Cataract Surgery

Everyone over age 40 has cataracts. The human crystalline lens is only completely clear until that age when it starts developing yellowing, clouding and hardening. These opacities are referred to as "cataractous lens changes" or simply, cataract. Early on these minor lens changes don't cause any perceptible visual decrease for the patient, so no therapy is needed. As the clouding increases however, visual tasks become difficult and at some point cataract surgery is needed to restore vision. In fact, the need for cataract surgery is so common, that it is said that everyone will need cataract surgery if they live long enough. Sufferers usually describe the condition as being similar to looking through a piece of wax paper, or a gradual blurring or dimming of vision. Reading, computer use and TV watching may become more difficult, and driving a car, especially at night, can actually become dangerous. Cataract patients may also be troubled by bothersome glare, halos around lights, or even double vision. As the cataract becomes worse, frequent changes in eyeglass prescriptions may become necessary.

Currently there are no medical treatments to reverse or prevent the development of cataracts. Once they form, there is only one way to achieve clear vision again, and that is to physically remove the cataract from the eye with surgery. Cataract surgery is for those who:

• Find that their quality of life has been impaired by poor vision
• Have been diagnosed with cataracts
• Are willing to undergo a short, usually painless surgical procedure to restore vision

The art and science of cataract surgery has progressed dramatically over the last thirty years. Years ago, patients were practically blind before surgery was considered, because surgery was riskier, took a long time to heal, and visual results were imperfect.

Nowadays, surgery is quick, relatively painless, much safer, and with vision results that correct not only the cloudy lens, but nearsightedness (myopia), farsightedness (hyperopia), astigmatism and presbyopia (loss of ability to focus) as well.

Surgical Experience

As opposed to years gone by when cataract surgery was done in the hospital on an inpatient basis, surgery at Virginia Beach Eye Center is now done at our in-office, state licensed, Medicare accredited and AAAHC certified ambulatory surgery center. This center was designed from the ground up as an eye center of excellence, and was the first eye surgery center in southeast Virginia with these credentials!

Our surgical suite contains all the most advanced eye surgery instrumentation available to insure a high quality surgical experience with the best results possible. We have a truly attentive and caring staff, who will be familiar to you since they are some of the same professionals who you have seen on the "clinic" side of our comprehensive practice during your office visits. We enjoy an extremely high patient satisfaction rate with regular praise about the ease and comfort of the surgical experience.

In our center, the surgery is performed with a mild sedative that you take orally, instead of the IV required in the hospital. We find this oral method to be just as effective as IV medication and eliminates, from most patient's perspectives, the worst part of the surgery. We then use very effective local anesthetics on and in the eye to prevent any significant pain during the procedure. These numbing medicines are simply dropped onto the eye and irrigated into the eye without needles. The surgery is performed beneath an operating microscope with the patient lying down in the "face up" (supine) position. During the surgery which takes about 15 minutes, the patient usually will see lights, colors and movement, but cannot make out any surgical detail.

The surgery itself involves making tiny, painless, self-sealing incisions in the eye followed by removal of the cataract with automated instrumentation and technique known as phaco-emulsification, an ultrasound method of lens removal. Here at VBEC, we use Abbott Medical Optics newest cataract removal unit, the WHITESTAR Signature™ with Ellips™ Transversal Ultrasound technology and Fusion™ Fluidics, one of the most technologically advanced units ever achieved. In modern cataract surgery the cataract is now disassembled, instead of completely removed as it was in years gone by. To visualize this, think of the cataract as if it were a cherry. First, we remove a circular piece of the front skin of the cherry with precise instruments. Then we scoop out the pulp and the pit of the cherry with our phaco unit and polish the back skin of the cherry with a diamond dusted cannula. Finally we implant our intraocular (IOL) lens inside this cherry skin "bag" where it becomes "shrink wrapped" inside the original lens covering. This is the best place for the IOL, as it becomes very securely fixed to the eye, is perfectly centered, and is in a very "biocompatible" position. An "immune privileged" space inside the eye where your immune system doesn't recognize it as a foreign object.

After surgery most patients notice an immediate improvement in vision with some mild blurriness and scratchiness that resolves overnight. You only stay in the post-operative recovery area a few minutes. Just long enough to have some juice, check your vital signs and go over your post-operative instructions. You are required to have a friend or family member drive you home because of your pre-operative sedation. You'll come in the next day for a brief post-op visit to see your surgeon, then usually a final post-op check at 4 weeks. If the other eye needs surgery, this is most commonly scheduled for 4 weeks after the first eye. This healing time between eyes allows us to check the refractive status of the first eye and adjust the IOL power for the second eye, improving the overall post-op vision result.

Patient Choices
One of the great things about modern cataract surgery is the ability to correct refractive errors like nearsightedness, farsightedness, astigmatism and presbyopia (loss of ability to focus) at the same time that we remove the cloudy lens. After surgery patients are often amazed by their visual clarity, even without glasses! Part of the reason for this marked improvement, is the development of intraocular lens implants (IOL's) that can help to bring back the vision of youth.

Here at Virginia Beach Eye Center, we utilize the Tecnis™ aspheric IOL designed to reduce some of the visual aberrations that occur with age. Before this IOL was developed, lens implants were only spherical (like a ball) in shape. This contributed to the overall "spherical aberration" of the eye, decreasing visual quality. The Tecnis™ aspheric IOL was designed to reduce this aberration, improving quality of vision and visual performance. The Tecnis™ IOL was the first designated as a New Technology IOL by Medicare (NTIOL) and was rewarded increased reimbursement on that basis. During the FDA trials, patients with this new technology in place were able to make an emergency stop in driving simulation tests much quicker than those with a standard IOL, increasing the safety of the driver, passengers and pedestrians. Learn more >>

The standard IOL (including Tecnis™) paid for by health insurance is a monofocal lens. This literally means one focus. Patients choosing this technology have three choices regarding IOL power and post-operative focal length when they are not wearing glasses: 1) Both eyes set for distance, 2) Both eyes set for near (reading), and 3) One eye set for distance, and one set for near, known as monovision.

Both for distance--Post-operatively these patients will usually have excellent distance vision without glasses and require reading glasses for all their near activities including reading, using the computer, etc. Often patients can just use inexpensive over-the-counter reading glasses. Some patients, even though they have good distance vision without glasses, will still use bifocals for the convenience of always having their reading glasses on, so they don't have to go find them or hang them around their neck. 90% of all monofocal IOL patients choose this setting.

Both for near--Patients choosing this setting are almost always lifelong nearsighted individuals who have always been able to see well to read or do near work without glasses. They have been naturally always set for near, and comfortable with their nearsighted focus. They are often patients who love doing near tasks such as reading, sewing, doing puzzles, and other near activities. They usually want to continue to have excellent near vision without having to focus and have not experienced monovision. Post-operatively they will need to wear glasses for all their distance activities including driving, watching TV, etc. Some will wear single vision, distance only, glasses when needed. Others will wear bifocals for regular distance and near vision, but remove their glasses when doing any prolonged near tasks. Only about 5% of monofocal patients choose this post-op result.

Monovision (One eye set for distance / the other for near-reading)--Monovision means one eye set for distance vision and the other eye set for near vision and reading. This is done in an attempt to significantly reduce the need for glasses in most daily life circumstances. Most patients who are successful with monovision are glasses free, except possibly driving at night or for detailed 3 dimensional near work such as sewing, woodcarving, etc. Usually the dominant eye is set for distance and the non-dominant eye is set for near vision. Find out more »

Advanced Techniques

Limbal Relaxing Incisions (LRI)--Correction of Astigmatism--In cataract surgery, the most important problem that we are correcting is the clouding of the lens by removing it and placing a crystal clear intraocular lens implant (IOL). This takes away the vision loss caused by the cataract. The second most important part of the surgery is taking away significant nearsightedness or farsightedness by calculating the proper power of the IOL for your eye that will give you good vision (at the focal length you choose). This calculation is generated using very sophisticated laser equipment to measure your eyes unique characteristics, and then plugging this data into advanced mathematical modeling formulas.

If your eye has significant astigmatism however, simply removing the cataract and correcting the nearsightedness or farsightedness with the IOL will not completely clear your vision. Patients with astigmatism have a congenital abnormal curvature to the cornea (front part of the eye), which causes the light from an object of regard to be out of focus. Fortunately, we are now able during cataract surgery to correct astigmatism using tiny peripheral corneal incisions (LRI) that don't materially add to the length or risk of surgery. This technique can significantly improve the likelihood that you will be glasses free for your desired focal length. This surgical correction of your astigmatism is not covered by any health insurance since it is considered "non-medically necessary". We do offer commercial medical financing for these life changing procedures. Learn more about LRI in our LRI Information and Consent section.

Crystalens AO™ Accommodating Lens Implant--Correction of Presbyopia--The "final frontier" in cataract surgery and really ophthalmology in general is the surgical correction of the loss of focusing ability of the human crystalline lens. Crystalens AO™ addresses this issue by giving us the first focusing lens implant in the world. We can now correct the cataract blurring by removing the cloudy lens, the nearsightedness or farsightedness by adjusting the IOL power, the astigmatism by performing LRI, and presbyopia now by implanting Crystalens AO™. This lens implant has a proven but limited amount of focusing ability, so we often correct one eye more for distance and the other eye slightly more for near. This is termed "blended vision" and does not have the same difficulties with adaptation as we see in the full monovision method (one eye set for distance, the other set for moderate nearsightedness). This is because the power difference is much less. Often less than the patient had naturally prior to surgery. This method allows us to achieve a better range of vision and produces the highest patient satisfaction possible. Learn more »

Now fast forward several years later and the "emperor has new clothes", with several "new technology" multifocals being introduced including Restor™, ReZoom™ and the Tecnis™ Mutifocal with huge advertising budgets behind them and paid experts galore touting their benefits. And once again, Dr. Garrett is seeing a steady stream of unhappy patients from other eye surgeons who have received multifocals, asking to have their multifocal IOL's removed. There are certainly patients that are very happy with their multifocal implants. But here's the rub....you can't tell who is going to be happy and who isn't going to be happy pre-operatively, and if you're not happy it means another operation to remove and replace the lens that your current eye surgeon may not be willing to perform!

The problem with multifocals is not the particular lens used, it is the optical abnormalities that occur when any multifocal IOL is used. A multifocal IOL has ridges or rings of different power built into the lens to focus both distance and near light onto the retina at the same time. This means that only half the available light focused onto the retina is from each position. This degrades the image quality significantly causing blurred images and decreased ability to see well in low light situations. The rings in the multifocal IOL also cause halo-like rings of light to be seen around all point sources of light at night time, such as headlights, street lights, stop lights, etc. These optical problems with the multifocal lens never go away, and it is true that many patients adapt to them over time, but some have permanent bothersome side effects, and some can even be seriously disabled. The really telling fact about multifocal lenses is that they are not used in astronomy, photography, television, the military, spectacles, microscopes and not even in ophthalmic instrumentation! This is because they produce a poor image compared with a monofocal (one focus) lens. Why would you want that type of lens implanted in your eye? The Crystalens AO™ implant has all the advantages of a monofocal IOL, with the addition of focusing ability to help you see better at near, far and everything in-between. And with the latest version, Crystalens AO™, this IOL now also corrects for spherical aberration (like the Tecnis™ IOL) resulting in even better outcomes! ]

The upgrade to Crystalens AO™ implantation is not covered by health insurance as it is considered a non-medically necessary procedure. If limbal relaxing incisions (LRI) are needed to correct astigmatism, they are included in the upgrade fee to Crystalens AO™. We do offer commercial medical financing to help our patients afford these life changing procedures. Learn more about Crystalens AO™ at crystalens.com.

Successful Cataract Surgery
Everyone heals somewhat differently, but almost all cataract patients report improvement in their vision almost immediately after the procedure. Most patients return to their normal work and lifestyle routines within a day or two. According to a survey conducted by the American Society of Cataract and Refractive Surgery, more than 98% of cataract patients have their vision successfully improved after surgery. Many patients experience vision that is actually better than before they ever developed cataracts. Once removed, cataracts will not grow back. About 20% of the time however, the thin membrane (called the posterior capsule) behind the lens implant clouds up, blurring vision. This can occur from days to years after the surgery, but is easily corrected with a very simple and painless laser procedure called posterior (YAG) capsulotomy. If needed the results of this surgery are usually permanent, giving patients a lifetime of better vision.

Insurance Questions
You may be covered! Medicare and many major insurance policies will pay for cataract surgery if your vision is sufficiently impaired. Once you have been diagnosed with a cataract in one or both eyes and before you have surgery, your insurance would like to know if you believe your vision is interfering with your daily activities. Please ask yourself the following questions.

• Do you avoid driving at night, or do you have problems with night driving because of your vision?
• Are you bothered by glare on bright days or with oncoming headlights at night?
• Are you having difficulty reading small print such as newspapers, books, or medicine bottles, even when you are wearing your glasses?
• Do you have trouble with close work, such as threading a needle?
• Do you have trouble recognizing peoples' faces from across the street?
• Have you experienced trouble watching television because of decreased vision?
• Are you having any other particular problems with your daily living activities as a result of poor vision?

If you answered "Yes" to any of the questions above, then you may benefit from cataract surgery. If not, then you may not need the surgery at this time. Because the surgery is almost always elective, postponing it usually does not present a risk to the health of your eyes. We urge you to discuss these issues with your physician.

The Choice Is Yours
It can take months or years for a cataract to develop. How do you know when it is time to have a cataract removed? The answer is quite simple. The time to have your cataract removed is when you believe your quality of life would be better if you could see better.

Contact us to schedule a free evaluation to determine if you are a candidate for cataract surgery.