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John C Hagan III, MD, FACS, FAAO  
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Consider ALL the Options Before Your Cataract Surgery: Working Through What’s Best For You

Aug 10, 2013 - 90 comments
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Decisions before cataract surg



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Consider ALL the Options Before Your Cataract Surgery: Working Through What’s Best For You

John C. Hagan, MD, Fellow American Academy of Ophthalmology, Fellow American College of Surgeons.

Many decisions have to be made before having cataract surgery. The first is whether you need the surgery or not. Assuming you have made the decision to have surgery this is a discussion of the many options and choices you have.  THERE IS NO “BEST” TYPE OF PHACOEMULSIFICATION CATARACT SURGERY AND NO “BEST” INTRAOCULAR LENS. NO TARGETED POST SURGERY REFRACTIVE ERROR IS FOR EVERYONE. THESE DECISIONS WILL VARY FROM PERSON TO PERSON AND MUST BE INDIVIDUALIZED.  

We all have different visual needs.  Cataract surgery will be done earlier on a person needing perfect vision in all lighting circumstances, think airline pilots, truck drivers and heart surgeons. Surgery is done much later, if at all, on the very, very elderly, functioning combative or uncooperative dementia patients, those with terminal illnesses. In general cataract surgery is generally offered when a person is experiencing moderate or severe visual difficulties in activities they enjoy or need to do and the cataract is the sole or main cause.

Although the person is usually the one that makes the determination about how much of a problem his/her vision is in some cases surgery is strongly recommended by the ophthalmologist, optometrist or family.  Examples include inability to drive safely or legally; difficulty seeing the inside of the eye, major progressive physical or psychiatric disease, and if center of the cataract is getting “rock hard” (so called ‘brunescent or brown/black cataract) or could start to break up in the eye (so called ‘too ripe’).

Assuming cataract surgery is appropriate, the decisions that must be made include: which eye to operate on first, what type of IOL to insert, desired-targeted post-operative refractive error, how much glasses will need to be worn post operatively [NOTE: glasses are almost uniformly needed post operatively and are usually modern progressive bifocals]  SOME OF THE TIME a small % of people after cataract surgery can function without glasses or with inexpensive over the counter reading glasses.  Equally important is the choice of surgeon-ophthalmologist (Eye MD: a physician Doctor of Medicine or Doctor of Osteopathy that has been to medical school, medical-surgical residency and in many cases taken a special surgical fellowship.  Ophthalmologists provide a complete range of medical and surgical services.  Eye MDs must be distinguished from non-physician optometrists (OD) and opticians).

This discussion is not meant to be encyclopedic nor to give you “the answer.” As stated previous “the correct” answer will be different for different people. Informative is based on the most common questions posted on the American Academy of Ophthalmology MedHelp Eye Forums.

1. Where there is a difference of more than 1.50 diopters between the eyes post operatively glasses are often difficult or impossible to adjust to. The condition is called "aneisometrophia".  Part of the problem is due to the difference in image size each eye has with the glasses on; this is called “aneisokonia”.  Seek out Eye Forum posts on this problem by JodieJ. She had this problem post operatively and she clearly outlines her struggle and eventual success.
2. With modern cataract surgery not only do we try and make the person see better but we want the best possible vision without glasses and the two eyes to "work together" comfortably.  Tests are done preoperatively to help pick the proper IOL power to leave a targeted post op refractive error. This is not an exact science and the margin of error is +/- 0.50 but INCREASES with high myopia (long eye) or high hyperopia (short eye), eyes with previous RK, lasik, injury or additional eye diseases.
3. Typically the targeted post op refraction is between 0.00 (not needing glasses for distances of 20 feet (6 meter) or more) and -3.00 which has great vision for tiny detail at reading distance 13-14 inches.  Any difference of greater than 1.50 diopter post op may have trouble with glasses (some people tolerate much larger numbers but you never know). The range of relatively clear vision without glasses on is called “depth of focus” and will vary from person to person based on things like pupil size and corneal structure.
4. Some people that are highly myopic or highly hyperopic that do not have cataracts elect to have the lens of the eye removed (same technique as cataract surgery) and an intra-ocular lens (IOL) put in to eliminate thick glasses and improve vision without glasses. It is called "clear lensectomy" or "clear lens cataract surgery” or “refractive lens exchange”. This is done to reduce the thickness of their glasses or make them much more glasses independent.  We are not discussing whether that is appropriate surgery. The IOL and refractive problems are the same as those having cataract surgery.
5. A refractive error that makes some people happy post cataract surgery and often enables them to function without glasses for many things is 0.00 in the dominant eye for distance and -1.25 or -1.50 for the "reading eye." In good lighting they often can read without glasses. With glasses (the RX would be 0.00 distance eye -1.50 near eye and reading add of +3.00 diopters and the type glasses a no line bifocal) The glasses would be worn when best binocular vision is needed e.g. driving especially at night, sporting events or sports participation (gives the best depth perception) and prolonged reading or computer use. (This is called mini-monovision with distance bias)  If a person wanted to shift the clearest vision to intermediate and near (example some accountants, engraver, graphic design artist) the numbers change: -1.25 intermediate vision and -2.75 or -3.00 for reading/near eye. The glasses RX would be -1.25 and -2.75 with +3.00 add in progressive bifocals.
6.   If the person having surgery has astigmatism (aspherical or not round cornea) then the glasses RX will need a "cylinder" lens (second and third part of RX indicated by “cylinder and axis).  The vision without glasses will be less clear due to uncorrected astigmatism.   Assuming our models listed in above example and 1.50 diopters of corneal astigmatism the mini-monofocal distance bias will be 0.00 +1.00 axis 180 and the intermediate/near bias eye will be -1.25 +1.00 axis 180 and a +3.00 add in no line bifocals. This is more blurry vision than 0.00 at distance or -1.25 for near/intermediate.
7. NOTE: glasses can be written in PLUS CYLINDERS OR MINUS CYLINDERS (you can tell which by whether the sign in front of the cylinder number is + (plus) or – (minus) The two formula look very different and prescriptions in plus cylinder cannot be compared with minus cylinder.  Think about your body weight: your weight numbers will look very different whether it is recorded as pounds or kilograms since 1 kg = 2.2 lbs.  A discussion of this subject and the formula for changing plus cylinder to minus cylinders or vice versa is available at   http://en.wikipedia.org/wiki/Eyeglass_prescription
8.  Correction of astigmatism at the time of cataract surgery is desirable.  There are different ways to accomplish this; some are simple while others complex. Some will not generate extra surgical or IOL fees but others will:  placement of incision along steep axis of cornea-make incision larger-use more steroid drops; surgical or laser corneal relaxing incisions; toric IOLs or toric mutifocal IOLs; rounding the cornea at time of surgery with brand new (2013) femtosecond laser; post operatively using  lasik surgery to remove residual astigmatism.
9. In cases where one eye has a cataract that is symptomatic and causing problems with important functions such as driving, reading, recognizing faces, glare avoidance, etc.  but the other eye has no cataract or a cataract that is small and not troublesome in people with large refractive errors special attention needs to be made to choice of IOL.   If targeting of the patient/surgeon desired refractive error post operatively generates a difference in the two eyes greater than 1.50 diopters, the person should know it may be difficult to wear glasses conformably and/or glasses (no line bifocals usually) plus a contact lens on the un-operated eye. Or  lasik or other post-operative refractive surgery may need to be done on the un-operated or operated eye to help them work together.
10. The problems outlined in #9 above may require surgery on the “other” eye to re-establish the ability of the eyes to work together with and without glasses. This can be true even if the cataract is small or even non-cataractous.  
11. So called “Premium” IOLs (toric, multi-focal and accommodating) are used to reduce dependence on glasses. For almost all people they do not eliminate glasses 100% of the time. Even people that consider themselves “not needing glasses after cataract surgery” often wear glasses for special purposes such as night driving and prolonged reading or computer use. Premium IOLs are more expensive, have a greater chance of complication (although in the hands of an experienced ophthalmic surgery the risk is small), and produce unwanted glare and scattered light (dysphotopsia) more than modern aspheric monofocal IOLs.  
12. It is also fair to say that some ophthalmology and optometry offices exert effort to encourage people to “upgrade’ from monofocal IOLs to “premium” IOLs. In sales this is not called “upgrading” but “upselling”. Also it’s important to know that some optometrists receive part of the surgical payment for cataract/IOL surgery, this is known as “co-management”.  Premium IOLs are not better than monofocal IOLs; they are not designed to make everyone 100% glasses independent all the time. Most ophthalmologists and optometrists do present a fair discussion of each type of IOL and let an informed patient make the choice that suits them best.
13. While cataract/IOL surgery is the most common type of surgery done on adults and has a very low complication rate it is not risk free NO SURGERY IS RISK FREE; THAT’S WHY YOU READ (or have read to you) AND SIGN A SURGICAL CONSENT FORM THAT INFORMS YOU OF THE DIAGNOSIS, YOUR OPTIONS AND POSSIBLE RISKS AND COMPLICATIONS. These risks cannot be entirely eliminated. No surgery is entirely “routine and risk free”   Think about driving an automobile. Driving is “routine” to most of us. Yet everyday there are people injured or killed in automobiles. We continue to drive because, with care, the risk is relatively low. Think of cataract surgery the same way.
14. In most all cases cataract surgery is elective. You can take your time and make these important decisions. There is nothing wrong with seeking a second opinion from a different ophthalmic surgeon. You can also access the many helpful discussions on these topics at the two AAO Medhelp Eye Forums by using the search feature or looking in the archives.

15. This information is not meant to give you specific recommendations. This posting is for information purposes only. You should rely on your own multi-source research and discussions with your ophthalmologist, optometrist and personal physician.







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by suezq56, Aug 12, 2013
Thank you very much for a clear and concise article.  It's very helpful.

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by caregiver222, Aug 12, 2013
An excellent article. Thank you.

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by ill13632, Aug 12, 2013
I'm very myopic, nearsighted, if I have lasik surgery will I possibly go blind or have retinal detachment?  Thanks very much!

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by radar7, Aug 18, 2013
I had a cataract operation done on my left eye as night driving was becoming a bit of a problem.  Developed negative dysphotopsia which I feel is more of a bother to me than the cataract that I had.  The consent form that I signed and the literature I was given to read pre-op never mentioned this problem at all. I find this very disappointing. I wish more doctors give patients the pros and cons of cataract surgery as you have done in this excellent article.

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by jerseygirl1046, Aug 20, 2013
My husband had retinal detachment surgery 8 months ago.  He has double vision now, what can he do?  Thank You for anything you can suggest, I am concerned about his driving.  He is 67 years old.

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by John C Hagan III, MD, FACS, FAAOBlank, Aug 20, 2013
Go to the community eye forum, use the search feature and archives and read about double vision and cataractd surgery. Go to www.geteyesmart.org and find a Eye MD ophthalmologist near you that specializes in strabismus/pediatric eye surgery.   Go see him/her for 2nd opinion.

JCH MD

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by zwar, Aug 21, 2013
Dear sir,
              I am 28 years old and having floughter problem in my right eye that make my job more complex while working in office on PC and one major think spot comes in front of my vision that moves after many tries to move eye from right to left then it disappear for sometime but appears again. I feel little bit heavy eye bearing some wait.so please let me know what should i do?

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by kpbf, Sep 02, 2013
by kpbf

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by kpbf, Sep 02, 2013
by kpbf, Sept. 2nd, 2013

Dear Dr. Hagan,
I recently had a tecnis Model ZMB00 Diopter +21.0 D +4D multifocal lens put into my right eye on Aug. 8th and then in my left eye on Aug. 22nd.  On my day after appointments, the doctor said I had 20/20 vision in both eyes.

Unfortunately, I did not do enough research before the surgery and now I am very worried that I made a mistake especially after reading your information above.  My right eye had a severe cataract but my left eye had a small one starting.  I said I would love to not have to use glasses and she said I was a perfect candidate for the multifocal lense. The doctor did not discuss my needs or the option of the distance only lense. She also said it would be much better if I had the second eye done quickly.  I should have waited to see how the first eye responded.  It has been 2 weeks and my reading vision is somewhat doubled or shadowed.  I can read the small print but due to it not being clear my eyes feel very strained.  My intermediate vision is poor.  My distance vision is good.  I test children and use the computer for my job therefore this is a serious problem.  I have ghosting and halos during the day which I have not read of anyone else having and severe halos, star bursting, and glare at night that is painful.  I can't even drive.  I live out in the country and have elderly parents.  

My doctor's appt. is this week.  I read an article by Dr. Rosenfeld outlining seven steps to take when caring for unhappy patients.  He said definitely do not have the YAG laser capsulotomy done if you think you may want the lens explanted.  He suggested residual refractive error, residual astigmatism, ocular surface disease, poor IOL centralization, and maculopathy as well as the posterior capsular opacification which involves the YAG laser.  What do you suggest?  Do you feel any of these suggestions will help? Should I avoid any others if I may want my lens explanted.

Can I have the lenses explanted and have distance lenses put in?  How soon would I have to have them done to avoid scar tissue?  What are the risks?  Will the distance lenses cause the severe halos and star bursts that I am experiencing?

Do you know of any eye specialists that do explants in or around Louisiana?  If not, who and where would you recommend?

Thanks so much for your help,
I have been so worried that I may not be able to drive at night!!!
Pam

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by John C Hagan III, MD, FACS, FAAOBlank, Sep 02, 2013
See what your surgeon says. Then get an independent 2nd opinion. LSU has a great ophthalmology department.

JCH MD

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by John C Hagan III, MD, FACS, FAAOBlank, Sep 02, 2013
This is faculty at LSU:



  

LSU Eye Center  





Clinical Faculty

Marie  D.  Acierno, M.D. - Neuro-Ophthalmology
Bruce A. Barron, M.D. - Cornea Service
Donald  R.  Bergsma, M.D. - Comprehensive Ophthalmology
Maria D. Bernal, M.D. - Cornea and Uveitis
Christine Connolly, M.D. - Comprehensive Ophthalmology
Ira  B.  Fuller, M.D. - Retina Service
Yen Ngo, M.D. - Glaucoma
P. Sean O'Sullivan, M.D. - Retina Service
Maria Reinoso, M.D. - Retina Service
Jayne S. Weiss, M.D. - Cornea, Cataract and Refractive Surgery
  
Dr, Jayne S. Weiss MD is the best match for you Pam.

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by kpbf, Sep 03, 2013

Thanks so much!
You are a wonderful person to take time out of your busy schedule to help us!
I had a wonderful quality of life and just want it back.

Sincerely,
Pam

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by dubois564, Sep 15, 2013
Dear Dr. Hagan,

Could you kindly recommend an ophtalmologist in Boston area who is specialized in high myopia and cataract?  

Thank you in advance.

Best regards,

D

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by John C Hagan III, MD, FACS, FAAOBlank, Sep 15, 2013
I do not know anyone personally there but Mass Eye & Ear is as good as they get.
JCH MD

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by AnnSalem, Sep 22, 2013
Dr. Hagan,
I very much wish I had read your article prior to my cataract surgery three months prior.  I had a Restore IOL implant with laser technology and anesthesia applied on a sponge in the eyelid.  My ophthalmologist was pleased with the healing progress, even though my vision still required quite a bit of correction with glasses.  My major concern is that I have experienced a pain in my eye since the few days after the weekly regimen of drops were discontinued.  I can best describe this as a nerve type pain on the cranial nerves on the right orbital side of my eye, and recently pain under the eye towards the bridge of my nose.  I have returned four times to the doctor who prescribed another week of Prednisolone.  This did not work.  The only thing that changes is the intensity of the pain from hour to hour.  Some days, I look at a clock to know when I can take the next pain reliever.  I have tried Excedrin, Ibuprofen, hydrocodone in one episode, ice pack, etc.  On my last visit, the ophthalmologist indicated he had never seen this and didn't know what to recommend.  At my suggestion, he ordered an MRI although he does not suspect this will show any answers.  Subsequently, I went to my internist who tried Celebrex for an anti-inflammatory and Afrin to take off any pressure under the eye.  This is only an experiment, as he expects I have nerve damage.  Next week, he wants to try Neurontin.  The Celebrix/Afrin is not helping.  I have been very patient thinking this was post op inflammation, but now I am fairly frightened that I have permanent nerve damage.  This level of pain is not tolerable long term.  Can you please advise me of appropriate next steps.  Are there cases of anesthesia causing nerve damage?  Any direction you can provide would be most appreciated.

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by John C Hagan III, MD, FACS, FAAOBlank, Sep 22, 2013
No none of the typical complications of cataract surgery include prolonged pain. Painful nerve damage persisting for long periods of time are unknown after cataract surgery. You would need to look for another cause (sinus disease, facial pain syndromes, cluster headaches, etc

JCH MD

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by Cataractjeweler01, Oct 23, 2013
Dr. Hagen,

I am a 37 year old jeweler who had a cataract in one eye. My Dr. Shoemaker in Sarasota fl, told my that the tecnis multi-focal lens was best to see close up. But now that I had it done I can not see the detail in which I could. But when tested by the card they give me to read I do much better. Even though I could not see out of my left eye will before now it seems it is disrupting both eyes when looking close up detail. I was offered to do a mon-focal lens instead. He suggested near vision and loss distance.  What do you think?

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by John C Hagan III, MD, FACS, FAAOBlank, Oct 23, 2013
The two eyes often fight one another with only one done that is called rivalry. You can try your work with a bifocal lens over the operative eye or even a jeweler's loupe.

I would suggest you get independent 2nd and 3rd opinion about your options. I suspect most will involve glasses some or most time  and/or surgery on the second eye if it has a cataract and you need more power for near vision in that eye.

JCH MD

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by Sparty1984, Nov 01, 2013
I'm 52 and scheduled to have cataract surgery soon, my right eye was measured at -17 dioptors with just under 2 dioptors of astigmatism ( this eye has a scleral buckle due to detachment 12 years ago). Left eye i believe was -14 dioptors with around 1.25 dioptors of astigmatism. I'm having the lensx procedure and was told that I would need a -3 lens but they only come in powers down to -6, this will be a acrysof toric lens for a target of -2 dioptors of myopia.  The left eye will have a non toric acrysof with the astigmatism corrected by the laser with target of Plano.  My doctors thinks this mono vision should work well and if I'm not satisfied we could tweak the residual myopia with prk later.  My question does this seem reasonable or should the lens selection for the right be a lower number that could get closer to Plano.  I'm just curios to other opinions on this.

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by John C Hagan III, MD, FACS, FAAOBlank, Nov 04, 2013
LE post op uncorrected refractive error of -3.00 and RE of 0.00  would be full mono-vision and is discussed in my blog article. It works for some people not for others.

JCH MD

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by Sparty1984, Nov 04, 2013
Thanks , should I consider a lowered powered non toric lens for the right eye and worry as much about the astigmatism?

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by Sfwolfe, Dec 04, 2013
Wonderful,informative article.  Thanks so much!

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by David274, Dec 05, 2013
After reading about increased incidence of complications with multifocal lens, I am rethinking having ReStor lens.  There seems to be less information regarding post-op experience with Toric monofocal lens.  I have astigmatism with -7,0 D and -7.5 D with glaucoma and cataracts in both eyes.  I am leaning toward Toric   The physician recommends cataract surgery on both eyes within one week interval.    Can you comment on Toric lens, and surgery interval?   Shouldn't I wait at least two to three weeks between eye surgery?

Thanks for providing a forum for discussion
David

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by John C Hagan III, MD, FACS, FAAOBlank, Dec 05, 2013
We use toric monofocal IOLS in our practice with much success. They are more predictable for correcting astigmatism than corneal incisions.  We do not operate on the second eye until the eye has healed and the patient is very happy with the result on the first eye;  generally we do surgery about 5-6 weeks apart.
JCH MD

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by fletch361, Jan 02, 2014
I am 52 years old and require cataract surgery on both eyes as a result of having vitrectomy surgeries on both eyes for macular holes (right eye 15 months ago -- left eye 6 months ago).  I am very nearsighted -8.0  in right and -7.0 in left per contact lenses prescription.  The holes closed successfully in the surgeries.  I have slight distortion out of center of right eye but overall can see pretty clearly with my contacts -- until cataracts started to form.  I am considering the Crystalens implants vs. standard lens to eliminate the need to wear contacts/glasses to see and hopefully may just need readers.  I am a computer analyst and on a computer 10 hours a day so need my near vision.  Do you have any advice on Crystalens?  The cataract specialist I am seeing does do laser cataract surgery as well and will correct slight astigmatism in my left eye.  In my online research I see very few success stories and more complaints making me skeptical; however most only post complaints.  Thank you.  Nancy

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by John C Hagan III, MD, FACS, FAAOBlank, Jan 02, 2014
Refractive and accommodate IOLs like Crystalens are NOT a good choice for someone with macular disease like you have (macular hole repair).  

JCH MD

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by John C Hagan III, MD, FACS, FAAOBlank, Jan 29, 2014
Just returned from a surgical conference in which the results of the femtosecond laser were presented and they were extremely impressive especially when coupled with intraoperative wavefront aberrometry and astigmantism correction at the time of cataract surgery. Anticipate more and more surgeons will be offering this technology which is NOT covered by most insurance plans resulting in out of pocket expenses increase.

JCH MD

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by penken, Feb 08, 2014
Dr. Hagan,
I cannot thank you enough for taking time to inform so many of us dealing with unusual vision issues.  I will be having a second cataract surgery soon, but I m going to postpone and let one eye heal. My surgeon seems to be rushing me to choose a prescription for my right eye. I am having difficulty deciding on the best option.  I m glad to hear of the successes of the femtosecond laser.  I will have an astigmatism corrected and an IOL put in after cataract is removed. Just wish I didn't need reading glasses but so thankful to see as I was a -19 in the L eye and now have 20/30 vision.  I could not qualify for the Toric lens due to high myopia.  I posted  my entire complicated vision story on another thread earlier  today.  I also have strabismus. Here is my story...
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.  
If I wanted a 2nd opinion here in the Jacksonville Fl area could you recommend someone? I am happy with my eye group of specialists, I just wish they were more forthcoming with information.  Thanks again.  Penny

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by John C Hagan III, MD, FACS, FAAOBlank, Feb 08, 2014
Glad you enjoy the article. I cannot give you an "opinion"  As indicated there are different answers for different people. If you and your surgeon really can't decide see another surgeon for a second opinion.
JCHMD

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by Terry132, Feb 21, 2014
I had cataract surgery on  left eye about 8 yrs ago with a lens implant - no idea what kind of lens. No problems with that eye since then. Cataract in right eye grew large until vision became blurry (especially if I covered the treated eye). Ophthalmologist said right eye cataract was large and recommended removal & astigmatic lens implant. Had surgery two days ago. After surgery doctor told me that 1) she decided against astigmatic implant and tried 'regular' lens; 2) eye tissue wouldn't hold 'regular' lens during surgery so she withdrew the lens. 3) she said eye was too stressed to insert lens 4) am now without cataract and without lens 5) she says to wait for about 3 or 4 weeks and then insert another 'regular' lens on the outside of the tissue (rather than the inside) 6) meanwhile, I am unable to work -- mostly I work at computer and am very uncomfortable. I am miserable and have 2nd post-operative checkup tomorrow.

I think I should get second opinion about how to continue to get right eye fixed.  Right now it is much worse than before surgery. What do you suggest? Can you give me any further information about this failure to be able to insert lens in eye?  Can the eye function reasonably well without a lens implant? I am 65.

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by OneEyedJill, May 23, 2014
OMG !!  Thank you, Dr. Hagan.  I have never read such comprehensive material about the many considerations involved in cataract surgery.    I think many of us worry that we won't receive such individualized treatment.  My mother, who had Alzheimers, refused cataract surgery from fear and distrust.  In the  late 1980s, she  went blind, and died with what I can only describe as a look of terror that I was legally helpless to prevent.  They say knowledge empowers, but  it doesn't necessarily remove the fear of making the wrong choices.   Still, it is  always better to know the choices and consideratons,  than to later wish I'd known  (-:

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by Fraidycat13, Jun 11, 2014
Dr. Hagan,  Interesting article. I have cataracts in both eyes and trying to decide if permaclear is the right choice. I read articles where people had crystalens or restore lens and had many problems with the crystalens. What is the difference between all 3, pro or con on them? What would you recommend to your patient?  Thank you.

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by John C Hagan III, MD, FACS, FAAOBlank, Jun 11, 2014
Read the article again you'll learn even more.  Our practice uses Crystalens. Personally I would never consider a ReStor IOL in my eye.  Since I am all about precise optics, good night vision and have worn glasses for 50 years I would not personally choose any multifocal IOL and would go with monofocal asphric IOLs like the Technis our practice uses.. However some people hate glasses are willing to pay a lot more to use glasses a lot less and willing to put up with varying levels of dysphotopsia. There are ophthalmologists that have had cataract surgery on themselves and have had ReStor and Crystalens put in their eye.

JCH MD

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by CurlyButterfly, Jul 12, 2014
Dear Dr. John C Hagan III,
   Would you be willing to read my post I've put on medhelp and give me your input? I've been emailing back and forth with a lady who has had similar eyes as mine who has already had surgery for cataracts (which has been helpful). I wondered what your opinion might be. I've read a lot that you've written which has also been very helpful. Here is the medhelp link: http://www.medhelp.org/posts/Eye-Care/Cataracts--Toric-IOL-for-Astigmatism/show/2231723

Thank you for your time, it is TRULY appreciated! My surgery is scheduled for the end of this month. Bless you for doing this work here on medhelp.org.

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by skigirl23, Jul 16, 2014
Gosh, thanks for the great article. I am an artist who has been struggling with what to do so that I will not loose all intermediate vision.  I am also an athlete and love the idea of skiing without glasses---although I already own the goggles with the fan!!  I will reread this article until I get it--thanks.

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by learyeyed, Oct 04, 2014
Dr. Hagan,
  I am a 70 year old female. My only eye problems are cataracts ( both 2+), astigmatism ( both about .75), hyperopia, and I assume presbyopia. Cataract surgery scheduled in a couple of weeks, with a top-notch surgeon MD, in cataracts, lasik,corneal transplant, femtosecond laser cataract surgery, and etc. He will be using the femtosecond laser machine for my surgery.  I want the best clearest crisp uncorrected distance vision possible. I use binoculars for bird, and wildlife watching almost every day, and I can not wear my glasses when I do, because of essential tremors, not being able to hold my hands steady, I hurt my nose with my glasses on. Binoculars have rubber cups.  I would like to be able to see to drive at night, (haven't driven at night for past 3 years). Would like to see better in dim light. I would like to read things on grocery store shelves without glasses, and see at least 11 to 12 feet away for watching TV, and being able to read the on screen guide, when in bed at night without glasses. I would not mind wearing glasses for closeup reading or the computer. I am very active, do all sorts of projects, closeup, like sewing, and far away, like playing golf.  This is what I can dream for, but in the end just be thankful for some kind of vision.  Multifocals and crystalens are out.  With the research I have done, I narrowed it down to toric or monofocal. With the low astigmatism, overcorrection would be a concern, with the toric. My surgeon uses both the Staar and the Tecnis brand lenses. Here is my problem. He wants to use the Staar toric AA4203TL or TF. I don't know which. I wanted the Tecnis toric ZA9003, but he did not want that one.  I think the Staar is inferior to Tecnis because of it being silicone, and all of its other past problems which you are probably aware of without my listing them. One of my concerns is if I would have an eye problem where they would have to use silicone oil in my eye. I can not understand why, with a brilliant of a doctor as he seems to be, why he would choose such and inferior lens which the Staar toric seems to be.  I like the Tecnis with the features it has, and it is aspheric. At my age I don't know if the feature of it being aspheric would benefit me in the long run.  I talked with my surgeons nurse again, and she insists he made the best call with the Starr toric. This is my second surgeon I have been to. The first one wanted to implant torics also.  I am worried about being overcorrected for astigmatism, and getting an older style lens with too many faults, like the Staar. I have already paid this surgeon fully for the toric upgrade so the money is not the issue, and I don't want to go through the hassle of a third opinion.  Should I just go with his choice and hope and pray that everything turns out alright or what. Maybe you or someone who posts on here can enlighten me. Thanks much.

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by John C Hagan III, MD, FACS, FAAOBlank, Oct 04, 2014
There is no best IOL or all surgeons would use it. Just like there is no "best automobile".  All of the lens you mention are by reputable companies with good quality control.  You have set up so many qualifications and stipulations that you have almost guaranteed that no IOL and no surgeon could meet all your expectations.

You can always step back, postpone surgery and get a third opinion.

You might re-read my article again. If both eyes are set for distance 0.00 you will not be able to see a TV set at 12 feet away clearly because "distance" is 20 feet and further.

JCH MD

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by Melliforte, Dec 04, 2014
Dr. Hagan,

I am planning to have cataract surgery in 2015 and came across your helpful and detailed article about the many considerations that should go into decisions made with regard to IOL replacement. I am very interested in the Bausch + Lomb enVista lens that was FDA approved in 2012 and would like to discuss its suitability for me with a surgeon in my area (Atlanta, Georgia) who has experience with it. Have you heard of or worked with this lens enough to have an opinion about it? Do you or does anyone reading this know of a surgeon in Atlanta who has experience performing enVista lens implants?

Bausch + Lomb enVista IOL:
http://www.bausch.com/ecp/our-products/cataract-surgery/lens-systems/envista-iol#.VIEHZFfF9cs

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by John C Hagan III, MD, FACS, FAAOBlank, Dec 04, 2014
Melliforte:   I trained at Emory Dept of Ophthalmology which is world famous. I do not know private practitioners to recommend but I'm sure there are many.  B&L is a quality company. I do not have any experience with the enVista lens.  I have seen hundreds of patients with acrylic lens with glistenings but never had a single complaint so I think the "sizzle" of this lens is overstated.

JHagan MD


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by Canesee, Jan 20, 2015
Dear doctor
I am 54 years old and my eyes were perfect up until I was about 42. Over the last few years they have got worse and I now use 3.0 reading glasses. My long vision has faded but is still ok. I am booked in to have oculentis m plus lens fitted to my right eye this Friday. Now reading all this bad feed back am very worried. Would you recommend this to save me from my reading glasses?
Graham


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by John C Hagan III, MD, FACS, FAAOBlank, Jan 20, 2015
This discussion is only for people with cataracts and reduced vision not corrected with glasses.  Near vision getting worse as we age is normal and is called "Presbyopia"

JCH MD

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by PenelopeLane, Jan 20, 2015
I had cateract surgery 6 days ago.    In addition to cateracts, my eyes have VERY narrow angles, and have been a source of agonizing pain off and on for decades.  The surgeons say that the new lenses will prevent an iridotomy.  After the first surgery of last week, I am seeing light streaks from all lights at night since the 2nd day.  All set for other eye surgery in 4 weeks, also at Wilmer in Md.   My question is simple.  Do light streaks ever go away on their own while the eye heals?   The eye was set for distance 24.0. It is an AcrySof  MA50BM.  

The right eye will be set for near distance only.  

Thank you for your help!


PL

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by John C Hagan III, MD, FACS, FAAOBlank, Jan 20, 2015
Please do discuss with your surgeon, Wilmer at JH is among the best in the world. The MA50BM is a high quality monofocal IOL not associated with a high incidence of "dysphotopsia"  (search the word and read about, I have published studies on same).  In most people these streaks go away as swelling decreases and any residual refractive error is corrected with glasses.

In most cases with monofocal IOL gone by 2-3 weeks post surgery.  Permanent dysphotopsia much more likely in multifocal IOLs like ReStor

JCH MD

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by PenelopeLane, Jan 20, 2015
Thank you.

I understand Wilmer is a superb Hospital, but it takes weeks for them to respond, which is very frustrating.  I have researched the lens only yesterday, but found nothing that indicated how long it could take.  Knowing the facts keeps me calm . . .

I do not want more troubles with my eyes.  Decades of it has been debilitating, and frightening.


Thank you for your kindness, Dr. Hagan.   I feel better!

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by John C Hagan III, MD, FACS, FAAOBlank, Jan 20, 2015
Every reason to suspect you will do well. JCH MD

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by Mizmo412, Feb 10, 2015
Thank you so much for the write up above.  My situation is addressed in #9; non-dominant eye has cataract ready for surgery, dominant eye has cataract as well, but not deemed as significant for surgery yet.  I have very good distance vision, and require +1.5 for reading.

The Dr was pushing ReStor, but I'm not willing to deal with the halos/glare or reducing the sharpness of my distance vision.  I've been trying contacts to mimic monovision and seem to be able to tolerate it.  

Dr is recommending -1.75 or -2.0 anticipating further denigration of my vision.  However, neither worked for me with contact trial; I was unable to read the computer.  

How much additional denigration should I anticipate after implanting an IOL?  I'm 54; I've read that most of the change occurs during 40's & 50's.  My thought is to go with mini-monovision, with -1.5 in the non-dominant eye, which would give me near vision now though I may need readers for near vision in the future.  It also minimizes depth perception issues, which is somewhat of a concern, since I am a skier.

Is there any reason to consider Crystalens?  I initially eliminated after 2nd Dr told me they tend not to work over the long term, but haven't seen that issue validated in the research I've read.  What I have read is that Crystalens is good for intermediate and distance and most likely will require glasses for near vision.  If so, I don't see advantage over mini-monovision -- am I missing something?

Finally, could explain mini-monovision with distance bias in layman's terms?  If I understand correctly, distance glasses would essentially reverse the IOL and near glasses Rx would be for both eyes, with distance eye getting an addition 1.50.  I lost you at +3.00 for progressive bifocals.

Thanks in advance for your response.



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by John C Hagan III, MD, FACS, FAAOBlank, Feb 10, 2015
The loss of focus power with age called presbyopia stops when an IOL is put in the eye.   Mini-mono distance bias would be to leave your operated eye which has good vision at 20 ft or further (  glasses RX would be zero or as we say plano) and in your unoperated eye to put in an IOL to leave you about -1.25 or -1.50     With no glasses distance and mid vision (shopping, speedometer, etc) should be clear. For prolonged reading, very small print or prolonged computer use you would need glasses generally no line progressive     Mini-mono near bias is for myopic people that have always been able to read with out glasses and want to keep it that way.  Their target refraction would be about -1.50 and -2.50   they should be able to read well without glasses and likely use a computer. They would need glasses (again no line progressives for distance like drtiving) they are use to that and don't mind.

Our practices uses Crystalens and when done by a skilled experienced surgeon it is the best of all the multifocal/accommodating IOLs in my opinion. We also have people that have had a monofocal IOL successfully set for distance like you that have a Crystalens in the other eye and they can use computer and read without glasses.  Again to use both eyes need progressive bifocals.

The thing that makes this difficult: there is no best IOL there are lots of good ones, there is no single answer for every person and what makes one person extremely happy another might consider a poor result and be very unhappy

JCH MD



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by Joanlimsaw, Mar 15, 2015
Dr Hagan

I have bilateral cataracts and have been advised to remove them.
Since at a young age I've been rather myopic and at present -9.25 and -10.5
I also have astigmatism but not sure how much
Plus glaucoma in both eyes, the left eye having lost about 20% sight.

My doctor suggests that I have intraoccular lens in my dominant eye for far vision and in the less dominant eye for closer/ reading vision as I have been using contact lenses following this principle.
But now I am having the lenses implanted into my eye and would dearly like your opinion on it.
Thanks




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by John C Hagan III, MD, FACS, FAAOBlank, Mar 15, 2015
If you are use to "mono-vision" (discussed in my article) then you might opt for what is called "full mono-vision"  i.e. distance eye Plano (zero power) to -0.25 and for reading -2.75   however there would still be some distances you would still need glasses to see (intermediate vision ) and of course you would only be using one eye for distance and one for near to your acuity and depth perception will be reduced since these require both eyes being used together.

Most myopic patients are use to glasses and do not object to wearing them post operatively and are generally happier with the mini-monovision with near bias or mini-monovision with distance bias.  You might inquire about your astigmatism and if over 1 diopter discuss toric IOL

JCH MD

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by Joanlimsaw, Mar 16, 2015
Dr Hagen

Is it advisable for a bilateral cataract patient who has bilateral glaucoma and has lost,about 20% sight in one eye to have premium multifocal iols?
Also some degree of bilateral astigmatism and highly myopic

Thank you

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by John C Hagan III, MD, FACS, FAAOBlank, Mar 16, 2015
A toric lens would not be a problem but multifocal and accommodating IOLs are something I advise my glaucoma patients against.

JCHMD

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by abrahamic, Mar 17, 2015
Dr. Hagan,

I'm a 30-year old man with big cataracts in the non-dominant right eye. I scheduled for cataract surgery in 7 weeks, but upon seeking a second opinion, I was diagnosed with Uveitis, high cup/disc ratio (I'm not sure how serious this is) in the cataractous right eye, and possibly some signs of Fuch's Corneal Dystrophy in the non-cataractous left eye.

1- Do I have to reschedule my cataract to avoid any complications? (2nd Dr suggested extensive checkup to find out the cuase of Uveitis which may have cuased the cataracts)

3-When I develop presbyopia in my dominant right left eye in 10-15 years, how will that affect the near/intermediate correction I intend to choose with the IOL in the non-dominant eye? (I currently wear 1.25 near correction in the left eye, and my distance is just fine for driving 20/30)

Thank you for taking the time to address our questions.

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by John C Hagan III, MD, FACS, FAAOBlank, Mar 17, 2015
1. Since cataract surgery is elective and uveitis is a special problem I would suggest having the uveitis evaluated before the surgery. It make a difference in which medications and how long they are used before/after your surgery.
2. Assuming the dominant LE does not develop a cataract after presbyopia you will likely need to wear progressive bifocals to use the two eyes together.

JCH MD

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by Joanlimsaw, Mar 25, 2015
Hello Dr Hagan

Does intermediate vision mean the distance referring to an arm's length from the eye?
As I'm considering aspheric iols for long vision in one eye and close/reading vision in the other eye, you stated in your reply that I may need glasses to see in intermediate vision. Are you referring needing glasses to read on the computer screen for example or is it that everything within this distanc of area will be blurred?

Thank you


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by Joanlimsaw, Mar 25, 2015
Hello Dr Hagan

Does intermediate vision mean the distance referring to an arm's length from the eye?
As I'm considering aspheric iols for long vision in one eye and close/reading vision in the other eye, you stated in your reply that I may need glasses to see in intermediate vision. Are you referring needing glasses to read on the computer screen for example or is it that everything within this distanc of area will be blurred?

Thank you


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by John C Hagan III, MD, FACS, FAAOBlank, Mar 25, 2015
It is an admittedly inexact term but roughly 3 to 15 feet, would encompass computer, shopping and watching TV in small to medium size rooms.
JCHMD

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by Joanlimsaw, Apr 03, 2015
Dear Dr Hagan

I am going to have my 1st cataract operation within the next few days.
Can you please tell me if an implanted iol needs to be removed and replaced, would it be complicated and difficult with risk of eye damage?
Thank you for your prompt answer always

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by John C Hagan III, MD, FACS, FAAOBlank, Apr 03, 2015
It is extremely rare to have to remove or replace a intraocular lens.  Probably less than 1 in 1000. And not difficult to replace  if necessary.
JCH. MD.

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by Joanlimsaw, Apr 07, 2015
Dr Hagan

I have just had an aspheric mono iol implanted in the right eye for long distance 6 hours ago
In that eye the image slants somewhat to the right and is not horizontal. Is it too soon to worry? Must I give more time for the eye to adjust?


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by John C Hagan III, MD, FACS, FAAOBlank, Apr 07, 2015
The MedHelp legal staff has advised us not to answer questions asked about surgery or in the immediate post operative period so you will need to ask your surgeon that.
Best of Luck.
JCH MD

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by Joanlimsaw, Apr 07, 2015

Thank you Dr Hagan.
I do understand your stand point.
However I do want to thank you for your help every step of the way to my iol implant.

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by SLMitchell, Apr 13, 2015
First of all, thank-you so much for all your invaluable information! I have cataracts in both eyes, worst in my non-dominant right eye.  I have been myopic since a teenager.  I have to have something done soon; however, I have been researching this issue and iols for many months and am still immobilized by a lack of decision re: which iol to have, whether to have laser-assisted surgery, etc.  I will come up with the additional money for the premium lenses if they are worth it! I thought the nanoflex lens sounded great, but cannot find current information regarding its track-record. Also, is there some "miracle" lens about to be approved that would be worth waiting for?  Thanks for any input you might offer.

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by John C Hagan III, MD, FACS, FAAOBlank, Apr 15, 2015
Since you are myopic you are use to wearing glasses and seeing clearly up close without glasses.  So spending the extra money for an accommodating or multifocal IOL would likely not be worth it for you and these lens are more prone to cause glare (dysphotopsia). If you have astigmatism a toric IOL is worth considering.  Cataract IOL is highly successful and at present very few patient spend the extra money for laser assisted surgery. However the technology while it adds some benefits is not really necessary if money is a problem.  At present 99% of our patients do not opt for femtosecond laser.

There will always be new IOLs coming out none are going to be breakthrough.  If you need the surgery don't put it off. I saw 4 patients yesterday for their last post cataract/IOL surgery visit and they were all ecstatically happy.

JCH MD

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by Joanlimsaw, Apr 18, 2015
Dear Dr Hagan

It's been 11 days since I had an aspheric iol implanted in my right eye.
I received good clear sight all along until yesterday night watching television that the images were not sharp  anymore until this morning
As instructed by my doctor I have Tobradex drops 5 times daily since after the cataract operation
What can cause this and is it temporary?

Thank you

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by Joanlimsaw, Apr 18, 2015
Regarding above letter I forgot to mention that since yesterday morning I have a sore throat so could be an impending cold/ virus infection

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by John C Hagan III, MD, FACS, FAAOBlank, Apr 18, 2015
Sorry have to repeat:

The MedHelp legal staff has advised us not to answer questions asked about surgery or in the immediate post operative period so you will need to ask your surgeon that. All major changes should be reported. Minor day to day fluctuations are not unusual.
Best of Luck.
JCH MD


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by mizdara, Apr 20, 2015
Dr. Hagan, ten years ago I had cataract surgery for my right eye and received an implant for distance vision. Now I have been advised that I required a laser correction. In addition, it is now time to remove the cataract in my left eye. It was recommended to me to get a lens for close vision in that eye and thus eliminate the need for glasses. Two questions: Which proceedure should be done first and because I am a jeweler, should I consider the recommended lens or just get another lens for distance and use reading glasses plus jeweler's optics? I want the easiest and most effective solution.

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by John C Hagan III, MD, FACS, FAAOBlank, Apr 20, 2015
Likely the procedure you need on your RE is a yag laser capsulotomy. If that is the case it is generally done first.  Sometimes the other eye bothers you less and sometimes more when the RE sees better. I suggest you re-read my article and get a second opinion about lens choices.  As a jeweler you need the best possible vision out of both eyes to allow yo to work.  The recommendation you have been given to have one eye for distance and one for near and not need glasses is not really the case.   That is called full mono-vision and is discussed in my article.  If you choose that option you will be doing your jeweler work with one eye, your driving with the other eye, you lose depth perception, don't see as well, there will be distances you can't see well and full mono-vision glasses are often difficult to adjust to and wear.

JCH MD

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by Joanlimsaw, Apr 30, 2015
Dear Dr Hagan

Can you tell me how serious is the possibility of vision loss for post op cataracts patients with glaucoma?
How high an IOP before it poses to be a danger and is vision loss reversible once the IOP is down to normal controlled level again?

Thank you

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by John C Hagan III, MD, FACS, FAAOBlank, Apr 30, 2015
For the great majority of glaucoma patients cataract surgery does not impose increased risk and extremely often the intraocular pressure goes down several points. Cataract surgery is now thought of as a treatment for glaucoma. For patients not well controlled or on several eye drops new types of glaucoma operations called MIGS procedures are often done at the same time.

In both normal and glaucoma patients there is sometimes a spike of IOP after surgery especially if the surgery was complicated but generally can be controlled with eye drops.

So bottom line cataract surgery is usually good for glaucoma and is being done earlier in glaucoma patients than non glaucoma patients.

JCH MD

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by sharmex, May 17, 2015
Dear Dr Hagen :
I am an active 79 year old  Internist from Hickory NC  .I have bilateral cataracts,I could not pass the Driver test at the local DMV, I was sent to an Otholmologist who  gave me Diamox and combigan and few days later wated me to come back. My IOP was 40 initially in the R eyer inputou and 18 in the Left. A few  days later he recheked the pressure in the R eye it was 12, he scheduled me cataract removal surgery.
I went and after 40 min. i came out of sugery,my wife was told he could not put an IOL as there was no tissue to hold it,he told me later the posterior bag collapsed and he put four stiches to hold it. I am blind in in oe eye now!
Thanks for your input
Govind sharma, MD

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by John C Hagan III, MD, FACS, FAAOBlank, May 17, 2015
Dr. Sharma: In a situation like this generally I would recommend going to the finest tertiary eye care center that you can get to and from on a regular basis. Examples might be Duke, U of NC, Vanderbilt or Emory. I would do this ASAP. Likely your local ophthalmologist would be more than happy to have the help of an internationally known department of ophthalmology.
Your most important eye is the unoperated eye and everything needs to be done to be sure that it will not have an attack of glaucoma as the R eye did.  The fact that you failed your drivers license and had cataracts suggests you have not had your eyes examined regularly by an ophthalmologist as these problems with cataracts typically develop over years.
Another question is why did your RE have an IOP of 40.  Was it angle closure glaucoma due to the cataract. This is highly possible especially if you are hyperopic (farsighted). That puts your LE at high risk of having the same problem and hence the need for a world class group of ophthalmologists.
It is likely that your RE will not end of blind but you may need the services of a retina surgeon to be sure there is no retained lens nucleus or cortex, a glaucoma specialist to control the IOP in the RE and examine the LE to be sure it could not suffer the same fate.  After the operative eye has quiet down, inflammation controlled, IOP controlled the Eye will need either fitting with a aphakic contact lens or you would need a posterior chamber IOL sewed into the eye by a ophthalmologist that specializes in cataract surgery complications.
I would urge you to move quickly on this situation. This is why we have referral centers like Duke, UNC, Emory, Vanderbilt and others. Best of luck.
JHaganMD


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by excaptain, May 30, 2015
Dear Dr. Hagan,

First, I can't say enough how grateful I am for your post and for all your contributions to the forum. My situation is probably rather peculiar, I would love to hear your thoughts.

I am male, 39, and in 2007 I had a vitrectomy on my right (dominant) eye for severe floaters (secondary to partial PVD (probably related to a car accident I had in 2006)). There was one complication from the vitrectomy (which was sutureless), and that was severe hypotony. Unfortunately the cause was misdiagnosed as choroidal effusions, whereas in reality it was leakage from the scleral incisions. The hypotony eventually resolved on its own but only after 3 months where for 2 of those 3 months they gave me steroid drops (they thought the cause was choroidal effusion) so that probably delayed resolution of the hypotony (in addition to not suturing the incisions, of course). In any case, after the hypotony resolved vision returned to 20/20 and everything was fine until about 6 months ago, when vision started to gradually deteriorate. Cataract was diagnosed in April.

The questions I have are:

1. Before the cataract in my right eye started, I was -2.00 in both eyes (with minor astigmatism of -0.5 in right eye caused by the vitrectomy). I have been myopic all my life, and I used -2.00 glasses basically for everything (including computer work and reading at arm's length) and I don't mind them at all. I am planning to ask the cataract surgeon to aim for a -2.50 prescription so that I remain myopic, my eyes do not have a big prescription difference (-2.00 and -2.50), and that I can continue to use one pair of glasses "for everything". The idea is that the right eye with -2.50 will allow me to see very near without glasses if I wish, but generally for reading (at arm's length) computer work and far distance I will use the same pair of -2.00 (LE), -2.50 (RE) glasses (instead of having a bunch of readers for the various distances). Am I understanding this correctly or will I still need various pairs of glasses or progressives? Do you think perhaps I should think about trying to aim for -2.75 or -3.00? Also I'm thinking aiming for an IOL that optimizes for "near" reading will also be beneficial once presbyopia sets in in my left eye (this is already happening; I find it harder and hard to focus on very near objects with that eye).

2. I am thinking of asking for the Alcon Monofocal Natural lens (the yellow tilted one). This is for two reasons. First, since the left eye does not have a cataract and hopefully will not have one for several decades, I want the color and brightness seen by both eyes to be roughly the same, and I believe the Alcon Natural lens will do that. Also since, hopefully, I will live several decades with the IOL in my eye, the potential protective benefits against AMD over such a long period seem like something that will have more significance for me as opposed to a very elderly person. Am I on the right track here?

3. Even though the hypotony has not returned since it resolved 8 years ago, I am  worried that the vitrectomy incisions may open up during the cataract surgery and this would cause hypotony again. After all, the vitrectomy incisions were never sutured and they only did heal after 3 months after a lot of steroid drops that were prescribed in error. I of course will mention all this to my surgeon, but is there anything related to this concern that me or my surgeon might specifically need to pay attention to during the operation or in the post-op period?

4. The retinal specialist who diagnosed the cataract said that I should have it removed "this year" because, due to the vitrectomy, if I wait the cataract will be harder ("like a rock") than a usual cataract. Are there any issues generally related to cataract after vitrectomy that I need to pay special attention to during the operation or in the post-op period?


I have an appointment with a cataract surgeon next month to discuss options, so more than anything I would be grateful for any information that I could use to query my surgeon in order to have the best surgery and outcome possible. Of course, I understand that this is the internet and that you cannot give specific medical advice for my case, what I am looking for is pointers and what issues I should discuss with my surgeon.

Thank you in advance, and thank you again for all your amazing help in this forum.


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by John C Hagan III, MD, FACS, FAAOBlank, May 30, 2015
No the same glasses won't work because the IOL (intraocular lens) is fixed focus and does not adjust to focus at different lengths. So if you end up -2.50 and have those glasses on you will not be able to see clear at distances closer than 20 feet with them on.  Even if you did not have cataracts in 3-4 years because of presbyopia you would not be able to read with your distance glasses. on.   You will also have problems with your eyes working together with the LE until it has cataract surgery (this may be quite a while as the likely cause of your cataract RE is the vitrectomy and a reason I don't recommend these floater procedures to my patients).  Most surgeons would advise you not to aim for a near reading refraction greater than -2 or -2.25 at most.  

2. All Alcon lens are excellent.   Again I want you to discuss with your surgeon the major problems of your eyes working together post surgery.  Since the LE does not have a cataract you might want to discuss a Crystalens or multifocal IOL for the RE. You should consider getting a second opinion from another one or two cataract surgeons to make sure you understand your problems matching your eyes up.

3. Vitrectomy incisions are small and very very unlikely to "open up"  I would not worry about thiat.

4. A vitrectomized eye usually does not behave much different than one with normal vitreous other than the cataract and anterior chamber are often much deeper during surgery. Most surgeons can work around this easily.

As a summary I think you need to consult with a minimum of one and ideally two cataract/IOL surgeons to discuss further the problems you will have for a long time  with teaming the eyes up when one has had cataract surgery and the other hasn't.

JCH MD

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by excaptain, May 30, 2015
Thank you so much for kindly responding so fast. All of this is extremely important information that I will use to talk to my surgeon. In particular, I think that indeed I will ask to aim for a -2.00 or -2.25 outcome instead of -2.50 to -3.00 that I was thinking about before. I will also definitely ask about the crystalens (I'm not considering a multifocal like Restor because of the huge amount of problems that people have been reporting on this forum and many other places).

Most importantly, I will thoroughly discuss post-surgery expectations and how the eyes might be expected to work together. Probably the solution will be progressive lenses of some sort. Actually it is quite surprising to me how well my brain has been able to cope with the cataract: even though my right eye basically has had a myopic shift from -2.00 to at least -5.75, with severe monoocular diplopia in that eye and -1.25 astigmatism (up from -0.5), and even though I am wearing cheap temporary glasses that don't correct all that (-5.25 for right eye with -0.5 astigmatism) the amazing thing is that when both eyes are open basically the brain takes all the image from my left eye but keeps good 3D vision (depth perception) by somehow incorporating the right eye information and eliminating all the unwanted artefacts such as the monocular diplopia, and I get very good 20/20 vision if both eyes are open. This is probably a little similar to full monovision? Of course, the cataract is getting worse and fast (it was about a diopter a increase in prescription every month, though that has now slowed down it seems) so I'm not sure how much longer I will be able to tolerate it going forwards. Anyways the fact that I can tolerate a 3.75 diopter difference without major problems gives me some hope regarding the eyes being able to work together after the surgery.

Thanks again for all your help, and the amazingly fast response. I am so grateful. God bless you.

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by John C Hagan III, MD, FACS, FAAOBlank, May 31, 2015
Yes best of luck. Your "can do" attitude will help as well as your ability to wear glasses now with -5.25 in one eye and -2.00 in the other. Most people can't handle that at all.
JCH MD

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by excaptain, Jun 02, 2015
Thank you again Dr. Hagan. Also, I am writing here because due to your comments regarding thinking about how the eyes would work together after surgery, I was searching around and I found an amazing technology I was unaware of until yesterday, from a company called Adlens, which have just come out with variable prescription glasses which can adjust the prescription INDEPENDENTLY for each eye, whenever you wish (using a knob for each eye) over a range of 2.5 diopters, and you can have those glasses made to a distance prescription up to -6.00!

I am posting here because I think this will be of great interest not only for single-cataract patients like myself, but rather also to all monofocal lens cataract patients and actually everyone who is currently using progressives for any reason. Actually the company specifically mentions the post-cataract use and also has a white paper on how this might help with fluctuating vision due to diabetic retinal disorders (not that I have them, but others in this forum might). Here is the link:

https://www.adlens.com/product/adlensfocuss-quantum/

and here is an explanation of the technology:

https://www.adlens.com/our-technology/

and a video:

https://youtu.be/BWB3grviSKs

These seem to be much better than progressives because they have a much larger field of view without distortions. Actually they JUST started offering this widely for consumers, and I do mean JUST: I searched for this yesterday, and it turns out that yesterday, June 1, 2015, was their official nationwide rollout day for these glasses! How is that for great timing! here is the site of the rollout:

http://adlensfocuss.com/

I also continued to dig around and I found this in-depth (very positive) review of these glasses (by an "early adopter" during the testing phase):

http://encinitascomputerhelp.com/techblog2/?p=311

and there is even a youtube review of the glasses:

https://www.youtube.com/watch?v=bPXDIqC4af4

I gave Adlens a call today, and they confirmed that I can get these glasses with my prescription, including astigmatism. It is not cheap though: about $900. So definitely more expensive than regular glasses, however, maybe that's not the fair comparison: it is much cheaper than an accommodating lens such as Crystalens and without the increased risks of a bad outcome that I've seen people report on this forum. Also the convenience of adjusting the prescription on each eye is so much better than tilting my head up an down, and the field of view is much better, so I can definitely see myself shelling out the extra money for these glasses. I'm just amazed that this thing came on market at the exact same day that I searched for it.

Anyways, this was a long post, but I think this information may be useful for many cataract patients and eye patients in general, so I thought I should post it.

Thanks again Dr. Hagan for pointing out how wrong I was regarding the thought about using the distance glasses post-cataract; this set me on the path to finding these things. I did a search on "adlens" on medhelp and I could not find any references, so this is probably new information to forum participants - I hope it is useful.

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by John C Hagan III, MD, FACS, FAAOBlank, Jun 02, 2015
I have no experience or knowledge of this lens and cannot make any comments.  Any progressive multifocal glasses can have the reading/intermediate lens separately adjusted. I did this today on a patient in late 40s with a traumatic cataract in one eye   RE. The LE eye does not have a cataract.  This is what the RX looked like:

RE: -1.25                                      Add: +3.25        20/20 Vision
LE: +0.50 + 0.75 axis 180            Add: +1.75        20/20 Vision


JCH MD

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by taniakbsn123, Jun 20, 2015
My Mother in Law just had cataract surgery with corrective lens placement.  I don't have specifics on how they corrected her vision, but I believe she was expecting to have 20/20 vision or better.  She is very disappointed as she is only able to see 20/30 at this time.  It has been less than a month since her surgeries.  We are trying to be supportive and I'm a RN, but this is just not my field.  What is the success rate for this type of surgery and can you expect to have crisp perfect vision after the procedure?  What are the risks for changing out lenses if the are not working out correctly?  

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by John C Hagan III, MD, FACS, FAAOBlank, Jun 20, 2015
I don't think you've read the introduction paper I wrote for  these series of discussions.   Go read it and then if you have any questions please post.

JCH MD

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by Cooper2013, Jun 23, 2015
I'm 58 female and I was diagnosed with cataracts in both eyes about 3 years ago and they had not been bothering me much until recently the one in my R (dominant) eye (fuzzy vision, difficulty reading street signs, words on TV). My left eye improved with new corrective eyeglass lenses, but not my right which remained fuzzy with updated lens.  The eye surgeon I went to said that even though my left isn't bothering me as much, cataract surgery would need to be done on both eyes due to my high myopia which I understand. He said there would be no reason to postpone cataract surgery given the vision my right eye is giving me.
I inquired about Multifocal lenses as I would like to be less dependent on glasses.
As a high myopic, are there special considerations for a multifocal lens?  Or would I be better off with the regular IOL.  I was given information on Tecnis 2.75 and Crystalens HD.
I have worn glasses since I was 6 years old, so if I need to have "readers" while doing computer work it wouldn't bother me much, however I would like to have more freedom from glasses while out and about at the grocery store reading labels, texting on my iphone or ipad and driving, although I don't do alot of night driving I like to feel confident of my vision behind the wheel.
I was fairly confident of wanting to go with the Crystalens or Tecnis 2.75 until I started reading some posts and the problems associated with them.  I want to feel like I've made an improvement with my cataract surgery and not created more problems for myself.  As I age will these mulitfocal lenses not perform as well? Also, my astigmatism is not very bad?  But I see comments about Lasik to correct and my astigmatism wasn't addressed at my consult and I forgot to ask.

OD -9.25     cylinder +1.25     Axis 120     Add +2.00
OS -9.25                   +0.75             050            +2.00


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by John C Hagan III, MD, FACS, FAAOBlank, Jun 23, 2015
Our practice uses the Crystalens and its success is very much dependent on the skill and experience of the surgeon. Fortunately our lead refractive surgeons are superb. I do not know if the Crystalens comes in the power you would need, you would need some measurements on the length of your eye, corneal curve, etc then compare with their power range.  I have no experience with the Technis lens for multifocal use but the monofocal IOLs are excellent.

Please re-read my intro article as it has very helpful and important information for you.

The IOL does not age like the human lens so the glasses RX and post operative refraction does not change with age like the human eye ages. Whether you choose a monofocal IOL or a accommodating IOL you likely will be much happier, see much better and be much less glasses dependent after your surgery given the high myopia you have now.

The risk of a retinal detachment is higher in high myopes and goes up even more after cataract surgery. Consider asking your cataract surgeon to refer you to a retinal surgeon before surgery to carefully examine your retina for holes, thin areas that might need to be treated BEFORE cataract surgery and ask about having the retina surgeon re-examine your eye a week or two after cataract surgery.

JCH MD

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by Cooper2013, Jun 24, 2015
Dr. Hagen,

Thank you for the info, in particular about examining the retina for holes and thin areas before cataract surgery.  You have also reassured me that I would probably be happier with my vision after surgery and less dependent on glasses...YEA!

I'm still wondering about astigmatism..having worn contacts that didn't correct astigmatism when I was younger, I'm familiar with what the vision was like then.  Witih glasses, my astigmatism has been corrected but with cataract surgery I would not have that correction?  I know my astigmatism is not enough to warrant toric lenses and in some of these posts I've read where some people have thought their astigmatism got worse.  Would that be able to be fixed if it got to be an issue?

Thank you for any and all info, this has been informative for me.


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by John C Hagan III, MD, FACS, FAAOBlank, Jun 24, 2015
Multifocal IOLs are not available with toric corrections.  The placement of the incision can be altered to reduce astigmatism by operating on the steep axis,  corneal relaxing incisions can be use or you can wait and see how you do after surgery. If it should be a problem then post operative astigmatic lasik could be done.

Since you're shopping for high end surgery you might also investigate femtoscecond laser surgery.  It adds to the cost but its the state of the art. The femtosecond laser makes the incision into the eye, reshapes the cornea to eliminate astigmatism, makes the opening into the lens, breaks the cataract into very small particles that are much easier to remove, double checks the power and alignment of the IOL while its still in the eye.

JCH MD

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by carolyn_mw, Jun 24, 2015
Dr. Hagan,

I'd like to add my thanks also for your information and the time you take to offer advice.

I'm a 58 yr old female with a cataract in my right eye.  It developed fairly quickly over the last 18 months and interferes with daily activities.  I just had an appointment with a well known doctor and was pretty much just told that I would 'love' the results of going with a multifocal IOL and not really presented with information about the monofocal lenses.  After reading your information I definitely want to get a second opinion.

I work with computers all day and enjoy other close up activities such as fly tying, beading, and gardening.  I'm nearsighted and have worn glasses since early teens and am comfortable with them so being 'glasses independent' is not a big factor for me.  I have had progressive lenses in the past but did not like having to always tilt my head to find the 'sweet spot' for the focus I needed and have had tri-focals for about 5 years now.  My mother developed the wet version of AMD in her late 60's so the chance of my developing this also has me concerned about the mulitfocal lenses.

I'm thinking that I would be happier with mono focal IOLs and am wondering if you have any recommendations for other doctors or facilities in Omaha, NE.

Thanks,
Carolyn

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by John C Hagan III, MD, FACS, FAAOBlank, Jun 25, 2015
One thing that I have pointed out and acknowledge exists everywhere is "pressure to upgrade". Reimbursement for cataract surgery and IOL insertion has decreased dramatically over the past two decades even though the operation is much more complex, the patient expectations much higher, expenses have gone up dramatically and malpractice insurance and junk lawsuits have escalated.  That is why cataract surgery is no longer done in hospitals and is in outpatient surgery centers in which the surgeons have an ownership.   There is something wrong when putting a crown on a tooth costs the patient 2 to 3 times what cataract/IOL surgery costs.  

Some upgrades like toric IOLs and femtosecond lasers I think can be justified. We have many happy patients with Crystalens in their eyes including one of my best friends. The majority of our IOLs however are monofocal. At this time 6/25/15  if I were having cataract surgery I would choose a monofocal or toric IOL.  This is not true for everyone especially people that hate glasses or that would put up with reduced quality of vision and glare to avoid glasses as much as possible.

I believe everything else I can say is covered in the long article. I do not know any surgeons to recommend in Omaha.  Consider 3 different opinions and don't be afraid to resist the pressure to upgrade.

As far as the wet AMD.  There is a big lifestyle component to reducing the risks of developing: don't smoke or us any nicotine or marijuana products; protect your eyes (skin also) from sun exposure with sunglasses, UV blocking coating on all glasses, hat, high SPF sunscreen; eat a great diet----vegetables, fruit, fish, fiber, nuts, berries. Avoid fatty foods both saturated fats and high calorie processed carbs;  look up food that is rich in lutein (spinach and kale are highest) and eat lots of lutein rich food. Obesity is a risk factor for AMD so watch your weight and exercise moderately.  AREDS 2 supplements have not been shown to reduce the risk of AMD developing in people that eat good diets so there is no evidence taking them will help.  I suggest to my patients with this type of family history that they consider taking lutein 10-20 mgm/day as a supplement. The amount of Lutein in centrum generic vitamins is miniscule (1/4 mgm).

JCH MD

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by excaptain, Jun 25, 2015
Dear Dr. Hagan,

I have seen two cataract surgeons and I thought I'd post an update. Both surgeons are highly respected in the area I live in. I discussed with both surgeons aiming for -2.00 prescription, and they both agreed it was a good idea to aim for that target. Both surgeons said they are very comfortable operating on vitrectomized eye (have done hundreds of those procedures) so they were very confident they could operate successfully. I discussed at length how the eyes would work together after surgery with the first surgeon, who said that we could explore usage of progressives but that in his experience for young eyes it may still be possible to use distance correction for lenses, where for near vision I would look beneath the glasses and for intermediate vision the accommodating eye would take over. Perhaps that is possible though that sounds a little optimistic to me.

The first surgeon does not work with Alcon natural lens (only with Tecnis) so that is the primary reason why I will choose to do the surgery with the second surgeon, who uses Alcon lenses exclusively. Actually the first surgeon did work with Alcon natural lenses a few years back, but the hospital he works in got a better deal for the Tecnis lenses so he does not have access to the Alcon lenses anymore, though he said they are great lenses. I think it is prudent to insist on a blue-blocking IOL because a clear IOL is more likely to produce a color and brightness imbalance with the other eye. The first surgeon said that the brain will successfully meld the two colors together, which is probably correct, but still, I don't want colors and brightness to be completely different in the other eye - it might be bothersome and weird. Also the potential AMD protection benefits of the blue light filter seem important, especially since the lens will (hopefully) be in my eye for several decades.

Another reason I will be going with the second surgeon is that she agreed to do the operation under general anesthesia. I know that this is generally a topical/IV anesthesia sort of procedure, however, it boggles my mind that such a surgery would be done under such minimal anesthesia when the lens capsule walls are only 20 microns thin. Wouldn't even a slight movement of the eye or head during surgery be dangerous (cause a capsular tear)? Of course this has to be weighed against the dangers of general anesthesia but, still, my gut tells me that it would be better for me to be complete immobilized. I also had general anesthesia for the vitrectomy. The surgeon said that usually general anesthesia is not indicated for cataract surgery, however if I was anxious about it she had no problem in offering it.

One thing I did want to ask you, Dr. Hagan, is, in your experience (speaking generally of course), how long after a cataract in a vitrectomized eye starts to affect vision does the cataract need to be operated upon? Specifically, when does it become too "hard" for it to be operated upon? After a year? Two years? The retinal specialist who diagnosed me said I should get it operated on "this year" (2015), so I assume in the next 6 months. The first cataract surgeon who saw me said my cataract is a 6 or 7 on a scale of 1 to 10, but that a cataract that is too hard would be a "9" and that comfortably I have one year before it reaches that state. I told the second cataract surgeon about what the retinal specialist said but she was not too worried, even though she said my cataract was "dense". The only reason I am asking is that while I am on the waiting list for surgery for the second cataract surgeon, the wait list is up to a year (she is very much in demand). She said she has done 1000 cataract surgeries a year for the past 15 years. I really think she is "the one" to do my cataract operation but I am a little concerned that the cataract will "harden" during the wait. Do you have any experience with predicting when a cataract is too "hard" (of course, asking generally, not my specific case)? How long after a cataract is diagnosed for vitrectomized patients does it in your experience, on average, become too hard to be operated upon without major complications? Note that my cataract was NOT present in August 2014 (as per a routine annual examination by a retinal specialist) and I was -2.00 in that eye. My vision started to be affected by November 2014 and by April 2015 my prescription had gone up from -2.00 to -5.75 in the affected eye. Is this a particularly fast cataract progression in your experience?

Thanks (again) in advance!


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by John C Hagan III, MD, FACS, FAAOBlank, Jun 25, 2015
99.9% of cataract surgery in USA is done under topical/injection. It is much safer, less expensive and faster recovery.  General anesthesia does not guarantee that there will be no movement as patients can "get light" and move. The only patients we do under general are patients with agitated dementia and combative/non-cooperative.  The cataract/IOL usually takes 15 minutes whereas a vitrectomy can take several hours.  Your call. We would not do a "nervous patient" under general just use sedation and injection (not topical) and reassurance and "Vocal local".

There is no way to predict how fast any cataract will grown, by anyone, all we can do is speak in generalizations. Understanding this is a generalization most patients with vitrectomies will need cataract surgery in 3-5 years.  Also grading a cataract on any scale is non-standardized and what might be a "hard cataract" for one surgery might be middle hardness for another.   Even rock hard cataracts can be operated on its just that the complication rate may be 2=5% higher.   The main complications of cataract surgery are 1. capsular tear  2. vitreous loss   3. nuclear fragments dropping into the back of the eye  4. hemorrhagic problems.   With small to medium cataracts one of these might occur 1-3% of the time with rock hard it might be 5-7%  so the odds are still in your favor.

Several of our local surgeons staff the only eye hospital in Northern Haiti and virtually every cataract is rock hard or a tense white "over-ripe" cataract. Their complications rate is only about 4-5% even in a primitive setting.

A surgeon could not do 1000 cases a year and be booked a year ahead of time if their results were anything less than stellar. Just be aware that some of these mega-cataract practices use huge pressure to upsell things like toric, multifocal, femtosecond laser and gift staff bonuses for every person that upgrades from the plain vanilla monofocal IOL.

JCH MD

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by excaptain, Jun 26, 2015
Thanks as always Dr. Hagan for the quick and very informative response. I had no idea your staff does such amazing work in Haiti - you and your colleagues are truly what medicine is all about. Your comments regarding hard/mature cataracts as well as the fact that both surgeons I saw were not overly concerned give me hope that this is not as critical an issue as I thought it was.

Regarding the surgeon I chose, indeed she is very respected and she seemed very thorough and attentive during the appointment. It took 2 months just to get an appointment with her. What's REALLY nice about her is that she ONLY offers monofocal and toric monofocal lenses, not multifocal and not femtosecond laser. When I arrived at the office the first thing her staff handed me is a page explaining the different lenses, and for multifocal lenses it specifically said that they do not do them because (I'm quoting) "for most people, the benefits of the multifocal IOL are not worth the potential side effects, including reduced vision in dim lighting and permanent glare and halos".  So she is very patient-focused, and that is the impression I got from meeting her.

Regarding the general anesthesia, I hear you and really I'm not too sure what would be the best course of action. I never had conscious sedation but on the other hand the general anesthesia for the vitrectomy was perfectly done and I had absolutely no side effects (not even nausea). Also the general anesthesia for the cataract will be done with an anesthesiologist in a hospital which has an emergency department, so it is not being done in a clinic which would be ill-equipped to handle an emergency. Not that I expect an emergency - I understand that most complications from general anesthesia happen to older people who have heart problems. But, there is an additional risk there, no doubt. From my point of view there is another advantage to general anesthesia - I will probably get to do the operation sooner, since the timing of the operation is based mainly on the availability of the hospital anesthesiologist - and the surgeon said that while she has no control upon when the hospital assigns an anesthesiologist to her, it may be possible to have the operation in September of October, but I will get only 2 weeks notice. On the other hand, for IV conscious sedation anesthesia the wait list is 10 months long - I will get more advanced notice but the wait will be quite long. So actually choosing general anesthesia might be beneficial in terms of timing for this particular surgeon. We'll see. Anyways the important point is (and I believe this is the point of this entire thread) is that one has to do "homework" before choosing a cataract surgeon. In fact, there are a lot of clinics here that would be able to do the surgery within 2 weeks, but they are the sort of "mega cataract" clinic that you mentioned that are mostly about money; as much as I want the cataract to be taken care of ASAP, I'm not considering going to those clinics.

Once again, thank you so much for the quick response and all the information, it is gratefully appreciated.

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by John C Hagan III, MD, FACS, FAAOBlank, Jun 27, 2015
Okay best of luck.  JCH MD

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