Cataract Surgery After LASIK

Is Cataract Surgery Different Because I’ve Already Had LASIK?

Scott Grealish M.D.
EyeHealth Northwest Cataract and LASIK Surgery Specialist
Portland, Oregon

Since 1995, when LASIK surgery became an FDA approved and highly effective way for people to improve their eyesight without glasses, literally millions have chosen to have LASIK on their eyes. As good as LASIK is, the one thing it has never done is to stop time from marching on. Those of us in our 40’s who have undergone LASIK understand that our reading vision gets weaker every year as we age. It is actually the “stiffening”, or aging of the lens inside our eyes that causes the trouble for all people, whether they’ve had LASIK or not. Lucky for us, the distance vision we gained from LASIK stays solid in virtually everyone. However, as we enter the late 50’s and early 60’s, the aging of the lens inside of our eye doesn’t just create poor reading ability, the lens actually turns yellow and cloudy. This is called a Cataract, named by the Egyptians (the first Cataract surgeons) thousands of years ago after the waterfalls on the Nile River they called “Cataracts”. Cataracts affect our vision at all distances, especially under difficult lighting conditions with glare and at night. Luckily, Cataract surgery has evolved into one of the safest, easiest (for patient’s!), and most effective procedures available. In fact it rivals LASIK in most of those aspects. However, although LASIK is the number one elective procedure in the US, Cataract surgery is the number one surgery period. More of us are living longer and staying active as we age. No wonder more people are choosing to have their cloudy lens replaced with a lens implant that will stay clear the rest of their lives.

Now that the “Baby Boomers” who embraced LASIK over the past 15 years have aged, surgeons like myself who specialize in Cataract and Lasik surgery are seeing many patients who have developed Cataracts and have already had
LASIK surgery. As it turns out, there are many additional considerations both patients and surgeons must consider before proceeding with Cataract surgery after LASIK. This is a complex area of Ophthalmology and my first recommendation is to seek out consultation with a surgeon who has experience in this area if you have had LASIK and believe you may have developed Cataract. As you’ll see, only one on one consultation can help you make the best choices for your eyes.

I have had an opportunity to perform many thousands of LASIK and Cataract surgeries in the past 15 years and I now see patients almost every day who have the combination of both prior LASIK and developing Cataract. The biggest distinguishing feature of these patient’s as compared to “normal” Cataract patients is that most are much younger and have relatively small cataracts with relatively large complaints about their vision. This makes sense to me, after all, when we get LASIK and go from “bad” vision to “good” vision, we understand better than most the real value of “good” vision. We naturally pay more attention to our eyes over the years; in fact most of my former LASIK patients are extremely perceptive about any degradation in vision over the years. They typically come in for evaluation in the early stages of Cataract development because they can tell “something is” not right.

LASIK patients who develop Cataract have two other distinguishing features. First, they are seldom afraid to proceed with Cataract surgery since they have almost uniformly had a good experience with their LASIK and they trust both the technology and their surgeon. Second, they almost universally expect that technology and surgeon to deliver a perfect outcome. While I completely understand that expectation, it is my goal in writing this article to deliver something a little different and in the end more important: REALISTIC EXPECTATIONS.

All surgeons and patients want a perfect outcome. In this world, what we actually have are very good (but not perfect) surgeries and very good (but not perfect) outcomes. Here are some of the technical issues we face as surgeons and patients when we have the special case of Cataract after prior LASIK that require some extra thought and consideration about what we can realistically expect for our vision after surgery.

First, the good news. Since 2005 we have been able to perform Cataract surgery using special lens implants which can reduce and in some cases eliminate the need for glasses after surgery, even for reading. So, if you had LASIK, got great distance vision but still needed reading glasses, and have now developed Cataract, your surgeon can perform Cataract surgery and not only improve your vision by eliminating the Cataract forever, but also reduce or eliminate your need for reading glasses while still maintaining your great distance vision without glasses. Now that’s a terrific medical scenario: Your’re born with bad eyes requiring glasses or contacts, LASIK fixes your problem. You age and not only need reading glasses, but eventually get poor vision from Cataract. The Cataract surgery not only fixes the poor vision, it makes you read better without glasses and now in the later decades of life you see better than you ever have!

Ok, now the “bad” news. First, there is a premium charge you will pay out of pocket to receive the “premium” lens implants that can offer that kind of result. This ranges in price, but can be several thousand dollars per eye. Your insurance will not cover this (to learn why please see my article “A Brief History of Premium Lens Implants”).

Next, all patients should realize that getting the best outcome often involves multiple surgical steps and more detailed pre-operative and post-operative testing and examinations. None of this is particularly difficult, but I certainly think of it as a “process” that can take 6 months or more to complete. It is far from the “instant gratification” type experience LASIK typically offers. Patient’s should be prepared to walk through that process with their surgeons if they strive for the
best results.

I’ll give a typical example to illustrate the “process”. “Joe” returns to his surgeon for his yearly check at age 60 having undergone LASIK 10 years ago. “Joe” knows that night driving has gotten a lot harder the past year, especially when it’s raining and particularly in his right eye. His surgeon finds Cataract in both eyes, worse in the right which explains “Joe’s” symptoms. After detailed counseling “Joe” decides to have the surgery “sooner than later” ( many patients would delay surgery which is perfectly OK from a medical viewpoint, we all have different visual needs and therefore timing of surgery after the diagnosis of Cataract can vary by years). “Joe’s main goal is to get rid of the Cataract, but a close second is his goal to get rid of glasses if at all possible, so he asks his surgeon to give him the “best” lens implant for his goals and pays an extra fee for the more expensive lens and the extra associated services. (See my article on “Choosing your Lens Implant” and below for more info). “Joe’s” surgeon takes numerous computer measurements of his eyes (similar to those before LASIK) and performs the extra computer calculations necessary to chose the best strength lens implant after LASIK surgery. The surgeon explains that these calculations are LESS accurate after LASIK than in a normal Cataract surgery which means the surgeon has LESS chance than normal of giving “Joe” the exact focus he desires after Cataract surgery. This is the key take home message for patients. In “Joe’s case, he turns out being able to read just fine without glasses, but now his distance vision is blurry, similar to when he was nearsighted before his LASIK! Lucky his surgeon had explained that there was a good chance this would happen and it would be a temporary problem because the second step of the process is to wait a few months for healing to finalize, then perform another LASIK type surgery (technically, often a variant called LASEK is used here instead) to fix “Joe’s” focusing problem for his distance vision. Once “Joe” heals from the laser, he finally has good distance vision and like the majority of patient’s with Premium Lens Implants he finds his reading vision is quite acceptable (but not perfect) without glasses. “Joe” is now happy with his right eye, but that happiness has made him less happy with his left eye which now looks “yellow and cloudy” in comparison. This is quite typical; in fact a majority of Cataract patients have both eyes done weeks apart. So “Joe” has another ten minute routine Cataract surgery and this eye turns out the same as the first, slightly better near than far without glasses. This time “Joe” and his surgeon decide not to do another LASIK procedure, because “Joe” notices that by working together at two slightly different focal points his eyes actually have an even better range of focus for near vision. This is also commonly a goal pre-operatively rather than an unintended outcome. We call this monovision (or in small amounts of imbalance “mini-monovision”) and it can be extremely helpful for some patients, and annoying for others (who then would elect more LASIK surgery to create more balanced vision).

The story ends there until “Joe” returns to his surgeon 6 months later noticing a gradual blurring of both eyes which reminds him of when the Cataracts first appeared. In reality the Cataract can’t reappear, but many patients develop a
haze behind the lens implant over the first few years after surgery. This is especially common and noticeable with some of the “Premium” lens implants. As many as 50% of these patients will require a second laser procedure called a
Yag laser which can simply remove the haze in less than a minute. This is a terrific technology allowing surgeons to painlessly, quickly, and safely treat the most common “complication” of Cataract surgery. It’s both a permanent fix (the haze can’t return) and covered by insurance. “Joe” gets one eye lasered, and after a quick check the next week realizes that the vision is back to normal in that eye, but still blurry in the other, so the next week he gets the Yag laser on his other eye.

Finally “Joe’s” surgeon announces the good news that his eyes are healthy, his focus is likely to remain stable the rest of his life, and he has reached the end of the “process” for dealing with Cataracts after LASIK. In the fictitious case of “Joe”, the Cataract surgery was followed by both LASIK and a Yag laser. Most patients will in fact achieve their goals with the Cataract surgery alone, a much quicker and simpler process which for them is really no different than an ordinary Cataract surgery.

One last subject comes up specifically in the context of Cataract surgery after prior LASIK. Which is the best lens implant to choose? I’ve already touched on the concept of choosing the right strength lens implant, a more difficult task for your surgeon in this case, but nothing you as a patient can influence. The type of lens implant is a different issue. There are many complex optical reasons why current lens implants work slightly differently after LASIK, and frankly this is an area where you are going to have to trust the judgment of your surgeon because it is difficult to convey the issues to a lay person. However, patient’s can be partners in the decision process in several important ways. First, clearly state your goals and desires for your vision after surgery. Next, listen carefully to your surgeon’s explanation of the pros and cons of the various options. Most importantly, realize that the pro’s and con’s actually apply to you, and especially if your vision ultimately falls short of your expectations, realize that making good informed decisions before surgery, and applying the best surgical techniques is the real goal. In my experience, making the best effort to optimize outcomes is the highest goal. I find that at the end of the “process”, that effort is always rewarded with YOUR best possible vision