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EYE CARE AND                                                                                                                                                                                                   EYE CARE AND
       QUALITY OF LIFE                                                                                                                                                                                                QUALITY OF LIFE




        Cataract Surgery in 2024                                                                                                   tion bring increasing levels of anesthesia risk, which are simply not


                                                                                                                                   justified in an ambulatory procedure lasting 10 minutes. Sedation
        By Scott A. Thomas, MD                                                                                                     is often delivered intravenously, but liquid oral diazepam and even
                                                                                                                                   sublingual ketamine/midazolam lozenges are used. I tell patients
                                                                                                                                   the sedative will be used to help them relax but is not intended
           Cataract continues to be the most common cause of vision impair-  cient and satisfying for both patient and surgeon. There are, however,   to render them completely unconscious. A few minutes discussing
        ment in the United States and worldwide. The incidence is nearly uni-  certain slightly vexing issues that I repeatedly have to address in clinic.  risks of deeper anesthesia usually convinces the patients they can
        versal in the later years of life. Studies have shown a variety of benefits                                                handle more than they initially thought. Minimizing anesthesia
        of cataract surgery, including decreased depression indices, improved   Things I Wish My Patients Knew About Cataract Surgery:  risk also keeps cataract surgery open to many patients with sig-
        performance on Mini Mental State Examinations, decreased cumula-  1.  “Do you take the eye out to work on it (on the back table)?”    nificant comorbidities. For patients suffering from end-stage pul-
        tive risk of falls in elderly patients, and others. Reduced rates of motor   This one usually came from the patient’s uncle who swears that   monary disease, cancer or heart failure, severe visual impairment
        vehicle collisions have also been shown following cataract surgery. One   when he had cataract surgery, the eye was removed and reinstalled   dramatically reduces their quality of life. In other words, people
        study showed 79 percent of patients greater than 90 years of age were   after the cataract was taken care of. I have considered replying that   with limited life expectancy shouldn’t be condemned to blindness
        better able to manage activities of daily living, and 43 percent were   the extraocular muscles, optic nerve and various arteries and veins   as well, if it is in our power to help.
        still alive at the four-year follow-up. In short, reducing in the visual   would object to such treatment, but I usually just assure the patient   4.  “How long after surgery until I can lean over?”  This one has
        impairment, which comes inevitably with natural aging, is an essential   that the eye will remain in the orbit at all times.  historical significance. In the early- and mid-20th century, cata-
        intervention to prolong independence and quality of life among older   2.  “I want the cataract removed but no lens implant.”  I’m not   ract removal by the intracapsular method required a large incision   The author at work.
        people. Continued refinement in surgical techniques have incremen-  sure what motivates this request. The human eye requires about 60   encompassing one-third to one-half of the entire corneal diameter,
        tally made the surgery safer and more tolerable for patients. Experience   diopters (D) of focusing power, and the cornea provides about 40   and there were no micro-sutures to close the incision. It was very   All these technological improvements come with a cost, some of
        and technology make it routinely rapid, minimally painful, and with   D. The crystalline lens provides the other 20 D. If that power is not   unstable for weeks. However, typical phacoemulsification surgery   which is passed onto the patient in an era of declining third-party
        a quick recovery.                                        replaced during cataract surgery by implanting an intraocular lens,   is done through a 2.4mm self-sealing incision, which is quite stable  payer reimbursements. Given the near-universal incidence, low risk
           Still, cataract surgery is a technically difficult procedure with a   the aphakic eye will be severely out of focus. This was the case in   upon leaving the OR. While eye rubbing is discouraged for a few   nature of the procedure, it is not surprising that cataract surgery is
        steep learning curve. I am approaching the 20th anniversary of per-  the 1950s and 1960s, before IOLs were available. Patients had to   days, if the patient bends over after surgery, nothing will fall out.   the most commonly performed procedure in Medicare Part B, and its
        forming my first cataract surgeries, as a PGY-3 resident. I remember   wear aphakic spectacles (aka “Coke bottle glasses”). With modern   5.  “Do I stop taking my blood thinners?”  No. Extensive research   greatest expenditure. It is therefore also not surprising that it has been
        the excitement and anxiety experienced by probably every surgical res-  IOLs, there is a good chance the patient will not need prescription   has shown that routine topical cataract surgery on anticoagulants  the subject of multiple rounds of reimbursement cuts. From 2010 to
        ident. The stakes were high, as phacoemulsification is a very dynamic   spectacles at all. When I further explain that the IOLs are inert,   has no increased risk of perioperative hemorrhage, but discontinu-  2020, surgeon reimbursement by Medicare allowable charges fell 22
        surgery and things can go wrong in an instant, even before a super-  will last a lifetime and cannot be seen or felt by the patient, the   ing anticoagulation has a risk of thromboembolic events.   percent. At the same time, cataract surgery is widely accepted as one
        vising physician has an opportunity to intervene. Working under an   objection melts away.                                                                                     of the most cost-effective medical interventions. Continued econom-
        operating microscope where the entire field of view is approximately   3.  “During surgery, I don’t want to feel anything.”  Patients are   Tremendous resources have been invested in technology to  ic pressure may bring further changes in common practice, such as
        2.5 cm, and only the tips of the instruments are visible, was extremely   often rightly apprehensive about the prospect of a surgery inside   improve refractive outcomes and approach true spectacle indepen-  immediate (same-day) bilateral sequential cataract surgery, or surgery
        awkward at first (see Figures 1 and 2). After many years and thousands   their eye. Some respond by avoiding it as long as possible. But when   dence. Femtosecond laser-assisted cataract surgery (FLACS) was   in office suites rather than certified ASCs.
        of cases, the stress level is diminished, to say the least.  they can no longer delay, they may expect to have no awareness of   introduced almost 15 years ago but after initial enthusiasm, utiliza-  Like many medical advances, modern phacoemulsification cataract
           Just as for a musician or an athlete, repetition is an excellent teach-  the procedure at all. Alas, this is more than I can promise. Routine   tion has declined. Contrary to popular understanding, the laser does  surgery has had a tremendous impact on millions of people, restoring
        er. Performing the same procedure over and over grants cataract sur-  cataract surgery is done with topical anesthesia (local anesthet-  not remove the cataract; rather it creates two corneal incisions and the   physiologic function, which increases quality and probably quantity
        geons the opportunity to refine their techniques both in the operating   ic eye drops usually with supplemental lidocaine in the anterior   circular capsulotomy needed to access the lens nucleus; thereafter the   of life. Everyone reading this article (including the author) is likely to
        room and the clinic. The pre- and post-op care of the patient in the   chamber); some degree of conscious sedation is commonly used   surgery proceeds with the intraocular ultrasound aspiration probe as   experience the degradation of vision due to cataract, and the efficient
        office has its own demands and over time can also be made more effi-  but general anesthesia is rarely considered. Increasing levels of seda-  usual. Some surgeons rely on the technology while others find it to be   process of reversing that degradation. Without hyperbole, cataract
                                                                                                                                 a time-consuming add-on that provides little to no proven benefit to  surgery is the most cost-effective medical intervention for improving
                                                                                                                                 patients over manual surgery.                         quality of life. It is satisfying and humbling to repeatedly and frequent-
                                                                                                                                   If the benefits of laser-assisted cataract surgery are doubtful, the   ly provide this life-changing service to my patients.
                                                                                                                                 improvements in intraocular lens (IOL) technology are not. Modern
                                                                                                                                 IOLs and methods of surgical planning can correct myopia, hyperopia  Reference:
                                                                                                                                 and astigmatism in most patients with a high degree of accuracy, but   American Academy of Ophthalmology, “Cataract in the Adult Eye
                                                                                                                                 presbyopia correction remains the most vexing refractive error. No IOL  Preferred Practice Pattern”
                                                                                                                                 technology currently available can reproduce the seamless adjustment
                                                                                                                                 of natural accommodation in a healthy young phakic eye. Current iter-
                                                                                                                                 ations of diffractive multifocal IOLs (e.g. PanOptix, Alcon) reliably
                                                                                                                                 produce good uncorrected vision both near and far, but patients may
                                                                                                                                 experience various types of visual disturbances of night vision, and a
                                                                                                                                 modest reduction in contrast sensitivity. The Light Adjustable Lens   Scott A. Thomas, MD, has practiced comprehensive/cataract
                                                                                                                                 (RxSight) offers the unique ability to adjust the lens power several   ophthalmology in San Antonio and surrounding areas since
                                                                                                                                 times in the weeks following surgery, with brief office treatments of   finishing residency in 2007. He practices at the San Antonio Eye
                                                                                                                                 directed UV light. This allows a fine tuning of any residual refractive   Center. Dr. Thomas is a member of the Bexar County Medical
                          Just another day at the office.                                                                        error, with some degree of presbyopia correction.           Society

         20     SAN ANTONIO MEDICINE  • May 2024                                                                                                                                                                     Visit us at www.bcms.org     21
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