Jane Styche

Okay, good evening, everyone. Welcome to our Ophthalmology webinar. My name is Jane Styche, I'm the Eye Unit Manager and I'll be your host for this evening.

Our expert presenter is Consultant Ophthalmic Surgeon, Mr Jonathan Aboshiha.

This presentation will be followed by a Q&A session, if you'd like to ask any questions during our presentation please do so by using the Q&A icon which is the bottom of your screen, this can be done with or without giving your name. Please note that this session is being recorded if you do provide your name.

If you would like to book a consultation, we'll provide you with contact details at the end of the presentation. I'll now hand over to Mr Aboshiha and you'll hear from me again shortly.

Mr Jonathan Aboshiha

Hello, everyone. Thanks for joining. So, as Jane said, my name is Jonathan Aboshiha,  I'm one of the Consultants in the team at Benenden Hospital’s Eye Unit and I'm just going to talk today a little bit about cataracts and some other general eye conditions and then let you know at the end some details in case any of these issues are affecting you and I believe we also have a question and answers session once we've been through the slides.

So, a little bit about me, there we go so my name is Jonathan and I studied medicine at Cambridge and then finished my clinical studies in London and then went off to Australia. I was a Neurosurgeon for a bit before specializing in eyes and then came back to the UK. I was here for about 10 years at Moorfields where I did some research as well and led to my PhD as well as some extra training in cataracts and refractive surgery and then I came to work in Benenden about two years ago.

So, as I said, the session today is mainly covering cataracts, what types there are, causes, symptoms, what we can do about them, what you might expect if you're heading towards cataract surgery and we're going to touch base on a few other topics such as YAG laser treatment and some common eyelid conditions and dry eyes, things to do with your lacrimal glands and a few questions at the end. Hopefully will be done by seven o'clock.

So, what are cataracts? Well cataracts are cloudy lenses inside the eye, I believe it's a Greek etymology from a waterfall and I think the the prevailing thought many thousands of years ago was that the water in the eye had gone cloudy, a bit like when you see water fall through a waterfall.

So when the lens is clear which is for the most part of our life until about the age of 30, light comes in actually mostly focused at the cornea about 70% of the light we focus on our eyes, but the reason the lens is important is that that is the part of the eye that can change the focus. If you look at something close up the lens actually changes shape and you can see the lens here it's the big blue blob and the picture on the left and when we look at something in the distance it changes shape again and it does that so it can focus the light on the retina which is this yellow layer at the back of the of the eye. If you think of the eye as a camera it's probably the easiest way to think of it, the front of the eye is the lens which in real life is both the cornea the front surface of the eye and the lens itself and the back of the eye is a photographic film and that's the yellow part, the retina and you need both of those to work well in order to see a good picture in your brain and there's an awful lot of post processing done by your brain afterwards when the lens becomes cloudy, we call that a cataract and that causes problems with the vision which we'll go through in a bit.

A question I often get asked is when the right time is to do cataracts, well everyone over 30 has a bit of cataract, I used to say it's a bit like your teeth going yellow or piano keys going yellow over the over the years. The time to do it is when your vision is affected such that you're happy to go ahead with surgery, it's an incredibly safe operation, the most common equation done on the NHS but all surgery has a risk even if it's very small it's always worth considering the risks for the benefits it's always a balancing act. When your lens gets cloudy, often you or your optician or GP will send you in here or into a hospital that offers a cataract surgery, saying I think you need the cataracts out so what do we actually do? Well, we're trying to get rid of this cloudy lens and it becomes cloudy in different ways.

The most common gradual clouding of the whole lens is called nuclear sclerosis and all that means is the central part you can see the picture on the right here becomes denser and denser and eventually becomes more yellow and that's because it's blocking out the blue light, so one of the things many people notice after cataract surgery is that the world seems a bit brighter and a bit bluer and I think they've done some studies about what man a might have painted had they been availed cataract surgery and you know their pictures were not quite as wonderful, not that I'm saying it's a reason to keep the cataracts but they were certainly more blue and a bit harsher, so you'll see the world as you were as you saw it when you were 10. That's why the Cataract can look look yellow and as it gets denser and denser it first of all starts to change your prescription with your optometrist optician and so you'll find that your prescription is getting more and more short-sighted and that's sometimes what we call second sight and then eventually no glasses at all will fix that because this is a cloudy lens inside the eye and you need to make that clear with the surgery to remove it.

Another common type of cataract is something called cortical, you can see here the picture on the right you see these little spokes a bit like spokes on a bicycle wheel and that's the part of the Cataract or the cortex, hence the name, which is outside the middle part which is called the nucleus, hence the name on the previous slide. The reason these develop in different ways is still not very well known, we know there are certain risks like some medications sunlight but we think the main risk factor is just growing up and getting older some people might get a lot of cortical cataracts some people might get a lot of the first type we don't really know why some people get some types and others others.

This is, I mention this in particular, called a posterior subcapsular that’s a cataract it's a fancy name but basically it's a kind of cloudiness in the thin layer of the back of the lens and the reason it's particularly relevant is because that's the focal point of the light and so even a very small amount of posterior subcapsular of the Cataract can have quite a large effect on your vision and it can sometimes be a little trickier to remove. Especially if you leave it very late because what we're trying to do in cataract surgery is remove the cloudy lens from inside its natural bag which is called the capsule hence this word subcapsular. The capsule is very very thin and transparent which is what makes the surgery tricky compared to some other surgeries, even brain surgery because actually operating on basement membranes of single cells, so it's very very thin, very fragile when it becomes cloudy as you can see in the picture in the right, it can it can really give you a lot of problems with glare especially, so you know no one likes driving those new headlights but if you have one of these and you are really going to make it very problematic.

Then this is a less common one, it's called a posterior polar cataract and it's just the back of the back of the lens that's what the posterior bit and polar means it's just at one of the poles of the cataract which is a lens and is almost a bit like a sphere so you know the North and South Pole and in the lens of the eye we have the anterior and the posterior poles. Again, these quite unusual and they're sort of of some interest but at the end of the day when you take the cataract out you take all of these out and they go through a tube and into the bin. I have had people ask can keep theirs, unfortunately not because by the surgery it's mushing it up and removing it.

So, what causes cataracts? Well you can be born with it certain genetic conditions or infections when you're in your mother's womb and that's congenital format, so people have had injuries tend to have cataracts especially the injury to the eye that's touched the lens in some way or trauma from surgery so there are some surgeries that you have to your eyes for the back of the eye that can then eventually cause cataract. Systemic disease, that's just a fancy way of saying disease in the rest of the body and the most common one is probably something like diabetes where people form cataracts a bit earlier and drug related there are a whole lot of drugs that can cause or medication that can cause cataracts. But the most notable one is steroid use, so people who might have used a lot of steroids either in their eyes as drops for other eye conditions or other conditions such as inflammation or polymyalgia, they might have had steroids and that can hasten the onset of cataracts. And, although we put it last in the list, it's actually the first cause which is all of us get them as we get older, it's a natural part of getting older so anyone ever says you have cataracts, don't think you have necessarily a disease it's a bit like saying you've got wrinkles, it's part of it's a badge of honour that you've lived around long enough to get them. But time to operate on them is when they affect your vision, not just because someone has told you you have them and that's really important.

What are the symptoms of cataracts, well it's really a reverse effect of all the symptoms of at least all the features of normal vision so colours as I said can appear more faded and yellow, you tend to see less bright blues and that's because of the nature of the cloudiness the lens. As you get older, the main symptom is blurred vision and that's because in a when we're very young and the lens is very clear that's able it's able to transmit the light because the little structural chemicals or proteins in the lens are held at exactly the right distance relative to the wavelength of light to allow the light to pass pass through, it is actually quite remarkably never biological material that's transparent but through you know the wonders of our human body that is something we have for most of our lives. As the cataract gets denser, first of all it bends the light as I said earlier your prescription changes normally become more short-sighted and that's why some people talk about something called second sight and then eventually it's cloudy despite any pair of glasses and that's normally the time to do a surgery because it's always easier in the safer to have glasses than to have surgery. You get a lot of glare with cataracts and that's often the first symptom because the light instead of being transmitted cleanly through the eyes scattered by these proteins that aren't in the right place, as I said change in prescriptions a lot from the earliest one and double vision that can also be a feature of cataracts, the only thing to mention there is there are other causes of double vision and we always talk about something called monocular double vision that means that you see the double vision even just through one eye, if you ever see two clear images and you close one eye and the double vision disappears and that's normally not cataract and it can be quite urgent to treat that, so if you ever get double vision with both eyes open clear two images you close one eye it disappears then it's best to go to A&E and get that sorted out but you can have double vision or more often what we call ghosting which is not too clear images but a sort of second image around it.

So, reasons for treatment, there are clinical reasons that are nothing to do with vision. One of them is something called angle closure glaucoma and that's to do with how the fluid in the eye is kept in balance, your eye is an inflatable ball and it's always kept in balance for the fluid flowing into the eye and fluid flowing out and the angle is like the plug hole of your eye and if that gets small or closed off that could be a problem and sometimes we remove lenses to make more space in the eye to enable the pressure to become normal. As I mentioned before, there's some surgery in the back of the eye for people with retinal tears, detachments and they often result in a cataract at some point and that's not because the surgery has gone wrong it's just the nature of playing around in the back of the eye. Also there are some reasons where people have diabetes in the back of the eye and everyone should be having annual screening as part of our national screening program, if you can't see well enough into that you never know what to do about the diabetic retinal changes and so sometimes patients come in they've been asked by their diabetic screeners to have cataract surgery to enable the screener to see clearly in inside. But the most common cause and reason for surgery is that that we as individuals or you as patients say I don't see as well as I need to to do the things I want to do, it's always you know how does it affect something called your activities of daily living if you have no effect and someone's just told you have cataract surgery, there isn't any point in doing it because you're trying to alleviate a problem and there is a risk although it's very very small one of the safest surgery surgeries we offer. So most the time people have symptoms and that's you know it really bothers me when I'm driving the glaze really problematic from other cars or I can't see the subtitles on the TV, things like that and as I said there's a bit of a debate about the change of glasses as cataract surgery becomes safer and safer some people feel that that's a reasonable reason for doing the surgery just to avoid constantly changing glasses, which can become an expensive habit and again preventing you from doing things that make your life enjoyable such as your hobbies.

So the main thing we do with cataract surgery and historically has been to replace the cloudy lens with a plastic lens and this was apparently because one of the medical students who was around with one of the pioneers Sir Harold Ridley of cataract surgery once said you know boss, I think back in those days probably you know your Lordship, why don't we replace the lens? Because for thousands of years all people did for cataract surgery was to remove it and so through the bravery and learning from the World War II fighter pilots, they realized that the canopies from the Spitfires weren't causing any inflammation in the eyes and they said well let's use that material which is Perspex or something similar so all the lenses that we put into the eye made of plastic and the main one that we use is a monofocal lens and that's really used almost universally in the NHS and that gives you one point of focus and 99% of the time that is made good for distance, vision, driving, watching TV, you can choose I think it's in our leaflet as well to have that aim for near vision, the only thing I would caution about near vision is that distance vision is the same for everybody and near vision is almost invariably different for everyone one person's near is doing something very close depends on your arm length and so forth so when you if you decide you want to have a monofocal lens aiming for near Vision it's a really good type an idea of what distance you want that near to be to help the surgeon decide what kind of lens to put in.

The monofocal lens is a sort of point-and-shoot cameras they are not good for both distance and near at the same time so you'll almost always need glasses nothing in surgery is always it's almost always an almost always you'll most likely need glasses either for near most commonly setting your distance vision as well as we can without glasses, which is the normal process of getting older or if you choose to have near vision focus you need some glasses of a distance which includes driving and so forth. There's also something called astigmatism, that's where the front of the eye or the cornea is shaped more like a rugby ball than a football and that's because none of us are perfect, they're not made of factories or biological entities and all of us have a bit of astigmatism but if we have over a certain amount that tends to blur the image even with a clear lens put inside the eye and so you can also have something called a toric lens and toric just means to correct astigmatism, you'd only be offered that you had enough astigmatism for it to be worth it. You can have a toric monofocal lens which will try and get you better vision in the distance if you didn't correct the astigmatism if you had significant astigmatism then you would need glasses for distance and near and as I said on the slide this is something that most ophthalmic surgeons and ophthalmologists do.

So something else Benenden has which is reasonably unique certainly compared to the NHS Services is the option of special lenses, the thing to think about with special lenses is they're all about glasses, it's all about how good you can get your vision without glasses, whether that's to avoid glasses per near vision and reading or whether that's to avoid losses but distance or trying to avoid glasses for everything. The sort of all bells and whistles one is something called a multi-focal lens and that's really trying to effectively through a different mechanism put something like varifocal glasses inside your eye that gives you good distance vision, intermediate vision, which is about half a meter and near vision which is about a foot or 30 centimetres and that's aiming to do that without any corrective lenses on your nose or contact lenses and that may be advantageous because you do certain activities sport or you're outdoors or you don't like even just having to find your reading glasses every time you go looking at a menu. As there is in surgery is a give and a take this sort of side effects or potential side effects for the multifocal lenses everyone will see some halos around bright lights like our headlights, they normally notice in particular first few weeks and months and then up to about six months the brain adapts and then people find they don't really notice them at all but they can still see them if they look for them. They also reduce something called contrast sensitivity and that just means in dim light if you're reading at night you'll have to turn the light up a little bit, they're not suitable for everyone, some people with something called irregular astigmatism and certain other eye conditions wouldn't be suitable so everybody who would like to be considered for these lenses at Benenden gets an extra work up in a special lens dedicated clinic where they have extra scans and so forth because obviously there's a financial cost to these lenses we want to make sure we have the best chance possible of making sure they work in the way that the people who who choose to have them expect them to work.

As I mentioned before, toric just means to correct astigmatism and in special lenses you may well need a toric multifocal lens or a toric special lens and normally these lenses are only put in by surgeons such myself who've had experience in refractive surgery, refraction lens surgery because there's quite a lot of other variables and parameters you have to think about to make sure they work as I said it's really important that the right people have the right lenses otherwise you can you can find they don't do everything they say on the on the can another option is a sort of middle ground it's called an EDOF which stands for extended depth of focus lens, they are often a good choice for people who for whatever reason wouldn't be good candidate-free true multi-vocal lens and the difference really between the multifocal and the EDOF lenses is that the multifocal lens is trying to get you to see at the distance at intermediate and near without your glasses whereas the EDOF lens is trying to get you see just in the distance and intermediate so about 50 centimetres or half a meter it is they're not designed for reading up close without your glasses so just be aware of that but you can have those conversations with people in the clinic so here's a picture of two different types of lenses so on the left you can see the monofocal lens it's pretty simple it's point and shoot and it's just a clear lens plastic lens that focuses at one point and on the right is a multi-focal lens you can see the little rings and depending on which of those rings the light coming into the eye hits It's focused for either near intermediate or distance vision and the aim is to get you out of your glasses.

Before the surgery, what do we do well we give you some drops to make your pupils big so we can have a good look in the back of the eye and through the pupil which is really just black because it's a hole so we can see in the back of the eye we check your blood pressure blood glucose and there is an option to have some sedation if required if you're really really anxious about it most people are actually fine luckily we're the opposite of the dentist and then the dentist on the caller be careful what I say but most people really dread eye surgery and most people think it's it's much less awesome than they've had anticipated which makes sense because there's nearly half a million calorie operations then a year and if it was awful there would be lots of people walking around saying how awkward it is dark clothing and something comfortable it can be a little bit on the cool side in theatre so it's always better to have an extra jumper just in case just that's for infection control and obviously A light meal breakfast and maybe Shavers saves the champagne or after the surgery or go immediately after otherwise January so what are the surgical steps that we're doing so we the surgeon will be sitting in a chair up around your head obviously making sure that you're comfortable we'll put some drops in the eyes and some iodine drops to clean the eyes we then clean the eye and put a little drape now that drape is like a piece of very thin paper that sits over your face and chest can be a little bit claustrophobic just for a few moments until we lift it off so you've got some room to breathe and then we put a little clip called a speculum which just keeps your eyelid open a lot of people wonder about blinking so you don't have to worry about blinking that just feels a little bit odd for about 30 seconds and then you really don't even notice it's in there. So nothing in the operation is painful and then you have to stare at a bright light that's probably the most difficult bit because you just got to look at the bright light but keep nice and still so I always say it's a game of statues keeping your head and body nice and still breathing normally blinking normally and just go to your happy place pretending on the beach and yeah I play calming music I think other people do though we've got some surgeons they're great singers but we also ask that them and yourselves no singing or dancing again until after surgery.

So it takes about 10 to 15 minutes, can take a little longer if it's a complicated case but that's about ballpark you're probably in the theatre for about half an hour and you normally if you come you'll come in a morning slot and afternoon slot. We make a little incision in the cornea, we do this thing called a capsular rexus it's a fancy name for making a little hole in that very clear in cellophane-like bag that contains the cloudy lens because that's the bag in which we put the plastic. People ask how does the plastic lens stay in place or there's a natural bag or the capsule and the rhexis just means that we carry a little hole in it baker emulsification is a fancy word for breaking up with ultrasound people have asked do we use lasers there are lasers available in the world but all the studies have shown they're no safe and they have some other issues so they're not really used they're more of a marketing thing in the US we then do something called irrigation aspiration that's just to maintain the eyes shape as I said before it's a balance of fluid going in and out of the eye so all of this you're going to hear noises the machine talking in this lovely American accent and most of the surgeons will just tell you okay you'll feel a bit of pressure now this is a bit of water and so forth the intraocular lens or IOL is then implanted and from your point of view that's the kind of fun bit that's the psychedelic experience as everyone says you get a little kaleidoscope as it goes in that's quite nice most people said told me but I've never met anyone who hasn't said it's a nice thing to look at and then something called intra camera antibiotics that means we put some antibiotics inside the eye at the end to reduce the risk of any infection, we just close up the wounds normally, we don't stitch them they're just close using a technique called hydration. Occasionally we do stitch in some very very tiny dissolvable suture, if that happens in your case don't worry that's kind of used to be routine and they just dissolve and then we give you a transparent shield and you go next door and get tea and biscuits for being brave. So cataract surgery surgical steps just as I spoke about earlier the capsular rexus is the bit where we make a little opening in the clear capsule in which the lens sits that's the picture on the left the middle picture you can see that little probe that's the tip that's the paper emulsification with the ultrasound and that can be a little noisy, sometimes you can hear that and then there's the lens insertion and the lens is now very clever they're folded up like little tacos and they go into these tiny two millimetre incisions that we operate through and they open up and they do a really good job and they're much much safer and cleaner than you know even 20 years ago.

What's the recovery like? Well, it is an operation so you'll get a bit of grittiness you know, mild discomfort and normally people take paracetamol, that's fine and that's a day or two feeling that and we give you some eye drops to help prevent any infection and to control any swelling and then normally later that evening the local anaesthetic wears off and you can feel it and when I say discomfort it's like having some grit in your eyes. You get covered with this little transparent shield which you can see in that picture but normally you keep that on for a couple of days if you can at night that's just to stop you rubbing your eyes when you're unconscious because the eye is pretty fragile in the first few days. It takes about four to six weeks for the eye to fully heal back to the strength it was before the operation but certainly in the first week or two you've got to take it easy you tend to buy tend to advise avoid driving and heavy lifting and if you're into the gym and stuff like that you might have a couple of weeks where you just yeah take it easy.

So another treatment that we offer is something called YAG laser treatment, the YAG is just an abbreviation of a type of laser that we use and this is used to correct something called posterior capture a pacification, this is sometimes people worry this is the cataract growing back or the lens becoming cloudy but if you recall I mentioned something about World War II fighter pilots it's actually a miracle that we can put a foreign body into the eye and not have a huge healing response if you did that you know strapping or anything else you would find that it would you know the body would constantly try and get rid of it. Pretty much the only thing that we notice when we put these sterile plastic lenses in the eye is there's a sort of healing response in the capsule sometimes becomes a little bit cloudy as the cells go around it and it's a bit like I describe it as dust around the lens but not on the lens and we can polish that dust off very very safely very easily in the clinic, it doesn't require an operation just put your head a little machine and it lasers off, you don't feel any pain and it takes about five minutes and that's in about probably one in four or one in five people that happens in the first year. So, the symptoms you get from that often very similar to cataracts things like blur and glare and as I said it just uses a very very concentrated beam of light to dust off the membrane and usually people are very happy with that and then that doesn't grow back.

So some other conditions that are treated here at Benenden, we have some treatments for eyelid conditions from drops and so forth we've got a Consultants who specialize in this part of the eyes because would you believe it for something as small as the eye there are about seven sub-specialties, so we will spend years training in little bits of the eye which is a bit embarrassing when you talk to a general surgeon. So the surgery can be carried out for cosmetic reasons if you've got droopy eyelids or bags under your eyes and so forth or it's obscuring your vision and that's called a blepharoplasty and it's one of the most common form of performed cosmetic procedures in the UK and it can take years off you I’m told, I haven't had one yet.

Dry eyes are very very common that's more my area of expertise, often people are just given some drops or buy some drops over the counter from somewhere like a pharmacist and that normally sorts out most people but there can be people that have more persistent dry eyes that aren't really treated by those dry eye drops and there might be other things that they need they're doing for example putting the glands around their lids to work again. It does happen as you get older and it certain that it happens when you're concentrating more the other thing to know is if you have dry eyes and you have cataract surgery all the cleaning fluids and so forth that we use tend to make the eyes a bit dryer for two or three months afterwards it will get better but just bear in mind bear that in mind if you have trials already and there are some other higher level treatments available for dry eyes if you're finding that you're using the lubricated you're up to a lot and still having some issues the opposite of dry eyes or though often is sometimes related is watery eyes so water wise can be initially a symptom of dry eyes and it's a reflexed hearing as your body detects the dryness and that's normally the first symptom of dry eyes. It can be also to do with blocked tear ducts and so forth and again our specialists to look after the lids can check if you're tear blocked it teared up sorry it's blocked and they can offer the your procedure to open the tear ducts that you're not having water to tear you down your face they can also check whether causes such as allergies and infections.

So, I think that's most of my chat about the conditions that we offer treatment for here at Benenden. Just to say that you know it's a great unit, I've been in several hospitals and it's really one of the best places I've worked and you know it's got a CQC rating of Outstanding which is a rare thing in the NHS, I think that when we looked it up and there are only 8% of NHS acute core services have that rating, that's the highest level you can get from the CQC which is the regulatory body of hospitals, so that's something that you know. A big thank you to Jane and the team here for maintaining that level of excellence, there's free parking as well which is a big win in life, so when you when you arrive you'll be you'll be seen by a nurse they'll go through your medical history, check your blood pressure, check your vision and the eye pressure so forth, they also do some other tests something called biometry where they're measuring your eye to calculate what lens goes inside the eye. A lot of people ask me about you know does it matter about my prescription and it certainly does but your prescription that your optician gives you is a combination of two things and that's the prescription in the in the your natural lens which is why when you get a cataract it's changing and the prescription due to the optics of the eye itself which is to do with the length of your eye and the curvature of your cornea and so it's not as important because when we remove your lens or your cloudy lens which is called the cataract it's really the parameter of the eye itself that determine what power lens. Almost everybody has a different powered lens to everybody else because we're all unique and individual and often we can have different powered lenses between our two eyes and it's it's all about what you agree with the with the consultant about where you want your focus to be aimed for after the surgery in the special lens clinic. We do even further tests and scans something called a pence cam scan which looks a great detail at your cornea or the front surface of the eye because we need to know very accurately what kind of astigmatism you have there are different ways to measure that and also to look about whether you're suitable for those multi-vocal or extended depth of focus lenses and everybody gets a oct scanner an OCT scanner the macula which is the specialized part about the size of a pinhead in your retina and that's what all of the lens and the corner are trying to do is to focus the light onto that macular and some of you may have heard of a condition called age-related macular degeneration or AMD and that's where it where it comes from macro just I think is Latin for sports it's just a tiny little spot in the retina where most of our useful vision is which is why when you look at someone in front of you you can see the details of their face but off to the side out of your peripheral vision everything's a bit blurry because it's not focused on that central macular.

You'll see the Consultants, we only have Consultants here which is great for cataract surgery because the biggest risk factor for cataract surgery or complications is a Junior Ophthalmologist, now that's you know I've been one, we've all been one but that is just the unfortunately the truth so the great thing about Benenden is only Consultants and that removes the major risk factor in cataract surgery. Although as I said there is always the risk to any any surgical intervention albeit small the consultant will have a look at your eyes on a machine called a slit lamp where you put your head on a on a chin rest and shine some lights into your eyes they'll discuss with you the results of the examinations any particular issues that might be pertinent to your eyes have a chat with you about the type of anaesthetic almost all the cases here we do are under something called topical anaesthetic that means eye drops so no injections rarely we can do the injections here around the eye if required Benenden does not do cataract surgery under general anaesthesia I.E asleep and probably maybe between three and five percent of all the cataract surgery done in the UK is is still done on general anaesthesia so it's a very much reduced proportion compared to when I started 20 years ago but it still is a possibility but if that is something you want that wouldn't be something that bending could offer that would have to be done on the NHS. So most people are fine and they lie there as I said about 15 minutes looking at the bright light and it's all over before they know it we have a chat with you a discussion about whether you want surgery what kind of surgery you want what kind of lens you want to put in and then he has said particular risk for yourself and a discussion about which type of lens it's now a legal requirement for everybody who has caloric surgery to be at least be told of the option of the special lenses multi-focal lenses because changes in the law so even NHS patients should be told about the option even if they couldn't get that option at the particular school they're being seen at.

We ask you to sign a consent form we should give you a copy in the clinic of the consent from your signing because obviously your eyes are dilated so it's a bit unfair to something you sign the blank check so do ask for a copy if the consultant does give it to you automatically that most of them do and that's really just a sunrise version of a wonderful booklet that Benenden has that explains everything about the surgery which we give you on the day as well so you can read all of that and be well informed before you come in for your surgery and then there's a 24 hour phone line if you have any questions or any other concerns either before or after the surgery.

I think now we are on to the question-and-answer session which is chaired by Jane.

Jane Styche

Thank you very much for your presentation. We've actually got lots of questions, so I hope you're ready.

So the first question we've got is do we cover ptosis surgery here at Benenden

Mr Jonathan Aboshiha

It's not something I do I would have to defer to I think Mr Deborah or Miss Hawkes I think they would I think they would be able to do that but yeah it is a surgery that we do here.

Jane Styche

Yeah, okay. So I think some of these questions may have been answered throughout the presentation. Can the lens be operated on twice if it goes cloudy?

Mr Jonathan Aboshiha

Again, yeah you can so the the reason you want to get these things right the first time is it's much harder to remove a lens once it's gone in the eye because it's rolled up like a taco but it unfolds so it can be a bit tricky to remove them so the best thing is to choose the lens you want be sure of it that's why if you're even thinking about special lenses much better in my experience that go and have a discussion because you'll either be told you're not eligible in which case you know you'll you'll know you made the right decision or you you'll have you'll be armed with the knowledge to make that decision because what you don't want to do is six months later go I wish I'd had that and I'd like to change it because very few surgeons will do that for you it's it's much riskier the lenses themselves well they don't go as I said nothing is never there have been some reports not the lenses that we use of some lenses going cloudy and there's something like one in fifty thousand or one of five hundred thousand but there's no no cases of our lenses going cloudy again the cloudiness that about one in four people experience is the is the something called a posterior capsular pacification and that's a healing response to the lens being put inside the eye so the lens itself doesn't go cloudy again.

Jane Styche

Okay, so the next person has two cataracts forming one started forming four years ago and one's recently just been diagnosed this is a concern, but a bigger concern is that they have floaters in both eyes and the right eye is almost like looking through a neck curtain can anything be done about these floaters?

Mr Jonathan Aboshiha

So good question because there are two issues so the cataracts the time to do the Cataract is when the Cataract symptoms are bothering you and they tend to be blurry vision and glare that it affects the point that you want to have the surgery bloaters are something completely different they're the jelly in the back of the eye getting I'm afraid to say something like a wrinkle and as we get older just like the lens gets a bit cloudy like our teeth go yellow the jelly the clear jelly in the back of the eye becomes a bit wrinkly and then we get floaters now it's not normally a problem but if you suddenly get a lot of floaters and this participle especially if they're associated with flashing lights or a dark shadow across your vision then you must go and see someone in a e straight away because that can be a symptom of a tear in the retina so the jelly can condense and pull away on the back of the eye and make a little tear in the retina and that needs to be treated otherwise you can get retinal detachment which is a bigger problem to fix so after caloric surgery some people can notice their cataracts there sorry their floaters more and that's because they just see better and sometimes the surgery itself can take few more floaters but normally it's because the floaters are there anyway but you just see them more when the cataract's gone is there anything you can do well that's an interesting question as I said probably when I started my career we were telling patients you know just put up with them but we have a couple of very good vitrio retinal surgeons here who they do cataract surgery but they also specialize not here at Benenden but elsewhere at Richfield retinal surgery and the vitriol bit is the jelly that has the wrinkles and it's now become as cataract so it'd be much much safer and so there is a procedure called a floaterectomy which is really a vitrectomy for floaters and it's increasingly now being done for people who have really bothersome floaters because most floaters a bit like the issues with the multifocal lens Halos most voters people notice them when they first see them and then they kind of disappear and actually what's happening is the brain is programming them out of their their visual perception and six months later you can still see the flow to there but people aren't aware of them but for people where they just really keep noticing the floaters and it really bothers them there is this procedure called a floaterectomy it's not something offered at Benenden but there are lots of places that can do it and some of the surgeons the VR surgeons here are very good and I'm sure if you contact us they'll be happy to show you show you where to go for that.

Jane Styche

So, I think you've answered this already but do cataracts have to be ripe before they're operated?

Mr Jonathan Aboshiha

Wow brilliant it's a million dollar question so sort of philosophical question yeah it depends how you Define ripe it ripe yes in the sense that ripe for me would be when you as an individual feel that your vision is effective such that you want to you want to go ahead with surgery and you know what the risks are that's right for me in that sense but in the traditional sense no we used to think they had to get to a certain density a certain cloudiness before we would operate and that's really based on the fact that it was much less safe surgery back in the day and so you didn't want to risk you know relatively good vision for an operation that might have a complication now and it even probably as recently as I think five or ten years ago the NHS had certain criteria where they would say you can't you're not eligible for cataract surgery on the NHS unless your vision is worse than driving standard which is about reading a number plate at 20 meters and that again that was maybe an indication of visual ripeness as opposed to sort of physically how dense it was but that's also been stopped or should have been stopped and the Royal College have said very explicitly that you know say your professional goal for you your fighter pilot you can't wait for that person to drop their Vision to the point where they can't even drive a car down the road you know it's going to be fair some people you know they have terrible glare and they've got really good distance vision or relatively good but the glare really bothers them and and it's all about you know you as an empowerment it's your decision about what the symptom is that's relevant to you it's not for a doctor or optician or anyone else to tell you what symptom is is is is indication for surgery it's about you to say look this symptom really bothers me the glare's awful I know I can see 20-20 but declare is terrible and I want something done about it then then there is no such thing as ripe and and there shouldn't be rationing by the NHS or any other unit about surgery obviously if your vision is perfectly good and you have no symptoms then you might think why would you want surgery but there's no no longer a desire or need for it to be quote ripe it's about when you feel that the time for surgery is right.

Jane Styche

Okay, can you recommend any treatment for blepharitis?

Mr Jonathan Aboshiha

Yes, I won't go into too much debate now, but you know we're happy to see you about it, it's a bit hard to say on a on a call because blepharitis is actually a kind of umbrella name in a slightly formed out of usage. Now amongst those of us that specialize in that part of the eye it's normally something called gland dysfunction but there can be different types of blepharitis posterior and anterior so it would depend on the on the cause and that there certainly are different treatments that are more efficacious than just putting drops in if I had to say one thing that I'm happy to say to everyone without worrying that it might not be right for one particular person is it's normally a big thing in the west is the ratio of Omega-three to omega-six and that's like you know oily fish one of them is anti-inflammatory and one of them is pro-inflammatory and we know that in the western diets we just don't get enough of this thing called omega-three which is anti-inflammatory and the ratio should be about one to one and probably most western diets about two0 times as much inflammatory stuff to one one of the one twenty to one you know against us are not in our favour so if there's one thing I can say it's it's you know healthy diet omega-three if you are going to buy supplements by those supplements that have been proven to work because the ones that are at lower dose haven't really been shown to work and the reason that helps in blepharitis is we think that it changes the consistency of the of the glands of the oil which actually is produced by little glands that open into the eyelid they go onto the surface of the cornea and they stop the tear film evaporating so if you just put artificial tears onto an eye that doesn't have a system to stop the tear film evaporating it gives you a bit of symptomatic relief for a few minutes or half an hour but it doesn't deal with the underlying problem there are other things you can do hot compress and massage with certain pads that have been shown to heat up to a degree whether the the fixed secretions actually liquefy but probably the the biggest thing you do to fundamentally change if you're if you're implying it's a posterior blepharitis or meibomian gland dysfunction is to get more omega-three on board but again there's a lot of debates about you know in the studies whether it works or not you know they reanalyse it they say it doesn't work and it's a difficult condition because it's a chronic condition I always tell people it's a bit like having dry skin there's not one tail dry hair you're not going to take a tablet or a course of tablets and get rid of your dry hair or your dry skin is lifestyle changes and it's often there's no one thing that will fix it but if you do lots of little things they might each take it down a little bit to the point where it's not bothering you so much.

Jane Styche

Okay so how long after cataract surgery might you start experiencing watery eyes?

Mr Jonathan Aboshiha

Depends whether you had water ice to begin with as I said watery eyes is often a a early symptom of dry eyes because the eye detects the dryness and that you have a reflex tearing from the gland up here that produces tears it's not a normal thing to get watery eyes but it's it's certainly not an uncommon thing to get watery eyes that's normally just because the it sort of all the cleaning and the manipulation of the island of the surgery can make the eye a little bit upset a little bit dry on the surface for a month or two so normally for a couple of months you you might get some dry ice symptoms a bit of grittiness and that can result in watery eyes but the surgery itself doesn't necessarily cause watery eyes it's just that the eyes can get a little bit dry afterwards okay so this person had laser corrective surgery 14 years ago took correction astigmatism but the vision has started deteriorating again and the condition has returned can this be further corrected so laser vision correction isn't something we do at Benenden you can always correct anything or try to the question is always about risk versus benefit read treatments of lasers is always always a little bit less predictable it's not uncommon when you have a laser position correction and this is where we're changing the shape of the cornea at the front of the eye to it's not uncommon for that to regress you know the effects it's great for a few years because sometimes can wear off it's just part of the body trying to heal the effects of the laser the most important thing in terms of cataract surgery is you tell your cataract surgeon that you've had that laser done if I can get as much information as possible especially you want to know whether the treatment was basically done for long-sightedness or short-sightedness or what we call hyperopic laser treatment or myopic you really really important to know that because laser surgery on the cornea makes the the mathematical models that predict which lens to use years later in calories actually less predictable and we have to make certain allowances for that so if you've had any laser surgery what we call laser vision correction on the front of the eye this is not for diabetes or anything but on the front surface of the eye to get rid of glasses or remove astigmatism then try and bring as much information as you can about that laser treatment that you had to your clinic for cataract surgery because the surgeons that see you will need to know that in order to adjust for that when they choose the power of the lens implant. Of everything having cataract surgery if you have an epiretinal membrane no greater risk of cataract surgery you just have to be aware that the membrane a bit like my camera analogy is at the back of the eye that's in the film of the camera and it can it can have very little effect or it can cause Distortion or even reduce the vision a bit and so the cataract is just tinkering around with the lens at the front it's not tinkering with the film at the back and you’re the visual image you see is a function of both so sometimes if you have enough retinal membranes if it's really bad they might send you off would refer you through a GP NHS or a vitro retinal surgeon who deals on the back of the eye to see if they want to treat that first or combine that with cataract surgery but if it's a mild one they would just say to you just be aware what they call a god of prognosis that there's something else here that might affect the vision and even when the cataract surgery goes perfectly that might slightly limit the vision but it's not that it will cause any greater risk for the cataract surgery itself which is something else to be aware of that might be affecting the vision.

Jane Styche

So, this person had recent visual fields test and was missing some of the little dots at the top of the screen, they've got an appointment in the NHS for further investigation and glaucoma was mentioned to them. So I'm not sure the question is but I imagine the question is is that relevant to cataract surgery?

Mr Jonathan Aboshiha

Oh yeah it's better to go to the NHS, they can't list you a cataract surgery if you're still waiting a diagnosis or potential diagnosis of glaucoma. Glaucoma is high pressure in the eye which is called the silent field of vision because if you don't pick it up you don't notice it until many years later you start losing your peripheral vision so it's always a thing that you want to get identified and treated if possible. Normally it's just a drop at night which makes your eyelashes look lovely, so most people quite like the treatment but it's much better to get that appointment and work out and ask them do I have glaucoma or not or am I going home or suspect or do I just have high pressure in my eye, do I need treatment and get all of that information with your discharge letter when you come to Benenden for your cataract surgery because they'll need to know that  the doctors here before they listed for the cataract surgery.

Jane Styche

So, this person wants to know if you have cataract surgery through the NHS and you're not given alternative lenses for example to correct astigmatism can you have a different lens put in later?

Mr Jonathan Aboshiha

That's an advanced question so you should always be offered that even if they can't they should always mention the option I mean when I started we used to do target lenses on the NHS but I think refunding there's very few places that increasingly places are not doing that so that's to correct astigmatism can you put a secondary what we call a secondary lens in you can you can either do laser vision correction afterwards or you could put a secondary lens in but both of those procedures are much more involved and potentially riskier than just having if you can have the caloric surgery anyway having the right lens put in at the time and so if you've already had it done and they they said that you've got loads of astigmatism we can't have offer you a toroid lens and you had it done on the NHS and you now think I wish I'd corrected the astigmatism there are things you can do secondary lenses and and or laser vision correction the frontier eye but it's it's always better in the first instance to to just have the correct lens put in to correct all your visual conditions and then you'd have to worry about because all those other things also have risks everything you do has a risk what is a pentagram scan for a pen scam scan is to measure the shape of the cornea the front and back surface because they both affect the optics very carefully it uses something called shine plug Imaging which I think was invented in World War One by some buys flying over Germany in biplanes and they would use the shadows cast by the camera and the light and the sun to work out heights of buildings and you know whether there were troops in there and so forth so it's a very very fancy camera that rotates around the eye as far as you're concerned it's just a light that scans but it gives us a huge amount of information about the cornea at the front of the eye which helps us in much more detail work out what kind of lens especially for multi-focal you should have I would be very wary of any if you were going anywhere else for your special lens surgery be very wary of anywhere that doesn't have something like a pentagram there are some surgeons who will you know because obviously there's a financial element who maybe haven't done refraction training who will put in multi-focal lenses just based on the basic biometry and I think that's really be very cautious of that because there's an awful lot that can surprise you in the cornea if you haven't measured it before and then I'm a corneal surgeon trained at Moorfields and you know I know first-hand that doing that without those pentagram scans or something with a different that's the most common popular machine but there are a few other models but if you're going anywhere and you know you decide to do that and it's not abandoned just do ask your surgeon how are you measuring the astigmatism in the cornea do you have a corneal what's called topographer or tomography corneal topography that's how you measure the shape of the corner in great detail.

Jane Styche

Do you treat glaucoma through surgery?

Mr Jonathan Aboshiha

You one can I don't personally I'm not a glaucoma surgeon but I have in the past you can do that most commonly glaucoma now is treated with drops or a bit of laser but Advanced glaucoma that's not responsive to drops or laser can be treated for the surgery I don't think it's done here at Bennington but we can do some assessments with that woman and let you get on at least that takes a bit of the wasting time especially if you think you have back lab program.

Jane Styche

So, this next person was prescribed varifocal glasses which actually made them feel quite unwell and giddy and nauseous and they wonder whether they'd have the same experience if they had multi-focal lenses?

Mr Jonathan Aboshiha

Excellent question, so the answer is generally no and the reason that the multi-focal sorry the varifocal glasses tend to affect you is something called a back vertex distance I.E the glasses are quite a long way in away from the focal point of the eye which is just at the back of the lens and so you get a prismatic effect when you're looking up and down through them, so the multi-focal don't cause those same side effects they do have some side effects and the main one is halos around bright lights like a you know extremely bright car headlight or you know that you notice in the first few weeks a month and then they suffer down and people don't notice them but yeah you don't get the same effects of the varifocal glasses because that's normally because of the position of the lens of the glasses relative to the focal point of the eye you know it's a couple of centimetres out in front.

Jane Styche

If you have cataracts in both eyes do you have them done together?

Mr Jonathan Aboshiha

So that's another interesting question. Historically no because of the risk infection but it's become so safe now we do offer same day both eye surgery the work done and about that there are theoretical tiny one in a million risks of infection in both eyes but especially for the multi-focal and premium lenses we do abandon offer them on the same day and I'd probably say about 70% of my patients prefer to just get them both done on the same day because you have one period of recovery one lot of drops and so forth they don't offer mono-focal lenses in the same day here I don't forget that they do for the special lenses.

Jane Styche

So, this person wants to know if there's any treatment for epi-retinal membrane?

Mr Jonathan Aboshiha

Yeah. The normal best treatment is to do nothing, but if it gets bad and peel it off in an operation and that's a VR surgery people do the back of the eye as mentioned earlier and that tends to be only when the membranes are really causing problems and the main problem tends to be distortion of your central vision.

Jane Styche

Okay so this person had both eyes operated on about five years ago, however they've never really noticed much benefit with their site they do have an astigmatism in both eyes and wonder if having a toric cleanse might improve their vision?

Mr Jonathan Aboshiha

I think if you've already had the surgery it's probably not worth pursuing more surgery to correct the astigmatism you know you have to be really driven to get rid of your glasses and there's just higher risks for that there might be some people have other conditions in their eye which might be why your vision is not good but if your vision now you've had the cataracts taken out clear monofocal lenses put in that didn't correct your wrist I.E non-toric lenses. I think the best thing is to you know just check that your vision with your glasses is good if it's not good then there's something else going on then you'll need to have a check-up for why that is probably the opposition is the first best point of call and so this person wonders they have uveitis but they don't have any of the regular symptoms they just have cloudiness and blurry vision and they wonder whether it can it lead to any longer term eye conditions so UV items is inflammation inside the eye it can be in the front of the eye the back of the eye or throughout the eye it's quite common at the front of the eye and often we don't find a cause in over half cases but if you keep getting it then you do need a check-up for some other conditions that might be psoriasis or rheumatoid or so forth and closing spondylitis either sort of autoimmune conditions that general population might have that cause iritis it can you just have to be aware sometimes you get a bit of iritis or uveitis inflammation inside the eye after surgery but it doesn't really affect cataract surgery eventually you know the cataracts will will happen the only caveat to that is often people who've had uveitis throughout the life will have had lots of courses of steroid eye drops to suppress the inflammation and that will often mean they get cataracts earlier in life.

Jane Styche

How long after cataract surgery do people require YAG laser?

Mr Jonathan Aboshiha

The studies show that it's about 20 to 25 percent of people require a laser polish within the first year, if you live long enough everyone will eventually get that little membrane or healing response because it's just a very slow healing response around the lens which is really all that you get you don't get any other inflammation and come out so about portrait people in the first year and you know quite a few people in the years to come. You know if you leave it say you have caloric surgery when you're 25 you almost invariably get some of this pacification in your lifetime.

Jane Styche

So this person has asked I've learned that I also have glaucoma in my left eye it may not be possible for me to have toric lenses fitted, what is your view on this please?

Mr Jonathan Aboshiha

Yeah but I think the it's always about first you know harm as a doctor so you know the doctors and hospitals are all happy to give you the best then possible because it's also a financial incentive but we have to weigh that up as any potential risk now if you had very mild glaucoma maybe on a couple of drops there was no nerve damage no field also minimal then I think I'd be happy to put toric lens in there's a bit of a debate about multi-vocal lenses again in mild glaucoma I consider it but anything more than that I probably wouldn't and the reason is that people worry about anything you know what might be seen as fancy that then might have even if that complication risk is you know half a percent or something like that if there was a pressure rise and it damaged the nerve and so forth and people would say you know why are we trying to do something clever but I think I certainly consider putting a toric in it depends on you know each of us as individuals if you had a horrific glaucoma and really very fragile nerve the best thing is to do a very simple procedure when no no other risks.

Jane Styche

Well thank you very much. I'm sorry if we didn't have an opportunity to answer everybody's questions but if you provided your name in your question, we will do so via email.

If you would like to discuss or book a consultation, our Private Patients team will be available between eight and six, Monday to Friday.

We are offering a discount for joining this session for seven days with the terms on the screen.

You will receive a short survey and I'd be grateful if you could spare a few minutes to let us have your feedback on our webinar.

Our next webinar is on Wednesday the 22 of February at six and that is on hand and wrist surgery. Visit our website to sign up for that.

So, on behalf of myself and the team at Benenden Hospital, I'd like to thank you for joining us and we hope to hear from you very soon. Thank you and goodbye.