to + 18.0 and all in glass lenses.

One funny thing.............when waking up at night with open curtains a street light shines at me at a certain angle that lets me see the edges of the implant as a very clear hairline circle.

We just ran some quick VAs on me yesterday. I came up with OD 20/70, and OS 20/50 minus 3. I guess that means I'm ready.:D
Can't wait!

[Chris Ryser]

We just ran some quick VAs on me yesterday. I came up with OD 20/70, and OS 20/50 minus 3. I guess that means I'm ready.:D
Can't wait!

Wow................. I can feel for you. My right eye was 20/45 (which is the legal limit for driving) and I used to get nuts on the computer which I need for hours during the day.
I would say.............you are ready for sure and you will feel like a newborn when you walk out the clinic one hour after surgery..........the world has never looked as good.

[TechGeek]

Recommends cataract surgery whenever a) the cataract is the only correctable major problem b) when the patient complains about their vision even with glasses/contacts c) WHEN THE PT IS READY. (this is not medical advice, I'm no doctor!!!)

As far as

so I didn't think the cataracts could reform

you are correct. There is no lens (natural lens) for them to reform in...but they can (and do!) often opacify... a quick yag laser can take care of that though :)

The doctor basically "clears" the pt for surgery and then it is up to the pt...

[chip anderson]

Ain't the catract that opacifies, or the IOL for that matter. It is the capsule the natural lens was in (and now the pseudo-lens is in) that opacifies. Can be opened up with laser or needle, equally effecively.

Chip

[TechGeek]

yeah...I'd go with the yag...

Thanks for the clerification Chip!

[Kornika]

when they come in for a cataract consult is ...

"Cataract surgery can almost always be safely put off until you determine that it has become a hindrance to your lifestyle -- meaning you are unable to do the things you NEED to do and the things you ENJOY doing."

I then demonstrate to them the BCVA at distance and near that they can hope to achieve without cataract surgery. If they are less than 20/40 (BCVA) in either eye, I then perform a brightness acuity test (BAT).

In our practice, we also have the patient fill out a "lifestyle questionnaire" that asks patients such questions as, "Do you have difficulty, even with glasses ... reading, seeing road signs, etc.?"

*shrug*

Just my two cents.

[chip anderson]

Old Sam Johnson, who was a "cuttin' surgeon" always said: "The time to have catract surgery is when you can't see well enough to do what you would like to do." I would ammend this as say you have to evaluate yourself one eye at a time.
I have seen patients who maintain good vision in one eye and put off surgery until it gets bad enough to be a problem. In my humble opinion surgery should be done on the first eye when it alone doesn't see well enough to do what you would normally do.
Now I have known other surgeons what would let the patient get bad enough to practically walk into walls.
Have known some that did surgery as soon as the check cleared.
And one now retired who occasionally did caatract surgery when the patient didn't even have cataracts.

Who's right? Why me of course!

Chip