What exactly is a cataract?
The human lens in the eye is normally crystal clear, but when it becomes opaque, we call it a 'cataract'. A cataract is NOT a film or growth that occurs in the eye. It is simply a cloudy lens. As the opacity worsens, it prevents light from properly focusing on the retina, the light sensitive tissue lining the back of the eye. Early lens changes or opacities may not disturb vision significantly. But as the lens continues to change, the vision becomes blurred and the person notices glare, haziness, and difficulty with seeing street signs or reading, for example.

The cornea is the clear dome of tissue at the front of the eye that helps focus light (contact lenses sit on the cornea). The lens is located behind the iris, the blue, green, or brown part of the eye. The lens has three parts: the capsule, the cortex, and the nucleus. All parts of the lens are normally clear.

What are the types of cataracts?
There are different types of opacities that cause cataracts. Each is described by its location within the lens. The most common type of cataract is the one associated with aging: the nuclear cataract. Often, patients have features of more than one type.

A nuclear cataract occurs in the center of the lens. Common symptoms include blurring or dimming of your vision, glare and visual distortion. A nuclear cataract makes the vision seem dimmer and patients typically feel that they need to use strong lights in order to read books or magazines. Everyone starts getting early nuclear cataract changes in their 50s and this may contribute to the need for reading glasses or bifocals.

Nuclear-Overall cloudiness of the lens         
A cortical cataract begins as wedge-shaped opacities in the cortex of the lens, much like spokes on the wheel of a bicycle. The spokes extend from the outside of the lens to the center. When the spokes reach the center, they interfere with the transmission of light and cause glare and haziness to the vision. A cortical cataract typically develops slowly, but it may impair both distance and near vision so significantly that surgery may be indicated at a relatively early stage.

Cortical-Spokes of opacities
A subcapsular cataract develops slowly and starts as a small grain-like opacity under the capsule, usually at the back of the lens. Significant visual symptoms may not appear until the cataract is well developed. Typical symptoms are glare and blur. A subcapsular cataract is often found in people with diabetes or high levels of myopia, and in people taking steroids.

Subcapsular -Central grainy opacities                  

 What are the symptoms of cataracts?

• Blurry or hazy vision, or dim vision that requires brighter lights in order to read small print
• Increased glare and sensitivity to light, especially in bright sunlight or while driving at night
• A yellowing of the vision
• Increased nearsightedness, requiring frequent changes in your glasses prescription
• Distortion, double images, or ghosting of the vision

Blurring of the Vision	Glare and Light Sensitivity	Yellowing of the Vision
Ghosting / Double Vision	Clear Vision After Cataract Surgery

Who gets cataracts?
Like gray hair, cataracts are basically unavoidable. For most people, cataracts in the form of slight lens opacities start to develop in their 50s and surgery is typically performed in their 50s, 60s, and 70s. For nearly all patients, the cataracts are related to age, lifetime sun exposure, and genetics. In the other patients, the cataract may be related to diabetes, steroid use (for asthma, allergies, or immune problems), or trauma. Cataracts are a leading cause of blindness but, fortunately, cataracts are easily treated and cured. Everyone who lives long enough will end up having cataract surgery, and this explains why it is the number one surgery performed in the USA, with about 3 million performed last year.

How are cataracts diagnosed and treated?
You'll need to have a thorough examination of your eyes, including dilation and an attempt at a new glasses prescription. At first, a change in your eyeglass prescription may be all that is needed to temporarily improve your vision. When you feel that your vision affects your daily activities or your lifestyle and you desire better vision, cataract surgery should be considered. Cataracts can only be removed with surgery.

At what point do I need cataract surgery?
There is no single objective test to determine the need for cataract surgery. The final decision for cataract surgery is made by the patient and depends on how much the decreased vision from the cataract is bothersome. My patients are highly intelligent and informed patients, and I prefer to explain their current status in plain English, and have them make their own decisions. Doing cataract surgery at an earlier stage makes for a quicker recovery and a technically easier surgery. Waiting until the vision is very poor can often make the surgery and the recovery more involved. Cataract surgery is an elective surgery and it's up to the patient to decide when to undergo surgery. Similarly, refractive lens surgery is scheduled when the patient would like better vision and less dependence on glasses.

The California Department of Motor Vehicles requires that drivers have 20/40 vision (with or without glasses) in their better eye to qualify for a license. Some patients choose to wait until their vision is approximately at this 20/40 level. However, many active patients who still work, drive, and use computers have higher demands for their vision. These patients tend to choose surgery at an earlier stage.

Some patients choose to have surgery even before they develop vision-blocking cataracts. For these patients, who are typically in their 50s, refractive lens surgery is performed in order to eliminate or reduce the need for glasses and to regain their near vision. With their astigmatism managed and a multi-focal lens implanted, the vast majority (92% in the official FDA study) of these patients see well at distance, intermediate, and near, and they never or just occasionally use glasses. The remaining 8% also saw quite well, but they used glasses more than just occasionally.

The bottom line is: If you're happy with your vision and it doesn't cause difficulties with reading, computer use, driving, working, or your active lifestyle, then you should postpone the surgery. If you want and need better vision for your activities right now, and would like to see more clearly, then schedule the surgery. They're your eyes, and you decide what's best.

How is cataract surgery performed?
Cataract surgery is a way to replace the cloudy lens with a crystal clear lens, thereby restoring vision. In modern techniques, the posterior capsule of the natural lens is left in place to support the man-made replacement lens that is implanted at the time of surgery.

There are three different ways of performing this surgery:

• In extracapsular surgery the nucleus of the lens is taken out in one piece through a very large incision, and the softer parts of the lens are then aspirated. The man-made lens is then placed in the eye. This technique always requires many sutures (about 10 sutures is typical), a needle injection behind the eyeball for anesthesia, significant bleeding, and months of recovery. This is the original technique of surgery that has been around for decades, and it's still performed by some ophthalmologists because it's technically easier to learn. Be warned that this type of surgery typically creates a lot of astigmatism and you may never be able to see 20/20 without powerful glasses.
  
  
• In phacoemulsification the hard nucleus is broken up by ultrasonic fragmentation (using sound waves) within the eye, and can then be aspirated. The man-made lens is then placed in the eye. This allows a somewhat smaller incision to be used. Phacoemulsification has gained in popularity in recent years, and is now a more common form of cataract removal in the United States. This procedure has been used for approximately 15-20 years, although recent advances and refinements have made it safer and more effective than previously. This is typically performed using needle-injection anesthesia, one or two sutures, and less bleeding. The recovery time until the vision stabilizes is reduced to approximately 2 months. This surgery can cause an increase in the astigmatism and may require that you wear glasses full-time to correct your vision after the surgery.
  
  
• Clear-corneal phacoemulsification is a more advanced version of the last technique mentioned. In this technique, as performed by me, no needles are used, and the painful anesthetic injection behind the eyeball is not given. Instead the eye is numbed with eye-drops and the patient is given a mild intra-venous relaxing medication by the anesthesiologist. The incision in the eye is ultra-small, approximately 1/8th of an inch or less, and it is made with an actual gem-quality diamond. This creates such a tiny and fine incision, that it is self-sealing, and no stitches are required. The man-made lens is one of the top-of-the line models that can be folded or compressed during insertion, and then opened once inside the eye. The name "clear-corneal" refers to the incision, which is made at the edge of the clear tissue named the cornea. Due to the location of this incision, there is typically no bleeding (not even one drop), and the day after the surgery, the eye won't be red at all. The recovery for this surgery is very quick, with good vision within a day or two. When combined with astigmatism management, the pre-existing astigmatism can be lessened and further post-operative astigmatism can be prevented.

So why don't all surgeons perform this Advanced Clear-Corneal method?

Cataract surgery is not an easy surgery to perform, and no surgeon is born knowing how to perform it well. The surgery is performed while the surgeon looks through an operating microscope that greatly magnifies the view of the eye. This also means that a very steady hand is important. It is easier to perform the older techniques of cataract surgery, rather than learning the newer technique. Like any other highly technical task, it requires natural talent and considerable practice, at least a few hundred surgeries. No other ophthalmologist in the Los Angeles area performs the surgery quite the same way as I do. Some eye surgeons are sharp and are able to learn some of the newer techniques. However, there are still surgeons who still perform out-dated types of surgery, and uninformed patients don't realize the difference until it's too late.