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Demystifying Cataracts and
Cataract Surgery
Monica Khalil, MD
Summit Medical Group
June 28, 2017
What is a cataract?
A cataract is a clouding of the eye's lens,
which is normally clear.
Causes of cataracts
• ADVANCED AGE
• Ultraviolet radiation from sunlight and other sources
• Diabetes
• Hypertension
• Obesity
• Smoking
• Prolonged use of corticosteroid medications
• Previous eye injury or inflammation
• Previous eye surgery
• Significant alcohol consumption
• High myopia
• Family history
Cataract symptoms
• Hazy, cloudy vision
• Glare
• Seeing double (when you see two
images instead of one)
• Having trouble seeing well at night,
or needing more light when reading
• Seeing bright colors as faded or
yellow instead
Simulation of vision with
Cataracts
Examples of cataracts
Prevalence
• Nearly 25.7 million Americans over age
40 have cataracts. The number is
projected to increase to 45.6 million by
2050.
 http://forecasting.preventblindness.org/
• Cataract surgery is the most common
elective surgery among Medicare
beneficiaries in the United States.
 http://www.ncbi.nlm.nih.gov/pubmed/22978
526?dopt=Abstract
Benefits
 Multiple studies have demonstrated its
association with improved quality of life,
reduced risk of falling and fewer car crashes.
• http://www.ncbi.nlm.nih.gov/pubmed/22851116
• http://www.ncbi.nlm.nih.gov/pubmed/22273356
• One study found that those who had cataract
surgery had a 40 % lower long-term mortality
risk than those who did not.
 http://www.aaojournal.org/article/S0161-
64201300143-7/fulltext
How is a Cataract Detected?
• Visual Acuity Test: Determines how well
you can see at various distances.
• Dilated eye exam where drops are
placed in the eyes to dilate or widen the
pupils.
 This will allow for evaluation of the
cataracts, optic nerve, and retina.
Are you Ready to have Cataract Surgery?
Are you Ready to have Cataract Surgery?
• Are your cataracts impacting your daily or
occupational activities?
• Are your cataracts affecting your ability to
drive safely at night?
• Are your cataracts interfering with the outdoor
activities you enjoy?
• Can you manage your cataracts in other
ways?
What Happens if you DON’T
have cataract surgery?
• Your vision will gradually get worse over time.
• Cataracts never stay the same
• Cataracts never get better
• Cataract surgery is not an emergency
• Cataracts that become very dense can
become:
 Harder to remove
 Associated with an increased risk of complications
About Surgery
• Same day procedure
• Done under sterile conditions
• Topical anesthetic +/-IV sedation
• Can be done with or without assistance of
laser
• Typically takes 15-20 minutes
• Cataract is broken up into pieces, and
removed
• Intraocular lens is inserted
• Incision is sealed, typically without stitches
Cataract Surgery animation surgery
Traditional Cataract Surgery
• Incision is created with a small blade
• The sac which holds the cataract is
opened up manually with handheld
instruments.
• Phacoemulsification (ultrasound power)
is used to break the lens up into pieces.
• Those pieces are then removed using
ultrasound power.
• An artificial lens is placed into the eye
Laser assisted cataract surgery
• In laser cataract surgery, a femtosecond laser
replaces or assists use of a hand-held
surgical tool for the following steps in cataract
surgery:
 The corneal incision
 The anterior capsulotomy (opening the sac which
holds the cataract)
 Cataract fragmentation
• Removal of cataract pieces must still be done
using traditional ultrasound
• Implant must still be placed in the traditional
manner
Laser assisted cataract surgery
• Pros:
 Can cut down on the amount of phaco
energy used to remove the cataract since
the laser has already broken the lens into
pieces.
 Precision of placing incisions exactly as
planned pre-operatively
 This can also be used to correct
astigmatism
Laser assisted cataract surgery
• Cons:
 Not covered by insurance
 Longer procedure time
 Not everyone is a candidate
 Laser can produce gas bubbles
within the sac that holds the
cataract. In rare cases, these can
rupture the sac.
Intraocular lenses (IOLs)
• An intraocular lens is a tiny,
artificial lens for the eye. It
replaces the eye’s natural lens
that is removed during cataract
surgery.
• IOLs come in different powers,
just like glasses or contact
lenses.
IOLs
• Monofocal: It has one focusing distance
 It is set to focus on distance OR close up
OR intermediate range
 Pros:
• covered by insurance
• Most commonly selected IOL
• Unlikely to get halos aftewards
 Cons:
• Must wear glasses for the other distances
Monofocal IOL
IOL-monovision
• Monovision is where two different
monofocal IOLs are used in order to
minimize the need for glasses.
 The dominant eye is used to correct the
distance vision.
 The non-dominant eye is used to correct
the reading vision.
 This is frequently done with contact lenses
IOL-monovision
• Pros:
 Can minimize the need for glasses
 Usually covered by insurance unless
astigmatism needs to be corrected.
• Cons:
 Lack of binocular vision
 There are truly three different distances
(far, intermediate, near), but only two eyes!
IOLs
• Multifocal: Provides both distance and
near focus at the same time. Designed
so that the brain learns to select the
correct focus automatically.
• Pros: 75-80% of people who get these lenses
do not need to use glasses for anything
• Cons:
– Not covered by insurance
– Often associated with halos around lights at night.
– Not everyone is a candidate for this type of lens
Halos with multifocal IOLs
Multifocal IOL
IOLs
• Accommodative lens:
 Lens that moves inside of the eye to allow
focusing at different distances
• Pros: May allow for some degree of
independence from glasses.
• Cons:
– Not covered by insurance
– Sometimes, with time and scarring, the movement of
the lens becomes limited, and it no longer functions
as intended
Accommodative IOL
IOLs
• Toric IOL (for astigmatism reduction):
 Astigmatism is a refractive error caused by
an uneven curve in your cornea or lens.
• Astigmatism may be corrected by glasses or
contacts.
• It may be corrected by an astigmatism
correcting lens:
– Pros: Typically well tolerated.
– Cons:
» Not covered by insurance
» May move out of position in the early post
operative period and require re-positioning.
Astigmatism correction
Toric IOLs
IOLs
• Symfony:
 Lens option that corrects distance and
intermediate vision, but still mandates the
need for reading glasses.
 Pros:
• Less likely to induce halos than multifocal IOL
• Can also correct astigmatism
 Cons:
• Not covered by insurance
• May also induce halos
Symfony IOL
Which IOL is right for YOU?
• This will involve discussion with your
ophthalmologist. It depends largely on:
 Your pre-existing ocular/medical conditions
 The measurements of your eye
 Your feelings about glasses
 Financial considerations
What things may limit your visual recovery?
• Pre-existing medical conditions
 Diabetes that has already caused damage
to the retina
 Hypertension that has already caused
damage to the retina
What things may limit your visual recovery?
• Pre-existing ocular conditions
 Macular degeneration
 Glaucoma
 Other diseases or conditions which affect
the optic nerve and/or retinal health
Risks of Surgery
Overwhelmingly successful and well tolerated,
with a greater than 95% success rate.
Risks of Surgery
• Risks include:
• Infection:
 Rate in the US is 6 or 7 out of 10,000 people
 Can be devastating, and can result in loss of
vision and even loss of the eye itself.
 How we try to prevent it:
• Topical antibiotic drops before surgery, morning or
surgery, during surgery, and after surgery
• Cleansing of the eye prior to surgery
• Sterile operative technique, and careful post operative
handling
Risks of Surgery
• Bleeding inside of the eye (<1%)
• Swelling of the retina (1-5%)
• Risk of need for additional surgery:
 Retinal detachment (<1%)
 Retained pieces of cataract inside of the
eye (<1%)
 Wound leak (<1%)
Risks of Surgery
• Chronic inflammation (<1%)
• Development of glaucoma (<1%)
• Prescription error may not be
completely corrected with intraocular
lens.
 There is a higher likelihood of this in very
near-sighted or very far sighted individuals
Restrictions after Surgery
• No swimming for 2 weeks
• No eye makeup or powder makeup for
at least 1 week.
• No heavy lifting, bending, or straining
for 2 weeks.
• Remain in an area where you have
access to quality medical care for at
least a month after surgery
Drops
• You will need to use drops before and
after cataract surgery. These will
include:
 Antibiotic drops
 Anti-inflammatory drops
 Steroid eye drops
Drops after Surgery
Recovery
• The amount of time it takes for vision to
recover varies from one person to the next,
typically next day to a few days
• This also depends on how dense the cataract
is, and how much swelling resulted from
surgery
• Downtime from work is usually around 2
days, unless job is very demanding physically
A Few Thoughts
• Cataracts can never return. Ever.
• This is not considered a painful
procedure
 Most people take nothing for pain
afterwards
 Sometimes patients take Tylenol or Advil.
• You will not see the cataract surgery
happening to your eye. At most you will
see colors, lights and shadows.
Down the Road
• The intraocular lenses will last forever. It
would take major trauma to
dislocate/damage the lens
• Sometimes, people develop scar tissue
behind the lens, and complain of foggy
vision
 This is called “after cataract” or “secondary
cataract”
 This can be corrected with a laser
procedure in the office
QUESTIONS?

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Demystifying Cataracts and Cataract Surgery

  • 1. Demystifying Cataracts and Cataract Surgery Monica Khalil, MD Summit Medical Group June 28, 2017
  • 2. What is a cataract? A cataract is a clouding of the eye's lens, which is normally clear.
  • 3. Causes of cataracts • ADVANCED AGE • Ultraviolet radiation from sunlight and other sources • Diabetes • Hypertension • Obesity • Smoking • Prolonged use of corticosteroid medications • Previous eye injury or inflammation • Previous eye surgery • Significant alcohol consumption • High myopia • Family history
  • 4. Cataract symptoms • Hazy, cloudy vision • Glare • Seeing double (when you see two images instead of one) • Having trouble seeing well at night, or needing more light when reading • Seeing bright colors as faded or yellow instead
  • 5. Simulation of vision with Cataracts
  • 7. Prevalence • Nearly 25.7 million Americans over age 40 have cataracts. The number is projected to increase to 45.6 million by 2050.  http://forecasting.preventblindness.org/ • Cataract surgery is the most common elective surgery among Medicare beneficiaries in the United States.  http://www.ncbi.nlm.nih.gov/pubmed/22978 526?dopt=Abstract
  • 8. Benefits  Multiple studies have demonstrated its association with improved quality of life, reduced risk of falling and fewer car crashes. • http://www.ncbi.nlm.nih.gov/pubmed/22851116 • http://www.ncbi.nlm.nih.gov/pubmed/22273356 • One study found that those who had cataract surgery had a 40 % lower long-term mortality risk than those who did not.  http://www.aaojournal.org/article/S0161- 64201300143-7/fulltext
  • 9. How is a Cataract Detected? • Visual Acuity Test: Determines how well you can see at various distances. • Dilated eye exam where drops are placed in the eyes to dilate or widen the pupils.  This will allow for evaluation of the cataracts, optic nerve, and retina.
  • 10. Are you Ready to have Cataract Surgery?
  • 11. Are you Ready to have Cataract Surgery? • Are your cataracts impacting your daily or occupational activities? • Are your cataracts affecting your ability to drive safely at night? • Are your cataracts interfering with the outdoor activities you enjoy? • Can you manage your cataracts in other ways?
  • 12. What Happens if you DON’T have cataract surgery? • Your vision will gradually get worse over time. • Cataracts never stay the same • Cataracts never get better • Cataract surgery is not an emergency • Cataracts that become very dense can become:  Harder to remove  Associated with an increased risk of complications
  • 13. About Surgery • Same day procedure • Done under sterile conditions • Topical anesthetic +/-IV sedation • Can be done with or without assistance of laser • Typically takes 15-20 minutes • Cataract is broken up into pieces, and removed • Intraocular lens is inserted • Incision is sealed, typically without stitches
  • 14.
  • 16. Traditional Cataract Surgery • Incision is created with a small blade • The sac which holds the cataract is opened up manually with handheld instruments. • Phacoemulsification (ultrasound power) is used to break the lens up into pieces. • Those pieces are then removed using ultrasound power. • An artificial lens is placed into the eye
  • 17. Laser assisted cataract surgery • In laser cataract surgery, a femtosecond laser replaces or assists use of a hand-held surgical tool for the following steps in cataract surgery:  The corneal incision  The anterior capsulotomy (opening the sac which holds the cataract)  Cataract fragmentation • Removal of cataract pieces must still be done using traditional ultrasound • Implant must still be placed in the traditional manner
  • 18. Laser assisted cataract surgery • Pros:  Can cut down on the amount of phaco energy used to remove the cataract since the laser has already broken the lens into pieces.  Precision of placing incisions exactly as planned pre-operatively  This can also be used to correct astigmatism
  • 19. Laser assisted cataract surgery • Cons:  Not covered by insurance  Longer procedure time  Not everyone is a candidate  Laser can produce gas bubbles within the sac that holds the cataract. In rare cases, these can rupture the sac.
  • 20. Intraocular lenses (IOLs) • An intraocular lens is a tiny, artificial lens for the eye. It replaces the eye’s natural lens that is removed during cataract surgery. • IOLs come in different powers, just like glasses or contact lenses.
  • 21. IOLs • Monofocal: It has one focusing distance  It is set to focus on distance OR close up OR intermediate range  Pros: • covered by insurance • Most commonly selected IOL • Unlikely to get halos aftewards  Cons: • Must wear glasses for the other distances
  • 23. IOL-monovision • Monovision is where two different monofocal IOLs are used in order to minimize the need for glasses.  The dominant eye is used to correct the distance vision.  The non-dominant eye is used to correct the reading vision.  This is frequently done with contact lenses
  • 24. IOL-monovision • Pros:  Can minimize the need for glasses  Usually covered by insurance unless astigmatism needs to be corrected. • Cons:  Lack of binocular vision  There are truly three different distances (far, intermediate, near), but only two eyes!
  • 25. IOLs • Multifocal: Provides both distance and near focus at the same time. Designed so that the brain learns to select the correct focus automatically. • Pros: 75-80% of people who get these lenses do not need to use glasses for anything • Cons: – Not covered by insurance – Often associated with halos around lights at night. – Not everyone is a candidate for this type of lens
  • 28. IOLs • Accommodative lens:  Lens that moves inside of the eye to allow focusing at different distances • Pros: May allow for some degree of independence from glasses. • Cons: – Not covered by insurance – Sometimes, with time and scarring, the movement of the lens becomes limited, and it no longer functions as intended
  • 30. IOLs • Toric IOL (for astigmatism reduction):  Astigmatism is a refractive error caused by an uneven curve in your cornea or lens. • Astigmatism may be corrected by glasses or contacts. • It may be corrected by an astigmatism correcting lens: – Pros: Typically well tolerated. – Cons: » Not covered by insurance » May move out of position in the early post operative period and require re-positioning.
  • 33. IOLs • Symfony:  Lens option that corrects distance and intermediate vision, but still mandates the need for reading glasses.  Pros: • Less likely to induce halos than multifocal IOL • Can also correct astigmatism  Cons: • Not covered by insurance • May also induce halos
  • 35. Which IOL is right for YOU? • This will involve discussion with your ophthalmologist. It depends largely on:  Your pre-existing ocular/medical conditions  The measurements of your eye  Your feelings about glasses  Financial considerations
  • 36. What things may limit your visual recovery? • Pre-existing medical conditions  Diabetes that has already caused damage to the retina  Hypertension that has already caused damage to the retina
  • 37. What things may limit your visual recovery? • Pre-existing ocular conditions  Macular degeneration  Glaucoma  Other diseases or conditions which affect the optic nerve and/or retinal health
  • 38. Risks of Surgery Overwhelmingly successful and well tolerated, with a greater than 95% success rate.
  • 39. Risks of Surgery • Risks include: • Infection:  Rate in the US is 6 or 7 out of 10,000 people  Can be devastating, and can result in loss of vision and even loss of the eye itself.  How we try to prevent it: • Topical antibiotic drops before surgery, morning or surgery, during surgery, and after surgery • Cleansing of the eye prior to surgery • Sterile operative technique, and careful post operative handling
  • 40. Risks of Surgery • Bleeding inside of the eye (<1%) • Swelling of the retina (1-5%) • Risk of need for additional surgery:  Retinal detachment (<1%)  Retained pieces of cataract inside of the eye (<1%)  Wound leak (<1%)
  • 41. Risks of Surgery • Chronic inflammation (<1%) • Development of glaucoma (<1%) • Prescription error may not be completely corrected with intraocular lens.  There is a higher likelihood of this in very near-sighted or very far sighted individuals
  • 42. Restrictions after Surgery • No swimming for 2 weeks • No eye makeup or powder makeup for at least 1 week. • No heavy lifting, bending, or straining for 2 weeks. • Remain in an area where you have access to quality medical care for at least a month after surgery
  • 43. Drops • You will need to use drops before and after cataract surgery. These will include:  Antibiotic drops  Anti-inflammatory drops  Steroid eye drops
  • 45. Recovery • The amount of time it takes for vision to recover varies from one person to the next, typically next day to a few days • This also depends on how dense the cataract is, and how much swelling resulted from surgery • Downtime from work is usually around 2 days, unless job is very demanding physically
  • 46. A Few Thoughts • Cataracts can never return. Ever. • This is not considered a painful procedure  Most people take nothing for pain afterwards  Sometimes patients take Tylenol or Advil. • You will not see the cataract surgery happening to your eye. At most you will see colors, lights and shadows.
  • 47. Down the Road • The intraocular lenses will last forever. It would take major trauma to dislocate/damage the lens • Sometimes, people develop scar tissue behind the lens, and complain of foggy vision  This is called “after cataract” or “secondary cataract”  This can be corrected with a laser procedure in the office
  • 48.