Clinical Consultations: Cataract

Cataract

C. Stephen Foster, M.D.

CATARACT: a scum or a film or a growth on the eye: right? Wrong! A cataract is none of these. The word cataract simply means the development of an opacity in the crystalline lens inside the eye. We all have such a lens sitting just behind the pupil. And this lens does exactly the same job that the lens of a camera does: it focuses light rays into a clear picture onto the "film" (retina) in the back of the eye. If the crystalline lens becomes something other than perfectly clear (cataract), a clear view of the world will no longer be possible. And while there is no known effective medication to reverse cataract that has already developed, there are things that may be effective at stopping the development of cataract in the first place or at retarding the progression of cataract once it has begun. For example, protection of the eye from exposure to ultraviolet light may well provide some measure of protection from developing cataract. The use of antioxidants and of an aspirin once daily are other possible factors that might provide some protection against cataract development.

Once cataract does develop, however, and is distracting or disabling to the patient, the only effective known method of treatment is surgical removal of the cataract. Of all the surgeries known to man, this is without doubt the safest and the most effective surgery. And while this is extremely gratifying, it should also be realized that cataract surgery is not without potential risk of complication. The likelihood of a complication, which results in loss of vision, is quite small. The risk of developing a complication, which makes the outcome of the surgery less than perfect, is approximately 4%. This means then, that approximately 96% of patients who undergo cataract surgery are extremely pleased with the outcome, with improved vision and comfort in doing and seeing the things that they need to do and see.

Having difficulty doing and seeing the things that one needs to do and see, we believe is the primary indicator for proceeding to arrange for cataract surgery. The mere presence of a cataract is not in and of itself a sufficient reason to arrange for surgery. Many patients are able to see and do virtually everything that they need to see and do despite the presence of a small cataract. But once the cataract becomes annoying, or even progresses to the point of becoming disabling, it is appropriate for the patient to have a discussion with his or her ophthalmologist about proceeding with surgical removal of the cataract.

Surgical removal of cataract has undergone many developments over the past two decades. A common misconception is that "laser" is generally used to "take off" the cataract. This is virtually never the case, although we use lasers for many different indications in ophthalmology, and we use very sophisticated mechanical devices, which are sometimes confused with laser to perform cataract surgery. The surgery itself is generally done on an outpatient basis, and typically takes anywhere from 15 to 30 minutes to perform. A small incision is made for removal of the cataract and, generally, an artificial lens (lens implant) is placed in the eye after the cataract has been removed. The patient is typically asked to return for re-evaluation the following day to make certain that everything is perfect, and to begin with the post-operative medications (drops) that are typically prescribed following cataract surgery. The patient may see extremely well the moment the patch is removed (the day after surgery); in some instances, it may take several weeks for the patient to enjoy the full benefits of improved vision following the surgery. Restrictions in physical activity following surgery are generally minimal, and are limited to restrictions on activities which could dramatically raise the pressure in the eye (bending at the waist to lift something heavy), activities that could result in exertion of pressure on the outside of the eye (sleeping with the eye pressed against the hand or pillow), and extremely vigorous jarring activity (for example jogging). Medications are generally tapered and discontinued within a relatively short period after surgery, and glasses for seeing the sharpest that the eye can possibly see, both at distance and at near, are then prescribed, unless the lens implant that has been chosen by the patient is one of the so-called premium lenses developed by new technology and requiring out of pocket premium payment by the patient, since insurers do not cover the additional costs associated with the care of patients requesting these special lenses, which are intended to enable patients to see well both at distance and at near without glasses; approximately 85% of patients chosing such lenses achieve this goal of good vision without glasses.Only one eye is generally operated upon at a time, though, assuming that things go extremely well with the surgery, the other eye may appropriately have surgery relatively soon after the first eye has been successfully rehabilitated.