I had dinner last night with one of LA’s top cataract surgeons, Dr. Barry Seibel.  He is one of the few surgeons on the Westside of LA who actually did write an influential textbook on cataract surgery, Phacodynamics (I have a dog-eared copy in my office).  For those of you who don’t know it already, almost every cataract and refractive surgeon on the Westside says he or she has taught (insert ridiculously large number here) other surgeons or was one of the first to do this or that surgery…yadda, yadda, yadda (oh boy am I gonna get flamed by some slick Westside surgeons for that comment).  The difference is that Dr. Seibel actually did write a real textbook that has been read (or should have been read) by most ophthalmology residents since the book was originally published.  This was not some sort of ghostwritten vanity press book produced as a marketing shill.  It’s the real thing and a continual source of reference for me and other surgeons.

If you live on the Westside and have cataracts I’d recommend scheduling a consultation with him (BTW, I have no financial interest or arrangement with Dr. Seibel and suppose I should be asking you to come and see me, but I know that if you live on the Westside you’re not going to schlep out to the San Gabriel Valley anyway - so just save the gas, stay off the freeway, and go see Dr. Seibel).

In any case, Dr. Seibel and I had a wonderful conversation which had nothing to do with phacodynamics but made me realize that most people have no idea about the complexity involved with physically removing a cataract.  In order to give you an idea of the dynamic process involved in emulsifying and removing a cataract try the following mental experiment (don’t really do this as it’s just a metaphor):

Imagine you have a plastic trash bag (the cheap thin ones from a discount store, not the Heavy Duty Hefty bag) - this is going to be our imaginary capsular bag.  In the eye this bag is only a few millionths of a meter thick.  Now fill it up with oatmeal - this is our model cataract.  Let it sit overnight so that the oatmeal gets real hard and sticky.  Now, in order to remove the cataract we are going to use an instrument that both pours fluid into the bag and vacuums the oatmeal out of the bag.  For imaginary purposes we’ll use a vacuum cleaner with the hose attachment and ducttape a garden hose to it so that both nozzles face the same direction.

OK, turn on the vacuum cleaner and water hose.  Stick it in the bag full of crusty oatmeal - uh, this is actually a bit messier than cataract surgery.  Can you see the water hose breaking up the oatmeal and he vacuum sucking it out?  Good.  Not too difficult, right?

Oh, but wait, there’s oatmeal stuck to the sides of the plastic bag.  You’ve got to get that out too.  In real cataract surgery if you leave part of the cataract stuck to the capsular bag your patient won’t see any better after surgery than they did before - in fact, they might be worse off with inflammation, poorer vision, and a painful eye.

Anyone who has ever used the vacuum cleaner attachments knows that if you get them anywhere near loose fabric, the vacuum will suck the fabric into the nozzle.  If you get your nozzle too close to the side of the plastic bag, the bag will get sucked into the nozzle and tear.  Now you’ve got a big hole through which all of the oatmeal has just spilled out onto your floor.  In cataract surgery we call this a “capsular rent” and try to avoid it at all costs because such a tear will allow the remaining cataract to spill into the back of the eye resulting in floaters, inflammation, and increased risk of infection or retinal detachment.

Right about now you might be thinking, “That sounds like a bad idea, why would anyone try to do something like use a water hose and vacuum to take a cataract out?”  Well, it does sound risky and early pioneers of phacoemulsification such as the late Dr. Charles Kelman (a true renaissance man) were severly chastized by their fellow surgeons for taking “unnecessary risks.”  However, the method of cataract surgery used at the time was called “delivering” the cataract (as in delivering a baby).  It required a large incision, took weeks to months for the eye to heal, and had it’s own set of surgical risks.  Fortunately, the techniques and technology of phacoemulsification have significantly evolved over the last 40 years.

A major reason we can now remove cataracts safely using a microscopic water hose and vacuum is that the fluidics of phacoemulsification have been studied and taught by doctors such as Barry Seibel.  Tools and techniques have been developed that allow cataract surgeons to get very close to the capsular bag (close enough to remove individual microscopic strands of cataract) without tearing the bag.

In short, modern cataract surgery is nothing short of miraculous.  Even after performing over 2,000 cataract surgeries, I often find myself in awe at what can be done thanks to the imagination, efforts, and risks of the many pioneer surgeons (and their patients) that preceeded me.  We all owe them a debt of gratitude.

Glaucoma is a progressive loss of the “nerve fiber layer” of the eye.  This layer is essentially a series of wires that transmit the signal from the eye to the brain.  Just as a frayed cable from your DVD to your TV would result in a poor quality picture, loss of the nerve fiber layer results in poor vision.   The standard treatment for glaucoma is to lower the intraocular pressure in the eye with drops, laser or surgery.  Unfortunately, all drops have local side effects, laser does not work for everyone, and surgical treatments such as trabeculectomy have significant risks assoiciated with them.  For more on glaucoma, visit my practice website and search “glaucoma.”

One of the risks of cataract surgery is a temporary increase in intraocular pressure (IOP).  Because of this, in the past when someone had an elevated IOP and needed cataract surgery it was often done along with trabeculectomy (a glaucoma surgery).  The problem with this approach was that trabeculectomy did not work that well when done at the same time as cataract surgery and vision could actually be limited or decreased for a time because of the glaucoma surgery - hardly what was intended or desired by the patient or surgeon.

So, with the blessing of the glucoma specialist, some cataract surgeons were removing the cataract without trabeculectomy even in patients with elevated IOP.  If the IOP increased then the patient was taken back to the operating room for glaucoma surgery.  If the IOP was OK, then vision generally improved and the patient and surgeon avoided the hassle of glaucoma surgery.

But, a trend was noted: fewer patients than expected needed the trabeculectomy.  Could it be that cataract surgery alone lowered the IOP?

Dr. Richard Lindstrom wanted to know so he reviewed the charts of 712 patients with ocular hypertension (high pressures but no damage to the nerve fiber layer), glaucoma, or suspected glaucoma who had been treated with cataract surgery alone (no trabeculectomy at the time of cataract surgery).  The results of his study were impressive.  The higher the IOP the greater the effect of cataract surgery.  IOP was lowered as much as 30% after cataract surgery!

These results are nothing short of amazing and could change the way we think about current methods of treating glaucoma.  I just about fall out of my chair when a glaucoma drop lowers the IOP by 30% so it appears that cataract surgery is about as successful in treating IOP as the best of the prescription medications.

Now, before you go out and ask your eye doctor to remove your cataract to treat your glaucoma you should know that there is one huge barrier that will keep him or her from obliging you: Medicare and most insurances do not cover cataract surgery when the reason for surgery is anything other than “visually significant cataract affecting the activities of daily living.”  And, although logic dictates that untreated glaucoma would eventually result in such a loss of vision, Medicare and most insurances don’t really care about the future (if they did they would cover cataract surgery in patients without cataracts simply because we know that “someday” the cataract would cause a loss of vision).

Oh, and don’t ask your surgeon to “fudge” the reason as a cataract.  That’s fraud and I’m sure you wouldn’t really ask your surgeon to put his or her license on the line (as well as heavy fines, possible jail time, etc.) so that you can get coverage from your insurance.

So, what can be done?  The same thing that must be done whenever a change in Medicare is necessary: write to your senators and congressmen and ask them to pressure the Centers for Medicare and Medicaid Services (CMS) to cover cataract surgery as a treatement for ocular hypertension, glaucoma, and suspected glaucoma.  Once Medicare allows this other insurances generally follow suit.

Until then, if you have glaucoma and can convince your surgeon to treat it with removal of your lens (technically called a clear lens extraction, or refractive lens exchange) expect this to be treated as “refractive” surgery and have a price tag of anywhere between $3,300 and $6,000 per eye depending on the center, surgeon, and lens used.

There has been a movement toward sutureless cataract surgery over the last ten years.  The main reasons for this movement are that sutures take time to place, can be uncomfortable (during and after surgery), may induce astigmatism, sometimes have to be removed after surgery, can cause an unsightly bleed on the surface of the eye, and are costly.  These reasons have led to surgeons even advertising their surgery as “no stitch.”  Although sexy, this may not actually be in every patient’s best interest.

There is some evidence that placing a suture may provide additional protection from infection.  Since infection is one of the few things that can result in blindness after cataract surgery, this is certainly worth pursuing.  However, the risk of infection without a suture is still small (about 1 in 500).  With a suture this risk decreases to about 1 in 1000.  Thus, in order to prevent one infection 1,000 sutures would have to be placed.  Considering the costs of the suture, OR time, additional post-op time removing sutures, etc. the additional amount that would have to be spent to avoid this one infection is somewhere in the $20,000-50,000 range.  Granted, it is difficult to place a value on the loss of vision (I would place this value far above $50,000).  However, the economic realities being what they are, insurances, the government, and surgery centers are all evaluating these costs very carefully.

Enter the lowly mussel.  It’s not just for steaming anymore.  Dr. Roger Narayan and colleagues at North Carolina State University have developed a method to use a naturally made “glue” produced by a mussel to seal incisions such as those made during cataract surgery.  The trick with using any adhesive with eye surgery is to limit the amount used and to have a smooth surface.

Enter ink jet technology.  The same technology used to print your kids photos can be used to finely control the application of a liquid such as the glue derived from mussels.  From a cataract surgeon’s perspective this is very exciting technology.  Potentially, I could simply spray a bit of mussel glue on the corneal incision at the end of every cataract surgery and achieve all of the following: lower infection risk, fast application, no induced astigmatism, no patient discomfort, no need to remove the suture later, and no unsightly red eye.  The real question is “How much will this cost?”

The Day After Surgery

1) You should arrive at your surgeon’s office at the scheduled time (usually in the morning). Please bring your drops with you.

2) Your surgeon’s staff will remove your eye shield and check your vision. Your vision may or may not be better the first day after surgery as there are many variables that can affect vision early after surgery.  Most people who do not have other diseases of the eye will experience significant improvement in their vision with new glasses by one month after surgery.

3) Your surgeon (or his or her staff) will check your vision and intraocular pressure.  Your surgeon will complete a brief examination of the eye.  Sometimes it is necessary to lower the intraocular pressure either in the office or with additional drops.

4)  You may receive a pair of “cataract glasses” (wrap around plastic sunglasses) to be used when you are outside.  This is mostly for comfort as bright lights will be bothersome while the eye is healing.

5)  The first week after surgery you will be swimming in drops.  These drops protect the eye from infection and inflammation.  Your surgeon may have removed the cataract and replaced it with a new lens, but the ball is in your court after surgery.  It is critical for proper healing that you use your eyedrops as instructed and limit your activities to those approved by your surgeon.

6)  You will likely have another appointment with your surgeon about a week after surgery.  By this time 95% of the healing is done and your vision should be clearer (unless you have corneal astigmatism or other ocular disease such as glaucoma or macular degeneration that could limit your vision).  You may be seen by the surgeon or another doctor.  The purpose of this visit is primarily to confirm that the eye is healing as anticipated and to re-instruct you in the care of your eye.  Most likely the doctor will allow you to reduce the number of drops you have to use.

7)  Around two to four weeks after surgery your eye can be checked for new glasses.  Unless you chose a “presbyopia-correcting IOL” you will need bifocals or both distance and near glasses.  Some optometrists prefer to double check this refraction in another week or so to confirm that the eye is no longer changing as it heals.  You can also schedule surgery on your second eye around this time if you have a significant cataract in your other eye.

8)  I prefer my patients to keep the eye “clean and dry” for the first month after surgery.  Essentially, this means no swimming and no gardening.  It’s generally OK to take a shower and wash one’s face or hair.  It is not OK to submerge the eye under water or work in the dirt.

9)  As for physical activities, I instruct my patients to avoid lifting objects greater than 20 pounds for the first few weeks.  For grandparents, it’s a good idea not to lift that toddler grandchild (toddlers have an uncanny way of whacking an eye after surgery when they are excited or upset).  Light aerobic activity such as a Stairmaster or stationary bike is OK but I’d stay away from kick-boxing or high-impact aerobics.

10) It is usually OK to resume driving a few days after surgery (assuming you were driving prior to surgery) but this should be confirmed with the surgeon.

11) Ocular irritation and a little redness in the white part of the eye is OK. However, any significant pain, swelling, or loss of vision is not.  These symptoms demand an immediate call to your surgeon.

In general the post-operative experience is uneventful other than the usual “Wow!” experience of improved vision.  However, following the guidelines of your surgeon is critical to the success of the surgery.

Note: these posts will reflect my personal preferences.  Other surgeons will have their own set of expectations.  Each surgeon creates a set of guidelines based on his or her experience, training, techniques, and understanding of the literature.  Additionally, I will modify these guidelines based on the needs or health of an individual patient.

So, assuming you have already chosen a surgeon and he or she has confirmed that you have a cataract and you would benefit from cataract surgery, what can you expect Prior to Cataract Surgery?

If you are a contact lens wearer you will need to stop wearing the lens in the eye that will have surgery for at least three weeks prior to surgery. You may need to return to the office multiple times to have your corneal curvature measured prior to surgery.

You will need to coordinate pre-operative medical clearance from your internist or family physician.  This may include blood testing, an EKG, and a physical exam.   This should be done at least two weeks (but not more than a month) prior to surgery.

You will need to come into the office for additional testing of the eye and to complete the necessary paperwork prior to surgery.  Please make sure to bring your consent and filled out questionnaire with you. Expect to be in our office for two to three hours.

Expect a call from us about two to three days prior to surgery to let you know what time you need to arrive at the surgery center.

You will be using drops in the eye that will be operated on beginning three or four days prior to surgery.  These drops function to protect the eye from infection and inflammation.  We may have samples of some of the drops, but you will have to go to the pharmacy to pick up the others.

You can eat  the night before surgery.  After midnight, however, you should not eat or drink anything.

Next post: What to Expect the Day of Surgery

Unfortunately, the general experience of most people who have had cataract surgery does not apply when there is a history of diabetic retinopathy.  People with otherwise healthy eyes might note that their vision was better before they even left the operating room.   However, most of these people do not have diabetic retinopathy (for more on diabetic retinopathy visit my practice website and search for “diabetic retinopathy” - a list of articles and educational animations will be visible).

A history of diabetic retinopathy increases the risk of surgery.  Eyes with a history of retinopathy are at higher risk of macular edema (swelling of the retina), and infection. Treating these conditions can be challenging.

Additionally, decreased night vision is often a result of the laser treatment for proliferative retinopathy (that’s still better than the alternative of no treatment - loss of central and overall vision).  Cataract surgery may help by allowing more light into the eye, but it will not completely improve it - there will still be some permanent limitation of night vision.

The most important thing someone with Diabetes can do to limit these additional risks of cataract surgery is to maintain good control of the blood sugar.

The incisions were then hydrated…

One method of closing the incision is to hydrate’ it.  Essentially, a sterile salt solution is injected into the cornea.  This results in a local swelling around the incision forcing the incision closed. Often this acts as a substitute for suturing the incision.  The problem is that we really don’t know how long this swelling lasts.  Will it keep the incision closed long enough to protect the eye from infection?  For this reason I will often add a suture (see last post).

…and the anterior chamber was formed to physiologic pressure (confirmed by intraoperative tonometry) at which pressure the incisions were checked and felt to be watertight and of good integrity.

Basically, sterile saline is injected into the eye through the paracentesis (small 1mm incision) to bring the pressure in the eye back up to a ‘normal’ pressure.  The incisions are then checked for leaks.

The lid speculum and drapes were then removed followed by placement of Vigamox drops in the fornices on the left.

Remember the bent-paperclip-like device used to keep the eye open?  We don’t need that anymore as the surgery is over.  As a final step to protect from infection a drop of antibiotic is placed on the surface of the eye.  Some surgeons inject an antibiotic into the eye at the end of surgery.  To date there is no agreement in the US as to which provides more protection.  There is a recently published European study that supports using an injection.  However, the antibiotic used in the European study is not readily available for intraocular use in the USA.  Therefore, most North American surgeons feel the risks of using a ‘compounded’ antibiotic (made by hand) outweights the potential protection it might provide.  As mentioned in my last post, I have not had an episode of acute endophthalmitis in over 2,000 cases of cataract surgery using topical, not intraocular antibiotics.    As this rate is smilar to that experienced with the European method there does not seem to be a convincing reason to change.  Again, using the wisdom of my father, ‘If it’s not broke, don’t fix it.’

A shield was then placed over the left eye which the patient was instructed to keep on the eye except during placement of Nevanac, Vigamox, Omnipred 1% drops which she is to use including the day of surgery.

With topical anesthetic there is no need to patch the eye.  A shield with little holes in it is sufficient to protect the eye from rubbing when the patient is sleeping.  Additionally a shield is easier to take on and off than a patch.  This is important in order to get the antibiotic and anti-inflammatory protection of the prescription drops.

She was instructed to avoid any heavy exertion…

Basically, I tell my patients not to pick up anything over 20 pounds, avoid swimming, gardening, high-impact aerobic activities, and “jerking” activities such as roller coaster riding, bungee jumping, skydiving, and the like.  Most standard daily activities are just fine.

…and is to follow up in my office the day after surgery.

It is also acceptable to follow-up the day of surgery.

She tolerated the procedure well.

This is an understatement.  Most people find cataract surgery to be a painless procedure and look forward to having surgery on their second eye shortly after their first eye has healed from surgery.

A single 10-0 Vicryl suture was then placed in the temporal corneal incision and the knot was buried in the corneal stroma.

These sutures are incredibly thin (about as thick as a strand of blond baby hair), difficult to work with (ever tried tying a knot of thin hair?), and expensive (about $15 per suture).  Thus, suturing the incision is skipped by many surgeons.

No doubt you’ve seen advertisements for ‘no-stitch’ cataract surgery.  It’s sexy not to place a suture.  And, it probably isn’t necessary every time.  If I am convinced beyond a doubt that the incision is watertight without the need for a suture then I won’t place one either.

There are many reasons given for not placing a suture as it (1) may result in irritation; (2) can result in surface bleeding aka a ’sub-conjunctival hemorrhage;’ (3) might have to be removed in the office.  Certainly no surgeon wants his or her patients to have a beet-red eye after surgery because a suture was placed.  And, a sub-conjunctival hemorrhage can look awful: ‘what happened to your eye!’  is another phrase surgeons don’t want their patients to hear (it makes for bad advertising).

Additionally, as mentioned above, suturing is time consuming and expensive.  Placing a suture can add five minutes to the time of surgery.  This may not sound like much, but consider this: my average cataract surgery without placing a suture lasts 12-14 minutes.  By placing a suture I have just increased my surgery time by almost 40%.  Believe it or not, with the downward pressure on cataract surgery reimbursement (it is now about 1/10th of what it was in the 1970s) the only way for a surgeon and surgery center to make ends meet is to be efficient.

I like performing surgery and insurance companies know that most cataract surgeons would do this as a hobby.  Thus, as long as I am not losing money on my surgery I’ll keep doing it.  And, as long as my surgery center allows, I’ll keep placing a suture when I think it is needed.  Why?  Because placing a suture may decrease the risk of infection.  I mentioned earlier that infection is one of the few things that can result in a loss of vision (or even blindness).  If I can reduce the risk of infection from 1 in 500 to 1 in 1,000 or 2,000 then I will.

To date I have performed over 2,000 cataract surgeries without a single case of acute endophthalmitis (early infection of the eye).  Most published studies on endophthalmitis report rates of 1 in 500 to 1 in 1,000.  I believe part of the reason my patients have avoided this complication is my meticulous attention to incision closure and use of a suture when I feel it would benefit the integrity of the incision.

One more post to go…