She usually attends an eye hospital in Tokyo every four months, but three days earlier her vision had suddenly become much hazier, and she first visited us.
Apart from cataracts with strong cortical opacity in both eyes there was no retinal or macular disease, so we diagnosed reduced vision due to cataract progression and proposed surgery as one solution. Incidentally, cataracts do not usually cause "sudden" loss of vision, but when cortical opacity from the periphery of the lens reaches the center, some people, like her, feel it happened "suddenly."
Right eye preoperative slit-lamp photo Right eye preoperative retroillumination photo
After discussion she wished to have surgery, and since she is a painter (in oils), we first recommended a monofocal lens that reliably and clearly shows the distance she wants to see. However, she also gives lectures and said she would be happy if, if possible, she could read her manuscript on the desk without glasses...
She had always had hyperopic eyes, about +2.5 D right and +4.0 D left, and could not do without reading glasses, so, although its near add is weak, we confidently recommended the non-diffractive segmental refractive LENTIS Comfort as a value-added lens that prioritizes her work performance with little loss of contrast. The reason I, usually cautious, could be confident was that in her case there would be almost nothing worse after surgery than before = improved vision and contrast at all distances could be expected.
Naturally surgery began with the right eye, whose vision was more reduced; we set the target refraction to secure distance reliably first, treating near vision as a bonus if it came. Some patients see near better than the specifications suggest, so sacrificing distance from the outset when setting the power narrows the possibilities. It depends on the situation, but especially for hyperopic eyes, I think it is better, unless there is a strong reason, to start by securing distance.
She told us she was very anxious before surgery, so we did a rehearsal beforehand (in the operating room under the microscope, with a drape over the face and a lid speculum in place) and confirmed, to be safe, that she would not become agitated before operating (in the past, claustrophobia has been discovered this way).
The cataract itself had almost nothing unusual about it, so right eye surgery was completed without problems and without refractive error, and postoperative uncorrected vision was 1.2 distance / 1.0 near, better than expected not only at distance but at near too.
For the left eye we kept open the possibility of setting the power more toward near, but she wished to see the same as with the right eye, so we operated with the same target refraction. The left eye surgery was also completed without problems, with very good postoperative uncorrected vision of 1.2p distance / 0.8p near, and after surgery she was delighted, saying, "I can see the canvas distance without glasses, and blue looks so beautiful!"; she felt eager to resume her creative work. With cataracts, blue wavelengths are blocked, so red to yellow wavelengths reach the retina preferentially. It is a well-known story among ophthalmologists that the Impressionist Claude Monet, famous for his "Water Lilies," suffered from cataracts in later life and came to use many yellowish tones in his work.
Right eye postoperative slit-lamp photo Right eye postoperative retroillumination photo
The pre- and postoperative fundus photos below probably convey the improvement in vision from surgery more impressively than photos of the cataract or intraocular lens. Removing the cataract opacity of course improves the patient's vision, and for us ophthalmologists it also makes fundus lesions easier to find, improving the quality of examinations, so it is not unusual for new lesions to be found after surgery.
Right eye preoperative fundus photo ⇒ Right eye postoperative fundus photo
She originally had hyperopia in both eyes, so with LENTIS Comfort or even a monofocal lens, as long as the target refraction was not set wrongly and no postoperative refractive error occurred, she was unlikely to be left dissatisfied. When I was a supervising doctor at a university hospital assigning cases to residents, I had them start with surgery on patients like her, to avoid trouble that might harm patients and to build the residents' confidence.
If she had been myopic at about −3.0 D, I would not recommend setting LENTIS Comfort, with its near add of about 1.5 D, for distance. That is because there would be a point (the near focal distance) where the result after surgery would lose to her state before surgery, and even if distance vision improved, she might be left dissatisfied. Of course a result better than before surgery at every distance is desirable, but no lens can see everything from far to near as in one's youth, so some trade-off is usually unavoidable.
To raise your own satisfaction after surgery, we recommend that anyone now considering surgery identify and organize what you are satisfied with now = what you don't want changed after surgery and what you are dissatisfied with now = what you want surgery to improve, and tell your doctor.
2021.11.14