Cataract Surgery – My Story

I recently had the lenses in both of my eyes replaced with Intraocular Lenses (IOLs).  I had very thick and dense brown and yellow cataracts by the time I had the surgery because I was having a hard time deciding what kind of IOLs to get.  There are a lot of choices, but no single option completely restores your vision. There are pluses and minuses to every option.

Some people ask how to know when you need to have cataract surgery such that it qualifies for your medical insurance to help pay the expenses. Your optometrist can tell you, or you can visit an ophthalmologist to find out.  One way to know you need surgery is when your optometrist can no longer correct your vision with glasses to get you to a 20-40 correction for driving. Another way is to have your cataracts examined by an ophthalmologist, and if they reach a certain size and/or density or both, it’s time. For most people this happens in their middle to late 70’s. Other people go much longer before they need it, and many people need it much sooner.

Don’t assume that your insurance will pay for everything. Typically, they pay for basic monofocal lenses, the surgery, and put some money towards one pair of glasses if you need them after the surgery.  Currently as of this writing, Medicare does not pay for laser surgery to remove your cataracts, and they don’t pay for any type of lens other than the standard monofocal lens. If you want either of these or both, you pay for it yourself and the costs can be quite high. If you have insurance other than Medicare, it might cover the laser.

Thankfully, my optometrist made the decision of which lenses to get easy for me, as I describe in Here ‘s How I Decided. But first, an overview of the basic IOL choices.

Lense Options

Conventional Monofocal lenses use a single focal point and are typically spherical in shape.  They can be set to any distance you want. Most people choose to have both eyes set to distance and then use reading glasses. Another option is to have both eyes set to near, and then use glasses for driving, for when you need to read something in the distance, or to watch TV if your TV is more than 7 or 8 feet away. Some people choose monovision, which is when you have one eye set to near and the other eye set to far. The brain adjusts and learns which eye to look through depending on the distance. This works about 70% of the time with about 30% of people never fully adjusting.

Premium aspheric IOLs use a single point of focus and match the asherical shape and quality of the natural eye more closely. This means they can provide sharper vision in general, sharper vision in low-light conditions, and sharper vision for people with large pupils. Premium aspheric IOls include toric lenses (astygmatism correction built into the lens) and accommodating IOLs (slightly flexible lenses to make near objects appear sharper). My husband got toric lenses  set to the near-point and loves them because now he only needs glasses for driving.

Multifocal lenses provide two or more focal points by splitting light between distance, intermediate, and near.  Your brain learns to focus only on one distance at a time, and that leaves the blur from the other focal points to possibly cause halos and flare.  These lenses can provide better near vision than accommodating IOLs, but are more likely to cause flares and halos or slightly blurred distance vision as a trade-off.

EDOF-IOLs (extended-depth-of-focus) create one elongated focal point that provides improved near and intermediate vision without the trade-off of blurred distance vision. See Discussion of  extended depth of focus IOLs  and  FDA Update: Next Generation IOLs for more information.

With multifocal  or EDOF IOLs you might not need to wear glasses as much as you might with monofocal lenses, but you might not have the sharpest vision possible and you might also need glasses for reading small print or for driving at night.

Everyone’s eyesight changes as they age because the visual machinery we all have is more than just the lens. So it’s possible to spend a lot of money on multifocal lenses and not need glasses very much for awhile, but have that change as you age.

See Intraocular Cataract Lenses for more information about lens types and options.

Here’s How I Decided

The final decision on lenses depends on your personal visual needs and your lifestyle. It also depends on your budget. Here is one way to determine what that might mean for you.

At my last eye appointment when my optometrist me told it was time because he could no longer correct my vision so I would be legal to drive, I asked how to decide on the lenses. My optometrist started asking me questions. He of course knew that as long as I have needed glasses, it has been for driving only. I have always had good close-up vision. So his questions to me went something like this:

  1. Do you like the vision you have now? (Yes)
  2. Do you like not having to wear glasses for things like reading, cooking, washing, or picking out your clothes? (Yes)
  3. Do you mind wearing glasses for driving, or are you okay with that? (I am fine with just wearing glasses for driving)

So, he said to me, get monofocal lenses set to the vision you have now (I don’t have much astigmatism so I don’t need toric lenses). That would be each lens set to close-up about 18 inches out for where I would have the sharpest focus. I asked if I would be able to use the computer without glasses, and he asked me if I can do that now, and I said yes. So, he said then you would be able to do it after the surgery too because you would be getting the vision you have now.

I asked him what is wrong with multifocal lenses, and he just said, then you won’t have the sharpest possible vision at any distance. (See the discussion of multifocal lenses above to understand why. ) Also, premium, multifocal, and EDOF  lenses are expensive and insurance doesn’t cover them so you pay out of pocket thousands of dollars for each eye. What he was recommending for me would give me the sharpest possible vision near and far (with glasses).

Note: Can’t comment personally about any of the other lenses, but anyone who has them and wants to weigh in in the comments section, please do!

Most people get monofocal lenses with correction for distance. That way you have very good vision after about 2 to 3 ft. from your face all the way out. You get more vision than you do with them set to the near point (like I did) and don’t need glasses for driving, but most people with this setting need glasses for reading and anything else that involves close up details. Basically you have a blur around you at the near point until you put on your reading glasses. Depending on your lifestyle and personality, you might be okay with that or not. Some people don’t even notice it until they try to read something.  But if you spend a lot of time doing close-up things and much less time driving or doing other distance-related activities such as sports, you might prefer the near correction over the distance correction. For example, you might ask yourself, how much would it annoy me to have to put on glasses to read my shampoo bottle in the shower?

glasses-and-chain.jpg
My glasses with a chain I made from an old necklace chain and two necklace clasps that I bought at a crafts store.

I wasn’t okay with the idea of having a close-up blur around me. As an older person, I don’t drive as much as I used to and spend way more time at home doing close-up things and being on the computer.  When I go out for walks, I can see fine even though it’s somewhat blurred in the distance.  I can admire plants, see cars coming, and see down the street. The sunnier the day, the better I see in the distance, and the less I notice the distance blur.

If I want to read a sign or just see details in the distance, I put my glasses on, which I wear around my neck on a chain. It’s a much better lifestyle choice for me to mostly just use glasses for driving.

One thing I’ve noticed is after doing a lot of close-up work, the distance blur  is worse for me than when my eyes are relaxed.  After some minutes as my eyes relax, I am able to see better in the distance.

The Outcome

If you are a myope like me and want to go with near vision, you will need to work with your optometrist and/or ophthalmologist to decide where to set the focus. About 18″ out worked out to be perfect for me. I can read most print unless it’s very, very tiny (then I use a magnifying glass) and I can see and work on the computer just fine.

Right now I have excellent close-up vision that is about 20-20 at the near point, and with my glasses I am about 20-15 or so for distance. Also, if as I age my distance vision gets worse, I can get stronger glasses for the distance and keep driving.  So, if you don’t mind wearing glasses some of the time, you get the sharpest vision at two points with monofocal lenses plus glasses with both eyes set at the same distance (either near or far). If you have a lot of astigmatism, go with toric lenses, which are monofocal lenses with astigmatism correction.
If you go the nearsighted route, you might or might not be able to see the TV. Our TV is about 9 ft. away, and I can see if just fine. It’s not crisp and clear, but I don’t mind that. I can read most of the text on the screen, but not the program guide unless I’m feeling very, very relaxed at which time, the program guide comes in clear enough so that I can read it without leaning forward or walking a few steps closer. If it really bothers me, I can also put my glasses on to read the guide. Black and white and/or subtitled movies require that I wear my glasses.
Also, even though multifocal lenses are known for halos and flare at night, both my husband and I experience them with our monofocal lenses – which are supposed to be better about that. I had considered getting multifocal lenses because I really liked the idea of not needing glasses so much, but I’m glad I didn’t spend $9,000 for both eyes for multifocal lenses because not only would I have likely had more flare and halos than I have now with the monofocal lenses, but given that I have very small pupils, I would have probably always needed to wear glasses for driving at night.  It wouldn’t have been much of an improvement over what I have now and would have cost us a lot of additional money.

The Surgery

The surgery itself is nothing to be afraid of. They had me on a hospital bed under nice warm covers with a cap on my head. They give you drugs so that you don’t feel the surgery and are not aware of anything happening to your eye. You can hear the doctor if he or she says anything or asks you a question, and you can reply, but you don’t feel the surgery. You feel completely relaxed and content.

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Cataract Surgery – My Story

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