Procedure 66984

Cataract removal by ultrasound & vacuum (Phacoemulsification FAY-ko-ee-mul-sih-fih-KAY-shun)

Replacement of the cataract with an IntraOcular Lens (IOL) implant

Anesthesia by preservative free xylocaine numbing drops and gel

No needles. No stitches. No patch. No hospital gown. No restrictions of activities afterward.

Diagnosis 366.99

Cataract

What Is a Cataract

A cataract is a clouding of the normally clear focusing lens of your eye.

Symptoms

When your cataract becomes cloudy (opacified) enough it interferes with your vision. Depending on the size, thickness and type of cataract, you may notice a decrease in your distance vision only, a decrease in your near vision only, or a decrease in both your distance and near vision. With cataracts, your vision may vary depending on lighting. You may see halos around lights at night, glare, and you may experience ghosting (double/twin vision). Your sight may be dim, hazy, or cloudy and colors may look dull.

Cause

Cataract formation is a normal maturing process by which your clear lens proteins become cloudy, similar to the process of your hair becoming white. At birth your lens consists of a clear liquid inside a clear yolk sac. Around age forty your lens begins to yellow and becomes a gel. You begin to need reading glasses or bifocals at this age. Around age sixty your yellowing lens becomes cloudy and the gel hardens to a rubbery consistency. You begin to need trifocals around this age. When the clouding begins to interfere with your vision or an eye test shows poor vision, the cloudy lens of your eye is called a cataract.

Sometimes eye conditions and injuries, or medical conditions such as diabetes lead to premature cataracts. Ultra-violet B or cortisone (steroids) may accelerate cataract formation.

Cataracts Have a Purpose

Like wedding pictures photographed through a soft-focus lens, cataracts soften our maturing looks and mellow our outlook on life. Early cataracts can benefit you with what is called second sight (near sightedness) which enables you to read without reading glasses. Enjoy your cataract-vision until the clouding interferes with your quality of life.

Cure

Remove the clouded cataract lens. Replace the cataract with a clear artificial lens implant.

Reason

To see better

When

The American Academy of Ophthalmology recommends cataract removal:

* when your vision drops to 20/40 or worse;

* when you are no longer happy with your vision;

* when you are in danger of losing your drivers license; or

* when your cataract is over-ripe and can cause medical problems for your eye.

You need only one eye and only 20/40 vision with or without glasses in that eye to have an unrestricted daytime and nighttime driver's license in Illinois. With 20/70 vision, you are restricted to a daytime driver's license. Medicare prefers you wait until your vision is 20/50, unless you document a reason that the cataract interferes with your quality of life. With today's modern techniques, we like to correct a cataract when your vision is between 20/40 and 20/100 because the cataract is just the right consistency for the ultrasound and self-sealing incision. You do not need to wait until your cataract is ripe. The doctor encourages your decision when your cataract becomes over-ripe and in danger of causing your eye medical trouble. The outcome is just as good whether you wait or do it now.

Procedure Description

In a cataract procedure, we remove the clouded (cataractous) natural lens of your eye. We replace your clouded natural lens with a clear artificial lens implant. Your natural lens has two parts: the clouded yolk, and the clear sac. Modern (phacoemulsification) ultrasound waves liquefy the clouded yolk. Suction vacuums the liquefied clouded yolk out of its clear sac. Into the clear sac we place an artificial lens implant centered by support struts. The clear sac shrink-wraps around your implant forming scar tissue to hold your implant permanently in place without stitches. If we cannot save the lens sac, we place the implant in front of your iris.

The procedure is performed through a no-stitch entrance, like the self-sealing one-way flap on a basketball. Therefore, if you need to move, cough, or go to the bathroom during the procedure, you may ask Dr. Wayne to stop at any time because the entry is self-sealing. We can resume after you are comfortable. Xylocaine drops and gel numb both the inside and outside of your eye. If you begin to feel pressure, ask for more drops. They work instantly.

The clear sack that shrink-wraps around your implant may later become cloudy. If it does, you will need another and different procedure called a YAG laser. The YAG laser clears the cloudy tissue (also called an after-cataract or a secondary cataract.) It is not a return of the first cataract. Neither cataract ever comes back.

Alternative Treatments

You may choose to live with your cataract. A cataract does not harm your eye, cause pain, or tearing. It simply interferes with your vision. After removing your cataract, there are four ways to restore your vision.

-Thick cataract glasses that magnify and distort your vision about 25%.

-Contact lenses that magnify your vision about 8% and are hard to handle.

-Monofocal intraocular artificial lens implant - normal vision at one distance

-Multifocal intraocular artificial lens implant - normal vision over a range of distances

The artificial intraocular lens (IOL) implant provides normal vision. It is smaller than a contact lens and has support struts to center and hold it inside the sac that formerly held the cataract. This plastic polymethyl methacralate or foldable soft elastomer lens implant remains in your eye permanently. It lasts a lifetime and never needs cleaning. A few people have a serious eye condition that prevents using an implant.

We custom calculate the power and size of your implant. We measure the shape and size of your eye to determine the power. A computer ultrasound A-scan device measures the size (diameter / length) of your eye. The A-scan device, placed in front of your eye, emits sound waves that travel to the back of your eye. The length of time the sound waves take to get to the back of your eye helps the computer to automatically calculate the length of your eye. Another device called a keratometer, measures your corneal curvature (shape of the surface of your eye.) A computer custom calculates the power and size of your implant from the A-scan and K readings.

On rare 1/500 occasions, the sound wave mistakes an eye structure for the back of the eye, giving an erroneous reading. For this reason, we perform A-scan readings on both eyes, though you may have a cataract in only one eye. Assuming that both eyes should be similar in size, a significant difference in the readings lead us to question the readings and repeat them. Additionally, we check the refractive power of the implant within the first week after surgery to determine if the implant should be exchanged for a different power.

Monofocal Lens Implant: We calculate the implant in your dominant eye to focus clearly in the distance and your other eye to focus clearly up close. We give you bifocals so you can see clearly with both eyes in the distance and up close. With today's high technology, one out of three people need no glasses for distance or reading the paper. One out of three need glasses only to read or only to drive. One out of three are nearsighted or farsighted, needing bifocals for distance & near.

Multifocal Lens Implant: Today you have a choice of the monofocal or the multifocal implant. The monofocal implant provides good focus at one distance, requiring glasses to focus sharply at other distances. The multifocal implant provides good focus over a range of distances helping you achieve less dependence on glasses, though you may want glasses at times for the sharpest possible vision for critical tasks. You are a good candidate for the multifocal implant only if you plan to have the multifocal in both eyes. The eyes cannot work together well with a monofocal in one eye and a multifocal in the other.

The multifocal lens has five concentric zones similar to a bull's eye. The lens is designed to use 100% of available light, approximately half of light is distributed for distance vision (50%), one third to near vision (37%) and the remainder to intermediate vision (13%), which enables the lens to focus over a range of distances.

There is a trade-off for choosing the multifocal lens over the monofocal lens. You may experience halos around lights at night (15% chance compared to a 6% chance with the monofocal lens), glare (11% chance compared to a 1% chance with the monofocal lens), less color contrast because only part of the light goes to a particular focus point, and a decrease in sharpness of vision.

According to the multifocal implant manufacturer Allergan, Inc., you have a 92% chance of achieving 20/40 (legal driving vision) or better without glasses, and a 97% chance of achieving 20/40 or better with glasses. With the monofocal implant, you have a 50% chance of achieving 20/40 or better vision without glasses and a 99% of achieving 20/40 or better with glasses. If you have the multifocal lens in both eyes you have: an 8% chance of "always" wearing glasses compared to a 34% chance with the monofocal lens; a 51% chance of "occasionally" wearing glasses for fine detail work compared to a 54% chance with the monofocal lens; and a 41% chance of "never" wearing glasses for distance or near, compared to a 12% chance with the monofocal lens. With the multifocal implant, you have a 30 % chance of not being 20/20 with glasses, compared to 1% of not being 20/20 with glasses and a monofocal implant.

According to Allergan, Inc., less than 1% of patients ask to have the multifocal lens removed and replaced with the monofocal lens. If your job requires night driving, or very fine close work, or halos/glare would not be acceptable, you may prefer the monofocal lens.

You are eligible for the multifocal implant if you have little to no astigmatism and if you are planning to have the multifocal implant in both eyes. You cannot use both eyes together with a monofocal in one eye and a multifocal in the other.

Risks

The results of surgery in your case cannot be guaranteed. Complications may occur weeks, months, or years later and require additional treatment or surgery.

Risks of surgery in general: There is the possibility of complications due to anesthesia, drug reactions, or other factors, which may involve other parts of your body, including the possibility of brain damage, death, heart attack and stroke. Risks of anesthetic injections include perforation of the eyeball, damage to the optic nerve, interference with circulation to the retina (stroke to the eye), respiratory depression and high blood pressure. To prevent anesthetic injection complications, Dr. Wayne almost never uses injections or needles. Instead, Dr. Wayne uses highly effective numbing eye drops and gel.

Risks of eye surgery in general: Total loss of the eye, total loss of vision, worse vision than you had before surgery, infection, hemorrhage, and failure of the wound to heal.

Risks of cataract surgery: Inability to remove the whole cataract, requiring another procedure to remove the cataract from behind; opening of the clear posterior capsule lens yolk sack; vitreous coming forward requiring removal (vitrectomy); unround pupil; sluggish pupil; inability to dilate the pupil; loss of corneal clarity; constant irritation and redness; light sensitivity; retinal swelling; retinal detachment; glaucoma; double vision; and lid drop.

Risks of implant surgery: Inability to place the implant in the eye at all; inability to place the implant in the lens yolk sac (capsule or bag); the need to put the implant in front of the iris instead of behind the iris; and the possibility that at a later date the implant may have to be removed, replaced, or repositioned.

It is impossible to state every complication that may occur. On the lighter side, after you see better, you risk noticing wrinkles and gray hair you never knew you had. You also begin to see more dust around your home.

Benefits - Expectation

You can expect both your distance and near vision to improve. You should see brighter colors, less haze, decreased glare, and decreased haloes around headlights. A cataract procedure does not cure tearing, burning, itching, tired eyes or dropped lids.

Probability of Success

Dr. Wayne has statistics on all her surgical outcomes for the last three years. You may ask for a computer printout of Dr. Wayne's personal surgical results. In summary you have a 98% probability that you will attain 20/40 legal driving vision or better if there are no other preexisting conditions such as hardening of the arteries of the retina, macular degeneration, old stroke to the eye, glaucoma damage, corneal dystrophy, etc. With today's technology, you have a 50% probability that after cataract replacement with a custom powered implant, you will need no glasses to pass your drivers' license test.

Flexible Iris Retractors - Additional Step for Eyes That Fail To Dilate

Some eyes fail to dilate well with drops. You may need an additional step in your cataract procedure. This involves using nylon sutures as fine as a human hair to help hold the iris-pupil open. Your pupil may be a different size after your procedure and may not open and close as rapidly as before. Initials __________

Dilation Barrage

If your pupils are hard to dilate, you can help minimize the need for the extra step by using murocoll 2 dilating eye drops to stretch the pupil preoperatively. Use 1 drop every hour while awake every Monday for four weeks. Close your inner tear drain pore by pressing on the inner corner of your lids to prevent the drop from entering your mucous membrane cavities. The eye drop can elevate your blood pressure. Use your home blood pressure kit to measure your blood pressure after instilling the eye drop to be sure your blood pressure remains within normal range. Measure the size of your pupil with the half circles Dr. Wayne gives to you to verify that you are progressively enlarging your pupils. Initials ____________

Living Will

Yes, I have a living will and I brought it with me__________________________________________________

No, I do not have a living will, If my heart stops, YES _____do everything to bring me back, or NO_____ do not resuscitate me back to life.

Decision

Ideally, you are the one to make the final decision to have a cataract procedure. Tell us if you need family to collaberate and share in your decision, or if you want us to make the final decision for you.

Permission

I received a copy of this five-page informed consent information along with videotape about the procedure to take home and keep. I understand that Eileen Marie Wayne, M.D. will personally perform the entire procedure. I have received all the explanation that I wish to receive and I have been given the opportunity to ask questions. I have no further questions. I wish to have a cataract operation with a monofocal_________ Initials or multifocal ____________ Initials intraocular lens implant.

Signature: _________________________________________________________________________Right Eye

Witness: ____________________________________________________________Date__________________

Signature___________________________________________________________________________Left Eye

Witness: ____________________________________________________________Date__________________

Secondary Implant

Since my cataract was previously removed years ago and doctor told me that my eye is medically suitable for lens implantation, I wish to have an intraocular lens implant.

Signature: _________________________________________________________________________________

Witness: ______________________________________________________Date________________________