What Is The Best Lens For Cataract Surgery?

In this post, we are going to specifically address the most important decision you need to make almost as soon as you decide to go through with cataract surgery or a refractive lens exchange: which lens should I choose to put in my eye?

A cataract is a dirty lens inside the eye, and this lens serves an important role. When you are young, the lens is clear and flexible and allows your eye to focus at near, but as you get older the lens becomes cloudy. Once your quality of life is impacted by your vision from the cloudy lens, the treatment is cataract surgery. If you are not a candidate for LASIK or PRK surgery, you might also make a decision to do a clear lens exchange where we remove your natural lens to put in a synthetic lens so that you might not need to wear glasses or contact lenses.

During cataract surgery, we take out the lens in your eye using an ultrasound machine called a phacoemulsification machine. After we take the lens out we put in a new lens and this lens will most likely stay in your eye for the rest of your life. But which lens should you pick?

There are three main classes of lenses that I’ll touch on today. Lens technology changes constantly and there will be new lenses and features available by the time you see this video that might not be available at the time of filming, so a disclaimer that I’m going to be very general so this video can stay relevant for a while. Make sure you discuss your individualized lens choices with your eye care provider and your surgeon prior to making your decision.

MONOFOCAL LENSES

This lens is covered as part of the cost of cataract surgery by most insurance plans including Medicare and will overall give you the best quality of vision. This lens is the same power throughout so if you have astigmatism, or a cornea with an imperfect curvature, and decide to go with this default lens you will most likely need to wear glasses for best distance, intermediate, and near vision after surgery. 

TORIC LENSES

If you have regular astigmatism and you want the option to be glasses-free for some activities, you might want to think of a toric lens, or a lens that offsets some of the imperfect curvature of the cornea. This lens has an axis of cylinder power to offset the shape of the cornea so that you have your best chance of seeing well at a specified focal point without glasses. 

WIth a monofocal lens or a toric lens, you can decide for each eye whether you want to see well for distance vision, which is helpful for driving or watching TV, intermediate vision, like for computer vision, and near vision for reading fine print or nutrition labels. You might also want to consider monovision or mini-monovision, where your dominant eye is set for distance and your nondominant eye is set for intermediate or near vision to give you a range of vision. This is not ideal for everyone, but if you have experience with monovision contacts or refractive surgery, this is a great option.

MULTIFOCAL LENSES

Another lens option is a category called multifocal lenses, or lenses that can focus light at distance, intermediate, and near. This is a great option if you absolutely hate wearing glasses and these also come with astigmatism-correction if needed. We only want to offer a multifocal lens if you have otherwise perfect eyes without an irregular cornea or other eye diseases such as age-related macular degeneration or a retinal scar. 

Here are 5 questions that will help you figure out which lens choice is right for you.

1. Are you okay with wearing glasses? If you are, then you might just consider a standard monofocal lens and match your two eyes so they work well together. You will definitely need reading glasses for fine print with these lenses, and if you have significant astigmatism, you might just need a progressive or bifocal glasses that you would need to wear at all times.

2. Do you have significant astigmatism? If you have astigmatism in your glasses and/or your doctor tells you that you have astigmatism based on your tests, you might want to consider a toric lens to help correct that astigmatism. 

3. Are you okay with wearing reading glasses? If so, then you can have both eyes focused at distance so that you maximize 3D vision. If you hate the idea of wearing ANY kind of glasses, you might want to consider monovision or multifocal lenses.

4. Have you done well with monovision contact lenses or did well with monovision LASIK or PRK? If so, you should consider replicating this with your intraocular lenses.

5. Do you hate the idea of wearing glasses or is the idea of monovision unpalatable? The last type of lens you should consider is a multifocal intraocular lens, which typically has multiple rings with various powers within the lens to help focus light at various focal points within the eye. This lens gives you a larger range to see distance, intermediate, and near without glasses. If you are interested in a multifocal lens, you need to ask yourself if a low amount of nighttime glare is going to bother you. This can be a really difficult question for most people to answer, and this is an impossible question for your eye care provider or your surgeon to answer on your behalf, so I advise you to ask your family members or friends if they think you are detail-oriented. While many are happy with their choice to go forward with a multifocal lens, there are definitely those who are not and once the lens is in the eye, it can be quite dangerous to take it out and there is not much we can do besides changing out the lens to help with quality of vision.

If you were having cataract surgery today, which lens options would you choose? Thanks for reading, and best of luck on your upcoming surgery!

Ocular Rosacea

Today, I am going to address a very common and underdiagnosed cause of dry eye: Ocular Rosacea. 

Rosacea is a skin condition of the mid-face that affects up to 20% of people. People with rosacea are typically prone to a long blush or flush that can resemble a sunburn, acne-like bumps referred to as papules or pustules, or skin texture changes. Rosacea tends to start around middle-age, in cycles, and is usually triggered by sun exposure, heat, stress, red wine and other alcohol, caffeine, and spicy foods. 

While we don’t really understand the mechanism of rosacea, we do know this is an inflammatory condition with an abnormal immune system response, and that there is a genetic component to this condition. There are multiple theories on why some people get rosacea, including theories linking the bacteria in our gut or small intestine bacterial overgrowth and mites called Demodex that may be inducing skin inflammation.

There are 4 types of rosacea and many people affected by rosacea may experience more than one type. Besides ocular or eye rosacea, which I will get to later in the video, there is erythematotelangiectatic rosacea, which is characterized by a prolonged blush and persistent redness of the face. With this type of rosacea, you can often see enlarged small blood vessels on the skin. Another type is papulopustular rosacea, which is characterized by whitehead pustules, which are red and pus-filled blemishes on the cheeks, chin, and forehead that are often confused with acne. The most rare and severe form is phymatous rosacea, which can result in thickening and discoloration of the skin. Phymatous rosacea usually affects the nose and is more common in men than women. 

So how does this condition affect our eyes?

Well, this is a disease of the mid-face, and guess what is also in our mid-face? Our lower eyelids! In ocular rosacea, we see inflammation of our lower eyelids, classically lid margin telangiectasias. This is easily seen and noted with the slit-lamp microscope we use in our eye clinic. 

In ocular rosacea, eyelid inflammation can cause blockage of the meibomian, or oil, glands that provide the oil layer of our tears. Having blocked oil glands can cause a form of evaporative dry eye, where you make tears but don’t make good quality tears to lubricate your eyes and make you more prone to styes and chalazia, which are caused by blocked sweat and oil glands on the eyelids. In addition to dry eye, the eyelids can feel irritated and itchy from all the inflammation.

In general, there are multiple treatments for rosacea, many of which are beyond the scope of this video on ocular or eye rosacea. First and foremost, preventing and avoiding triggers is the most effective thing you can do. If you suffer from rosacea or you think you might have rosacea, please consult with your dermatologist about a treatment plan for your skin that might work for you.

For ocular rosacea, the treatment principles are similar to treating rosacea of the skin. There are a few levels of treatments that I discuss with my patients, depending on severity of disease and previous response to medications.

TREATMENT #1

Just like with skin rosacea, we want to avoid flares, whatever that may be. For some, this includes avoiding heat and warm compresses to the eyes and eyelids, which is unfortunately an effective treatment for almost every other type of dry eye. 

TREATMENT #2

With minor irritation or symptoms, lubricating eye drops, specifically preservative-free eye artificial tears, work best. Just how inflamed rosacea skin is sensitive, the eyes and eyelids of rosacea patients are usually sensitive as well and avoiding any triggers, including unnecessary preservatives, can be helpful.

TREATMENT #3

If preservative-free tears are not enough, we might need to escalate treatment to a short-term, low-dose steroid eye drop for flares. We never want to stay on steroids for a long time if we can help it, as steroid eye drops for years, even at low doses, can accelerate cataracts and elevate eye pressure in a small percentage of patients.

TREATMENT #4

Just like with other types of skin rosacea, oral antibiotics, such as tetracyclines like doxycycline, can be effective in some cases of ocular rosacea. Doxycycline at low doses (under 50mg) has anti-inflammatory properties that both clinically and symptomatically can help with rosacea when taken long term.

TREATMENT #5

A newer treatment for rosacea and ocular rosacea is Intense Pulsed Light or IPL, a laser treatment that has been used for hyperpigmentation of the skin and other types of rosacea and is now being increasingly used for ocular rosacea. This treatment can be effective with multiple uses, and there are some eye doctors who use a specific ocular protocol for ocular rosacea with notable success. While this is still not a common tool in every eye clinic, this is becoming increasingly popular and we might be seeing this tool in more eye clinics as a treatment option for this form of dry and irritated eyes and eyelids.