Page 20 - May 2024 SAM PDF

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

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