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. The aim is to enable you to take an informed decision at every crossroad of your treatment plan.
You had a problem in 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.
Step one: Do not panic.
At any point of time, there are about 20 million people in whole world who have cataract, and about 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. Internet has lot content on this topic, but I would recommend NIH and Wikipedia as reference sites for basic information about cataract. Do not correlate that information with your case as it will leave you more confused. Ask you doctor the questions you have about yourself.
Step two: Confirm why you developed the cataract?
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.
Step three: Do you actually need surgery?
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 cataract 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.
Step four: Can it be postponed?
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. Cataract due to aging, unless contraindicated by the doctor, can be easily delayed for few months to accommodate more pressing employment and family matters.
Step five: When to get operated?
Two conditions to qualify
I think the two conditions mentioned below should be met before surgery is planned in age related cataract.
- Reasonable expectation of improvement in vision after surgery
- Stable associated diseases like, diabetes, hypertension, asthma etc.
Step six: Where to get operated?
An accredited eye hospital
There are no rule of thumb to identify a good hospital from the rest, but certain general guidelines may be followed.
- Prefer a hospital/ facility which accredited by some accreditation agencies like NABH in India.
- Dedicated eye hospitals have better developed facilities for eye care that an eye department in a multi-specialty hospital.
- A facility with multiple eye surgeon practicing different eye specialties has better services than single surgeon facility.
- If you have personal acquaintance with the reputed individual surgeon, that’s the best choice.
Step seven: What type of surgery should you have ?
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 high precision laser. Other steps are common between laser assisted and traditional method. The down side is that it is more expensive that traditional method. 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 ).
Step eight: What type of anesthesia should you have ?
The eye is anesthetized with a drop of anesthetic ( Topical anesthesia ).
It’s same as surgery. It’s the same as surgery. The eye is anesthetized with a drop of anesthetic ( Topical anesthesia ) is the usual way to operate an age-related cataract. There are other methods of anesthesia which may be required in certain situations. You should discuss with your doctor which anesthesia is best in your case. Insisting on surgery under topical anesthesia is a bad idea.
Step nine: What type of lens should be implanted ?
Indian Mono -focal foldable lens
Posterior chamber lens are commonly used, unless it is not possible to implant that lens in eye due to medical reasons. They rigid and fold-able. Fold-able lens are better. They are available by different brands, and place of manufacturing (Indian /imported). Often the imported lens are 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 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 among the two.
Indian versus imported lenses
In eighties and nineties, when ophthalmologist 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 US and Europe, as there were no lens manufacturers in India. Though the imported lens were of good quality but were very expensive. In nineties some Indian companies started manufacturing lens in India. The lens manufactured were quite cheap, but the quality wan not as good as those of the imported once.
Now days there are many Indian companies who 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, overall quality of lens manufactures in India matches with any of the manufacturers from abroad.
So in my view, it 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 concern of this pricing of the lens in India. Quite likely, we may have some government regulation on price control of 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 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 explain 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.
Step ten: What are the complications of surgery of 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 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 facility in the hospital and its policy regarding the management of this complication.
Step eleven: Post operative care after cataract surgery
- 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.