Options for Cataract Surgery in 21st Century: IOL Options

Being diagnosed with a cataract is hard enough, especially, if one is not expecting to hear this diagnosis.

Having to then make multiple decisions regarding this diagnosis can be overwhelming. This is especially difficult when a patient is alone with no family members or friends to help process and remember what the surgeon and staff said.

The chart below tries to put all the options on one page.

Here are some questions that you might want to ask before surgery.

 1. When should the cataract be done? Your eye surgeon can grade the cataract and along with objective information (your vision in the dark and possibly a brightness acuity test [light shined in the eye to reproduce night driving conditions]. Together you can decide if the vision and your daily activities are significantly affected by the cataract. Most patients when they reach the “worse than 20/40” mark are significantly bothered by the cataract. Most surgeons recommend not waiting too long to have the cataract removed as it will take more energy to remove the cataract in general which increases the risks of surgery and prolongs recovery time.

 2. What type of cataract is present and does this increase my risk for complications or needing a laser after the cataract surgery? Patients who have a posterior subcapsular cataract have a higher rate of needing a Yag laser after the cataract surgery.

 3. Type of energy that will be used: Ultrasound (Phacoemulsification) or Laser (Femtosecond laswer) with ultrasound.
Standard ultrasound has been used since the beginning of modern day cataract extraction. It has a good safety profile and effectively removes the cataract. However, the new breakthroughs in laser cataract surgery are remarkable. Early studies are showing that the amount of total energy needed in the eye to remove the cataract is significantly decreased. This translates into a faster recovery time and less complication. The vast majority of ophthalmologists I know would demand laser cataract surgery if given a choice (personal survey).

 4. Type of implant to be used. This is where confusion can arise: which one is the best?
It depends on what your expectations are: how much do you read, drive, use computer? Will you be annoyed with haloes and glare? Will you be annoyed if you have to use reading glasses. Every patient is very different, so each patient has to be aware of these options.

5. Implant Types:
1) PMMA: hardly used any more unless in special cases: prior complicated cataract surgery, for instance
2) Acrylic: lens of choice given its safety profile and easy of insertion and low inflammation risk and low risk of secondary PCO (the haziness on the posterior capsule) that happens in between 10-20% of patients in general.
3) Silicone: a good choice as well, especially if one of the newer versions. Generally not used in patients with proliferative diabetic retinopathy: they may need Silicone Oil in their vitreous (back gel part of eye) Silicone oil droplets adhere irreversibly to silicone IOL
4) Aphakia: Sometimes, we cannot place an implant during the first surgery. We leave the patient aphakic–without an implant.
This can occur for various reasons:
a. There was not enough support in the capsular bag to place an implant (this is not uncommon in Pseudoexfoliation PXF patients; patients with a history of trauma; patients with a history of Flomax, or other oral meds).
b. Complications, such as, severe hemorrhage or expulsive hemorrhage.
c. Patient has excessive movement of the head and will require general anesthesia.
d. Rarely, a surgeon may decide to leave the patient aphakic as the eye size is so long that the patient will achieve good vision without a lens. This is rare as most surgeons like to have an implant present to keep the vitreous pushed back in case a Yag capsulotomy of the capsule is needed in the future.

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