50 years ago this was a common and important question for cataract patients and their ophthalmologist to address. The modern technology of how cataracts are now removed, how surgical wounds are constructed and sealed, and how intra—ocular lens implants (rather than thick “aphakic” spectacles) are the universal methods of visual rehabilitation all combine to make the “ripeness” question obsolete.
This post is not about the high tech and elegant methods ophthalmic surgeons employ to restore excellent vision for cataract patients. Instead, it is about when doctor and patient should be discussing the proper timing of cataract surgery.
Nearly everyone is born with a crystal clear lens inside each eye. As time goes by (or less commonly as a result of eye trauma or medication side effects) this natural aging lens can become discolored, frosted, opacified or otherwise imperfect. The mere presence of lens aging and loss of clarity is not in itself a reason to undergo cataract surgery. In the early phases of cataract development a simple change in glasses may restore vision to the level that the patient finds to be acceptable.
Here comes the most important message of this post:
A patient should consider cataract surgery when their own visual needs are not being satisfied and when their decrease in visual function can be attributed to cataract progression and not predominately to other eye diseases.
Visual needs and visual function are highly personal and are not exclusively measured by the best line you can read on an eye chart in the doctor’s office.
In our first group, consider patients who have given up reading or driving for reasons that have nothing to do with their vision. Perhaps their reading comprehension and interest have diminished with age. Perhaps they have a neurologic disease that has robbed them of quick reflexes such that they (or their family) have decided that safe driving, even with excellent vision, has evolved beyond their physical capability and they have surrendered their driver’s license. Although these people in our first group still require good vision to enjoy their golden years; it is not the same level of precise vision required by our second group of patients. Consider the second group of patients to include a jeweler, an avid reader, an office worker using a computer, or a bus driver with a night time route.
Both groups of patients might have identical cataracts and might be able to read the exact same line on the eye chart, let’s say 20/50, or 4 lines off the bottom of the eye chart. Patients in the first group can still do things important to them like helping to raise their grandchildren or watching TV. Patients in the second group would find computer use and reading in dim illumination to be difficult or impossible, and they would not meet the State of CT requirement for an unrestricted personal driver’s license, or a commercial driver’s license.
Hence I have described 2 groups of people each having the same degree of cataract and same level of vision. Yet, one group can continue to enjoy their life without restriction and without complaint, while patients in the the other group might not be able to pursue their hobby or livelihood unless their vision is improved by cataract surgery.
Having the correct diagnosis and realistic expectations is essential to a happy surgical outcome and is the other important factor in deciding when to have cataract surgery.
The presence of a cataract, even one of moderate severity, does not necessarily make it the major source of visual loss. Many patients with cataracts also have unappreciated or underestimated second or third eye diseases, largely responsible for their loss of vision. The most common diseases of aging that often emerge simultaneously with cataracts are macula degeneration, glaucoma, diabetic retinal changes (diabetic retinopathy) and diseases of the optic nerve. Your ophthalmologist has sophisticated tests at his disposal and can call upon colleagues with sub–specialty training in these other diseases to help answer the question of “how much vision is lost from the cataract and how much vision is lost from other eye diseases”. In the presence of mild macular degeneration or well controlled and early glaucoma, removing the cataract is likely to restore nearly all lost visual function. On the other hand, patients with severe macula degeneration and only mild cataracts are often not appropriate candidates for cataract surgery as such an operation will commonly have little to no impact on their vision.
The key is to have confidence in your ophthalmologist who should be including you on his or her thoughts about how much vision might be restored by cataract surgery if you have other simultaneous eye diseases that might be impairing you vision. Your ophthalmologist should take the time to do those tests that help make this a more informed decision. If you have past eye care records from a previous ophthalmologist they should review those to better appreciate your level of vision before your cataracts developed and progressed.
In summary, when to have cataract surgery no longer is a question of “ripeness”. It is a decision based on an honest dialog with your ophthalmologist that weighs your own visual needs and their knowledge of the overall health of your eye; specifically including the possible impact of other active or quiet eye diseases that your ophthalmologist might be monitoring or treating.
Martin Shapiro, MD