Cataracts and the elderly
August 12, 2022 8:26 AM Subscribe
You are not my relative's doctor nor her ophthalmologist, this will not constitute medical advice. But I could use your help thinking this through.
My family member "Beatriz" is 80 years old, and has diabetes and hypertension. She has astigmatism (worse in left eye) and cataracts (worse in right eye). She was told she needed cataract removal two years ago, and delayed treatment. During the most recent consult, the right eye had deteriorated further. She likes this ophthalmologist, and he's done thousands of surgeries.
Medicare covers standard removal and mono lens insertion. Beatriz agreed to pay $1,800 out of pocket (per eye) to cover laser removal, which was recommended due to her pre-existing conditions. Other specialists (endocrinologist, primary care physician) also said the laser technique was the better choice. The left eye procedure, which is expected to be less difficult, is scheduled for later this month, and the right eye procedure is next month.
Now the ophthalmologist is recommending a toric lens (an Alcon AcrySof IQ, per brochure attached to surgical coordinator's email) for the left eye, to correct the astigmatism. (The right eye would need a corrective lens, too.) These lenses would be discounted. Per the email, "Most patients will still need glasses for reading but not for the distance."
Per eye, Beatriz's options are:
Standard cataract surgery with an astigmatism lens for $1,800
Laser cataract surgery with an astigmatism lens for $2,500
I want Beatriz to heal as well as possible. I hope a toric lens might reduce overall fall risk. Beatriz was already annoyed about the laser technique cost, is reliably suspicious of newer technology and last-minute upsells, and will likely argue that her age makes the additional $1,400 for both eyes (thus making $3,600 into 5K overall out of pocket) a waste of money.
Is healing/adjusting post toric lens much different from the mono lens? Are there known issues with the AcrySof IQ? How significant are age and medical conditions in this process? Should I not even mention the toric lens rec, because she needs glasses for distance -- so, for driving, and the family is already trying to get her give that up? Any insight would really help, I have to present the new info midweek. Thanks so much.
My family member "Beatriz" is 80 years old, and has diabetes and hypertension. She has astigmatism (worse in left eye) and cataracts (worse in right eye). She was told she needed cataract removal two years ago, and delayed treatment. During the most recent consult, the right eye had deteriorated further. She likes this ophthalmologist, and he's done thousands of surgeries.
Medicare covers standard removal and mono lens insertion. Beatriz agreed to pay $1,800 out of pocket (per eye) to cover laser removal, which was recommended due to her pre-existing conditions. Other specialists (endocrinologist, primary care physician) also said the laser technique was the better choice. The left eye procedure, which is expected to be less difficult, is scheduled for later this month, and the right eye procedure is next month.
Now the ophthalmologist is recommending a toric lens (an Alcon AcrySof IQ, per brochure attached to surgical coordinator's email) for the left eye, to correct the astigmatism. (The right eye would need a corrective lens, too.) These lenses would be discounted. Per the email, "Most patients will still need glasses for reading but not for the distance."
Per eye, Beatriz's options are:
Standard cataract surgery with an astigmatism lens for $1,800
Laser cataract surgery with an astigmatism lens for $2,500
I want Beatriz to heal as well as possible. I hope a toric lens might reduce overall fall risk. Beatriz was already annoyed about the laser technique cost, is reliably suspicious of newer technology and last-minute upsells, and will likely argue that her age makes the additional $1,400 for both eyes (thus making $3,600 into 5K overall out of pocket) a waste of money.
Is healing/adjusting post toric lens much different from the mono lens? Are there known issues with the AcrySof IQ? How significant are age and medical conditions in this process? Should I not even mention the toric lens rec, because she needs glasses for distance -- so, for driving, and the family is already trying to get her give that up? Any insight would really help, I have to present the new info midweek. Thanks so much.
Response by poster: I agree. She accepted the laser option b/c of the better healing argument, but she will balk at the additional lens cost, newness of product, and late-breaking rec. So, we're on board for the previously (exhaustively) discussed laser procedure, but I would like talking points to present a good argument for this next hurdle.
posted by Iris Gambol at 8:57 AM on August 12, 2022
posted by Iris Gambol at 8:57 AM on August 12, 2022
My mother had a cataract scraped at the age of 97. She got 2.5 years of use from the procedure. Which is 10x longer than she got from the stair-lift. Things not mentioned in Beatriz's tale
1) that post-op care will require drops four times a day for 4 weeks.
Team Beatriz will have to muster 2 minutes * 4 times * 4 weeks for this.
2) Informed consent: ask searching questions about "They didn't adequately inform my mother that a disagreeable side effect of cataract treatment is painful sensitivity to bright sunlight". Also my mother stopped taking part of the post-op pharma because it made her feel depressed.
My mother never went back for the second eye BMMV.
3) The possibility of Charles Bonnet Syndrome is a factor.
posted by BobTheScientist at 9:09 AM on August 12, 2022
1) that post-op care will require drops four times a day for 4 weeks.
Team Beatriz will have to muster 2 minutes * 4 times * 4 weeks for this.
2) Informed consent: ask searching questions about "They didn't adequately inform my mother that a disagreeable side effect of cataract treatment is painful sensitivity to bright sunlight". Also my mother stopped taking part of the post-op pharma because it made her feel depressed.
My mother never went back for the second eye BMMV.
3) The possibility of Charles Bonnet Syndrome is a factor.
posted by BobTheScientist at 9:09 AM on August 12, 2022
Unless the astigmatism is severe, I don't believe its correction will reduce the risk of a fall.
I don't think that there is any difference in healing time between a toric lens and a simple lens.
I opted for laser dissection of my lens instead of ultrasound phacoemulsification because the surgeon I used did about 90% laser removal, and I wanted him in is comfort zone. I was okay with the extra expense to do that.
The informed consent was terrifying (worst case mentions blindness and pain for the rest of your life in the affected eye), and nobody mentioned it until I signed the form.
How does B feel about wearing glasses to correct for astigmatism while reading? Both of the surgeons that I consulted to get my eye done assumed that I did not want to wear glasses in the future, and that I would be happy with one eye for distance vision, and one eye for close vision and reading. They were incorrect in their assumptions.
posted by the Real Dan at 9:29 AM on August 12, 2022
I don't think that there is any difference in healing time between a toric lens and a simple lens.
I opted for laser dissection of my lens instead of ultrasound phacoemulsification because the surgeon I used did about 90% laser removal, and I wanted him in is comfort zone. I was okay with the extra expense to do that.
The informed consent was terrifying (worst case mentions blindness and pain for the rest of your life in the affected eye), and nobody mentioned it until I signed the form.
How does B feel about wearing glasses to correct for astigmatism while reading? Both of the surgeons that I consulted to get my eye done assumed that I did not want to wear glasses in the future, and that I would be happy with one eye for distance vision, and one eye for close vision and reading. They were incorrect in their assumptions.
posted by the Real Dan at 9:29 AM on August 12, 2022
I had toric lens implants last year (pre-cataract, but it's the same surgery). It's the exact same procedure as standard lenses, and so there should be no difference with healing time.
I still have a tiny bit of astigmatism, which affects very close-up vision, but nothing cheap readers won't sort out.
I have had no issues with depth perception (which can happen if you have a different lens in each eye). I think the questions that should be asked are around depth perception and how having a toric and a standard lens might affect this. I know that after I'd had my first eye 'done' and was wearing a prescription contact in the other eye for six weeks or so, I had to be careful around stairs, particular stepping down.
posted by essexjan at 9:52 AM on August 12, 2022
I still have a tiny bit of astigmatism, which affects very close-up vision, but nothing cheap readers won't sort out.
I have had no issues with depth perception (which can happen if you have a different lens in each eye). I think the questions that should be asked are around depth perception and how having a toric and a standard lens might affect this. I know that after I'd had my first eye 'done' and was wearing a prescription contact in the other eye for six weeks or so, I had to be careful around stairs, particular stepping down.
posted by essexjan at 9:52 AM on August 12, 2022
I would not recommend placing IOLs to correct astigmatism. Astigmatism can be caused by the lens, the cornea, or some combination. There is no guarantee that her astigmatism post cataract surgery will be the same as pre-surgery. In my case, the severity of my astigmatism measured with a post-op refraction was about 50% better compared to pre-op measurements. Thus, a lens selected based on pre-op measurement would have over-corrected the astigmatism.
posted by sudogeek at 1:25 PM on August 12, 2022
posted by sudogeek at 1:25 PM on August 12, 2022
I am an ophthalmologist. I am not your family member's ophthalmologist, this is not medical advice, etc.
Laser-assisted cataract surgery is not for better wound healing. It is often used for better lens centration for certain types of premium lenses, as well as for making corneal incisons for astigmatism correction.
Astigmatism can be corrected using the manual incision technique, the laser, and/or a special toric intraocular lens. The patient's individual situation determines which is best.
In most cases, laser cataract surgery is not superior to conventional cataract surgery. There are some situations in which it is useful, but it is not universally preferable.
posted by aquamvidam at 4:01 PM on August 12, 2022 [3 favorites]
Laser-assisted cataract surgery is not for better wound healing. It is often used for better lens centration for certain types of premium lenses, as well as for making corneal incisons for astigmatism correction.
Astigmatism can be corrected using the manual incision technique, the laser, and/or a special toric intraocular lens. The patient's individual situation determines which is best.
In most cases, laser cataract surgery is not superior to conventional cataract surgery. There are some situations in which it is useful, but it is not universally preferable.
posted by aquamvidam at 4:01 PM on August 12, 2022 [3 favorites]
One more thing: healing between a regular and a toric lens should be the same. What a toric lens does is make a person less dependent on glasses/contacts for some situations, which can potentially reduce fall risk.
I don't think it's ethical to withhold the option of good uncorrected vision as a way to get her to stop driving.
Questions to ask the doctor:
- What might her vision be like without the toric lens (i.e., with a standard lens)? That is, does she have a LOT of astigmatism, or just a bit?
- Can the surgery be safely performed without the laser? How much would the laser help - a little, a medium amount, or a lot?
posted by aquamvidam at 4:08 PM on August 12, 2022 [1 favorite]
I don't think it's ethical to withhold the option of good uncorrected vision as a way to get her to stop driving.
Questions to ask the doctor:
- What might her vision be like without the toric lens (i.e., with a standard lens)? That is, does she have a LOT of astigmatism, or just a bit?
- Can the surgery be safely performed without the laser? How much would the laser help - a little, a medium amount, or a lot?
posted by aquamvidam at 4:08 PM on August 12, 2022 [1 favorite]
I am scheduled for cataract surgery next month. I have some astigmatism but after consultation with my surgeon I'm not getting toric implants. I haven't been able to find toric contact lenses that are comfortable enough to wear all day, and when I did try them they had a tendency to float or rotate out of place so the correction was never that great for me anyway. In our consultation the surgeon said two things: (1) I'm at the lowest level of astigmatism for which they even consider a toric implant, and (2) sometimes the need for it changes simply as a result of the surgery. In my particular case, since my astigmatism is on the lower end and I'm used to contacts that don't correct my astigmatism, toric implants didn't seem to be worth paying the additional cost, which would not be covered by insurance. Maybe I'll feel like this wasn't the best decision after the surgery, but for now I'm good with it.
My surgeon offers a scan that happens in between removal of the old lens and placement of the insert called ORA that's supposed to provide an even more accurate prescription for the insert than the doctor can do before the procedure. Unlike the toric lens the surgeon did seem to think it's worth me paying for. It is, of course, not paid for by insurance. Amusingly enough it does involve lasers, but not for the surgery itself. If the question is a choice between different premium upgrades, that might be one to consider.
BTW there's one other option I didn't see in your list: they can give different prescriptions to each eye, with one eye optimized for close reading and the other optimized for distance (instead of doing both the same). Some people prefer that to having reading glasses. I feel like I'm not a great candidate for that for other reasons, but maybe your family member is.
posted by fedward at 8:21 PM on August 12, 2022
My surgeon offers a scan that happens in between removal of the old lens and placement of the insert called ORA that's supposed to provide an even more accurate prescription for the insert than the doctor can do before the procedure. Unlike the toric lens the surgeon did seem to think it's worth me paying for. It is, of course, not paid for by insurance. Amusingly enough it does involve lasers, but not for the surgery itself. If the question is a choice between different premium upgrades, that might be one to consider.
BTW there's one other option I didn't see in your list: they can give different prescriptions to each eye, with one eye optimized for close reading and the other optimized for distance (instead of doing both the same). Some people prefer that to having reading glasses. I feel like I'm not a great candidate for that for other reasons, but maybe your family member is.
posted by fedward at 8:21 PM on August 12, 2022
If she's used to wearing glasses then the only question is would she miss the extra money. Lens, AFAIK, is virtually the same.
posted by kschang at 6:05 PM on August 13, 2022
posted by kschang at 6:05 PM on August 13, 2022
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If it were me or my family member, I would look at the cold hard facts. How much will the added cost affect her life for the rest of her life? Is she just trying to not get "taken" or upsold or does she have legitimate financial concerns? What is her life expectancy at this point? She is 80 with diabetes and hypertension. 10 years? Her actuarial table cannot be good. How important are her eyes? Does she read or watch TV alot? Me, I would rather lose every other sense than my sight. For the last years of my life, I would like to be able to see without much effort. My hearing is already deteriorated.
What is a waste of money? Is she saying that she would rather take more time to heal and take more risk to save money? Is she going to run out?
Sometimes you cannot afford a bargain. Your eyesight and quality of life over your last years seems way more important than being able to leave money to your grandchild or favorite charity. Just my $0.02.
posted by JohnnyGunn at 8:42 AM on August 12, 2022 [1 favorite]