If your vision has been getting worse and your eye doctor has told you that you might need to consider surgery, you have several choices. First, all types of cataract surgery amount to the same thing—removing from your eye the old, clouded lens with which you were born and replacing it with a synthetic one called an intraocular lens, or IOL. There are three main forms this surgery can take.
The type of surgery you end up undergoing will be driven partly by your stated preference, partly by what your ophthalmologist offers, partly by the particularities of your case, and partly by your ability to afford or get insurance to cover the type of procedure you would like.
Phacoemulsification. This is the most common cataract surgery method in use today. After numbing your eye, the surgeon uses a scalpel to make a tiny incision, 2 millimeters or less in length, in the cornea to penetrate the lens capsule, a thin membrane that surrounds the lens. Then the team uses a device called a phaco machine that, with great precision, directs sound waves at the lens to break it apart. In fact, if you have a blender with an “emulsify” setting, you can probably guess what “phacoemulsification” entails…using the sound waves to liquify the lens, which is then vacuumed out. The new IOL is placed inside the capsule. Phacoemulsification takes 30 minutes or less.
This method works best if the cataract has not matured to the point where it has become difficult to break apart. For that reason, as the medical community has shifted to embrace phacoemulsification as the primary method of cataract surgery, it has become common to begin recommending surgery earlier in the development of the cataract.
Extracapsular cataract surgery. Just as with phacoemulsification, this method consists of making an incision through which to remove the lens that has the cataract. However, in extracapsular surgery, the lens is not liquified or broken apart to facilitate its removal and is instead taken out intact. This means making a larger incision that must be closed with stitches. Today, extracapsular surgery is usually reserved for people with very advanced cataracts in which the lenses have thickened and hardened to the point where emulsification would not be effective.
Extracapsular surgery is still an outpatient procedure but because of the larger incision and sutures, its recovery time is usually longer. Another disadvantage is that in some people the posterior capsule clouds over years later, causing vision loss until it is corrected surgically.
Femtosecond laser-assisted cataract surgery (FLACS). This newer form of cataract surgery uses a laser to make the incision giving the ophthalmologist access to the lens. Then, instead of emulsifying the old lens or taking it out intact, the surgeon uses the laser to break it up into pieces, which are then extracted. Because of the precision and accuracy provided by the laser, this type of surgery is considered minimally risky, and people tend to have good recoveries from it.
Not everyone, however, will have access to it. People with very mature, thickened cataracts will likely still need to resort to extracapsular surgery. And many insurance companies are not convinced that FLACS, which is more expensive than other types of surgery, produces superior outcomes. So people often must pay for it out of pocket, putting it out of reach of many.
The method of surgery is not the only decision you and your ophthalmologist will be making together. The other major decision relates to the different types of lenses for cataract surgery, that is, what kind of intraocular lens to put in to replace your old, natural, clouded-over lens.
One of the major upsides to cataract surgery is the possibility of correcting vision problems that you’ve had for a long time. Some people are fortunate enough to no longer need reading glasses after surgery because the IOLs they have implanted are more flexible than their original lenses had been for years, allowing them to focus on fields of vision that were blurry to them before.
Today, a variety of lens types are available. Most fall into these categories:
Monofocal lenses. As the name implies, these lenses provide a focus that is good for clear viewing at a certain distance. Your doctor may ask you whether it’s more important for you to see at long distances (if you’re, say, an avid hunter or golfer) or at short distances (if you read a lot, work on a computer or do hobbies that require close-in work).
Most insurance companies and Medicare cover what are called fixed-focus monofocal lenses, but there’s now another type of monofocal lens called an accommodating-focus monofocal lens. Accommodating-focus lenses respond to movements of your eye muscles to change their shape, allowing you to focus similarly to how the lenses you were born with work. People with accommodating-focus monofocals tend to excel at seeing at medium and long distances but require reading glasses for close-in viewing.
Some people who have surgery on both eyes opt for a strategy called monovision, in which one eye receives a monofocal lens for far-away viewing and the other eye receives a monofocal lens for close-up viewing. After a brief training period, the brain adjusts and the person develops the ability to see well at both ranges. Monovision works particularly well in people who have already used this strategy in the form of contact lenses.
Multifocal (wide-range) lenses. Just as eyeglass lenses are sometimes divided into sections that allow for both distance and close-up viewing, so are some IOLs. Multifocals may come with two focal points or three (trifocals).
Trifocal lenses provide focus at far, intermediate, and close distances but may cause a glaring or halo effect at night.
Extended depth-of-focus lenses do away with this halo effect. However, while they excel at long and intermediate distances, they usually require the person to wear reading glasses to see up close.
Toric lenses. These lenses are made specifically for people with astigmatism. They’re shaped differently from most IOLs to accommodate the oblong shape of the cornea in people with that condition. You can get toric lenses in monofocal, bifocal, trifocal, or extended depth-of-focus versions.Light-adjustable lenses. One of the downsides to most IOLs is that once you’ve made your choice of lens, you’re stuck with it after the surgery. Despite all the precision instrumentation involved, it’s possible that you and your doctor will be slightly off in the lens strength you’ve chosen. But light-adjustable lenses allow for fine-tuning after the surgery. They’re made of material that changes shape when exposed to certain wavelengths of UV light. In the weeks after this surgery, people revisit the ophthalmologist for light treatments that refashion the lens to meet the recipient’s preferences. Once the correct focus has been achieved, the lenses are “locked in” so they can no longer change. People who get light-adjustable lenses are the ones most likely to achieve 20/20 vision. Unfortunately, light-adjustable lenses are prohibitively expensive for many people and are not yet very widely available.
