Is this experience typical?

[LynneAV]

I am scheduled for cataract surgery in one week, from the MD who has been treating me for uveitis. (The uveitis has been quiet for 7 months, but I was warned that it could flare due to the surgery). I am upset and seriously thinking of canceling the surgery. Nobody seems willing or able to tell me what kind of lens will be implanted, and this is making me insane. I need to plan ahead. Will they keep me nearsighted as I am now, and therefore my current glasses will be usable when my eye recovers? Or will there be a huge surprise with my vision and a long delay for ordering new glasses when I cannot drive or function? The eye center acts as if this is an unusual question and not very important. I can't get answers on this.

Secondly, today I received the packet of information that gives me all my orders -- and "anesthesia" is referred to, although not explained. It sounds as if some type of general anesthesia is planned (there are orders not to eat or drink, instructions to pay the anesthesiologist corporation separately, etc.). But everything I've read about cataract surgery on adults says that only a local anesthetic is usually required, and that is what I have been expecting.

If I change doctors, my insurance company will no doubt balk at paying for double testing and I'll have to pay for the second set of pre-surgery tests myself, but I'm thinking it might be worth it ... or, am I being unreasonable and merely a nervous patient?  

[LynneAV]

HAPPY UPDATE!  Overjoyed with the results.

After canceling my July cataract surgery and venting and dramatizing on this board for awhile, I managed to calm down, regroup, and get my questions answered and concerns addressed by my eye doctor and staff. I re-scheduled the surgery for yesterday, but remained very apprehensive both about my uveitis and uncertainty about being able to adapt to a change to my usual vision, bad as it was.

I became pretty much OK with having my dominant near-sighted cataract eye set for distance after learning that my other eye is barely near-sighted (alll my life I had thought both eyes were equally near-sighted), but I still had reservations about being able to see in the shower, put on make-up, etc. But I agreed that the distance setting for a very dominant eye, in this case, was the best decision and we went ahead.  I received the AcrySof IQ. I was awake during the operation and heard only, "Good, good, good ..." from my doctor, which was very reassuring. (I was hoping there wouldn't be any "OOOPS!") I had a patch on overnight and returned this morning to have it removed. I wouldn't open my eye upon command because I was too scared to know the results, and I think they were getting a tiny bit exasperated with me, ha. But when I did finally take a look -- it was a miracle. I started crying right then and there and couldn't stop, kept repeating that it was a miracle. I have never had vision like this, not my entire life, not even with contact lenses.

And, my uveitis has not flared .... knocking on wood, but this was such a worry also. I feel so good today that I want to take on the world and accomplish every project I have pending. I am in no pain and full of energy, and the happiest I have been since I can remember. It was such an unexpected bonus to have such incredible vision. Guess what, there are not two stop signs at our corner, and I could actually recognize my husband standing out on the front lawn and actually see my black kitty against the dark green sofa.

I will get progressive bifocals to help my other eye and to assist for reading, but at the moment I am not at all disabled and can get around and do everything I need to do -- and better than I have in my entire life, actually. I am so thrilled.

XOXO to everybody who provided input and helped me hash out the details here.

[JodieJ]

You might try lined bifocals instead of progressives.  I think you'll get sharper distance vision.  I know other people with mild myopia who remove their glasses for near vision tasks. (Hey, whatever works.)

It's best to verify the anesthesia to be used beforehand.  I hate sedation, too, and it was standard at the surgery center I used.  (For whatever reason, it seems to be standard for cataract surgery in just about all the surgery centers in my city.  Elsewhere on this forum, Dr. Hagan has stated that sedation is rarely used at the surgery center associated with his practice.)  After discussing it with my surgeon, he agreed to let me skip the sedation.  You'll have to decide whether this is a deal breaker if your surgeon won't go along with your wishes.  It seems to me that your judgment about appropriate clothing is sound; I'm sure you'll get no comments if your top doesn't zip or button up the front.  

[LynneAV]

Thank you for understanding what I am trying to say. That is very refreshing, I've been feeling like I'm talking Greek in my doctor's office. It alarmed me when all I could get from them were "infomercial" type testimonials from other patients who can drive and swim and watch TV without glasses -- **AGAIN** . Since I NEVER COULD do any of those things without glasses, none of that applies to me, and it was getting very boring and repetitive as well as annoying.

Up to now I have never been able to get progressive bifocal glasses that give me more than so-so distance correction -- it's much better than with no glasses at all, but not what I consider "good enough" and nowhere near as good as what I got with contact lenses. Nobody can say why, so I live with it. Also, they can't seem to make the near vision part of the glasses work at all for me, therefore I just take the glasses off to see close or near-intermediate. When I report this problem, I get "the look" that tells me I am crazy (as if I have some reason for lying and actually prefer this constant on/off/on/off/on/off routine?). I can live with it.

Personally I would prefer no sedation because that is what gives me an unbearable, screaming headache for the entire day after any procedure, on top of the headache and discomfort from the dehydration and low blood sugar and caffeine withdrawal caused by the "no water and no food" stipulation that goes along with sedation. From what I've read, sedation for cataract surgery is usually only given upon request to those patients who think they cannot deal with their anxiety. This was never discussed with me. If sedation is optional, I'd like to do without it and increase my comfort and recovery a million percent (not to mention decreasing cost to my insurance company). I am not nervous about the procedure itself, only about what "correction" they were intending to give me, and by the fact that this is some secret.

Oh, by the way, do you know the reason behind the order for a special outfit to wear during the procedure? "Loose and buttoning in front" only applies to my bathrobe or maybe my husband's winter parka ... If they are trying to protect the eye by preventing a patient from pulling a shirt over her head, then it's simply a matter of demonstrating how a woman my age has decades of practice getting dressed without touching make-up and hairdo, heh. I will cooperate 100% with anything I can, but it goes better with me if I can know reasons for demands.

[JodieJ]

If you chose to have good near vision without correction (which is close to what you have now), you would have good vision at all distances with progressive glasses.  Given your history of eye turning, you might not be a great candidate for blended vision/monovision.

Now that you have some idea about your options and what you want, you are in a position to discuss your goals for your vision with your surgeon (or a different surgeon).  If you chose a near vision correction, your old glasses might work all right until you got a new lens for your operated eye.  (Ask the surgeon.)  Since your (former?) surgeon hadn't asked about your preferences, I suspect that she was planning to correct your eye for good distance vision (which would make everything within arm's length blurry.)  Also ask about recommendations for your second eye.

Given the instructions you received, it sounds like the surgery center uses light IV sedation during the procedure.  You will be awake but drowsy and not anxious, and you probably won't remember much about the procedure.  (Cataract surgery is not painful, and everything is over in about 15 minutes or less.)  It's never a bad idea to ask about the anesthesia to be used during your consultation with the surgeon.  

[LynneAV]

Thank you very much, JodieJ. I do not know what my current prescription is, but before cataract, I had outstanding close vision and could read the most minute print, thread sewing needles for everyone else, etc. Also I had good intermediate vision and did not wear glasses for the computer, face to face interaction, or other office or house work. I have to remove my progressive bifocals to see adequately near and close-intermediate -- they cannot get that right for me, so I am always removing glasses to write a check or find something in my purse, read a label in a store; always fumbling with glasses and dropping them.  I wore hard contact lenses for decades and enjoyed perfect vision, especially distance. But after presbyteria set in at age 40 and I lost all my near and intermediate vision while wearing contacts, I had to switch to bifocal glasses and I have not had good distance vision ever since -- no ability to read road signs in time to switch lanes, etc.  I've seen several different optometrists for prescriptions over the years, so this must be "just me."

The main issue is that I have only one cataract, so my weak right eye will have to remain nearsighted, at least until a cataract forms. I believe that giving my very over-dominant cataract left eye a farsighted lens will cause my weak right eye to turn inward  (an infant through early 20's problem of mine) and I would become intolerably far-sighted. I am very used to seeing extremely well for 90 percent of what I do, which is close up and intermediate work. It's really only for driving, taking walks outdoors, reading end of aisle signs in supermarkets, etc. that I need good distance vision.

I think I might "freak out" if my good close vision were to be destroyed, especially by surprise, and the thought of my right eye turning inward again is appalling.

If I have to choose only one, I think I could function better in the world with good near vision rather than with good far vision, but I could be wrong and I appreciate the discussion.

[JodieJ]

Shame on your surgeon and her staff for not explaining this to you.  Cataract surgery today can correct nearsightedness and farsightedness.  There are even lenses that can correct astigmatism.  (Limbal relaxing incisions correct astigmatism, too.)  It's not an exact science, but in most cases the power calculations can bring the patient's vision very close to the selected target.  Monofocal IOLs correct your vision for one target only--distance, intermediate, or near vision.  For example, if your target was good distance vision for both eyes, you probably wouldn't need glasses for driving or watching movies post-surgery (but you would need correction for tasks like cooking, using the computer, sewing and reading.)  To expand their range of vision, some people choose different targets for each eye (called "blended vision" or "mini monovision".)  Distance vision in the dominant eye and intermediate vision in the non-dominant eye is very popular.  My friend with this correction only needs glasses for prolonged reading or seeing small print.  Another possibility is targeting intermediate vision for one eye and near vision for the other.  (Some people who are used to being nearsighted prefer this; they only need glasses for distance tasks like driving.)  In any case, your surgeon should not be selecting your vision targets without consulting you!

You didn't post your current prescription for your glasses, but I suspect that you or more than just slightly nearsighted.  I was very nearsighted in both eyes before cataract surgery.  I chose to have both my eyes corrected for good distance vision.  After I had my first eye done, my old glasses would not work--even with one lens removed.  But I could drive the day after surgery with a contact lens in my second eye.  (It's worth trying a one-day disposable contact like 1-day Acuvue moist for the time between your surgeries, even if you've never worn contacts before.)  I predict that you will be so pleased with your vision in your first eye that you'll be eager to have your second eye done, too.

You probably have more questions, so go ahead and post them.      

[LynneAV]

Since I am nearsighted, wouldn't I have to wait for new glasses to be made after the surgery before I could see well enough to drive, etc?  Unless they could exactly match my current nearsightedness with the IOL so that my current glasses are still usable, is that possible?  This is the question I could not get an answer to. I can understand that things are much easier if someone has good vision in both eyes to start with, or is farsighted in both eyes already and only needs reading glasses.  I would love to hear what other nearsighted patients decided to do when only one eye is getting a new lens, and how it worked out for them. Anyway, I canceled my appointment and won't do anything until I understand this better.

[John C Hagan III, MD, FACS, FAAO]

Your friend's experiences with cataract surgery, especially if done by skilled surgeon using an aspheric monofocal IOL, is very atypical. Cataract surgery is the most common and successful surgery done on adults with about 3 million in the USA alone.

Make sure you have emergency transportation for the first 3-4 days post surgery (friends, family). Even our one eyed patients that have IOL surgery are usually driving using their operated eye 2-5 days after surgery.

Good luck. Do your research now to reduce the chance of problems latter.

JCH MD

[LynneAV]

Thank you for your replies. I have the same reservations that you both pointed out, that this kind of unresponsiveness bodes badly for the future outcome. I just called the surgery center and left a voice mail to cancel the appointment.

Dr. Hagan, the cataract problem could be an emergency for me if anything unusual happens in the household, because I cannot see to drive safely, I cannot read any signs whatsoever. I can see other cars on the road, so I stick to the main street to drive up and down to the supermarket, but there could be an emergency where I am needed to see a whole lot better than that. I cannot read any labels on my husband drug bottles, or food jars, etc., reading bills and balancing the checkbook is becoming impossible without a huge magnifying glass and bright light,etc.  It really is getting to be a problem -- especially the impaired driving.

I understand about using a surgical center, but it should be disclosed to us patients who use their satellite office, that surgery is so far away -- before they go ahead and schedule it and put us through all the pre-testing. The transportation problem was revealed to me only after I went through all the preliminary routines, and that was just plain mean and dishonest.

I am not on Medicare. I have premium insurance, the kind that over-pays for services, to make up for losses to doctors for the low Medicare reimbursements for other patients. What my insurance company doesn't pay, is billed to me. Even so, I understand containing costs and appreciate it -- but I have a transportation problem if I cannot drive myself, and I need full disclosure on important subjects like that.

I don't know what to do now. Unfortunately, among my friends and family members and aquaintances who have had cataract surgery: One has blindness due to retinal detatchment, one is in agony due to bad vision and repetitive surgeries and uveitis, one claims he is being driven mad due to halos and plain bad vision, several are 20 years my senior and don't use their eyes for anything except TV and therefore their experience does not relate to mine, and then there is one who reports a wonderful outcome -- but this one person had good distance vision in both eyes before the surgery and therefore his experience does not relate to my nearsightedness case. I am not enthusiastic whatsoever about having this surgery, but also can't see withoiut it. (My other eye is non-dominant and is not pitching in to help me see, and my progressive bifocal glasses have become almost useless.)

[John C Hagan III, MD, FACS, FAAO]

Another comment: our staff and physicians are incredibly busy also but we always discuss this, answers answer every question.  If they are this uncommunitive now think what it would be like if you had a complication when good communications are extremely important.

In my own personal care for me and my family. We have chosen outstanding physicians who additionally are great communicators and answer our questions.

Surgery is not an emergency for you. Ask around lots of people have had that type of surgery and are always willing to share their thoughts. You can also call the hospital and get a list of surgeons that operate there.

Know this.  If you are in the USA the federal government has cut the fee for cataract surgery so low (average is about $650 and falling fast) that surgeons often lose money during surgery in a hospital. That is to say they would make more money staying in the office and not doing surgery. To compensate for this almost all eye surgeons do surgery in a surgicenter they own or partially own. Medicare pays a "facility fee" and when you add this to the surgical fee and vigorous management of expenses at the surgery center a very most profit can be made. So it will be hard to find a surgeon that operates in a hospital. In Kansas City I can't think of a single surgeon that does cataract surgery in the hospital. Hospitals are happy with this since it frees up ther operating rooms for bigger, more serious cases.

JCH MD

[JodieJ]

Please don't proceed with the surgery without discussing your targeted post-surgery vision with your surgeon.  There have been several posts on this site from some very unhappy people who failed to do this.  Be informed about your options (e.g., mini-monovision with monofocals) before you do this.  If your surgeon doesn't have time to meet with you or dismisses your goals for your vision, then find a different surgeon.  There shouldn't be a problem with your insurance.

[LynneAV]

Thank you very much. I really, really needed validation on the refractive error issue before I made further fuss about it. Yes, I've seen the MD many dozens of times for the uveitis over the past year, but she is always in an incredible hurry. After she confirmed with me that my cataract was ready for removing, I was handed off to the office staff. I've had phone conversations about it, but they end with vague statements like "Oh then I'll have to go look up what your prescription is now, I'll call you back tomorrow." And then the matter is dropped until I bug somebody again. I have told them that because I am the caregiver and driver in the family, I must plan in advance for worst case scenarios so that I will have the backup assistance in place that could be required, ahead of time. This doesn't seem to impress anybody. Ha, I am not at all combative, but I can see how patients who are completely ignored and dismissed could become combatitive and the doctor thus wanting total sedation on them. I think the anesthesia details should have been explained voluntarily, also.

Thank you again. I have some thinking to do. The other (and very bad) surprise was that the surgery cannot be done at the hospital near the doctor's office and around the corner to our home -- I was informed after the pre-tests were done that the surgery center is an hour drive away on the freeway. And I was so careful to choose a physician who was affiliated with my local hospital for this exact reason. I feel like this is one "gotcha" after another.

[John C Hagan III, MD, FACS, FAAO]

1. Cataract/IOL is almost never done under general. The sole exception might be a combative patient with Alzheimers. Even under local they want you to have an empty stomach as on occassion there can be some nausea before, during or after.
2. The discussion of the post operative refractive error is extremely important and something that should always take into account your wishes. Also if there might be conflict between the eyes after surgery that might make glasses wearing difficult should be clearly outlined. We always always do this. Prevents a lot of unhappiness and surprises post op.
I would suggest you call and more or less demand a visit with your surgeon (if you hae uveitis you much know him/her well as that is usally a lot of office time).  If you need to reschedule your surgery so be it. When you go in discuss what post operative refractive error YOU WISH.  He/she can advise you from there.

As for the IOL I think everyone doing cataract surgery should be able to offer their patient a high quality ASPHERIC MONOFOCAL IOL like those made by Tecnis, Alcon and B&L.

More expensive upgrade "premium" multifocal IOLs are a whole different deal and I would never advise a uveitis patient to get that type of IOL.

Only if this face to face fails to get answers would I consider going to a different surgeon.

JCH MD