Cataract surgery: an ultimate patient’s guide

What should you do if you are told that you have a cataract? It’s a stepwise guide to help you decide what to pick when you have multiple options to choose from. The aim is to enable you to make an informed decision at every crossroad of your treatment plan.

You had a problem with reading the fine print in the newspaper. You went to a doctor, and he/she says you have a cataract. You ask him why is it has happened, and he/she consoles you that it’s merely because of aging and not much you could have done. When you ask him/her, what should you do, the often the answer is “go for surgery.”

Such an experience leaves a patient with more question than an answer to his problem. Here is the list of steps you should take to handle it.

A cataract is a very common clinical condition and is treatable.

At any point in time, there are about 20 million people in the whole world who have cataracts, and about a third of them are in India. Around half a million people undergo cataract surgery every year in India alone, which means that it is very much treatable. The Internet has a lot of content on this topic, but I would recommend NIH and Wikipedia as reference sites for basic information about cataracts. Do not correlate that information with your case as it will leave you more confused.  Ask your doctor the questions you have about yourself.

Consult an eye surgeon

Usually its age, but there could be other reasons also. There are many types of cataract, and many ways to classify it. Do not try to find the answers on the internet because it requires a lot of professional expertise to decide the cause. Just because you have, diabetes does not mean you have a diabetic cataract.  Ask your doctor to explain. It’s important to know the reason. Discuss with your doctor, the other medical conditions, you have,  like diabetes, hypertension, asthma, thyroid dysfunctions, etc.

Ask your doctor why you can not see?

Just because you have the cataract, does not automatically means you immediately require surgery. Mostly it is because of the poor vision due to cataracts that people decide to have the surgery. Sometimes there are other reasons for poor vision, which can only be determined by your doctor. You should discuss with your doctor, the extent to which your vision is compromised due to cataract, in the affected eye, and with both the eyes open. You should also discuss the likely visual gain after cataract surgery in these situations.
An important reason for people to be unsatisfied with the surgical outcome is the lack of significant improvement in vision after surgery. You should also discuss what exactly is the room for improvement in your vision after surgery, in the affected eye, and with both the eyes open.

Ask you doctor , if you can safely postpone your surgery.

Mostly it is not an emergency. Discuss with your doctor, if you can postpone your surgery. Cataracts due to aging, unless contraindicated by the doctor, can be easily delayed for a few months to accommodate more pressing employment and family matters.

 Two conditions to qualify

I think the two conditions mentioned below should be met before surgery is planned in age-related cataracts.

1. Reasonable expectation of improvement in vision after surgery
2. Stably associated diseases like diabetes, hypertension, asthma, etc.

Phaco-emulsification with posterior chamber lens implantation, commonly known as Phaco.

The most common surgical method for age-related cataract is Phaco-emulsification with posterior chamber lens implantation, commonly known as Phaco. It’s neither required nor possible in every patient. Certain conditions in a given patient may need other surgical methods. You should discuss with your doctor which surgery is best in your situation. You should never insist on a particular type of surgery with your doctor.

Robotic/Laser-assisted cataract surgery

It’s a new technique in which some critical surgical steps are done using a high precision laser. Other steps are common between laser-assisted and traditional methods. The downside is that it is more expensive than traditional methods. The available scientific evidence by researchers (Popovic M, Day AC) does not document any significant difference in the visual outcome after either of these techniques ( Robotic/conventional Phaco ).

An accredited eye hospital

There is no rule of thumb to identify a good hospital from the rest, but certain general guidelines may be followed.

1. Prefer a hospital/ facility accredited by some accreditation agencies like NABH in India.
2. Dedicated eye hospitals have better-developed facilities for eye care that an eye department in a multi-specialty hospital.
3. A facility with multiple eye surgeons practicing different eye specialties has better services than a single surgeon facility.
4. If you have personal acquaintance with the reputed individual surgeon, that’s the best choice.

Phaco-emulsification with posterior chamber lens implantation, commonly known as Phaco.

The most common surgical method for age-related cataract is Phaco-emulsification with posterior chamber lens implantation, commonly known as Phaco. It’s neither required nor possible in every patient. Certain conditions in a given patient may need other surgical methods. You should discuss with your doctor which surgery is best in your situation. You should never insist on a particular type of surgery with your doctor.

Robotic/Laser-assisted cataract surgery

It’s a new technique in which some critical surgical steps are done using a high precision laser. Other steps are common between laser-assisted and traditional methods. The downside is that it is more expensive than traditional methods. The available scientific evidence by researchers (Popovic M, Day AC) does not document any significant difference in the visual outcome after either of these techniques ( Robotic/conventional Phaco ).

Indian Mono -focal foldable lens

The posterior chamber lens is commonly used unless it is not possible to implant that lens in the eye due to medical reasons. The rigid and fold-able. Fold-able lenses are better. They are available by different brands, and place of manufacturing (Indian /imported). Often the imported lens is expensive. I could not find a single scientific report which says that visual gain after surgery has any relation with the brand or the place of manufacturing of lens.

Foldable lens versus non-foldable (rigid) lens?

Foldable lenses are more popular and expensive that their non-foldable (rigid) counterparts if all other parameters are the same (design, brand, country of origin). There are only two scientific studies (one from Thailand, other from France ) which were designed to see the difference in the vision and other outcomes after the surgery, among these type of lenses. Neither of the two studies reported any difference between the two.

Indian versus imported lenses

In the eighties and nineties, when ophthalmologists began to switch to lens implantation (rather than leaving the eye without the lens and giving the patient thick glasses). At that time the lens needed to be imported from the US and Europe, as there were no lens manufacturers in India. Though the imported lens was of good quality but was very expensive. In the nineties, some Indian companies started manufacturing lenses in India. The lens manufactured was quite cheap, but the quality wan not as good as those of the imported once.

Nowadays there are many Indian companies that are manufacturing the lenses in India, and also exporting it to many other countries, which include US and Europe. Since they have to meet stringent FDA and EC guidelines for that, the overall quality of lens manufacturers in India matches with any of the manufacturers from abroad.

So in my view, as far as the quality of the comparable lens (similar lens material and design) is concerned, there is no difference.  The imported Lens usually cost 3 to 5 times as much as an Indian lens. Various government bodies are raising concerns about this pricing of the lens in India. Quite likely, we may have some government regulation on price control of the lens, in day to come.

Imported: Alcon, AMO, Zeiss, Bausch & Lomb, Hoya.

Indian companies: Appasamy, Omni, Aurolabs, Biotech, Care,

Monofocal and a multifocal lens

Another critical issue is to decide between monofocal and a multifocal lens. The latter is supposed to provide the functional vision for both near and distance, but the lens is expensive. But that does not guarantee spectacle free life after the surgery. Some cases may still need glasses for a specific type of task, even after uneventful cataract surgery with a multi-focal lens. Moreover, it is associated with a particular kind of vision-related complications like glare and reduced contrast of images. An article by Dr. Evans appropriately explains the pros and cons. If you want to know more, there are many good scientific publications on this issue. Discussion with your doctor is the best way out. If you are still in doubt, gamble on the mono-focal lens.

Posterior capsular Rent ( PCR ) is (relatively common complication ) occurring during the surgery

Endophthalmitis ( infection in the eye after cataract surgery)

Complications are associated with every surgical procedure. Cataract surgery is no exception to this rule.

Posterior capsular Rent ( PCR ) is (a relatively common complication ) occurring during the surgery and Endophthalmitis ( infection in the eye after cataract surgery) is an uncommon complication happening after completion of the cataract surgery. These may require vitreoretinal surgical support.  Discuss with your doctor regarding the availability of back up facilities in the hospital and its policy regarding the management of this complication.

Eye hygiene

Eye protection

Regular use of eye drops/medications 

Eye hygiene, protection and regular use of eye drops/medications constitute the primary post-operative care. But the attention is individualized as per surgery and patient parameters. It is essential to understand it and follow the instructions issued clearly.