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Category: Cataracts

What is a cataract, and what are my options for treatment?

Dr. Jessica Boeckmann, cataract specialist, recently sat down with Randy Alvarez of the Wellness Hour to answer these questions. She discusses what cataracts are, when to seek treatment, and the various lens upgrades available to our patients.

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- [Randy] You're watching The Wellness Hour, news that makes you healthier. I'm Randy Alvarez. Today's topic, what you need to know if you're considering cataract surgery. We're talking about the latest advancements. Today in studio, we have an expert on this topic, Dr. Jessica Boeckmann. Dr.

Boeckmann, welcome to the program.

- [Dr. Boeckmann] Thanks, Randy.

- Now, before we get into today's topic, for people that don't know Acuity Eye Group, I guess you're the third largest ophthalmology group in the U.S., so what's your role there and tell us a little bit about who the typical patient is?

- Okay, well, great. Acuity Eye Group, like you said, is the third largest eye group in the country. We're a multi-specialty eye group, which means we have retina specialist, glaucoma specialist, cataract surgeons, optometrists all rolled into one package so we can give you the best eye care available.

- So, what is your role specifically? I mean, all you do is cataracts?

- No. I do a lot of different things. I treat dry eyes, I treat glaucoma, I monitor patients for diabetic retinopathy, I take care of dry macular degeneration, but my specialty is cataract surgery.

- Okay, you're one of the busiest surgeons in Orange County, if not the busiest.

- I am. I am. I'm not the busiest, but I'm in the top. I am one of the busiest.

- But you do about 600 plus of these a year, cataract surgeries?

- Yes, I do. I do about 600 a year, very busy practice, very rewarding surgery. And I'm glad I get to offer help to these patients.

- Okay, good. What's new? Has a lot changed?

- Oh, yeah. A lot has changed. I have a lot of patients who've come in to me and their father had cataract surgery years and years ago and they're like, "He had to stay at hospital for a week," and I tell them, "Cataract surgery today is nothing like your dad had before." It's straightforward. You get to go home that same day. The surgery itself only takes 15 minutes, recovery is pretty easy and straightforward, and a lot of patients will see better the next day.

- So, let's start from the very beginning. What is a cataract? If you live long enough, does everybody get them?

- Yes, everyone will get one cataract in each eye if they live long enough, and some people find this very scary, but the good news is that cataract is such a treatable disease that if you've lived long enough to get cataract surgery, your vision is actually going to be better after you have it. So, it's so rewarding that you have a patient who doesn't see very well and then they leave your office with better vision than when they...or they leave the surgery with better vision than what they came in with.

- So, your eye, the lens… - Yes, so, the lens… - …so as you get older, what, it develops wrinkles or what's going on?

- No, so the lens is nice and small when you're born, it's about a millimeter. And that lens continues to change shape and change color as you get older. So, the average age of cataract surgery in United States is 65...or 69, and at that time, instead of being a millimeter in thickness, the lens is about 4 to 5 millimeters in thickness. So, because it's thicker and yellow in color, it actually blocks light from passing to the back of the eye.

So in some cases, you can think of it as looking out of a dirty window. Like, everything on the outside is very dim and cloudy and you can't see until you either replace that window, which is the case in cataract surgery.

- So, these people don't even know what's really going on, right, because it's so slow.

- Very, very slow.

- Is that right? And most people who have cataracts, they don't even realize how... They know that their vision's worse but it happens so gradually that some people don't even really realize it.

- And insurance covers it, right?

- It does. It covers it.

- So, if you're over the age of 70, is it fair to say, "You have a little bit of cataract," or, "you have some cataracts going?"

- You do. I would say yes, 100% of people over 70 have a cataract, if they haven't had cataract surgery. But insurance determines cataract surgery medically necessary when your vision can no longer be corrected to 20/40 or better. So, most patients at age 69 will need cataract surgery...

- Is your challenge, I guess as a group or as a individual physician, to getting people to get checked out early? Is that the problem?

- I think that that is a fair statement because whenever you're older, cataract surgery is technically more difficult because the lens is thicker. And then, obviously, the older you are, in most cases, it takes you longer to heal so I prefer to do cataract surgery right when they're ready. I don't like people to wait too long because their outcomes may not be as good. That being said, they'll still heal, just slower.

- Now, you say, for many people, it is life-changing.

- It is. Cataract surgery is truly life-changing for many reasons. Oftentime, people don't realize how much vision they don't have until after I do the cataract surgery. So, I have several patients who are golfers, who love to golf every day but for some reason, after they tee off, they can't see the ball when it's far away.

And I'll do cataract surgery and they're like, "Doctor, I can see when the ball gets on the green," and it's wonderful for them because they're able to participate more fully in their passions. And other people don't notice... It's the funniest thing. Women always tell me after cataract surgery, "I didn't realize how dusty my house was," and then the men always tell me how well they can see the score on the TV, on the football game.

- Is that right?

- Yeah.

- Everything's clear?

- It's so funny because women always are like, "I can't believe how dusty my house was," or things like that, and then, the men, it's always about sports. I had this one patient, for example, who came into my office, I did both cataracts on both her eyes, and she told me that before she had the cataract surgery done, that she always thought she had painted her ceiling a shade of yellow and she thought in her head why she would, why anyone would paint their ceiling yellow.

But then, after she removed the cataracts, she realized her ceiling wasn't yellow, it was just because everything looked yellow with her cataracts. Same thing with another patient I had. She made her husband change all the lights in her bathroom because she thought all the lights were too yellow and too dim, and her husband kept telling her, "No, the lights aren't yellow.

The lights aren't yellow," and she kept insisting they were. And then, she had her cataracts out and she realized her husband was right and she was wrong. And I have other patients who say, "I didn't realize how many wrinkles I had on my face."

- Well, you know, I think… - So, all sorts of things.

- …we were talking on the phone, like a woman in her 70s putting on makeup.

- Exactly.

- Now, she could see and before, she couldn't. Yeah. So, it's so nice… Well, with women seeing in the mirror with makeup, that's, you know, a lot of women wear makeup and you have to have very fine vision to be able to put on your makeup. And a lot of people have trouble putting on makeup, or threading needles, things that require a lot of fine vision, and once you take out the cataract, you're able to do those things easier.

- We've been doing the program here for the last 20 years on television and I try not to endorse any of the doctors that come on the show but I have to endorse you because you took care of my father.

- I did.

- I have an 82-year-old father who had all of these, like, limiting beliefs, "Well, Randy, my cataract, I was told by the VA, it's not like mature enough or it's not ready to do anything," but he's like stumbling around, can't see when he drives, can't read at all, and literally, after the surgery, he's seeing the next day.

- Yes, yes.

- And now, I think it's been, you know, about a month out. He says he could drive. He said it's like the lights had been turned on. Okay, let's talk about these premium lenses.

- Okay.

- Okay. And we've had a discussion about this. My father, all of his friends, he says... You know, he's a social guy. He's 82, he plays tennis and gives trumpet lessons, but he was saying that all of his friends, none of them could see up close. They all have reading glasses. Now, and I asked you a little bit about it in the green room but because of the premium lens, that's why he doesn't need readers.

- Reading glasses, yes. So, basically, when it comes to picking a lens and they're either...there are many different choices. For simplicity, there's a choice that is covered by insurance. In some patients, that's a very good choice especially if you have any other diseases in the back of the eye like macular degeneration, glaucoma, diabetic retinopathy, that lens is a great choice.

But for people with really healthy eyes, there are more options. And then, there's some options which, they're called premium lenses, extended depth of focus lenses, or multifocal lenses is commonly known to the public, and these lenses give you a little bit more range of vision. So, not only do they give you distance vision, but they give you some computer vision, and also in some cases, you can see really well without glasses to read up close.

- Now, my father says it's like HD. He's telling me, he goes, "You know what HD television is?" I go, "Yeah, I think I do," he goes, "Well, that's the way it is now."

- It is.

- He goes, "And they didn't even tell me this." You probably told him but he didn't hear it. But I guess it takes a lot of them by surprise. So, a premium lens, so if he didn't get a premium lens, he'd be like everybody else wearing glass, right?

- Because your father had astigmatism too, which means his eye, instead of being perfectly round, is shaped more like an oval instead of a nice ball, he would have had to have progressive lenses if he chose the standard lens because he would have to see lenses...he would have to have glasses to see far away, he'd have to have glasses to see the computer, and then he'd have to have a pair of glasses to read.

So, he would be pretty much dependent on trifocal lenses for most every activity to have the crispest, clearest vision. But what we did with him, is we combined a laser-assisted cataract surgery with one of the newer premium lenses to give him more of that natural range of vision that only young people have.

- Okay, good. Now, so, insurance covers... So, if somebody has cataracts, pretty much all insurance covers… - Yes, yes.

- …that? Okay. They do. They do.

- And if they spend a little bit more, I mean, just literally a little bit more cash out of pocket, now they can get a lens that has like a bifocal? Am I saying the wrong thing?

- It's like a bifocal. It's not exactly, in optical terms, it's not called a bifocal but for...

- Reading?

- Reading, it, kind of, is correlatable with that.

- Because he can completely see now. He couldn't read a book before, now he can.

- Yes, exactly.

- Yeah. He couldn't read music before but now, he can. We talked and most patients will come in and, correct me if I'm wrong, and they just want the type of cataract surgery that is covered by insurance. They don't want any out-of-pocket. Okay, but let's talk about the options and why the patients should probably take a closer look at these premium lenses, how much better they are.

Let's talk about that.

- Premium lenses have come so far in recent years and we're lucky that we have this technology to give to our patients. And a lot of patients will say, "I don't mind wearing glasses," but if you throw in the converse and say, "Well, wouldn't you be happier if you didn't have to be as reliant on glasses?" that may improve their life even more, and especially, nowadays, where most people are on their cell phones all the time.

My parents are in their 60s, they'll need cataract surgery soon. Right now, my mom has to put on reading glasses to see her cell phone, but these lenses now can get you out of glasses where you don't have to put something on and off your head all the time or keep reading glasses around your house, in your pocket, in your car, in your purse. And so, the newer technology that we have today really does just give you that extra advantage in the vision department that if something happened, you didn't need your glasses.

- So, for a very little amount out of your pocket, you can lose your glasses. I guess if you're over 50, I guess 45 plus, you start wearing readers.

- Exactly.

- You're at the restaurant, you have to do a flashlight to see the menu.

- Menu. My father recently went out, and if you're just tuning in now, my father just had this procedure on both of his eyes, he's 82, but he says, "I don't even have to use a light." For him now, it's a big deal.

- No, he doesn't.

- You don't need a light to look at the… - It's a big deal.

- …menu. And he's saying, "Geez. I wish I would have done this at about 72." He feels like he lost 10 good years.

- Well, luckily, he waited till the technology is as good as it is now. It wasn't as good 10 years ago, so we were able to really get your father a really good vision with these premium lenses.

- Now, many people that weren't even really wearing glasses before they're 69 years old. You said that's the average. They get what's covered by insurance and then they regret it. What do you mean by that?

- They regret it because everyone's lens has a natural range of focusing power and over time, around 45, you start to lose your near vision. About 55, you start to lose your computer vision, and 65 to 69, you lose all range of vision. So, you're pretty much dependent on trifocals. What happens in some of my younger patients who get cataract surgery...

- Younger meaning 69?

- Probably more around 60 to 65.

- Okay, okay.

- Their lens still have some accommodative power which means they can still, they don't need glasses for quite everything. But when we do cataract surgery, we put in a lens that doesn't have any accommodation. And so, they lose their intermediate range of vision, and intermediate range of vision is very important because that's your dashboard, that's your computer screen, that's your cell phone, when you're having a conversation with someone, that's their face.

And so, when you abruptly lose that intermediate range of vision, you're very unhappy and it makes you very frustrated that you're so dependent on glasses to see so clearly. So, especially in the younger patients, they really do benefit from these upgraded lenses because it's a quality of life issue, and their quality of life is just better.

- So, for people 65 plus, they get what's covered by insurance, the standard cataract surgery like a new lens, right, standard lens. They're now, for sure, going to be dependent on glasses for up close vision?

- Well, it depends. You can either put the standard lens in for up close, but then you'd be dependent on glasses for distance or...

- So you'll get one or the other?

- You get one or the other. And some people do well with what's called a monovision, but monovision means one eye is for close and one eye is for far, and I never recommend that in people who haven't had monovision before.

- But certain people's lifestyles jump out at you like, "Oh boy, they would be an ideal candidate for a premium lens," people that play golf, people that play tennis people, people that are bowling, people that are playing cards and they have to hold and look…you know.

- And you'd be surprised, 60 now is not what 60 used to be, or 70 now isn't what… - It's young.

- …70 used to be. It's young. And the baby boomers who are retiring now, they're going out traveling across the world, playing golf, have, you know, RVs they travel around the country in, go to baseball games, go to their grandkid's sporting events, they just have a lot of fun. And so, the premium lenses, I like to say, are more of a lifestyle-type lens, like they just help you enjoy these activities more.

- You think if they knew how good it could be, that they would all do it, they would all opt for taking a little bit of cash out of their pocket and getting the premium lens?

- I think so. I think the majority of people would rather have a premium lens than the lens that's covered by insurance. That being said, there are some people who aren't candidates for premium lenses.

- Now, let's talk about downtime for a moment because... So my father goes in, he gets it done, he walks out, I guess he's just wearing some glasses, one eye is covered...

- There's a patch.

- Just one eye patch, but the next day, he's able to take off the patch and go about his business, and then I think like about a month later or maybe even less than a month, he goes in, gets the other eye done.

- He went, I think his eyes were two weeks apart.

- He had two weeks?

- Two weeks.

- And it's done.

- It's done.

- And he says he's been a little obnoxious to all of his friends because they are the ones that have the non-premium lenses.

- And he just picks up the newspaper and can read it.

- Yeah, he said they didn't even believe it. They were saying, "Let me see." He was reading in front of them and they go, "Come on," and they had to check to see.

- They had to put their glasses on to check.

- They had to put their glasses on to check. We're going to take a quick break. When we come back, more about the lasers and why people should pick laser in this process. You're watching The Wellness Hour, I'm Randy Alvarez. We'll be right back.

- [Joe] I hang around with a bunch of old guys and when I told them my problem, that I couldn't see very good, couldn't see the color, couldn't see very good, and the grass did look brown instead of green, but it's been accepted because it happens to everybody. However, my son told me that's not true, so he set up and he got me cataract surgery with the premium lens and now, I can read without glasses and he opened up a whole new world.

Everything is bright. I can see perfect again. So, I've told all my friends. What else can I say? It's a whole new world. It's like if you go watching a movie and it's in black and white, and all of a sudden it turns color. That's exactly what happened.

That's the best I can explain it. All the doctors are great at Acuity. In fact, everybody is. If I want something, all I do is text them and ask the question and they get back to me within five minutes, no problem.

- You're watching The Wellness Hour, news that makes you healthier. I'm Randy Alvarez. Today's topic, what you need to know if you're considering cataract surgery and specifically, why you should ask your doctor for a premium lens. With us, we have Jessica Boeckmann. So Dr. Boeckmann, so, the laser, why the laser? Why does somebody want the laser involved in this cataract surgery?

- Well, the laser is important because you can get a better result with the laser. The laser adds an extra layer of precision and accuracy that can't be done by hand. It's reproducible the same way every single time and more importantly, it can fix the astigmatism of the eye and give you a better result.

- Is there a noticeable difference when you use the laser and when you don't use the laser as far as outcome?

- Yes, for outcome. Especially in patients who have astigmatism because I can use the laser to fix your astigmatism and get you out of glasses for distance. If I don't use the laser to fix the astigmatism, you'll still have to have glasses to see.

- So, insurance does not cover this laser?

- No, insurance does not.

- But this is very inexpensive… - It's not very expensive… - …to do this.

- …to do the laser. The good thing about the laser too is it, especially in sick patients who have really big cataracts or have had diabetes for a long time, the laser just helps give you the better outcome because it helps the surgeon do his or her job easier and whenever they can get their job done better, you're going to have a better result.

- And this takes you about 9 minutes, is that right? Because you do 15 in a day.

- Yeah. So the laser itself takes about 3 minutes and then we'll go to the surgery, and the surgery takes about 10 minutes.

- And what about pain? What do people tell you?

- There is some pressure on the eye, but most patients don't complain at all. They'll say, "Oh, that was...I felt a little pressure but it's not painful."

- Do you see a lot of husbands and wives doing this together?

- Yes, I've done husbands and wives on the same day, and it's so cute because they'll be there together and I'll do the husband first and the wife second, and the child takes both their mom and dad home. It's like just a little tune-up. I love doing husbands and wives on the same day, I think it's cute.

- Okay, so when a patient goes into one of your centers, and I guess you're the third largest ophthalmology group in the country with this consistent care wherever they go, do they actually say, you know, "I have a cataract and tell me about these premium lenses?"

- Most of the time, they don't know about it.

- I mean, is that the lingo? They're called premium lenses?

- They are called premium lenses. Most of the time, people don't know much about them and a lot of times, they'll see me, "I can't see very well. I just don't feel comfortable driving at night. There's lots of glare and halos around headlights. I have to have really bright lights to read my book," and I explain to them, like, "Well, actually, all those symptoms are related to your cataracts. And so, what we do is we do cataract surgery which is the lens replacement surgery."

And they're like, "Oh, a lens replacement," and then you throw in the extra layer of, "You have choices," and which type of lens you want to put in their eye. And oftentimes, they're a little bit confused because that's a lot of information all at once, "You mean I have to make the choice? What does that mean?" you know. And so, then you'll see them that time and you'll talk to them and counsel them, and I like to give them some reading material and then bring them back in a week, and I also tell them to talk to their friends to see what type of lens that their neighbor got because I don't want them to think that if their neighbor got the standard one and that was her result, that doesn't mean I can't get them better vision than their neighbor may have had, which...

They're always talking. They're comparing.

- They're always going, "My neighbor had this, that's what I want."

- Yes, yes. "My neighbor had this, this is what I want. My neighbor had this, this is what I want. My neighbor said not to get the laser. My neighbor said to get the multifocal."

- Is that right? Well, people are googling everything now.

- They are, they are.

- So, they come in, and do they ever have somewhat wrong information and you have to… - They do.

- …to take a deep breath and, kind of, explain? And I'm like, "This is not... This is comparing apples to oranges. I can't comment on what Susie had but I can tell you what would be best for your eye."

- So, the premium lenses, really just help you see better.

- They do.

- Period?

- Yes.

- Up close, you could see up...

- They have to be more of a range of vision without glasses.

- Now, we are just about out of time but when should somebody...what are the signs or symptoms when somebody should see somebody?

- Well, most oftenly, patients will just start noticing that their vision is just not as good as it used to be and they're having trouble doing things that they normally did without problems. These things include driving at night, reading, trouble with glare and halos around headlights, and overall, just, things just aren't as crisp, and when these things start to happen, I really think that you should start to get evaluated because you don't know how big the cataract is because you can't see it and we can evaluate it for you.

- So now, do you see the optometrist? Do you see the ophthalmologist? What is it?

- If you're over the age of 65, I would think that it would be best just to go see an ophthalmologist because there are a lot of different eye diseases that can start to occur at that age, younger patients, it's, you need to have cataracts before 60… you need to have cataract surgery before 65. That being said, there are some instances where younger people do need cataract surgery but for the most part, at the age of 65, I would recommend going to see an ophthalmologist.

- Now are you of the opinion that people wait too long?

- Some people, yes.

- I mean, overall?

- Overall?

- Across the country, that people are waiting too long for their cataracts to really get in the way of their life and then they finally do something about them?

- No, I don't think so. I think most patients who are healthy take care of their cataracts at appropriate times. There are occasionally patients who aren't as healthy, who have really bad diabetes, you know, who have undergone chemotherapy who will develop cataracts earlier and could potentially have benefited from surgery at an earlier age.

- So, those people with advanced or controllable diabetes, it's okay, you could do the surgery?

- Yeah.

- There must be a guide. The insurance says, "Look, they have to have a certain amount… - Of cataracts. - …of cataracts in order to get it covered."

- So, first of all, insurance covers it when the vision's 20/40 or worse but there are some cases where your vision will be actually better than 20/40 but you'll have a lot of glare and halos at night.

- You can't drive at night.

- You can't drive at night. So, because that's interfering with your activities of daily living, so if that happens, then insurance will cover it.

- So, insurance will usually cover it if you're saying, "Hey, look. I can't drive at night anymore. It's dangerous."

- Exactly. Exactly.

- It's covered. It's covered.

- Good. Now, so Medicare, or Medicaid, or whatever, those also you accept?

- Yes, yes.

- So, they can get that done?

- They can get that done.

- And so, people... But there are still a lot of people that are afraid to get this done.

- They are because it's their eyeball, but the good news is, I mean, it's a very, a relatively low-risk surgery and the recovery time's so low and the benefits outweigh the risks.

- Okay. And they should definitely ask, "Tell me about these premium lenses."

- They definitely should because the thing with cataract surgery is once you get it done, whichever lens you choose, you have to keep the rest of your life. So, if you get the premium lens, you get to keep that for another 20 to 30 years. If you get the standard lens, you also keep that for 20 or 30 years.

- Have you had two friends, one opted to not do a premium lense, one did?

- And husbands and wives who choose one and another. And I had a husband, actually I think I'm operating on the wife the coming up week, the husband got the premium lens and the wife was like, "Oh, I don't think I want it," and I asked her, I'm like, "Well, if your husband had it, why wouldn't you do the same for yourself?"

- Well, what'd she say?

- She said, "Well, I'll think about it," but she's getting the premium.

- She's going to get the premium?

- She is, yeah. I mean, look. I mean, if you have an option not to wear glasses... And like you said, some people like the glasses.

- They do.

- They could hide bags in the eyes, things like that, but for that close-up vision, I mean, that's great… - I would like it.

- …if you can get that. I would be very sad to lose my near vision and I know that's something that'll happen to me, you know, as I get older, but to be able to give that back to someone is also a very big reward.

- Now, on this program, we've done fall prevention shows and eyes are really never talked about, but if you're 75, 80… - And they should be.

- …and people are getting injured all the time from falling down. And the first thing my dad told me is… - He can see.

- …he didn't anticipate this, is that he could see things on the floor now. He's not bumping into things.

- There's a recent study that was actually published in the Journal of American Medical Association that said that having cataract surgery prolongs someone's life and that's because...

- That's one of the reasons.

- Yeah. If decreased risk of falls, it stimulates you so you're less inclined to get dementia. And so, it has lots of other benefits just besides seeing better.

- Okay, good. So, just about every time people are better off with these premium lenses?

- Not every time.

- Because not everyone's a candidate.

- Not everyone's a candidate.

- Would you say 70% of the time?

- Yeah, I'd say 70%.

- Seventy percent of the time?

- Yeah, with realistic expectations that you will have some glare at night around lights, sometimes you won't get all the smallest print, you won't be able to see with the premium lenses but I like to say they're more of a lifestyle lens that you go to the store and you can read labels, and you go to a restaurant, you can read the menu, but for that tiny, tiny print in newspapers, you're still going to have to put on a pair of cheaters.

So active people, those are the best candidates, people that are traveling, people that do water sports… - Yes.

- …golf, whatever? But even if you think about it, even if you were, say, like you're a wheelchair-bound patient who lives in a nursing home, there are still benefits to having a premium lens as long as your eye is healthy because those are the people who forget to wear reading glasses and now you have glasses, they'll still be able to have near vision with them even if there are limitations in their normal activities of daily living such as walking or running.

They can't do those things, but at least they could see up close without glasses, if they can't get to them.

- We are completely out of time, but if somebody's watching this and they've heard what you had to say, maybe they're the 65 or 69 plus that probably have cataracts, but they're putting it off, or they're skeptical, or they're afraid, what do you say to them?

- I'd say, come in and get checked out, I'd love to see them, take a look at their cataracts, and we can talk about options of whether they need surgery right now or maybe it's okay to wait.

- Now, I know you have offices all over Orange County but people see you? You do your own consults?

- Yes, I do.

- And you also see them after as well?

- Yes, I see my post-op patients as well.

- Okay, good. I want to thank you for coming on the show.

- Thank you.

- Very good. You've been watching The Wellness Hour, I'm Randy Alvarez. For now, I wish you good health.

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