Cataract surgery is an amazing procedure that can prevent one of the most common causes of blindness and vision impairment regardless of the patient’s age. It often leaves patients with better vision than they had even before the cataracts developed. Patients often report that colors seem significantly brighter, images sharper, and experience less intense glare from the sun and headlights. They also report a greater ease overall with focusing.
These benefits make a significant difference in the quality of life of many patients by making reading, working, driving, sports and other activities easier. They also give older patients more independence and reduce the risk of dangerous accidents like falls. This is especially true for those suffering from other disabilities or symptoms of aging like deafness or dementia.
Refractive Cataract Surgery
Refractive cataract surgery is a new advanced technique in cataract surgery performed to specifically reduce the need for glasses. It requires the removal of the cloudy or dysfunctional natural lens and replacement with an artificial lens. This replacement lens is called an intraocular lens, or IOL. IOLs can correct nearsightedness, farsightedness, presbyopia (the need for reading glasses), and astigmatism.
Recent dramatic advances in technology have improved the results of cataract surgery. Many patients elect to have refractive cataract surgery performed to reduce dependence on glasses or contact lenses in addition to removal of the cataract. Of course, even without refractive cataract surgery, patients will typically achieve excellent vision, but will need glasses or lenses to achieve their best possible vision. Often, they still experience an improvement in vision, even from before when the cataracts developed. In the past, implant lenses were designed to provide clearer vision than the cloudy cataract lens that was removed, but newer implant lenses, in conjunction with the other elements of refractive cataract surgery, have now allowed patients to have a better chance to reduce or eliminate dependence on glasses.
Cataract surgery is considered a very successful, common procedure, with a low complication rate of only about two percent. About 1.5 million cataract surgeries are performed each year in the United States. Dr. Cornell perform cataract surgery using the most modern techniques, such as phacoemulsification (ultrasound to break up the cataract). Phacoemulsification involves making a small incision in the peripheral cornea so that a foldable intraocular lens implant can be inserted, which minimizes the incision. Each patient is required to have a comprehensive ophthalmologic examination and consultation to determine if they need cataract surgery, and if so, which approach is best for them.
Your Experience
Cataract surgery can typically be performed in 15 to 20 minutes at the Specialty Surgical Center located at 9001 Wilshire Blvd. in Beverly Hills. The surgery is an outpatient procedure, but the patient should anticipate staying in the surgery center for about three hours from check-in to departure. Cataract surgery is usually performed using a topical anesthetic (applied in the form of eye drops) and light intravenous sedation, and most patients experience minimal discomfort and have relatively minimal restrictions after cataract surgery.
For more information regarding our surgical center and more specific instructions regarding the cataract surgery process, please click here.
Our doctors have been performing refractive cataract surgery for over fifteen years as part of a commitment to improving the optical results for our patients after cataract surgery. We perform an examination and an evaluation of medical history for each patient, then discuss what the patient hopes to get out of the surgery in order to achieve the best possible results. After surgery, some patients may not have achieved the refractive results that they expected. If their targeted vision is not as expected, patients typically could still see very well with glasses, but may have the additional options of PRK, LASIK or sometimes a lens exchange.
Your Options
The best option will depend on each individual’s particular eyes and visual goals.
- Femtosecond laser-assisted cataract surgery
- Crystalens® IOL
- Trulign® IOL
- Multifocal lens IOL
- Toric IOL
- Tecnis Symfony® IOL
How to Decide Which Surgical Options Are Right For You
The first level of decision-making when choosing premium intraocular implant lenses (IOL) is how much interest there is in being less dependent on glasses to see well after cataract surgery. If one wants to continue to wear glasses after cataract surgery at all distances, then they may choose to have a standard IOL. If, however, the motivation is to be less dependent on glasses and have better vision without glasses or contact lenses, then one might consider a premium implant lens. There are additional fees over and above what insurance will pay if a premium implant lens is chosen.
In order to best consider IOL options, one should understand that there are three distances in the world from a vision point of view: -Distance vision generally includes everything from about 4 feet to infinity. This includes driving vision, movies, television viewing, seeing people across the room, road signs, and general walking around vision. For most people desiring less dependence on glasses, this is the minimum target and most important. -Intermediate vision is an increasingly important distance, and generally extends from about 4 feet in to about 14 inches. This includes most computer work, car dashboard, card playing, grocery store shelves, eating food, and interpersonal visual tasks. -Near vision is up close vision. This includes reading, and may include specific tasks like sewing, hobbies, or other occupational tasks.
The next thing to understand is the specific circumstances of one’s own eyes, and this will be discussed in detail at the time of the cataract consultation.
Astigmatism: Astigmatism will be a very important part of this conversation. Astigmatism is present when the eye is not round, but instead shaped more like a football or the back of a spoon rather than like a round ball. Astigmatism creates a need for glasses at all distances, so if the goal is to have good vision at distance without glasses, even for the distance target, the level of astigmatism will need to be decreased. As part of the cataract consultation, the level of astigmatism will be measured and discussed, and the options to correct it will be explained. If there are greater amounts of astigmatism, then a toric implant lens should be considered. This is a type of implant lens that is lined up with the patient’s pre-existing astigmatism and is quite good at significantly improving astigmatism. If there are smaller amounts of astigmatism, then this may be able to be improved by choosing a femtosecond laser assist during cataract surgery. One of the benefits of using the laser to assist with the surgery is that we can use the laser to create incisions in the cornea in order to reduce the level of astigmatism. There are additional fees for toric implant lenses and the femtosecond laser, but these options can allow for a better chance to have better vision without glasses after cataract surgery.
Current Optical Status: During the cataract consultation, we will also be reviewing the patient’s optical status. Which is the dominant eye? Is the patient nearsighted, farsighted or neither? Does the patient need glasses (or contact lenses) for distance, reading, computer or all three? Does the patient wear contact lenses, and if so, for monovision, multifocal or distance only? This part of the consultation will help the patient consider which distances are most important as we review the surgical options.
Presbyopia: Presbyopia is the normal age-related condition that starts in the 40s and leads to the need for a different optical correction for distance, intermediate and near vision. For people without cataract who are neither nearsighted nor farsighted, this may just require reading glasses. Others wear progressive glasses, separate reading, distance, and computer glasses, or a variety of contact lens options. After cataract surgery, the various intraocular implant lenses and laser technology options can potentially reduce dependence on glasses at all three distances: distance, intermediate and near.
Medical Eye Issues: At cataract consultation, we will also a complete a very thorough examination of the health of both eyes. If there are any medical conditions present, these conditions may have an impact on the implant lens options available, and these issues will be explained in full depth at the time of the consultation. Important ocular medical conditions include macular degeneration, diabetic retinopathy, epiretinal membranes, retinal problems, pseudoexfoliation, corneal problems, previous refractive surgery with LASIK, PRK or radial keratotomy (RK) and other conditions.
IOL (intraocular implant lens) Options
At this point, one may start to consider the various IOL options. As discussed, there are many individual variables that make the best choice for one’s dependence on visual needs, visual goals, pre-existing astigmatism and ocular health. As a result, the following IOL options are discussed generally and individual options will be reviewed at the time of the cataract consultation with each patient.
Standard IOL: These implant lenses are fully covered by medical insurance, but do not address astigmatism or presbyopia. They are safe and optically excellent, but generally patients will likely need glasses for all three distances (distance, intermediate and near) to get the best vision.
Standard Toric IOL: These implant lenses have an astigmatism correction built into the lens, so when placed in the eye and aligned with the patient’s pre-existing astigmatism, can allow for quite good vision at one distance (distance, intermediate or near). It is more than likely that glasses may be required for better vision at other distances. There are additional fees for toric lenses.
Crystalens and Trulign IOL: These implant lenses are the only FDA approved accommodating intraocular implant lenses. The Trulign is the toric version (fixes larger amounts of astigmatism) of the Crystalens; they both work the same way. These lenses are able to move a little bit inside the eye, allowing patients to have a bigger range of vision without glasses compared to standard or standard toric lenses. They are not, however, good enough to go all the way from perfect distance to perfect reading vision, but are generally quite good at giving two out of three distances without glasses. As a result, after both eyes are done, we are generally able to get quite good distance and intermediate vision, and 50% of patients do not need reading glasses. These lenses are also less prone than most standard lenses to optical aberrations including edge glare and night time optical aberrations. There are additional fees for the Trulign and Crystalens, and those additional fees include a LASIK or PRK touch up within the first year if the target of good distance vision is not achieved. It is impossible to achieve excellent distance vision in all cases because of the biology of human variation, so missing the intended target is possible with all types of implant lenses, and can be fixed with glasses, contact lenses, or laser vision correction with LASIK or PRK.
Vivity and Vivity Toric IOL: These are FDA approved extended depth of focus implant lenses. These lenses, much like the Trulign and Crystalens, can reduce astigmatism and increase the range of vision without glasses, but are also not good enough to go all the way from perfect distance to perfect reading. In comparison to the Trulign and Crystalens, because the optics of the Vivity are not dependent upon movement of the lens (which is less predictable), the range of vision is more predictable, and only 35% of patients still need reading glasses. There are additional fees for the Vivity lenses, and that additional fee also includes a LASIK or PRK touch up if the distance target is not achieved acceptably.
Symfony and Symfony Toric IOL: These are also FDA approved extended depth of focus implant lenses. These lenses, much like the Vivity lenses, can reduce astigmatism and increase the range of vision without glasses, but are also not good enough to go all the way from perfect distance to perfect reading. In comparison to the Vivity the range of vision is a bit more predictable, and only 25% of patients still need reading glasses. The tradeoff for less dependence on reading glasses with the Symfony lens is that 15% of patients have a spider web visual effect around lights at night. There are additional fees for the Symfony lenses, and that additional fee also includes a LASIK or PRK touch up if the distance target is not achieved acceptably.
PanOptix and Synergy - Multifocal IOL: These lenses actually have multiple lens powers built into the lens, so most patients (over 90%) do not need intermediate or reading glasses. These are not good lenses if you have other medical ocular problems such as macular degeneration, or other retinal problems or certain corneal problems. The other issue with these lenses is that 30% of people have halos or rings around lights at night. These lenses also have an additional fee that also includes a LASIK or PRK touch up if the distance target is not acceptably achieved.
Femtosecond Laser Option
Almost all patients whose pupils dilate normally are candidates to choose a femtosecond laser assist to their cataract surgery. With this option, three of the steps of cataract surgery are performed using a femtosecond laser before starting the actual surgery. The laser is used to break up the cataract before going into the operating room, allowing the cataract to be removed more gently with less manipulation of the tissues. The laser is also used to create the circular opening in the capsule (the bag around the cataract), and the laser makes a perfectly sized, perfectly centered, and perfectly round opening, which may allow the IOL implant lens to sit in a more predictable position. Lastly, the laser allows for the creation of very accurate and precise laser incisions in the cornea to reduce pre-existing astigmatism and potentially allow for better vision without glasses. There is an additional fee for the femtosecond laser.
As you can see, the important decisions about which IOL is chosen and which surgical option is best are highly personal decisions that will be discussed at length during the cataract consultation. There are no perfect options for everyone, but there are very good options depending on your optical goals.
Risks and Complications of Cataract Surgery
The following outlines the average risks and complications of cataract surgery. Please understand that many patients have additional risks based on the biology of the eyes and we will outline your specific risks and complications during the cataract consultation.
The overall complications of cataract surgery come out to two percent, although each individual may have specific complications that are higher than the average person. Be sure to pay close attention during the consultation to determine if there are additional risks over and above the average patient’s risks.
There is a one percent risk of a retinal detachment that is fixable by a retina specialist with additional surgery over 94% of the time. Swelling of retina occurs one percent of the time, and this can often be fixed using eye drops. However, if the swelling remains, there are additional treatments the retina specialist can do to help the swelling.
The artificial lenses we use are generally safe and stable inside the eye. However, less than one percent of the time we may have to go back and re-operate to re-position, exchange or replace the lens. We complete a series of calculations to get the power of the lens optimized in order to accomplish each individual’s optical goals. Most patients want at least good distance vision without glasses. We can never guarantee perfect vision, and some patients may possibly end up more nearsighted, farsighted or with more astigmatism after surgery. This can be fixed with glasses, contact lenses, an IOL exchange, LASIK or PRK surgery. LASIK allows us to fine-tune the optics of the eye without having to go back inside the eye. All artificial lenses, some more than others, carry the possibility of unwanted optical side-effects. These include: edge-glare with a flicker/flutter or a dark shadow on the outside edge of your vision. This is very common in the first few hours or days after surgery. The unwanted optical side-effects typically go away in almost everyone, however, in the occasional person when the symptoms do not resolve, additional procedures can be done to reduce or eliminate those symptoms.
During surgery, the cataract may not have enough support and can literally fall into the back of the eye. If this does occur, we must have a retina specialist come in within a week or two to do a second surgery to finish removing the lens. In our practice, this occurs less than 1/1,000 surgeries. The cornea can become cloudy or swollen after surgery, and this typically clears up within a week or two. Rarely the cornea stays cloudy in which case a corneal transplant may be required. This occurs less than 1/2,000 surgeries in our practice. The rarest but most serious complications include infection, inflammation or bleeding inside the eyes which all occur less than 1/3,500 surgeries, but can lead to a loss in vision. Cosmetically, the upper eyelid can droop a little, which occurs less than one percent of the time. If the eyelids droop enough to become problematic, we can go back 3-4 months down the road to lift them back up.
These are the average risks and complications of cataract surgery. Please understand that many patients have additional risks based on the biology of the eyes and these specific risks and complications will be outlined thoroughly during the cataract consultation. We offer our cataract surgery solutions for patients from Beverly Hills, Los Angeles, West Hollywood, Culver City, Santa Monica and close-by locations.
