Cataracts, Cornea, Externa Disease and Refractive Surgery

The following information is intended to help you make an informed decision about having cataract surgery and decide on the type of intraocular lens implant that you would like to have.

How is cataract surgery performed?

In most cases, anesthesia is obtained with eye drops and minimal intravenous sedation. In rare cases, injections around the eye or general anesthesia may be required. A very small incision is placed in your cornea (the transparent structure in front of the iris).

Next, your cataract is broken up into tiny pieces and removed with an ultrasound device (commonly mistaken for a laser) that vibrates at high frequency. This procedure is termed phacoemulsification.

An intraocular lens (IOL) is implanted inside the eye—usually in the same space originally occupied by your natural lens. Finally, the very small incision initially created is closed, usually without sutures.

This surgical technique achieves rapid visual rehabilitation with minimal discomfort and avoids the risks of injected anesthetics. Bandages are unnecessary, and bleeding around the eye is rare. You will usually go home without an eye patch and will immediately start using a variety of eye drops to help your eye heal after surgery.

Now, many of these surgical steps can be performed with the use of a laser, the femtosecond laser, instead of blades.

Postoperative care: Your eye will be examined the day after surgery by your surgeon or an eye doctor chosen by your surgeon, and then at intervals determined by your surgeon. During the early recovery period, you will place drops in your eyes for about two to four weeks, depending on your individual needs. You should be able to resume most normal activities within one or two days, but you must avoid swimming and active sports such as basketball and racquetball for at least two weeks.

Most patients return to work within three to four days. Your vision will usually be stable within two to three weeks, at which time glasses or contact lenses will be prescribed if necessary. Only one eye will undergo surgery at a time, and in the absence of complications, surgery in the second eye can usually be scheduled one to six weeks after the first eye undergoes surgery.

Risks and complications of cataract surgery

Modern cataract surgery is extremely safe and effective and complications are rare. However, serious complications can occur even with properly performed cataract surgery, and in rare cases these complications can permanently and seriously reduce your vision.

There are risks associated with anesthesia and sedation, which include injury to the eye, heart and breathing problems, and in very rare cases, death. During or after surgery, intraocular infection, intraocular bleeding, intraocular inflammation, or retinal detachment can occur, and these complications can rarely cause permanent blindness. It may not be possible to implant the specific intraocular lens you have chosen or any intraocular lens at all. The intraocular lens can become decentered or dislocated, and in some instances require a second surgical procedure to reposition or replace the lens.

While the methods used to calculate the necessary intraocular lens power are very accurate in most patients, the final result may be different from what you and your surgeon planned. The proper intraocular lens power is especially difficult to predict in patients who have had LASIK, radial keratotomy, other refractive surgical procedures, and some diseases of the cornea. Having your refractive surgery records will assist in calculating the IOL power, so please try to obtain them prior to your cataract surgery.

It is impossible to list all of the possible risks and complications associated with this proposed surgery or any other treatment. Risks and complications that are considered to be unforeseeable, remote, or commonly known are not discussed. In addition, even though cataract surgery has been performed for many years, there still may be long-term effects that are not yet known or anticipated.

How removing the cataract will affect your vision

The goal of cataract surgery is to correct the decreased vision that is caused by the cataract. Cataract surgery will not correct other causes of decreased vision, such as glaucoma, diabetes, or age-related macular degeneration. Vision may not be completely normal after cataract surgery because these or other abnormalities may not have been diagnosed before cataract surgery was performed.

The need for glasses or contacts after cataract surgery; astigmatism and presbyopia

The purpose of cataract surgery is to improve the quality of vision that can be obtained with the best possible glasses or contact lens prescription you can be given. Although an attempt is made to provide good vision without glasses or contact lenses, this is not always possible. Because the calculation of the intraocular lens (IOL) power is not perfect, IOLs may not completely correct astigmatism, and the actual location the IOL occupies within the eye (which affects its power) is not completely predictable. Thus, correction with glasses or contact lenses is frequently necessary after cataract surgery.

Astigmatism and alternatives for distance vision after surgery

Some patients have significant astigmatism, which is an irregularly shaped cornea that causes objects to appear somewhat distorted at all distances.

Presbyopia (near vision) and alternatives for near vision after surgery

At about age 45, people with good distance vision begin to have difficulty with near vision. If they require corrective lenses to see at distance, the same lenses do not produce good vision at near because the optical system of the eye must change its power to change its point of focus. This is normally accomplished by changing the power of the lens inside the eye.

As we age, the lens becomes stiff, so it cannot change the focal point of the eye from distance to near. Bifocal glasses contain lenses that have different powers in the top and bottom of the lens. The top of the lens focuses distant objects, and the bottom focuses near objects. If no correction is needed for clear distance vision, non-prescription reading glasses correct near vision.

Options for correcting presbyopia after cataract surgery

  • You can have a standard monofocal intraocular lens for near or distance vision and continue to wear glasses or contact lenses to correct the astigmatism.
  • You can have a monofocal intraocular lens placed using femtosecond laser-assisted cataract surgery, which can address low amounts of astigmatism at the time of cataract surgery.
  • You can have a special lens, toric IOL, implanted that can correct astigmatism. Since most insurance companies will not cover the cost of a toric IOL, there is an additional out-of-pocket charge for this type of lens and professional services associated with its use.
  • You can have refractive surgery such as LASIK or photorefractive keratectomy (PRK) several months after cataract surgery to correct not only astigmatism, but also any residual nearsightedness or farsightedness. There is an additional charge for LASIK or PRK that is not covered by insurance.

Limitations of cataract surgery

No matter which type of intraocular lens (IOL) is chosen for your surgery, there are factors that could affect your visual outcome after surgery:

  • Cataract surgery can not correct decreased vision caused by conditions or diseases of the cornea, iris, optic nerve or retina such as: keratoconus, glaucoma, diabetes, or age-related macular degeneration.
  • The proper selection of the IOL, while based upon sophisticated equipment and computer formulas, is not an exact science, so glasses or contact lenses may be required to obtain vision that is acceptable to you after surgery.
  • Individual healing factors cannot be predicted with 100% accuracy, so the final prescription of the eye after surgery in not completely predictable.
  • If a monofocal IOL is implanted in both eyes in an effort to achieve the best distance vision possible, either bifocal or reading glasses or contacts will be needed after cataract surgery to obtain adequate near vision.
  • Multifocal IOLs may reduce dependency on glasses but might also result in reduced quality of vision, which may become worse in dim light or fog. They may also cause some visual side effects such as rings or circles around lights at night. It may be difficult to distinguish an object from a dark background, which will be more noticeable in areas with less light. Driving at night may be affected.
  • Any residual refractive error after surgery may need to be corrected with eyeglasses, contact lenses, refractive surgery or replacement of the IOL.

Specific intraocular lens (IOL) implant options

Monofocal IOL: Monfocal, or single vision lenses, are the standard lenses that have been implanted at the time of routine cataract surgery for many years. These lenses take the place of your cataract and can help you see distant objects. However, these lenses will not correct astigmatism and will not correct near vision, so it is likely that you will need to wear glasses at least part-time for distance activities and full time for near work.

Toric IOL: In addition to correcting nearsightedness or farsightedness, toric lenses have the ability to correct astigmatism. If you have significant astigmatism before surgery, then this lens option will provide you with a better opportunity to have clear distance vision without glasses. Toric lenses still correct primarily distance vision and will not correct near vision.

Multifocal IOL: Multifocal lenses are appropriate for some patients who have a strong desire to see distant and near objects without glasses and who are willing to potentially somewhat compromise the quality of their vision to obtain freedom from glasses. The two available multifocal IOLs are the ReZoom lens (AMO) and the ReSTOR lens (Alcon). In appropriate candidates, multifocal lenses can improve distance, intermediate (computer distance), and near vision and can reduce your dependency on spectacles at all of these distances; however, neither lens restores the natural vision at all distances you had as a youth, and you may experience some problems with these lenses. These include, but are not limited to: poor night vision, including glare and halos, less sharpness of vision than may be obtained with a monofocal IOL and spectacles, and inadequate near and intermediate vision that still may require the use of glasses. Multifocal lenses may require some time for adaptation, and in very rare cases, the vision obtained with multifocal lenses may be so poor that replacement of the lens with a monofocal lens may be necessary. This is a separate procedure for which there will be a charge, and it carries additional surgical risks.

Pseudo-accommodative IOL: The crystalens® is a pseudo-accommodative IOL that is designed to provide good distance acuity and a moderate amount of intermediate and near correction. Most patients find that they still require reading glasses for most near tasks. The crystalens® is not offered as an intraocular lens option at Emory.

Pricing for intraocular lens implant and LASIK options

Your insurance company will generally cover the cost of cataract surgery with implantation of a standard monofocal intraocular lens (IOL). Each insurance plan is different, so you should check with your individual carrier to confirm fees that are applicable to y

ou.

In addition to these fees, there are out-of-pocket expenses for the different IOL and LASIK options mentioned. These additional fees cover the cost of the lens or LASIK technology and the added physician and technician time required to make the appropriate calculations necessary for your eyes.

Physicians