Cataract Surgery
Cataract surgery is one of the safest, most effective types of surgery. It's also one of the most successful. Over one million cataract extractions with intraocular lens implants were done in 2003. In the vast majority of cases, patients do well and obtain excellent vision postoperatively. However, all cataract surgery and all cataract surgeons are not the same. There is a tremendous variation in how cataract surgery is done, most of these differences can be attributed to cutting corners in order to save money and increase the surgeon’s profit (meanwhile increasing the risk to the patient). There are important questions to ask your cataract surgeon prior to undergoing cataract surgery that may allow you to better assess the risks associated with your particular surgery.
Because cataract surgery lends itself to assembly line type surgery, in certain instances, the surgeon may feel compelled to rush or control overhead costs, thereby placing your eye at increased risks for postoperative problems. Assembly line surgery offers little if any benefit to the patient but significant financial benefits to the surgeon. The surgeons at Central Florida Eye Specialists P.L. feel your vision is one of your most precious senses and should be accorded the care it deserves.
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There are three important phases of cataract surgery. The first phase includes the preoperative evaluation and assessment. This is when the decision to proceed with cataract surgery is made. The next phase is the actual surgery itself and the third phase and sometimes most important phase is the postoperative care. We will walk through each of the phases and review what would be important if you were undergoing cataract surgery and the questions to ask about the surgeon prior to proceeding with surgery.
Phase One
The preoperative period and evaluation lays the foundation for successful cataract surgery. It is essential that the operating surgeon completely examine the patient’s eyes prior to cataract surgery. It is essential that the surgeon personally conduct this extensive eye exam because he is the one that will be operating and frequently, can detect subtle deviations from normal that help him plan a safe and successful surgical procedure. When the preoperative evaluation is done outside of the office, by another physician, ophthalmologist or optometrist and then referred to the office for cataract surgery without the surgeon personally examining the patient, these subtle findings can be missed.
After you and your eye doctor have decided that you will have cataract surgery, your doctor will measure your eye to determine the proper power of the IOL that will be placed in your eye during surgery. Your doctor will then work with you to decide which IOL is best for your visual needs. There are two basic types of IOLs, each designed for a specific corrective function.
Intraocular lens (IOL):
Monofocal lenses provide corrective power in only one segment of your visual range (typically distance vision), while multifocal lenses are designed to correct a range of vision – near through distance. You may be a candidate for the AcrySof® ReSTOR® IOL, which is an advanced type of multifocal IOL or the Crystalens IOL, unlike a standard IOL, can treat both cataracts and presbyopia—loss of near and intermediate vision or the single-focal lens implant AcrySof® Toric IOL for cataract patients with astigmatism.
In addition, it is important to be checked by the surgeon, at least, one to three days preoperatively to make sure that no signs of infection present that may increase the risk of endophthalmitis, which is a postoperative infection that can result in the loss of the eye. Also, at the evaluation one to three days preoperatively, the patient has a chance to ask the surgeon any last minute questions and to review the preoperative drops, medication schedule and possible postoperative care questions that should be addressed preoperatively.
Phase Two
At the preoperative visit, the eyelids should be examined for signs of styes or other possible infectious problems. One question that we are asked quite frequently is whether we use a stitch or no-stitch technique. The decision to use a stitch or no-stitch is frequently more important to the surgeon’s ego and his ability to rapidly do cases than it is to the ultimate safety to your eye. If at the close of surgery the surgeon gently pushes on the eye and the wound opens spontaneously, it is very likely that the patient while instilling their drops and wiping the eye after the drops, will open the wound, this allows bacteria to get inside the eye and could result in a severe eye infection and possibly loss of the eye. In this instance, a stitch would be preferred, as it significantly decreases the risks of severe postoperative infection. Probably a more important question to ask your surgeon, at this point, is whether he is going to use a very small incision, for example, 2.5 to 3 millimeter incision with a foldable lens, or a larger 5 to 5.5 millimeter incision with a solid plastic lens. There is no question that the smaller incision provides a number of advantages. The primary reason that most surgeons do not use a foldable lens and insist on using a hard plastic lens is because the hard plastic lens is much less expensive and if the surgeon is operating out of his own surgery center, he has the opportunity to make significantly more money by using the larger 5 to 5.5 millimeter lens than the more costly foldable lens that can go in through the very small incision. Although ultimately more profitable to the surgeon, the larger incision increases the patients risk of postoperative complications. Postoperative problems include an increased risk of infection or endophthalmitis, the possibility of the iris or the colored portion of the eye prolapsing or sliding out through the wound, causing distortion of the pupil and an increased risk of infection and long term swelling of the macula called cystoid macular edema. The difference is so great that if your surgeon refuses to use a small foldable lens, we strongly suggest another evaluation by another ophthalmic surgeon who uses a very small incision and the foldable lens. We at Central Florida Eye Specialists P.L. feel it is wrong to put the surgeons profit ahead of what’s best for the patient.
Phase Three
The third phase of surgery is the postoperative phase. The questions regarding the postoperative care should be addressed in the preoperative evaluation because once you are in the postoperative period, it is too late to find another surgeon who you feel may provide better postoperative care for your eye. Probably the most important postoperative period is the first week after surgery. It is critical that you ask your surgeon, will he be the one checking your eye following your surgery, or will this be delegated to someone outside of the practice? Although, most patients do very well following surgery, some of the more common catastrophic complications are best dealt with in the first one to four days following surgery. The operating surgeon who obviously knows exactly what happened at the time of surgery is in a much better position to diagnose and treat these complications.
Another important question to ask your operating surgeon is the availability of an ophthalmic surgeon after hours and on the weekend. If you call the office on a Saturday or Sunday or a weekday night, are you going to be talking to a surgical ophthalmologist who does cataract surgery, or are you going to be talking to an ancillary staff, someone who has no experience in cataract surgery. In addition, it is probably important to make sure that your physician has hospital admitting privileges at least at one hospital, that way, if by any chance you needed to make an emergency room visit, it is likely that your ophthalmic surgeon or another ophthalmic surgeon that shares call with him will be available to exam your eye if necessary. Also, although most cataract surgery is done in outpatient surgery centers, by having admitting privileges and being on the active staff at the hospital assures that the physician has undergone credentialing by a neutral review committee. Although such review is also done in outpatient surgery centers, the person doing the review is often the surgeon himself or one of his employees, thus hardly a neutral evaluation of his skills. Medicare and most insurers provide a 90 day postoperative care period for cataract surgery and during this time, your operating surgeon should be available for postoperative checks and any emergencies that may occur. If your surgeon can not assure you of his availability or the availability of a covering ophthalmic surgeon, it is probably worthwhile to find another ophthalmic surgeon to perform your cataract surgery.
As you can see, there are a number of different philosophies regarding cataract surgery. As a patient, each one of us has only two eyes and should do everything in our power to preserve our vision and not be mislead by grandiose advertisement, but only by face to face questions that we are allowed to ask the surgeon who is going to be operating on our eyes.
The following is a brief check list that you may find helpful when discussing your surgery with your ophthalmic surgeon.
Frequently Asked Questions (FAQ):
Your eye surgeon operates while looking through a highly specialized microscope, designed exclusively for this purpose. A very small, beveled incision, less than 1/8 of an inch, is made at the edge of the "clear cornea". The clear cornea is the transparent covering of the front of the eye.
The incision is just large enough to allow a microscopic instrument the size of a pen tip to pass through it. Once the microscopic instrument is actually passed through the tiny incision, ultrasound from the tip of the microscopic instrument will be used to gently break the cataract into pieces small enough to be washed away, drawn through the instrument and removed from the eye.
Through the tiny incision, a microsurgical, ultrasonic, oscillating probe is inserted, which gently fragments the cloudy lens, using high frequency sound waves. Simultaneously, this same instrument suctions out the fragmented pieces. This process is called "phacoemulsification". The posterior capsule, an elastic bag-like membrane that held the lens, is left in place.
The incision is commonly called "self-sealing" because the eye's natural internal pressure holds the incision tightly closed allowing the eye to heal without stitches. The chances of developing astigmatism (distorted vision) after surgery are significantly decreased by eliminating stitches, which tend to pull the eye's surface slightly out of its natural shape.
Once all the minuscule bits of the cataract have been removed, a tiny new clear implant lens is folded, inserted through the small incision, and allowed to open up inside the posterior capsule.
The surgery typically takes 20-30 minutes, and is performed on an outpatient basis. This means that you will have the surgery and then go home, usually around 30 minutes afterwards. Most of the time only local anesthesia is used, so you will be awake for the entire process. After the surgery, you are taken to the recovery room and then released. You will need someone to drive you home.
A special YAG laser is used to remove capsular haze by the following — An opening is made in the scar tissue with the laser, allowing vision to be restored. With modern intraocular lens implant designs, and materials, the incidence of posterior capsule clouding has fallen to approximately one percent.
Our patients most often report that their surgery was remarkably pleasant, and that pain was not even a consideration. Some have even told us that they haven't felt that relaxed in years!
At Central Florida Eye Specialists and Laser Center, we promise to be attentive to your needs and well-being and will do everything possible to make sure you are completely comfortable throughout the entire procedure. You will be given a relaxant to enhance calmness and will neither see nor feel any part of your eye surgery. After you are released, we will call you that evening to see that you are doing well. The same afternoon or next morning, you will visit with your physician for evaluation and to address any concerns you might have. We are always here for you.
There are times when a cataract can be removed successfully but vision is not improved — because of other conditions or diseases of the eye. One such disease is macular degeneration, where the central part of the retina — the area that is critical for "fine" seeing — is damaged. Occasionally, macular degeneration cannot be diagnosed prior to the cataract removal because the presence of the cataract itself may prevent seeing the macula in sufficient detail. It is sometimes only after the cataract is removed that macular degeneration is diagnosed.
In addition, other pre-existing conditions of the eye can limit vision after cataract surgery, such as diabetic retinopathy or glaucoma. All such pre-existing conditions limit the eye's ability to regain normal vision, even if the cataract surgery itself is a huge success.
All that said, remember that cataract surgery has a high success rate, higher than any other surgical procedure. It is most likely that your vision will be remarkably better and that your quality of life improved.
The afternoon of your surgery or the day following, you will have an office appointment to ensure that you are healing properly. Your vision could be blurred from ointments associated with eye surgery or you might see quite clearly. Every patient is an individual and heals somewhat differently.
Over the following weeks, visual clarity progressively improves, and after one month, the eye is typically healed and ready for refracting for new glasses, if needed. Follow-up visits are usually scheduled for the next day, one week, and then one month after surgery. During this time you will be using eye drops to help the eye to heal and to prevent infection.
For the first four days following cataract surgery, we ask you to avoid any and all heavy lifting or bending over that bring your head below the level of your heart. After that, and for the month following surgery, you can resume most of your normal activities, but minimize lifting, bending, and straining. Carrying reasonably lightweight objects, such as a purse or a small bag of groceries, is usually fine.
You will also be asked to avoid getting water in the operated eye for one to two weeks. Avoid swimming. Water that is normally safe for showering and drinking has bacteria in it, and this can possibly cause an infection where the incision was made in your eye. Just adjust your routine to wash your hair leaning backwards rather than forwards or have someone else wash it for you.
You don't need to stay indoors, but try to avoid being out in the wind, as something might blow in your eye. You'll need to keep your hands out of your eyes as well. Your surgeon may give you an eye-shield to wear at bedtime to inhibit possible rubbing or pressing on the eye in your sleep. Avoid eye make-up for six weeks. As for returning to work or driving, this varies from one patient to another and the kind of work involved. Discuss your situation with your doctor who is here to address all of your concerns.
Once a cataract has been removed, light can once again pass undistorted through the cornea and the newly implanted artificial lens, to the retina in the back of the eye. However, you may still be required to wear glasses to see more clearly because the incoming light needs to be focused directly on the retina. If you eye cannot do so on its own, eyeglasses will be needed to provide that focus.
In addition, the implanted artificial lens cannot change shape for close vision the way a natural, youthful lens does. A natural lens accommodates, or changes shape, to bring objects into focus at distance, or close up. The intraocular lens implant provides clearest vision at a single focal distance, with the great majority implanted to correct for distance vision. This means that an eye focused for distance will have sharpest vision for activities such as driving, but, if you do not qualify for an accommodating lens implant, you would still require bifocal lenses or reading glasses in order to see clearly at close range.
Questions to ask your cataract surgeon:
- Will the surgeon examine my eyes prior to surgery?
- Does the surgeon perform small incision surgery?
- What type of anesthetic will be used? Topical (drops only) or injections?
- If you are sensitive to light or have trouble keeping your eye open you may be more comfortable with injections for your surgery
- What type of intraocular lens (implant) will be used? Will it be a foldable implant that can be inserted through a small incision or a larger hard plastic implant that will require a larger incision?
- Larger incisions increase the likelihood of wound leaks and thus infections that could result in the loss of the eye. If a larger incision is necessary it should be closed with a suture.
- Is the surgeon on the active staff at a local hospital?
- If urgent medical problems arise during surgery, is the surgeon able to admit me to the local hospital or will I just be sent to the emergency room and not see the surgeon in the hospital?
- Is the surgeon (or another ophthalmic surgeon) available after hours and on weekends for emergencies?
- Will I see the surgeon after the procedure or will he be in a hurry to go onto the next operation?
- Will the surgeon personally do the post operative care?
