When Is the Right Time to Get Cataract Surgery?

Cataract surgery is one of those miracles of modern medicine that we take for granted. We forget that cataracts were once the leading cause of blindness in this country and that having cataract surgery required a monk-like ability to lie in bed with your head perfectly still for a week or more while the incision healed. The results weren’t terrific either. They would take out the lens and give you coke-bottle thick glasses with prisms to focus the eyes. I remember my father wearing a pair of those.

Still, that was an improvement on cataract surgery ancient times-style. They used a process called “couching,” where the doctor hit the eye with a blunt object, forcing the cataract to move to the back of the eye.

Nowadays, the cataract complication rate is one percent and a variety of lenses can be implanted to allow accommodation to near and far distances. Unfortunately, as the surgery has improved, the public’s understanding of it hasn’t. A lot of misconceptions about modern cataract surgery — especially the misconception about “ripe” cataracts —inhibit people who need it from getting it when they need it.

What Exactly Is a Cataract?

A cataract is a clouding of the eye’s lens. When we look at something, light rays travel into our eye through the pupil and are focused through the lens onto the retina, a layer of light-sensitive cells at the back of the eye. The lens must be clear in order to focus light properly onto the retina. If the lens has become cloudy, this is called a cataract. As cataracts advance, they become more opaque and harden, eventually causing blindness.

The “Ripe Cataract” Myth

The major misconception is that your cataract needs to be “ripe,” —in other words, advanced to a certain point—before you can get it removed. The concept of ripeness had validity not long ago, when you had to be nearly blind to get a cataract removed safely—but techniques have changed.

“When my dad did this surgery there was a different technique,” ophthalmologist Brett Katzen MD explains, “the incision wasn’t microscopic like it is now. To get access to the lens they’d use a hook to get the cataract out. It was like removing a watermelon seed–you wanted it hard so it didn’t break apart.”

Technology advanced rapidly in the late ’60s when small-incision surgery was invented. An instrument was used to break up the cataract in a process called phacaoemulsification so the cataract could be removed without damaging the eye. With this type of surgery, the less ripe the better, since the softer the lens is, the easier it is to remove it with the ultrasonic instrument. “Now we don’t use stitches or a patch on the eye. Patients can walk out seeing perfectly.” says Dr. Katzen.

In fact, explains Dr. Roy Chuck, Chairman of the Department of Opthamology at Einstein Montefiore Medical Center, “When a cataract gets rock hard it’s technically difficult to remove. This is a good reason not to let cataracts get worse.”

How’s Your Vision?

So, if waiting as long as possible is no longer the answer, when is the right time to have cataract surgery? Doctors today say you should get your cataracts removed when your vision is 20/40 or worse, and more importantly, when cataracts affect your daily activities, like reading, sewing or driving at night.

That also happens to be when Medicare and private insurers will begin to cover the surgery. According to Dr. Chuck, they want your vision to be “significantly impaired” before they’ll kick in. Since cataracts develop so slowly and we tend to adjust to impairment from day to day, that means staying aware of your changing vision.

“Some people have decent clarity of vision, but the glare starts to bother them—they realize things look dimmer,” he notes. That’s when they should come in for testing to see if they have a cataract. “When we remove a cataract, people are aghast at how bright their wardrobe is. They didn’t realize they’d been living with a wardrobe malfunction.”

Which Lens to Choose

Unless you can afford to pay for what Medicare won’t cover, there is not much choice: Medicare will cover a single vision lens that can be calibrated for either distance, reading or something in between, which means you’ll probably need bifocals or glasses with progressive lenses after surgery.  There are newer lenses that correct astigmatism and also allow almost normal vision, but they’re quite expensive and Medicare doesn’t cover them. If you can afford to pay an extra thousand or more per eye, ask your surgeon about the new multifocal or accommodative lenses.

How to Pick a Cataract surgeon

I developed cataracts very young because I had diabetes and was referred to one of the best surgeons in New York because I was so myopic. I saw a lot of botched cataract surgery cases in his office because he was the go-to guy for repairs.

Despite the fact that the complication rate is very low with cataract surgery, do choose the best doctor you can find.  This is your eyes we’re talking about; find a surgeon that does a lot of cataract surgery, not just the occasional case.

• Read “The Facts About Cataract Surgery” at the National Eye Institute website
• See “The Ultimate Cataract Surgery Mixtape” on Senior Planet

Have you had cataract Surgery? How long did you wait? Share your experience in the comments below.