Cataract

Technical side

Cataract surgery

The lens becomes opaque with age.  In France, the average age of people having cataract procedures is about 72 years old, but it is not uncommon to treat cataracts from the age of 40. In such cases, the cataract is often related to an identified ocular cause (glaucoma, retinal detachment,...) or a general cause, metabolic disorders (diabetes, phosphocalcic dysfunction...), or a trauma, or drugs (corticosteroids) or toxins (UV rays, sun, smoking and alcohol drinking). The family history also plays a role.
Cataract surgery is the most common surgery procedure in France with nearly 700,000 cases each year.

Symptoms are variable and multiple and range from vision reduction to discomfort when driving at night, to glare, decreased perception of contrasts or double vision... The symptoms depend on the type of cataract, that can be nuclear (central), peripheral (cortical), posterior (subcapsular) or mixed.

The assessment

The assessment includes visual acuity tests, intraocular pressure measurement and a clinical examination using a slit lamp.
A review of the retina and optic nerve, both clinical and with an OCT test if necessary, allows a prognosis for visual recovery. It is generally good if the other structures of the eye are properly functional.
A corneal topography completes this assessment in the case of associated astigmatism, which can be corrected at the same time.

Indeed today, the very accurate surgical techniques for microincisions of less than 1.8 mm (MICS for Micro Incision Cataract Surgery), allow predictability of the postoperative refractive outcomes. Improvement of the refractive status may be offered to the patient who, during the cataract surgery, will be freed from their myopia, hyperopia, or astigmatism, or even their presbyopia for a better vision, but also to significantly reduce their dependence on glass wearing.
From curative, cataract surgery has now become a refractive surgery that not only treats the disorder, but brings better vision than before and without glasses.

The calculation of the implant power is paramount in this case and uses sophisticated optical biometric tests with a precision of less than 0.50 diopters, in most cases.
Specific online calculators are also available to surgeons for Premium cataract surgery with toric or multifocal implants (Intra Ocular Lens, IOL) with complex mathematical power calculations and use many specific settings

Surgical procedure

It is usually performed as an outpatient procedure under local anaesthetic with topical eye drops. It usually lasts less than 10 minutes and is painless. The standard technique remains phacoemulsification of the lens by MICS, i.e. by1.8 mm microincision. An ultrasound probe will emulsify the lens, which is then sucked up The lens bag is left in place and serves as a support for the replacement artificial lens called an "IOL", Intra Ocular Lens. There is no need for stitches as the microincision is self-sealing.
A cover or a bandage is generally placed on the eye until the next day.

The eye can sometimes feel "itch" in the first hours post-surgery but there is usually no postoperative pain.

Eye drops are always prescribed for 2 to 4 weeks, depending on the case.

Visual recovery is usually very fast with good vision as soon as the next day. If necessary, additional glasses may be prescribed three weeks later.

All risk of trauma to the operated eye should be avoided in the following month, as well as any risk of infection; it is therefore advised to avoid activities in dirty environments, swimming, makeup...

Intra ocular lens

The introduction of intraocular lens (IOL) in the 1980s marked a radical change in cataract surgery. Since 2005, amazing technological advances associated with new microincision technologies have paved the way for predictable, precise and refractive surgery.
In France, these IOL are now made of acrylic, whether hydrophilic or hydrophobic. They all have UV filters and some of them also have more or less powerful blue light filters.

Today, it is possible to get rid of any optical correction after cataract surgery, both for distance and near vision.

Intra Ocular Lens are divided into three broad categories:

  1. Standard IOL:

    They are monofocal but very high technology. Usually calculated for distance vision, they offer remarkable visual comfort thanks to high-precision aspheric optics; these are either "aberration free aspheric" or "negative aspheric" optics so as to compensate for physiological corneal aberrations.
    There are no contraindications to these IOLs and they can be implanted into any eye, regardless of the state of the retina or the optic nerve.
    Glasses correction is necessary most of the time for near vision and intermediate vision.

    The costs of these implants are fully covered by the French social security as part of cataract surgery.
     

  2. Toric IOL:

    They are used in the treatment of corneal astigmatism, by compensating it, and implanted at the same time as cataract surgery. Once reserved for severe astigmatism, they can now be offered for astigmatisms starting from 0.50 diopters. This brings clear vision to astigmatic patients without glasses for distance vision when these implants are monofocal, and for both distance and near vision without glasses when using toric multifocal implants.
    The surgery does not last any longer and is not more painful.
    The surgeon must simply identify the axes of your eye before the surgery and in a seated position.In order to be efficient, the implant must be positioned on a specific axis. Moreover, the calculations of power for these implants are very precise and performed by special calculators made available to the surgeon and proposed specifically by each manufacturer for its type of implant.

    Patients particularly appreciate toric implants which allow them to see better than ever without glasses, which is very comfortable.

    As part of a cataract surgery procedure, these implants are covered by the French social security on the basis of a standard implant, the cost difference is borne by the patient.
     

  3. Multifocal IOL:
    These implants allow independence from glasses because they bring good distance and near vision, but also intermediate vision for some (vision on screen at 70 cm).

    With their development and constant improvement in recent years, they have become an integral part of the treatment options offered to patients.

    Diffractive IOL are the most widely used multifocal IOLs today. They can be diffractive only or diffractive/refractive. Some are bifocal, always with a first focal point for distance vision and another dedicated either to intermediate vision or near vision. Further implants are trifocals for all three types of vision immediately. Some are also toric, allowing astigmatic patients to benefit from the advantages of multifocality. The technical specificity of these implants results in specific indications, based on the eye and patient's expectations.

    These implants can only be offered to patients who do not have any eye disease as this technology is based on light separation onto different focal points. The need for an underlying healthy and functional anatomical system is easily understood and this is necessary to get optimal visual outcomes.

    The preoperative assessment often includes a retinal examination by OCT and always includes a high precision optical biometry to determine the implant power.

    These implants are very efficient. However, they can have some moderate side effects due to their design, mainly halos in night vision. Car headlights or streetlamps can cause these night halos. This discomfort usually disappears within a few weeks and the patient can drive normally.
    Near and intermediate visions are good with adequate lighting conditions because light distribution on these focal points is lower than that distributed for distance vision.

    The implantation of these multifocal IOLs is part of a phacorefractive surgery approach and for this reason, an accurate, thorough and comprehensive assessment is needed to get the right indication for the right outcome. It should be noted that not all patients are eligible for this type of implant and if you are not eligible, your surgeon will explain why.

    As part of cataract surgery, these implants are covered by the French social security on the basis of a standard implant, the cost difference is borne by the patient.

Risks of cataract surgery

This widely performed surgery is very safe, but as with any procedure surgical, there may be risks.
Your surgeon will give you a specific and complete information sheet drafted by the learned ophthalmology societies, SFO (Société Française d'Ophtalmologie) and SAFIR (Société de l'Association Française des Implants et de la Chirurgie Réfractive).
The risk of infection is rare, less than one in 5,000 procedures, but it can be potentially serious. The infection can be contracted during and after the procedure due to saprophytic germs, i.e. germs usually present in the eye and skin conjunctiva despite aseptic precautions and postoperative drops.
The main risk of surgical complications is capsule rupture - one to two in 1,000 procedures - and may postpone placement of the implant in a second surgery procedure, after a posterior vitrectomy. In this case, the use of a standard implant is recommended.
In males, some medications for the prostate may cause incorrect dilation of the iris, in which case the surgical technique needs to be tailored.
Retinal detachment is a rare complication, facilitated by severe myopia.
Finally, macular edema can occur within a few weeks of surgery but this generally disappear in a few weeks with medical treatment.

A secondary cataract is a very common and benign phenomenon. It is characterized by clouding of the capsular bag left in place to receive the implant. Opacification occurs within a time-frame of 18 to 36 months in general, and all the more quickly when the subject is young. A simple outpatient treatment with Yag laser brings immediate and painless vision recovery.

Clear lens surgery

This is the same as cataract surgery. It can be considered before the cataract on the lens has progressed too much, as part of presbyopia or severe ametropia surgery.
It is indicated for patients from 55 years old and who are not eligible for other types of surgery.
It is an efficient surgery with the same outcomes and risks as cataract surgery.
You will be given a specific and complete information sheet drafted by the learned ophthalmology societies, SFO and SAFIR.
This surgery has sustained effect over time, it is permanent. The patient will not develop another cataract in the future since the natural lens has been removed.

In this context, lens surgery is not covered by the French social security and you will receive an adequate cost estimation.