Cataract Surgeon – James S. Lewis, MD
Serving Northeast Philadelphia, Phoenixville, Main Line, King of Prussia and Conshohocken
Animation Explaining Cataracts
What is a Cataract?
A cataract is a clouding of the natural lens. All of us start life with a clear natural lens. Cataract is a normal aging change of the natural lens occurring at any time from our teenage years to our nineties. Conditions like diabetes, steroid use, kidney disease, inflammatory disorders, ocular trauma, and prolonged sun exposure can hasten cataract development. A cataract usually develops slowly over years and gradually degrades your ability to drive at night, read small print, and achieve excellent vision with glasses and/or contacts. Sometimes a cataract develops over several months. Rarely, a cataract appears to develop suddenly; this is usually because a patient covers the good eye and suddenly recognizes he or she has been relying on the opposite eye. When the benefits of surgery outweigh the risks, a cataract is considered “ripe”.
Cataract surgery is nothing more than exchanging your cloudy natural lens for a clear, customized manufactured lens (also called an implant or IOL: Intraocular Lens). The implant lasts forever and requires no maintenance. Your implant is not visible to others, it is not subject to rejection, and it reduces your dependence on glasses and contact lenses. The vast majority of Dr. Lewis’ Philadelphia cataract surgery patients achieve 20/20 vision following cataract surgery.
How long does surgery take?
Five minutes. Although you are not asleep, cataract patients are given sedation by a board-certified anesthesiologist relieving any anxiety and most memory of the surgery. Most patients report seeing exotic colors in a dream-like state. There is no discomfort, in fact, almost all patients describe cataract surgery as a pleasant experience.
When can I go back to work?
You can go back to work the next day. You can lift and bend over but we prefer you avoid getting large amounts of water, dirt or toxic fumes in your eye for at least one week. Safety glasses are always a good idea. Runners, weightlifters, and exercise enthusiasts can resume their activities on the first postoperative day. You can wash your hair at any time.
Does it hurt?
No. Extremely potent topical anesthesia in conjunction with intravenous sedation makes this a painless procedure. Our Philadelphia and Bucks County cataracts patients typically have no difficulties holding still or keeping their eye open. At the conclusion of the procedure most patients don’t believe they had surgery.
What is the Recovery Period?
98% of patients are legal to drive themselves the next morning. You can start reading and watching TV immediately. Most patients recognize a significant visual improvement immediately after surgery. Your vision continues to improve for about one week. We provide over the counter reading glasses while your eye heals. If patients want or need glasses they can be prescribed anytime after the first or second week.
Will I feel or see anything?
No. You see only colors and shapes. Your eye is anesthetized and there is no pain or unpleasant sensation.
Can I take care of myself alone?
Yes. Almost all patients are entirely self-sufficient after surgery. In fact, patients are usually more independent the day after surgery than the day before. It is usually a good idea to go home and get some sleep after your operation. Even patients with only one good eye should be self-sufficient.
What are the risks?
Approximately 2 million cataract surgeries are performed in the United States each year and as many as 10 million worldwide. Naturally, with that many procedures there will be reports of almost every possible complication. Our data shows a complication rate lower than .5% with 99.5% patients having an excellent post-operative course and an excellent visual result. Infection occurs in less than 1 in 5000 cases and retinal detachment occurs in less than 1 in 3000 cases. Other complications including corneal decompensation, persistent macular edema, implant instability, power calculation errors, and glaucoma. All of these problematic cases add up to less than one half percent. In almost all of these cases further surgery, additional medications, or additional time results in recovery and a net improvement in vision. It is extremely rare for patients to end up worse than they started.
What is the Van Service?
The two surgery centers (Wills Eye and Kremer Eye Center) I use provide van service. The drivers will pick you up from your home the day of surgery and take you back home once surgery is complete. You can also bring someone with you for company on the van. The van drivers help make this an easy and pleasant experience.
How safe are these implants?
Extremely safe. The development of the intraocular lens was the single most important development in the field of Ophthalmology and Optometry over the last century. The refinement in lens design, materials, and manufacture since the 1940’s is one of the great medical success stories. Implants used since 1990 are safe, reliable, and effective. All of our Philadelphia lens implants patients receive implants that are FDA approved, such as ReSTOR, ReZoom or Crystalens.
How long between eyes?
We can’t perform cataract surgery in both eyes on the same day. Although several Canadian and English physicians have successfully performed thousands of bilateral cataract surgery procedures.
My personal preference is to perform the second cataract surgery anywhere from 3 days to 3 weeks later. This assumes a perfect result in the first eye with total recovery of vision. This eliminates imbalance between the two eyes, cuts out some followup visits, and reduces paperwork including referrals, medical clearance, and lab testing. Most patients also enjoy getting the entire process completed and find it easier to put post-operative drops in both eyes together rather than one at a time. Naturally, if a patient prefers or the surgeon recommends, it is trivial to postpone the second procedure. Some patients, however, prefer to allow one eye to heal completely before having surgery on the other.
What can I expect after surgery?
Your vision will be brighter, colors will be enhanced, and clarity will improve. Many patients described their operated eye as High Definition compared to their un-operated eye. Because your refractive correction (glasses or contacts) is “built into” your implant, your old glasses are no longer necessary. Often, all that is needed is a pair of over the counter reading glasses or some thin prescription glasses.
It takes some time to become accustomed to the brightness of colors. Within a week the other eye’s vision appears to have a yellow cast. Rarely, there is a small amount foreign body sensation that resolves within the first 24 hours.
Do I have to use drops?
Yes. We start pre-operative antibiotics and pre-operative anti-inflammatory drops four days in advance. Patients are asked to continue these medications for one week after surgery along with a topical steroid. Because suppressing inflammation is critical after cataract surgery we usually continue this steroid drop and another anti-inflammatory medication for as long as two months. This medication strategy has been found to be optimal for reducing post-operative complications.
No. After nearly 2000 cases of Dropless™ Cataract Surgery, we no longer ask patients to use topical medications. No drops before, during, or after cataract surgery.
A one-day follow up examination is standard. Additional questions are answered and medication instructions reviewed. If access to these medications is limited due to fiscal concerns, we can usually provide them to you without cost.
Do cataracts come back?
No. Once the natural lens is replaced by the manufactured intraocular lens implant (IOL) a cataract can not return. Intentionally, we leave the posterior skin of the natural lens (the capsule) to hold the implant. This capsule often opacifies with time. Twelve weeks to twelve years after surgery a painless in-office laser called the YAG removes the cloudy capsule. If you notice that your vision has degraded slightly several months or years after cataract surgery you might need a YAG. Sometimes, your referring doctor will send you back to us for the YAG procedure.
A YAG laser is only needed once in each eye following cataract surgery. Some patients never require a YAG.
The implant remains stable after the YAG procedure. In fact, with the modern very small incision cataract surgery implant stability is outstanding.
Will insurance cover my surgery?
Yes, in almost all cases. Some companies require that you pay some form of co-pay (usually $150 to $200) for the procedure. Patients with deductibles will have to satisfy that requirement as well. Those with secondary insurance, Medicare, Medicaid, HMO’s, PPO’s, and indemnity coverage are usually very well covered.
We make it a policy to guide patients to affordable insurance programs. We are almost always successful in obtaining good coverage for this surgery for our patients without insurance. In the rare case in which no medical insurance is possible, our costs for the cash paying patient is kept low.
Who is my surgeon?
All surgery is performed by me, Dr. James Lewis. I see everyone pre-operatively and post-operatively along with Dr. Brett Neal and Dr. Marcus Devlin. I no longer train resident-surgeons and no portion of the procedure is handed off to a student. Our practice teaches pre-operative and post-operative management to hundreds of eye doctors in training. The surgery, however, is strictly personalized, private care by James Lewis, MD.
How can I be sure I have the right doctor?
I performed my first cataract surgery in 1983 as a resident at Duke University Eye Center. I continued my training as Senior Registrar and Corneal Fellow at Flinder’s Eye Center in Adelaide, South Australia. In 1987 I became the Director of Cornea Surgery at Hahnemann University and Chief Consultant in Cataract and Corneal Surgery at the Pennsylvania College of Optometry in Philadelphia. I have lectured for virtually all of the major Ophthalmic Surgery Companies including Alcon, Allergan, Bausch and Lomb, Staar, Moria and Stereo Optical. I have published peer-review articles on surgical technique as well as frequent contribution to trade journals and eye surgeon video teaching organizations.
I have performed approximately 25,000 cataract surgeries, 1000 corneal transplants, and 8500 LASIK procedures. I have performed more Aquaflow™ procedures (cataract surgery combined with glaucoma surgery) than any other surgeon in the United States.
Because our practice uses a custom designed electronic medical record, our implant calculations are checked and double checked virtually eliminating errors. Furthermore, our clinical results are easy to monitor. Staar Surgical, a major IOL manufacturer, used our computer database to optimize implant lens power calculations for all surgeons using their latest and most popular intraocular lens, the nanoFlex.
Finally, our practice prides itself on optimizing results for each patient. Compassionate doctors, technicians and office personnel make your experience a pleasant one. While we perform a large amount of surgery, we always have time to spend with our patients. We are on call 24/7/365.
What about astigmatism?
Most regular astigmatism can be treated at the time of your cataract surgery. This usually involves special incisions (RLI’s: Relaxing Limbal Incisions) made in the peripheral cornea. I have been doing this for patients, without cost, for over a decade. In patients with very large amounts of astigmatism, outside the range of RLI’s, we can use special implants (some have additional cost) and post-cataract excimer laser treatment to help you achieve spectacle independence.
What about premium implants?
Congress has permitted implant manufacturers to add a surcharge for Premium Implants. This can cost as much as $2500 extra per eye. These are an excellent option for patients with the resources. Premium lenses like ReStor, Tecnis Multifocal and ReZoom are called multifocal lenses because they split the light between distance and near. Patients can usually see well in the distance and close without spectacles. The trade-off is that patients usually get used to some dysphotopsias, especially are point sources of light. Most patients tolerate this very well.
Crystalens is the only lens recognized by the FDA in the accommodative category. Crystalens does not cause glare, halos, or starbursts but is often only moderately successful at producing excellent intermediate and reading vision. The Crystalens mimics the natural lens by changing focus. Unfortunately, this lens is more effective in some patients than others.
NanoFlex is an FDA approved intraocular lens that exhibits many of the premium characteristics of the Crystalens. In addition, it is composed of Collamer, a unique material found to be extremely biocompatible and optically superb. NanoFlex provides excellent distance and intermediate vision (laptop distance) and does not have an additional cost. nanoFlex is my primary lens choice for the vast majority of patients. I have personally used the material in nanoFlex in almost all of my cataract surgeries for over a decade.
One day, the manufacturers of nanoFlex may decide to add a surcharge. I hope that day never comes. For now, it is a Premium Quality Implant option with no additional cost to the patient.