Basic Cataract Surgery, Custom Cataract Surgery and Refractive Lens Exchange

The recent explosion of technology in cataract and refractive surgery has opened up new worlds of vision to our patients. Because we now have so many options that were previously unavailable, many patients are confused by the choices that they face when it comes to rehabilitating their vision at the time of eye surgery. To help you navigate through the seas of confusion with regard to these choices, I have prepared this handout.

At the end of the handout, you will find a flowchart with self-directed questions to help you choose a plan that works best for you as well as a chart summarizing all of the options, including costs, advantages, and disadvantages of each approach.

Let’s start with a few definitions:

A cataract is a cloudy lens. You can imagine how the cloudy lens blocks light that needs to enter your eye, thus causing blurry vision. Cataract surgery is indicated when the vision worsens to the point where, even with glasses or contact lenses, the patient has trouble functioning with activities of daily living such as reading or driving.

Cataract surgery works by removing the cloudy lens and replacing it with a clear lens, called an intraocular lens (IOL) or an implant. There are many types of implants we can use, depending upon your situation and your goals.

Understand that the primary goal of Basic Cataract Surgery is to remove the cloudy lens (the cataract) and replace it with a clear lens—the implant. Replacing the cloudy lens with an implant allows the eye to regain its potential for vision. In order to get the best possible vision after cataract surgery, it is often necessary to wear glasses or contact lenses, especially for reading.

For patients with active lifestyles who desire less dependence on glasses and contacts, we can achieve these goals with Custom Cataract Surgery, using advanced technology implants such as aspheric lenses to reduce spherical aberration, Toric lenses to reduce astigmatism, and multifocal lenses to provide simultaneous far and near vision without glasses. These options are described in greater detail in this handout.

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For patients without clinically significant cataracts who desire the benefits of the newer technology intraocular lenses, we offer a procedure that we call Refractive Lens Exchange. With Refractive Lens Exchange, the goals are somewhat different from patients having traditional cataract surgery. Because these patients already have adequate vision with glasses (whereas cataract patients do not), the primary goal of Refractive Lens Exchange is to reduce or eliminate your dependence on glasses and contact lenses. Understand that although most of our patients who undergo Custom Cataract Surgery and Refractive Lens Exchange will have decreased dependence on glasses and contacts—and many functions entirely without them—it is impossible to guarantee that all patients will be able to function without glasses for all things.

Basic Cataract Surgery

Those patients who simply want to see better but do not mind wearing contact lenses or eyeglasses are best served by having Basic Cataract Surgery. Basic Cataract Surgery is the least expensive option for our cataract patients, yet we find that these patients enjoy excellent quality of vision after surgery. With Basic Cataract Surgery we use traditional Monofocal lenses with powers that typically are calculated to help you see far away. This is the option that most of our patients choose. It uses the tried and true technology of traditional Monofocal IOL’s that has been developed with great success for over 50 years.

After Basic Cataract Surgery, most patients require reading glasses and/or bifocals to achieve their best vision. Reading glasses have the virtue of being inexpensive (generally around $10) and readily available without a prescription.

Understand that although an effort is made to lessen dependence on glasses even with our basic surgery, there is no guarantee to eliminate glasses, especially for reading. The Monofocal lenses used in Basic Cataract Surgery are covered by Medicare and private insurance, plus whatever deductible or copay your plan may have. Patients who choose Basic Cataract Surgery who later desire reduced dependence on glasses after surgery must understand that further refractive procedures such as LASIK, PRK, or intraocular lens exchange are the financial responsibility of the patient.

Custom Cataract Surgery

Many of our patients who are younger and have more active lifestyles want to be able to see without glasses. The goal of Custom Cataract Surgery is to reduce or eliminate your dependence on eyeglasses and contact lenses. Custom Cataract Surgery has as its basis the same procedures used in traditional cataract surgery, but involves extra testing, materials, and procedures to improve the patient’s chances of becoming less dependent on glasses. The additional procedures involved with Custom Cataract Surgery are considered to be in the category of luxury or cosmetic procedures; thus, they are not covered by insurance. Understand that after cataract surgery, in order to achieve your best vision, it is possible that you may need

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3 to have one or two laser procedures, namely a YAG laser capsulotomy and/or laser vision correction such as LASIK or PRK.

In order to assess your suitability for Custom Cataract Surgery, a battery of tests is performed. We call these tests our Refractive Services Package, which involves screening tests not normally covered by insurance or Medicare.

Refractive Services Package

The tests included with the Refractive Services Package include corneal topography with Pentacam topographers and assessment of macular function and the health of your optic nerve with OCT. Refractive Services are not covered by Medicare or insurance, but the cost of the testing, $______, is applied to the cost of the first implant if you choose to have Custom Astigmatism or Custom Multifocal surgery. If you choose Custom Distance or Custom Monovision, there is no additional out of pocket fee associated with those programs after the testing has been completed. Patients who have a history of prior refractive surgery such as LASIK, PRK, or RK are required to have a Refractive Services Package examination in order to plan their surgery

Custom Cataract Surgery Options

There are four options we offer for our Custom Cataract Surgery patients: Custom Distance, Custom Monovision, Custom Astigmatic, and Custom Multifocal. Understand that special cases, especially those patients with a history of prior refractive surgery such as LASIK, PRK, or RK, may require the use of more than one technology or procedure in order to obtain the desired result. Dr. Silk will work with you to help you make the best choice for you.

Custom Distance Our Custom Distance program involves the use of Monofocal, aspheric intraocular lenses set for distance vision in each eye. Extra testing with our Refractive Services Packages helps us customize our choice of implant to your eye. By measuring your spherical aberration prior to surgery, aspheric lenses can often be used to reduce your aberration profile after surgery. The goal with Custom Distance is to see well enough with each eye to pass a driver’s license test without glasses.

Custom Monovision With Custom Monovision, we aim for distance vision in the dominant eye. We aim for reading vision in the non-dominant eye by making it nearsighted. Having one eye set for distance and one eye set for near increases the number of things that you can do without glasses. This approach after cataract surgery or refractive lens exchange works best in patients who have a history of successful contact lens wear for monovision.

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The disadvantage with monovision is that both eyes may no longer work together for distance or near vision. Some patients, realizing the advantage of increased freedom from glasses and contacts, tolerate this disparity extremely well. Other patients are unable to tolerate the imbalance between the two eyes, thus we find this plan works best in patients with a history of successful monovision with contact lenses. Some patients find after surgery that prescription glasses allow the eyes to work together better for driving or extended periods of reading. The goal with Custom Monovision is to see well enough to pass a driver’s test and read a newspaper without glasses.

Custom Astigmatic In order to understand Custom Astigmatic Surgery, it is important to have a good understanding about astigmatism. An eye without astigmatism has focusing elements (namely the cornea and the lens) that are essentially spherical, like a basketball. Eyes with astigmatism have a shape more like the surface of a football or an egg. You can imagine that eyes with refracting surfaces shaped like footballs do not focus light very well!

If astigmatism is not corrected, even patients with clear lenses after cataract surgery will have blurred vision. Traditionally, astigmatism is corrected with eyeglasses or contact lenses. For those patients with cataracts and astigmatism who desire increased freedom from glasses, there are several surgical methods for correcting astigmatism:

 Limbal Relaxing Incisions (LRI): these are made at the time of cataract surgery with a diamond blade or a femtosecond laser. As they heal, they flatten the steep part of the cornea and steepen the flat part of the cornea, thus making the cornea rounder.  Placement of a Toric (Astigmatism Correcting) Intraocular Lens: this procedure involves the addition of a more expensive type of implant that corrects for astigmatism, and has the advantage of being more precise than LRI’s. Rarely, Toric implants can rotate out of position after surgery, requiring surgical repositioning.  Excimer laser refractive surgery (PRK and LASIK): PRK and LASIK are the most precise methods for reducing astigmatism. Sometimes an excimer laser “touchup” procedure is necessary after custom surgery to fine tune vision.

Prior to surgery for astigmatism, a number of special measurements are taken, and extra care is needed in the planning for and execution of surgery. Custom Astigmatic Surgery will be used to target either distance vision in both eyes or monovision, depending upon your goals. Because astigmatism can otherwise be easily corrected with eyeglasses, surgical correction of astigmatism is considered by Medicare and private insurance carriers to be a cosmetic or luxury procedure and is not covered by insurance.

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Custom Multifocal The newest generation of multifocal implants include the Tecnis Multifocal Lens (TMF), “extended depth of focus” Symfony and Symfony Toric lenses, made by Johnson and Johnson, and the “trifocal” PanOptix lens made by Alcon. Our practice has extensive experience with multifocal lenses. The TMF, Symfony and PanOptix lenses work by providing simultaneous near and far vision in each eye, thus allowing both eyes to work together for both distance and near.

Weaknesses inherent in all multifocal IOL designs include aberrations that can cause glare and halos, especially at night around oncoming headlights. About 2-3% patients describe the glare and halos with multifocal lenses as “severe.” Multifocal lenses work best with binocular vision (both eyes working together), therefore, you will not get the full effect of multifocal vision until you have had surgery on your second eye.

Although multifocal lenses may represent your best option for reducing your dependence upon glasses and contact lenses, it is impossible to guarantee that you will be able to throw away your glasses. Reading glasses, for instance, will always magnify near objects, thus making them easier to see, even with a multifocal lens in place. Because Medicare and private insurance companies consider multifocal lenses to represent a luxury technology that is not absolutely necessary for good vision, these lenses are not covered by Medicare and insurance.

Refractive Lens Exchange

Refractive Lens Exchange is a procedure that utilizes all of the available technologies we have for cataract and refractive surgery to improve vision and lessen dependence upon glasses and contact lenses in people who do not have clinically significant cataracts. All of the options discussed above, including multifocal lenses, traditional Monofocal lenses for distance vision, monovision, Toric intraocular lenses for correction of astigmatism, and limbal relaxing incisions, can be used to achieve decreased dependence upon glasses and contact lenses.

A Few Words Regarding Intraocular Lens Power Calculations

Although the techniques we use to measure the eye and calculate IOL powers are state of the art, they are not perfect. We make every effort to ensure that our patients’ refractive results are as intended. Because of some inherent limitations of these technologies, a small percentage of patients may have an unpredictable outcome after surgery, especially in patients who have had prior refractive surgery such as RK, LASIK, or PRK. A way to think of this is to imagine that some patients may under- or over-respond to surgery, despite our computer

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6 calculations and measurements prior to surgery. Although these are not common, under- or over-responses to surgery are a statistical inevitability and the possibility that you may be one of these over or under responders must be taken into account as you consider surgery.

Tuning Up Your Vision After Surgery

Regardless of the option you choose for rehabilitating your vision after cataract surgery or refractive lens exchange, understand that further surgery such as YAG laser capsulotomy, PRK, LASIK, and/or intraocular lens exchange may be required to fine tune your vision afterwards. These options are described in further detail below. YAG laser capsulotomy is covered by insurance and is often necessary in up to 50% of patients in the short or long term after surgery. PRK and LASIK are not covered by insurance, but are offered to our refractive cataract surgery patients as a free benefit, if necessary, within 12 months after surgery. Basic cataract surgery patients who elect to have PRK or LASIK after cataract surgery are subject to our normal fee schedule.

Posterior Capsular Opacification (“After Cataracts”) and the YAG Laser

In some patients after cataract surgery, the membrane that holds the intraocular lens in place can become wrinkled or cloudy with scar tissue. This is called Posterior Capsular Opacification (PCO), or an “after cataract,” and is commonly seen after cataract surgery. If posterior capsular opacification develops, the patient typically notices the onset of blurred vision. PCO is easily treated with the YAG laser. The YAG laser is a “cold” laser which disrupts the scar tissue behind the implant, thus opening up the visual pathway for more light to enter the eye. Because there are no nerve endings in the scar tissue, there is no pain associated with the procedure. Side effects after the treatment include the presence of floaters which typically resolve after several days. YAG laser treatments are covered as a medical necessity under all insurance plans, including Medicare and Medicaid.

LASIK and PRK Enhancements after Cataract Surgery

If further LASIK or PRK is necessary for any of our Custom Cataract Surgery patients, Dr. Silk will waive his professional fees. For those patients who choose to have Basic Cataract Surgery, understand that additional refractive procedures are NOT covered and are your financial responsibility. LASIK and PRK work by reshaping the cornea so as to correct residual refractive errors such as nearsightedness, farsightedness, and/or astigmatism that sometimes occur after cataract surgery.

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Remember that all of the options presented above represent efforts to reduce your dependence upon glasses and contact lenses. None of these options can guarantee you to throw your glasses away. Talk with us about which of these options might be best for you.

Additional Procedures:

1) Lasers are becoming more commonly used to assist in cataract surgery and help to streamline the surgery. There have been many studies comparing the outcomes of traditional (by hand) surgery vs Laser assisted cataract surgery and the outcomes for both are outstanding. We believe that with both methods will improve your vision and the there are no clear advantages of one technique over the other. However, there are patients who feel more comfortable with having a laser to assist with the surgery. Dr. Silk is very experienced with both techniques and can comfortably perform either one. However medical insurance will not cover the cost of the use of a laser and there will be an additional cost of $______per eye.

2) Dry eye disease (DED) affects millions of Americans and is one of the most common causes of decreased vision. Patients with DED will commonly complain of burning, stinging and redness of the eyes. They will also say their vision is blurry throughout the day. DED patients who also have cataracts should strongly consider having their dry eyes treated before having cataract surgery to insure they achieve the best vision possible. We offer many in office treatment options such as:

 Blephex to remove the dried oil and dead skin from your eyelids which can be an irritant to your eyes.

 TempSure Envy which uses warm heat to melt the clogged oil glands and allow for removal so the healthy clean oil can come to the surface of your eye.

Both of these procedures are very comfortable and take 15-20 minutes to perform. The cost for a one- time treatment for either of these is $_____ for both eyes.

How to Make a Decision

A flow chart with self-directed questions to help you choose an option that is right for you follows at the end of this handout, along with a summary table of all these options and costs. Please read the flow chart, indicate how you would like for us to rehabilitate your vision, and bring this handout to your visit with Dr. Silk. We hope that this information has been helpful to you. If you have further questions, Dr. Silk and our staff are happy to answer them for you.

www.silkvision.net 3301 Woodburn Rd. Suite 308 | Annandale, VA 22003 |912-352-3120

START HERE YES “I want to see well without glasses or Custom Cataract Surgery I want to be less dependent on contact lenses after surgery” glasses and wouldn’t mind Yes or No (follow arrows) paying a little bit extra Custom Distance Will need inexpensive reading glasses/bifocals for near I want the best distance vision (e.g., to pass a drivers’ test without glasses) and I wouldn’t Custom Astigmatism NO mind reading glasses (This option can be combined I wouldn’t mind wearing with other plans for distance or glasses or I just want monovision) whatever is covered by insurance I have astigmatism that needs to be corrected (if you’re not sure, your doctor can help answer this Custom Monovision question) (One eye for far, one for near; eyes may not work together)

Basic Cataract I want to see well without Custom Multifocal Surgery glasses or contacts for both far and near Symfony or PanOptix (higher chance of needing (Eyes work together for far and glasses for far and near) near vision, may see halos)

Basic Cataract Custom Cataract Surgery Surgery Custom Distance Custom Monovision Custom Astigmatic Custom Multifocal What is it? Traditional cataract Surgery aiming for best One eye set for far; Custom correction of Extended depth of surgery possible distance vision one for near. Custom astigmatism with a focus or trifocal working distance for Toric intraocular lens implant provides near defined by you or limbal relaxing simultaneous far and incisions (LRI’s) near vision without glasses What’s Monofocal intraocular  Refractive Services  Refractive Services  Refractive  Refractive included? lens (implant) Package (RSP) Package Services Package Services Package  LASIK/PRK  LASIK/PRK  Toric implant  Symfony or and/or limbal PanOptix relaxing incisions implant  LASIK/PRK  LASIK/PRK Goal Better vision Less dependence on Less dependence on Less dependence on Less dependence on glasses for distance: glasses: pass a driver’s glasses: better glasses: pass a pass a driver’s test test and read a quality of vision by driver’s test and read without glasses newspaper without reducing distortion a newspaper without glasses caused by glasses astigmatism Advantages Affordable Both eyes set together Good range of distance Better vision without Best overall range of for distance only. Yields and near vision glasses. Can be used vision. Eyes work best quality distance without glasses. for distance or together without vision without glasses Works best if you have monovision targets glasses for both far with minimal aberrations successful history of and near. Can also at night monovision contact correct astigmatism lens wear if needed. Disadvantages Greater chance of Need reading glasses Eyes may not work Small chance Toric You may see rings or needing glasses or and/or bifocals for up well together. You lens may rotate and starbursts around contacts for both close may have a blurry zone need repositioning. headlights at night distance and near between far and near. Need readers for near. What does it Covered by insurance $____for both eyes $_____ for both $_____ per eye $______per eye cost? and your standard (includes Refractive eyes (includes (includes Refractive (includes Refractive deductible & Services Package) Refractive Services Services Package) Service s Package) copayment Package)

 Please call our office for pricing