Cataract

Cataracts? You can have brighter, clearer vision!

Simple Steps to Better Vision

You have been diagnosed with a cataract and are considering cataract surgery. This is an exciting time, but it can also be a scary and confusing experience. Fortunately, modern techniques with cataract surgery make this one of the safest and most successful surgeries, and most people do great. Dr. Peter DeBry is one of the leading cataract surgeons in Henderson and Las Vegas. The rewards of a successful surgery include brighter and clearer vision, in many cases without glasses! Because there is so much to understand about cataract surgery, Dr. DeBry has created this web information to help you prepare for and be more educated about cataract surgery. Please read through the information and send us any questions you may. It should cover all aspects of cataract surgery.

What is a Cataract?

Your eye is amazing! The eye is designed to take in the images from the world around you, focus the light and provide a clear picture that is sent by electrical signals to the brain. The eye has a lens just like a camera that helps to focus the light and make a clear picture inside the eye. At birth, your natural lens is perfectly clear, just like glass.

As you age, the lens proteins start to break down and the lens becomes cloudy. This cloudy lens is known as a cataract. Many people have the misconception that a cataract is a film or cloudiness that develops in front of the eye. This is incorrect. A cataract is simply a cloudy lens. A cataract surgery is, therefore, a lens replacement surgery.

In this picture see how the new clear plastic lens has replaced the cloudy cataract lens, restoring clear vision.

 

Cataract Symptoms

As cataracts develop, several visual symptoms may occur. Many of these symptoms are not noticed with early cataracts because they are mild and the visual changes occur gradually. Common cataract symptoms include:

  • Blurry vision at distance and up close
  • Halos or starbursts around lights, mainly noticed at night
  • Glare from oncoming headlights or bright sunlight is extremely bothersome
  • Low light situations make seeing more difficult, such as a dim restaurant
  • Small print is difficult to read
  • Frequent changes are required in your glasses prescription

 

When to Remove a Cataract?

Simple Steps to Better Vision

Many patients ask “When is the right time to remove a cataract?” The answer is very simple. The time for you to consider cataract surgery is when you feel dissatisfied with your vision. Here are some common scenarios that may lead you to consider cataract surgery:

  • I feel unsafe driving because I cannot see the street signs until I am very close to them.
  • I have stopped driving at night because I can’t see well when other cars are coming towards me.
  • I love reading but have been reading less because it has become difficult to see the small print.
  • Everything just seems hazy and foggy. It looks like my glasses are smudged, but taking them off and cleaning them constantly does nothing.
  • I am having a difficult time seeing the scores on the TV when I watch a basketball or football game.

A common misconception is that cataract surgery should not be done until the cataract is “ripe”. In reality, a cataract should be removed when it is causing visual symptoms. People are unique and there is a wide range of visual needs. Some people with visually demanding professions such as engineers and architects may notice even minor changes to their vision and be unhappy.  Dr. DeBry will be able to help you determine when to remove a cataract.

 

What is the Treatment for a Cataract?

There is no cataract treatment such as drops or medications that can fully reverse the cloudiness in the lens that develops with age. Therefore,  once the lens starts to turn cloudy and symptoms develop, the primary cataract treatment is surgery.

  • With cataract surgery a very small incision (only 3 mm or 1/8 of an inch) is made in the side of the cornea (the front window of the eye). A small ultrasound instrument is placed in the eye.
  • The instrument then breaks up the cataract into very small fragments using ultrasound energy and vacuums it out of the eye. A new, clear artificial lens is then placed inside the eye to restore sharp clear vision.

Many patients feel like they have turned back the clock a decade with their new cataract treatment.

What are the Risks Associated with Cataract Surgery?

Cataract surgery is an extremely safe and effective procedure, but there are rare cataract surgery risks associated with the surgery. These complications are unusual, but some of them are potentially sight-threatening. Some patients do not like to hear about scary problems related to a medical procedure. If this is you then skip this section. We believe that it is important for you to understand all the possible risks associated with a procedure. As with any surgical procedure, there is a risk of infection with cataract surgery. A severe infection inside the eye, known as endophthalmitis, may occur. In the United States only 1 out of every 500 surgeries develops an infection. This can often be treated without any permanent vision loss. Antibiotic eye drops are used before and after the surgery to reduce the possibility of infection.

Several problems could result in the need for additional surgery in the weeks or months following cataract surgery. This situation occurs in less than 1-in-100 patients. Problems requiring an additional surgery include retinal detachment; cataract fragments retained in the eye, poor position of the artificial lens implant, and blurred vision due to incorrect lens power.

  • The retina is the layer of tissue inside the eye that allows you to see. As a result of the surgery, the retina may detach, similar to wallpaper peeling off a wall. Should this occur, a retina specialist will need to perform another procedure to reattach the retina.
  • At times, pieces of the cataract break off and are not able to be removed completely from the eye. In some cases, a small piece will not create problems. With bigger fragments, a second procedure is required to remove them.
  • The new lens implanted after the cataract is removed is held in position by a very thin membrane. Any weakness or tear in this membrane may cause the lens to shift and no longer be in perfect position. If the shift is large enough to affect the vision, a second procedure may be necessary to reposition the lens implant.
  • The power of your lens implant is determined using complex math equations and detailed measurements of your eye. Small errors in these measurements may result in an overestimation or underestimation of the power of the lens implant. In rare cases, a second operation may be required to remove the old lens and replace it with a better one.

Swelling develops when tissue injury occurs. You may have seen a friend or relative with a sprained ankle and noticed the bruising and swelling that developed. Swelling can also occur as a result of a cataract procedure. It occurs most commonly in the cornea, but can also be seen in the retina. When present, swelling can cause the vision to be blurry. The treatment for retinal swelling is anti-inflammatory eye drops. Your consent form contains a detailed list of possible side effects and complications from cataract surgery. Please read it carefully and ask Dr. DeBry or your surgery counselor any questions you may have about risks from the surgery.

 

How Do I Know Which Lens to Choose?

When your cataract is removed, a new lens is placed inside of your eye. This makes cataract surgery an exciting time because patients who had been nearsighted or farsighted can now be made to have excellent vision without glasses. 20 years ago all patients receive the same type of lens with their cataract surgery. Over the last 10 years, manufacturing companies have developed new lens technologies. These lens options can give you additional benefits, but also more choices that need to be made in determining your lens implant type. Because of these multiple options, lens selection can be a frustrating process. The problem with intraocular lenses inserted with cataract surgery is that there is no way to try them before surgery to see which one you like the best. There are 2 important things to consider when choosing the artificial lens to be used in your cataract surgery: the type of lens and the power of the lens. Choosing a cataract lens depends on many personal factors, including

  • What activities do you do during the day and which ones would you like to do without glasses if possible?
  • Are you able to pay extra money for a lens that does more than the standard lens covered by your insurance company?
  • At what distances would you like to see most clearly without glasses – near (reading), intermediate (computer screen), or far (driving)?

In order to determine the power of the lens implant, a series of eye measurements is performed. These measurements are then used in complex mathematical equations to calculate the power of your new lens. Because of variability in biological systems (not every eye is the same), there can be inaccuracies in the formulas.

There are now many different lens options available to patients. You and Dr. DeBry will work together to determine the perfect lens for you. Currently, the following types of lenses are available…

  • Standard lens (monofocal) – This high-quality, clear lens delivers excellent vision at only one distance. The focal point or distance at maximum clarity can be set to distance (driving, golfing, watching TV), intermediate (grocery store shelves, computer, car dashboard), or near (reading, hobbies). There is no extra out-of-pocket cost with a monofocal lens.
  • Multifocal lens – Designed to reduce your need for eyeglasses for both distance and near vision, this lens gives you clear vision at several distances. This is a special lens and is not fully covered by insurance so there would be an extra payment for this lens.
  • Toric lens – Designed to treat astigmatism and deliver excellent vision at a single distance. This special lens is also not fully covered by insurance.
  • Accommodating lens (Crystalens) – Designed with hinges intended to allow this lens to shift its position inside to focus at varying distances.
  • Aspheric lens – Designed to improve contrast sensitivity and visual clarity under certain circumstances.
  • Monovision – this implant technique uses a monofocal lens with a different power in each eye so that you don’t have to use glasses for most of your daily activities. Your dominant eye is generally set for distance, and the other eye is set for near. Many people successfully use monovision with contact lenses. Successful monovision requires cataract surgery to each eye.

Am I a good candidate for a Multifocal Lens?

With a standard monofocal lens implant, the vision will be very clear in the distance but very blurry up close (for reading) without glasses. Some patients have even complained that they could not see their food at the dinner table without using reading glasses. Multifocal lenses were developed to allow patients to see well at several distances WITHOUT GLASSES after cataract surgery. Multifocal lenses offer benefits above and beyond those of standard lenses. They are not covered by insurance and require an additional out-of-pocket expense. Therefore, it is important to evaluate the following considerations when determining whether a multifocal lens is right for you.

Eye diseases, such as glaucoma, diabetic retinopathy, diabetic macular edema, or macular degeneration, can negatively affect the health of the eyes and the quality of the vision. These diseases, even in early stages, could cause problems with premium lenses. A multifocal lens is not recommended if you have one of these eye diseases.

Visual needs should also be considered when deciding on a multifocal lens. The technology contained in these lenses that allow you to read without glasses may lead to mild symptoms such as glare, halos, or decreased contrast sensitivity in certain conditions, such as night driving or dim restaurant lighting. Some patients rarely notice visual effects related to the lens implant. Others notice the effects but are not significantly bothered by them. If you feel you would not be able to adapt to these visual symptoms, you probably are not an ideal candidate for a multifocal lens.

Motivation to not wear glasses should also be determined when selecting a multifocal lens. These lenses are designed for patients who are motivated to not have to wear glasses after their cataract surgery. Some patients are accustomed to wearing glasses and do not mind using them after surgery. The additional cost of a multifocal lens would not be a reasonable investment for these patients. For other patients, eliminating the need for glasses is a strong desire. Paying the additional out-of-pocket cost for a special lens would make much more sense for these patients, as these lenses would give them the best option to achieve their goal to be free from glasses.

In summary, ideal candidates for multifocal lenses are patients with healthy eyes, little to no astigmatism, motivation to be less dependent on eyeglasses or contact lenses, and willingness to adapt to minor visual effects from the lens. Patients selecting a multifocal lens can reasonably expect to have good vision for reading and driving. Because no current technology is perfect there may still be circumstances where glasses are required to achieve a comfortable vision.

How much do multifocal lenses cost?

The average charge across the country for a multifocal lens implant is around $2500. This may seem expensive but remember: this lens will be used for the rest of your life, and you only have one opportunity to choose the best lens for you at the time of your surgery. Financing plans are available if you would like to pay for the lens over a period of several years. With these low-cost options, you may be able to pay as little as a few hundred dollars a month for your new lens.

Tell me more about astigmatism!

To review, Astigmatism means that the cornea or front window of your eye has an oblong shape and curvature similar to a football. A normal cornea has a more rounded shape similar to a basketball. People with astigmatism do not have clear vision unless they are wearing glasses or contact lenses. During cataract surgery, astigmatism can be treated, resulting in clearer vision. Many people who have astigmatism treated during their cataract surgery can see clearly without glasses for the first time in their life. Low amounts of astigmatism are treated with corneal incisions (limbal relaxing incisions). Using a calibrated diamond blade, very small incisions are placed in the cornea to change the shape of the cornea. Larger amounts of astigmatism are corrected by implanting a special intraocular lens, called a toric lens. Astigmatism treatments are considered by most insurance companies to be an elective component in addition to the cataract procedure and therefore have additional out-of-pocket costs. This generally ranges from $500-$1500 depending on the treatment required.

Life Situation

Recommended Lens

Would like to take full advantage of lens technology and avoid glasses after cataract surgery Multifocal lens
Contact lens wearer currently using monovision Monofocal lens with monovision
Currently wearing glasses because of astigmatism Toric astigmatism correcting lens or limbal relaxing incisions
Biggest problem is glare driving at night Aspheric monofocal lens
Enjoy being nearsighted and reading without glasses, willing to wear glasses for driving Monofocal lens set for near
Do not mind wearing glasses, especially for reading Monofocal lens set for distance
Would like to avoid glasses for most situations except for reading small print Mild monovision with monofocal lens

Are There Different Options for Incisions with Cataract Surgery?

In 2012 the FDA approved the first laser designed to be used during cataract surgery. Laser cataract surgery makes very precise incisions in the cornea using laser technology. The laser then makes a perfectly circular opening on the lens surface. The same small ultrasound probe used in regular cataract surgery is then used to liquefy and remove the cloudy cataract lens. Astigmatism treatments can also be performed with a laser (limbal relaxing incisions). Because this new technology is expensive there is an additional cost for a cataract surgery performed with a laser. You now have the choice of having standard cataract surgery performed with a blade or laser cataract surgery. Not all patients qualify for laser cataract surgery because according to Medicare the only part of the procedure that can be charged an additional fee is the astigmatism treatment. Even if you want to have the laser done, Medicare will not allow your doctor to charge you more for this procedure unless astigmatism is being treated at the same time. In some ways this does not make sense, but Medicare is trying to protect you from extra charges that may not improve your surgical outcome.

What Happens Before the Surgery?

When can I eat before cataract surgery?

Generally, you can eat up until midnight the night prior to your surgery. In other words, no breakfast allowed including fluids such as milk or coffee. If your surgery is to take place later in the day, your surgeon may specify a different time. Please remember to not eat breakfast the morning of your procedure. It can be very frustrating to go through all the preparation and then have your procedure canceled or do the surgery with no sedation because you ate.

Since I am fasting, should I take my regular medications as usual the morning of my procedure?

Yes, you should take your medications as usual unless directed to do otherwise by your surgeon. Many times, patients will arrive at the surgery center without having taken their medications and their blood pressure or blood sugar is elevated. In most cases, we are able to normalize these levels and perform the surgery as scheduled, but occasionally surgery is cancelled due to high blood pressure or blood sugar. If you need to take medications in the morning, drink only a sip of water with the medications.

If you are taking eye drops for glaucoma, it is very important to use them as usual unless your surgeon instructs you to do otherwise.

Do I need to start eye drops before the surgery?

Most eye surgeons recommend that their patients start their medicated eye drops a few days before cataract surgery. There are several reasons that this may be beneficial. The antibiotic eye drop may decrease the number of bacteria living in your eye and reduce the risk of infection. The anti-inflammatory and steroid drops may help your eye to be more comfortable and heal quickly if started before the procedure. Finally, by starting the medications before your surgery, you will have a few days to work on any medication problems such as formulary restrictions or a pharmacy that needs to order the medication for you. If you are unable to start the medications prior to the surgery, do not be concerned. You are likely to have great results from the surgery even if the drops are started that day. Occasionally we get phone calls with panicked patients thinking that their surgery needs to get canceled because they forgot to take the eye drops.

What Should I Expect on the Day of Surgery?

Cataract Surgery Day:
Why do I need someone to drive me home after surgery?

You will require a driver on cataract surgery day. You will be receiving medications for sedation during the procedure and will not be able to operate a motor vehicle safely until the effects of these medications wear off in a few hours. You may feel normal and safe to drive, but for your safety and the safety of those around you, it is best to have the assistance of another driver on the day of surgery. If you arrive at the surgery center without a driver, your surgery may be canceled. If you run into difficulties finding a friend, neighbor, or family member who can drive you on your surgery day, please call our surgery scheduler. There are often community resources available that could help you get the required transportation.

How early should I arrive at the surgery center and what should I bring and wear?

On cataract surgery day, plan to arrive at the surgery center at the time indicated by your surgery scheduler. This is usually one hour prior to your scheduled surgery time. This will provide the staff enough time for checking you in and getting you prepared for the surgery. Please bathe or shower in the evening or the morning of your surgery. Avoid wearing makeup. Do not bring jewelry or valuables if possible. Wear comfortable loose-fitting clothes. Bring your eye medications so the nurses can confirm that you have the correct bottles.

What happens before my cataract surgery?

When you arrive at the surgery center you will have some paperwork to fill out. Any co-pays or deductibles related to the surgery will also be collected. Please remember to bring a credit card or check book to the surgery center. Several things happen in the pre-operative area. This is where you will be prepared to have your surgery done. Your vital signs (blood pressure, blood sugar, heart rate, temperature) will be checked by a nurse. An IV line may be inserted to allow sedating medications to be administered before and during the procedure. You will also be given eye drops to help dilate your pupil to allow the surgeon a good view of the cataract. Other eye drops anesthetize the eye so you do not feel pain during the procedure. The nurses will have you lay on a bed where you can relax while you are waiting for your surgery appointment.

What can I expect during my cataract surgery?

In the operating room, you will first be positioned properly for surgery. This is lying comfortably on your back with a small cushion under your head and neck. The anesthesiologist or nurse anesthetist will begin administering the relaxing medicines through your IV to help you feel comfortable. The perfect amount of sedation will make you comfortable but not asleep. Patients who get too much sedation can become confused and wake up suddenly with dangerous movements that could cause problems with the procedure. Therefore, we want you relaxed but not completely asleep. If you have a high level of anxiety, please share this with the anesthesiologist. In this case extra medications can be given. A nurse will then cleanse the skin around the eye with an antiseptic (Povidone iodine). After this is done, you will be covered with a sterile drape which covers your face and upper body. This can be a little claustrophobic but the drape is very light and there is plenty of air underneath. If you need to cough or clear your throat after the surgery has started, let your surgeon know before doing so.

A small wire (speculum) is used to keep your eye open during the surgery. You don’t have to worry about blinking because the speculum will hold your eye open. It is best for you to keep both eyes open during the procedure. Once the speculum is placed, your primary responsibility is to look straight ahead at the bright microscope lights at all times. This places your eye in the perfect position for the surgeon. The best way to avoid pain is to keep both of your eyes open and relaxed.

During the surgery, you will see bright lights. Some patients describe a kaleidoscope with lots of vibrant and beautiful colors. You may feel a pressure sensation as the cataract is removed and the new lens implant is inserted into your eye. You should not feel any sharp pain. If you experience pain, let your surgeon know and more medication can be given to help relieve the pain. This medication may burn slightly when it is given, but your eye will be numb in a few seconds. You will hear the buzz of the instrument used to break up the cataract and you may feel cool water on your face. These are all normal aspects of the surgery. A typical cataract surgery takes between 10 and 20 minutes. It usually done before you know it.

What happens in recovery?

In the recovery area, the nursing staff will make sure you are stable before releasing you to your designated responsible party. You can have a drink and a little snack. They will also go over important information, including how to use your eye drops and what to do in the event of an emergency. Because you may still be sleepy, it is helpful to have another adult available to listen to the instructions.  We will do all we can to make your cataract surgery day a smooth and gentle experience.

 

What Happens After the Surgery?

After Cataract Surgery – What I can I expect?

You will most likely have three follow-up appointments after your cataract surgery. Your first follow-up appointment is the day after your surgery. We also recommend that you have a driver for this visit. This is not an absolute requirement but is probably safer for you because of possible blurred vision. At this appointment, your vision and eye pressure will be checked, and detailed instructions will be given for the eye drops you will use. We generally expect that the vision will be a little blurry, but this should improve in the first few days following surgery. It is not unusual to have an elevated eye pressure for the first few days after the surgery. If the eye pressure is elevated, you may need to use an additional eye drop to help lower the pressure.

The second follow-up appointment usually takes place about 1-2 weeks after the surgery. Usually, the schedule for your eye drops will be changed at this appointment and reviewed with you. Your eye may be dilated again at this appointment to allow a thorough examination of the retina.

The final follow-up appointment happens about 1 month after the cataract surgery. At this appointment, you will be checked for a prescription for eyeglasses. Most patients at this appointment will be instructed to stop using all of the surgery-related eye drops.

In general, your eye should feel better and have better vision each day after the surgery. If a day or two passes and you notice worsening symptoms of pain, redness, or blurred vision, contact your doctor immediately.

Which Dr. will I see for my post-operative care?

Your surgeon bears primary responsibility for making sure that your surgery has the best outcome. You will almost always see your surgeon on the day after the surgery. If you have a family optometrist, they can also see you for some of your post-operative care. You might choose to have follow-up visits with your optometrist if their office is more conveniently located, or you have a relationship with that doctor that would make your follow-up care more comfortable in their office. Shared post-operative care is known as co-management. If you choose to have your follow-up care with your optometrist, it is important that you know that you can return to your surgeon at any time or with any problems.

Are there any activity restrictions after surgery?

Modern cataract surgery has a very quick recovery and there are minimal activity restrictions.

  • Do not rub your eye for at least the first week after surgery. If you rubbed your eye you could push open the incision and cause an infection.
  • Avoid strenuous activities for one week after the surgery such as lifting heavy rocks in the garden, or high impact exercise. Normal household activities are generally safe.
  • There are no restrictions with bending or lifting most household objects.
  • You may bathe or shower the day after your surgery. Keep your eye closed while you shower and avoid getting water to directly into the eye.
  • You should not swim or bathe with your face under the water for one week after the procedure. You can be in a pool if you keep your head above water.

What vision changes should I expect?

After cataract surgery, most patients with healthy eyes end up having vision that would allow them to pass the DMV vision test without eyeglasses. Many patients are amazed by the brightness of colors and the clarity of their vision. Most people find that after cataract surgery they are able to perform their normal distance visual tasks without a significant need for glasses. Things we hear…

  • Doctor, I didn’t notice how dirty my house was! Now I can see the dirt on the floor and have to do a deep house cleaning.
  • Doctor, I looked in my closet and found out that my black dress is really navy blue. Colors are so bright now.
  • I can see the rocks and trees on the mountains miles away.

What about my glasses after the surgery?

Within a few days after your surgery, your vision will likely have improved to a point where you see better without glasses. If this is your first cataract surgery and you are nearsighted or farsighted, you probably will still need your glasses to sharpen the vision in your other eye. This can feel awkward because one eye needs glasses and the other one does not. A good way to cope with the change in your vision is to remove the lens from your glasses in front of the surgical eye. If you have difficulty doing this at home, most glasses stores such as LensCrafters can help you. Another option is to just keep your glasses on in which case the surgical eye will not see clearly, or remove the glasses completely in which case the nonsurgical eye cannot see clearly. If you have a cataract in the other eye, doing that surgery within a few weeks can start the recovery process faster and help give you equal vision.