In honor of Cataract Awareness Month, YourSightMatters.com interviewed cataract specialist Dr. John S. Berestka for helpful information including surgical options, common misconceptions and the latest research.
What is a cataract?
A cataract is a clouding of the lens of the eye due to changes in proteins that make up the lens. As we age, the lens thickens and hardens. Certain factors can cause cataracts to develop more quickly such as ultraviolet radiation (UV rays) smoking, diabetes, steroids and nutrition deficiency. Even the most healthy and active individuals will likely develop cataracts at some point in their lives.
What are signs and symptoms of cataracts?
Some of the signs and symptoms of cataracts are cloudy or blurred vision, sensitivity to glare, seeing halos around lights, colors appearing faded or yellowed, and double vision. Cataracts can make daily activities like reading, watching television, driving, distance vision and night vision more difficult. When cataracts are in advanced stages, you may see the telltale discolored pupil that can look gray or white. In the United States, most cases of cataracts do not progress to this level, but it is very common to see visible cataracts in third world countries.
Can cataracts be treated?
Cataracts are one of the most treatable eye diseases. This is good news because most people will start developing cataracts in their late 50s or early 60s. Most adults will not have their cataracts removed until they are in their late 60s or early 70s but it is generally just a matter of time. The thick, hardened lens can be surgically removed and replaced with a lens made out of plastic or silicone. In one surgical procedure and a short recovery time, most vision issues due to cataracts can be greatly improved.
What are some common myths and misconceptions about cataracts?
Until you have a better understanding of what a cataract is and how it is treated, there are many misconceptions about cataracts. One of the most humorous misconceptions, which is quite common, is that some people think that their doctor will take out their eyeball, remove the cataract and put the eye back in the socket. I assure you that this is not how cataract surgery is performed! Most cataract surgeries can be successfully completed with a tiny incision of 2.2-2.5 mm in length.
Another myth about the method of cataract removal is that some patients think the cataract will just come to the surface of their eye and the doctor will scrape it off. In fact, the cataract is not on top of your eye, although in advanced stages it may appear to be. It is located on the lens of the eye, behind the iris or colored part of the eye. A small incision is made in the eye to remove the cataract.
Many people might think that their cataracts may be too advanced and are inoperable. Even if you have hand motion vision (a situation where a patient can recognize a hand being waved, but he or she cannot count the fingers on the hand), cataract removal can provide you with excellent vision, but each case is unique and the vision outcome is often dependent on the overall health of the eye.
What are some common questions that patients have about cataract surgery?
Anytime that the eyes are involved, there are always a lot of questions. I actually think it is important that my patients ask as many questions as they need to so they can understand more about the procedure. Here are some of the most common questions I receive from patients and their answers:
What new research and products are available for cataracts?
Much of the new research into cataracts has to do with the technology that is emerging to help treat cataracts surgically. The ability to customize the type of lens that I insert into the eye provides patients with more options than in years past. We now have lenses that can correct both near and distance vision at the same time, as well as lenses that correct astigmatism.
The entire process of removing a cataract is very sophisticated now. The deteriorated lens is broken up into tiny fragments using a method called phacoemulsification and removed from the eye, creating space for a new, artificial lens called an intraocular lens (IOL).
An IOL is generally made out of plastic, and it is folded up like a burrito. Using the incision that I used to remove the old lens, I insert the folded IOL into the eye and it opens up in that space. Ten years ago, there were few options for IOLs and we only had single distance lenses. Now, there are multifocal IOLs, which act like no-line bifocal glasses and Toric IOLs that can correct multiple issues simultaneously. One of the most exciting advancements in cataract surgery is that cataract surgery can be performed in conjunction with glaucoma surgery. What used to be two separate procedures now can be combined into one surgery in two parts. It is not uncommon, as people age, to develop both cataracts and glaucoma. Today, there are devices like the iStent which can help lower eye pressure for glaucoma patients. This device carries less risk and can hopefully prevent the need for trabeculectomy or other more invasive surgeries. I prefer doing the cataract surgery first and then inserting the iStent at the end of the procedure. The iStent has been shown to be helpful at blunting the pressure spikes that are common to glaucoma patients after cataract surgery.
There are also devices that are currently in clinical trials which will likely enhance and improve cataract surgery and glaucoma surgery outcomes. There is a newer generation iStent that is easier to place, and other stenting devices called CyPass and Hydrus. There is also another type of device called the XEN Implant. All of these devices are intended to help drain fluid from the eye.
What can you tell me about laser cataract surgery and how it differs from the traditional surgery option?
I use the laser to remove some cataracts but certainly not all cataracts. The laser is an impressive tool that makes precise cuts, and it is especially useful for a patient who has significant astigmatism or when I am inserting a premium intraocular lens. For patients with severe astigmatism, the laser can help reduce the need for glasses.
I reserve laser cataract surgery for patients with astigmatism or presbyopia to help reduce the need for glasses. When it is necessary, the laser offers the precision that the human hand cannot match. However, with small incision cataract surgery, incisions are so small that it is not necessary to use a laser in most cases.
Who should consider getting cataract surgery?
As we age, most of us will develop a cataract in one or both eyes. When I tell my patients that they are developing a cataract, it often surprises them. This is because cataracts tend to develop very gradually. I explain to my patients that, over time, they will notice that they struggle with distance vision and night vision, as well as the presence of halos and glare.
Cataracts are not a problem until they begin infringing on our daily lives and affect our ability to read a book, drive a car, or see clearly at night. When my patients feel like cataracts are affecting their daily lives, I encourage them to consider surgery. When cataracts have gotten to the point where a patient is not legal to drive, I try to convince them to get cataract surgery.
What are the benefits of cataract surgery?
The best benefit of cataract surgery is that it can restore your vision. It is one of the best and most accurate surgeries performed worldwide, and it gets you back doing the things you want to do. When you cannot see clearly, your activities and hobbies are restricted. Cataract surgery gives you your life back. It can also prevent injury and actually keep you safe. The Journal of the American Medical Association released a study in 2012 detailing the reduced risk of hip fracture in seniors after cataract surgery. In essence, you are safer on your feet and safer behind the wheel when you see better.
What are the risks with cataract surgery?
There are few risks associated with cataract surgery, but all surgical procedures have some risk. The most severe risks are infection (1 in 1000), retinal tear (1 in about 250), and bleeding (extremely rare). There are several common occurrences following cataract surgery that are unpleasant but less of a risk. These can include eye floaters, seeing flashing lights for a week or two, and feelings of scratchiness.
Some patients may develop a “secondary cataract” later on. It is not actually a cataract but the scarring of the capsule that holds the lens. All cataracts are contained in a capsule of sorts, and when the cataract is removed, the capsule stays intact except for an incision where the cataract was removed. A secondary cataract forms when the capsule that contained the cataract tries to grow back and scar tissue begins to obstruct vision. If a patient has similar complaints of blurred vision, I can perform a laser procedure called a YAG capsulotomy to restore clear vision.
The final risk is more of an inconvenience than anything else. There is sometimes a small amount of general discomfort after cataract surgery, but Tylenol is usually sufficient to ease any mild pain for the first night after surgery.
Will I need reading glasses after cataract surgery?
Every eye is different, which makes each patient a unique case. Depending on the IOL lens a patient will choose, some may experience a period of time after surgery when they do not require corrective lenses, but someday they will probably need to wear glasses again. Our bodies change, and our eyes change. Certain patients may only need glasses for distance vision and driving, and others may only need glasses for reading. I do not promise my patients specific results after surgery because nothing is permanent. Contrary to what some people may think, cataract surgeons do not replace one type of intraocular lens with another type of lens years later. It is possible but not routinely done. If your eyesight changes and you need more than what your IOL can provide, you will need to supplement with glasses.
If I have astigmatism, what are my options with cataract surgery?
Astigmatism is a common eye condition characterized by an irregularly shaped cornea which results in blurred vision. There are several options for patients who have both cataracts and astigmatism. For patients with milder astigmatism, I may use a procedure called limbal relaxing incisions (LRI). LRI involves mapping the cornea and making small, partial thickness incisions in the peripheral cornea at certain depths and diameters which allows the cornea to be more rounded when it heals. This, in turn, reduces astigmatism and sharpens the vision. There are two ways of performing the LRI. It can be done by hand with a diamond blade or with a laser.
The femtosecond laser is effective in correcting the shape of the cornea in patients with lower level astigmatism. The advantage of the femtosecond laser is in its precision. The laser can make cuts of very specific depths and lengths that cannot be replicated by the human hand. It works by generating ultrashort pulses, using low energy which prevents tissue damage.
Another treatment for patients with more pronounced astigmatism is a Toric intraocular lens (IOL), which helps correct distortions due to the shape of the cornea. This is probably my favorite technology available. I see such positive effects of Toric IOLs in patients who previously had limited vision and had to wear fairly thick glasses or saw poorly out of their soft contact lenses.
What would you say to patients who are considering cataract surgery?
I always tell my patients about the benefits and risks of surgery, and I remind them that removing a cataract is their decision.
The most important thing that I want my patients to keep in mind is to have realistic expectations. I cannot promise life-changing results, but almost everyone experiences improved vision after cataract surgery.
Many patients have an erroneous assumption that cataract surgery will eliminate their need for glasses. I make no promises to my patients because our eyes will continue to change as we get older. The corneal curvature can change, or the patient may develop another eye condition like glaucoma or macular degeneration. Any of these factors could influence their need for eyeglasses. I would tell a patient that cataract surgery can greatly reduce the need for glasses, but no one should expect that cataract surgery is a fix-all that will eliminate the need for glasses either immediately after surgery or years down the road.
John S. Berestka, M.D., is a comprehensive ophthalmologist specializing in corneal, glaucoma and refractive surgery. He received his Doctorate of Medicine degree from Johns Hopkins University, and his residency at Harvard Medical School's Massachusetts Eye and Ear Infirmary. The most rewarding part of his career is “restoring vision to patients with complex eye problems”.