Vicky

Okay, once again, good evening, and a very warm welcome to our webinar on cataract surgery and special lenses. My name's Vicky, and I'm hosting this session. I'm delighted to be joined by our expert speaker, Mr Syed Shahid, a consultant ophthalmologist.

Tonight's session will begin with a presentation from Mr Shahid and myself, followed by a live Q&A. If you have questions at any point, please feel free to submit them using the Q&A icon at the bottom of your screen.

You're welcome to ask these questions anonymously or include your name, but just to note that the session is being recorded, so any names shared will be visible in the recording.

 to help us get through as many questions as possible, we'd please ask you to keep your questions brief.

If you're interested in booking a consultation, we'll share all of the relevant contact details at the end of this session.

So, I will now hand over to Mr Shahid to go through the presentation. Thanks, Mr Shahid.

Mr Syed Shahid

Thank you, Vicky, for the introduction. It's really a pleasure to be here and talk about cataract surgery and special lenses here at Benenden.

So, just a little bit about myself. So, I obtained my medical degree from the University of Bristol about 15 years ago.

I then completed a Masters in Clinical Ophthalmology in London.

 started my ophthalmology training, within the London deanery.

Once I'd completed my training, I did some, further advanced surgical fellowships in complex cataract surgery and, vitreoretinal surgery at Moorfields Eye Hospital.

What that means is that, apart from doing, sort of routine and complex cataract surgery, I also have expertise in complications that occur during and after cataract surgery.

As well as other retinal conditions, such as retinal detachments, macular holes, and advanced sort of diabetic retinopathy and epiretinal membranes.

I've also done a couple of years as a local consultant in Moorfields before I started my substantive post about five years ago, in East Kent.

So, we'll move on to the meat of the presentation. So, in this session, I'll talk to you about overview of cataracts and the different types of cataracts, what sort of causes a cataract and the symptoms to expect when you have a cataract.

Then we'll focus on cataract surgery here at Benenden, the work up to the surgery, and what, being here on the day actually involves.

We'll talk a little bit about the various lens options available, for your cataract surgery, and then the risks of surgery and the recovery afterwards. And we'll end by just talking a little bit about the eye unit and the consultants who work here.

So this is a cross-section of the human eye, so it's split from the side.

Can I, if you can see my pointer here, the front of the eye is covered by this transparent structure we call the cornea.

Towards the front of the eye, just behind the coloured part of the eye, which is what gives us the colour in our eye, the iris, you have the lens that sits in the eye. And then behind the lens is this large space that contains a jelly-like substance that we call the vitreous humor.

 then right at the back of the eye, you have what we call the retina, which processes the image of the eye, and then sends it via this structure called the optic nerve to the brain.

Now, just before we talk any further, you hear a lot about lens and cataract, and I just want to, just help you understand that the lens in the eye is what becomes the cataract.

It's not two separate structures, because I think sometimes patients get confused when we use these terminologies, quite interchangeably.

So, the lens, as we age, or for various other reasons, can become cloudy, and then we call it a cataract. So lens replacement surgery in adulthood, when you have a cataract, is called cataract surgery, essentially.

Now, when you look at the eye from the front, what you cannot see here is this transparent structure that covers the front of the eye, and that's the cornea that we saw in the cross-section.

The pupil is the part in the middle, so that's this bit here the lens sits behind the pupil. Again, it's because it's a cartoon image, you can't really see it, but it sits behind the pupil, essentially.

The human eye is very similar to a camera, and actually, a camera is designed on the functionality of how the human eye actually works. So, just like, the camera has a lens, we have the cornea and the lens that focuses the image onto the back of the eye.

The film of the camera is exactly the same as the retina because that's where the image falls. And again, just like the camera, you get an inverted image at the back of the eye, and then as this is processed in the brain, it's then flipped to the right orientation, so that when we see our worlds, we see it the straight way up.

Okay and it's a continuous process, and that's why when you have your eyes open, you don't have a delay where everything is black before the image is processed. It's just a continuous thing that works all the time, where the brain is able to continuously process the image that we are seeing all the time.

So, when we are younger, the lens is very nice and clear we have a clear image of our surroundings, you have bright colours and sharp edges to everything.

As the lens loses that transparency, when we get older it starts to become a little bit more opaque.

What that means is that clear lens is now starting to turn slightly yellowish, and in advance case, a little bit brownish and the first thing that happens is the brightness in our eyes reduces.

So the image is not as bright as it once was. Sometimes you need more light to see the images properly, and also you start to lose a little bit of the colour and the distinction between different structures that's when the lens is called a cataract.

There are various types of cataract, and when you see your consultant or your optometrist for an assessment of whether or not you have cataract, they will try and make a judgment of what type of cataract you have.

So, the most common type of cataract is this thing called a nuclear sclerotic cataract. And what determines what type of cataract you have?

Well, as you can see from this image here the lens is kind of like a ball-like structure. So depending on which part of the lens becomes cloudy, we determine what type of cataract you have.

So a nucleus cataract is essentially a lens that has become gradually yellowish-brown with age, and it affects the central part of the lens, and this is quite obvious when we look at your lens on the slit lamp with a dilated pupil.

A cortical cataract affects the front part of the lens, and you get these spoke-like structures, again, which are very obvious when you're dilated, and we have a look at you.

The main symptoms that a cortical cataract will give you is sort of glare, because as the light hits these spoke-like structures, it doesn't pass through like a normal lens would allow it to pass through, and the light is scattered, and so it gives you glare, particularly when you're looking at headlights or when you're looking at street lamps.

Finally, the other common type of cataract you see is something called a posterior subcapsular cataract. This type of cataract tends to affect the back part of the lens. So, again, if you can see my point is, this part of the lens it affects.

What happens with this type of cataract is your vision could be good, it could be good, and suddenly, as it encroaches a central part of the vision, your vision suddenly goes, right? It is a gradual process, but people notice that this comes on a little bit more quickly than the other types of cataracts.

Again, it scatters the light, and particularly causes trouble when you're trying to read, or when you're trying to drive at nighttime.

Finally, there's something called a polar or posterior polar cataract, and this is usually a type of cataract that you're born with. It's also called a congenital cataract.

Thankfully, when it's quite mild, it doesn't need cataract surgery in childhood, although some children do need cataract surgery as a result of this type of cataract.

But as we get older, this kind of cataract can grow, and it can start to obscure the vision more and more. And you can see from the image that it affects the central part of the lens.

You can see that's a little bit of a cloudiness right in the centre, and therefore, when it becomes more pronounced, that's the bit of the vision that we rely on for reading, for looking at detail, and so it starts to get affected.

The thing about this type of cataract is that it needs, sometimes special equipment to have to deal with, because it can cause a weakening of the support for the lens, and it may require a slightly more nuanced cataract operation, which is why we take time to determine what type of cataract you have when you see us, before we then decide on the surgery.

So, what causes cataract? Well, the most common cause for a cataract, as we can all imagine, is age, unfortunately, and there's nothing we can do about that. It's wear and tear changes that occur in the lens as we get older.

Smoking, unfortunately, affects every part of the body, and the eye is not immune to problems with smoking and can cause cataract amongst other issues within the eye.

Systemic disease such as diabetes can cause specific types of cataract, like this like the posterior subcapsular cataract that we spoke about and you may need cataract surgery slightly earlier on in life if it starts to affect your vision, in diabetes.

We spoke a little bit about congenital cataract, so it's that last image I showed you, where the cataract occurs in childhood, but if it advances as we get older, we may need to take it out.

Trauma can cause certain types of cataracts again, and these cataracts tend to come on very quickly.

It's important to tell the surgeon that you've had trauma to the eye, because this can make the cataract surgery a tiny bit more challenging, depending on the level of trauma you had, and we may need to have, again, special equipment at hand to be able to deal with cataracts as a result of trauma.

Finally, drugs can also cause cataracts, the most common of which is steroid. So, if you have if you take you've been taking steroid tablets for a long time, or if you've been having steroid drops on and off.

For various conditions in your eye, then this can cause cataract fairly quickly, and again, it's just important to tell your surgeon that you are on these types of treatment.

It's important to understand when cataract surgery is needed the really good consultants that I worked for in the past during my training.

They always say that don't try and fix something that's not broken just because you've been told you have a cataract may not mean that you need cataract surgery.

What I tell my patients is that if you x-ray everybody's knees or hips after a certain age, they will have a degree of arthritis.

But if you're not symptomatic, if you're not in pain you don't need a knee or a hip replacement, and cataracts are exactly the same. So, you may see your optician or your optometrist who may say, oh yeah, you have a cataract.

But if it's not affecting your vision, we may not need to do anything for it.

Oka so, the symptoms that cataracts cause are firstly, the colours start to dim, and as the cataract progresses, your vision might become a little bit blurry. This particularly

Causes problems when the Light is dim, so at nighttime also when you try and read. When you're driving, it may cause glare, especially with the type of headlights that we have these days. Lots of patients complain of glare when driving at night, and the first thing that happens is that, for safety reasons, they stop driving. And then you know that it's a good reason to have your cataract done.

It can also cause you to become more short-sighted as the cataract in the eye grows, and so you may need to be changing your prescription quite frequently. And finally, when the cataract is quite advanced, it can cause double vision, and it's a specific type of double vision, so if you're getting double vision with both eyes open.

That's not generally because of a cataract, and it's quite important to investigate that further.

Cataract usually causes double vision when one eye is closed, and with an eye that has a more advanced cataract, you can then get double vision.

So, I touched upon this in the previous slide, but the reasons for surgery are primarily if the cataract is affecting your daily life and your activities. So, if you like to read, if you like to watch television, and suddenly you're not able to do that, or you're having to give things up.

Because you feel that it's more of a struggle and more of a strain, then it's probably time to see your optometrist to see whether it's a reversible cause, like a cataract that's causing your visual problems.

In UK, we have certain driving standards in terms of vision, and so if you feel that driving is a problem, or if your optometrist tells you that you don't meet the standard for driving. Then that's a good reason to get cataract surgery.

Like I said before, if your glasses are changing quite frequently because a cataract is growing and changing your prescription.

It's very expensive to change your glasses every few months, and so again, your optometrist will suggest that you see a cataract surgeon to try and get your cataract done.

Finally, if it's stopping you from leading the quality of life that you always hope for in terms of your sporting hobbies, painting, reading, and as we get older, caring for grandchildren, then that might be time to see your optometrist to get referred for cataract surgery.

There are certain scenarios, from a clinical point of view, where your ophthalmologist or your optometrist might suggest that you have cataract surgery, even if it's not affecting the quality of your vision.

Certain types of glaucoma, where the lens grows and blocks off the drainage angle in the eye, can cause the pressure in the eye to go up quite significantly. And this can damage the nerve at the back of the eye, and cause you to lose vision. And therefore if you're at risk of this problem.

Your clinician might tell you that, look, it may be sensible to have cataract surgery.

When I do retinal surgery, I know that in some cases, the cataract is going to grow very rapidly after the surgery, and to spare the patient coming back in a few months to have their cataract done after the retinal operation, I may suggest we do it together, more of a more as a convenience.

Finally, if, say, for example, you're getting screening images because you have diabetes.

It may be that the cataract stops the screening service from taking good images of the back of the eye, despite the cataract not actually causing you any trouble in terms of your vision. But then they might suggest you have your cataracts done just so that they can get good quality images to monitor the progress of your condition.

It's just worth mentioning here, we all know Monet, who's, was a great French impressionist, back in, sort of, the late 1800s and the early 1900s.

So, the top image, if you can see, let me just move this out of the way for you. The top image is this, sort of depiction of the water lilies, and you can see he's got nice, vibrant colours with clear, distinct bridge, above the water.

He developed a he developed cataracts in about 1912. And over the next, sort of, 10 to 15 years, the cataract progressed quite rapidly, and you can see that in 1922, when he drew the same image.

One is the colours are very different, so everything became murky, it became cloudy, and you have warmer colours, such as yellow, red, and brown.

 he lost complete distinction of the various structures, and this happens because as the cataract advances, and you let it get to a point where your vision is affected quite significantly, you're less able to distinguish between different structures that you're looking at.

Even after his cataract surgery, I think in the 1920s, unfortunately, his vision never returned to what it was, because as you can imagine, at that time, cataract surgery was not very advanced, and they actually didn't have the ability to put a lens in the eye when they took the cataract out, so your image was out of focus.

The first lens replacement was actually done in 1940s by a gentleman called, Harold Ridley, and this was in St. Thomas' Hospital in London.

I think it's just it's quite interesting to see how the image has changed over time.

So, for the next few minutes, we'll talk about what actually happens when you come to Benenden for your cataract surgery.

So, the first appointment you have will be for what we call a pre-assessment. You'll be met by one of our lovely nurses, and they'll take a detailed sort of medical and social history from you to ensure that you're safe to have cataract surgery, and to jot down any medications that you might be on, and check things like blood pressure and stuff to make sure it's within the normal limit.

They'll check your vision, they'll check your pressure, and we more often than not do other investigations, such as take pictures of the back of the eye to make sure you have a healthy retina.

Then do something called biometry that tells us what type of lens needs to go into your eye after we take the cataract out, so you're still able to focus.

You then see the consultant eye surgeon, who will look at your eye and examine you to make sure that the cataract is, in fact, what's causing the problem with your vision, and there's nothing else that, you know, the optician might have missed, or that it might be caught might result in losing vision more rapidly than a cataract.

They'll then talk about any previous ophthalmic history that you might have, and things that are relevant are any laser surgery to correct your vision when you were younger, any trauma to your eye, or any other type of eye surgery, like squint surgery when you were a child.

They'll then talk to you about the different types of lens choices available, and we'll touch upon this in a second, and then get you to sign a consent form after discussing the risks and benefits of surgery for your eye.

So, in terms of the lens choices, so the monofocal lens is by far the most commonly used lens in the UK, and this is used for pretty much all of the NHS patients across the country even in the private sector, it's a very commonly used lens because it's a great lens that gives you very good quality of vision.

As the name suggests, it has a single focal point, and usually, we aim so that patients can see well in the distance, and then you need glasses correction for intermediate and near vision. Some patients who've been short-sighted for the majority of their life will prefer to have a focal point for near then they wear glasses for distance vision, like for driving and watching television, etc.

We'll touch upon astigmatism in a minute, but patients who have significant astigmatism might still require glasses for both distance as well as close work with monofocal lenses.

The extended depth of focus and the multifocal lenses are part of our special lens choices that are available to patients. And these are great lenses because they give you more spectacle independence.

You can have a range of vision, ranging from distance to intermediate to near vision, depending on the type of lens that you choose. And this is great for patients who want to be spectacle independent after the surgery.

They're not suitable for everybody, though, because if you have other significant eye conditions, such as significant diabetic retinopathy, glaucoma, severe dry eye, or macular problems such as macular degeneration, then you will not benefit from having this type of lens, and actually, it may degrade the quality of the image that you perceive after the surgery.

So, your surgeon, if you are interested in this type of lens, will go through a number of different things and do a full assessment of the eye to make sure that you will benefit from these type of lenses.

Finally, toric lenses. Rather than being a whole subset on its own, toric lenses can be incorporated into monofocal, as well as multifocal and extended depth of focus lenses, to correct something called astigmatism.

Now, what is astigmatism? It's quite a complex topic, but just in simple terms, if you imagine that a normal eye is like a is like a football.

Lots of patients actually don't have an eye that's entirely normal and shaped like a football. It's more a cross between a football and a rugby ball or an egg. It means that it's not fully round, it can be slightly ovalish, which means that there is different steepness, in the vertical plane compared to the horizontal plane.

Because of that, if you just put a standard monofocal or a multifocal lens, it doesn't take away that component of astigmatism, and you may still end up needing glasses. And that's why for all of the extended depth of focus and the multifocal lenses.

Your surgeon will choose a toric version of the lens if you have significant astigmatism, and if you're getting a monofocal lens.

If you don’t want glasses afterwards, you'll need to be referred to the special lens clinic, so they can then talk to you about a toric lens.

I can I can answer more questions about this in the Q&A session at the end if you'd like.

So, what happens? You've been seen by the consultant, you've been listed for surgery, and then on the day, you turn up for your cataract operation. So, when you arrive, again, you're met by one of our really lovely nurses, who will take you into our theatre suite.

You'll have drops put into your eye to dilate your pupil, they'll check your blood pressure and your blood sugar, if that's relevant.

They'll offer you some oral sedation if you're very anxious, and this can really help take the edge off your anxiety and calm your nerves.

One thing to bear in mind is that it's always good to wear comfortable clothes when you come for cataract surgery, so that you're not wearing something that's too tight, or something that's going to, you know, cause you to be a bit give you discomfort during the procedure itself.

You have a light meal, and please don't drink any alcohol on the day.

So, when the nurse has prepared you for the surgery by dilating the pupil, the consultant will come, they'll reiterate the consent, and just tell you what's going to be done, for your eye. You then go into the operating theatre, and you'll sit in something like a dentist's chair it'll slowly recline, so you're in a lying down position.

We normally make sure that you're comfortable before we start the surgery. The surgery itself takes about 10 to 15 minutes or so to do, but can sometimes take a bit longer if the cataract is a bit more challenging.

The eye is cleaned with some antiseptic, you have a little sterile drape that's placed on the eye, and this is just to keep everything nice and sterile. And then a small clip is placed in the eye to stop you from blinking, so you don't have to worry about closing your eye halfway through the procedure.

You have something called a microscope that comes down from the ceiling, and this helps the surgeon look into your eye while they're operating, and you'll have certain lights shining from the microscope that they will ask you to focus on during the surgery. You'll have a little bit of calming music to just help you through the process.

So, the various steps of the cataract surgery involve, I showed you the images before. The cataract is like a little ball. It sits in something we call a capsule, which is the skin of the cataract.

So, essentially, we make a hole in the capsule that gives us access to the cloudy lens. We then use ultrasound energy to break that lens up and take it out, and then we put a clear lens into that bag to keep it nice and secure. So it's the majority of surgery we do is without the use of any sutures, and the incisions we make are, a maximum of about 2.5 millimetres or so.

This is just a cartoon representation of what that actually involves. So, you can see there's a dilated pupil there. You've got the cloudy lens, which is the cataract.

This is the probe that delivers the ultrasound energy. It breaks up the cataract, and then you have this clear lens that goes into the eye. It's, again, it's a folded lens, and the special instruments that are used to deliver the lens into the eye.

Then, when it's in the eye, it opens up nicely, and it's nice and secure inside that bag.

In terms of the recovery, so once a cataract surgery is done, you're sat back upright, and we normally say, you know, take a couple of minutes before you get off the chair, because you're laying flat, some people get a little bit dizzy afterwards, and then you're taken into the recovery room, where another colleague talks to you about the do's and don'ts after cataract surgery, and you have a little video that it tells you about what you need to do in terms of your drops and the activities you can do afterwards.

The eye will feel a little bit gritty for about a day or so, and then start to settle down. Depending on the how the eye heals up, the vision may settle down very quickly after the surgery, so within a couple of days, but can sometimes take a week or two before it fully settles. And we say that

It can take up to four to six weeks before all the wounds heal up nicely, so just make sure that you’re gentle with the eye, don't rub your eye, try not to, put water in your eye, and just use the precautions to try and prevent any damage to the eye after the surgery.

We normally ring you at one week after the surgery to make sure the eye is settling well, and if you've chosen to have the other eye done, we'll then sort out a date for the second eye. If you have any problems, you're welcome to contact us before that, or if we pick up any issues at that one-week phone call, we'll bring you into the clinic to make sure that everything is settling okay.

So, what's very important to understand is, we've spoken about the surgery and how it can make things better for you, but obviously, being an invasive procedure, there are risks to a cataract operation, which brings me back to the fact that we should not try and fix something that's not broken.

So, if you don't have any symptoms from your cataract, when we see you in the cataract clinic, we might well tell you that you don't need anything doing. So, you know, come back to us in a year, come back to us in 18 months, when it actually starts to affect your vision.

Although cataract surgery is safe for about 90-95% of cases, the main risks that you can get during surgery are a one% chance of a breach of that bag that holds the lens. And what this means is that during the initial operation, you may not have enough support to put a new lens in the eye, and you may need further surgery.

To put a new lens in the eye and remove the remainder of the cataract.

Thankfully, in the majority of these cases, people do very well, and the vision recovers, but it just means that the visual rehabilitation takes a little bit longer, because you may need more than one procedure to have this completed.

The worst complication you can have from surgery is obviously sight loss. Thankfully.

The incidence of this is about one in 1,000 to about one in 2,000, and this is generally because of an infection in the eye from having, an invasive procedure.

And despite all the measures that we take in cleaning the eye with antiseptic, putting antibiotics into the eye, the incidents from the studies across the world have shown that it's about one in 1,000 to one in 2,000 of an infection in the eye.

There are other risks that you can have, such as inflammation inside the eye, swelling at the back of the eye, that either we will monitor for and look for, or your optician will look for after the cataract surgery, and most of these things can be dealt with an extended course of eye drops after the operation.

So finally, Eye Unit, it's a state-of-the-art unit, has excellent equipment to investigate before the surgery, and also surgical equipment in terms of giving you the best possible chance of a good cataract operation, good recovery afterwards.

We have about seven or eight experienced consultants who all undertake cataract surgery, and we all work on different days of the week. And we also have a very dedicated ophthalmic nursing team that have worked at Benenden for a while who know exactly how the cataract patient pathway works, and are usually able to answer any questions that you may have before or after the surgery.

As a result, we've been rated by the Care Quality Commission as outstanding, and there's not a lot of healthcare providers out there that get this rating from the CQC.

So, this is just, The picture of the ophthalmic consultants, and they are couple of new consultants have also started with us that you might meet if you come to our department.

We're really going to end with this slide here, and I'll be happy to take any questions that may have arise during the presentation. I'll pass you back on to Vicky.

Vicky

Thanks, Mr Shahid, that was really interesting. Okay, so let's move on to our Q&A session. We're really pleased to have so many of you join us today, and while we may not be able to answer every question, we'll do our best to cover as many as we can. So to help us get through as many as possible.

Just ask if you could keep your questions brief, and also while we're answering the questions, you can see the pricing details on the side as well.

So, first question,

Anonymous asks, I'm very short-sighted, minus eight, and need advice on what monofocal lens to choose, or whether it's better to choose a different lens for each eye.

Mr Syed Shahid

So, it's a very good question. If you're very short-sighted, a monofocal lens is absolutely fine. I've put lots of monofocal lenses for short-sighted patients, and you just have to decide whether you want to remain short-sighted, because, as I mentioned in the talk, some people who have been short-sighted all their life would want that ability to be able to read without the need for glasses, and you can have then have a monofocal lens that focuses you for near.

But then it does mean that you will still need glasses for, distance vision, so for driving, or for watching television and things like that. If you're minus eight, when we do cataract surgery to leave you short-sighted, we can bring you down to about a minus two, minus 2.5, so you won't be as short-sighted as you were before.

So it just depends on what you require your vision for, and this is the detailed discussion you need to have with your consultant on the day of your pre-assessment.

Because together, then you can make a plan of what's the best outcome for you. In terms of leaving one eye short and one eye long, that is it's called monovision, and that is also a possibility.

Usually tends to be better for those people who've had that, again, for many years. So some people, just with the way their eyes are made, have more vision from a young age. And so they have one eye that sees for distance, and one eye that sees for near.

You can still have this if you haven't had that, but we always suggest that you see your optometrist and do a trial of contact lenses with Monovision.

Because some people will be unhappy because their brain does not cope with the difference in prescription between the eyes. And so, before we do that for you, we always want to know that you've had a period where you've adjusted to the monovision, and then we'll be very happy to discuss that and then sort that out for you during your cataract surgery.

Vicky

Lovely, thank you very much. I hope that's helpful. Next question, is astigmatism similar to the effects of having a cataract?

Mr Syed Shahid

So, astigmatism blurs vision. What it what astigmatism does is it makes your vision slightly out of focus. So not exactly like the cataract, because the cataract will cause things to become less bright and less colourful over a period of time.

But astigmatism just keeps things slightly out of focus. Now, low levels of astigmatism, or depending on the type of astigmatism, might actually benefit the eye. But it's quite a complex topic because everybody has different degree of astigmatism, and the cataract itself causes some astigmatism.

So, as the cataract grows, your astigmatism can worsen, and the the reason this is important is that not everybody with astigmatism will need a toric lens. So, if the cataract is causing astigmatism, we know that that astigmatism is likely going to go away when we take the cataract out.

But if the astigmatism comes from a structure inherent to the eye, like the cornea, then that might be something that needs to be corrected either with glasses after cataract surgery, or with the help of a special lens, like a toric lens.

Vicky

Yeah, lovely, thank you.

Next question. I have inflammatory arthritis, and I think it's affected my eyesight. I do also have a cataract.

Will this autoimmune disease affect the operation? Person's asking, they've also had quite a few steroid injections.

Mr Syed Shahid

Yeah, that's an excellent question, and it's very, very relevant, actually. So it the short answer is yes, it does, because when you've had inflammation in the eye, especially if you've required steroid injections into your eye then, you can have changes, and we'll pick this up when we see you in the pre-assessment clinic, where the pupils can sometimes be a bit stuck down, you may not dilate so well and cataract surgery because we are going into an environment that's otherwise sterile causes inflammation.

So, if you've had episodes of inflammation in the eye in the past, it just means that we might need to keep a closer watch on you after the surgery.

We may need to give you extra drops after the surgery to counter that inflammation that we are now bringing into the eye as a result of the surgery.

It absolutely does not mean that you can't have cataract surgery, but you do need a period of a few months when you've not had any inflammation inside the eye before we can do your cataract. Now, if you've got inflammatory arthritis, and that hasn't affected your eyes and just your joints, then that's different.

You're still at risk of getting inflammation in the eye, but if you've had no episodes of inflammation in the eye, then you're less likely to develop inflammation as a result after the operation.

Vicky

Lovely, thank you very much, hope that was helpful. Next question is from Susanna, and Susanna asks, what does intermediate focus mean?

Mr Syed Shahid

So, intermediate focus, Susanna, is basically things like using the computer. So, your near vision is, say, for example, when you're trying to, read a book. Your distance vision is obvious when you're driving and you’re watching television and things, and near vision and intermediate vision is anywhere about 80 centimetres, so, you know, using a computer, for example.

So if you have a monofocal lens, you will have good distance vision, but you may not be able to use a computer or read without the need for glasses.

Sorry, without the use of glasses, basically.

Vicky

Okay, lovely, thank you. Hope that was helpful, Susanna.

Next question, somebody's asked, would I need to have had and bring along a recent prescription?

Mr Syed Shahid

It's always useful to bring along a recent prescription. Usually what happens is you get referred for cataract surgery by your optometrist, and they will send your prescription to us, so we will have that on our file. But, you know, by all means, if you can bring one with you in case this, you know, you never trust technology, so if it's not you don't have you don't have the referral letter, then it's useful to see your prescription.

We should almost not do cataract surgery until we know what your current prescription is, because it really determines what the focus of your lens will be after the surgery, and just helps us have a more healthy discussion with you regarding your refractive outcome.

Vicky

Okay, thank you.

Next question. When the cataract breaks up, is there any risk of any residual debris?

Mr Syed Shahid

So, again, very good question. So normally, we will take out all the cataract debris, when we do your surgery.

I very briefly mentioned this condition that you may need laser treatment for a few months or a few years after cataract surgery. And essentially what happens is, although the lenses that we use these days are very well made, and they're pretty inert.

The interaction of the lens with the natural capsule that the cataract sits in can cause some debris to grow over the months or years after the cataract operation.

And that's when you notice that the vision becomes gradually worse over time, and you come back to us, and then we can do a bit of laser treatment to clear that debris.

Vicky

Thank you very much. Next question, something I was wondering as well, what is the lens made of?

Mr Syed Shahid

Oh, so now you're asking. So, there's a number of different materials. So, the original lenses were made of something called PMMA, which was quite a rigid material, but these days, you have the sort of cloud there's so many different things that come into making a lens, and they're classified as either hydrophobic material, where they repel water, or hydrophilic material what this means is that the lens is able to molds into different shapes, and that's what you need to be able to put it to a small incision.

It's things like acrylic and all of those things, so all the structures, all the material they make the lens out of the eye doesn't react to it.

Otherwise, you'll get inflammation because you put a foreign object into the eye. So, yeah, it's a complex structure these days of what these materials are made of.

Vicky

Great, thank you, I hope that's reassuring. Next question is from Nicola, and Nicola says, I've had a detached retina, does this cause more complications with the surgery?

Mr Syed Shahid

Yeah, Nicola, so again, very good question. I deal with a lot of cataracts after retinal detachment, because I do a lot of retinal detachment surgery. It does increase one thing to say is that, and you may have noticed, that the cataract progresses more rapidly after retinal detachment surgery, and your surgeon would have spoken to you about this at the time. It can be a little bit more challenging after retinal detachment surgery because the support for the lens may not be as strong.

Because we've taken away that vitreous jelly that sits behind the lens. Having said that, thankfully, the vast majority of cases of cataract surgery after retinal detachment surgery are routine.

So, again, your consultant will discuss this with you at the time of your pre-assessment. But hopefully, there shouldn't be, there are things that we need to consider as surgeons, but the majority of cases go well.

Vicky

Thank you, that's helpful, Nicola. Next question. Could you explain what's possible and not possible for someone with dry eye condition?

Mr Syed Shahid

So, dry eye is quite a common problem that lots of people get as you get older.

It depends on the degree of dry eye. If you have mild dry that most of us do then, you have your cataract surgery as normal, and you may have to augment your dry eye with some dry eye drops.

For some reason, even though it's only a 10-15 minute procedure, a lot of patients will get dry eye symptoms after cataract surgery. So they'll complain of a bit of grittiness, a bit of foreign body sensation. It usually tends to subside with time. Now, where dry eye becomes very important is when you're thinking about a multifocal lens.

Because the tear film has to be of good quality, again, to be able to get the maximum out of a multifocal lens. A multifocal lens does lots of different things because it's trying to focus you in the distance for your intermediate vision, as well as your near vision.

If the tear film is not of very good quality, then that really degrades the image that you're getting. So that's one of the things that the refractive surgeon will check for before they offer you a multifocal lens. Again, if you have a little bit of dry eye, then they'll just make sure that, you know, they ask you to treat the dry eye before your surgery. If you have severe dry eye, then unfortunately that is a contraindication to having a multifocal lens.

Vicky

Okay, lovely, thank you. Next question is from Ian, and Ian asks, I've got astigmatism in my right eye. How does this affect cataract surgery and the choice of lens for best effect?

Mr Syed Shahid

Yeah. So, you know, it depends on the level of astigmatism. Like I said, astigmatism can come from the cataract itself, so some of the measurements that we do in our pre-assessment clinic will tell us whether the astigmatism is affecting your cornea, and if so.

Then the, you have the option of going for a standard monofocal lens and correcting the astigmatism after the surgery with glasses. Or, you can say that you want a toric lens, in which case you go to one of our special lens clinics, where they will try and correct the astigmatism with a type of lens that goes into the eye itself.

Yu can still have a monofocal lens, but it means that for the focal point you corrected, you will not need glasses. You will still need glasses for, say, for example, if you go for distance vision, you will still need glasses for reading.

But if you have astigmatism and go for a normal monofocal lens, you may need glasses for distance as well as for reading, and you may not be able to it'll still give you good vision, it's just that rather than the lens inside the eye correcting the astigmatism, your lens outside the eye in your spectacles will correct the astigmatism.

So, again, it just depends on what you would like for your eye, and how spectacularly independent you would like to be after the surgery.

Vicky

Lovely, thank you. Hope that was helpful, Ian.

Next question, interesting one. How do you manage floppy iris syndrome during cataract surgery?

Mr Syed Shahid

Yeah. So, floppy iris, what that means is that, when we dilate the pupil for cataract surgery, the better the pupil is dilated, the safer it is to do the surgery, because you have more access to the cataract.

Floppy iris means that during the surgery, the iris can come down, so it can start off dilated, but as the fluidics inside the eye change, the pupil can then start to come down.

There's some medications that we can use if we think some people on certain medications will be at higher risk of floppy iris, and so we, at the start of the surgery, may put some medication into the eye to try and reduce that risk.

Sometimes we can do this when the eyes starts to become floppy but essentially, given it's all about the experience of the surgeon, so we deal with a lot of floppy irises because we do so much cataract surgery. So personally, I do about maybe 1,000 to 1,500 cataract operations a year, so I've dealt with a lot of floppy iris, and we just have to be more gentle inside the eye.

If you don't notice that the iris is moving around during the surgery to try and prevent damage. But yeah, there is medication we can use in the eye. If the pupil is very floppy and it's not dilating well, then we can use certain rings or certain hooks to keep the iris out of our surgical site.

Vicky

Okay, lovely, thank you. Next question, somebody asks, what are the implications for someone prone to keloid scarring regarding cataract surgery or laser surgery?

Mr Syed Shahid

So, I don't think there is a direct correlation that I've come across in between keloid scarring. So, for those who don't know, keloid scarring is just a sort of, a very hyper-intense scarring that some people get. So, for example, if you get a cut, it'll heal up with quite a, you know, out-of-proportion scar to what you would expect a cut to heal from.

I have never seen that in the eye itself, so I don't think it has any direct implications to you having cataract surgery.

Vicky

Very lovely, hopefully that puts your mind at rest.

Time for a couple more questions. Can you have cataract surgery if you have a degree of blepharitis at the time of surgery?

Mr Syed Shahid

Yes, everybody has a degree of blepharitis. If you look at my eyes under a microscope, you'll have you'll see blepharitis, so it depends on how bad the blepharitis is.

Why is it important? Because, you know, I told you about the one in one,000 to one in two,000 cases of infection in the eye, and that usually doesn't come from the surgical environment, or the surgeon. It usually comes from the bugs that sit on the eyelids. So, if most people will have some degree of blepharitis, and that's why we use things like iodine to clean around the eye and the eyelids.

To try and kill off as many bugs as possible, and we put antibiotics into the eye, because that deals with the common bugs that cause infection.

If your blepharitis is very severe, then we may suggest treating that with antibiotic creams and things before your surgery itself.

Vicky

Lovely, thank you.

Next question is from Jane, and Jane suffers from hay fever, and she asks, should she avoid the summertime for surgery?

Mr Syed Shahid

Jane, that's a great question. Yes, I would suggest if your hay fever is very bad, and despite the use of antihistamines, if you're getting itchy eyes and watery eyes, then it's probably best not to compound that with another surgical procedure to your eye.

Obviously, if your hay fever is well controlled with oral antihistamines, then it's not a contraindication to having cataract surgery. But if you're worried about it, then, you know, it's better to leave it till the winter months.

Vicky

Okay, great, hope that's helpful. And looks like the final question here. If you have a small astigmatism, is it the case that toric lenses would not be appropriate for use?

Mr Syed Shahid

That's correct. So, depending on the level of astigmatism, your surgeon will tell you whether or not you need a toric lens, and bear in mind that most people don't actually have a toric lens. One is because it's not offered on the NHS, at least in this region, and people lots of people are happy to wear glasses after cataract surgery.

Remember that if you have a cataract, even with astigmatism, cataract surgery will still help improve your vision and give you clarity to your vision, because the main thing that's stopping you from seeing is your cataract.

So even if you have astigmatism, putting on a pair of glasses after your cataract surgery will give you crystal clear vision. And if you have low levels of astigmatism, it's not advisable to have a toric lens because, like I said, every lens comes with its own problems. A toric lens has to be put in

Specific plane inside the eye, and it can rotate at the end of the surgery, it can rotate after the surgery, and it may lose its benefit.

Some people then need further surgery to try and orientate the lens back into the position it should be in. So, there's nothing out there that comes without that small element of risk, and so if you have low levels of astigmatism that we don't think requires a toric lens, we will not offer that to you.

Vicky

We've had one last question just, snuck in there. Amitriptyline is known to cause dry eye. Does this mean multifocal lenses will not be suitable?

Mr Syed Shahid

Amitriptyline can, it just depends on the level of dry eye, is what I would say. So there's, like I said, dry eye is a very common condition.

Just because you're on amitriptyline does not mean that you can't have a multifocal lens. So, it'll depend on the degree of dry eye and how that's affecting your cornea, which is the front window of the eye, and again, we will make an assessment of this when we see you in clinic.

So the short answer is no. It just depends on the severity of the trial.

Vicky

Lovely, thank you.

So I think that's it for questions. Thanks, everyone, for your questions and for being part of this evening's session. Mr Shahid, if you could move to the final slide, that would be Sure.

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