Online Health Chat with Annapurna Singh, MD

May 18, 2016

Description

A cataract is a clouding of the normally clear lens of the eye. It is similar to looking through a fogged-up window. This clouding can weaken vision. In time, as the cataract increases, surgery will be needed to restore your vision. Take this opportunity to have your cataract questions answered by specialist, Anna Singh, MD.

Cataract is a normal aging change of the eye. Cataracts often form slowly and include these symptoms:

  • Vision that is cloudy, blurry, foggy or filmy
  • Glare or light sensitivity
  • Nearsightedness (second sight)
  • Need for brighter light to read
  • Poor night vision
  • Changes in the way you see color, especially yellow

In the early stages of cataract development, vision may be improved simply by a change in your prescription. In time, as the cataract increases, blurred vision and other symptoms will not be relieved by glasses, and surgery will be recommended. Traditional cataract surgery involves manually removing and replacing the lens with a new, artificial lens.

Laser cataract surgery refines the cataract extraction, allowing for a more accurate and quicker process. Using a touch screen computer with 3D imaging, the laser system helps with surgical planning, enabling eye surgeons to precisely program the size, shape and location of each incision. Surgeons can then guide the laser to create tiny, precise incisions in the eye through which the cloudy lens can be removed and a new lens implanted.


About the Speaker

Annapurna Singh, MD, is a board-certified ophthalmologist specializing in cataracts and glaucoma. She sees patients at Cleveland Clinic main campus and at Hillcrest Hospital.

Take advantage of this opportunity to ask Dr. Singh questions about when surgery is right for you and if you qualify for femtosecond laser cataract surgery.


Let’s Chat About Cataracts


Cataract Concepts

yless1: I have had cataracts for years, and they were growing very slowly. All of a sudden, their growth seems to have become more aggressive. I was reading that there is a link between statin use and cataracts. Is it the statins that I am taking that is accelerating the growth of my cataracts?

Anna_Singh,_MD: It is hard to say without evaluating you. The link has been shown, but it could also be that your cataracts are just progressing.

easy rider: Do Vision Clarity eye drops help for small cataracts?

Anna_Singh,_MD: I am not aware of these drops and do not prescribe them to my patients.

johnnnita: About two years ago, during my annual eye exam, I was notified that I had the "initial" stage of cataracts. When I was told this during the exam, I was naturally upset. When I asked more about this, I was told that it was very, very early, this was not uncommon and that it could be "decades" before a need for surgery. During my latest exam, a different optometrist basically reconfirmed this. My first question is: Does that sound like something that an optometrist would say? I am 66 years old, 67 this August. I've worn corrective lenses since I was about nine years old due to astigmatism. Aside from this, until my cataract diagnosis, I had only one other issue (periodic diplopia related to "silent migraine"). My second question is the following: What other questions and information should I be asking/gathering related to future annual eye exams about my cataracts? Isn't there some sort of metric applied to the evolution of a cataract? Thank you.

Anna_Singh,_MD: It is not uncommon to have an early cataract at the age of 67. Regarding your second question, continue to get regular exams, and your vision will tell you when you need to have the surgery. You should consider surgery when you notice impairment and changes in your vision that affect your daily life and glasses no longer help. When your vision drops below 20/50 (20/20 is normal), insurance will cover the cataract surgery.

Betsysbest: My husband was diagnosed with cataracts last summer with a follow-up appointment this summer. Within a few months of the diagnosis, he started complaining about glare – in movie theaters, in the house, in stores. He wears sunglasses in the house if I have the blinds open and the lights on. Is this the cataracts accelerating?

Anna_Singh,_MD: Possibly, but he would have to be evaluated to determine the actual cause.

RayMC: First, I am age 68 and currently have Stage 1 cataracts in both eyes. Is there a standard rate of progression that I should be aware of, a timeline so to speak? Second, according to a report in the AMA Journal of Internal Medicine, patients who underwent PCI are 25 percent more likely than those not exposed to PCI to require cataract surgery. Is this only correlation or is it causation? Thanks.

Anna_Singh,_MD: There is no standard rate of progression in cataracts. I have not come across an increased number of PCI patients in my practice at Cleveland Clinic who have developed cataracts, but I am not familiar with the article you noted.


Surgical Specifics

johnnnita: What are the "necessary pre-op tests" that are typically given prior to surgery?

Anna_Singh,_MD: Before surgery, you will have lens power calculations for the lens we will be replacing in your eye, and an anesthesia evaluation.

AFIB: Is cataract surgery safe for me? I am being treated for high blood pressure. My BP is running about 150 over 97 even with BP medications.

Anna_Singh,_MD: Yes, it is safe. You will just need to be evaluated prior to surgery.

nutzy: What about people with a double chamber pacemaker implant? Could they undergo a laser cataract surgery?

Anna_Singh,_MD: Yes. Anesthesia has to give the OK.

dmack1106: I am having cataract surgery next year and want to know what "intraoperative wavefront aberrometry" means and should I pick a surgeon who has this skill. Also, should I pick a surgeon who uses laser rather than a scalpel?

Anna_Singh,_MD: Both are an option, but I tend to think of the laser as more of a "Mercedes" rather than the scalpel, which is a "Honda Civic." Both work and will give you good results, so it is your preference.

mo2mo: What type of anesthesia is used? Would I be completely "out" (general anesthesia) or do you use local anesthesia?

Anna_Singh,_MD: Now we use topical (eye drops). It just numbs your eye. Most of the time, we do not give injections and general anesthesia. However, we can give you something to help relieve anxiety.

RaySenior: Is surgery performed as an outpatient, then you return the next day for a follow up or does it require an overnight stay?

Anna_Singh,_MD: It is outpatient and we see you for follow up at one day, one week and one month.

mo2mo: How long does the surgery itself actually take?

Anna_Singh,_MD: Depending on the surgeon, it can range from 10 to 30 minutes.

AFIB: What are the risks of cataract surgery for patients who are on blood thinners, have high blood pressure, have A-fib with a two lead pacemaker and are 73 years of age?

Anna_Singh,_MD: We manage these symptoms in our patients on a routine basis when performing cataract surgery. We do not stop blood thinners in our patients for cataract surgery.

dmack1106: You did not answer what is "intraoperative wavefront aberrometry," will this increase my odds of successful surgery and should I only pick a doctor who has this skill. Also, how many cataract surgeries have you done and how many multifocal IOL have you done.

Anna_Singh,_MD: At Cleveland Clinic, we are not offering wavefront aberrometry at this time. It will not increase your odds of successful surgery. It is a way of telling if the lens we put in your eye is the correct power. That being said, it is not perfect. We currently have many tools to do this in other ways (measurements, in person evaluation). It is just another tool for precision.


Surgery at Cleveland Clinic

RaySenior: Do I have to be referred through the Clinic eye center to schedule surgery?

Anna_Singh,_MD: Yes, you would have to see one of our specialists for an evaluation, who would then schedule you for surgery. You would have to have all the necessary pre-operation tests to ensure that it is just the cataract that is affecting your vision and nothing else.

yless1: I would love to have my cataracts done at Cleveland Clinic. I live in Pittsburgh and would be driving in. What would the procedure be for coming in from out of town? Can I stay at a local hotel overnight or would I be required to bring someone with me? When would I be able to drive home?

Anna_Singh,_MD: Prior to surgery, you would need to come in for an appointment for pre-operation evaluation and measurements. Typically in my practice, patients have surgery on Thursday, I see them for follow up on Friday and then they can go home. Since you will be driving in from out of town, you will need someone to drive you to the hotel after surgery that night. Patients can typically drive themselves home after the post-op evaluation on Friday if they are comfortable doing so.

Tar Heel: What is your process for doing both eyes? I, too, will be traveling from out-of-town and would like to minimize travel time.

Anna_Singh,_MD: We do not do both eyes on the same day. Ideally, we wait two weeks, but we could wait one week since you will be traveling in from out of town. You will need to follow up one day, one week and one month after surgery, ideally (for each eye).


Making the Decision

mo2mo: What risks are involved in cataract surgery?

Anna_Singh,_MD: The biggest risks are hemorrhage, infection and loss of vision. These happen in less than one in 1000 patients.

RaySenior: Is it better to have surgery soon after the cataract is detected or wait a while until it really interferes with vision badly?

Anna_Singh,_MD: I would recommend having surgery when it starts to affect the quality of your life.

VirginiaResident: My ophthalmologist says I have early cataracts (I am 59) and one eye is just bad enough to have surgery if I want to. My biggest problem now is that I can see OK during the day but at night I have a lot of glare. Are there any special lenses I can get to reduce the nighttime glare?

Anna_Singh,_MD: You could try an antiglare coating on your glasses, but that probably would not be enough.

TKR: I am a Medicare patient. I have been evaluated through an ophthalmology office, and the result was that I need cataract surgery. I am very reluctant because the technician who did the testing went through all the tests very, very quickly, and I don't feel he was thorough at all. In addition, his hands were dirty. I could smell his hands when he was conducting the tests. I just want to make sure that he will not be involved on the day of surgery. I need to go meet with the doctor again for measurements. Or should I find another doctor. What do you recommend?

Anna_Singh,_MD: I would recommend choosing a surgeon and location that you are comfortable with.

llongan: I have a posterior vitreous detachment in one eye and sort of an odd feeling in that eye. I have had extensive eye tests with no findings to explain the sensation, which is hard to describe. Now I am thinking that the cataract is causing it because my eye is working hard to focus and can't. I am uncorrectable for glasses at this point, and I think I am at 20/30. Do you have any thoughts?

Anna_Singh,_MD: It is hard to answer your questions without an in person evaluation.


Lens Selection

Betsysbest: I have been diagnosed with cataracts, and the doctor wants to put in a lens that will offset my need to wear glasses. I have been nearsighted my whole life. I use a computer and currently have trifocals. Lately, I have been having trouble focusing with my glasses in the center area of my trifocals. Is this the cataract interfering? I have another appointment in June. I would be very interested in the multifocal lens. Should I wait for it?

Anna_Singh,_MD: You could try an antiglare coating on your glasses, but that probably would not be enough.

SusQ: Can the implanted lenses correct for astigmatism?

Anna_Singh,_MD: Yes, they can. More than 1.5 diopter is a special lens (Toric lens), less than 1.5 diopter can be corrected with laser cataract surgery.

dmack1106: What are the considerations when deciding to have regular cataract surgery or multifocal IOL? I am 75 and wear progressive lenses with bifocal, and use them for all activities: tennis, golf, reading, etc.  Can I eliminate wearing glasses with regular cataract surgery, or do I have to pay for multifocal IOL?

Anna_Singh,_MD: I would have to evaluate you to determine which type of cataract surgery would be better for you. If you got the multifocal lens, you would have to pay. It is not covered by insurance.

llongan: I was offered laser surgery with Lifestyle distance and near focused lens OR laser surgery with distance focused lens. The former corrects distance and some near vision and is $800 more than the latter, which corrects distance only. Is Lifestyle the brand of lens that you use, and if not, what brand do you use. Also, are there any advantages or disadvantages to either over the other beyond adding some near vision?

Anna_Singh,_MD: Lifestyle is not a brand name. It is your "lifestyle" i.e., being able to see far and near in your daily life.  Some people notice halos and do not feel that their vision is ever really clear with multifocal "lifestyle" lenses. Generally the monofocal lens gives clear vision, but you would need to wear reading glasses.

fmdk: When I had severe dry eye from medications, my ophthalmologist inserted silicone punctual plugs in my tear ducts to retain the tears. My body reacted to them and encapsulated the silicone plugs. They had to be removed. Should I be concerned about a reaction to a cataract lens if I ever need that surgery? My mother had a hip surgery and had to have the stainless steel removed from her body after a reaction to the metal.

Anna_Singh,_MD: We have never had to remove one because the patient has a reaction to the implant material. We sometimes do cataract surgery in babies who are born with cataracts and these implants last a lifetime.

llongan: What is the difference between multifocal IOL and accommodative IOL, and what are the pros and cons of each.

Anna_Singh,_MD: A multifocal lens has no moving parts, but the lens itself has different zones with different powers, while an accommodative lens is supposed to have some moving parts (helps you focus far and near). There is a risk of halos with the multifocal and a risk of the "parts not moving" in the accommodative.


Life After Surgery

RaySenior: How long does it take to heal after surgery?

Anna_Singh,_MD: Patients use a tapering dose of drops for about a month, but pretty much are functioning in a few days.

keberly1: My husband (60 years old) had cataract surgery on his right eye in early March. His vision is worse now than before surgery. He still sees shadows, halos, etc. in that eye. He continues under the care of his ophthalmologist who sent him to a colleague for assurance that his eye is healthy and normal, and she continues to assure him that it will get better. His doctor says there is still inflammation in the eye (he continues with eye drops two months post-op). Once the inflammation is cleared up, she is going to perform LASIK surgery on that eye to correct his vision. I’m just curious if this sounds like a typical result, and if he should seek another opinion. Thank you.

Anna_Singh,_MD: It sounds like there are two things going on, inflammation and a need for the LASIK surgery. These are not routine but can happen.

Reflect123: Two months ago, I had cataract surgery and an Acrysof IQ SN60WF lens was implanted in my eye. (Power 20.5 D; Length 13.0 mm; Optic 6.0 mm). (My doctor has done many thousands of these surgeries.) Now I see flashing in the outer edge of my vision. This happens under certain types of lights, especially in large stores with multiple florescent-type lighting. It also happens at home at my kitchen table with a hanging chandelier above. It does not happen in a darkened room. A retina specialist said there do not seem to be any retinal tears, although there may be a vitreous detachment in progress. As I plan for cataract surgery in my other eye, is there anything to be done, or not done, to avoid another eye that flashes? Would a different brand of lens be prudent? A different surgery technique? Also, is replacing the current IOL advisable? The flashing is annoying, but it only happens in the discrete type of situations I described. Thank you.

Anna_Singh,_MD: This phenomenon is called positive dysphotopsia. It is not common but occasionally happens. A very small percentage of patients are intolerant and desire lens exchange, which comes with its own risks.


Link with LASIK

roglander: How does prior LASIK surgery affect the cataract surgery?

Anna_Singh,_MD: That is a very good question. We have to be aware that you had LASIK surgery, and the measurements for the lens have to be specially calculated. There is no additional risk to the surgery if you've had LASIK.

ahem: I had LASIK in both eyes maybe 17 years ago and now have very dry eyes. (Either from the LASIK or rosacea or both.) I understand LASIK and/or dry eyes can make the outcome of cataract surgery more iffy. Is my understanding correct? Would you describe the risk and what is done to mitigate it? Also, what results might be expected?

Anna_Singh,_MD: Since you have dry eye, I would not recommend the multifocal lens. But in a standard cataract surgery or laser cataract surgery, it should not be a problem.


Insurance Issues

llongan: My eye doctor said that Medicare will only pay for cataract surgery done manually versus with a laser. Is this your experience, as there is quite a big price differential. Are there any conditions under which Medicare will pay for laser? Is anyone working on Medicare to cover laser in the near future?

Anna_Singh,_MD: This is correct. At Cleveland Clinic, we charge $1200 per eye for the use of the laser during cataract surgery. Medicare does however cover the rest of the surgery (anesthesia, surgery, physician, etc).

johnnnita: Regarding insurance coverage, is that with corrective lenses or without?

Anna_Singh,_MD: The amount of $1200 is the cost for the laser. The specialty lenses (Toric and multifocal) do have an additional charge. We would go over the cost at your pre-op evaluation.

johnnnita: I meant to ask is the 20/50 vision eligibility with or without corrective lenses?

Anna_Singh,_MD: With corrective lenses.


On the Horizon

SusQ: I am currently planning to have cataract surgery, and I wondered if there are any promising new and better options on the horizon that would be worth waiting for.

Anna_Singh,_MD: There will always be something new on the horizon. In my opinion, cataract surgery should be performed when it affects the quality of your life. A newer multifocal lens with fewer aberrations is on the horizon. It has had good reviews in Europe and we are waiting for it to come to the US.


Closing

That is all the time we have for questions today. Thank you, Dr. Singh, for taking time to educate us about cataracts.

Anna_Singh,_MD: Thank you for the great questions today. It has been my pleasure to chat with you all, and I hope the answers were helpful. I would be happy to see you for an evaluation or second opinion. To schedule an appointment, please call 216.444.2020.

On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at my.clevelandclinic.org.


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To make an appointment with Anna Singh, MD, or any of the other specialists in Cole Eye Institute at Cleveland Clinic, please call 216.444.2020 or call toll-free at 800.223.2273, ext. 42020. You can also visit us online at clevelandclinic.org/eye.


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