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Medical Forum / General / Vision / January 2006Why follow cataract development?
I have the early stage of a cataract forming. This was detected by my normal vision checkup and refraction , filed under vision insurance, not medical. The MD and OD who see me at this office have told me I should make a separate appt. under my medical insurance with the MD to have this followed. I did not think to ask why this was necessary. Other than the fact that some years down the road, I will need it removed, are there any dangers or problems arising from not having this checked every year? >I have the early stage of a cataract forming. This was detected by my > normal vision checkup and refraction , filed under vision insurance, [quoted text clipped - 4 lines] > removed, are there any dangers or problems arising from not having > this checked every year? Nope. You need a checkup every year or two for other problems.You'll be the first to know when a cataract becomes disabling. -MT > > [quoted text clipped - 14 lines] > > Agreed, except I wouldn't wait until they become disabling, since the procedure is so simple, safe and effective. I would certainly have them fixed as soon as I could afford the procedure, or as soon as my insurance would cover it. Another good idea is to have it fixed as soon as you find that your new glasses aren't giving you as good vision as they used to. No reason to become disabled or even close to it unless you are at high risk for retinal detachment (high myopia above -8.00) or some other medical risk factors. w.stacy, o.d. I can't imagine he would get rich from a cataract exam, so I'll have to ask why I need it when I soon go in for my refraction. I am about -6.00 and -6.75. What do you mean by "No reason to become disabled or even close to it unless you are at high risk for retinal detachment (high myopia above -8.00) or some other medical risk factors."? Are they not fixed when there is a high risk of detachment? Doesn't it become more difficult to examine the retina when the lens becomes opaque? I had heard that cataracts need to be "ripe" before they are taken out. Is that no longer the case because of new equipment or procedures? Thanks. > I can't imagine he would get rich from a cataract exam, so I'll have to > ask why I need it when I soon go in for my refraction. It's part of the insurance game. If they can dub it a medical evaluation (due to the cataract) the medical insurance will kick in (good for the docs), otherwise, they have to live with the (often paltry) vision insurance. (I'm doing some guessing here; you might want to tell us about your various insurances) > I am about -6.00 and -6.75. What do you mean by "No reason to become > disabled I think someone else used the term disability in describing when cat. surgery is indicated. That's old thinking, in my opinion. or even close to it unless you are at high risk for retinal > detachment (high myopia above -8.00) or some other medical risk > factors."? Are they not fixed when there is a high risk of detachment? There's a reluctance to do early intervention when risks exist, and this is a good thing. Remember Hippocrates, first do no harm. Sure, high myopes get cataract surgery, but I think they are made to wait longer than others due to that old RD risk. (-6.75 is moderately high, and yes, you have that risk factor, unlike a hyperope, who has no real risk for detachment and can, and should have the procedure as soon as possible). > Doesn't it become more difficult to examine the retina when the lens > becomes opaque? Sure. Another reason that sooner is better, all other things being equal. I had heard that cataracts need to be "ripe" before > they are taken out. Is that no longer the case because of new equipment > or procedures? Definitely old school. Nobody should wait that long, unless there are life-threatening problems. Those are few these days. After all, this can be done in a 10 minute outpatient procedure under local (eyedrops) anesthetic, with no stitches. How safe can it get? (YMMV, so if you go early, make sure you have a cataract specialist, not someone who is still learning or doing it part time). w.stacy, o.d. On 1/5/06 7:14 PM, in article mglvf.44907$BZ5.11070@newssvr13.news.prodigy.com, "William Stacy" <wstacy@obase.net> wrote: >> I can't imagine he would get rich from a cataract exam, so I'll have to >> ask why I need it when I soon go in for my refraction. [quoted text clipped - 39 lines] > > w.stacy, o.d. How safe can it get? The main worries I have are endophthalmitis and expulsive hemorrhage. Both have not really reduced in risk over the years or with newer procedures. In fact, there is some evidence that the newer clear corneal incisions may be associated with a higher risk of endophthalmitis than the older sutures incisions, although I still prefer to use clear corneal. And this risk is virtually unrelated to the choice of surgeon. The issue is not when it becomes disabling - I think the choice or words was a little wrong, but the overall idea was correct. It is really when it begins to interfere with one's activities or lifestyle. Someone who is active, driving, golfing and reading is in a different boat than a nursing home patient, for example. The person asking the question is a moderate myope, and has one more issue. If there is one (early) cataract, how to operate and not cause a high anisometropia (unequal uncomfortable eyeglass power). If you still ave a fairly clear lens in the other eye, you can't make the first eye -1.00 or so, with the other still being about -6.75. You don't want to leave them at a -5.00 either. Yes, you could use a contact in the unoperated eye, but not be everyone. This is a real conundrum in these situations. As per Hippocrates, first do no harm. It really doesn't need to be done "as soon as possible", just when it bothers the patient enough that the risk is worth it FOR THEM. > How safe can it get? The main worries I have are endophthalmitis and > expulsive hemorrhage. Both fairly rare occurrences, thankfully. But the odds for those are about the same whether you do it now or 5 years from now. So why not get it over with now, instead of having to endure 5 years of increasingly poor vision? And this risk is virtually unrelated to the choice of surgeon. Virtually is right. Don't forget to choose a surgeon with access to a good surgery center. And don't forget all the other risks that ARE associated with the choice of a surgeon. Like no limbal relaxing incisions when there's significant corneal toricity, or worse yet, ones that are 90 degrees off. Or damaged endothelium from sloppy or inexperienced technique. Or higher than normal rates of capsule rupture, miscalculated IOL powers, missing lens fragments, etc. etc. > The issue is not when it becomes disabling - I think the choice or words was > a little wrong, but the overall idea was correct. It is really when it > begins to interfere with one's activities or lifestyle. Someone who is > active, driving, golfing and reading is in a different boat than a nursing > home patient, for example. What does that mean? You think a bedridden patient should be put off longer than an active person? I completely disagree, and would even argue the opposite. Give them a little clear vision in their final months or years. > The person asking the question is a moderate myope, and has one more issue. > If there is one (early) cataract, how to operate and not cause a high [quoted text clipped - 3 lines] > a -5.00 either. Yes, you could use a contact in the unoperated eye, but not > be everyone. This is a real conundrum in these situations. Less of a conundrum now than it used to be. Believe me, when I had my 20/40 eye done, I couldn't get back in fast enough to get my 20/25 eye fixed (1 week). I did wear a contact for a few days of that week and could even tolerate my 3 D of aniso with glasses, but preferred the crisp 20/15 with full contrast sensitivity and night driving vision to my dull old 20/25 eye. > As per Hippocrates, first do no harm. It really doesn't need to be done "as > soon as possible", just when it bothers the patient enough that the risk is > worth it FOR THEM. As always, of course. But times are a changin', and I think refractive IOL procedures are here to stay, and a new sub-specialty is being born as we type. But for cataracts, all I can say is who wants to spend their golden years in a brunescent haze just because "they aren't ready yet". w.stacy, o.d. >> How safe can it get? The main worries I have are endophthalmitis and >> expulsive hemorrhage. [quoted text clipped - 3 lines] >it over with now, instead of having to endure 5 years of increasingly >poor vision? >> The issue is not when it becomes disabling - I think the choice or words was >> a little wrong, but the overall idea was correct. It is really when it [quoted text clipped - 6 lines] >argue the opposite. Give them a little clear vision in their final >months or years. Bill, I think you're still a tad giddy from your own extremely successful cat surgery:) http://bmj.bmjjournals.com/cgi/content/full/322/7294/1104 In addition, an older individual who performs less visually demanding tasks i.e. no night driving or very little driving, not an avid reader etc. usually does quite well with glasses that are Rx'd and designed optimally. They might need a 4x magnifier instead of a 2x mag to see very fine print, but that hardly justifies leaving them with potentially worse vision post surgery. Regards, Robert Martellaro ~~~~~~~~~~~~~~~~~~ Optician/Owner Roberts Optical robopt@execpc.com ~~~~~~~~~~~~~~~~~~ "An expert is a person who has made all the mistakes that can be made in a very narrow field." - Niels Bohr > I think you're still a tad giddy from your own extremely successful cat > surgery:) [quoted text clipped - 6 lines] > 4x magnifier instead of a 2x mag to see very fine print, but that hardly > justifies leaving them with potentially worse vision post surgery. I *am* still giddy, and proud of it. My point was the paradigm is shifting, that's for sure. Of course older people have more concomitant conditions and problems. So? I read that link and it is very interesting, but way too pessimistic. The author might as well be saying "grandpa might break his hip and die if he walks too much, so let's keep him in bed" If a 10 minute operation with VERY low risk can give 98 grandpas out of 100 better vision for the rest of their lives, well, you youngsters decide... but remember, your time is coming... w.stacy, o.d. Thanks for all the comments, recommendations and insight. I have some follow up comments and questions. Choosing a good, experienced surgeon is definitely on the top of my list. The threat of infection does concern me and I would have imagined that good sterile technique would be effective in preventing infection and thus would be surgeon dependent. Also, don't they use an antibiotic or antiseptic irrigation before they start the incision? I had read that a common source of infection is the staph in the patient's eylids. The problem of anisometropia was going to be in a follow up question, so I am glad it came up. It sounds as if I can't tolerate contacts and don't have LASIK or lens replacement surgery on the other eye, I am up the creek. I am 52 now and wore the old hard contacts in mid teens to 20. I gave them up because of discomfort, but maybe I can tolerate the RGPs (probably need because 2.25 astigmatism) or soft lenses. I suppose it wouldn't be a bad idea to try them out in the next few years to see how I tolerate them. I have Superior Vision insurance and it does not cover cataract exams, although as pointed out, there doesn't seem to be a good medical reason to examine them until the point that it becomes a big hindrance and I want the surgery. My med insurance is BCBS of Alabama and it seems to cover everything medical so far. >Thanks for all the comments, recommendations and insight. I have some >follow up comments and questions. >I am about -6.00 and -6.75. >The problem of anisometropia was going to be in a follow up question, >so I am glad it came up. It sounds as if I can't tolerate contacts >and don't have LASIK or lens replacement surgery on the other eye, I >am up the creek. Not true! You will have numerous options to choose from as to the type of prescription that will be required post surgery. For example, if the cataract is in one eye only, or if the other eye has a cataract but is much slower in developing, the best response would be to match the Rx of the fellow eye, resulting in vision similar to your historic vision, and will not require special glasses to deal with the Anisometropia (a disparity of about one diopter between the eyes) and/or Aniseikonia. If both eyes have advanced cataracts, then you might choose to keep the powers the same, cut the powers to about -3.00, cut further to about -.50, or anywhere in between to suit your taste. One might even try a little bit of monovision, but it's best to be conservative here- about one diopter is the most that our brains like to deal with, and considering that the accuracy of the axial length measurements/IOL powers being about +/- .50 you could unintentionally end up with two diopters or more power disparity. Moreover, if your like me (- 4.50 in both) and most other lifelong myopes in general, we really appreciate being able to read without glasses. For example, when reading and or looking at close objects, my "plano distance add +1.50" wife needs to use a glasses *and* a magnifying glass to see as well as I can see using no visual aids at all. As you can imagine I'm going to stay a myope when it's my turn for cataract surgery, you might wish to do the same. Hope this helps, Robert Martellaro ~~~~~~~~~~~~~~~~~~ Optician/Owner Roberts Optical robopt@execpc.com ~~~~~~~~~~~~~~~~~~ "An expert is a person who has made all the mistakes that can be made in a very narrow field." - Niels Bohr I am not clear on this. Assuming that I am about -6 in each eye. I get the left eye fixed and not the other. If I put a plano lens in the frame on the left side and keep the existing lens on the right side, are you saying that I should not have much trouble with aniseikonia? And if so why not? Won't I have a big difference in image sizes? >I am not clear on this. Assuming that I am about -6 in each eye. I get >the left eye fixed and not the other. If I put a plano lens in the >frame on the left side and keep the existing lens on the right side, >are you saying that I should not have much trouble with aniseikonia? No, I didn't say that. I did say that under most circumstances, for most myopic folks, you don't want to shoot for a plano Rx post-op. Best to keep the power about -6.00 to match the other eye, except for the circumstances that I outlined. Hope this helps Robert Martellaro ~~~~~~~~~~~~~~~~~~ Optician/Owner Roberts Optical robopt@execpc.com ~~~~~~~~~~~~~~~~~~ "An expert is a person who has made all the mistakes that can be made in a very narrow field." - Niels Bohr I don't think you'd want to shoot for -6.00 in the operated eye. You could make an argument for -3.00 or -4.00, but depending on the patient needs, I'd say shoot somewhere between 0.00 and -2.00. Sure there will be some aniseikonia, but most people can handle it. The ones that can't ususally can wear a CL on the myopic eye. The ones who have problems with glasses AND can't wear a CL should get the other eye done, cataract or not. w.stacy, o.d. > > [quoted text clipped - 20 lines] > - Niels Bohr > >I don't think you'd want to shoot for -6.00 in the operated eye. You >could make an argument for -3.00 or -4.00, but depending on the patient >needs, I'd say shoot somewhere between 0.00 and -2.00. Sure there will >be some aniseikonia, but most people can handle it. No binocular vision, no progressives unless you'll take a slab-off (not likely), and a general feeling like the glasses aren't right, with no near capability (if you bring it down to 0.00 All of this for what reason? Truism...Old myopes want to stay myopes. The younger (and some older) refractive surgeons can't quite grasp this, with their mind set stuck on minimizing refractive error, instead of what would be best for the patient. >The ones that can't >ususally can wear a CL on the myopic eye. If they could wear contacts they wouldn't be wearing glasses. Most folks age 65 to 95 aren't particularly thrilled when they are told they will have to wear a contact lens after catract surgery. All they want is to see about as well as they did ten years ago, not like they saw when they were eight years old, and with as little fuss as possible. >The ones who have problems >with glasses AND can't wear a CL should get the other eye done, cataract >or not. If it wasn't for that darn Hippocratic oath thing I'd bet more surgeons would see it your way. However, I see a lot of compromised vision after cataract surgery, probably no more than average, but enough to be a bit more circumspect. It's an interesting subject, I guess we'll agree to disagree to some extent. I suppose I could be a slightly less conservative, but anecdotal evidence says it may still be too soon to make any dramatic changes in my line of thinking. Regards, >> >> [quoted text clipped - 20 lines] >> - Niels Bohr >> Robert Martellaro ~~~~~~~~~~~~~~~~~~ Optician/Owner Roberts Optical robopt@execpc.com ~~~~~~~~~~~~~~~~~~ "An expert is a person who has made all the mistakes that can be made in a very narrow field." - Niels Bohr > > [quoted text clipped - 8 lines] >you bring it down to 0.00 All of this for what reason? > Well the vast majority of cataracts are bilateral, and usually the second, better eye is done soon after the first. So at worst, the person may have to put up with some aniso for a while. The main reason is obvious. Less dependence on glasses. I don't think I've ever seen a -6.00 pseudophakic eye. >Truism...Old myopes want to stay myopes. The younger (and some older) refractive >surgeons can't quite grasp this, with their mind set stuck on minimizing >refractive error, instead of what would be best for the patient. > > I agree that it's best to err on the side of myopia, even for hyperopes, but -6.00 is a pretty serious refractive error to do on purpose, esp. with a lens that'll be in there the rest of your life. I think the most I'd go along with is -2.00 or -2.50, for someone who wants to read without glasses. >>The ones that can't >>ususally can wear a CL on the myopic eye. [quoted text clipped - 7 lines] > > Most in that age group are going to have the other eye done within a month. >>The ones who have problems >>with glasses AND can't wear a CL should get the other eye done, cataract [quoted text clipped - 6 lines] > > In this case, I'd say Hippocrates is not in the way. You are doing good to give a senior citizen who's been -6.00 all their adult life a certain indepence from glasses, at least part of the time. >It's an interesting subject, I guess we'll agree to disagree to some extent. I >suppose I could be a slightly less conservative, but anecdotal evidence says it >may still be too soon to make any dramatic changes in my line of thinking. > I think we're not that far apart, but your question does raise the issue of how much induced aniso can most people comfortably tolerate with glasses. I'm guessing around 2 or 3 D. without slab-off, and at least 5 or 6 D. with slab off. > ... Old myopes want to stay myopes. Oh yeah??! Well I guess it beats the sh.t out of hyperopia. > The younger (and some older) refractive surgeons can't quite grasp this, > with their mind set stuck on minimizing refractive error, instead of what > would be best for the patient. ... Crazy mixed-up fools, won't they ever learn??! -- Dicky On 1/5/06 10:54 PM, in article juovf.51555$q%.46805@newssvr12.news.prodigy.com, "William Stacy" <wstacy@obase.net> wrote: >> The issue is not when it becomes disabling - I think the choice or words was >> a little wrong, but the overall idea was correct. It is really when it [quoted text clipped - 6 lines] > argue the opposite. Give them a little clear vision in their final > months or years. I mean that the visual needs of a bedridden patient are not the same as someone who is driving, for example. "A little clear vision" is all relative. If they can read and do their activities comfortably, there is no reason to do an operation, which can be a major strain on some elderly people - lot of visits, anxiety, eyedrops, and special care. What is not clear enough for one may be plenty clear enough for someone else. You can't assume everyone requires or desires the same vision. > I have the early stage of a cataract forming. This was detected by my > normal vision checkup and refraction , filed under vision insurance, > not medical. The MD and OD who see me at this office have told me I > should make a separate appt. under my medical insurance with the MD > to have this followed. I did not think to ask why this was necessary. Your vision insurance probably doesn't cover medical problems -- just glasses and/or contacts -- and the dollar amount is probably limited. Your medical insurance covers medical procedures, including cataract exams and removal. > Other than the fact that some years down the road, I will need it > removed, are there any dangers or problems arising from not having > this checked every year?  SignatureCheers, Bev ========================================================== "The last thing you want is for somebody to commit suicide before executing them." -Gary Deland, former Utah director for corrections |
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