Louise King

Good evening, everyone. Welcome to our webinar on cataract surgery and special lenses. My name is Louise, and I’m your host this evening. Our expert presenter is Miss Han Bin Lee, a Consultant Ophthalmologist. This presentation will be followed by a question-and-answer session. If you'd like to ask a question during or after the presentation, please do so using the Q&A icon, which is at the bottom of your screen. This can be done with or without providing your name. Please note that the session is being recorded. If you do provide your name and if you'd like to book your consultation, we'll provide contact details at the end of this session. I’ll now hand it over to Miss Han Bin Lee, and you'll hear from me again shortly. Thank you.

Miss Han Bin Lee

Thank you. Louise, Good evening, everyone. Thank you for joining us. This evening, my name is Han Bin Lee, and I’m a Consultant Ophthalmologist at Benenden. So, this evening, we're going to cover what a cataract is, what the surgery involves, and what to expect. We'll discuss your process through the IE unit, and at the end, we'll answer your questions. I’m a consultant at Benenden, specialising in special lenses, and I’m also a full-time consultant at Fley Health NHS Foundation Trust.

So, these two images demonstrate the anatomy of the eye, and in relation to cataract surgery, the key areas include the cornea, as you can see here. Hopefully, you can see my cursor. the lens, which then becomes your cataract, and then behind the cataract is something called the vitreous humour, which we often refer to as vitreous jelly, and then the retina, which is the nerve layer of your eye. The eye itself acts like a camera, so the lens light goes through these structures and then reaches the back of your retina, where it goes to the optic nerve, and the information is then processed in the brain. So, when your lens loses transparency, when it becomes a cataract, that's when the visual disturbances start, and that can be seen in a number of ways. For example, you may have been able to see an eagle 50 metres away, but that may now seem very blurry, and we'll discuss what types of cataracts can affect you.

So this is an image that we've taken on a slit lamp, which is a microscope, and this is how your eye is usually examined when you go and see your optometrist or your eye consultant, and nuclear sclerosis is one of the most common types of cataract, and it's often the most common in and related to ageing and getting wiser in life, and you can see that there's this yellowish haze. Cortical cataracts are also quite common; you can see these white spokes, and they can also cause a visual disturbance.

I don't know whether you can appreciate the haze that you can see in this thin slip beam here, and this can also cause fairly significant visual disturbance. This is called the posterior subcapsular cataract, so this type of cataract really affects the back part of your natural lens. The posterior polar cataract: you can see most of the lens is clear, but this tiny little circle can really affect your vision quite significantly, and this again affects the back part of your natural lens.

What are the causes of cataracts? As I’ve mentioned, the most common cause is age-related, so as time goes on in your life, your natural clear crystalline lens gets hazy. People who smoke tend to get cataracts earlier, or if you have systemic conditions like diabetes, some people are born with cataracts. If you've had any injuries to your eye, that can then accelerate the formation of a cataract. Too, a cataract can really affect you in a number of ways. You may find that the garden, the flowers that you are seeing, or the painting that you are doing just seem a little faded and the colours are not as brilliant as they were before, or you may simply notice that your vision is blurry. You may drive a lot at night, and the oncoming headlights are very bright. You may see halos and glare, or your optometrist may tell you that your glasses frequently need changing, and developing a cataract can certainly contribute to that. Some patients with a cataract may notice that they see double vision when they cover one eye, and all of these can present at different times. And really, the way we treat cataracts has changed. We no longer wait for the vision to drop to a certain level, so it's all about how it's affecting your life and how it affects you as a person. So, there are many reasons why someone may choose to have cataract surgery. The most common reason is that it's affecting your work, your daily activities, your ability to drive to work, or your hobbies, such as playing tennis or golf, painting, or reading. And there are also clinical reasons. When a cataract develops and it gets very thick, some patients are more at risk of developing an acute angle closure glaucoma attack, where the pressure in the eye suddenly goes up. This might be the reason why they might need a cataract operation, or they may be having a retinal operation, and it may be combined with the procedure. In patients who have diabetes, a cataract may obscure views to the back of the eye, making retinal screening appointments difficult.

As many of you may already know, Claude Monet's vision was famously affected by cataracts, and you can see in this painting that before he was diagnosed with cataracts, the brilliant colours of his Japanese foot bridge were present, but after he started developing cataracts, he described his garden as being more yellow and murky, and you can really see the contrast of how cataracts affected his sight.

So, what can you expect with cataract surgery? First, a specialist nurse, our unit nurse, and a technician will take a detailed medical and social history. They'll measure your blood pressure, and your blood sugar levels, and they'll also check your visual accuracy. This is like the vision check you may have already had at your optometrist; they'll check your eye pressure, and they will also do some special investigations that relate to your cataract surgery. one being biometry, which is measurement of your eye, so for example, the length of the eye, the different curvatures of the eye, the compartments, as well as a scan of the back of your eye. your retina, and we will scan the central part of your retina called the macular. For patients who may be opting to have a special lens or have astigmatism, we will also carry out a scan called a pentacam, which maps out the curvature of the window of your eye cornea. After this, you'll be seen by a consultant, and he or she will carry out an eye examination on the microscope. This is where you place your chin on the slit lamp.

Following this, they will discuss and confirm your eye and health history. They'll review your test results, and then they'll go into the discussion of what you would like to achieve with your surgery, the type of anaesthetic that we offer, and the benefits and risks of surgery. In this consultation, you'll also have a chat about what refractive outcome you may want. For example, after cataract surgery, your natural lens is being removed and an implant is inserted, so the prescription of your eye will change, and this discussion will be had during your consultation. Typically, a patient may choose to correct their vision for distance, and this is the kind of information that we will discuss in depth, and then we'll also go through the consent process with you, and you'll be given a copy of your consent form.

There are a number of lens options and you may have already heard of monofocal lenses these are most commonly used lenses and they are able to offer a one focusing distance to give you good clarity of vision so they can be either set to focus your vision for distance intermediate so middle such as your computer or your mobile phone or for near for reading now most patients do to correct their vision for distance and wear glasses for reading and computer work if they do opt for this type of lens however if you're used to being short-sighted so if you're myopic and you want to retain your reading vision that can also be an option that you can decide to go for or if you are used to something called monovision where you use one eye for distance and one eye for reading and you've been doing this for some time with contact lenses then that can also be an excellent option with the single focus lenses now if you have a astigmatism which I’ll come to on the next slide then with a monofocal lens all the astigmatism is unlikely to be corrected with this surgery so you will require glasses for distance and near.

What is astigmatism? So the cornea the window of your eye is usually dome shaped or round shaped like a ball but when you have a astigmatism the curvature of your cornea is not the same in the two angles so it's shaped more like an egg or a rugby ball and astigmatism contributes to your glasses prescription and the prescription of your eye and if it's significant it can make your vision blurry and it is surprisingly common when someone has cataract surgery following their operation the astigmatism can be corrected either with glasses or contact lenses or laser however there's also the option to correct astigmatism during surgery with a lens called a toric intraocular lens and this image is showing an example of a toric intraocular lens and you can see these two lines and those lines are what we will use to orientate the lens inside your eye in a specific angle and that will treat most of your astigmatism and therefore make you less dependent on glasses depending on what distance you go for other options include extended depth of focus lenses These lenses mainly aim to correct your vision for distance and for intermediate vision, so for example, in computer work, cooking, gardening, and also dashboard vision, some patients will also be able to get a degree of reading vision, for example, in large print, but with these lenses for small print, reading in dim lighting, or reading a menu in a romantic restaurant, you will require a light pair of reading glasses, and with these lenses we can also correct astigmatism.

Then there's also the option of multifocal lenses. You can see the rings here, which give you different zones to correct your vision for distance intermediate, and near now these aim to reduce glasses dependence for all activities. However, some patients may still require a small pair of reading glasses, especially in dim lighting, and although they have the extra technology, there is a small risk of having glare and reduced contrast sensitivity. They're not suitable for everyone, so some patients are very keen on having spectacle independence, and they accept the slight trade-off of having glare and reduced contrast sensitivity.

So, what actually happens on the day when you go for your surgery? So, you'll be admitted as a day patient. We'll carry out the pre-operative checks. Your pupils will be dilated, ready for surgery. We'll check your blood pressure and blood glucose. If you feel very nervous, you can take a tablet to relax. We advise you to wear comfortable coloured clothing because we use iodine to clean around the eye. It's advisable to have a light meal or breakfast before you attend, and we advise you that you don't have any alcohol before attending surgery so the surgery itself it takes between 10 to 20 minutes you'll be taken into the operating room sit on a comfortable operating chair and we will lie you position you back on the chair so that the head is positioned parallel to the ceiling you'll have a pillow underneath your leg to take the pressure off your back will give you local anaesthetic drops and iodine drops and the eye will be cleaned and a drape will cover your face to about this length and if you feel very claustrophobic we can always lift the drape and stick it to the microscope so that you have a little bit more space than a small speculum will gently open your eye so you don't have to worry about blinking and you'll be advised to look straight into the operating light with both eyes and blink as normal and some surgeons will play some nice relaxing music and you’re advised to relax as much as you can in the circumstances

So, I’ll briefly take you through some of the surgical steps for your interest. So, cataract surgery is now done through a very small incision, typically 2.2 mm, then we open up the capsule of your cataract, and that's called the capsulorrhexis, then we use ultrasound technology, which is called formic, to break up the cataract and also to aspirate the cataract. After this, we insert the intraocular lens. Now the lens is placed in the eye without any sutures, and following the lens insertion, we also instil antibiotics directly into the eye and seal the eye, and then you'll have a clear shield to protect the eye, which you'll be advised to wear.

Cataract surgery recovery The full healing process can take four to six weeks. Most patients can return to their usual activities after one or two weeks, and you will be given eye drops for four weeks following surgery to reduce the risk of infection, inflammation, and swelling. Your vision will feel blurry immediately after your operation because you'll have local anaesthetics in the eye, and you will have had a bright light on your eye during surgery. After the anaesthetic wears off, your vision will start to come back, and the day after surgery is when you'll start to notice the brightness, and that will improve each day.

Then we now come to the risks of surgery, so it's really important to remember that cataract surgery is very safe, it's very successful, and it improves your vision and quality of life, but it's like with all surgeries, there are unfortunately risks, and some of the risks include problems that can happen during surgery, such as a small tear in the thin capsule that I showed you that holds your cataract or part of the cataract that can displace the back of the eye. After surgery, there are other risks, such as retinal detachment, which is when the nerve layer splits away from the balloon casing of your eye infection. Inflammation and issues with the lens implant. Now, what's important to know and remember is that most complications can be treated with either further drops of laser treatment or surgery. However, there is a very serious risk of potential visual loss to the eye as a result of a complication in one in a thousand patients. This should be discussed in detail again in your consultation, wherever you go to have your eye operation, so we are a dedicated Eye Unit in Benenden.

We have a team of 12 experienced consultants and also a dedicated ophthalmic team, including nurses, technicians, healthcare assistants, and administrative staff who are used to dealing with cataract patients, lenses, and equipment.

I think that concludes the presentation. So, these are my colleagues, some of whom you may also have met, and we have a short patient testimonial that I’ll play for you. Hi, my name is Delia, and I’m a Benenden member. I had my cataracts removed in February and March. I have severe astigmatism, which was corrected over the last year. I’ve really struggled with reading; I couldn't read very small print, and driving was a real problem, so much so that I had to give up driving at night. I was offered toric lenses to correct astigmatism, and I chose to have one lens for distance and one lens for reading, which has been mind changing because I’ve now been able to totally dispense with contact lenses and glasses. The procedure was really short—about 15 minutes—and nearly painless. There was really good follow-up after the operation. I was given a phone call 24 hours later. I had a booklet given to me. I also had a droplet charge to help me put the drops in. Well, in the three to four months since I’ve had the procedure, it's been life changing. I’ve been wearing glasses and later lenses since the age of 11. I can now drive at night, read, and swim without worrying about water. Guessing in my eyes, it's an absolute miracle colour. The world seems a brighter place, and the colours almost jump out at me. I would 100% recommend Benenden Hospital. My treatment has been excellent from start to finish; it couldn't be better.

Louise King

Okay, yes, now we'll take some questions, so thank you very much for that really interesting presentation. We have many questions, so I will try to get through as many as we can.

The first one is: Are short flights allowed post-procedure?

Miss Han Bin Lee

We usually advise you not to travel immediately after surgery, so I would advise you not to travel for at least a week to two weeks just in case you develop a problem and you need us and we need to see you, but usually, after cataract surgery, we don't put any, you know, expansible gas in the ice, so technically, flights are fine, but I would normally advise patients not to travel immediately afterwards.

Louise King

Okay, this person says they have dry eye syndrome. Will this cause any more problems with this procedure?

Miss Han Bin Lee

Yes, that's a really good question. Dry eye syndrome can sometimes feel worse after cataract surgery, so I would advise that you increase your dry treatment or that you see someone prior to having cataract surgery to optimise the surface of your eye, as this can affect the outcome of surgery.

Louise King

Okay, how accurate can you be pre-op as to whether or not glass will be needed afterwards?

Miss Han Bin Lee

Okay, yes, that's a really good question too. It really depends on your previous ocular history, for example, whether you've had any laser eye surgery, as this can affect the accuracy and level of your prescription, and it also depends on what kind of outcome you choose to have, whether you are shortsighted or longsighted, and how you know the degree of your prescription as well as what kind of lens you ought to have. But your eye doctor should be able to give you reasonable advice on how close they think they might be able to get for you with surgery. It's difficult to guarantee 100% perfection, but we can try to get you as close as possible to what you want to achieve.

Louise King

Okay, thank you. Having glaucoma controlled by drops complicates having toric lenses fitted as part of the cataract procedure.

Miss Han Bin Lee

So, it depends on the degree of glaucoma, how advanced the glaucoma is, and whether you're currently on glaucoma drops following a previous glaucoma operation such as a trabeculectomy. If it's just drops and you've never had gloma surgery before, then a toric lens can still technically be used, but I think it would depend on the severity of the glaucoma and the eye pressure. I do still use toric lenses in patients with mild glaucoma where it's well controlled, but I think it would depend on your full eye examination.

Louise King

Okay, this person says they are allergic to shellfish. If you use iodine, can they still have surgery?

Miss Han Bin Lee

Yes, we can still use iodine. If you have an iodine allergy, we do have an alternative that we can use.

Louise King

This person says they have a relaxing device called a sensate, which is worn around the neck, and they listen to music, medicine, or meditation while wearing it. Is there something that could be worn during the operation?

Miss Han Bin Lee

I think we would need to look at the device just to make sure that we would have enough space to carry out the operation, and also, during surgery, we put an adhesive drape that will be stuck down to your eye area and that will cover your face as well, but sometimes some fluid can drip through to your ear, and we wouldn't want to damage your machine, so it's probably best to bring the machine to show us if you can during surgery during your preoperative assessment so that we can have a look.

Louise King

That sounds sensible. This person says it's better to have cataract surgery sooner than later or wait until it's really bad.

Miss Han Bin Lee

So nowadays, cataract surgery is all about your symptoms, so it depends on whether it's affecting your life. Essentially, many years ago, there was a certain visual standard that you had to be worse than in order to have cataract surgery, but now if it's affecting your life, for example, driving, reading, or working, then you can have cataract surgery. Of course, it is an elective procedure, so it's up to you whether you want to go ahead with the operation, so there's no kind of hard and fast rule. Probably if the cataracts are already quite advanced, then I would generally advise people to have it sooner rather than later because when cataracts become very thick or dense, as we say, the operation can potentially come with a slightly higher risk of having problems.

Louise King

Thank you for noting that the arms of the cataracts would line the wall of the eye to support the cataract within the pocket. Are all eyes the same size, or do the sizes of the cataract implants vary?

Miss Han Bin Lee

Yes, that's a really good question, and it's a question that we get often in clinics. So, one of the key investigations that we do when you go to a cataract clinic is the measurement called biometry, which is where we measure the length of your eye, the depth of the front chamber of your eye, and the curvature of the window of your eye, and we use these measurements to calculate your lens. For example, someone who's very long-sighted will have a different-sized lens than someone who's very shortsighted, so it depends on your eye prescription. Even if you know you have two eyes, one eye might have, for example, a plus 20 lens, but the other eye may end up having a plus 18 lens, so there is a difference depending on the eye measurements.

Louise King

Thank you. This person's eyes have been lasered, and they ask how this will affect them having a cataract operation now.

Miss Han Bin Lee

Okay, so if you've had laser refractive surgery where you had laser to the cornea, it does change the shape of your cornea and the relationship of the front and back of the cornea, so it can make the lens calculations less accurate compared to someone who hasn't had any laser eye surgery. However, there are now very good lens calculation formulas available, and if you were to go for cataract surgery, we would use that and compare a few different formulas to pick the best lens for you. There is a slightly higher chance that you may not exactly reach the target that you had hoped for, but unfortunately, that is a risk with having, you know, had it, but I would say nowadays there's lots of good formulas out there.

Louise King

Sharon says they have a prescription that includes Islam. Will this necessitate them wearing spectacles all the time after their surgery?

Miss Han Bin Lee

Yes, again, a very good question. It depends on the degree of the prism and how big it is. Sometimes after cataract surgery, patients find that their prism prescription reduces, but it really depends on why you're wearing the prism, so it would be a case-by-case situation. It may be that if you're wearing quite a big prism, you may still need some of that in a pair of glasses after surgery. Okay, what kind of tablets do you use to relax? So, it depends on which unit you go to. There are a number of tablets that you can have in the unit here at Benenden.

Louise King

Christine says she lives on her own and will need support after surgery.

Miss Han Bin Lee

Okay, so it is helpful to have someone nearby or someone who can come and stay with you for the first night of surgery. However, lots of patients who live on their own can still manage. What I would suggest is that, in that case, just try and get everything in order at home. Have your evening meal ready. Make sure the house is in order before you come for surgery so that you don't have to do too much that first night and the next day. With your eye drops, we can show you how to use them, or if you're at another hospital, they should be able to demonstrate how to use those drops following surgery.

Louise King

Irene says she has age-related degeneration. How will this affect the operation?

Miss Han Bin Lee

So, this doesn't. I’m assuming you're talking about macular degeneration. This doesn't affect the technicalities of the operation itself, but it can affect the outcome of surgery because we're dealing with the lens, which is in the front compartment of the eye. We're not working on the retina. You may find that compared to someone who doesn't have any changes in the macular, the visual improvement may be not as much, so a slightly guarded visual prognosis.

Louise King

Allison says that she's heard that you shouldn't bend after surgery. She has a small dog. Is it the case that you shouldn't be bending?

Miss Han Bin Lee

Yes, that is a really good question. So, we generally advise patients not to bend over for at least one week following cataract surgery, and this is especially true if someone has had a toric lens that can rotate in the eye. The other concern is if one eye is blurry and there are other objects around the ground as you're bending over that may poke you in the eye. That would be of concern, so yes, in general, I would say to avoid bending over for at least one week.

Louise King

How soon can a second eye be treated?

Miss Han Bin Lee

Second eye surgery is usually done between four and six weeks after the first eye. In some patients, it may be sooner, but there's no hard and fast rule to it.

Louise King

Yes, and I guess related to that, can you have both eyes done at the same time?

Miss Han Bin Lee

Yes, bilateral cataract surgery has become more popular, particularly ever since COVID, and it has been the case in lots of different countries like Sweden and Canada. It can be carried out at Benenden at the moment. Bilateral surgery is usually for patients who are having special lenses because it helps with quickly adapting to the special lenses, so it depends on where you have your surgery as well, but it is possible, and although the risks of having bilateral surgery are very small, it is something that you should also consider in your decision-making about the potential risk of developing problems in both eyes.

Louise King

This person's read that not everyone can adapt to EF lenses. What does this mean, and what happens if this is the case? Can they be changed?

Miss Han Bin Lee

Yes, great question. So yes, now the compromise between having extra technology and the lens is that it can increase the chance of people feeling that their contrast sensitivity isn't as good or that they may experience halos and glare. Now most people do adapt to the lens with time; it's called neuroadaptation, and the time period can really vary from person to person, typically 3 to six months. There are some patients who don't adapt to this and want to have the lens removed, and this can be done, although the surgery for exchanging the lens itself for a different lens is not without risk.

Louise King

This person doesn't have cataracts but asks if they can still have eye surgery to correct astigmatism and long-distance vision.

Miss Han Bin Lee

Okay, so it would depend on the degree of your astigmatism and your eye prescription, and I would suggest that you go and see an optometrist to have this chat first because it also really depends on your occupation, your age, and the general health of your eye. It's not a hard and fast rule, but if you don't have a cataract at all, then that becomes a lens exchange, which then takes you into a different area. There are lots of different ways to treat astigmatism, not just cataract surgery, so I would suggest you go and see your optometrist first to have a chat about this because it would also depend on all the other factors about you as a person, not just having the operation.

Louise King

This person has a syndrome that I’m going to try and pronounce, but it might be SHR syndrome. What does this affect? It can give you very dry eyes and a dry mouth.

Miss Han Bin Lee

Yes, that's a really good question. Patients who have SHR can experience dry eyes essentially after surgery, so it would be really important to again optimise the dry eye disease and the surface of the eye before having surgery, and I would recommend, after having cataract surgery, increasing the frequency of your usual eye lubrication.

Louise King

Audrey says she had eye surgery a year ago to remove sun damage. Will this affect her surgery? She also suffers from dry eyes and blepharitis.

Miss Han Bin Lee

Now it would depend on where exactly the sun damage was removed. If it was in the eyelids, then yes, it shouldn't be a problem. You can still have cataract surgery. If this was on the surface of your eye, for example, the conjunctiva, so above the white casing of your eye, then that may change things slightly, but I would advise that your ophthalmologists come and see us. It would be really case-by-case, I would say, and I’m glad to hear the blepharitis has cleared up because that's also really important to do prior to your cataract operation.

Louise King

So, I think I’m understanding the question. Can you see someone's already had cataract lenses, but then newer lenses come out and they're replaced? That's how I read it.

Miss Han Bin Lee

Yes, sorry, it would depend on how long the lens has been in the eye because the longer the lens has been in the eye, the more complicated the exchange process would be, and in general, I would advise you, if you are satisfied with the vision and you're managing well with your glasses, that if it's been a very long time since you've had surgery, it's probably best to manage it conservatively because exchanging the lens is not risk-free and there may be other options that you could explore apart from simply exchanging the lens, so yes, I would advise them to have a consultation to consider that. So, the intraocular lens stays forever, and some patients develop something called posterior capsular pacification, typically a year to two years following surgery, where someone may say that your cataract has grown back, but in fact it's actually the cells on the capsule that's holding your lens that's causing the vision to be foggy, and this can be easily resolved with a procedure called YAG laser capsulotomy that can clear your vision, so essentially the lens is permanent.

Louise King

Can you use an eyebath to administer drops?

Miss Han Bin Lee

I would advise you to use an eye dropper to use the drops. If it's an eye bath that isn't with any other fluid, then that should be fine, but it would be best for you to show us what exactly you mean so that we're giving you the best advice on that.

Louise King

Yes, and can you have a general anaesthetic if you're very nervous?

Miss Han Bin Lee

Yes, if you are generally fit and well, and if you are very nervous, you can have a general anaesthetic for your cataract surgery at your local hospital. We don't offer a general anaesthetic for cataract surgery at Benenden. What I say to patients is that if you're not sure, there is also the option of having the surgery with oral sedation, and you can also have an extra anaesthetic injection around the eye, which then helps you feel less of the operation itself, so that is an alternative if you go to your doctor. For example, if you want to have a general anaesthetic but want to find out about different options, there are alternatives to that.

Louise King

I think we might just do a couple more, and then we'll, if you've provided your name, email you the answers at a later date, so I’ll just answer some of the anonymous ones here. So, a question is: is sneezing an issue after the operation?

Miss Han Bin Lee

No, I mean the eye is sealed at the end of the procedure, unless during this sneeze you know there's inadvertent damage to the eye, like, for example, if you poke your eye or if you accidentally hit your eye with something, then yes, there is a risk, but no, just sneezing.

Louise King

Okay, and the last question we'll cover is: How often do toric lenses move and need to be adjusted at another visit?

Miss Han Bin Lee

Yeah, excellent question. They don't move very often because they offer good stability, but it's really important in the first hour, particularly after toric lens surgery, that you kind of sit, rest, and sit quietly; you don't rub your eyes; you don't bend over; and also, in the first week, about four to five% of toric lenses may need a rotation. However, the second surgery to rotate is a little bit like having a cataract operation but shorter, so it's not a major issue if it requires rotation.

Louise King

Okay, so thank you very much. I’m sorry if we didn't answer all of your questions, but if you've provided your name, we'll be able to answer yours via email.

Can we just move on to the next slide? Sorry, so as a thank you for joining this session, we're offering 50% off the value of your consultation. a call back from a dedicated private patient advisor and an email tomorrow with a recording of this session and further information and updates on news and future events.

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