Cloudy outlook, silver lining

Cataracts are No. 1 cause of vision loss over 40, but surgery can improve sight

Information and illustrations about the mechanics of sight.
Information and illustrations about the mechanics of sight.

When the moon hits your eye, you don't see it go by -- that could be a cataract.

photo

Courtesy of UAMS

Dr. Romona Davis is a surgeon and teacher at UAMS.

A cataract is a buildup of protein that clouds the lens of the eye, preventing light from passing clearly through and causing partial, or in extreme cases total, loss of vision. For centuries, the solution has been surgery, and as recently as 80 years ago, this was a dire undertaking with a real risk of blindness.

Technology has made cataract surgery comparatively easy and routine. It's done on an outpatient basis and no longer requires extended in-hospital recuperation. And most patients can resume normal activities that same day.

The procedure breaks up the cataract, using ultrasound, in just a few minutes, after which the surgeon implants a new, artificial lens to replace the old, clouded one.

The new lens can provide corrections for myopia -- nearsightedness -- and other vision problems. And some high-end lenses could also correct astigmatism, a blurring of vision due either to the irregular shape of the cornea or a curvature of the lens.

"There are some patients who are what we consider high myopes, who see the best they have ever seen with the correction," says Dr. Romona L. Davis, an ophthalmologist with the Harvey and Bernice Jones Eye Institute at the University of Arkansas for Medical Sciences, where she's also on the faculty of the UAMS College of Medicine.

"We measure the length of the eye, and we do what their natural lens was not capable of doing."

The independent journalism website allaboutvision.com notes that cataracts are the most common cause of vision loss in people over 40 and the principal cause of blindness in the world. Cataracts affect more than 22 million Americans age 40 and older, and as the population ages, doctors predict more than 30 million Americans will develop cataracts by 2020.

Ophthalmologists say few people escape. "It's one of those blessings of the aged, one of the gifts," Davis says.

"If you live long enough, you're going to have that happen," adds ophthalmologist Thomas Moseley Jr., who practices at Doctors Park Eye Clinic on the Baptist Medical Center campus.

SYMPTOMS AND DIAGNOSIS

Diagnosing cataracts requires dilating the pupil, expanding its size so the doctor can get a better look at the condition of the lens and the other parts of the eye.

Symptoms include cloudy, blurry, foggy or filmy vision. Cataracts also cause changes in the way people see color (the discolored lens acts as a filter), problems driving at night (such as glare from oncoming headlights), double vision and progressive nearsightedness, often called "second sight" because some people may no longer need reading glasses. (It's a short-lived benefit that will go away as the cataract worsens.)

"For most patients, it's a gradual change," Davis explains.

Removing cataracts is the most frequently performed surgery in the United States. Doctors do more than 1.5 million procedures each year. "More than 95 percent of patients who have undergone this procedure have vastly improved vision, and the outcomes are quite good," Davis says.

However, a cataract diagnosis doesn't either automatically or immediately mean you'll require surgery.

"I have several patients who are in their 80s and who have never had cataract surgery, and they see pretty well," Moseley says. "Those people we just kind of watch." He recommends surgery only "if their vision gets to a point where it gets very difficult for them to do their daily activities."

"There are several nonsurgical treatment options," Davis says. "The first is to try to correct vision with glasses or contact lenses; improving the light for reading or working; and avoiding driving at night, because some cataracts cause worsening glare.

"If the cataract progresses beyond that, surgery becomes an option, but it's not a must. The discussion needs to happen at some point about how significant the cataracts are to the individual's needs. And the patient needs to take a role in determining whether their lifestyle is being affected -- whether they feel their ability to read and work has been affected; whether they feel safe driving at night; whether they are losing their independence; whether, because of their declining vision, they are avoiding the things they would have typically enjoyed; whether they begin to feel unsafe going up and down stairs.

"If the patient is unsure, I tell them, 'If you are not on board with doing something about it, fine, wait.' Because the one thing I am certain of is that the cataract will get worse.

"'And when you are ready, then we'll do it.'"

Medical conditions might mandate surgery, however, Davis says: "If the patient has, say, a retina problem -- the retina lies farther inside of the eye than the cataract, and sometimes the cataract impedes the treatment of that condition. So I take the cataract out so that my retina colleague can manage the diabetic retinopathy or macular degeneration or other condition."

QUICK PROCEDURE

Moseley says he does four to six cataract surgeries in an average morning.

"The actual procedure itself does not take all that long," he says, "about 15 or 20 minutes. The pre-op, getting them into the [operating room], getting them out of the OR -- I think we spend as much time getting them ready as it does for the procedure itself."

During surgery, drops and a gel anesthetize the eye and dilate the pupil for easy access to the cataract, Davis says, and "most of our cases are done under topical anesthesia." An intravenous medication helps keep patients calm and comfortable, but generally they're awake throughout.

She uses a small blade to make a small incision through the cornea and then a larger incision in the "capsule" of the cataract. Using a technique called "phaco-emulsification," the doctor inserts a probe that uses ultrasound "to emulsify the lens and break it up into tiny segments ... and then it also suctions it out," Davis adds.

"We place an artificial implant into the capsule so it's anatomically in the same location as the cataract was. And once that is complete, we just ensure that the wounds are self-sealing without sutures, and we administer antibiotics to the surface of the eye."

There are conditions that can complicate the surgery. For example, certain medications, especially Flomax -- mostly taken by older men to ease the pressures of enlarged prostates -- have a side effect on the eye.

"Everybody gets dilating drops to make the pupil as big as we can possibly get it," Moseley explains, "but some people who are on Flomax or have other pupil abnormalities due to injury or inflammation, we have to do iris retraction -- there are several small instruments or mechanisms [with which] we can manually dilate the pupil."

It's not just men, Moseley adds. "There are a lot of [women] on the medicine because they have urinary problems or kidney stones. It's a pretty popular medicine -- unfortunately for cataract surgeons."

AFTERWARD

There has also been a big change in recovery time -- an hour or less in the recovery room, Davis say. "Back in the day, you had to spend a week in the hospital with sandbags around your head," Moseley says. "Now, most people can get around, go to lunch after surgery."

As with any surgery, "Patients are advised to be on light duty for a week, no bending, lifting or straining," Davis notes. There's a good reason: "We have no stitches; you could actually increase the pressure in your eye and force fluid out of it, and we don't want that to happen while it's healing."

POSITIVE RESULTS

"A standard cataract surgery will, with a standard lens, correct vision at one-sixth distance," Davis says. "We have multifocal intraocular lenses that will reduce dependence on glasses, but we call those 'premium' lenses; insurance doesn't cover the additional cost."

A premium lens could provide an in-eye correction for astigmatism. "Lots of people have been unable to wear contact lenses, or have just had terrible vision because their astigmatism wasn't able to be corrected," she says. The cost of the lens is about $600 per eye above the cost of the surgery, but "this will eliminate the need for that astigmatism correction on your glasses for a lifetime."

Davis removed two cataracts from Little Rock native Ladie Shelton, 90, one last year and the other this year.

"Before the first one, I was so nervous," she says. "But I got through it just fine."

When it came time to do the second one, Shelton says, "there was nothing to it. She was talking to me and letting me know what was going on." Shelton went home the same day.

"It's just amazing how well I can see now. I don't need my glasses anymore." Well, she admits, she puts them on to read the tiny type in her telephone directory.

"It's seldom that we operate on two eyes [at the same time] unless there's a trauma," Davis says. "We will operate on the second eye as soon as we confirm that the first eye is doing well. If the patient is satisfied with [the post-surgical vision], we might wait several years."

While now routine, the surgery is not without risks. "The greatest would be vitreous loss; there's a chamber behind the cataract called the 'vitreous chamber,' this gel-like substance, and if during the surgery there is a breach of the membrane that houses the cataract, that can come forward," Davis says.

"Other risks include elevated eye pressure, which we can manage. And the risk of infection is very, very small -- about 0.1 percent."

ActiveStyle on 06/08/2015

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