What to Know About Cataracts and Your Lens Options Before Surgery

What Are Cataracts and How Do They Affect Your Vision?

Interviewer: If you've ever felt like your vision might be getting a little fuzzy, maybe a glare at night, headlights looking like starbursts, colors not popping the way they used to, you are not alone. One of the most common reasons that happens is actually cataracts. And the good news is that it's treatable, especially with some of the lens options available.

To walk us through what cataracts are, what symptoms matter, and what some of these treatments look like today, we are joined by Dr. Austin Nakatsuka, a glaucoma and cataract specialist at University of Utah Health, John A. Moran Eye Center.

So, Dr. Nakatsuka, let's start at square one. When people hear the word "cataract," what exactly is happening? And what does it mean for their quality of life?

Dr. Nakatsuka: Cataract is essentially when the natural lens in the eye, or the eye that you're born with, starts to become cloudy. It starts to become opaque, meaning that the light does not go through as it normally should, and that light starts to scatter. And it actually becomes a little bit yellowish or brownish.

Early Signs of Cataracts

Interviewer: Oh, so that's a color thing. Okay.

Dr. Nakatsuka: Yeah, partly the color thing. Now, this happens slowly over a period of time, so that a lot of people don't realize what's going on. Same thing with the cataract. Usually, it's slowly over time; people don't realize that they're seeing less and less as that cataract is getting thicker and worse, and the light is scattering. And they don't realize that they're actually not seeing well, and they're not seeing things that they should be seeing.

Interviewer: So, what is it that actually causes the cataract? Is it just age?

Dr. Nakatsuka: Yeah. So you could call it that. It's age over time that causes the cataract to become worse. But essentially, what's happening is a very scientific process where free radicals are forming in the lens itself, creating proteins that cause that lens to become a little bit thicker and more opaque and cloudy. And it's age that contributes to that, but UV light is really the deal there. So the sunlight is our enemy in that regard.

How to Slow Cataract Progression

Interviewer: Sure. And so, I guess, before we get into some of the treatments, like, you know, an ounce of prevention is worth a pound of cure, right? So, is there any way to prevent or, maybe, delay cataracts in a patient?

Dr. Nakatsuka: Yeah, absolutely. And one of the easy ways to do that is to move locations. And when I say that, I mean if you live in a sunny location, like where I'm from in Honolulu, Hawaii, you tend to get cataracts a lot sooner. If you spend a lot of time surfing, if you spend a lot of time outdoors playing tennis or golf without sunglasses, in particular, you will develop a faster, thicker, harder cataract earlier in life.

Interviewer: Or skiing here in Utah.

Dr. Nakatsuka: That's right, exactly.

Interviewer: Perfect, got you.

Dr. Nakatsuka: That's a perfect analogy. The good news is, you know, if you wear protective eyewear, then that should significantly delay the onset of the cataract. But if you don't, then that cataract comes on sooner. Now, to some extent, we can't avoid it, unless you live in a box or house the rest of your life, with no sunlight exposure. But the best thing that one can do is to wear protective eyewear outside.

Diagnosing Cataracts During an Eye Exam

Interviewer: So, say a patient has come in. They've noticed some of these signs. They've been diagnosed with a cataract. Where do we start with treatment options? Do we go straight to the lenses, or are there other things that we want to try first?

Dr. Nakatsuka: The most important thing when it comes to evaluating for a cataract is to get an eye examination from a qualified eye health professional. So when you go to the eye doctor, typically, what's done is it's not just a check on your vision, on glasses prescription, or even eye pressure, but it's a look at your eyes themselves to determine, "Hey, is there something going on inside your eye that is causing a problem?"

And one of the main things that we look for, especially in certain ages of patients, is if the cataract is developing in a patient's eye. And the qualified health professional or eye professional is able to see with their very own eyes through a microscope how badly a cataract is progressing in someone's eye, and they can then make an assessment and judgment call about how badly this cataract may be affecting a patient's vision.

Now we also do other types of testing, like testing the visual acuity, so that eye chart with the Es on it, you know, that has utility in determining how poorly a patient is seeing, and we can attribute that to the cataracts. And then we do other types of testing to determine is it predominantly from the cataracts or is it from something else?

Surgery Is the Only Effective Treatment for Cataracts

That being said, once a qualified eye professional states, "Hey, this patient has a cataract that is probably visually significant," there aren't a whole lot of other therapies that can be utilized to mitigate that. Really, the number one treatment for cataract surgery still, even now, is cataract surgery.

Now there are drops that are currently in the FDA approval phase or clinical trial phase that purportedly can delay the onset of cataracts. They are not yet publicly released, or we don't use them in the clinic just yet. And I just want to state that none of those have been scientifically proven to actually stop or delay the onset of cataracts.

Understanding Your Lens Options After Cataract Surgery

Interviewer: Okay. So we're going to go to surgery. That's probably the best way to treat cataracts. And we have another piece that we'll link to if anyone listening is interested in kind of the ins and outs of a surgery, start to finish. But I did want to spend some extra time talking about these lenses.

Dr. Nakatsuka: I spend most of my time in the clinic, after talking about the cataracts and the cataract surgery, discussing the lenses, because, nowadays, there are so many different options that we did not have before, which is both good and bad, in the sense that we have a number of options that patients can choose from, but it gives you more decision-making points, which naturally can be a pain point in terms of determining your medical care and what's best for you. So it is what I do love talking about with patients.

Now I'm going to go over sort of the general options that we have out there, and I'm also going to discuss what might be right for particular patients. But at the end of the day, certain lens choices are really best for certain patients, and that's really a decision that needs to be made between a patient and their eye care professional, or really their cataract surgeon.

Monofocal

So the standard lens that is generally covered by insurance is called a monofocal lens, meaning a single-focus lens. And essentially, it is a lens that focuses at one distance. And the nice thing is, we can choose. So a patient can choose which . . . 89% of patients do choose to have distance vision, with the lens focusing for good distance vision, so being able to see the mountains or being able to see the TV. But that focus point is ideal for that location and distance. That being said, up close, so reading, for instance, or even computer vision, may not be quite as in focus. It may be a little bit blurry, and that's because that lens doesn't focus for that distance. It focuses on far away.

Now the opposite can also hold true. A patient can choose to have their focus set at a different distance, such as reading, especially if that's something that they're used to, or it can even be set for computer vision. And then they would require glasses for distance correction or seeing far away. So that's the monofocal, single-focus lenses, the lenses that focus for one distance.

Multifocal

Another type of lens, we call the multifocal lens. So the multifocal lens is sort of like a trifocal lens that you wear in glasses. So most people over the age of 50s to 60s understand this already, that they lose their near vision and they need glasses that allow you to be able to see up close, and some of them will wear these trifocal lenses, which focus for intermediate levels, so like computer level vision and for reading level vision. And they're made up of different lenses within the glasses that have different focus points. There have been lenses that are created that have those different lenses all combined into one, so that it gives you the ability to actually focus at those three points of vision, both far away, computer level, and up close.

That sounds like a great lens that everybody should have because it gives you the ability, in general, to see far and close without needing any glasses correction. And that's true. That's what you're paying for. That lens does cost quite a bit more out of pocket, beyond what the insurance will cover. That's what the benefit of that lens is for: to be able to get you to the situation where, most likely, you will not need any form of glasses to see well for any level of distance after the cataract surgery.

Extended Depth of Focus

I do want to say about those lenses that there are some aspects of that lens that don't work for certain people. So between you and your provider, they need to look at everything regarding your eye and determine that you're a good candidate for it. And I say that because when you have multiple lenses combined in one lens, sometimes the quality of the vision can be affected a little bit. And for certain people with certain types of eyes, if the quality of their vision is going to be affected a little bit by, say, a change in the cornea, the front surface of the eye, then you add to that the lens in there that affects the quality of the vision, overall, that you get from that lens may not be quite up to par, or it might not be quite up to the monofocal lens, right?

Interviewer: Okay.

Dr. Nakatsuka: And so certain people are not good candidates for that multifocal lens, that lens that focuses on multiple distances. So those are the trifocal lenses. There are two more lenses I would like to talk about.

So there is a lens that's called an extended depth of focus lens, and basically, that lens gives you close to or as close to the ability to see a blended range of vision, from far to near, as close to as possible as what you're able to do when you were 20s or 30s, or even younger, when you were a kid.

Interviewer: Wow.

Dr. Nakatsuka: So I do tell patients, you know, unfortunately, we don't have the technology to be able to give you back that, what we call, accommodation or ability to see the whole range of vision, from distance to up close, as when you were a kid. But the extended depth of focus lenses kind of give you a blend of that or a taste of that, and they are able to give you a little bit of a range of vision, from far away to up close. So that is a particular lens that is also not covered by insurance, but may give you more of a range of vision.

Interviewer: And I think I've seen online, it's the acronym EDOF, extended depth of focus.

Dr. Nakatsuka: That is correct.

Interviewer: Is that it?

Dr. Nakatsuka: That is correct, yes. So that is another class of lenses that you may experience, or you may see. Two of the lenses within that category right now are called the Symfony and Vivity lenses, both by different companies.

Light-adjustable Lenses

Now there is a lens class that is, I would say, the newest one in the market, and that is called the light-adjustable lens. And so there is a lens out there where once the lens is put into your eyes, that lens can be adjusted with light energy after the surgery to focus it exactly where you want it to focus. So we say, "Hey, wait a minute, you know, isn't it the fact that once I have cataract surgery, if I wore glasses before, and you put a new lens in my eye, you know, you focus it for far away, I'll be able to see 20/20 for far away?"

Because of our lens technology and our technologies that predict where these lenses sort of focus for you, yes, that's true that we are often able to get ballpark, pretty close to kind of where you want it to be. So I do tell patients, "Yes, we try to aim for, of course, 20/20 vision for if you choose distance vision, 20/20 vision for distance." But it's a little bit of a ballpark because we don't know 100% exactly if it's going to land exactly at that range.

How to Choose the Right Lens for Your Lifestyle

Now, most people are close enough that they feel pretty good about it, especially the average patient. But there's a number of patients out there who have had procedures done on their cornea, something called radial keratotomy or RK, and even some patients who have had LASIK surgery, which is a little bit more predictable and not as variable as that previous surgery called RK surgery, where their cornea is not quite completely, we would say, stable, and so it's a little harder to predict where their focus point will be after the surgery.

Vision Goals

And so in a number of those cases, or someone who just says, "I want 100% guarantee that the lens focuses exactly where I want it to focus for," whether that be far away or that be close, then there is an option for putting in the specialty lens that can be focused after the surgery to kind of focus it right where you want it to be. And that is one of the newer technologies out there, and is a very nice technology to have.

Cost

That being said, there are some things to know about that type of lens. It does require an extensive post-operative process, with a number of visits afterward, to be able to focus that lens exactly where it needs to be. So it is sort of an arduous process. It does cost quite a bit more out of pocket, oftentimes more than the other lenses I described, because there's so much involved in it. And technically, that lens is still a lens that's focused for either one focus point, either far or close.

And those are generally the lens choices that you have available.

Setting Realistic Expectations for Cataract Surgery

Interviewer: So, of course, anyone listening should, you know, really talk to their cataract surgeon or their eye specialist about what option would be best for them. But if there was one thing that you would like someone with cataracts, who's considering options, you know, is there anything that they should know about how they could make their decision and make it well?

Dr. Nakatsuka: I think, first off, the important thing to know in terms of expectations for a patient is what cataract surgery can and can't do. And so, first off, when we talk about doing cataract surgery, it's predominantly a medical procedure first. So all those things I talked about in terms of the lenses, you know, are great in terms of giving you sort of the best vision to not necessarily need glasses after surgery. But predominantly, before that, you go to an eye doctor, you go to a cataract surgeon to have cataract surgery as a medical procedure. That's why it's covered by insurance.

So that means that your vision is being affected by the cataract, and glasses are not making it any better. And that's also a way to diagnose it, is that glasses are just not working out for you, and a new pair of glasses is not working out for you. And that means that you have that cataract in the way of your vision. So you have a cloudy lens inside your eye that's blocking light, and it just needs to be replaced and needs to be replaced with something clear. And so that's what cataract surgery is about.

So, first and foremost, understand that you have cataract surgery if you have a problem. If you don't have a problem and you're looking merely for a way to kind of get out of glasses, then understand that, first off, insurance may not pay for that, but secondly, you're talking about some involved processes that may or may not work for you, okay? So make sure that you are going there for the right purpose, that, "Hey, you know, I have a problem that I need to be corrected."

From there, a doctor can sort of tailor the treatment based on your needs. And I will just say, in general, most patients, whatever they're used to before the cataract surgery, tend to kind of want to stay that way. So, for instance, there are patients who are nearsighted, meaning that they use glasses to see far away and use them for driving, and then they take off their glasses to read up close. Some people do want to swap and see far away and use reading glasses up close. But if you've been like that for all of your life, you're used to taking glasses off to read, and usually you want to stay that way. So that is just one example of a sort of tailor-made situation where you may not be like the normal population, and you want to kind of keep things for up close.

But make sure you talk to your provider about that and make sure that they understand that, so that they know that to keep things that way, rather than swapping you, because once cataract surgery is done, yes, there can be some things that you can do post-operatively to sort of change that. You can do LASIK. Sometimes it can warrant exchanging the lens in your eye. But once that cataract is taken out, that's it. You know, it's a permanent thing. We can't put your cataract back.

Cataract Surgery Is Safer and More Effective Than Ever

Interviewer: If there's a patient or the loved one of a patient who's maybe worried about this cataract surgery, what do you tell them to give them a little bit of reassurance?

Dr. Nakatsuka: When it comes to cataract surgery, even though it has that word "surgery" in it, which is very scary, you know, I like to use the word "procedure" because it is a less invasive type of surgery out there. As far as the actual procedure itself, for those who have had cataract surgery, they know the procedure is usually relatively quick. That is largely because we, as cataract surgeons, have gotten really good at doing it. In the old days, this used to be very long, couple-hour-long procedures, and you used to have to be in the hospital for a week afterward. And now it's an outpatient procedure, and the cataract surgery itself is actually sometimes less than 10 minutes.

Interviewer: Wow.

Dr. Nakatsuka: So, as far as things go, the technology has really improved. We're able to do this with less and less invasive methods. We're able to do it in a way so that the healing is really quick. And most patients do really, really well. And so, as far as things go, I would say that for people who are worried about cataract surgery, I understand your concern. It is a procedure after all, and there is risk. But the risks are, in general, fairly low compared to other big medical procedures. And it is definitely something where the rewards are high. Patients have very, very high sort of satisfaction rates afterward. In the clinic, we see this. Patients are very, very happy with the change in their life and function after this type of surgery, for what is a relatively quick surgery. So I do want people to know that the risks-to-benefits for this type of surgery is very high on the benefits side and usually low on the risks side.