Cataract Pre-Surgery Questions

Cataract Pre-Surgery Questions

Cataract Pre-Surgery Questions: 56 Things that you wish you knew before your cataract surgery

What do I need to know before cataract surgery?

What do I need to know before cataract surgery?

Macula - Although not always done, I would consider it a best practice to do an OCT prior to cataract surgery.    The special OCT image is a detailed cross-section of the retina and documents any imperfections or lack-of-imperfections prior to surgery.

Dry Eye - Mild, moderate or severe dry eye can negatively affect the outcome of cataract surgery.  Having a healthy cornea can help your surgeon’s team get better measurements for the implant so make sure that you follow your dry eye protocol to the letter before your measurements (not just prior to the surgery date).  It is NOT worth paying for a better lens implant if you have raging dry eye because the measurement accuracy is poor.

Folks with dry eyes can also have more discomfort post-surgery so ask your team if there is something more that you need to do prior to your surgery. 

Lashes and Lid Care - Poor/inadequate lid hygine prior to cataract surgery increases infection risk.  It is a best practice to use lid scrubs or gel care gel prior to your surgery.  Do not have eyelash extensions use or make-up a few days prior to your surgery date.

 

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Can you see the implant after cataract surgery?

Can you see the implant after cataract surgery?

The implant itself is not visible to an observer however an implant is more reflective than the natural lens.

Someone taking your picture or looking at you under bright lights may see an occasional glint or unnatural reflection.

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How long am I off work?

How long am I off work?

This is a question best answered by your surgeon and the answer will depend on the success of the procedure and your job.

Heavy physical jobs (e.g. fitness instructor) or those with critical vision (e.g. pilot, transport truck driver) will be off longer.  Light visual demand jobs can usually done after a couple of days but there are lots of eye drops, light sensitivity and poor initial vision due to normal inflammation.

Most cataract surgery is day surgery with no overnight hospital stay.  The procedure is quick (10 min) but set-up, follow-up and waiting usually means a full day at the surgery center.

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Can the implant come loose? Fall out? Can I rub it out?

Can the implant come loose?  Fall out?  Can I rub it out?

It would be unusual but an implant can come loose.  There are natural elastics (zonules) that hold it in place and if those are damaged by trauma or a degenerative condition… the lens can sink or fall into the back of the eye.   This is repairable but requires further surgery.

An implant can not fall out of the eye… just sink low or fall behind the iris.

This is nothing that you can control.  Touching or rubbing your eyes will not damage the implant.

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Does the implant last forever?

Does the implant last forever?

Yes – The implant will last forever.

The bag (capsule) that holds the implant in place can cloud (and be fixed)… but the actual implant will be fine for your lifetime.

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Does cataract surgery hurt?

Does cataract surgery hurt?

It would be extremely unusual for a patient to say in a follow-up visit that cataract removal hurt.  It has happened over my 25 years … but I could count the number of times on one hand.

By far the most common discomfort is a scratchy feeling that often persists for a couple of months post-surgery.

Most folks that reported that they experienced discomfort during the procedure say that it was an anesthetic issue … not enough or perhaps too long between drops and surgery.  This was quickly rectified with increased

anesthetic.

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Can my astigmatism be corrected with cataract surgery?

Can my astigmatism be corrected with cataract surgery?

Yes!  There are two options for fixing astigmatism.

[1] A special implant (toric) - corrected concurrently with cataract surgery.  70% of people could benefit and see better post surgery with an implant that fixes corneal astigmatism.

[2] LASIK post cataract removal - corrected once stable after cataract surgery (~3-6months)

Not all surgeons off this correction.  Talk to your Optometrist prior to surgeon referral.

 

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What is the wait time for cataract surgery (Ontario)?

What is the wait time for cataract surgery (Ontario)?

I can only speak to this for those of us in Ontario, Canada. 

Wait times for cataract surgery in Ontario vary dramatically depending upon surgeons, budgets and operating room time available for surgeons.

As of now – March 2020 – in London, Ontario… the wait times are approximately eight months from time of referral to time of surgery. 

In Ontario, you have the ability to go to a private center for cataract surgery.  If you are interested in this, you should discuss this with your Optometrist prior to your referral.   A private center may influence your wait time but not significantly.  Privately paying for a medical service can not buy your way to the front of the line but because less folks pay, the queue is shorter after you are assessed in your initial surgery consult.

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How much does cataract surgery cost?

How much does cataract surgery cost?

I can only speak to this for those of us in Ontario, Canada. 

If you have a visually significant cataract and desired, you could have cataract surgery done at no charge in Ontario.  However, most of my patients spend approximately $300-$400 per eye to have premium implants and the associated measurements.

If you elected to have an enhanced procedure or had a significant amount of astigmatism that you wanted to concurrently correct with surgery… these costs range from $1000 - $2500 extra per eye.

Speak to your surgeon about the $ details

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Ultrasound vs. laser … Is cataract surgery not always done with laser?

Ultrasound vs. laser … Is cataract surgery not always done with laser?

There is a common misconception that all cataract surgery is done with laser.  Perhaps because the procedure is so quick and efficient or that there is so much advertising for LASIK refractive surgery… but patients often confuse the two surgeries and how the procedure is done.

The two main clarifications that I make with patients are:

1] Cataract Surgery is not LASIK.   LASIK is a laser-based procedure to reshape the cornea (the outer surface) of the eye.  Cataract surgery removes the cloudy lens from inside the eye and replaces it with an implant.   In some circumstances these two procedures can be combined (not concurrently) but they are different procedures requiring different technologies and surgeon skill sets.

2] Cataract removal surgery typically uses ultrasound energy (not laser) to break up the natural lens to remove it.  However, laser energy can also be used for this purpose.  This is an increasingly popular option … but it is not widely done in this region - Ontario. 

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What are the pre-surgery eye measurements required for implants?

What are the pre-surgery eye measurements required for implants?

There are several eye measurements that a surgeon will take into consideration for your surgery.

1] The refraction (your glasses prescription)
2] The curve of the cornea
3] Measurements of the length of the eye (ultrasound)

These are all used to determine the best implant.   In this region, some of these measures are come with extra charges.  I always recommended these measurements be taken (even if a charge) because it does improve the accuracy of the final post-surgery glasses prescription (or lack thereof!).

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Are there needles used in cataract surgery?

Are there needles used in cataract surgery?

This is a common concern for folks as we discuss how the procedure is done.   It is extremely unlikely that needle would be required for the procedure.   Eye drops are used to numb the eye and dilated the pupil prior to surgery.

In rare circumstance, the only needle that is used is to place anesthetic behind the eyeball so that it temporary paralysis the eye muscles.

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I have heard of doing one eye for distance and one eye for near?

I have heard of doing one eye for distance and one eye for near?

Monovision is a method to fit contact lenses or determine the power of implants which intentionally creates clarity in the distance in one eye and clarity up close with the other eye.   It works well with early focusing difficulties but tends to fail as one requires increasingly different close/far powers with age.  Because implants do not have any dynamic focusing ability, the near/far powers are quite different.

In my experience this arrangement is not suitable for implants UNLESS the patient currently, successfully wears monovision-fit contact lenses.

It would be possible to trial contact lenses prior to surgery to simulate monovision but sometimes the cataract cloudiness is so significant that a proper trial is a challenge.

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Are both eyes done at the same time?

Are both eyes done at the same time?

Bilateral surgery varies by regional / surgeon.  In my area – Ontario Canada – it would be highly unusual to have bilateral cataract removal surgery.

This is done primarily to minimize infection risk.  Also, you will be patched for a short time after surgery as well.  Bilateral surgery would mean no sight or independence during this time.

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Will I have more night glare after cataract surgery?

Will I have more night glare after cataract surgery?

Maybe – The type of implant that you select / receive will influence night vision.  Some lenses are optically designed to help correct the aberrations associated with night glare.  Common post cataract surgery night vision issues are: glare, arcs, haloes, flashes, blur.

In some cases folks’ pupils are larger and/or less responsive post-surgery and this change effects the optics of the eye.

If you are in need of cataract surgery ... then you probably have a glare-causing cataract.   Your post surgical level of glare should be less than your current!

Important – A great pair of new lenses can do wonders to reduce glare.  It is not always the implant’s optics to blame!  You may just have a bit of residual prescription to be corrected.

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Will I be more light sensitive after cataract surgery?

Will I be more light sensitive after cataract surgery?

Immediately after surgery you will more light sensitive.  You will have inflammation in the eye that will cause increased light sensitivity.  Wear sunglasses!  You will also be light sensitive because the new, clear implant allows much more light into the eye vs. the cloudy natural lens that was removed.

Most folks say that their light sensitivity decreased significantly over the first couple of months post-surgery.

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Can cataract surgery make my macular degeneration (AMD) worse?

Can cataract surgery make my macular degeneration (AMD) worse?

The jury is still out here.  Speak to your surgeon but most surgeons will wait until the cataract absolutely needs to be done if there are macular concerns.

There is a school-of-thought that laser enhanced cataract surgery (femtosecond laser) is safer for AMD patients because it introduces less energy into the eye with therefore less chance of retinal inflammation.

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Should I get a bifocal / multifocal implant?

Should I get a bifocal / multifocal implant?

Some cataract surgeons will offer bifocal / multifocal implants.  These lenses ideally eliminate the need for distance and near glasses post-surgery.   Your case is unique and needs to be discussed with your eye care team but these are the general points that I speak to patients about regarding this premium option:

1] needs to be bilateral to work well [a] do both eyes on a short timeline and [b] consider if you lost vision from one eye in the future
2] good for general near vision but not detail.   Readers may still be required
3] may add to night glare
4] tremendous freedom
5] In my opinion, people who have previously successfully worn multifocal contact lenses make the best candidates
6] significantly more expensive

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How fast does cataract surgery need to be done?

How fast does cataract surgery need to be done?

An uncomplicated cataract does not need to be urgently treated however cataracts are progressive and vision will inevitably get worse.  There is a point where the risk to remove an advanced cataract increases as higher amounts of ultrasound energy are required.

This is a conversation to have with your eye care professional.

Be careful of driver’s license requirements.  In some regions there are long waits for cataract surgery and you would not want to fall under a driving requirement while waiting.

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I am confused about the enhanced implant and procedure options available for cataract surgery

I am confused about the enhanced implant and procedure options available for cataract surgery

Basic Cataract Surgery (lowest cost to patient or payor)  This procedure is usually hospital-based.  It is safe and effective and provides the medically necessary cataract surgery procedure with standard lens implant. 

Enhanced Cataract Surgery This typically hospital-based surgery is the same procedure as basic (above) however the lens implanted & the calculations around lens selection are improved.  The enhanced procedure often leads to a better refractive result post-surgery with less night glare. (no astigmatism correction)

Enhanced Cataract/Refractive Surgery  This procedure is done at a private facility that also offers LASIK.  There is great emphasis on achieving the best distance refractive result (i.e. no glasses for far vision).   Superior pre-surgery lens measurements and calculations are coupled with additional in-surgery procedures and post-surgery laser (LASIK if required and suitable) to deliver visual acuity excellence.  Low pre-existing astigmatism is corrected by this surgery. 

Enhanced Cataract/Refractive Surgery for Astigmatism  Hospital or private facility based procedure for higher degrees of pre-existing astigmatism.   There is great emphasis on achieving the best distance refractive result (i.e. no glasses for far vision).   Superior pre-surgery lens measurements and calculations predict the best special (toric) implant lens.

Enhanced+ Cataract/Refractive Surgery with a multifocal lens  Same as Enhanced Surgery above but the multifocal implant corrects both distance AND near vision and eliminates the need for reading glasses for most normal daily functions.

Enhanced Cataract/Refractive Surgery Procedure utilizing laser (for any above enhanced surgeries)  Instead of a blade and ultrasound...  laser technology is used for both making incisions and to remove your clouded natural lens.  Utilizing laser technology is thought to causes less trauma/inflammation to the delicate tissues of the eye and may be safer for some patients, shortens healing times and delivers a more precise end result.  Discuss details and current results with your surgeon.    Not generally available in hospital environments.

 

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I am scared of seeing a knife! Can I see what is happening?

I am scared of seeing a knife!  Can I see what is happening?

There is so much light flooding you and the operating suite plus... they are working so close to your face… you will not see anything.

You will hear the team … but not see the procedure happening.

Lots of folks are very queasy when it comes to their eyes.  When they come back after surgery... it is always "Well that was not so bad!"

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How long does cataract surgery take? They put you out right?

How long does cataract surgery take?   Is it under general anesthetic?

Typical, uncomplicated cataract surgery will take about 10 minutes to perform.  However, with preparation and waiting, most patients are at the surgery centre for several hours.  

General anesthetic will not be used unless there are special circumstances.  The anesthesiologist may give you some medication to relax.

Cataract removal is day surgery and you will not be admitted to a hospital unless something very unexpected was to happen. 

Lots of folks are very queazy when it comes to their eyes.  When they come back after surgery... it is always "Well that was not so bad!"

 

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How many appointments / visits is cataract surgery?

How many appointments / visits is cataract surgery?

In this area, the number of surgeon visits is typically 3 + 2 Optometry co-management visits.  The number depends on the surgeon and co-management arrangements at other clinics (such as ours).

Surgeon visit #1 – consultation to assess cataract and ocular health / prioritize / educate on options

Surgeon visit #2 – measurements done for lens selection (typically done with technician)

Surgeon visit #3 – surgery day (some surgeons do a later-same-day follow-up)

~Surgeon visit #4 – possible next day visit to surgeon’s clinic or co-management facility

Visit #5 – possible 1 week visit to surgeon’s clinic or co-management facility

Visit #6 – 1 month follow-up and refraction (new glasses prescription)

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Why are drops used before cataract surgery?

Why are drops used before cataract surgery?

Some surgeons will ask patients to use eye drops several days prior to cataract surgery.  These drops help reduce the risk of infection and post-surgery inflammation.

It is important that you follow the instructions exactly!  Not taking drops can lead to a last-minute cancellation of your surgery.

Also - it is a good practice to use non-preserved re-wetting drops prior to your eye measurements and also your cataract surgery.  Separate instilling these drops from the prescription medications by at least a couple of minutes or you risk diluting the medicine.

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How is modern cataract surgery done?

How is modern cataract surgery done?

There are lots of online highly graphic surgical videos but the KISS explanation that I use in clinic is:

Step 1] In a sterile specialized operative suite – day surgery – no general anesthetic
Step 2] Lots and lots of drops to numb the eye, sterilize the area and dilate the pupil
Step 3] Lots of bright light!
Step 4] Ultrasound or laser is used to break up natural lens which is then removed through small incision
Step 5] The implant lens is inserted rolled-up and unfolds to the same space which held the natural lens
Step 6] Lots of drops to control healing, pain and infection risk

Remember - You are in the hands of a skilled surgeon or I would not have referred you there!

See the end of this simple whiteboard video as well...

 

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I only see well from one eye – I am scared of having any surgery to my good eye!

I only see well from one eye – I am scared of having any surgery to my good eye!

Having poor vision in one eye due to injury or lazy eye (amblyopia) certainly increases the anxiety of having cataract surgery.   I typically advise to wait until surgery to the ‘good’ eye absolutely needed (e.g. driving requirement).

Obviously, the actual procedure has no more risk that normal… it is the understandable anxiety that needs to be added into the equation as to when to do the cataract removal.

Sometimes there is an argument to do cataract surgery in a poorly seeing (amblyopic) eye.  If your prescription ended up very different between your two eyes post-surgery… this can introduce perceptual, vertigo and balance issues.  It depended how much the poorly seeing eye was actually being used vs. suppressed pre-surgery.

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Can I go blind from cataracts or cataract surgery?

Can I go blind from cataracts?

Not all cataracts progress to completely limit sight.  However cataracts often progress to a level that severely limits daily functions like driving, reading and watching TV.  It is loss of this functional vision that motivates even the most nervous folks to proceed with cataract surgery.

I tell patients that if they had to choose something wrong with their eyes... cataracts are the best choice.  Cataracts are 'easy' to fix compared to most other eye health issues.  Results from cataract surgery are very predicable and successful.

 

Can I go blind from cataract surgery?

As with any surgery, you will discuss all risks with your surgeon’s team prior to you agreeing to proceed with surgery. 

The most serious complication of cataract removal that will be discussed is endophthalmitis.  This is an infection inside the eyeball and can be sight threatening.   In thousands of cataract surgery co-managements, I have never seen this in my practice but it certainly will be discussed as a risk.

The most common complications that I see are: Increased eye pressure (treated with drops), retinal inflammation (treated with time and/or drops) and foreign body sensation (treated with drops and time).

 

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Are my cataracts and my glaucoma related?

Are my cataracts and my glaucoma related?

Sometimes.   There are eye conditions (e.g. pseudoexfoliation syndrome) in which these typically unrelated ocular pathologies are very much related.  These conditions must be identified early and treated accordingly by your eye care professional team.

The typical form of glaucoma is unrelated to cataract.  Although not a treatment for glaucoma, removing the natural lens of the eye can increase intraocular fluid outflow and lower pressure.

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When should I do cataract surgery?

When should I do cataract surgery?

There is no exact answer here.   The factors that are typically considered are :

1] Visual Acuity.  
Albeit low risk, there are risks involved with cataract surgery.  The benefit of the surgery has to exceed the risk.  A decision to proceed with cataract removal is based on many factors but in general terms, most surgeons in this area will discourage a patient from proceeding until visual acuity falls below 20/50-ish.

2] Visual Demands and motivation
If you are a retiree and spend a limited amount of time at a computer, your visual demands may make it acceptable for you to tolerate less-than-perfect best vision.   If you are working as e.g. a full-time accountant or transport truck driver, your high visual demands would require you get cataract surgery sooner.
Some folks are just simply queasy about eyes and have low motivation to proceed.  You can procrastinate with cataract surgery (most) without worry however there will likely be a point where the procedure simply needs to be done (e.g. failed driving requirements)

3] Status of other eye
If you see well from your other (no or low cataract) eye.   There may be less rush to a surgical solution.

4] Driving status / Caregiver status
If you have a standard driver’s license or a special license or if you are caregiver to others… these things should be taken into consideration for when to do cataract surgery.

5] Symptomology
Years of looking in eyes has taught me that you cannot always predict someone’s symptoms based on the objective look of the cataract.   Some folks have minor cataract changes but are devastated by the blurry vision.  Others have what objectively appears as a advanced cataract, but are getting along fine with their day-to-day lives.    With low symptomology, a surgeon is much less like to proceed.

6] Interest in enhanced refractive improvement
For a patient to consider the increased expenses of enhanced cataract procedures, they are generally going to be highly motivated and anxious to proceed as soon as possible.

7] Secondary ocular health factors
There are some eye conditions where removing cataract early is important.  If the surgery is left too long, there is greater risk for a poorly placed or dislodged implant.  Your doctor will tell you if you have a condition that requires early cataract surgery.

8] Payor
Albeit a controversial topic, payors can influence decisions when cataract surgery is done: Personally funded vs. co-funded vs. government-funded vs. third-party funded
Payors also ultimately influence the type of cataract surgery: Basic vs. enhanced (premium or astigmatic or multifocal implants)

9] Large prescription swing of one eye
As a cataract develops it can cause a large shift in a prescription.  E.g. If one eye experiences a dramatic nearsighted shift the imbalance will not likely be tolerable and cause issues that are hard to fix with glasses.   The recommended solution is to restore the right/left balance through surgery to one or both eyes).

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