What I Need to Know Before Cataract Surgery? Here are the top 10 things you should know before getting cataract surgery:

Here are the top 10 things you should know before getting cataract surgery:

1. Cataract surgery is generally medically necessary if the best vision or glare test is worse than 20/40 in the eye in question. In certain patients with Pseudoexfoliation (PXF) and/or previous trauma and/or glaucoma, most surgeons prefer to do cataract surgery sooner as it makes the surgery safer.

2. Your vision is composed of the Quantity & Quality of visual acuity:
Quantity can be improved by cataract surgery.
Quality depends on your meibomian gland function and your general tear film (ie you can prove this by not blinking for a few minutes –which Dr. Cremers does not recommend: your vision will get very blurry due to the evaporation of your tear film.

It is essential to know what your meibomian glands look like before any eye surgery so you will know how much discomfort you will have after (ie, due to dryness often) and the recovery time (ie a patient with significant meibomian gland loss may take longer to recover from vision & discomfort).

3. Femtosecond laser-assisted cataract surgery (FLACS) is the safest way to help remove the majority of cataracts. Some eyes cannot have FLACS due to advanced glaucoma, prior trauma, astigmatism issues.

4. Intraocular Implants: all implants have their positives and negatives. No one lens gives you perfect vision at all distances. It can be confusing but this is the one time where your eyeMD has the chance to try to get you glasses free for distance, intermediate, and/or reading, depending on your eye measurements.

a. Monofocal IOLs: are the only ones covered by insurance. It generally will only help with distance: either for reading, intermediate, or distance. If you have corneal astigmatism (the window of the eye is shaped like an American Football), you might need glasses for all distances (ie, progressives, 3 different pairs of glasses or trifocals-which most patients dislike).

b. Symfony Depth of Focus: is a patient favorite as it gives you good vision at 2 distances, usually distance and computer. But many will still need reading vision. Most patients love this implant but rarely a patient will be bothered by the glare.

c. Active Focus and Multifocals (Alcon & Tecnis): +2.5D Multifocal works well for better intermediate vision but some patients dislike the glare. Other Multifocal implants can help one eye see better for distance or reading but some patients really hate the glare after surgery (as this was the reason why they needed cataract surgery in the first place 🙁

d. Trifocals: approved in Europe. Not FDA approved yet in the US. Some patients still hate the glare. It does not achieve 100% happiness either, nor 100% 20/20 Uncorrected Distance visual acuity (UDVA):
-at 12 months post-surgery:
—76.2% had fully restored UDVA.  
—39.8% had fully restored uncorrected intermediate visual acuity
— 22.6% had fully restored uncorrected near visual acuity.

The FDA trials for Symfony did better with UDVA of overall 84.5% were 20/20 or better. 

5. About 30% of patients need a YAG Capsulotomy with a YAG laser to open the posterior capsule after cataract surgery. It is considered part of the first surgery.

6. Most common issues/risks after cataract surgery are:
1. Need for glasses
2. Foreign body sensation usually due to an unstable tear film
3. Need for YAG capsulotomy
4. Glare/halos: usually improve with time.
5. Need for another surgery: this is uncommon. Causes: if there is a piece of cataract nucleus or cortex left; if the cornea decompensates and gets cloudy needing a DSEK or corneal transplant, IOL surprise (what the data said was the best IOL turns out to not be the best for the patient).
6. Other rarer risks: infection, loss of vision, loss of the eye, retinal detachment

7. If you have glaucoma ask your eyeMD about having a procedure at the time of Cataract Surgery to see if you can get off your glaucoma drops.

8. Sometimes the cataract is so dense, the eyeMD cannot tell if a patient had advanced macular degeneration and glaucoma. You will have to wait till after cataract surgery to determine what your best potential vision will be.

9. Diabetes & Diet & Keeping they eyelids clean: these go a long way to preventing vision issues after cataract surgery. Dr. Cremers recommends a low carbohydrate, low/no gluten or sugar diet as much as possible.

10. There are no guarantees with cataract surgery and it can be very frustrating to not have the vision you expected after cataract surgery. Thus it is very important to be sure your dry eye and diabetes is under control ideally before surgery.

I hope this helps you and your family.


Treating dry eye before cataract surgery improves outcomes

SAN DIEGO — Dry eye signs and symptoms, as well as higher-order aberrations, improved in patients scheduled for cataract surgery when treated preoperatively with Xiidra, according to a speaker here.
“There was a clear and significant improvement in [root mean square] higher-order aberrations when lifitegrast was used,” as well as improved accuracy of preoperative biometry, John A. Hovanesian, MD, FACS, said at the American Society of Cataract and Refractive Surgery annual meeting.
Hovanesian and colleagues measured biometry in patients with cataract and significant dry eye both before and after 4 weeks of treatment with Xiidra (lifitegrast ophthalmic solution 5%, Takeda). The researchers determined how lifitegrast affected the root mean square higher-order aberrations in the cornea measured with topography and the accuracy of preoperative biometry in predicting postoperative spherical equivalent, as well as SPEED scores and corneal stain.
Biometry was performed initially at presentation and again after a month of treatment with lifitegrast. Surgery was then performed, and refractive outcomes were evaluated 1 month postoperatively. In the first 17 patients of the 200-patient study, higher-order aberrations after lifitegrast were significantly reduced in 10 patients, remained unchanged in six patients and increased in one patient.
“We’re seeing an even more significant trend as this study nears completion. What that means is that RMS HOA is a predictor of patient satisfaction with premium IOLs,” Hovanesian said. “We almost double the likelihood that our patient will be happy with the outcomes after surgery when we treat dry eye in this manner.”
Regarding refractive accuracy, Hovanesian said there was a trend toward improvement as seen in the study’s early findings in 13 patients, and as the study approaches 100 patients enrolled, “there is now clearly a statistically significant trend toward greater accuracy.”
Additionally, patient-reported SPEED scores indicate that a majority of patients are asymptomatic for dry eye before cataract surgery; even so, SPEED scores improved by 62% in 21 patients, and as more data are compiled, results continue to show statistically significant improvement, Hovanesian said.
Of the 21 patients, corneal staining disappeared in 86%, conjunctival redness improved in 50% and tear breakup time improved in 90%, he said. – by Robert Linnehan
Hovanesian JA. The effect of lifitegrast on refractive accuracy, higher order aberrations, and symptoms in dry eye patients undergoing cataract surgery. Presented at: American Society of Cataract and Refractive Surgery annual meeting; May 3-7, 2019; San Diego.
Disclosure: Hovanesian reports he is a consultant for Takeda and the study was funded by a grant from Takeda.

Trifocal toric IOL provides good acuity at all distances

A premium diffractive-refractive trifocal toric IOL provided patients with astigmatism with effective near, intermediate and distance acuity.
In a multicenter European trial, 114 patients underwent phacoemulsification surgery with the AT LISA tri toric 939MP (Carl Zeiss Meditec). All but one patient had bilateral implantation.
All patients were at least 50 years old, had bilateral regular corneal astigmatism and required IOLs with sphere power up to +28.00 D and cylinder power between +1.00 D and +4.00 D.
Patients were evaluated postoperatively at 1 to 7 days and at 1, 3, 6 and 12 months. Binocular uncorrected visual acuities were no more than 0.3 logMAR in 99% for distance, 98.10% for intermediate and 91.40% for near, according to the study.
The authors reported stable uncorrected distance visual acuity (UDVA) at all follow-up times; at 12 months post-surgery, 76.2% had fully restored UDVA. They saw a significant improvement in binocular distance-corrected intermediate visual acuity at 1 month that remained stable up to 12 months. Also at 12 months, 39.8% had fully restored uncorrected intermediate visual acuity, and 22.6% had fully restored uncorrected near visual acuity.
Manifest cylinder was statistically significantly reduced at 1 day and even more significantly at 1 month. At 12 months, 79.7% of eyes had a cylinder value of ±0.50 D.
The researchers found the defocus curve of the trifocal to smoothly transition between the far and near focus. Contrast sensitivity was similar at each follow-up; specifically, it was in the normal range at 6 months.
The majority of patients said their quality of vision was good or very good at all follow-ups, and patient satisfaction for all visual outcomes was very high.
The authors concluded that the AT LISA tri toric provides “high levels of quality of vision at all distances and high level of spectacle independence.”
They did notice a slight trend towards overcorrection, which may be addressed with improvements in effective lens position calculations in the future, they said. – by Nancy Hemphill, ELS, FAAO
Disclosures: Piovella reports consulting for Acufocus, Carl Zeiss Meditec, Johnson & Johnson, Tear Lab and Tear Science. The other authors report no relevant financial disclosures.
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