Cataract Surgery- when I was wrong

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I have been a cataract surgeon for over a decade now, and with that experience, I am usually fairly accurate in my clinical assessment of how well my patient will fare after surgery. Occasionally I am surprised myself by the outcomes, just like I was on a case I operated on last week.

Mdm C is not your typical patient. She presented to me with poor vision in the right eye, and on examination she did indeed have a cataract in that eye. However, she was also markedly short sighted in that eye, and had been so since childhood. Her spectacle degree in that eye was 750 degrees, with astigmatism of 225 degrees. Her vision was perfect in the left eye without glasses. Due to the large imbalance between spectacle degrees of both eyes, she had lived her life without glasses and relied heavily on the left eye, and had lived with poor vision in the right eye for decades.

In this case, there is a high chance that she has developed a lazy eye in the right eye. In childhood, vision must be good in both eyes in order for pathways between the eye and brain to develop normally. If vision is better in one eye, the poorer eye will become “lazy” and the pathways to the brain will not develop normally. This is a condition known as amblyopia. Pathways mature when a child reaches the age of 8, and beyond that age, the vision in the lazy eye cannot be improved.

In Mdm C’s case, I felt that the likelihood was high that she had amblyopia in the right eye, as she had been highly short sighted in that eye all her life. As a result, even with cataract surgery, I felt her vision would not be as good as her left eye.

I discussed this at length with her and her son, explaining to them the benefits and risks of cataract surgery, as well as my concerns that her vision would not be perfect in the right eye even after surgery. However, as her vision in the right eye was very poor, she decided to proceed with surgery despite the guarded prognosis. Her vision was 6/120- she was only able to see the biggest letter on the chart.

Surgery proceeded uneventfully. I removed the cataract and implanted a toric intraocular lens in the right eye, which corrects for both short sightedness as well as astigmatism.

She returned for review on the first postoperative day. When I opened her chart, I thought I had the wrong patient. Her vision in the right eye was 6/6- perfect vision!

Mdm C was ecstatic. She had not seen well in the right eye for decades as it had always been highly short sighted, and had never worn glasses or contact lenses in that eye. For the first time in her life, she had good vision in both eyes.

I had been wrong about my assessment that she had a right lazy eye- and I had never been so happy to have made a misdiagnosis.

I am always delighted when my patients achieve good outcomes, there is nothing more satisfying to me than restoring vision to my patients. When outcomes exceed expectations, I can only be humble and grateful, to God for whom nothing is impossible, and to my patients, for putting their faith in me, and giving me the privilege of being their cataract surgeon.

 

 

 

 

 

Remembering Patient X

black-and-white-marina-bayI was recently asked to see a patient in the ICU. This patient was admitted for lymphoma and had developed a reaction to a drug she was taking. The reaction can also affect the Eye, and hence I was asked to review her.

She reminded me of a patient I operated on a few years ago. Mr X was an elderly gentleman who had end stage multiple myeloma and had been given 6 months to live. His Oncologist referred him to me because he had poor vision.

I examined him and found that he had significant cataracts in both eyes, causing his vision to be quite poor. I was hesistant to offer him cataract surgery because he did not have long to live, and didn’t have much time to reap the full benefits of cataract surgery. I did not want him to spend his time and his money on surgery if he had more fulfilling ways to spend the limited resources he had left on earth.

He assured me that surgery was what he really wanted. He told me, “Doctor Chan, I do not have much time left. I just want to see my loved ones clearly in my last days. Will you help me?”

We scheduled surgery a few days later. Cataract surgery is always done one eye at a time, and I arranged for the worse eye to be done first. I also thought that if I restored vision in the worse eye, perhaps he would be satisfied and may not want to proceed with the second eye.

Surgery went well and was uncomplicated. On the first postoperative day, he could see 6/6- perfect normal vision. He was elated. The first question he asked me was, “Doctor Chan, when can we do the second eye?”

I could not refuse him. We scheduled surgery 2 days later.

Mr X had a good outcome for the other eye as well, and achieved 6/6 vision in both eyes for distance. As I had implanted monofocal intraocular lens implants for both eyes, he required reading glasses to read, but was happy with the outcome.

His gratitude was palpable. He said, “Thank you Doctor Chan, you have made a dying man very happy”.

I reviewed him again a week after surgery, and again a month later. He was subsequently discharged to a hospice that cared for him in his final days. He did not show up for the appointment I made for him 6 months after surgery.

Every patient is special to me, I cherish each and every one of them, and I am always humbled by the privilege to help them. Mr X, however, reminded me what I studied Medicine for, why I worked so hard as a trainee to become an Ophthalmologist, and what debt I owe society for the privilege of being a doctor.

Mr X, I will always remember you. Thank you for the privilege of being your cataract surgeon. I am grateful for the trust you had in me. It was my great honour to have helped make your last days brighter and more comfortable. May you rest in peace.sakura

Cataract Surgery- What to Expect

Have you or anyone you know been diagnosed with a cataract and are contemplating surgery for it? I have done well over a thousand cataract operations in my career, but I have to be honest- I have never been on the other side of the table, and have never had the procedure done myself. A good friend (an Anesthetist I have worked with for many years), however, has had both his cataract surgeries done, and I made him give me a blow-by-blow account of the experience, so that I could better understand what my patients go through. Here’s what to expect on the day of surgery.

 

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This Eye badly needs Cataract Surgery!

 

 

The Preoperative Preparation

If asked to fast before surgery, please do fast! Please do not cheat and eat if instructed not to do so. During surgery, mild sedative medications may be given to you if you feel anxious, to calm your nerves for a better surgery experience. It is important that these medications be given on an empty stomach, in case you feel nausea and retch- regurgitated stomach contents can actually go down the breathing tube and cause serious lung problems! Fasting is usually from 12 midnight the night before for surgery listed in the morning, and from 6am on the day of surgery for surgery listed in the afternoon.

You will be asked to report early for surgery because preoperative eyedrops have to be instilled into the eye, to prepare the eye for the cataract operation. These drops are needed to dilate the pupil of the eye to allow the cataract, which lies behind the pupil, to be removed. Drops usually take about an hour to reach peak effect.

 

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Before and After Pupil Dilation

 

The Surgery Experience

Once ready, you will be taken to an operating theatre. If you have requested for an Anesthetist to be present, he or she will set a line on the back of your hand- this is used to administer sedative medications to relieve your anxiety and make you more calm.

The Eye itself requires some anesthetic for surgery as well, and this is usually administered via eyedrops. Your surgeon will usually administer these drops him/herself. Occasionally, an injection may be required to achieve complete numbness of the eye. This is given just below the eye, through the skin on the lower eyelid. It sounds intimidating, but really only takes a few seconds to give and it is over!

Surgery is done on an operating table, with the help of an operating microscope. Once your face has been cleaned and a sterile surgical draped placed over you, a small metal speculum will be used to help to keep your eye open throughout the surgery. The speculum will cause mild discomfort and a feeling of pressure around the eye- do alert your surgeon if the discomfort is unbearable, as the speculum can be adjusted to your comfort.

 

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The Speculum- uncomfortable, but not as bad as it looks I promise!

 

Once surgery starts, you will be asked to look straight ahead at the microscope. What you will see is 3 bright lights arranged in a triangle. Although it is difficult to maintain your focus on the 3 lights – the body’s instinct is to close the eye, it is imperative that you try your best to focus on the lights during surgery.

You will first feel mild pressure as the surgeon makes 2 incisions in the cornea (the transparent tissue in the front of the eye), and makes a small hole in the capsule of the cataract. Some water is injected around the cataract to loosen it, then the ultrasound (phaco) probe is inserted into the eye.

When the probe is activated, a buzzing sound is heard, and this sound is usually interspersed with higher pitched sounds as varying amounts of ultrasound is applied to break up the cataract. Do not be alarmed by the machine noises, they are perfectly normal!

Once the cataract has been removed, the intraocular lens has to be inserted in its place to give you good vision after the surgery. I have been told that this is the most uncomfortable part of the surgery. Intraocular lenses are small, foldable acrylic or silicone implants that are injected into the eye through the main incision. The lens is usually about 13mm long and 6mm wide, but has to squeeze through a tiny 2.65mm incision, hence the patient usually feels the most pressure as in enters the eye. Thankfully, lens insertion is usually over in a matter of seconds.

 

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Intraocular lenses are folded and injected into the eye via a small 2.65mm incision

 

Once the lens has been inserted, surgery is more or less done! What remains is to instil medications into the eye, ensure the wounds do not leak (they generally are self sealing and do not need to be stitched), and the operation is over.

In some circumstances, additional steps such as the use of a Femtosecond Laser or a Computer Guided Toric Lens Placement system may slightly prolong surgery. More about these exciting technology in another post!

What will I see and hear during Surgery?

Patients are often fearful that they will see instruments going in and out of their eyes. In fact, this is not the case. Usually what is seen at the start of surgery is the 3 bright lights of the operating microscope. These 3 lights gradually become a bright blur as surgery progresses, and even at the end of surgery when the drapes are removed, vision is not clear. This is because the light-sensitive pigment in the retina of the eye gets bleached by the microsope light, and regeneration of the pigment requires some time in a dimmer environment. Hence, you will only begin to see clearer in the recovery room after surgery is completed.

The operating theater is a busy working environment the Surgeon, Anesthetist and Nurses work together to perform the operation on the patient. In addition to the beeps and buzzing of the machines, you can expect to hear people talking- the Surgeon requesting for instruments from the Scrub Nurse, the Anesthetist giving instructions to his Nurse. Your Surgeon or Anesthetist may even talk to you, to keep you calm and keep you company during your surgery!

What happens Postoperatively?

Once surgery is over, you will be brought to a recovery room to be monitored. Patients are often fasted for surgery and come out pretty hungry, so milo and cookies are served! After the nurses have shown you how to instil your postoperative eye drops and care for your eye, you can be discharged to go home.

 

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The postoperative hot beverage and cookies- something to look forward to after surgery!

 

I hope this has been a useful guide on what to expect from Cataract Surgery! Many of my patients are intimidated by the prospect of surgery, but come out the other side surprised by how pain-free and simple the process is. Do write to me if you have questions, I will be glad to answer them.