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OPHTHOBOOK-CHAPTERS

Chapter 10: Introduction

to the lens and cataract
surgery
Timothy Root, MD 112 Comments

If you’re rotating through an ophthalmology

department, you’re going to be dragged into
surgery at some point. Cataract surgery is our
signature operation, so it’s worthwhile to
familiarize yourself with basic lens anatomy and
surgical goals.

The eye is the most amazing organ in the human

body, and the lens is one of the most impressive
structures within it! Not only is the lens the
densest tissue in the body (highest protein
content and lowest water percentage) it also
remains optically clear for years despite constant
bombardment by light radiation. The lens can
even use it’s mighty-morphing transformer
powers to change shape and thus it’s focusing
power! Not bad, eh?

Some Cataract Terminology

Phakic: When you have your natural lens

Psudophakic eye: When a cataract is
replaced with an artificial lens
Aphakik eye: When a cataract is removed but
isn’t replaced.

Lens Anatomy
We can’t
go any
further in
our
discussion
without
first
describing the anatomy of the lens and how it sits
in the eye. When conceptualizing the structure of
the lens, you may find it useful to think of it like a
yummy peanut M&M candy. Thus, there is an
outer capsule like a “hard candy shell” that
surrounds the lens. Inside you’ll find the chocolate
layer (the lens cortex) and the inner nut (the hard
lens nucleus). These three layers are clear, of
course, but that’s the general layout.

Cataracts can form at different layers within the

lens, and the location can give you clues to the
causative insult and explain specific visual
complaints. The lens layers become even more
relevant during surgery – with cataract extraction,
we tear a round hole through the anterior capsule,
suck out the cortex and nucleus (the chocolate
and the peanut), and inject a prosthetic lens into
the remaining capsular bag.

Now, we know the structure of the lens and we

know the lens sits behind the iris … but what
keeps the lens from falling into the back of the
eye? The lens is actually suspended behind the
iris by zonular fibers. These zonules attach at the
equator of the lens like trampoline springs and
attach the lens to the surrounding ciliary body.
The ciliary body is a ring of muscle sitting behind
the iris. Trauma and surgical mishaps can break
the zonules and cause the lens to de-center or
even fall into the back of the eye.

Accommodation
Now, I just said that the lens is suspended by
spoke-like zonules to the ciliary body. But what is
this mysterious ciliary body? The ciliary body is a
ring of muscle that sits directly underneath the
iris. You can’t see it directly by standard exam
without using mirrors, but this ciliary body is
important for two reasons: it produces the
aqueous fluid that nourishes the eye and it
controls lens focusing.

The ciliary
muscle can
be thought
of as a
camera
diaphragm,
or if you
prefer a
more entertaining description, a sphincter muscle.
When this sphincter contracts, the central “hole”
gets smaller causing the zonular “springs” to
relax. With zonular relaxation, the lens relaxes and
gets rounder. This rounding makes the lens more
powerful and allows you to read close-up.

Unfortunately, as we age our lens becomes harder

and does not “relax” into a sphere very well, no
matter how hard the ciliary body contracts. This
loss of lens accommodation is called presbyopia
and explains why we need the extra power of
bifocals to read after the age of 40.

Fun Fact!
Ever wondered how those “blue blocker”
sunglasses are supposed to improve vision?
You know, those yellow tinted-glasses that
sport enthusiasts and hunters wear?

They work because all lens systems, including

the eye, suffer from some degree of
chromatic aberration. This occurs because
some wavelengths of light are bent more
when going through a lens or prism system.
Red light is bent the least, so the color red
tends to focus slightly behind the retina, while
blue light bends more, thus focuses in front of
the retina. This creates a mild blur because
not all colors can be perfectly focused at the
same time.

Yellow-tinted glasses only allow certain

wavelengths to pass through. This eliminates
chromatic aberration and the image appears
sharper.

Cataract Types and Mechanism:

The lens begins as a clear magnifying glass inside
your eye, but with time can opacify. Most
cataracts are of idiopathic etiology, though there
are many associated conditions that lead to both
congenital and environmentally induced lens
opacities. Here is a short summary of the
important cataract types:

Nuclear sclerotic cataracts

NSCs are the most common type of cataract and
many consider them to be a normal maturation of
the lens. Over time, the lens becomes larger and
brunescent (yellow or brown) especially in the
denser central nucleus. If this process goes on
long enough the opacity eventually leads to visual
obstruction and problems with glare. The lens can
become so big that it pushes the iris forward,
placing the patient at increased risk for angle
closure glaucoma.

With far-advanced cataracts the middle cortical

layer (the chocolate layer) can liquefy and
become milky white and the nucleus layer (the
central peanut) gets hard and falls to the bottom
of the capsular bag. These end-stage
“Morgagnian cataracts” are rarely seen in this
country and are particularly hard to remove at
surgery.

Some patients with nuclear sclerotic cataracts will

develop so called “second sight” where it seems
like the vision improves. This is because the round
cataract lens is more powerful and offsets the
coexisting presbyopia allowing older patients to
read better. Their vision really hasn’t really
improved, it’s just that their cataracts are working
like weak bifocals inside their eyes.

Posterior Subcapsular Cataract:

The PSC cataract
forms on the back of
the lens, on the inner
surface of the
posterior capsule bag.
These cataracts tend
to occur in patients on
steroids, with
diabetes, and those
with history of ocular
inflammation. The
opacity looks like breadcrumbs or sand sprinkled
onto the back of the lens. This posterior location
creates significant vision difficulty despite
appearing innocuous on slit-lamp exam. PSC
cataracts are quite common, and often occur in
conjunction with some degree of NSC.

Posterior versus Anterior located cataracts.

Posterior cataracts cause more visual complaints
than anterior cataracts. This is because of the
optics of the eye. Advanced optics are beyond the
scope of this book. Keep in mind, though, that the
eye has an overall refractive power of
approximately 60 diopters (40 from the cornea,
and 20 from the lens). If you simplify the eye to a
single 60-diopter lens system, the important
“nodal point” of this system is near the back of
the lens.

The closer you get to this nodal point, a greater

number of light rays will be affected. Thus, small
PSC cataracts are more significant than larger
anterior cataracts.

Congenital Cataracts:
Lens opacities in children are of concern because
they can mask deadly disease (remember the
differential for leukocoria from the pediatric
chapter?) but also because they are highly
amblyogenic.

Cataracts in the newborn can be idiopathic or

inherited. If small or anteriorly located, they may
be visually insignificant. However, when
approaching a leukocoric pupil, you should first
rule out potentially deadly disease. This includes
cataract masqueraders like retinoblastoma, and
deadly causes of cataract like the TORCH
infections and galactosemia.

A true cataract needs to be removed quickly,

usually within the first two months of life, because
they are highly amblyogenic. Cataract surgery is
challenging in this age-group as children have
impressive inflammatory responses and are not
easy to examine pre- and post-operatively. After
taking the cataract out, you don’t implant a
prosthetic implant in newborns, but wait a few
years because their eyes are still growing. The
family must deal with powerful aphakic glasses or
contact lens placement until the child is old
enough for the secondary lens implantation.

Traumatic Cataract:
A cataract can form after blunt or penetrating
injuries to the eye. When the outer lens capsule
breaks, the inner lens swells with water and turns
white. These injuries typically occur in young men
and the lenses are very soft and easy to suck out.
Removal and implant placement can be
complicated, though, as the blunt force often
tears the zonular support. If the lens is barely
hanging in position, it may be safer to consult a
retina specialist to remove the lens from behind (a
pars plana approach) to keep the lens from falling
back into the eye.

Lens Nutrition and Glucose metabolism

The cells that make up the adult lens have no
innervation or blood supply, and thus derive their
nutrition entirely from the surrounding aqueous
fluid. Because of this low O2 tension, these lens
cells survive almost entirely on glycolysis.

Poorly controlled diabetics can have very high

levels of glucose. If high enough, the lens
metabolism can shunt down a sorbital pathway.
Sorbital buildup in the lens then creates an
osmotic swelling of the lens with resulting
refractive changes!

If a diabetic patient complains of episodic blurring

vision, find out what their glucose has been
running. If it has been high recently, don’t
prescribe glasses, as their prescription may still
be changing from lens swelling.

Posterior Capsular Opacification (PCO):

A posterior capsule opacification isn’t a true
cataract, but an “after cataract” that forms after a
cataract surgery. I’ll be talking about the cataract
surgery technique in a second, but basically, we
suck out the cortex and nucleus (the chocolate
and the peanut) and inject a new lens into the
remaining capsule (the hard candy shell).

Residual lens epithelial cells are left behind after

surgery. These orphaned epithelial cells get
confused (and lonely) and can migrate along the
back surface of the implant and opacify the
posterior capsular bag.

This is a common occurrence and fortunately is

easily treated in clinic with a laser. The YAG laser
is used to blast a hole in the posterior capsule. We
don’t break a large hole, as you don’t want the
implant to fall into the back of the eye, but one big
enough to clear the visual access. This is known
as a YAG capsulotomy.

One more topic … Lens Dislocations

As already mentioned, a lens can dislocate from
traumatic force (such as a punch to the eye). It
can also dislocate because of inherited diseases
that affect zonular strength. The two major
causes of hereditary lens dislocation are Marfan’s
syndrome and homocystinurea.

Marfan’s disease is an autosomal dominant

disease of fibrillin. These patients have tall body
habitus, arachnodactyle and can have lens
subluxation with the lens dislocating upwards.
This can create large astigmatism as the patient is
looking through the edge of the lens, and may
eventually require cataract extraction.

FUN FACT:
Some historians believe that Abraham Lincoln
may have
had Marfans syndrome.

Homocystinurea is an autosomally recessive

heriditary disorder that results in an absence of
cystathionine B-synthetase. This enzyme causes
the conversion of homocysteine to cystathionine.
These patients have a marfanoid habitus,
arachnodactyly, and there is a 50% incidence of
mental retardation. The lens zonules are largely
composed of cysteine, and without good
cysteine, the zonules become brittle and can
break. The majority of these patients develop
downward lens dislocations. They also have poor
peripheral circulation and are subject to
thromboembolic events under general anesthesia.

Is the patient ripe for surgery?

Most people over 50 have some degree of
cataract in their lens. The question then becomes
“should you have surgery or not.” This is not
always a clear-cut choice: you can be amazed at
the dense cataracts that patients are still able to
see through, and conversely, the seemingly
“wimpy cataract” that causes major visual
complaints.

There is a saying in ophthalmology, “If you can

see in, than the patient can see out.” That is to
say, if you can see the retina clearly with your
ophthalmoscope, it is likely that the patient can
see clearly through their lens. More objectively,
we generally use 20/50 as a cut-off for surgery as
this is the minimal driving acuity in most states,
but patients have different visual needs. A visual
acuity of 20/30 is not acceptable for a young
commercial airline pilot. Conversely, potentially
life-threatening anesthesia might not be
necessary for a 20/70 nursing home patient who
likes jazz music and is happy with his vision.

Acuity isn’t everything:

One big complaint
that people have is
glare. In the dark a
patient may see
fine. But have them
drive into the sun or
at night with car
headlights coming
at them, and they
become blinded by
the scattering of light through their hazy lens.
Many patients tell us that they no longer drive at
night. We can test glare in the clinic by checking
vision while shining a light in the eye. Also, you
can more formally test glare with the BAT
(brightness acuity tester) device. This is a light-
bulb illuminated hemisphere with a view hole that
induces glare.

Another indication for surgery is the presence of

underlying retinal disease such as advanced
diabetic retinopathy. If a cataract interferes with
careful fundus examination or laser treatment, the
lens needs to come out.

Who decides?
Ultimately, it’s your patient’s decision whether to
have surgery. In an ideal world without operative
complications everyone should have cataract
surgery as soon as the vision drops to 20/25.
Unfortunately, bad things can happen in surgery,
and patients have to decide if they’re vision is
affecting their life enough to take the risk of
surgery. Our job is to educate and inform our
patients about these risks and about their surgical
options.

Cataract Surgery – A historical prospective:

In Egyptian times, cataract surgery was a primitive
affair. Eye “surgeons” would take a sharp needle
and shove it into the eye to rip the lens from it’s
zonular support and allow it to fall into the back of
the eye. This technique, called “couching,” clears
the visual axis, because the lens is now bouncing
around in the bottom of the eye. Patients had
terrible vision after this (with approximately 20
diopters of hyperopia) but back in those days of
ultra-dense cataracts, this was an improvement
allowing these early patients to see basic shapes,
such as the outline of the pyramids and perhaps
their camel.

During World War 2, fighter pilots suffered from

penetrating eye injuries when fragments of their
Plexiglas cockpits exploded. Eye doctors of that
era found that the eye seems to tolerate plastic,
thus spawning the idea of using plastics to create
intraocular lens implants to replace the natural
lens.

Cataract implants have evolved since then. Now

we have lenses made of PMMA plastic, acrylic,
and silicone. These implants can be folded
through smaller incisions and placed in different
positions inside the eye – in the capsule, behind
the iris in the “sulcus,” or even sitting on top of the
iris in the anterior chamber.

Preoperative measurements: how to choose

your implant power?
Our goal in cataract surgery is to put the ideal
power intraocular lens into the eye such that the
patient won’t need additional glasses for viewing
distant objects. This is not always an easy task, as
everyone’s eyes are different and minor anterior-
posterior shifts in the lens placement will severely
affect the end refraction. There are many
formulas designed from both lens theory and
regression analysis to help you choose the correct
power lens. We won’t be going over these
formulas, but keep in mind that we need to
measure two things to come up with the right
prescription for the implant:

a. The corneal curvature: Remember that

the cornea-air interface actually performs the
majority of the refractive power of the eye.
The cornea performs approximately 40-
diopters of refraction, while the lens makes up
the last 20-diopters. A person with a powerful
cornea will need a less powerful lens. We
measure the curvature of the cornea with a
keratometer.

b. The length of the eye: The shorter the

eye, the more powerful lens you’ll need to
focus images onto the retina. We measure this
with the A-scan mode of a hand-held
ultrasound.

Cataract Surgery – How to Do it!

Cataract surgery is easy in concept, but actually
performing this surgery is challenging as you’re
working under a surgical microscope with delicate
ocular structures.

The Steps:
There are many steps to cataract extraction, and
many ways to go about it – everyone has their
own combination of machine settings,
viscoelastics, irrigating fluids, and preferred
instruments. Essentially, you can break down the
cataract surgery into a few steps:

1. Anesthesia
Dilate the pupil, prep, and anesthetize the eye.
Anesthetic can be given with simple topical
eyedrops like tetracaine. We can also perform a
retrobulbar block by injecting lidocaine/bupivicane
into the retrobulbar muscle cone to knock out
sensation through V1, and eye movement by
knocking out CN3 and CN6. The trochlear nerve
(CN4) actually runs outside the muscle cone, so
you can see some residual eye torsion movement
after the block. If you’ve never seen a retrobulbar
block, you’re in for a treat (it can look gruesome
the first time).

2. Enter the eye

The main surgical entry site can be performed
several ways. You can enter the eye by cutting
through the cornea, or you can spend more time
tunneling in from the sclera. A clear-cornea
incision is fastest, while the scleral tunnel takes
longer but is easier to extend if you run into
surgical complications.

3. Capsulorhexis
To get the lens out you need to tear a hole in the
anterior capsule (hard candy shell) of the lens.
This step is important to get right, because if the
rhexis is too small, it will make cortex and nucleus
removal harder. Also, the outer capsule you are
tearing is finicky and can tear incorrectly, with a
rip extending radially outwards to the equator (not
good). If you lose your capsule, you can lose
pieces of lens into the back of the eye. Poor
capsular support also makes implant placement
that much harder.

4. Phacoemulsify
We use an instrument called the phaco handpiece
to carve up the lens nucleus. This machine
oscillates at ultrasonic speeds and allows us to
groove ridges into the lens. After grooving, the
lens can be broken into pie-pieces and eaten up
one-by-one.

5. Cortical removal
After removing the inner nucleus, we can remove
the residual cortex (the middle chocolate layer) of
the lens. This cortex is soft but wants to stick to
the capsular bag. You don’t want to leave too
much, as it will cause inflammation and can cause
“after cataracts” (posterior capsule opacification).
We strip this with suction and vacuum it out.

You need to be careful with your posterior capsule

during this cleanup. The surgeon tries to maintain
the posterior capsule for a couple of reasons –
not only does it create a support structure for the
new lens, but it maintains the barrier between the
anterior and posterior chambers, keeping the
jelly-like vitreous from squeezing into the anterior
chamber.

6. Insert the lens

We usually use a foldable lens that can be
injected directly into the bag. If we’ve lost
capsular support (for example, we managed to
break the posterior capsule during phaco or
cortex removal), the lens can be placed on top of
the entire capsular bag, right behind the iris. If
support for this sulcus placement is questionable
(i.e. you’ve had a LOT of complications with the
case), a lens can be placed in the anterior
chamber on top of the iris, or sutured to the back
surface of the iris (tricky).

7. Close up
You now close the eye. Many small incision
corneal wounds are self-sealing, but some require
closure with 10-0 nylon suture that will eventually
biodegrade.

8. Postop care:
Immediately after surgery, antibiotics are dropped
and a shield is placed over the eye. The patient is
then seen the next day and will use antibiotic
drops and a steroid drop to decrease
inflammation.

Conclusion: Cataract surgery is not easy

Almost every ophthalmologist performs cataract
surgery, so there is a tendency to view this as a
simple procedure that only takes a few minutes.
Some cataract cowboys are able to perform an
extraction in ten minutes and may even downplay
the risk.

The reality is that cataract surgery is very difficult.

The lens is mostly clear, floating in clear aqueous,
supported by a microns-thin clear capsule that
wants to tear. The patient is usually awake, so any
small movement such as a cough or simple head
adjustment looks like an earthquake under the
microscope. Cataract extraction involves many
steps, and early mishaps at the beginning of the
case cascade and make the later steps that much
more difficult.

Look at it this way: any surgery that takes over

100 operations to develop basic proficiency has
got to be tough. Cataract surgery is like flying an
airplane … it takes many years of training,
screening, certification, accreditation to be
accomplished pilot, and most flights are
uneventful. But you want a qualified person
behind the wheel when you hit turbulence.

Fortunately, most of the time things go just fine.

PIMP QUESTIONS
1: What does it mean to have a phakic eye or an
aphakic eye?
Phakic means that the patient has their original
lens. Pseudophakic means that they have a
intraocular lens implant. Aphakic means that their
lens was removed, but no replacement lens was
placed.

2. What are the layers of the lens and what is

removed in cataract surgery?
There are three layers to the lens. The outer
capsule, the inner nucleus, and a middle cortex …
in a configuration like a peanut M&M candy.

3. When you accommodate (look at near

objects) do the zonules relax or tighten?
The zonules relax. With accommodation, the
spincter-like ciliary body contracts, the zonules
relax, and the lens relaxes and becomes rounder
(thus more powerful). You’re going to have to
think that one out a few times and look at the
drawing in this chapter.

4. What are the two functions of the ciliary

body?
The ciliary body changes lens shape, allowing fine
focusing and accommodation. It also produces
aqueous fluid that inflates the anterior chamber
and nourishes the avascular lens and cornea.

5. By what mechanism can a diabetic patient

have a temporary refractive error?
Too much glucose will switch the lens metabolism
from anaerobic glycolosis to a sorbitol pathway.
Sorbitol buildup in the lens creates an osmotic
swelling that changes the lens power (the round,
swollen lens makes images focus in front of the
retina, thus the patient is temporarily near-
sighted).

6. Why do yellow sunglasses make images

seem sharper?
All lens systems have chromatic abberation
because the different colors of light bend
differently. This means that images don’t focus
perfectly on the retina – the blue component
focuses slightly in front of the retina, while the red
component slightly behind. Tinted glasses limit
the spectrum of color that hits the retina, and
makes images appear sharper.

7. How soon should a child with a cataract go

to surgery?
Soon, as cataracts create a visual deprivation that
quickly leads to amblyopia. Some practitioners
recommend surgery prior to two months.

8. How can a cataract cause glaucoma?

Many cataracts are large, and this can push the
iris forward and predispose to angle closure
glaucoma. Also, end-stage cataracts can leak
proteins into the aqueous and the resulting
inflammatory cells (macrophages) can clog the
trabecular meshwork.

9. What measurements must you have to

calculate a lens implant power?
You need to know the cornea curvature (because
the cornea performs the majority of the eye’s
refractive power) and the length of the eye.

10. How much of the lens is removed in typical

cataract surgery?
With eye surgery, we create a hole in the anterior
capsule and suck out the inner nucleus and
cortex.

11. What’s the difference between and PCO

and a PSC cataract?
PCO: posterior capsular opacification. This is an
“after cataract” that forms on the back surface of
the posterior capsule after successful cataract
surgery. This opacity can be cleared with a YAG
laser.
PSC: posterior subcapsular cataract. This is a
cataract that forms on the back subcapsular
portion of the lens. These tend to occur more
often in diabetics and those on steroids, and tend
to be visually significant because of their posterior
positition.

12. What does it mean to place a lens “in the

sulcus?”
The sulcus is the space between the lens capsule
and the back of the iris. If the posterior capsule is
torn and can’t support the lens, you can often
place a lens on TOP of the entire capsule in this
potential space.

13. What drops are given after a cataract

surgery?
Usually an antibiotic, such as ciprofloxacin or
vigamox. Also, a steroid is given to decrease
inflammation.

Timothy Root, MD

Dr. Timothy Root is a

practicing ophthalmologist
and cataract surgeon in
Daytona Beach, Florida. His
books, video lectures, and
training resources can be
found at www.TimRoot.com

112 Comments

margaret Denton says:

I have been told that my implanted lens is

on an angle and there is a samll possiblity
that during replacement of the lens it may
slip back in to the viterous humor.

What are the chances of this happening?

What specality should an opthalmologist
have to do this surgery?

What is the possibility of permanent

damage being done to my eye?

What would have caused this slippage of

the lens?

My opthalmologist never mentioned it, but

sent me to an optomertrist to have ???
drops for a dilated pupil. The
opthalmologist never explained why I
needed this and the optometrist would not
touch my eye. Please help

Reply

admin says:

Well,
Hard to say given your history. Sounds as if
anything could have happened:

1. The implanted lens may be at an “angle”

because it tilted as your capsule
contracted.
2. One of the haptics of the lens implant
may be sitting in the sulcus
3. You may have had some zonular
dehiscence with instability of the
supporting capsule.
4. You may have had a posterior capsular
tear during the first surgery (common)

You should really speak with an

ophthalmologist whom you trust to look at
your eye under the microscope and give
you an opinion and give an opinion on your
chances … I’m just guessing.

I will say that this kind of lens tilt can

happen after surgery, even after a “perfect
surgery” without other complications or
difficulties.

As for the chances of a “dropped implant”

… this is really a possibility, as a secondary
operation is much more complicated and
difficult than the primary surgery. If the lens
DOES drop, it’s not the end of the world …
but you’ll need another surgery by a retina
surgeon to remove it.

Like I said, though, you really need to see

an eye doctor to examine your eye closely
and discuss this with you as it’s almost
impossible to guess without seeing the eye.

Reply

Bhargav Raut says:

Hello,
i am a medical student at the end of my
second year of medicine.
I recently heard about a new invention in
cataract surgery:
Its called the Nanoknife.
Its supposed to drastically reduce capsular
opacification after surgery.
Do you know about this?
Thanks
P:S– this page helped me get through my
end of rotation exam really well.

Reply

trapti sharma says:

hi,
i would like to know the blood sugar cut off
level & b.p prior to cataract surgery or any
ophthalmic surgery.
thanx

Reply

C. Allan Young says:

Following a disasterous cataract surgery.

(Eyeball filled with debris that required
vitrectomy that led to CME) I eventually
developed an elliptical iris that allows light
to leak past the lens implant and being
unfocussed produces haloes and glare. Is
this a common complication? The article is
good and I liked the style. C. Allan Young

Reply

yasser maslamani says:

dear all,
i am pharmacist and so interested in
cataract surgery. But I have one question:
what is the role of viscoelastic substances
like(H.A) in cataract surgery??
thanks

Editors Note: The viscoelastics used in

surgery serves two purposes. The first, is to
provide protection to delicate structures
inside the eye – primarily, the endothelial
surface of the cornea (those endothelial
pump cells are very sensitive and don’t
regenerate when lost). The second purpose
is to keep the anterior chamber deep (keep
the eye from ‘deflating’ when removing
instruments and inserting the implant).

Reply

Veronique Nas says:

I would like to know how you determine

(about) the preoperative myopia of a
patient that had cataract surgery without an
implantlens, and who needs a refraction of
+3 in his glasses.
Could you also include a formula? Thanks!
( I like your website a lot!!)

Reply

Veronique Nas says:

And can you help me with this: it is

generally assumed that high(er) myopia
correlates with low(er) vision. Is this true?
Can’t find anything good about it. Thanks!

Reply

Haitham says:

nice work

Reply

Carol Herrera says:

My mom recenty had eye surgery to have

cataracs removed.
In a recent surgery, her doctor told her one
of her lens in her right was tilted. The
doctor said my my mom can see netter than
before…but said she may trouble later with
sunlight. Should she have another surgery
to fix it? Are we doing more harm than
good.

Reply

steve says:

I had cataract surgery in June ’08 (IOL

implant) and later, in July 09, had retinal
reattachment surgery (intraocular surgery
with gas bubble)on the same eye for a
partially detached retina. The retina had
two flap tears that were repaired (cryo and
laser). Five months post retinal surgery I
have distorted vision in the operated eye:
the image I see slants downward, from right
to left (sloping horizontal axis of image) and
the image tends to be elongated vertically.
My IOL was sutured in place at the start of
the retinal surgery, I assume as a
precautionary measure. Is it possible that
my IOL was somehow displaced during my
retinal surgery and is causing this vision
distortion, or is it more likely that other
reasons for the distortion are more likely? Is
there a way an ophthomalic exam can
determine whether the IOL is in the right
place?

Thank you for your assistance. Your web

site has been very useful to me.

Steve

Reply

allan says:

Can you please tell me where did you derive

the A-constant in the SRK meaurement..

Reply

komal says:

hello,

pls tell me what is the cutoff glucose level

before cataract surgery.

my dad(diabetic) had 140 fasting on the

morning of surgery.the diabetologist told
the nurse on phone to give 4 units of
insulin.so he was given…and in an hour,his
level came down to 133.his surgery was
performed.On the night after surgery..his
ocular pressure had increased,he had
pain.but mannitol to reduce pressure was
gvn only next day…when v reported agin to
hospital.and later tht day v came to knw tht
diabetologist was denying tht he said the
nurse to gv insulin to my dad.i mean he was
like i first said the nurse to give bt then later
denied.i dont know y he behaved tht
day,isnt 140 more for fasting,n gvn insulin
must have only benefitted him na??
Now 3 wks later,when he is facing probs
with vision, n also
floaters,doc(opthlmologist) has told he has
gt retianl swelling,he was gvn tricot inj. n he
is on acular eye drops now for 2wks.pls gv
info.

Reply

moma says:
thank you
vvvvvvvvvvvvvvvvvvvvvvvvvvvvvery much

Reply

Raviteja Innamuri says:

Thanks for such a wonderful e learning

chapter!
Dear Sir,
I’m a 3rd year medical student in India and
I’ve an interesting doubt. Can the patient
see the operative procedure when done
since his Optic nerve is not targeted in
Anesthesia?
Thanks again.

Reply

Björn Johansson says:

Dear Raviteja,
good question – some patients are
worried before surgery that they will see
large knives and needles moving just in
front of their eye. Luckily, the microscope
lamp is so strong that the operated
patient cannot see any details with the
operated eye, and the other eye is
covered by sterile cloth. So no need to
worry about seeing fearful surgical tools.
On the other hand, if you use subtenonal
or (less common today) retrobulbar
anesthesia, the optic nerve is blocked
and the patient will experience that what
vision they have goes away. This might
scare them if they are not told in advance
that this is normal and that vision will
return after the anesthesia.
Best wishes
Bjorn Johansson, associate professor
Linkoping University Hospital Sweden

Reply

ahmed says:

good luke for all student of medical

and best wishes

Reply

NSENGIYUMVA Emmanuel
says:

Thank you!!!! you give important things.

Reply

cathy says:

what happens when a lens turns after

cataract surgery?

Reply

Sharon Smith says:

My Ophthalmologist told me today that my

lens implant had slipped changing the
shape of my eye which resulted in a
astigmatism and vision change. Can this be
corrected? Did he not put the lens in
correctly?

Reply

rahul says:

sir i just want to know can we dilate the

fundus by using tropicamide while we are
using steriod eye drop

Reply

lin companion says:

My sister recently had cataract surgery. She

now can read and see w/o glasses. She had
worn glasses since she was 1 yr. old due to
“short eye”…Could this type of surgery be
done years earlier to spare her needing
glasses for all those years?

Reply

arshad aziz says:

during eye refraction through retinoscopy

sometime scissor reflexes are seen,instead
of maridian reflexes,what should proper
step for the neuterlization is require.

Reply

leala davis says:

what happens when the pupil sticks to the

replacement lens not allowing the pupil to
function

Reply

haani says:

hi
i am a medical student of final year mbbs …
we have ophthalmology subject in final
year.. you book ,videos and fun part have
helped me a lot, and have created a special
interest in this subject.. thanks a lot, your
work is really appreciable

Reply

christiane says:

hi iam a med student from germany and got

ophthalmo for my last oral examination…
this site helped me out a lot!! makes
learning about the eye fun thanx!!!

Reply

william says:

Hi…
I am an Optometrist
I dont seems to find any information
regarding “Cortical cataracts.”..but runs into
them off and on from refering Doctors.
Please help!!

Reply

Abul Sharah says:

This is my first time to go to your website. I

found it informative and educational. I have
a question though. I need to have cataract
surgery for both eyes and I have two option
for the type of IOL: i)lens in one eye that will
provide near vision and an IOL in the other
eye that will provide distance vision, ii)lens
in both eyes that provides distant vision.
Can you tell me the pros and cons of the
two options? Thank you.

Tim Root: Abul, here is my standard

response to patients concerning
cataract-monovision:
Monovision is when one eye is set for
distance, while the other is set for near.
Many contact lens wearers use a
“monovision contact prescription” to avoid
reading glasses. Most will set their
dominant eye for distance and their non-
dominant eye set for reading.

While some people (like my mother)

tolerate this imbalance well, other people
hate monovision. The disparity between
their eyes makes them sick to their stomach
and unsteady on their feet. The blur at
distance ruins their depth perception for
driving, and reading becomes a chore
because one eye is doing all the work.

Imagine if we set your eyes permanently

this way during your surgery. If you don’t
like your monovision, it’s going to be hard to
change those implants! At least with
glasses or contacts we can take them off or
pop them out.

If you’ve been using monofocal contacts for

years without issue (or your eyes are
“naturally” focused this way), then we may
purposefully shoot for monovision … but
not without discussing this at length during
your clinic visit.

In the end, most people prefer to have both

eyes in synch with each other. You can
always put a contact in one eye for
monovision afterwards if you really want it.

Reply

Amanda says:

My daughter was born with congenital

catarracts and had then removed at six
months old. The lens capsules were
removed during the operation. Can you tell
me if there is an artificial lenses that can be
implanted that doesn’t require the lens
capsule to be present?

Reply

Elizabeth Maness says:

Sir,
I had cataract removal and a partial corneal
transplant in my right eye in June 2007. I
developed high eye pressure the evening
after the surgery which was releved the
next morning. Otherwise, everything was
fine. In the spring of 2009, I had to have a
YAG procedure due to clouding of my
vision. This was successful. I have again
developed clouding in the eye, essentially in
the same area as before. Is it possible that I
need another YAG? What could cause this
to happen? I do have Type II diabetes, but it
is controlled.

Thank you,
Elizabeth Maness

Reply

Mabruka Azzaruk says:

I am doing Cataract+IOL surgery audit(

biometry) to find out our predict errors and
then cutomise our A constsnt, could you
please help me where can I find causes for
refracive deviation to design my proforms
please.

Thank you

Mabruka Azzaruk

Reply

Sid Cullingham says:

After 2 years of lens replacement for

cataracts, I woke up this morning, and can
see an outline of my new lens ( I believe this
is what I am seeing) No pain or pressure.
Just disruptive. Any ideas?

Tim Root: Sid, you need call your local

ophthalmologist. If you are seeing
something round in your vision … it’s
probably NOT the implant, but more likely a
vitreous detachment. Many people see a
round, clear floater (called a Weiss Ring)
when the vitreous jelly inside the eye
contracts. While vitreous detachments are
usually harmless, this is sometimes a
harbinger of more serious problems like
retinal detachment, so call your
ophthalmologist first thing and get that eye
checked out today.

Reply

naveed says:

dear sir
iam a pilot and have flown since 1993.
throughout i had a slightly blured vision in
my left eye recently during optalmic eye
check up with dilation it was diagnosed that
i may be having the coronary cataract or
some call as blue dot cataract ,should i
continue to fly

Reply

alan hunter says:

i am a 47 yo male,in 1986 i had a tramatic

cateract,had an intraicular implant done at
the jewel srien clinic at UCLA.all done under
workman’s comp. i got a small
settlement,alot of grief.10 yrs of dry
eye,chemical sensitivity,the worst was the
iliments growing like grains of sand.my
lawyer was smart and got a judgement for
lifetime medical. well its 24 yrs later and the
lense has slipped out of its mounting. so it
seems to me putting a new lens in asap is
the smart thing to to. ..now the foot draging
by the ins company.seen 3 specialists that
do not want to touch it,seems the groove
the lens sits in is eroded away.this is going
on a year now and im very frieghtened. i
want to go back to jewel stien and have it
done despite the risk,which im told is 50/50
of loss of vision.the ins company offered
me 15k.i said no.they are asking for a
counter offer and termination of the
settlement.i now have contracted AIDA and
liver failure. so i am over whelmed. hould i
settle and whats that worth? what would
that link of surgury cost? is fixing the eye
doable. please give me your two cents.it
woud mean the world to me.sincerely,alan
hunter..818 692 1420

Reply

bente carmichael says:

hi, My mother inlaw had cataract surgery

and during surgery her iris slipped out,had
a small tear,fixed they said .This is only
happened yesterday.Today she is not
seeing that well,I told her to give it a few
days since she had the toric lens.I had
never heard of the iris slipping out.What is
your take on this. Thank you

Reply

Les Nakonieczny says:

Dear Sir/Madam,

My name is Les and I am 60 year old male

living in Australia. About 12 months ago I
began to experience unusually unstable
vision. The moment I stayed in the sunlight
for about a minute or longer without
wearing sunglasses my vision the next day
would go blurry and stay that way more or
less. Gradually my vision turned to opaque
and partially distorted when looking out
close or far. A few years ago I got myself a
pair of pin hole glasses for reading and it
was working just fine. I tried to put them 10
months ago and I have noticed that pin
holes this time were turning into white haze.
As it is of now I can hardly read wearing
them because my vision is dim and kind of
distorted and I see through white fog. I
went to see an eye doctor and he said that
there is some protein layer formed which
kind of obstructs the lenses. On top of it if I
look at something out there my eyes ache
and sting and it is not comfortable at all
times. I am forced now to wear sunglasses
at all times for the reason mentioned above.
I’d appreciate your comments if you don’t
mind.

With regards,
Les

Reply

doreen schleifer says:

50 year old post-LASIK patient (15 years

ago) with great results. Now had aggressive
cataracts removed and single distance
implants in both eyes. HATE VISION! why is
my distance vision soo strange and
disorienting even though acuity is 20/50?
Have no near or mid vision at all and little
depth perception. Peripheral vision on left
side poor. Now need progressive
eyeglasses full-time and even these do not
fix problems. Need YAK in both eyes (1
week post surgery), PRK in left eye and
surgeon suggests LASIK again in both eyes.
Will this help-is it likely to correct mid and
near or at least improve without
compromising distance vision? Are
piggyback lenses an option? Any other
suggestions? My surgeon is not exactly
forthcoming with info. Has anyone else
experienced such traumatizing vision after
catatact removal?

Reply

phyllis beving says:

I know a man about 50 years old who lost a

lens due to a childhood accident. He’s not
been under the care of a doctor since then.
Could that lens be replaced after all these
years. He was recently diagnosed with
diabetes.

Reply

nileema borade says:

hi
my born with cataract, we do the surgery
and remove the cataract when he is 2
months old. we use external lens now he is
4 years old. when we do the final operation
and implant internal lens. please tell me
urgent

Reply

Hildegard Fricke says:

Hallo,

My wife Hildegard (84) had her first catarac

operation 5 weeks ago. The membrane
behind the eye was raptured, resulting in
very extensive pain for almost 2 weeks. The
surgeon assured her,she will be alright and
prescribed eye drops she took every 2
hours during the day, and a guard was over
the eye during nights. She seen der doktor
twice during the next 4 weeks, and today
he revealed that he could not detect the
implanted lense and suspected it
disappeared in the lower eye. To retrieve it
she would have to consult a retina surgeon,
or he could ignore the lense and install a
replacement without further cost to
Hildegard.
The hidden lense would be of no harm to
her. She opted for that solution. Hildegard
has to see the doctor again in 4 weeks. By
then her injured eye should be healed and
the procedure could take place. Milder
pains are still prevailing, but further eye
drops are necessary. She would like to
know what the possible outcome oft this
misshab
could be. Your professional answer would
be very much appreciated.
Hildegard

Reply

sherrie says:

Hi
I had both lenses removed in the 1970’s due
to cataracts and
hve worn thick bifocals and contact lenses
since then. Are atificial lenses an option for
me?

Reply

ignatious says:

hi, i am a young man in my early

twenties.the problem is my vision is very
poor in the dark, do i need to wear some
spectacles????

Reply

Bella says:

@ignatious Is ur vision poor just in dark or

blurred even in day time?? n do you notice
glare on seein bright light? n wat abt double
vision? n do u c black spots?

Reply

Ron says:

With cataract surgery, assume a lens with

31.00 diopter was implanted by one
opthamologist and resulting vision was
worse than prior to surgery. A second
opthamologist was consulted and after
testing recommended a 27.00 diopter lens.
The eye which has yet to be operated was
to be a 34.00 diopter lens per the first
opthamologist while the second
opthamologist recommended a 30.50 lens.
During testing in the office of the first
opthamologist they had considerable
difficulty in getting measurements and had
to adjust the ultrasound apparatus to get
the instrument to read. Is it possible this
might suggest why the recommendations
were so much different? Question – what to
do in making a decision about surgery on
the second eye?

Reply

Freda says:

I had surgery 1 yr. ago & lens was put in

wrong. I seem to be looking thru fog. I had
Laser treatments on both eyes & now
having trouble with my right eye now & no
help for left eye. Could I have a second
surgery to correct that bad lens or do I have
to put up with this forever? It is ruining my
life. I fell recently & crackd a rib because I
can’t see properly. Please let me know what
you think about a second surgery, so I know
what to do. Thanks.

This is my valid email address.

Reply

Vijay says:

I heard that it is a good idea not to do lots

of reading within first week after cataract
surgery. The rapid changes in the size of
pupils can result in IOL sticking to it. Bit it is
ok to watch TV at a distance. Is this
correct?

Reply

dora parker says:

I had cataract surgery and everything was

good and seeing good. went back to the
doctor and she said she would do a yag
lazer on the eye and thats all you would
ever have to do. after doing it i now see
hugh starburst whenever car lights or other
lights hit it. what went wrong? the doctor
said there is nothing she can do about it.

Reply

Jahantab says:

What could be the reason if blood comes

out during laser operated cataract eye
surgery?

Reply

don says:

I recently had cataract surgery in left eye

and now i can see the rim of the new lens
as a dark curvy image,this is very
uncomfortable and irritating: my question
can the lens be taken back out and
replaced with another one?

Reply

‫ٮﺎء‬# ‫ ﻫ‬says:

thaaaaaaaaaaaaaaanks

Reply

Tracie says:

My mum has just had her cataract on her

first eye today, but they took out her old
lens but could not put a new one in. She
therefore has to wait 2 weeks and go back
to outpatients to see the consultant. Does
anyone know why they could not put a new
lens in? and why would she have to wait for
2 weeks?

Reply

Keith Harris says:

Hi

Due to a severe blow to the side of my

head, the left eye lens is almost detached
and wobbly. The surgeon says there is a
high risk that the lens will fall back into the
eye on attempted removal for replacement
with a lens implant as at present the ‘bag’
behind the lens is falling over the upper
edge of the lens.

Although I can ‘see’ with the eye, vision is

extremely poor and out of sync with the
other eye.

I am told that vision with this eye will never

be as good as before the accident.

What are the risks in this type of surgery?

Kind regards
Keith Harris
editor
newsmedianews.com

Reply

A K TEO says:

Your article is very informative. Thanks for

the good works.

In the cataract surgery procedure, a small

top part of the anterior was ripped or tear to
get access into the len itself. After the IOL
was injected and placed firmly inside the
capsule, what happen to the ripped part?
Would it grow or heal back again to cover
the len?

Thanks.

A K Teo
Singapore

Reply

lorraine z says:

i had cataract surgery 4 weeks ago. there

was a complication due to the cornea being
soft. i had stitches, but, i was always
myopic and now, i can see very clearly near,
but far objects are distorted (unable to
focus clearly) the surgeon says it is
astigmatism, WHICH I NEVER HAD
BEFORE! What am I to do before he does
the right eye when i cannot see out of the
left?

Reply

sondos says:

I am a medical student, in my 4th year

this topic helped me so much in my finals
I love ophthalmology more and moreee :))

Reply

suhanyah says:

wonderful guide.
Would like u to put some clips on SICS for
the benefit of us in the third world.
Exceptional guide for trainees

Reply

FRANK says:

On my lens implant card s there are two

numbers used in the power identification
part. Right has 22.0 D and left has a 21.5 D .
What do these numbers mean?

Reply

Bonnie Henson says:

First surgery with Starr implant on distance

lens for monovision resulted in 20/20 the
day after surgery, but the lens vaulted a
month later (an unusual outcome, I’m told),
which meant wearing a -1.25 strength
contact lens to be able to see clearly.
During second surgery three months later, a
different surgeon rotated the Starr lens
nearly 360 degrees to correct the vaulting
problem. It didn’t. Now he wants to perform
YAG Laser on capsule so lens will “relax.”
However, I fear complications (such as later
retinal detachment). The options? YAG laser
or wearing a -1.0 soft contact the rest of my
life to correct to 20/20. (The latter doesn’t
put me off, since I’ve worn contacts for
many years with no problems.) Seeking
input from other professionals about these
two options.

Reply

Sophie says:

Hi Dr. Root!

I’m a final year med student from Germany,

and after already using your brilliant site to
study for my ophtho exam a few years
back, I’m now returning to revise for my
state exams. Your humorous approach to
education is truly refreshing between
reading so many dry books. Thank you for
that, I wish there were more professors like
you.

Here are some things I noticed when

reading this chapter, for your consideration:
“The lens can even use it’s mighty-
morphing transformer powers to change
shape and thus it’s focusing power!”
– I’m not a native speaker, but I’m fairly sure
it should be ‘its’ both times – not ‘it’s’! I’m a
grammar nerd, okay.

You name the nuclear cataract as the most

common form – in my German book it’s
only second place (with ~30% of cases)
after the cortical cataract (~50% of cases
in the senile category). Maybe this differs in
different populations?!

Many thanks for your hard work,

Sophie

Reply

patient says:

hello…i was diognized with coates disease

at the age of 4 in my left eye and had
already loss my vision completely in that
eye.years after cataract developed on that
eye…it has been almost 12 years now the
cataract is mature…my doctor never
wanted to remove it because he thought my
eye would become dry…bt before 4-5
months ago i had convinced him to operate
to remove the cataract..bt during the
surgery he said that the cataract is too hard
and would need to use cutter that can
damage my eye….so it was just left there…i
would like to know if something could be
done…is performing surgery to that eye can
damage it…or maybe i should consult some
more experienced doctor…and what will
happen if i let the cataract unremoved…any
kind of suggestion would be helpful..thank
you

Reply

Karl Katterjohn says:

I had cataract surgery (simple IOL) with

corneal loosening for astigmatism
yesterday. I had a bleeder in the anterior
chamber. The bleeding appears to have
stopped and there is no apparent increase
in interocular pressure. Today it was 12.
How common is this situation and what are
the percentages for a positive outcome. I
am now taking Besivance, Prednisolone and
Ketorolac drops in the affected eye. The
surgeon appears competent and performs
over 75 cataracts surgeries per month. I do
have severe myopia (-11)

Reply

Helenea Dennis says:

Enjoyed this article as well as the different

scenarios, it is helping me to learn.
I had a cataract removed earlier this month,
I am 54, this was the result of an horse
related injury to this eye years ago.
My vision is worse and was told that the
zonule fibers are weak and unable to
sustain the lense and being fitted for a
contact.
In reading over this information as well as
being a Medical Massage Therapist, I am
wondering what I can do to help my eye
strenghten. I look at muscles in a different
way and understand their healing. Have
added eye exercises (I just found this out
yesterday) working acupuncuture points,
added larger doses of Magnesuim as well
as a repair tendon/ligament formula
(Chinese formula) to see if this would help
to strengthen the fibrillin.
It is so close to the surgery my Doctor, who
is amazing, said there may be a possibility
of it strengthening.
Any other suggestions? I feel very fortunate
that if worse comes to worse, I can resort to
a contact.
I am thrilled and awed at this procedure and
the human body.
Thank You,
H. Dennis.

Reply

Sharon Nelson says:

I had catarac surgery and crystal lens

implanted. It has been nearly 3 mos now
but I continue to see some colors
differently. I was a decorator, wardrobe
consultant prior and I KNOW colors.
However, now some of the same things I
KNEW (and everyone else knows) are black,
look navy blue. Also, some colors look plum
when, in fact, they are actually gray or
charcoal. Have you heard of this and will it
correct itself or is there any way to fix it?

Reply

Rodney Whitworth says:

Sharon,
Colors are a subjective phenomena. Not all
people see the same shade of a color or
even the same color when they look at an
object. Having been a decorator you must
have come across what seemed to be
terrible color schemes to you, but not the
your clients who were not seeing the same
colors you.
There are some physical characteristics of
the human body that are exactly the same
with all humans but color vision is not one
of them. As we age the crystalline lens
turns yellowish. After your operation you
are seeing through the same eyes as a child
and the colors are enhanced. A simple test
for you take is to look at the blue flame of a
gas fire and you will see a purple haze
around it which you may never have seen
before but has always been there.

Reply

Julian ketcher says:

Hi there,
I am a 40 year old man. Some 10 or so
years ago I had a trauma to my right eye,
this led to a detached retina.
The treatment originally was stitching the
retina back in place, this didn’t work so the
next treatment was ‘posturing’ with a gas
bubble in the eyeball. This too was
unsuccessful and the final treatment was to
remove the viscous fluid and replace it with
a heavier fluid which held the retina in place
while it healed.
This appeared to be successful but the
liquid led to a cataract being formed.
I had a lens replacement. It seems to be a
fixed focus, mid range. In a dark room with
a light source behind the person I am
talking to, the lens can appear to be
reflecting light and shimmering.
The vision in my left eye is perfect.
My iris in the right eye doesn’t seem to
change size when bright light is introduced.
Is a fixed iris the result of the lens
replacement? Am I more susceptible to
bright lights? Is this a medical fact or is it
dependent on aftercare and treatment?
Many thanks in advance

Reply

jweston says:

Great Site! Very helpful for my MS3

ophthalmology rotation. Thank you for
making it available online for free.

Reply

charlotte lee says:

Hi, Had caataract surgery about 6 years

ago with no problems. Drove to CA and
when I went through two tunnels, I thought
the lights were out in them because I could
not see even the car in front of me, Thank
God that the tunnel wasn’t that long. Is this
common with implanted lens or were the
lights really off?
If it is my eyes, don’t know how I can drive
long distances again for fear of this
happening again.

Thank you very much

Charlotte

Tim Root: Charlotte, your experience does

not sound like a cataract or lens issue, but
rather a slowness of dark adaptation. This
could be a normal aging change, or could
be the sign of retinal problems. For
example, I often hear this complaint from
people with macular degeneration. I
recommend seeing your eye doctor to look
into this.

Reply

Butch says:

I had a lens implant put in in January. Then

a month later my retina detached. Retina
surgeon said the implant was loose and I
was wondering if this could have caused my
retina to detach.

Reply

HfredZ says:

There is some thought as to adding a post-

op topical NSAID (ketorolac) esp with
diabetics to reduce the possibility of
CME…?

Reply

Gemma Hughes says:

Hi,

My 15 month old son has just been

diagnosed with ectopia lentis in both eyes
which he has had since birth. He doesn’t
seem to have any other symptoms which
would indicate any syndrome but he is
currently being checked. The doctor has
referred him to have regular checks, is it
more than likely that he will need surgery to
remove the dislocated lense and to put an
artificial one in? If so what ramifications
does this have? Will he still need glasses or
contacts? Will he be able to play sport and
in particular contact sport if he wishes
when he is older? Or will we have to sit him
out of sport????
His lenses are currently too high, what will
he be seeing? He doesn’t seem to have
much of a problem with his sight but he is
too young to tell. When he does have
surgery, will that be it, or will he be having
monthly checks for the rest of his life?

Reply

CarolLynn Williams says:

In the 3rd paragraph, there is a typo:

Psudophakic…

…which should be Pseudophakic.

Reply

sultana razia says:

hi, i m 36 years old, i m remothoid artritis

patient. i was take joint injection take
deltason medicine oral. six months i was
not seeing anything clear, doctor said i
need facco surjery, my present vision is
6/12, after 8/12 then i will ready to surjery
,now continue giving eye drops . plz tell me
what lens i will take both two distance lens
or only far distance lens or both. when i will
do my surjery, plz tell me what should i do.

Reply

Margaret Haze says:

My accommodating lens failed–I had 20/20

for 4 weeks and then in dropped to 20/60.
Went to another specialist and he talked
about piggybacking another lens on. What
would be the success of this?

Reply

J. Tinelli says:

I ad cataract surgery on my right eye five

months ago and had a ReStor lens
implanted. I have had difficulty since with
stinging in the eye and aching around the
eye socket. I have been to several
ophthomalogists but none can suggest
anything but eye drops which do help with
the stinging but not the pain on the outer
edge of the socket. Any ideas what can be
done? Could the wrong size lens have been
implanted?

Reply

Ray says:

Not allergic to drops by any chance.

Reply

rose says:

Hi your book is very educative .am an

ophthalmic nurse. I want to know the post
operative management and complications
after surgery. Thanks hope to hear from you

Reply

Bill says:

I recently had cataract surgery on my right

eye. They put in a crystal lens.
It’s been several weeks now and although I
can see up close I cannot see in the
distance. My doctor told me that the crystal
lens moved forward and they will now have
to do lasik.
I don’t understand how the crystal lens can
move forward if it is been embedded in my
eye.
Should I go to another optometrist for
another opinion?

Reply

Julie. says:

Hello, my 1 year old grandson has ectopia

lentis both eyes, his pupils are also
misaligned. He is to have lens replacement,
how often will he require this as he grows?
and how will he accomodate if zonules are
‘snapped/weak? He has had blood tests to
confirm or rule out Marfans or other cause
but not had results yet. He is bright knows
what things are and if instructed to pick up
say, ball he will crawl to it and pick it up. he
is able to see the tiniest things and watches
tv and recognises people no problems. My
daughter had obstetric cholestasis during
her pregnancy and traumatic forceps
delivery could this have any bearing? Any
information you have would be greatly
appreciated, thankyou Julie.

Reply

Amir Nasser says:

Hello,I am 70.I had cataract removed and

they put Lens.But still I need long sight pair
of glasses.Could I have second surgery to
get lens that does not need long sight
glasses.
Thank You.
Amir

Reply

sthembile says:

Hi. i would like to ask. my brother had an

eye operation 12 years back and now he
says the eye does not see. i would like to
know if is it possible for him to do another
eye operation so that the eye can work
again. Im so hurt about this im worried
about this thing.

Reply

Jenny says:

Hello, my 65 year old mum had successful

cataract surgery 3 years ago on both eyes;
she had severe myopia and astigmatism.
Recently one of the replacement lenses
came loose and has been floating around in
her eye. The surgeon told her that, due to
her severe eye conditions, he cannot redo
the surgery and the only option is to
remove the lens altogether without
replacing it. Will she be able to see
afterwards? I’m worried about her. Thanks!

Reply

WillfromSF says:

I am 67 and had cataract surgery three

weeks ago on my left eye. Before that I was
very very nearsighted, corrected by
glasses. I chose the lens to see distant
objects clearly. Although my vision at long
distances is fairly clear there is no distance
where I see text as clearly as with my right
corrected by glasses. And although I was
told that reading glasses will be needed
once my vision is fully stabilized I notice
that no over-the counter glasses help at all
with my reading currently. So why will they
work later since shouldn’t I be close to done
with the healing by now?

I have delayed doing my right eye as I am

concerned that my current healing is not on
track. Other problems include:
Contrast seems too sharp. It’s like I’m
looking through a lens that is too strong for
my acute nearsightedness.
Blues and whites look purplish particularly if
bright.
Too light sensitive.
I can’t focus both eyes together.
Tiny black dots moving across my vision
When looking at text – hazy, blurry,
shimmering, sometimes double image
(white text on black background.

I saw my opthamalogist last ten days ago

and she said my eye is just inflamed and
she now has me taking Prednisone drops 8
times a day.

Is something wrong and if so, how can it be

fixed.

Reply

Timothy Root, M.D. says:

@WillfromSF Will, I don’t normally answer

questions like this on my website (this is
more of a medical student teaching
project) but I’ll make a couple of
comments.

1. Blurry Vision: You’ve had one cataract

surgery, but If you haven’t been given
glasses, yet … there is no way to know
what your vision is going to be. If you
can’t see well at “any distance” than you
might have some residual astigmatism
that only glasses will fix. Here’s a trick …
punch a hole in a piece of paper, and try
looking through this pinhole around your
house. If your vision is markedly
improved, then we know that glasses will
probably get you that clarity you want.

2. Light Sensitivity: This sounds like some

residual inflammation (called iritis) as
your eye doctor described. Prednisilone
eye drops 8x a day is a LOT … indicating
that there is indeed some residual
inflammation seen on exam. This is good
… as the drops will treat it.

3. Tiny black dots: This is likely vitreous

floaters. While usually harmless, they can
be a sign of more serious problems like
an impending retinal detachment or
infection. Mention this to your doctor
(who has probably already looked in the
back of your eye to check the retina).

Ultimately, your eye condition can ONLY

be evaluated by an exam, so don’t take
this as medical advice.

Everything your telling me sounds pretty

typical, however … while most people
have excellent results, some people have
more inflammation and take longer to get
there. If your symptoms worsen suddenly
… see your doctor immediately. If you are
unsure of your eye’s progress, then get a
second opinion from another doctor in
town. Finally, hold off on the second
cataract until the first eye is to your liking.
Good luck!

Reply

WillfromSF says:

I appreciate the very useful info, Dr. Root,

as I am really perplexed (as you could tell)
about how best to manage the situation in
light of getting on with my life. Very helpful.

Reply

Kathy says:

Question: Can lens replacement surgery be

done a second time in same eye?

After having left eye with cataract/lens

replacement vision is now only 20/40. This
is dominate eye that was to be for distance.
Holding off now on second eye though it
too needs surgery. Was planning on having
that eye for reading. Now trying to figure
out what to do next.
Question is can the left eye have another
lens replacement to correct vision. Is lens
replacement a one time surgery per eye?

If I have right eye done for distance also

what is best approach ? How will the eyes
even up? Can my right eye have 20/20?

Reply

Mary Beth says:

After cataract surgery with a Technis single

focus IOL, I see a 1/4 halo with starburst to
the top left of my right eye and a 1/4 “glint”
to the bottom right at night around lights
and glare, also In the day if it is dark inside
and bright outside. It makes night driving
very distracting and I avoid it. I also
randomly see a disturbing moving pattern
of silver or grey overlapping trapezoids,
triangles? on the peripheral right side of the
implant eye. It has been 10 months since
my surgery. My doctor says the lens is
perfectly placed and that is all. Can you
help me understand why I have this
problem? It makes me want to have the IOL
removed. I was better off with the cataract.
Thank you.

Reply

jon battle says:

I’m a 58-year-old with retinal detachment

history both sides, good results, but in my
first RLE (next is postponed for the
moment) a deficiency of zonules turned up.
About 120 degrees of the arc are absent.
Surgeon went ahead and implanted anyway,
and commented that she also inserted
another component (MA68?) to help
stabilize. She rejected the capsular ring
option for fear of the whole thing falling
back into the (vitrectomied) eye. My Qs:
– Will the 120-degrees arc of ‘absent
zonules’ increase and and thus destroy the
whole thing?
– Is there any surgery that can stabilize the
new lens and substitute for deficiency of
zonules?
– I ask because having this ‘sword of
Damacles’ – it could fall to pieces any
moment – is a serious option-blocker and
potentially will cause me great harm.
?

Reply

Carol Maher says:

Yesterday I had realignment surgery for out

of position PC IOL. I am addicted to reading
on my iPhone. Could this cause more
problems with healing or possible new
slipping g out of position of the lens even
though I am focusing with the other eye
while reading? That is is the recovering eye
using the muscles to focus even if eye
closed? I’m really scared I will wreck my
eye. Drs nurse said it was ok to read on
iPhone.

Reply

Evelyn Morris says:

Hello, I had A Yag laser procedure done

3days ago,since then I am experiencing
what appears to be a membrane causing a
momentry blurry vision, I have a few
floaters also,but was told this was
normal.Do you think this should be reported
to my Opthalmologist?.

Reply

Ann Windchy says:

I am allergic to PMMA liquid and powder

mixture when it gets on my skin. I also can
not wear the silicone nose pads as I get
extremely red areas under them and I know
it is an allergy also. What kind of lens
should I have for my cataract surgery? I also
have astigmatism. I have been advised to
get laser surgery in conjunction with the
cataract surgery. Is it a good idea to do
both at the same time. Can you do one
first? then the other. What complications
can I expect.

Reply

anil says:

sir… i am having a black spot on my eye

lens…… at the time of seeing it will in front
of my eye lens…….. it is disturbing a lot to
me-……. so please give any solution

Reply

jon battle says:

– patient’s remark to Jnnny’s query re her

65-yo ‘mum’ (usage important –
presumably a Brit)…
– you have not listed and obviously cannot
list all the details on a site like this, but a
couple of things are clear:
(i) You need a second opinion. Is your mum
going to Moorfields? Private health?
Discuss with GP. Unfortunately in the UK, if
you are already seeing specialists not in
Moorfields, it is difficult to get into
Moorfields. But try. And you might get a
consultation with the best Private Health
surgeon you can find. Good luck – 200
pounds for a half-hour chat. BTW from my
own long and at times unhappy – but finally
good – experience with NHS eye-surgery
staff they have been over the entire range
from (a) incompetent to (b) world-best. So
you need to find (b).
(ii) you need to become ‘your own expert’,
so do lots of googling, esp surgeons’ blogs.
(iii) how good is the fellow eye? Your mum’s
overall quality of life over the next 10 years
is paramount. At one extreme, 2 years of
‘surgery-and-recup’ misery is bad. On the
other, 10 years of bad-vision misery is
worse.
(iv) To answer the q of aphakic vision – in
principle obviously this is possible with
thick spex as was the standard of practice
until the 60s when IOLs became universally
accepted. But in your mum’s specific case,
whether that is an acceptable solution, only
you and your mum, with expert help of a
specialist, can determine.
(v) Good luck.

Reply

Ginny says:

Why would I get sunglasses effect in my

eye. It usually happens in the morning as I
am awakening. It appears that I have
sunglasses on, but just one eye? I have ask
my eye specialist about this, but he doesn’t
seem to have an answer.

Reply

ROXy wall says:

I had a hard fall on my bottom yesterday 4

weeks after my catarac surgery i am 63 i
am not seeing as well in that eye today and
wondering if the fall is the reason ? i have
no pain just blur & some double vision with
reading i am not sure if it started before or
after the fall my vision was 20/20 and clear
until the last couple of days THANK YOU
SO MUCH IHOPE TO HEAR FROM YOU!
ROXY

Reply

Timothy Root, M.D. says:

Roxy wall, you need to see your cataract

surgeon to look at your eye. There are many
reasons … both from your surgery and
neurologically … why you might have
double vision. Call your eye surgeon.

Reply

sam dodd says:

i had cataract removed but no lens was

placed by surgeon.
he said i had missing zonules.
what can i do

Reply

Paul says:

After 3 detached retinas in the last 10

months, I have an Aphakik eye. My surgeon
is a truly Great Man, well respected and
knowledgeable.

However I would like to know what the new

implant is made from. The proposed new
 lens is from Alcon Labs. Acrylsof. I have
read the information from the manufacturer
and the clinical trails and it says safety is
“reasonable” for three years. I have asked
for a sample to get it analysed to see if any
of the ingredients may cause me problems,
but have come to a complete dead end. My
surgeon just says he has had no problems
in 15 years. Alcon wont even answer my
mails.

If I buy a tin a baked beans then the

ingredients are on the side! Am I being
unreasonable in asking for the safety of an
implant? Am I the only one? Any
constructive comments gratefully received.

Reply

Timothy Root, M.D. says:

Paul,
The implants we use (I also use the Alcon
lenses) are made of an acrylic plastic that
has been in use for decades. I’ve never
had a patient have a reaction to the
material and have never heard of
ANYONE having a reaction to this kind of
plastic. Because of this, eye doctors
don’t routinely discuss this possibility
with their patients. There are so many
OTHER things that could go wrong with a
cataract surgery … the implant “material”
is the aspect you should be LEAST
worried about. With prior retinal
detachment, you are at higher risk for
lens dislocation, zonular dehiscence, re-
detachment, capsular insufficiency,
macular edema, corneal edema … you
get the idea.

I searched around Alcon’s website, and

found a PDF with some more data on the
implants in question:
http://www.alconsurgical.com/pdfs/TOR2
40-DFU.pdf

Finally, I can see why your surgeon was

hesitant to give you a “sample” … we
don’t have “samples” to give out. These
things are packaged in sterile boxes and
somewhat expensive. The surgery center
or hospital “owns” the hardware and if
your doctor doesn’t own the center … he
can’t walk over and grab one. Even then,
he wouldn’t be able to get your medical
insurance to cover the loss. Finally, I’m
not sure what kind of testing you could
even perform with such a small piece of
plastic … it would fly off your finger if you
breathed hard.

Good luck with your surgery!

Reply

mark says:

Hi all. My son had a cataract surgery when

he was 5 months. And At his 8 yrs old we
decided to put a lenses to help him with
vision and by not wearing thick eye glasses.
But After Lense implant Doctor cleared
many scar Tissue on my sons eye before
implant was succesfully done. He had been
prescribed with Prednisolone Acetate 1.0%
and Ketorolac Tromethamine Opthalmic
solution. And when they check the pressure
of the eye it was high and prescribed with 2
new drops. and on the 2nd month to
present he was still getting the 4 drops and
pressure still didnt drop to normal eye
pressure. I wanna know why my sons eye
pressure didnt drop at all was the anti
inflammatory drops are causing them not to
make my sons eye pressure drop? and i
read some articles that u cant use the 2
drops for more than a month. please give
me idea on what should i know about.
Thnks

Reply

john waters says:

4/8/14
Hello, hopefully someone can help!
Due to accident have been blind in left eye
for 17 yrs. but 6 months ago a catatract
developed in right eye and soon thereafter
started loosing all vision bothclose and far.

Had Cataract Surgery 4/3/14 and right after

vision was 99% both near & far next day Dr.
said all lookks great and i was suprised i
could see so well and was happy, i only had
slight light sensetivity to headlights during
day and all stop lights till i got up close.

Sat 3rd day after, got up and noticed stuff

was fuzzy on walls and on TV i could no
more make out small letters and faces were
also messed up unless a close-upshot, then
i drove and noticed that all road/street signs
were un-readable unless i got right next to
them, no matter how large they were.

Sunday am i called Dr and explained that in

2 days all went bad and my distance vision
was the worst prob. since anything further
than 4 feet was unfocused, i had a distance
lens put in 21.0D but thought something
was wrong,so she said come in Mon for
checkup (1 week early).

Later Sunday i noticed with a lot of Blinking

i could momentarily read letters in distance
and the next morning on way to Dr. i could
not make out any street signs unless i was
totally at a stop and still could not read any
above me at a light!

I had been told before surgery i would have

only close-up vision probs and would need
read classes, however for 2 days after
Surgery, i needed nothingwhen i got to Dr.
she tested my Vision and said my Close-up
had gotten better than day after Surgery,
but i explained on way down to her that all
signs were fuzzy etc…..

She said it could take 6 weeks till i was

healed from Surgery, but she did not
explain why distance Vision had got so bad
and seemed upset that i came in and told
me to calm down.

I simply dont understand why with a lens for

distance it had the opposite affect?

Could somebody explain if my probs are

normal? Thank’s

Reply

Timothy Root, M.D. says:

John, when your surgeon chooses a lens

to give you good “distance vision” there
is no way to guarantee you’ll end up
perfect. The lens calculations we use to
pick your implant are based on average
eyes, and everyone has different internal
eye anatomy. Occasionally, someone will
end up different than expected and still
need glasses for both distance AND near
vision.

Also, the implant tends to shift and settle

into its final position in the eye over
several weeks, so it is common for your
focal point to shift during this time. This
is why we don’t prescribe glasses for at
least three weeks after cataract surgeon.
Everything you have written sounds
normal … just make sure you get your eye
checked to rule out more serious
problems like infection.

Reply

Daniel says:

I just ended up watching all your video

lectures. Currently studying for my
specialty entrance exam (equivalent of the
USMLE)

amazing work you have done. thank you

very much. i wish you all the success and
hope you make it as far as you wish and
even more.

Reply

jamie says:

My daughter was born with a torn lens in

her left eye. We discovered the blindness in
that eye when she was 4 years old. After
trying several treatments, we decided to
remove the lens with hopes of getting
vision through a contact lens.
Unfortunately, we were not successful. In
her “good eye” which is not so great, she
has a “lazy, wondering eye”, and , now 15,
she is more bothered by the appearance of
this than the blind eye. So, my questions
are: 1. We have been told differing opinions
on the possibility of surgically replacing the
lens to correct the blindness, what are your
thoughts and what is the optimum age is
surgery is possible? and, 2. Can her lazy
eye be corrected by surgery and do you
feel the risk might be too great? thanks so
much!

Reply

Pat Owens says:

My father (82) recently had cataract

surgery. The doctor said he had a very
small eye. Fluid was leaking at the incision
site so they tried glue and it did not hold so
they put in two stitches. Three weeks post
op they remove one stitch and the fluid
begins to leak again. He states it was to
soon to remove the stitch. He then glued
and placed a contact lens on the eye and
states now the stitch that remains will be
there for at least another month. Do the
lens come in a size to fit your eye or are
they all the same other than the strength of
the lens. I am afraid this lens is to big and it
will not seal at all. Any comments would be
helpful.

Reply

Ankit Niranjan says:

Question- can lens replacement surgery be

done a second time in the same eye?
After having eye with cataract/lens
replacement vision is now only 20/40 and I
still need long and reading sight of glasses.
Could I have second surgery to get the lens
that doesn’t need long and reading sight
glasses.
Plz sir suggest me
Thank you

Reply

fayaz rashid says:

when are you giong to upload its video ??

Reply

joe wright says:

twenty some years ago I had cataract

surgery. I am now having trouble with that
eye. What chances are there that the lens is
going bad?

Reply

carol cooper says:

Your article was very informative, thank

you. Just one question: I have just had
cataract surgery but the diopter is different
from what was intended. Do the zonal
fibers function when a new lens is inserted
such that the diopter changes?

Reply

Manuella R Glore says:

I had cataract surgery on both eyes several

years ago. I was not given an option of
having replacement lenses. Can lenses be
instilled after cataract surgery?

Reply

Jon Battle says:

Joe Wright – you don’t elaborate what you

mean by “go bad”. See a specialist.
Presumably you already know about
capsule clouding, but if you don’t,that
would be #1 possibility, fixed with trivial
laser. Never mind the others, just see the
specialist.

Reply

Lanod says:

I love the book – and I am jealous of your

many talents!!

On cataract surgery, for local anesthesia,

you say “We can also perform a retrobulbar
block by injecting lidocaine/bupivicane into
the retrobulbar muscle cone”.
Is it true to say that the retrobulbar block
procedure is no longer encouraged and
now a subtenon block is much preferred as
this have been proved to be safer?

Reply

Lynn Burkhart says:

You are to be commended for your talking

your time to educate both students and the
public. In today’s world, it is uncommon for
a professional to publish an easily readable
text on this normally esoteric subject.

Indeed, as I talked to a doctor who was

interviewing me for cataract surgery, I had
asked several questions which led him to
get up and walk away, referring me to the
young lady who was his assistant. He
described the surgery several times as
easy, even stating that I could within the
first year remove the lens with no problem
and change it out.

I realized if I was to feel comfortable, I’d

have to start at the basics and gain a much
better understanding of the eye
composition as well as a more in-depth
overview of the cataract procedure.

As you know, physicians generally treat

their patients from an authoritarian
viewpoint and my experience was quite
negative. I started a technology company
where we manufactured several types of
hydrogels for use in various industries,
having PhDs in polymer science working for
me.

Although I am retired now, I can say I’ve

never treated staff nor customers with a
demeaning attitude. Frankly, it’s offending
and speaks negatively of the persons
character.

I find your writing quite helpful, and speaks

quite well of your professionalism. Thanks!

Reply

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