FRESNO, Calif. -- Age related cataracts, cloudiness in the lens of one or both eyes, affect more than 22-million Americans. It's no longer a condition that is limited to seniors; younger people are developing cataracts, and many are electing to fix them at an earlier age.
Wendy Loll and her dance group love cutting loose on the dance floor, but Wendy was having trouble making it to performances.
"As the cataracts got worse the night-vision was really scary," Wendy Loll told Ivanhoe.
Doctor Jeffrey Whitman used a high-tech tool to diagnose this forty-something year old with a condition that used to be considered just a part of old age.
"What we are seeing is we see cataracts at a much earlier age than we used to, now part of that may be detection, we can detect them earlier," Jeffrey Whitman, M.D., Ophthalmologist at Key-Whitman Eye Center in Dallas told Ivanhoe.
To make that diagnosis, Whitman used a new device called an HD analyzer; it puts a low-level laser into the retina and measures light scatter which can indicate early signs of cataracts.
Whitman then corrected the problem with surgery, inserting high tech lenses to make Wendy's vision 20-20.
"You know we are in that bionic time in some ways," said Dr. Whitman.
All Wendy knows is that she's footloose, because she can see again.
"I would definitely recommend getting it checked out," said Loll, "don't be afraid, get it taken care of, it's no big deal and your eyes are precious."
Doctors say some possible reasons for younger patients to develop cataracts include sun exposure, medications and food additives and preservatives. According to the National Eye Institute, by age 80, more than half of all Americans either have a cataract or have had cataract surgery to replace the deteriorating lenses of the eyes.
BACKGROUND: The majority of cataracts are age-related; however, other factors can cause the condition. Diabetes, smoking and large alcohol consumption can increase the risk for developing cataracts as well as unprotected exposure to ultraviolet (UV) radiation and certain drugs such as corticosteroids, chlorpromazine, and other phenothiazine-related medications. Studies have suggested that cataracts can form as a result of certain nutritional deficiencies such as low levels of vitamin C, vitamin E and carotenoids. A cataract can be diagnosed by a comprehensive eye exam which takes into account a patient's history as well as examination of the retina, lens and pressure within the eye, among other factors.
TREATMENT: Treating cataracts may be as simple as a change in eye glass prescription, if it affects a patient minimally, as well as increased light when reading or anti-glare lenses when driving at night. Severe cataracts require surgery that remove a patients' lens and replace it with an artificial one. There are two approaches generally used for cataract surgery. Small incision cataracts surgery is performed by making an incision in the side of the cornea and inserting a tiny probe into the eye which emits ultrasound waves that soften and break-up the lens so it can be removed by suction. This process is called phacoemulsification. Extracapsular surgery is another type of surgery in which a larger incision is made in the cornea and the lens is removed in one piece.
NEW TECHNOLOGY: A new tool helping with the diagnosis of cataracts is the HD Analyzer which is a diagnostic system that allows for an objective analysis of optical quality in a person's eye. It objectively measures light scatter, which is not measurable using traditional aberrometry techniques. Light scatter is caused by several ocular factors such as corneal disease or imperfections on the ocular surface as well as cataract formation, which can lead to degradation in retinal image quality. The unique technology utilizes double-pass retinal imaging and uses a near infrared light source that is imaged onto the retina. The size and shape of the light are analyzed by the system in order to determine the higher order aberrations present as well as scattered light. It gives ophthalmologists the ability to go beyond traditional subjective means of vision assessment. For more information on the HD Analyzer, visit: http://www.medeuronet.com/our-products/visiometrics/.
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You deal with all of the eye issues that are out there which is considerable.
Dr. Whitman: Yes, and we deal with everything from pinkeye to glaucoma, diabetes cataracts or even a change in glasses.
Do you do macular degeneration?
Dr. Whitman: Yes we do. The only thing we probably don't do is surgical retina treatment.
What is a cataract problem and how does it develop?
Dr. Whitman: A cataract is a naturally occurring phenomenon where the lens of your eye that sits back behind the pupil of your eye becomes harder and denser as we get older. In our 40s it manifests itself by hey, I can't read I have to stretch my arms way out, focal length gets longer. But the natural continuation of that process as the lens gets more dense, you can't focus as much, is decreased colors, can't see signs as well, diminution of vision in general. It's just a continuum from when we're babies, to as we get older and are usually for most people in their 50s, 60s, 70s.
We have ways to treat it?
Dr. Whitman: Absolutely. In fact the ways to treat cataract have gotten better and better in terms of microsurgery. We now have femtosecond lasers to help us in the surgery to make it safer; really it's day and night from your grandparent's cataract surgery.
You also have new technology to help to diagnose as well.
Dr. Whitman: Yes, we have new technology to diagnose, we can even tell someone that has early cataract that's considering LASIK surgery whether that's the best thing or whether their cataract is advanced enough, that's called our HD analyzer. It can in some ways give us a look into the future even with somebody with very good vision to say, hey you are getting closer to having some true cataract maybe this treatment cataract surgery may be better than that treatment laser surgery.
How valuable is a device like that; especially in determining early problems?
Dr. Whitman: Some of these new devices like the HD analyzer are invaluable because in the past we would have operated on someone because they wanted a particular procedure and then two or three years later we and the patient may have regretted it because their vision begins to change. Not because their LASIK treatment was going bad but because their lens is going under that natural aging process, getting more dense and that changes their glasses prescription. It makes the patient unhappy and now we know, oh it really is an early cataract problem and taking care of the cataract is the way to take care of it, hopefully permanently.
It sounds to me like with the popularity of LASIK, they know the procedure is safe and available and you can correct your reading glass problem by having a LASIK done, you're seeing a lot of people in their early 40s who are experiencing it.
Dr. Whitman: You can't correct the reading problem with LASIK, you can correct the distance problem.
Is this an offshoot of this sort of popularity of LASIK; that more and more people are coming in at a younger age and you're seeing the cataract? Or is it a combination of that with the new technology?
Dr. Whitman: Actually I think it's a byproduct of that particular generation are people that are in their 40s and 50s that want more. Perhaps they've saved up no matter how the economy was affecting them and they want to look better, see better, perform better without the use of, in this case, glasses. But it's still divided into two sections, what we are seeing is we see cataracts at an earlier age much more than we used to. Now part of that may be detection, we can detect them earlier but truly perhaps due to environmental influences of the sun, maybe medications we take, preservatives and food, who knows. We're seeing cataracts at an earlier age, and that's a definite phenomenon. I see many more people in their early 50s with cataracts than I did 15 or 20 years ago. And then take that from what I call lifestyle cataract surgery. Meaning that, I don't want to wear reading glasses all the time, and perhaps they had LASIK before and they're going, you know I was out of glasses for a while now I've gotten older now I have to wear reading glasses. So now we have a high technology lens implants available for them that can correct astigmatism, that can help correct their vision for distance, intermediate and close up. They can see the computer, the road, and read their book. Now what I tell these patients we can make them better, we probably can't get them out of their glasses for everything they do, but our goal is to get them out of their glasses for the majority of what they do and that's usually fulfills their need very well.
Let's go back and talk about people needing cataract surgery at a younger age. Talk about that what you're seeing and what the theories are.
Dr. Whitman: There's really no definitive reason that we see cataracts at an earlier age. Of course there are younger people that come in with trauma, which is more frequent in that age group; trauma itself being hit in the eye can cause cataract. We know certain medications bring cataract on sooner, so if you're on an oral steroid, prednisone or something like that for a prolonged period of time, you're probably going to develop a cataract at an earlier age. But other general cataracts we have plenty of people even in their late 40s but definitely 50s or early 60s coming in with what I would call an age-related looking cataract but they are not age related yet. Now we do believe this may have to do with more sun exposure, it may have to do with preservatives in foods, it may have to do with you know the food, general food that we eat or just medications that we take that we haven't specifically identified yet as causing cataract.
Among those medications it sounds great for research scientists and they're probably working on it. One of the things mentioned was the increase in cholesterol medications?
Dr. Whitman: We found the increase in what we call statin use, and these are drugs that help treat high cholesterol; Lipitor and Crestor or drugs like that actually have a direct effect on our tear system. Because they actually decrease the oil input into our tear film and that's a critical part of our tear film. What we see is a lot more dry eye in that population taking those medicines. I'm one of them, so I had no dry eye until I started taking Crestor now I find out I had to put tears in all the time to keep my eyes comfortable.
And the lack of tears tends to lead to an increase in the hardening of lens?
Dr. Whitman: Well unfortunately we don't know if a change in the tear film is directly or indirectly related to cataract formation. The jury is out on that now, we really don't know if there's a direct effect.
That's interesting, is that a direct relationship to anti-cholesterol medications?
Dr. Whitman: I think it's that and also we have more patients wearing contact lenses. Contact lenses irritate the eye if you have any kind of dry eye there's a concern when you do LASIK surgery that it can irritate a dry eye problem that's there. I think that we interact with the eye more than we used to and that shows if there's a dry eye problem that there's more effect but the neat thing is that we have new dry eye problems. We even have a heating pulsating machine where you put a specific type of contact lens on the eye, it heats the eyelids and it pulsates around the eyelids kind of like a massage for your eyelids but it gets the bad oils out that are blocking secretion of your tears. And it can have an amazing effect.
Eyes and allergies go together.
Dr. Whitman: This time of year it's probably 25-percent of what we see.
We talked about this phenomenon of younger people is anything else about that that you have come across in terms of anecdotally that is really interesting to you about the number of young people?
Dr. Whitman: Well I think it mixes in with the definition of the baby boomer population in that I would say well over half of the people that are coming in wanting cataract surgery at an earlier age don't have cataract. They may have earlier starting cataract but their complaint is I don't want to wear glasses all the time it makes me look old. And we're in the Botox world now truly, you're using a crutch I look at it, when you use glasses all the time that you could lose, you could wake up there could be a fire and you can't see. If we can fix your eyes and make them better whether it be LASIK in the earlier age crowd, or cataract surgery from 40 years of age on up, you can truly build a better eye. We are that bionic time in some ways. There are many people coming in saying, what can you do for me? Perhaps they've had RK or LASIK in the past and now they've gotten older and they're saying, I could still see at distance but now I can't read, what can you do to fix me? We have high technology lenses like crystal lenses, toric lenses, we have multifocal lenses like ReSTOR and Tecnis. We have ways to fix it now that we did not have before.
And those lenses would be potentially part of the cataract surgery?
Dr. Whitman: Oh absolutely. In fact about 40 percent of the lenses I implant now are one of these high technology lenses that can do more, correct astigmatism, correct various distances of vision, decreased dependence on glasses.
Do you combine them?
Dr. Whitman: No, it's possible to do a single focus lens in one eye and one of the newer lenses in the other eye. When I say newer lenses a lot of these are 15 years old already, so they are not experimental. You know some people get afraid when you say newer and these lenses, the ones we're using here in United States are tried-and-true. But ideally we try not to mix and match because we find that binocular both eyes working together it's better if we try the same technologies. Sometimes we'll mix the technologies though, we find that we can do one type of high-technology lens in one eye another in the other eye that complement their vision and give them the best distance and best close up vision.
This sounds like people are almost electing to have cataract surgery almost as a preventative, is that fair to say?
Dr. Whitman: I would say about 25 percent of our patients are considering cataract surgery on an elective basis. We call that refractive lens exchange. The surgery is exactly the same, in fact, one of the nice things it's actually a little easier because they haven't formed a real dense cataract that can be problematic in removing and they heal quicker because they're younger.
There's nothing wrong with doing that? Until waiting until it's a severe problem?
Dr. Whitman: There are advantages of having the cataract problem taken care of earlier in terms of the ease of the surgery however, patients still need to be aware that the risks of doing any intraocular surgery are the same; healing problems, infections things like that. Thankfully in cataract surgery they're very rare, the results are routinely very good but again it's still surgery and patients need to evaluate the risks for themselves.
Talk a little bit about outcomes among the younger crowd that's coming in. Are you getting great outcomes?
Dr. Whitman: Well first of all I'll say throughout the United States cataract surgery is the safest elective surgery available. That being said I would step that up a few notches for our younger patients again because they're younger. They heal faster, they get less inflammation, and by the way, they can also be more demanding on the result because they're in the working crowd. They want to get back to what they're doing as quickly as possible and it's something at Key-Whitman that we really strive to do is that. We do so many of these that we have that expertise that were trying to get them back to their normal workaday lives as soon as possible.
What should an ordinary person look for, what are the indicators that they might have some kind of a cataract problem?
Dr. Whitman: I think number one, they should start looking for a change in color and that could be difficult because it comes on slowly. But if they find themselves having arguments with somebody painting the house or friends about color of their shirt or something like that it's time to come in and get that eye exam. If it's taking them longer to see the street sign, they have to get up closer to it again a sign. You don't have to be blind from cataracts in fact, it's rare for us to see that anymore because our techniques are better, and we discourage people from waiting until they can't see anymore it just makes the cataract surgery more difficult. When you start noticing those signs you need to go for that "annual eye exam" that you haven't gotten for three years or 20. And you need to come in because first of all anybody over 40 is at greater risk for glaucoma, retinal disease like macular degeneration, if you have diabetes, those things you're not going to pick them up early enough if you wait until you have a decrease in vision. Please, please, please come in for that yearly exam, we can pick up if there's early cataract change now, because we have the instruments to do it. I think another important thing is what you should look for when you're looking for an eye clinic to you know have your eyes evaluated and perhaps treated. I think one is you have to ask do you offer the full range of lens implants for cataract surgery; most doctors offer one of the new lenses, maybe two, and we offer all of them. We can help place the right lens to the right patient based on their lifestyle and I think that's an important thing. Do they have the femtosecond laser to help perform the cataract surgery with laser now? Unfortunately a lot of people thought that surgery was always done with lasers but that's very incorrect. We did it with sound wave to dissolve the lens and remove it, which we still use in the cataract procedure itself but using the femtosecond laser or what we call femto cataract surgery has really decreased the surgical time, decreased inflammation which leads to faster healing.
Getting back to the indicators, we have street signs, colors, what else?
Dr. Whitman: Street signs, can't see them, as well as I used to I have to get up closer to them, colors, perhaps I'm just walking down the street and I'm stepping down the curb and I can't negotiate the curb as well as I could before. Problems when you are pulling into a parking space and I can't see this clearly, my three-dimensional feeling just isn't as good as it was before. I think those are all very important things.
What about night?
Dr. Whitman: Night driving is an issue for patients all in itself. Usually we find it more of a problem in our older patients, bad if you're developing the type of cataract you can get in younger patients which is what we call a PSC or posterior subcapsular cataract; most of its affect occurs either bright sun or when bright lights hit you when you're driving. And what happens is light hits you, pupil gets smaller all the light has to go now through that cataract that's right in the middle and you're going to have horrible glare you can't see things as well, you feel dangerous, you may have to pull off from the side of the road. What happens unfortunately is a lot of people just stop driving at night rather than go to the eye doctor to see what the problem is. I think an alert to my patients would be you know you start having a problem with night driving, seeing colors well, seeing the street signs, you need to come in and get that regular eye examine and say, hey doc I don't feel comfortable driving at night anymore. I'm getting more glare, it doesn't happen all the time. They may not understand this issue where it only bothers me when lights hit me; come in for that exam and it's something very easy for us to pick up and to detect particularly with our new HD analyzer. It really can show you some good information.
Is there available information that indicates that the number of surgeries that are being performed for cataract is getting younger and younger?
Dr. Whitman: You know I haven't seen anything published, I'm not saying nothing is there I'm going to have to take a look.
Just again about what you're seeing.
Dr. Whitman: I'll say from what we're seeing, in our practice and talking to my colleagues because I'm very involved in all the national meetings, is that we're all seeing significant cataract, not just early cataract in younger and younger patients. I think that's something we're going to see more and more in the coming years perhaps because of what we're exposed to in our current age.
That's where the research comes in. It sounds like environmental factors, almost no matter what, you name the disease, illness or environmental factors, we're just beginning to learn about that.
Dr. Whitman: I think part of the issue is that we also have a more demanding public now. In other words I'm working longer and I'm very demanding on being able to read the fine print on the page or work with my computer, that's the number one thing we hear, or being able to drive about whether it be for fun or for work. I think we notice these things earlier being affected because of our demanding lifestyles.
What's the typical cost for cataract surgery?
Dr. Whitman: Well if it's a traditional lens and insurance is covering it, your insurance covers most of that. If it's one of the new what we call premium or high technology lenses, your insurance that would pay for a normal lens is placed towards that. Kind of like a discount on that and whatever the difference is the patient pays.
Let's say someone got the crystal lens if they had insurance, what would be the general ballpark?
Dr. Whitman: If they had insurance it's probably going to cost them in the three thousand to thirty-five hundred dollars range per eye.
That would be cost to the patient after insurance is paid?
Dr. Whitman: Exactly, because now they have to pay the higher cost of the lens and there are a number of the high-tech tests now that go along with doing those lenses. Often with those lenses we will do treatments such as LASIK or fine touch enhancements for a year after they had the lens implant done. It's something that doesn't come with traditional lens implant so there's greater value achieved by having the high technology or premium lens implants.
But a little more maintenance that goes along with it?
Dr. Whitman: Yes.
Let's talk about Wendy's case. Tell us what you recall about her particular case. She's in her 40s so she doesn't look like she's ready for cataracts.
Dr. Whitman: No, when these patients come in I always say, you're a baby what are you getting a cataract for? And we didn't see anything like trauma, or a particular medicine that was causing the problem. Her vision was about 20/40 in her right eye but it was twenty-two hundred in her left eye already. So she was living with decreased vision in that eye because she could function with her other eye for a good while. As soon as we saw her and examined her we could see the cataract there, a smaller cataract in the right eye but much bigger posterior cataract, as we were talking about before, in her left eye. Again these are the ones that particularly at night time the light hits you, the pupil get smaller light has to go right through the cataract and you're blinded and that was the case for her. This is really life-changing for her, she's had both cataracts performed and she sees 20/20 in both eyes now.
What level of satisfaction do you get when you help these people knowing that they have a long healthy life ahead of them and you're contributing to the quality of their life?
Dr. Whitman: Well I think one of the reasons I went into ophthalmology it's because I can see the effect of what I do very quickly. My friends that are internists will put someone on a blood pressure medicine, the patient won't feel different except maybe they'll get sick from the medication. I kid them about this all the time. For me I take the cataract out and often the next day or within the next week they are seeing great, I get a lot of hugs, I like that. My family's good at hugging me but it's really great getting it from the patients as well. The staff hears this all the time; they get hugs and kisses so it really makes it a nice day when you're seeing the post-op patients. Everybody likes post-op day because you've change somebody's life. And that's what we say at Key-Whitman we change people's lives.