A cataract is simply a cloudy lens. As you can imagine, the cloudy lens blocks light that needs to enter the eye, thus causing blurred vision. People with significant cataracts don’t see well even with glasses or contacts, and their blurred vision may cause difficulty reading, driving a car, or taking care of simple activities of daily living.
In principle, cataract surgery is quite simple: we remove the cloudy lens, and replace it with a clear one. The new lens is called an implant, or intraocular lens (IOL). New IOL technology has allowed us to offer our patients increased freedom from glasses and contact lenses by providing simultaneous near and far vision with Multifocal Intraocular Lenses such as the Tecnis Multifocal and the Restor. Even with traditional implants, we have found that over 90% of our patients see well enough to pass a driver’s license test without glasses, and for these patients, reading glasses or bifocals are all that is necessary to see up close.
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Using numbing eyedrops and gel, rather than injections with needles into the eyesocket, cataract surgery can be performed quickly and safely. Because no needles are used around the eyeball, there is no risk of perforating the eye or causing bleeding into the eyesocket. Therefore, patients on blood thinners (because of a previous stroke or heart condition) can continue those medicines, rather than having to stop them as was previously required. Finally, the use of numbing eyedrops preserves the function of the both the eyelids and the optic nerve. Hence no patch is required after surgery, and patients typically recover useful vision within an hour, rather than having to wait until the patch is removed the day following surgery to see again.
Everyone heals somewhat differently, but many cataract patients report improvement in their vision almost immediately. Most patients return to their normal work and lifestyle routines within a day or two.
Options for Rehabilitation of Vision after Cataract Surgery and Refractive Lens Exchange
Understand that the primary goal of cataract surgery is to remove the cloudy lens (the cataract) and replace it with a clear lens (the intraocular lens [IOL] or “implant”). Replacing the cloudy lens with an implant allows the eye to regain its potential for vision. In order to get the best vision after cataract surgery, it is often necessary to wear glasses or contact lenses. The vision obtainable with glasses or contact lenses after surgery is what we call “Best Corrected Visual Acuity” (BCVA).
A secondary goal of cataract surgery is to reduce your dependence upon glasses and contact lenses. Because of recent advances in IOL technology, as well as technology used to measure the eye and plan surgery, we can often make our patients less dependent on eyeglasses. Some patients are able to eliminate glasses entirely, although it is impossible to guarantee with any of these technologies that you will be able to function without glasses for all tasks.
For patients without clinically significant cataracts who undergo Refractive Lens Exchange, the goals are somewhat different. Because these patients already have adequate vision with glasses (whereas cataract patients do not), the primary goal of Refractive Lens Exchange is to reduce your dependence on glasses and contact lenses. Understand that although most of our patients who undergo Refractive Lens Exchange will have decreased dependence on glasses and contacts, it is impossible to guarantee that you will be able to function without glasses for all things.
Understand that the primary goal of Basic Cataract Surgery is to remove the cloudy lens (the cataract) and replace it with a clear lens—the implant. Replacing the cloudy lens with an implant allows the eye to regain its potential for vision. In order to get the best possible vision after cataract surgery, it is often necessary to wear glasses or contact lenses, especially for reading.
Because of recent advances in IOL technology, as well as technology used to measure the eye and plan surgery, we can often make our patients less dependent on eyeglasses. The use of special implants and surgical techniques to reduce our patients’ dependence upon glasses and contact lenses is what we call Custom Cataract Surgery. With these techniques, many of our patients are able to eliminate or substantially reduce their dependence on glasses or contacts. Unfortunately, Medicare and private insurance carriers do not cover the extra testing and screening involved with Custom Cataract Surgery.
For patients without clinically significant cataracts who desire the benefits of the newer technology intraocular lenses, we offer a procedure that we call Refractive Lens Exchange. With Refractive Lens Exchange, the goals are somewhat different from patients having traditional cataract surgery. Because these patients already have adequate vision with glasses (whereas cataract patients do not), the primary goal of Refractive Lens Exchange is to reduce or eliminate your dependence on glasses and contact lenses. Understand that although most of our patients who undergo Refractive Lens Exchange will have decreased dependence on glasses and contacts—and many function entirely without them—it is impossible to guarantee that all patients will be able to function without glasses for all things.
Basic Cataract Surgery
Those patients who simply want to see better but do not mind wearing contact lenses or eyeglasses are generally best served by having Basic Cataract Surgery. Basic Cataract Surgery is the least expensive option for our cataract patients, yet we find that these patients enjoy excellent quality of vision after surgery. Basic Cataract Surgery uses traditional monofocal lenses with powers that can be calculated to help you see far away or up close. This is the option that most of our patients choose. It uses the tried and true technology of traditional monofocal IOL’s that has been developed with great success for over 50 years.
After Basic Cataract Surgery, most patients require reading glasses and/or bifocals to achieve their best vision. Reading glasses have the virtue of being inexpensive (generally around $10) and readily available without a prescription.
Understand that although an effort is made to lessen dependence on glasses even with our basic surgery, there is no guarantee to eliminate glasses, especially for reading. The monofocal lenses used in Basic Cataract Surgery are covered by Medicare and private insurance. Patients who choose Basic Cataract Surgery who later desire reduced dependence on glasses after surgery must understand that further refractive procedures such as LASIK, PRK, or intraocular lens exchange are the financial responsibility of the patient.
Custom Cataract Surgery
The goal of Custom Cataract Surgery is to reduce or eliminate your dependence on eyeglasses and contact lenses. Custom Cataract Surgery has as its basis the same procedures used in traditional cataract surgery, but involves extra testing, materials, and procedures to improve the patient’s chances of becoming less dependent on glasses. The additional procedures involved with Custom Cataract Surgery are considered to be in the category of luxury or cosmetic procedures, and hence are not covered by insurance.
Refractive Services Package
In order to assess your suitability for Custom Cataract Surgery, a battery of tests is performed. We call these tests our Refractive Services Package, which involves screening tests not covered by insurance or Medicare. These screening tests include corneal topography with both the Atlas and Pentacam topographers, specular microscopy, and assessment of macular function with OCT. Although not covered by insurance, the cost of testing is similar to what you might spend on a good pair of eyeglasses.
There are four basic options we offer for our Custom Cataract Surgery patients: Custom Distance, Custom Monovision, Custom Astigmatic (Toric), and Custom Multifocal. Understand that special cases, especially those patients with a history of prior refractive surgery such as LASIK, PRK, or RK, may require the use of more than one technology or procedure in order to obtain the desired result. Dr. Schulze will work with you to help you make the best choice for you.
Our Custom Distance program involves the use of monofocal, aspheric intraocular lenses set for distance vision in each eye. Extra testing with our Refractive Services Packages helps us customize our choice of implant to your eye. By measuring your spherical aberration prior to surgery, aspheric lenses can often be used to reduce your aberration profile after surgery. The goal with Custom Distance is to see well enough with each eye to pass a driver’s license test without glasses.
With Custom Monovision, we aim for distance vision in the dominant eye. We aim for reading vision in the non-dominant eye by making it nearsighted. Having one eye set for distance and one eye set for near increases the number of things that you can do without glasses. This approach after cataract surgery or refractive lens exchange works best in patients who have previously had success wearing contact lenses for monovision.
The disadvantage with monovision is that both eyes may no longer work together for distance or near vision. Some patients, realizing the advantage of increased freedom from glasses and contacts, tolerate this disparity extremely well. Other patients are unable to tolerate the imbalance between the two eyes. The goal with Custom Monovision is to see well enough to pass a driver’s test and read a newspaper without glasses.
Custom Astigmatic (Toric) Surgery
In order to understand Custom Astigmatic Surgery, it is important to have a good understanding of astigmatism. An eye without astigmatism is essentially round, like a basketball. Eyes with astigmatism have a shape more like the surface of a football or an egg. You can imagine that eyes with refracting surfaces shaped like footballs do not focus light very well!
If astigmatism is not corrected, even patients with clear lenses after cataract surgery will have blurred vision. Traditionally, astigmatism is corrected with eyeglasses or contact lenses. For those patients with cataracts and astigmatism who desire increased freedom from glasses, there are several surgical methods for correcting astigmatism:
- Placement of a Toric (Astigmatism Correcting) Intraocular Lens: this procedure involves the use of a more expensive type of implant (a toric IOL) that corrects for astigmatism. Rarely, toric implants can rotate out of position after surgery, requiring surgical repositioning.
- Limbal Relaxing Incisions (LRI): these are made at the time of cataract surgery with a diamond. As they heal, they flatten the steep part of the cornea and steepen the flat part of the cornea, thus making the cornea more round.
- Excimer laser refractive surgery (PRK and LASIK): PRK and LASIK are the most precise methods for reducing astigmatism. Since most cases of astigmatism with cataracts can be easily managed with LRI’s and toric IOL’s, excimer laser refractive surgery is rarely necessary after cataract surgery.
Prior to surgery for astigmatism, a number of special measurements are taken, and extra care is needed in the planning for and execution of surgery. Custom Astigmatic Surgery will be used to target either distance vision in both eyes or monovision, depending upon your goals. Because astigmatism can otherwise be easily corrected for with eyeglasses, surgical correction of astigmatism is considered by Medicare and private insurance carriers to be a cosmetic or luxury procedure and is not covered by insurance.
Custom Multifocal Cataract Surgery
Multifocal intraocular lenses offer excellent potential for reducing your dependence on glasses and contact. Our practice has extensive experience with multifocal lenses dating back to 1997. Multifocal lenses work by providing simultaneous near and distance vision in each eye, thus allowing both eyes to work together for both distance and near.
- The Tecnis Multifocal lens: the Tecnis Multifocal provides excellent distance and near vision. It is now available in three different models, depending upon your specific needs for near vision.
Weaknesses inherent in all multifocal IOL designs include aberrations that can cause glare and halos, especially at night. About 1 in 20 patients describe the glare and halos with multifocal lenses as “severe.” Multifocal lenses work best with binocular vision (both eyes working together), therefore, you will not get the full effect of multifocal vision until you have had surgery on your second eye.
Although multifocal lenses may represent your best option for reducing your dependence upon glasses and contact lenses, it is impossible to guarantee that you will be able to throw away your glasses. Reading glasses, for instance, will always magnify near objects, thus making them easier to see, even with a multifocal lens in place. Because Medicare and private insurance companies consider multifocal lenses to represent a luxury technology that is not absolutely necessary for good vision, these lenses are not covered by Medicare and insurance.
Refractive Lens Exchange
Refractive Lens Exchange is a procedure that utilizes all of the available technologies we have for cataract and refractive surgery to improve vision and lessen dependence upon glasses and contact lenses in people who do not have cataracts. All of the options discussed above, including traditional monofocal lenses for binocular distance vision, monovision, toric intraocular lenses for correction of astigmatism, limbal relaxing incisions, and multifocal intraocular lenses, can be used to achieve decreased dependence upon glasses and contact lenses.
A Few Words Regarding Intraocular Lens Power Calculations
Although the techniques we use to measure the eye and calculate IOL powers are state of the art, they are not perfect. We make every effort to ensure that our patients’ refractive results are as intended. Because of some inherent limitations of these technologies, a small percentage of patients may have an unpredictable outcome after surgery, especially in patients who have had prior refractive surgery such as RK, LASIK, or PRK. A way to think of this is to imagine that some patients may under- or over-respond to surgery, despite our computer calculations and measurements prior to surgery. Although these are not common, under or over responses to surgery are a statistical inevitability and the possibility that you may be one of these over or under responders must be taken into account as you consider surgery.
Regardless of the option you choose for rehabilitating your vision after cataract surgery or refractive lens exchange, understand that further surgery such as PRK, LASIK, and/or intraocular lens exchange may be required to fine tune your vision afterwards.
LASIK and PRK Enhancements after Cataract Surgery
If further LASIK or PRK is necessary for any of our Custom Cataract Surgery patients, Dr. Schulze will waive his professional fees. Thus, if you should require PRK or LASIK after Custom Cataract Surgery to fine tune your vision, you will only be responsible for the facility fee to the surgery center that covers the operating expenses for the excimer laser, which amounts to a 50% discount of our standard combined fees for LASIK and PRK. For those patients who choose to have Basic Cataract Surgery, understand that additional refractive procedures are NOT covered and are your financial responsibility.
Remember that all of the options presented above represent efforts to reduce your dependence upon glasses and contact lenses. None of these options can guarantee you to throw your glasses away. Talk with us about which of these options might be best for you.
Posterior Capsular Opacification (“After Cataracts”) and the YAG Laser
In some patients after cataract surgery, the membrane that holds the intraocular lens in place can become wrinkled or cloudy with scar tissue. This is called Posterior Capsular Opacification (PCO), or an “after cataract,” and is commonly seen after cataract surgery. If posterior capsular opacification develops, the patient typically notices the onset of blurred vision. PCO is easily treated with the YAG laser. The YAG laser is a “cold” laser which disrupts the scar tissue behind the implant, thus opening up the visual pathway for more light to enter the eye. Because there are no nerve endings in the scar tissue, there is no pain associated with the procedure. Side effects after the treatment include the presence of floaters which typically resolve after several days. YAG laser treatments are covered as a medical necessity under all insurance plans, including Medicare and Medicaid.