A cataract is a clouding of the eye’s natural lens. Usually, it is an aging change of the lens. Most people over the age of 50 begin to develop signs of cataract formation. If the lens becomes sufficiently cloudy, it can start to affect a person’s vision and interfere with regular daily activities such as driving, reading, or watching television.
Besides aging, there can be other causes of cataracts. Cataracts can result from certain disease such as diabetes, or from medications such as steroids. Cataracts can result from injuries to the eye, or from other types of eye surgeries. People can even be born with cataracts.
In addition to cloudiness, cataract formation can cause the lens of the eye to become physically harder. There are different types of cataracts classified by how the lens becomes cloudy. The most common type of cataract is called nuclear sclerosis, which means the central part of the lens has both hardened and become cloudy.
Cataract formation can cause a shift in the focus of the eye. Often, nuclear sclerosis results in a near-sighted shift (myopic shift) in the vision. If the quality of vison is still good, the shift can be compensated with a change of eyeglass prescription. Sometimes the near-sighted shift can temporarily improve the ability to read, a phenomenon that is called “second-sight.” Eventually the progression of the cataract will degrade the quality of vision such that even a change in glasses will not improve the sight.
When a cataract has reached the point of interfering with regular daily activities, cataract surgery can be performed in order to restore the vison.
Modern cataract surgery represents one of the most remarkable advances in medical science. It is an extremely safe and rapid procedure. In most cases, cataract surgery restores the vision to a level equal to or better than what it was before the cataract developed.
Cataract surgery is a same-day procedure in an outpatient surgery setting. It is performed in an operating room using an operating microscope. In most cases, the surgery can be completed in less than ten minutes with the patient experiencing virtually no discomfort. Patients usually resume regular activities, including driving, the next day.
The procedure involves dissolving the lens of the eye with ultrasound energy and replacing the natural lens with a plastic artificial intraocular lens implant (IOL). After the ultrasound dissolves the lens (phacoemulsification), the IOL is inserted into the capsule where it then unfolds. The IOL is held in place by the capsule itself, which seals around the IOL. The IOL now serves as the new lens of the eye and stays in the eye permanently.
Phacoemulsicaiton and IOL Placement
Intraocular Lens Implant (IOL)
As with any surgical procedure, there can be riskswith cataract surgery. Fortunately, these risks are rare and cataract surgery is one of the most successful operations performed.
Cataract surgery is a very individualized procedure, with many optionsavailable for how the eyes will focus after surgery. It is important that patients fully understand the options that are offered to them to make an informed decision on the procedure that is best suited for them.
Although most cataract surgeries are routine, some cataracts present a challenge with respect to their removal and/or the placement of an intraocular lens implant (IOL), necessitating a more specialized surgery.
Often these “complex” cataracts are associated with other disease of the eye. Some of the more common conditions that lead to complex cataract surgery include exfoliation glaucoma, eye injury, previous eye surgery, small pupils, high myopia (extreme near-sightedness), and dense or “mature” cataracts. In cases of complex cataracts, removal of the lens is often more challenging because of weakness in the lens capsules. Similarly, a weak capsule can preclude the placement of a conventional IOL.
There are many sophisticated techniques and devices available that can be utilized to perform complex cataract surgery, with the goals always being the complete removal of the cataract, the placement of a permanent intraocular lens implant, and improvement in vision. Because of the incorporation of these special techniques, complex cataract is often a longer procedure and has a longer recovery time. Nonetheless, because of the advances in cataract surgery technology, complex cataract surgery has become a highly successful procedure.
Cataract surgery sometimes incorporates a laser to perform parts of the procedure. The laser used is called a femto-second laser. Therefore, cataract surgery performed with this laser is often called FLACS (Femto-Second Laser Assisted Cataract Surgery).
FLACS is utilized to help open the lens capsule, partially dissolve the cataract, and correct astigmatism.
FLACS is indicated in cases where the cataract is very dense, or when a more precise opening of the capsule is needed. It is also useful to correct smaller amounts of astigmatism which are below the level where a premium astigmatism-correcting IOL can be used.
Prior to about the age of 40, the natural lens of the eye can change its shape in order to focus at all different ranges: distance, intermediate and near. This change in lens shape is called accommodation. After the age of 40, a person experiences presbyopia- the permanent age-associated loss of accommodation. This is the reason that most people require reading glasses after this age. Astigmatism refers to uneven focusing in the eye. All eyes have some degree of astigmatism, and it usually due to how the cornea is shaped. Astigmatism is normally corrected with eyeglasses or contact lenses.
A variety of IOLs are considered Premium IOLs because they can increase the range of focus and/or correct astigmatism.
Conventional IOLs provide a fixed range of focus. If a conventional IOL is selected to give good distance vison, the patient will require glasses for reading. If a conventional IOL allows for good near vison, the patient will require glasses to see at distance. Conventional IOLs do not correct astigmatism.
Premium Multifocal IOLs can allow patients to see all distances clearly after cataract surgery.
Toric IOLs are designed to correct astigmatism so the eye focuses sharply.
A Variety of Premium IOLs are both multifocal and astigmatism-correcting.
It is the design of the Premium IOL, and not the surgery itself, which allows a premium IOL to give more of a range of focus and/or correct astigmatism.
Types of Premium Intraocular Lens Implants
Of note, there is an increased cost associated with premium IOLs because of the specialized designs, and because of the additional testing and calculations required to determine the appropriate IOL to use. This cost is not covered by a patient’s insurance, which usually only covers only the cost of the surgical procedure itself.
Cataract and Glaucoma Surgery are often performed together as combined procedures. This is because there is significant overlap between cataracts and glaucoma.
The lens of the eye, because of its position and size, can have significant effects on the fluid flow in the eye, causing the eye pressure to increase. Some glaucoma conditions, such as angle closure glaucoma, are the result of an enlarging cataract. Other conditions, such as steroid use or diabetes, can cause both cataracts and glaucoma. Secondary glaucoma, such as exfoliation glaucoma, are associated with both complex glaucoma and cataracts, each of which more difficult to treat.
As a result, in these and other situations, it is often more efficient to combine the glaucoma and cataract surgeries. The combined surgery can simultaneously achieve both improved vision and a lowering of the eye pressure. In addition, it is more convenient for the patient to have both types of surgery completed at the same time.
In cases where the glaucoma is mild and there is a coexisting cataract, combining cataract surgery with a MIGS procedure can reduce or eliminate the number of glaucoma drops that need to be used. In more severe glaucoma cases, the cataract surgery can be combined with a glaucoma drainage implant.
In certain situations, it is best to perform sequential procedures. This often depends on the relative complexity and severity of the cataract or the glaucoma. Either the glaucoma surgery or the cataract surgery is performed first, followed by the second type of procedure. The time between the procedures can be anywhere from weeks to months. This is to allow the eye to recover from the first procedure.
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