Kornmehl Laser Eye Associates
Frequently Asked Questions

Cataract Removal

What exactly is a cataract?

The human lens in the eye is normally crystal clear, but when the lens becomes opaque or cloudy, it is called a "cataract." A cataract is NOT a film or growth that occurs in the eye. It is simply a cloudy lens. As the opacity worsens, it prevents light from properly focusing on the retina, the light-sensitive tissue lining the back of the eye. Early lens changes or opacities may not disturb vision significantly, but as the lens continues to change, the vision becomes blurred and the person notices glare, haziness, and difficulty with seeing street signs or reading, for example.

The cornea is the clear dome of tissue at the front the eye that helps focus light (contact lenses sit on the cornea). The lens is located behind the iris, the blue, green or brown part of the eye. The lens has three parts: the capsule, the cortex, and the nucleus.

What are the types of cataracts?

There are different types of opacities that may cause cataracts. Each is described by its location within the lens. The most common type of cataract is the one associated with aging: the nuclear cataract. Often, patients have features of more than one type.


Nuclear Cataract – an overall cloudiness
of the lens

A nuclear cataract occurs in the center of the lens. Common symptoms include blurring or dimming of your vision, glare and visual distortion. A nuclear cataract makes the vision seem dimmer and patients typically feel that they need to use strong lights in order to read books or magazines. Many patients start getting early nuclear cataract changes in their 50s and this may contribute to the need for reading glasses or bifocals.

 


Cortica Cataract – spokes of opacities

A cortical cataract begins as wedge-shaped opacities in the cortex of the lens, much like spokes on the wheel of a bicycle. The spokes extend from the outside of the lens to the center. When spokes reach the center, they interfere with the transmission of light and cause glare and haziness to the vision. A cortical cataract typically develops slowly, but it may impair both distance and near vision so significantly that surgery may be indicated at a relatively early stage.

 


Subcapsular Cataract – central grainy opacities

A subcapsular cataract develops slowly and starts as a small grain-like opacity under the capsule, usually at the back of the lens. Significant visual symptoms may not appear until the cataract is well developed. Typical symptoms are glare and blur. A subcapsular cataract is often found in people with diabetes or high levels of myopia, and in people taking steroids.


What are the symptoms of cataracts?

Who gets cataracts?

Like gray hair, cataracts are basically unavoidable. For most people, cataracts in the form of slight lens opacities start to develop in patients' 50s and surgery is typically performed in their 50s, 60s, and 70s. For nearly all patients, the cataracts are related to age, lifetime sun exposure, and genetics. In the other patients, the cataract may be related to diabetes, steroid use (for asthma, allergies, or immune problems), or trauma. Cataracts are a leading cause of blindness but, fortunately, cataracts are easily treated and cured. Everyone who lives long enough will end up having cataract surgery, and this explains why it is the number one surgery performed in the United States, with about 3 million performed in 2008.

How are cataracts diagnosed and treated?

You'll need to have a thorough examination of your eyes, including dilation and an evaluation of your current glasses prescription. At first, a change in your eyeglass prescription may be all that is needed to temporarily improve your vision. When you feel that your vision affects your daily activities or your lifestyle and you desire better vision, cataract surgery in Boston should be considered. Cataracts can only be removed with surgery.

At what point do I need cataract surgery?

There is no single objective test to determine the need for cataract surgery. The final decision for cataract surgery is made by the patient and depends on how much the decreased vision from the cataract is bothersome. My patients are highly intelligent and informed, and I prefer to explain their current status in plain English, and have them make their own decisions. Doing cataract surgery at an earlier stage makes for a quicker recovery and a technically easier surgery. Waiting until the vision is very poor can often make the surgery and the recovery more involved. Cataract surgery is an elective surgery and it is up to the patient to decide when to undergo surgery. Similarly, refractive lens surgery is scheduled when the patient would like better vision and less dependence of glasses.

The Massachusetts Department of Motor Vehicles requires that drivers have 20/40 vision (with or without glasses) in their better eye to qualify for a license. Some patients choose to wait until their vision is approximately at this 20/40 level. However, many active patients who still work, drive, and use computers have higher demands for their vision. These patients tend to choose surgery at an earlier stage.

Some patients choose to have surgery even before they develop vision-blocking cataracts. For these patients, who are typically in their 50s, refractive lens surgery is performed in order to eliminate or reduce the need for glasses and to regain their near vision. With their astigmatism managed and a multifocal lens implanted, the vast majority (92 percent in the official FDA study) of these patients see well at distance, intermediate, and near, and may occasionally use glasses. The remaining 8 percent also saw quite well, but they used glasses more than just occasionally.

The bottom line is: if you're happy with your vision and it doesn't cause difficulties with reading, computer use, driving, working, or your active lifestyle, then you should postpone the surgery. If you want and need better vision for your activities right now, and would like to see more clearly, then schedule the surgery. Ultimately, they're your eyes, and you decide what's best.

How is cataract surgery performed?

Cataract surgery is a way to replace the cloudy lens with a crystal-clear lens, thereby restoring vision. In modern techniques, the posterior capsule of the natural lens is left in place to support the man-made replacement lens that is implanted at the time of surgery.

There are two different ways of performing this surgery:

What is a premium lens?

Up until recently, cataract surgery could only provide good vision at a single distance with most patients choosing good distance vision. New technology called premium lenses allow for improved distance, intermediate and near vision. Premium lenses include the Crystalens, ReStor and Toric lenses. The Toric lens corrects astigmatism but does not improve intermediate and near vision. There is an extra charge for the placement of a premium lens during cataract surgery and it is not covered by your private insurance or Medicare.

What kind of vision can I expect if I have the Crystalens?

The Crystalens is an accommodative intraocular lens that provides good intermediate and near vision along with distance vision. One hundred percent of patients will have improved intermediate vision with 92 percent having improved reading vision. Although the improvement in near and intermediate vision is impressive, the lens will not allow you to see like you did when you were 30 years old. Improvement in near vision is noted in approximately two weeks and continues to improve a year following implantation. One percent of patients do not notice significant improvement in their near vision, but do have improvement in their intermediate vision. Glare and halos are usually noted only in the first week after surgery.

What kind of vision can I expect with the ReStor lens?

The ReStor lens provides excellent near vision and distance vision. Intermediate vision is also improved. Improvement in near vision is noted in approximately three weeks and the final result may not be achieved for up to three months depending on how quickly individual patients can neuroadapt. Patients may notice minimal glare that often, but not always, resolves with time. A ReStor lens is only placed if cataract surgery will be performed on the opposite eye within four weeks of the first eye. If you have macular degeneration or glaucoma you are not a candidate for the ReStor lens.

What kind of vision can I expect with a Toric lens?

If you had pre-existing astigmatism prior to the development of the Toric lens, you would still require glasses for good distance vision following cataract surgery. The Toric lens allows for a reduction of astigmatism and provides clear vision at distance without glasses.

Is it possible I may require refractive corneal surgery after a premium lens is implanted?

There is a 5 percent chance that LASIK or PRK will be needed to provide you with optimal distance vision following placement of a premium lens. The final vision achieved with a premium lens is dependent on a patient's own wound healing, therefore, it is possible one could see well initially at distance but develop a refractive error over the next year or two.

Will there be an extra charge for corneal laser surgery after placement of the Crystalens or ReStor lens?

If astigmatism is induced by the placement of the premium lens, there will be no charge for corneal laser surgery to correct it. However, if astigmatism is present before cataract surgery and Dr. Kornmehl determines that a two-stage procedure is needed to reduce astigmatism and improve near and intermediate vision, there will be a fee for both the ReStor and Crystalens and the corneal laser surgery.

What could be the reason for decreased vision at distance, intermediate and near vision months or years after cataract surgery?

It is not uncommon for the thin membrane that the lens is placed in to opacify sometime after surgery. This can occur whether or not an implant is placed. A five-minute laser treatment (posterior capsulotomy) performed in the office can take care of this issue and is covered by insurance.

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Dr. Kornmehl has surgical privileges at 75 Francis Street, Boston, MA 02115 (617) 232-2090



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