Understand what is involved in the process of having cataracts addressed. The latest intraocular lens options will also be discussed.

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

6. Examples of 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

15. Cataract Surgery animation surgery

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

22. Monofocal IOL

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

26. Halos with multifocal IOLs

27. Multifocal IOL

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

29. Accommodative IOL

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.

31. Astigmatism correction

32. Toric IOLs

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

34. Symfony IOL

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

44. Drops after Surgery

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

49. QUESTIONS?