At the end of a bumpy road, in a stiflingly hot room with suspect air-conditioning, Dr. George Pronesti was literally seeing black—the insidious black of an untreated cataract stretching across the lens of a patient’s eye, partially blinding him. Pronesti was in Belize—a long way from Kremer Eye Center in King of Prussia, where he’s the national associate director—providing free ophthalmological care
to patients in underprivileged areas.
“We saw the worst cataracts any of us had treated,” he says. “Part of the reason is that there are only three ophthalmologists for the entire population of Belize—which is about 350,000 people—so patient care is delayed.”
Obviously, there’s no shortage of ophthalmologists in our area. Yet there are still patients who postpone cataract treatment. “The surgery used to be so invasive and the recovery so long that patients had it only as a last resort,” says Dr. Michael Negrey, who has practices in Havertown and Media. “Some people still have that impression.”
And there are the urban legends about cataract surgery gone wrong, leaving patients with vision more compromised than it was before the procedure. Cost is another factor. Estimates of $2,500 per eye, paid out of pocket, leave some thinking their vision isn’t bad enough, especially if it may limit their independence. “It’s not unlike fears of hip-replacement surgery—that it requires hospitalization and rehabilitation,” says Pronesti. “So many people decide to live with the discomfort, not realizing that the longer they wait, the more damage they do to the hip and the rest of their body.”
Here are the truths about cataracts.People of all ages can have them, but the vast majority of patients are over 65. Age causes the lens to yellow and harden. There may be a genetic component at work, as cataracts have been proven to run in families.
There are different kinds of cataracts, distinguished by where in the lens they reside. But the symptoms are generally the same and include blurred vision, trouble seeing at night, sensitivity to glare from lights, and a reduced ability to see colors.
Symptoms come about slowly. People often don’t realize how compromised their vision has become until an ophthalmologist detects the
cataract. The larger the cataract, the more difficult it is to remove. “We use backlighting to do the surgery, and we can’t see the cataract as well if it’s turned white,” Pronesti says. “If the cataracts have progressed to the point that they are yellow or brown—or black, in the worst case scenario—they harden, and we have to increase the amount of energy we use to remove them.”
Ultrasound is the most common energy used to break up the cataract and remove its debris from the lens. There is a newer technology that employs lasers, but Medicare doesn’t cover its cost. “Patients pay between $1,000 to $2,500 for that procedure,” Negrey says. “I use the laser, and it’s awesome technology. But most people do really well with the surgery that is covered by Medicare. Honestly, if the laser were a huge improvement, Medicare would cover it.”
Patients may also spend too much on intraocular lenses, which are placed over the pupils after cataract surgery. Standard IOLs are monofocal, and they provide long-distance vision only. Post-surgery, patients must use reading glasses. Negrey and Pronesti agree that the inexpensive drugstore variety is fine, but that does lead some patients to grouse that their vision was better before the procedure. “Never mind that their long-distance vision is vastly improved,” says Pronesti. “And they would eventually go blind if the cataracts weren’t removed.”
Multifocal lenses accommodate patients who eschew reading glasses. But high-tech multifocals carry a hefty price tag, and they often don’t deliver on their promise. “There are doctors who use multifocals and have good results,” Negrey says. “I don’t have that experience. I steer away from multifocals and find that most patients are happy with the monofocal lens, even if they are temporarily disappointed that they need reading glasses.”
Pronesti agrees. “The number of people who don’t tolerate multifocals is too high for me to use them with my patients,” he says.
And the cost of multifocals is not covered by insurance. “So when I hear that patients are unhappy with the cost of cataract surgery and the results, I often discover that they got the higher-priced laser surgery and the multifocal lenses,” Negrey says. “Those two factors would make me unhappy, too.”
Negrey and Pronesti offer the same tips: Ask a lot of questions, talk to insurance companies about what’s covered, and get a second opinion if an ophthalmologist is reluctant to consider the basic surgery and IOLs. “Doctors always know best,” says Negrey. “But it depends on which doctor you ask.”