FAQ: Cataracts and Cataract Surgery

Dr Clive Novis

What is a cataract?

A cataract is a cloudiness of the eye’s natural lens, which lies directly behind the pupil.

What causes cataracts?

The lens is mostly made of water and protein. The protein is arranged in a precise way that keeps the lens clear and lets light pass through it. But as we age, some of the protein may clump together and start to cloud a small area of the lens. This is a cataract, and over time, it may grow larger and cloud more of the lens, making it harder to see.

No one knows for sure why the eye’s lens changes as we age, forming cataracts. Besides advancing age, cataracts can also be caused by injury, chronic diseases and prolonged use of corticosteroid medication and smoking.

Can Cataracts Cause Blindness?

Yes - if left untreated, cataracts cause continual loss of vision, eventually leading to legal blindness or even total blindness. Visual outcomes of modern cataract surgery are so good that a person who was legally blind prior to surgery often is able to see well enough to drive without eyeglasses after cataract extraction and intraocular lens (IOL) implantation.

When should cataract surgery be considered?

For best results from cataract surgery, it’s generally recommended to have the surgery performed before the cataract causes low vision or legal blindness. Advanced cataracts that cause severe vision loss are more difficult to remove and increase the risk of cataract surgery complications.

Are cataracts found only in older people?

Most cataracts develop slowly over time and affect people over age 50. About half of the U.S. population has a cataract by age 65, and nearly everyone over age 75 has at least a mild cataract in one or both eyes. In rare cases, infants can have congenital cataracts. These usually are related to the mother having German measles, chickenpox, or another infectious disease during pregnancy; but sometimes they are inherited.

My doctor says I have a cataract, but he wants to wait a while before removing it. Why?

Mild cataracts often cause little or no vision problems. Your doctor is probably monitoring your cataract to see if it worsens and more significantly affects your vision or lifestyle before recommending surgery. Some cataracts never reach the stage where they need to be removed. But if your cataract worsens and you begin to have trouble seeing clearly for driving and other everyday tasks, it’s probably time to consider cataract surgery.

Is cataract surgery serious?

All surgery involves some risk. However, cataract surgery carries a very low risk and is one of the most rewarding and commonly performed surgical procedures.

How is a cataract removed?

A small incision is made in the front surface of the eye with a scalpel or diamond blade. A circular hole is then cut in the front of the thin membrane (anterior capsule) that encloses the eye’s natural lens. Typically the lens is then broken into smaller pieces with an ultrasonic device so it can be more easily removed from the eye. Once the entire lens is removed, it is replaced with a clear implant called an intraocular lens (IOL) to restore vision. In most cases, the eye heals quickly after surgery without stitches.

What is a “secondary cataract”?

In a minority of cases (perhaps 20 to 30 percent), months or years after cataract surgery, the posterior portion of the lens capsule that is left inside the eye during surgery for safety reasons becomes hazy, causing vision to again become blurred. This “secondary cataract” (also called posterior capsular opacification) usually can be easily treated with a less invasive follow-up procedure called a YAG laser capsulotomy. In most cases, this 15-minute procedure effectively restores clear vision.

My grandfather had cataract surgery years ago, and he had to wear thick glasses afterward. Is this still necessary?

Rarely does anyone have to wear thick, heavy spectacles after cataract surgery these days. Most modern cataract procedures replace your eye’s natural lens with an intraocular lens (IOL) that often can correct your distance vision to 20/20. In many cases, your cataract surgeon can choose an IOL that will provide functional vision without any spectacles at all except perhaps for reading glasses.

What are the possible side effects of cataract surgery?

As with any surgery, pain, infection, swelling and bleeding are possible, but very few people experience serious cataract surgery complications. In most cases, complications or side effects from the procedure can be successfully managed with medication or a follow-up procedure. To reduce your risk for problems after cataract surgery, be sure to follow the instructions your surgeon gives you and report any unusual symptoms immediately.

Are you awake during cataract surgery?

Most cases are done under local anaesthesia so, typically you are awake during cataract surgery. This eliminates risks associated with general anaesthesia (being “put to sleep”) and enables your cataract surgeon to communicate with you during your procedure. If the idea of being awake during cataract surgery concerns you, fear not — you will be given oral medication before the procedure so you are fully relaxed and feel no discomfort. You also may be given (or offered the choice of receiving) intravenous (IV) medication to help you remain calm and comfortable throughout the procedure.

The medication typically makes it difficult for most patients to remember their experience in the surgical suite after the brief 15 to 20-minute procedure has been completed and they are in the recovery area. Some cases need to be done under full general anaesthesia and with modern anaesthetics this is very safe too.

Within a short period of time after your procedure, you will be able to leave the surgery centre, but you should not drive after surgery. You should have someone with you to drive you home. “Within a short period of time after your procedure, you will be able to leave the surgery centre, but you should not drive after surgery. You should have someone with you to drive you home. ”

Can cataract surgery be performed on both eyes at the same time?

If you have cataracts in both eyes, surgery typically is performed on one eye, and then a few days or a few weeks later, it’s performed on the second eye. This approach allows the first eye to recover and your vision in that eye to stabilise before surgery is performed on the fellow eye. That said, modern cataract surgery is very safe and effective, and the rate of cataract complications is very low. This has led to some surgeons to begin offering simultaneous bilateral cataract surgery (SBCS) — in other words, cataract surgery performed on both eyes on the same day.

Cataract surgeons who support the idea of SBCS point out that a significant percentage of cataract surgeries in some European countries are performed in this fashion with no increased rate of complications. Also, advantages of same-day cataract surgery on both eyes include lower costs, fewer office visits, faster recovery of binocular vision for driving and other critical tasks, and a quicker return to normal living.

Spectacle Frame Alignment

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“The position of the ear, where the temple sits in relation to the place where the frame sits on the nose, can hugely influence the fit and optics of spectacles. ”

Acomfortable fitting spectacle frame defines ultimate customer satisfaction. The process starts with selecting a frame with adequate dimensions, which will allow manipulation and adjustments, once the lenses have been fitted. Nobody’s head or face is exactly symmetrical, and each individual has unique features, which will impact on how a spectacle frame sits on the face. Ears are usually not positioned exactly at the same height. One ear may be higher or lower than the other. The bridge of the nose may be relatively high or low in relation to the eyes. A head may require very long temples (side pieces) or very short ones. The position of the ear, where the temple sits in relation to the place where the frame sits on the nose, can hugely influence the fit and optics of spectacles. It’s very important that the optical dispenser takes note of all these features and selects a frame that can be fitted to overcome them.

What is the right frame choice?

There are three basic requirements in frame selections that must be met.

THE oPTICS

The frame dimensions and how it sits on the face, can impact directly on the functional outcome of the optical prescription. For instance, with multi focals, there has to be enough space (depth) below the eyes to allow for the reading section. It is the responsibility of the optometrist or the optical dispenser, to guide you, the customer, in this regard. It would be wrong to over-rule their advice in this regard because of your cosmetic demands.

THE CoMFoRT

Again, it is the duty of the optical dispenser to ensure that the end product will be comfortable. The power of the prescription, the lens material chosen, as well as the lens design can affect the shape and fit of the frame on the face. The dispenser must pre-empt the effect of these factors but must also take into account the anatomy of the head and face, as well as the unique facial features of the patient, when choosing a frame. Once the lenses have been cut and fitted into the frame, it will feel and perform differently. The person assisting you, must ensure that the design of the frame, its dimensions and the material it is made of will allow for it to be fitted to your face once the lenses have been fitted.

THE LooK

The cosmetic component of your spectacles is vitally important, and this is where you have all the say. However, the choice of frame on the basis of the look, cannot over-rule the factors mentioned above. All three of these conditions must be met.

It is important to take your time and to feel good about the choice you make. There should be no room for uncertainty. With today’s technology, one has the luxury of calling on a spouse or family and friends, by sending a photograph for a quick opinion.

Fitting the frame onto the face

There is more to it than meets the eye. Here are six routine steps the optical dispenser will work through during the fitting process.

1. FRonT VIEW

Look for horizontal tilt. This can be corrected by angling the temples (side pieces) up or down.

2. ToP VIEW

Both sides must be the same distance from the eyes (eye brows not always symmetrical) You want a gentle curve around the face – not straight or a negative curve. The specs must not fit too far out from the eyes (vertex distance). Apart from looking funny, it can affect your vision. It must not be too close so that your lashes will touch the lenses.

Incorrect - Retroscopic angle and uneven vertex distance

Correct- Correct Pantoscopic angle and even vertex distance

3. SIDE VIEW

Pantoscopic angle. This angle is determined by the point where the temples rest on the ears and the top of the bridge of the nose. An incorrect pantoscopic angle, can adversely affect vision. An incorrect angle as seen above in Fig.11, will also make the glasses look funny on the face.

TEMPLE WRAP: Soft Hugging curve

NARROW FRONT: Excessive Bowing WIDE FRONT: Negative Inward Curve

4. TEMPLE WRAP

The temple wrap must not apply any unwanted pressure on the wearer’s temples. A temple wrap that is too narrow will push the frame forward to slide down the wearer’s nose (it is like squeezing a pea between your fingers). This will produce indentations on the wearer’s temples. A temple wrap that is too wide will also cause a frame to constantly slide down the nose.

Incorrect - bend too far back

Incorrect - bend too far forward Correct

Incorrect - no bend into head

Incorrect - too much bend into head Correct - temple contours skull

5. TEMPLE LEnGTH AnD TEMPLE CURL

This curl should follow the contour behind the ear and is vital in keeping the specs firmly, but comfortable on the face. This should not be a sharp “hockey stick” bend.

Flush fitting

Pressure points

6. THE BRIDGE

Nose pads must be aligned to fit flush with the nose. There are three angles to consider when adjusting nose pads: The frontal, splay and vertical angles. Both nose pads should look symmetrical, unless the patient has some asymmetry such as a broken nose and should be equidistant from the frame.

Finally

It is not uncommon to experience some pressure points of discomfort shortly after getting your new specs. This is part of the settling in period and a follow-up alignment will usually sort this out.

Spectacle frames will not maintain their shape indefinitely. All spectacle wearers should be in the habit of having their frames re-aligned from time to time. As a rule, optometrists will provide this service free of charge and no appointment is required.

Pantone 7425C

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