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John C Hagan III, MD, FACS, FAAO  
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Kansas City, MO

Specialties: Ophthalmology

Interests: Eye-Medical Blog

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Timing of Cataract Surgery and High Myopia

Apr 07, 2010 - 12 comments

There is no universal time to do cataract surgery. The cardinal rule is that when the person is unable to do the things they need to do (drive at night, read, see clearly for TV, movies, perform their work) and the things they very much enjoy doing (crafts, hunting, shooting, sports, taking trips, going to friends and church at night) and the cataract is the only problem or the main problem then surgery is indicated provided the person understands the risks and the alternative of not having surgery. (In some cases there are risks to understand of NOT having surgery such as the cataract getting to hard [increases the risk of surgery], too 'ripe' [rare in the US but a big problem in so called third world countries requires emergency surgery], not being able to pass a drivers license, pilot's license, commercial driving license, increase risk of falls and disorientation in the elderly.

If there are other problems in the eye such as macular degeneration, glaucoma, diabetic retinopathy or maculopathy, amblyopia, etc. the problems will still be present after the surgery and will affect the final result. When groups of people that have had cataract surgery get together and talk about their results the variation in the final results are usually not due to complications but that those with poor vision post operatively have other problems in their eye that the cataract surgery did not, as was not expected to help.

Having said the above a commercial pilot, over the road trucker, a person that works at night, taxi drivers, etc will need cataract surgery at a relatively early stage to do their work safely and meet their job requirements. A person in their late 80's to early 90's that doesn't drive, doesn't read, rarely goes out of their house, that has multiple other physical or mental problems will likely not be bothered by a relatively large cataract and the best course of action may be to leave that 'big' cataract alone.

With your high myopia your vision was likely never a crisp 20/20 and never will be even with successful cataract surgery due to the myopic macular degeneration---something that can worsen with time. You are also at an increased risk of retinal detachment. (please see previous postings on vitreous detachment, retinal detachment, flashes/floaters/curtain & veils) on the ophthalmology website, the eyecare patient forum, use the "search feature" on the site.

Cataract surgery, even successful small incision surgery increases the risk of retinal detachment by as much as 5-10 times normal. (rough estimates 1 in 3-4 thousand for people not having had cataract surgery and no major risk factors to 1 in 500 or even less after umcomplicated surgery). Your risk without cataract surgery can be as high as 1 in 200 to 1 in 500. After cataract surgery your risk may be as high as 2-3%.

Provided you understand these risks you would be a candidate for cataract surgery anytime your feel it is a major problem as outlined above and your eye surgeon agrees.

This is what I do in my highly myopic patients that are considering or have decided to have cataract surgery.

1. I give them detailed "informed consent"
2. I sent them to a retinal specialist for a second opinion abour cataract surgery and a special detailed examination of the retinal looking for holes, tears, thin areas, vitreous traction, existing small retinal detachments. If these are present the retinal specialist will often use laser or a freezing treatment to bolster or strengthen these areas.
3. The surgery is done using several special techniques that lower the risk of surgery in the highly myopic.
4. I see the person more often than my regular patients. The myopic patient knows the symptoms of a possible retinal detachment (flashes, sudden increase of floaters, loss of peripheral vision). I instruct the patient on "finger counting visual fields" and have them check their peripheral vision at home daily.
5. At one week and 6 weeks the patient sees the retinal specialist to repeat the special examinination of the retina looking for new problems--if present they are treated.

I believe that is the information your need. If your vision is a big problem (not a small or medium size problem) and the cataract is the main reason and you have confidence in your surgeon and the surgeon agrees that surgery would be beneficial (BUT NO SURGERY IS EVERY RISK FREE) then you may want to proceed with the surgery.. (the risks are much, much less now than say 10-15 years ago due to better techniques). Because of your age (young) your will in all likelihood need cataract surgery sometime.

Good luck.


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by MortyS, Apr 08, 2010
Thanks, Dr. Hagan, but from a patient's point of view, cataract surgery is promoted--or suggested to be--almost a slam-dunk procedure. Take a look (I'm sure you already have) at information pamphlets, cataract surgery information in general on the Web, and the often-repeated "cataract surgery is the most-performed surgery of all," and you'll see--or have seen--how a patient can go into it naively, as I did, then had a ruptured lens capsule. Even my later surgeon for my other-eye cataract surgery has a pamphlet that would put almost every potential patient at ease--which is probably the point. If I knew of possible complications before my first cataract surgery, I would STILL have had it, but I would have worried more. Personally, I like to know possibilities, even if I don't like them, but I think most people would rather not. Best wishes, Morty S.

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by Echoetal, Oct 28, 2010
Thank you for this  information.  I am in the process of deciding on IOL's for cataracts.  I was not happy with the first Dr. recommended by my regular eye doctor and sought a second opinion.  I was treated by Dr. Foote as an intelligent human being, educating me in the procedures and types of lens' available without strong arming.  He did offer me choices starting with the basics on up to the premium including their pros and cons.  Now it is up to me to decide.  The first Dr. didn't give me information, gave me two choices of a regular lens for distance or a premium name brand lens, ran his patients through an assembly line like process and had no time or inclination (it seemed) to discuss or inform.  I was not willing to trust my most precious gift of sight to such a person.  

I use the internet and sites such as this one to help me make decisions on which vacuum cleaner is a good value to issues on health.  Comments from the public forums run the gamete from love it to hate it and everything in between.  I take into account whether the person is just ranting or has viable information about specific issues.  Yet it is still up to me to make my own decision using my list of questions presented to my doctor and his advise to trust that I made the best choice possible at the time.  These sites cannot and do not stand in place of ones own real life physician.  People who use it as such are doing themselves more harm than good.  Thank you for your honesty.  Echoetal  

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by my2eyes, Oct 28, 2010
Echoetal - I would take this decision VERY seriously!  I wish that I was more informed before I had my surgery.  I had my left eye done in May, and have regretted it ever since.  I assumed that needing reading glasses meant just for reading.  Unfortunately, it means a distance of about three feet.  Also, wearing reading glasses isn't always feasible.  To put eye make-up on is just about impossible.  Shaving in the shower is now more dangerous than I imagined.  To see an alarm clock in the morning takes coordination, when I'm not fully functioning (I need to close that eye, but when half asleep I naturally close the wrong one and cannot see a thing).  Though it's humorous, it gets to be aggravating.  Also, the worst happened to me last week.  There was an eyelash in my un-operated eye and could not see from operated eye well enough to remove it.

I don't want to sound so pessimistic, I know that none of these things are the end of the world, but they are only examples and are extremely frustrating!!  Perhaps you should take into consideration your age and activities that you are involved in.  I am 36 and still have young kids, so maybe I find it more frustrating than others may.  I admit that part of the frustration is the surprise factor.  I didn't realize how much it would effect my day - all day.  I also was under the impression that my distance vision would be great, so something like an alarm clock far away would work, but it doesn't.

Please look into all options carefully!  Good luck in whatever you decide!!!

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by Fleetfoot197, Dec 09, 2010
my2eyes.  Have you tried a big magnifiying loop for makeup, eyelash removal etc.  You might want to give it a try.

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by FallsChurchVA, May 18, 2011
I'm in a quandary and would appreciate some feedback. I'm a 53 year old female with a recent diagnosis of cataracts. I have other extenuating circumstances and am having difficulty deciding on the type of IOL to get for the best long-term results based on my history. This includes:

o Life long high-end myopia (started wearing glasses in 4th grade)
o Had prior LASIK on both eyes in 1996 at Kremer Eye Associates. At that time, my RX was -15 diopters prior to LASIK
o Since LASIK, have had fluctuating and worsening vision.    
o Currently wear gas permeable contacts with monovision
o I have ruled out the asperic implants in movovision style due to several factors including issues with depth perception  
o Had recent consult with retina specialist due to some concerns my opthalmologist had and was okayed for the cataract surgery.
o I do have astigmatism (not certain of the degree)
o My job involves working on the computer 8 to 10 hours per day. I am in front of a computer screen for 40 - 50 hours per week and do not want to be constantly bothered by having to wear reading glasses.

I am leaning toward the Crystalens which will cost me $6,000. This is the same amt. I paid for LASIK. I've noticed that not once has the facility followed up to track LASIK on high myopic patients. I do not want to contend with more problems after the cataract surgery that could have been prevented?

What is the best IOL for my situation? Thanks!!!

Paula - Falls Church, VA

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by hictx, Jun 05, 2011
Paula,

My situation is very similar to yours.  I am very near sighted with astigmatism since 4th grade.  I wear gas permeable contacts and work in front of a computer all day.  I recently consulted a cataract surgeon.  He said I should go with the basic IOL not Crystalens.  He said Crystalens will complicate the accuracy of vision correction.  The result will not be satisfactory.  I have not made a decision yet.  I would like to hear other people's experience.

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by Barbarella1880, Aug 26, 2011
My situation is also similar. I'm a 53 year old female, glasses since 4th grade, very near sighted, work on computer all day. I was diagnosed with cataracts a year ago. A few months later, I was diagnosed with myopic degeneration. I put off cataract surgery for 6 months while the myopic degeneration stabilized. I'm now ready for cataract surgery. My ophthalmologist recommended a standard/basic IOL or Crystalens. I saw another doctor for a second opinion. He said he would not recommend any kind of multifocal lens, only a standard/basic lens. I didn't completely understand why, but he said something about if my myopic degeneration worsened, the multifocal lens would not allow as much light to enter my eye as the other lens.

Did you have the cataract surgery yet? Which lend did you choose and how is it going?

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by john171, Sep 09, 2011
Hello Doctor,

I have a lazy eye which I have had all my life. I was due to have cataract surgery in that particular eye, but chickened out when I thought it may create double vision. I notice that the eyes don't line up and the doctor said perhaps prism glasses or eye muscle operation would help IF the double vision continued for a while after the operation. Was I right in not having the op? I have lived with one good eye all my life, and I need to be without glasses for my work. I am 64.

John

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by Zeeshanhaider, Sep 24, 2011
My both eyes are highly myopic since early childhood. I was wearing glasses since then. Particlularly my left eye is very weak and I can see only 10% through this. My right eye is better but still weak. I am wearing glasses with high powered lenses. In 1995 I had Excimer laser done in both eyes which stablized the vision. In 2010 I started experiencing blurry vision and I am experiencing vision problems since then. I consulted a few opthalmologists in my area and they diagnosed that I have catracts in both eyes. SInce, I am limited to my right eye due to very weak left eye and there is a chance to retinal detachment during surgery, I am much concerned about my furture. I am willing to travel to Kansas to get an opinion with you Dr. Hagan. Is it possible that you can respond to this blog entry and I can work to get an appointment with you. My email is ***@****.  

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by sunilkhera57, Jan 07, 2012
hello Doctor,

I am 26, male. I got my specticals with minor number when I was 12 years old. Now my Right eye number is 10, and left eye number is 4. Sometime I feel double vision, All the time lot of stress on my eyes. Still  in this age number is incresing and doctors say they can't stop it. It incresed like .25, .5 1, 2, 2.5 ...........now its 10.

Doctor Please suggest I am lossing my vision.

Regards,
Sunil

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by DrForEyes, Nov 25, 2012
The idea that cataract surgery should be entertained at the age of 90 is simply wrong. Highly myopic individuals develop visually significant cataracts at an earlier age than their emmeatropic peers. Waiting twenty years longer than necessary is not good advice at all.

Modern IOL calculations and measurements provide highly accurate results.

Post LASIK patients present a different situation since IOL calculations do not have the same level of accuracy.
But these patients should already know about this since LASIK surgeons have known about this for over 15 years.



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by penken, Feb 08, 2014
I am happy to have found this blog. I am a 53 year old female, highly myopic.   Glasses at age 2. Which  now is thankfully is correctable with contact lenses. -19.50 in R eye and -19 in left. I also have intermittent strabismus. I did 40 weeks of vision therapy a  year  ago. I am now able to tell when my right eye is on.  I had   2 strabismus  surgeries at ages 6  & 8. Right ye turns in if it isn't on and left eye turns in when R eye is on sometimes. This being said, I have developed cataracts and I was seeing double in L eye due to cataract.  I had successful cataract surgery last week and I am thrilled to see very well in the distance range, but I am disappointed with having to wear reading glasses. I had a standard IOL put in left eye, mild astigmatism.  The glare from lights  and headlights has I improved since cataract was removed, but  some long glare is still apparent along with some halos still remaining.
I am scheduled to have the R eye done at the end of the month. I have changed my mind twice on whether to have a lens put in for near or far vision.  I met with my long time eye doc to get an opinion.  My R eye has a  moderate astigmatism which he will work on with laser to correct.  
I am concerned that my eyes will not team and I will have constant eye turning in if I choose to have near vision in right  eye. I need another opinion and was hoping you coukd give me sone advice.  Thank you for your time.  Sorry for such a long post. I am so thrilled with the technology that has changed my life, just want to make the best decision.  
Penny

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