CATARACT SURGERY: What are my options?

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closeup of person's blue eye with computer graphic
by Dougherty Laser Vision

A cataract is a clouding of the natural lens of the eye.  Cataracts are most commonly caused by aging, but can be seen in younger people who have taken steroid medication for various medical conditions, diabetics, patients who had trauma to their eye and in patients who have spent significant time outdoors in sunlight or in tanning booths who have not worn adequate eye protection.  Cataract surgery involves removing the cloudy natural lens and replacing it with an intraocular lens (IOL).  The surgery is performed to remove the cataract and takes about 5 minutes to perform in the hands of an experienced surgeon.  Cataract surgery is very successful at improving vision in a matter of hours to a few days with minimal discomfort.

At the time of cataract surgery, most patients are unaware that the procedure can also be use to correct vision to minimize the need for glasses or contacts after the surgery. In our practice, we offer 3 vision correction packages that offer various levels of independence from glasses after surgery, each of which comes with a different level of out-of-pocket expense.

Unfortunately, basic IOLs do not allow for intermediate or reading vision without glasses.

The standard cataract lens package involves no out-of-pocket expense, but offers the least independence from glasses or contacts. This option is covered as part of the cataract surgery facility fee paid by your insurance carrier.  Because insurance does not pay for diagnosis or management of astigmatism (where the eye has 2 different curvatures, resulting in blurred vision for both distance and near), you may still be required to wear distance glasses for best vision with this package.  In addition, the basic IOL does not allow for intermediate (computer) or reading vision without glasses.

For those who are budget minded, but want to maximize their vision without glasses after cataract surgery, we offer our Economy Refractive Package.  This package includes testing and treatment for monovision (setting 1 eye for distance and the other for near to minimize needs for both distance and near glasses), testing and treatment for bilateral undercorrection (setting both eyes for up close), diagnosis and management of astigmatism with limbal relaxing incisions which reduce astigmatism in most patients, and discounted laser vision correction if it becomes necessary to minimize need for glasses after surgery.

For those patients who want the best vision without glasses after cataract surgery, we offer our Premium Refractive Package.  This package includes testing and treatment for monovision (if appropriate), testing and treatment for bilateral undercorrection (if appropriate), diagnosis and management of astigmatism, laser vision correction at no charge if it becomes necessary to minimize need for glasses after surgery, and a premium toric or presbyopic (near-enhancing) IOL.

Toric IOL’s work by correcting astigmatism, and are usually reserved for patients with moderate to high levels of astigmatism.  To minimize the need for reading glasses after cataract surgery, toric IOL’s can be used to create monovision or bilateral undercorrection.  Toric lens styles are more accurate than LRI’s at treating astigmatism.

There are a few lens styles that are out on the market today.

There are two types of presbyopic (reading enhanced) IOLs on the market— accommodative (near-enhanced) and multi-focal.

With respect to near-enhancing (accommodative) IOLs, there are multiple types available in the United States. However, the only lens that currently has FDA labeling for accommodation is the Crystalens, which gives good distance vision and also has hinges, which allow the lens to flex through contraction of the ciliary muscle in the eye to give better intermediate and reading vision.

There are two other lenses on the market that give excellent distance vision while enhancing near vision, possibly through an accommodative mechanism—the Staar Nanoflex and the Lenstec Softec HD.

While the Nanoflex and Softec HD lenses are not specifically labeled by the FDA for enhanced near vision, they are more effective, in my hands, than the Crystalens.

Multi-focal lenses (Restor and Tecnis) act by differentially bending light rays so that some are focused for near vision, others for distance in the same eye. Multi-focal IOLs are the most effective lenses on the market to completely eliminate distance and near glasses (unless the patient tolerates monovision, in which case near-enhanced IOLs with some monovision are also very effective for both distance and near vision without glasses). Restor works best for reading at about 16-21” and works well for intermediate vision (computer) but has the downside of losing some reading effect in low light conditions.

There are upsides and downsides to all lenses.

Tecnis, on the other hand, works best for people who like to read or do near activities much closer (12-16”). Tecnis is my preferred lens for patients whose employment requires a very close focal point, like nail technicians or jewelers. Tecnis allows for reading in low light situations but has the downside of some intermediate (computer) blur, requiring the patient to get closer to the computer screen or wear computer glasses to see well.

Both Restor and Tecnis, because of the multi-focal optics, have the downside of causing halos around lights, particularly in low light conditions like night driving. For the vast majority of patients, this symptom is minor, improves with time, and is well worth the trade-off to achieve excellent reading vision without glasses. I do not recommend multi-focal IOLs to patients who do a lot of night driving or might be bothered by nighttime halo.

In deciding on a multi-focal lens versus a near-enhancing lens, the choice is dependent upon your own visual needs. For patients who place more importance on eliminating the need for reading glasses, a multi-focal lens like the Tecnis or Restor is more appropriate. For patients who place more importance on crisp vision in low light conditions, but are comfortable with at least part-time reading glasses, a near enhanced lens like Nanoflex or Softec HD would be more appropriate. The only way to confidently eliminate reading glasses with a near-enhanced lens is by employing monovision. If a patient tolerates monovision, I favor monovision with a near-enhanced lens over a multi-focal lens, due to the lack of halos. Unfortunately, as will be discussed, not everyone tolerates monovision.

In summary, cataract surgery with an IOL implant is a highly effective procedure that has the potential benefit of reducing or eliminating the need for glasses after surgery.  While most insurances pay for a basic government issue IOL, there is some out-of-pocket expense required to minimize the need for glasses after cataract surgery.

To see if you are a candidate for cataract surgery call our office today at (805)-312-7671 and set up your cataract evaluation.  We serve patients in Santa Barbara County, Ventura County, and Los Angeles County.