Cataract surgery by a glaucoma doctor

If you live long enough, the lens inside your eye will become cloudy and will need to be replaced by a clear plastic lens implant. Cataract surgery is usually performed when the patient notices intolerable glare while driving or when general blurriness is no longer correctable with glasses.

Cataract surgery is a necessary component of many glaucoma surgeries because the natural lens can crowd the drain that keeps eye pressure down. Patients with pseudoexfoliation glaucoma often have cataracts which are more difficult to remove, so glaucoma surgeons become accustomed to challenging cataract surgeries.

LENS IMPLANTS and GLASSES

After cataract surgery, most patients will use reading glasses for close vision while having not much need for distance glasses. Almost all patients will see slightly better with distance glasses but only about 1 in 20 will need to wear distance glasses most of the time.

MONOFOCAL lenses focus at one particular distance; glasses are needed to see closer (or further) than that distance). Monofocal lenses give the most vivid vision with the least glare, but glasses are often useful to get the best focus. Monofocal implants are covered by insurance.

MULTIFOCAL lens implants are not covered by insurance. They can improve the ability to see clearly both near and far without glasses. However, they tend to reduce contrast (for example, the ability to see a white line on the edge of the road while driving in rain)and increase glare. The reduced contrast and increased glare cannot be improved by glasses. The loss of contrast can be an increasing problem later in life if there is substantial glaucoma damage or retinal disease such as macular degeneration or epiretinal membrane. Even aging can make contrast loss more of a problem, so Dr. Libre generally advises against multifocal lenses, though it is certainly true that many excellent doctors believe that they benefit their patients.

MONOVISION means that one eye sees far and the other sees close. This reduces the need for glasses to change the focus. However, the difference between the eyes reduces depth perception which can be frustrating. However, making one eye focussed just slightly closer than the other (mini-monovision) will reduce the dependence upon reading glasses without causing noticeable difficulty using the eyes together. Dr. Libre recommends this for most patients. The typical result is that patients after cataract surgery can read texts on the phone and larger print reading material, but will use reading glasses for smaller print and reading more than a few minutes.

TORIC lenses correct astigmatism or corneal warpage. Toric lenses are warped implants which counteract the warpage of the cornea. Like multifocal lenses, toric lenses are not covered by insurance. Unlike multifocal lenses, they do not reduce contrast or increase glare. Another option for correcting astigmatism without a toric lens, is to change the location and number of incisions in order to reduce the warpage of the cornea. Dr. Libre often recommends this for astigmatic patients.

The LIGHT ADJUSTABLE LENS (LAL) is an implant which can be fine-tuned by ultraviolet light several weeks after surgery. LAL patients will usually end up with less astigmatism and more precisely corrected mini-monovision, so they tend to see better without glasses than patients with traditional implants. There is no loss of contrast or increased glare. While they are less likely to use glasses, LAL patients will always see a little better with some additional corrective glasses for near or far. Disadvantages of the LAL: it costs $2500/eye; 3-5 additional postoperative visits are needed to adjust the implant; special sunglasses are used outdoors until the adjustments are completed, so that sunlight won’t cause random adjustments; the UV light is uncomfortably bright for some patients and probably better avoided for people with a family history of macular degeneration;.

Femtosecond laser can be used for some steps of cataract surgery, but most studies have found that the laser does not significantly improve outcomes and for this reason Dr Libre does not use the femtosecond laser.