Cataract Surgery Takes Big Leap Into 21st Century

His gradually clouding eyesight brought an end to independence for Connie Hart, a hard-living horse trader from Temecula. Being rolled on by a race horse couldn't bring him down, Hart said, but the tiny tissues that formed the lenses of his eyes almost did. And that's when the horseman, whose life had been similar to that of a 19th-Century cowboy, ran smack-dab into the 21st Century.

According to Dr. R.K. Massengill of the Pacific Coast Cataract Center in Rancho Bernardo, the surgeon who operated on Hart, few areas of medicine have benefited from space-age technology as much as cataract surgery. And it was these techniques and technological advances that restored Hart's sight and gave him the freedom that he relishes. He had moved in with his son when was "practically plumb blind," Hart said. Now he's back living on his own and, he says, "I can see just as clear as crystal."

In the United States alone this year, said Dr. Jerome Bettman, head of the ethics committee of the American Academy of Ophthalmology, more than 500,000 people will undergo surgery for the removal of cataracts. But most people find their understanding of the complexities of cataract surgery as hopelessly clouded as Hart's eyes once were. Earlier this year, a news story reported that a cataract surgeon had been indicted for, among other things, telling his patients that cataracts were contagious.

Part of the problem lies in the term itself. "Cataracts" sounds like the name of a "thing," not a condition, which it is. When a cataract is removed, it is actually the interior substance of the lens which is taken out. Dr. Geves S. Kenny, associate clinical professor of ophthalmology at UC San Diego and medical director of the San Diego Eye Bank, said many patients seem to think that a cataract is a film covering the surface of the eye. Instead, Kenny said, it is the clouding of the proteins inside the lens which causes the eyesight to become blurred.

Surgery Often Unsatisfactory

Surgeons have been able to remove cataracts for years, Kenny added, but the means for restoring sight were so unsatisfactory that poor vision was often preferable. "Cataract glasses and contact lenses were the only alternatives for focusing following surgery," said Kenny.

Now, however, new techniques usually can not only return the eyesight to what it was before the cataract formed, but, if there is an astigmatism, can often make the eyesight better than it ever has been.

Some surgeons, like Massengill, now take the time to reshape the eye following the removal of the cataract by changing the curvature of the cornea. Lens implants, which are permanently implanted in the eye, have, in nearly all cases, according to Kenny, become the best option for restoring clear vision. He said that lenses with ultraviolet filters--necessary for the protection of the retina--are also an important new advance. Otherwise, he said, patients need to wear sunglasses with ultraviolet filters any time their eyes are exposed to sunlight or even strong fluorescent lighting.

Kenny said that a common misconception about cataracts has to do with laser surgery. A laser can be used in cataract surgery, he said, but only to open the capsule of the lens, not to perform the cataract surgery itself. The procedure that was performed on Hart's eyes is "tiny-incision" cataract surgery, using ultrasound. Called phacoemulsification, an ultrasonic probe is inserted into the lens capsule and vibrated at a high frequency to emulsify the clouded lens material which is simultaneously suctioned from the capsule. The advantages of this type of surgery is that a small incision allows most patients to resume normal activities almost immediately. Hart said that he was back on his beloved horse Phyllis the next day.

Until recently, a cataract operation could cost the patient more than $1,000 per eye, even with insurance, said Stan Friedman, assistant vice president for Medicare Professional and Beneficiary Services for Transamerica/Occidental Life Insurance Co. It also involved a hospital stay and convalescence.

Hart is on a fixed income. He said that when he had his first surgery, he discovered that Medicare only covered part of the cost and he couldn't afford to pay the rest. The clinic was willing to pay the difference. Before it was time to operate on Hart's other eye, however, Medicare regulations had changed.

Cost Has Come Down

In the past year, the changes in Medicare and the increased use of outpatient surgical suites have made this procedure something that almost anyone can afford, according to Friedman.

According to Bettman, a recently implemented advertising code of ethics for the profession, which is the only such code in the health sciences professions that has been sanctioned by the Federal Trade Commission, now cracks down on physicians who advertise false information or claims to eminence.

Another aspect that especially appealed to Hart was that the surgery was performed at MSA, a fully certified, free-standing surgical suite on Clairemont Mesa Boulevard. According to Massengill, the advent of outpatient centers like this has been "a tremendous benefit to the patient . . . They don't have go into a hospital . . . with the fears that many of them have."

John Carr, marketing director of MSA, says that the use of the surgical center has increased from about 10 cases per month at the beginning of 1984 to more than 50. "In addition to the cost," Carr said, "patients like MSA because it's so much cheaper to get in and out of than a hospital. Admissions are not nearly as complicated."

Carr said that use of the center by physicians in other specialties has also increased considerably. When asked about any dangers in using the surgical center instead of a hospital operating room, Carr said the clinic has an EKG hooked up directly to nearby Sharp Memorial Hospital, and that the center was equipped to handle such problems. "In super-critical situations," he added, "we could transfer the patient immediately to Sharp."

Being able to see again--to be independent--seemed like a miracle to Hart, but cataract surgery may still not be for everyone, Kenny said.

If a patient has severe retinal problems, for example, he said, even though the cataract can be removed, there may be no appreciable improvement of the patient's sight. Kenny believes that retina testing with newly developed, sophisticated instruments can be a big help in determining the prognosis for cataract surgery.

When something as precious as your eyesight is involved, how do you choose a cataract surgeon?

Kenny said the best way to is talk to a doctor you trust and to others who have had cataract surgery and ask for their recommendations. Kenny said that the Eye Bank also maintains a list of surgeons. He said that although it doesn't rate them as to who is the best, the Eye Bank does ensure that only qualified surgeons remain on the list.

There's no question that Hart is pleased with the outcome of his surgery. He believes that it gave him more than his eyesight back--it gave him his freedom.

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