Technological advancements have made it possible for patients to undergo cataract surgery in a matter of minutes, and experience life-changing improvements in vision within 24 hours.

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BY
Francis Clark, MD
SENIOR SECTIONAL EDITOR
updated March 12, 2015
Source: http://www.docshop.com/education/vision/eye-
diseases/cataracts/technology
Technological advancements have made it possible for patients to
undergo cataract surgery in a matter of minutes, and experience life-
changing improvements in vision within 24 hours.
Cataracts are a progressive clouding of the crystalline lens, which can
eventually lead to blindness. Surgery is the only permanent solution.
The American Society of Corrective and Refractive Surgery reports that
cataract surgery is the single most commonly performed surgery in the
world, with approximately three million surgeries taking place each year
Cataract Surgery Technology

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in the United States alone. The sophisticated tools used in modern
cataract surgery make it virtually painless and incredibly effective. In
fact, most patients who undergo cataract surgery today no longer
require corrective eye wear.
By using a combination of advanced laser technology, hand-held tools,
ultrasound, and custom intraocular lenses (IOLs), I have personally
helped many patients to regain the independence and confidence that
only clear vision can provide. Patient education is essential to the
success of any surgical procedure, and if you are experiencing cataract
symptoms, or if you have been diagnosed with cataracts and are
considering surgery, it is important to understand how this technology
is used to maintain your safety and provide the best possible results.
Cataracts and the Evolution of Cataract
Surgery
The crystalline lens lies behind the cornea. It helps focus light upon the
retina at the back of the eye, which creates electrical impulses that are
carried to the brain and perceived as visual images. The lens is
responsible for approximately one third of the total focusing power of
the eye. In adults, the crystalline lens is about 10 millimeters in
diameter, about the same size as a pencil eraser.
The crystalline lens consists of water and protein. At any point in your
life - usually after age 40 - the proteins can begin to clump together,
causing vision to become clouded. While it is widely accepted that
excessive ultraviolet light exposure, trauma, and other conditions can
spur the development of cataracts, the precise cause of this condition
remains unknown. Having cataracts is often described as being similar
to looking out of a dirty window pane. The symptoms are usually
gradual. Patients describe colors as appearing slightly faded in the
earliest stages of cataracts. In later stages, vision may be limited to only
being able to distinguish between light and dark. In fact, the lens itself
becomes so clouded that it appears yellowish or milky white from the
outside.
In early stages of cataracts, you can continue to see relatively clearly by
maintaining an up-to-date glasses prescription and using ample light

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when reading. However, the condition can only be permanently
corrected by surgically removing the lens and replacing it with an IOL.
The modern approach to cataract surgery treats one eye at a time,
usually with about a month in between surgeries.
The first documented cataract
surgery took place in the 5th
Century B.C., and it involved
dislodging the lens from its
proper position, allowing it to float
freely in the vitreous cavity of the
eye. Of course, this did nothing to
restore focus. It wasn't until the
late 1700s that doctors were able
to actually remove the lens. At this time, the lens had to be removed in
one piece, and the incision followed half way around the circumference
of the cornea. Because fine sutures were still many years away,
patients had to be completely immobilized during recovery.
One of the most significant breakthroughs in cataract surgery occurred
in 1967, when Dr. Charles Kelman used ultrasound (high-frequency
sound waves) to break the lens into pieces that could be removed
through a smaller incision. Today, the femtosecond laser is often used
to initially break the lens into quadrants. Ultrasound is still used to
break the lens down further, and the standard device used to
administer the ultrasound doubles as a suction tool that removes the
pieces.
Until the late 20th Century, there was no solution for replacing the lens,
and patients had to wear especially thick glasses that afforded only
limited vision following surgery. The first IOL, developed by Dr. Harold
Ridley, gained FDA approval in 1981. Ridley treated many Royal Air
Force casualties during World War II. At that time, he noticed that when
shards of acrylic plastic from exploded aircraft cockpits became lodged
in a soldier's eye, they did not trigger rejection.
Based on this discovery, he created his first acrylic plastic IOL
prototype in 1949. This marked the beginning of an arduous fight to gain
acceptance in the medical community that would last more than 30
years. Ironically, the IOL is now one of the most commonly administered
The first documented
cataract surgery took
place in the 5th Century
B.C.

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prostheses used in medicine today - it is virtually unheard of for a
patient to undergo cataract surgery without having an IOL placed.
Ridley himself underwent IOL implantation in the 1990s, a time when
advancements in IOLs were presenting exciting new possibilities that
have made significant improvements in millions of patients' quality of
life.
Monofocal and Premium IOLs
IOLs look fundamentally similar to the natural crystalline lens - that is,
they consist of a small clear disk. However, IOLs typically have two
"arms" on opposing sides of the disk that can be contracted. Once the
IOL has been placed, the arms exert outward pressure, keeping the
device firmly in place within the eye.
The first IOLs were monofocal, correcting only distance vision.
Monofocal IOLs are still considered the standard, and are covered by
most insurance plans. Most patients who receive monofocal IOLs will
continue to use glasses for reading and other tasks requiring close
focus.
Today, there are premium multifocal IOL options that can correct near
(for reading), intermediate (computer use, watching television), and
distance vision. There are also several options in accommodating IOLs,
which move with the action of eye muscles to achieve focus at multiple
distances. If you are a candidate for a multifocal IOL, I would personally
recommend this lens to any cataract surgery patient wishing to improve
focus at multiple distances, as I find they provide consistently better
results.
If you have ever had perfect or near-perfect vision without glasses, it is
important to note that multifocal lenses will not restore that same
quality of vision. Nonetheless, they come very close, and can reduce or
eliminate a patient's need for glasses at all distances.
Connie now enjoys 20/20 vision, and

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Connie is a 60-year-old patient of mine who is experiencing tremendous
benefits after undergoing cataract surgery involving the placement of a
multifocal IOL. She had suffered with severe vision problems most of
her life.
"I haven't been able to see properly since I was 5 years old," Connie
said. "When I was offered an option to help me see normally, I was
ready to do it."
Though her vision had been a constant struggle throughout her life, the
final straw was the development of cataracts.
"My cataracts came on very quickly," Connie said. "When I went to see
Dr. Clark, he told me they had developed to a point where it was unsafe
to keep driving. Next, his assistant told me about multifocal lenses, and I
thought they were kidding me. Could something like this really be true? I
had my surgery last June, and the other eye was treated in July. The
prep time and actual procedure is nothing at all to go through. It took
about 10 minutes in all. I went in for the post-op after my second
surgery and he told me I could drive, all in a day's time."
Connie now enjoys 20/20 vision, and does not require corrective
eyewear to read or drive.
"I can't believe what I can see - shapes, colors - I'm in an amazing
world," she said.
Toric IOLs
While multifocal IOLs have made incredible changes in many of my
patients' lives, I'm also a big fan and early adopter of toric IOLs, which
are designed specifically to help patients with astigmatism. Astigmatism
occurs when the cornea is oval shaped instead of spherical, resulting in
does not require corrective eyewear to
read or drive

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blurred vision, halos, and other aberrations at all distances. The
correction that toric IOLs provide is highly accurate, and is capable of
restoring 20/20 vision for some patients. Many of my patients have
been ecstatic over the results toric lenses provide.
The Femtosecond Laser
Before the advent of the femtosecond laser in 2001, every step in
cataract surgery was performed using handheld instruments. In fact,
diamond blades are still safely and effectively used for certain
applications in many practices, including my own. Femtosecond (or
"femto") lasers are capable of delivering one quadrillion pulses of laser
light per second. In many practices, femto lasers are replacing keratome
blades as the preferred method of creating the corneal flap in LASIK eye
surgery.
Today, the femto laser can be used in four important steps of cataract
surgery:
Corneal incisions: These small incisions placed in the cornea grant
access to the lens capsule, and serve as the avenue of removal for the
clouded crystalline lens. The incisions created using the femto laser are
so precise that they require no sutures following surgery.
Capuslotomy: The crystalline lens is contained by a transparent
membrane that completely surrounds the lens. During the capsulotomy,
the femto laser is used to remove the front half of the capsule, while
leaving the back half intact, where the IOL is placed.
Breaking down the Clouded Lens: Following the capsulotomy, the femto
laser is used to soften the clouded lens. This prepares the lens for
phacoemulsification, the process of breaking the lens into four
quadrants using an ultrasound needle. The same device will
subsequently vacuum the pieces from within the eye through the
corneal incisions.
Limbal Relaxation Incisions (LRI): This optional step is used to correct
astigmatism as part of cataract surgery. LRIs can refine the shape of

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the astigmatic patient's cornea by "relaxing" the oval-like curvature to
achieve a more round shape. While certainly effective in some cases, I
have personally found that the results of LRIs are not as predictable as
those that toric lenses can provide, and I usually recommend that
patients consider a premium IOL instead.
After using the femto laser in
more than 200 procedures, I find
that it provides the very best
advantages when used to
perform the capsulotomy and the
breaking down of the lens. Every
ophthalmologist has his or her
own approach, and I actually
prefer to use a handheld tool to
create the corneal incisions. The
femto laser does not give me the
accuracy that I expect during this
crucial step, though other
surgeons may feel that they
perform better with a femto laser.
Though cataract surgery is the most common surgical procedure
performed in the world today, it is important to understand that there
are several different approaches, and it always pays to be very
discriminating when selecting surgeon. Advanced technology can
undoubtedly increase your chances of undergoing a successful
procedure with long-term benefits, but it is equally important to choose
a surgeon who has a reputation for delivering excellent results.
Technology, after all, is only as effective as the surgeon using it.
Cataract Diagnosis
While the IOL and the femtosecond laser helped make invaluable strides
in the safety and effectiveness of cataract surgery, other important
technology used in this process has remained relatively simple,
especially in the diagnostic stage. For instance, if your vision suddenly
changes - a common symptom of cataracts - your optometrist or
ophthalmologist will probably begin by administering a standard eye test
After using the femto laser
in more than 200
procedures, I find that it
provides the very best
advantages when used to
perform the capsulotomy
and the breaking down of
the lens

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involving an eye chart and a refractor. These tests will measure a
person's visual acuity and give your doctor the precise measurements
needed to aid in choosing an IOL specifically for you.
The tried-and-true tool for diagnosing cataracts and many other
conditions is the slit lamp, a device that was conceptualized in 1911, and
has continued to evolve over the years to become more accurate. The
basic concept is that the slit lamp shines a very thin sheet (or "slit") of
light into the eye, illuminating both the posterior and anterior segments
of the eye. A biomicroscope is then used to magnify this view, allowing
your ophthalmologist to fully analyze the cornea, crystalline lens, iris,
conjunctiva, and sclera. This can require the use of special eye drops to
dilate the pupils in order to maximize visibility.
When viewed using a biomicroscope and slit lamp, a lens affected by
cataracts will clearly show clouding. This one-of-a-kind view allows
your doctor to identify which stage your cataracts have reached, and
determine an appropriate course of action.
Ensuring the Highest Levels of Safety and
the Best Possible Outcomes
It is estimated that by age 80, most patients develop cataracts.
Fortunately, we are living in an era when the onset of cataracts means
anything but an end to your vision. While cataract surgery patients of
the past were fortunate to be able to achieve marginal vision following
surgery, today's patients have options that make it possible to achieve
20/20 vision.
While no one looks forward to needing cataract surgery, technology has
transformed the experience into something that is virtually painless,
takes mere minutes to complete, and can provide incredible benefits for
the rest of our lives. If you have been diagnosed with cataracts, use this
information to ask your surgeon plenty of informed questions about the
technology they use during surgery, and how these innovations are
used to ensure the best possible outcomes.
References & Resources

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Source: http://www.docshop.com/education/vision/eye-
diseases/cataracts/technology
Author: Francis Clark, MD
Publisher: DocShop