Cataract

Widely offered in NHS to improve distance vision

The Benefits of Monofocal IOLs:

Reliable clear distance vision: Monofocal IOLs offer exceptional visual clarity at the selected distance, allowing you to enjoy crisp and sharp vision for everyday activities.

Proven Track Record: Monofocal IOLs have been widely used for decades with a long history of safety and effectiveness. They are a trusted option for restoring vision in patients with cataracts or significant refractive errors.

Reduced Visual Disturbances: Compared to multifocal or EDOF lenses, monofocal IOLs may result in fewer visual disturbances such as halos, glare, or fluctuations in vision, particularly in low-light conditions.

Cost-Effective Solution: Monofocal IOLs are often more affordable than multifocal or EDOF lenses, making them an attractive option for patients seeking excellent visual outcomes without breaking the bank.

The limitations of monofocal IOLs:

No freedom from glasses: Only provides targeted clear vision usually for distance only, for near most likely needs reading glasses may also for intermediate distance (computer work)

No astigmatism correction: About 25% of eyes has significant astigmatism. These eyes may require toric IOLs to achieve the best visual results unaided, allowing for the greatest chance of spectacle independence.

Limited depth of focus: While monofocal IOLs will give excellent vision at the chosen distance (near or far), patients will still require glasses to adjust the focus for targets at other distances e.g. patients with monofocal lenses set for distance vision

EDOF IOLs provide a half-way option between monofocal and multifocal IOL options. They typically aim to give better depth of focus than a monofocal without some of the limitations associated with a multifocal lens. While patients may not be totally glasses free for all distances and/or activities they offer a nice compromise.

Though for established cases of glaucoma may not advocate multifocal IOL's, but EDOF lenses can be a good option.

Understanding Extended depth of focus (EDOF) IOLs:

EDOF intraocular lenses are state-of-the-art implants used to replace the natural lens of the eye during cataract surgery or refractive lens exchange procedures. Unlike traditional monofocal lenses, which provide clear vision at only one distance (usually far), EDOF IOLs offer good distance and intermediate vision that increases daily convenience. For example, EDOF IOLs may often allow someone to read labels or prices on shopping without reaching for the reading glasses. However, for reading a book or tablet for prolonged periods of time it may still be more comfortable to use reading glasses.

1. The Benefits of EDOF IOLs:

Increased Freedom from Glasses: EDOF IOLs reduce the need for glasses after cataract surgery. With these lenses, many patients enjoy clear vision for activities such as working on a computer, driving, cooking, using mobile phones and participating in hobbies - all without the inconvenience of corrective eyewear.

Improved Quality of Life: By providing clear vision at multiple distances, EDOF IOLs enhance quality of life and independence for individuals with cataracts or presbyopia. Say goodbye to the frustration of constantly searching for your glasses - the world is clearer and accessible.

Reduced dysphotopsia: While no IOLs (not even monofocals) give perfectly aberration free vision, EDOF lenses are associated with less intrusive aberrations compared with the stronger multifocal IOLs. This may allow for more comfortable vision at the cost of less perfect near/reading vision.

Increased Suitability: While multifocal IOLs require perfectly healthy eyes to achieve the best results, patients with mild other eye conditions may still be suitable for a carefully chosen EDOF lens.

Better contrast sensitivity: Compared to multifocal IOL's

Limitations of EDOF lenses:

Need for reading glasses: may need glasses to read small print.

Expensive: More expensive than monofocal IOL's

Glare and halos: Some patients may notice but less than with multifocal IOL's.

Unpredictable results: In patients with significant corneal and or retinal problems including uncorrected astigmatism.

2. Toric Intra Ocular Lenses:

Toric IOLs is designed to correct astigmatism, a common refractive error caused by irregular curvature of the cornea. By addressing both cataracts and astigmatism simultaneously, toric IOLs can significantly improve visual quality and reduce reliance on corrective lenses.

Astigmatism occurs when the cornea or lens of the eye has an irregular shape instead of football shape eye ball is like rugby ball, causing blurred or distorted vision at all distances. Toric IOLs is uniquely shaped to counteract this irregularity, providing clearer vision and reducing dependence on glasses or contact lenses.

Toric intraocular lenses are specialized implant, it is important to understand that toric lenses can also be monofocal, extended depth of focus or multifocal. I will advise you if I think you may require toric lenses to achieve the best visual results based on your personalised assessment.

The Benefits of Toric IOLs:

Sharper Visual Clarity: By neutralizing the cornea's irregular curvature, these lenses provide significantly more defined and reliable vision compared to standard lenses.

Reduced Dependence on Glasses: Most patients achieve legal driving vision (20/40) or better without glasses. Research shows that while roughly 66% of patients with standard lenses still need distance glasses, that number drops to about 19% for those with Toric IOLs.

Enhanced Night Vision: Modern designs,are specifically engineered to reduce glare and halos, making night driving safer and more comfortable.

Stability and Permanence: Unlike contact lenses that shift with each blink, Toric IOLs are securely implanted and designed to last a lifetime.

Better Contrast Sensitivity: Premium options like the use advanced aspheric optics to help patients see more clearly in dim lighting or foggy conditions.

Limitations of Toric IOL's:

Rotational stability: 2-7% of patients have some rotation of lens but < 2% patients had severe rotation>10° needing repositioning of lens.

Surgical precision required: Pre op marking and correct positioning of lens essential.

Residual astigmatism: 90'95% of patients < 1.00 Diopter of astigmatism.

Advanced treatment planning: I perform online calculation and place an order for customized lens for your needs.

3. Multifocal Intra Ocular lenses (IOLs):

These lenses provides clear vision at - near, and far to an extent intermediate distance. Multifocal IOLs reduce the need for reading glasses or bifocals, providing greater freedom and convenience in daily activities.

Understanding Multifocal Intraocular Lenses: Multifocal intraocular lenses are state-of-the-art implants used to replace the natural lens of the eye during cataract surgery or refractive lens exchange procedures. Unlike traditional monofocal lenses, which provide clear vision at only one distance (usually far), multifocal IOLs offer multiple focal points, allowing for clear vision at varying distances - near, intermediate, and far.

The Benefits of Multifocal IOLs: Freedom from Glasses: Multifocal IOLs reduce or eliminate the need for glasses or contact lenses after cataract surgery. With these lenses, many patients enjoy clear vision for activities such as reading, working on a computer, driving, and participating in hobbies - all without the inconvenience of corrective eyewear.

Improved Quality of Life: By providing clear vision at multiple distances, multifocal IOLs enhance quality of life and independence for individuals with cataracts or presbyopia. Say goodbye to the frustration of constantly searching for your glasses - with multifocal lenses, the world is clear and accessible.

Seamless Transitions: Multifocal IOLs offer smooth and seamless transitions between near, intermediate, and distance vision, allowing for effortless adaptation to various tasks and environments. Whether you're reading a book, using a smartphone, or enjoying the scenery outdoors, you can count on consistent visual clarity.

Limitations with multifocal IOL's: Not all patients are suitable to have multifocal lenses. visual clarity.

A systematic review (Cochrane, 2020) found halos were 3-5x more common in multifocal IOL patients compared to monofocal IOLs - majority adapts (neuroadaptation).

Large clinical trials of trifocal IOLs (e.g. AT LISA, PanOptix) report 20-30% of patients noticing halos, though satisfaction rates remain high (>85%). Severe, persistent glare/halos requiringIOL explantationare rare ( < 1-2% ).

Personalised Treatment: I will work closely with you to determine the most suitable multifocal IOL option based on your unique visual needs, lifestyle preferences, and ocular health. I prioritise personalised care to ensure that you achieve the best possible outcome from your cataract surgery.

Clear Lens Extraction (CLE) for Primary Angle-Closure and PACG: Current RCOpth Guidance

The Royal College of Ophthalmologists (RCOpth) strongly recommends phacoemulsification clear lens extraction (CLE) as the first-line, definitive treatment for:

• Primary angle-closure (PAC) with an intraocular pressure (IOP) greater than 30 mmHg
• Primary angle-closure glaucoma (PACG)

This recommendation is largely based on the results of the landmark EAGLE Trial (Effectiveness in Angle-closure Glaucoma of Lens Extraction), a large, multi-center randomized controlled study evaluating early lens extraction versus traditional treatment.

---

Why the EAGLE Trial Changed Practice

The EAGLE trial demonstrated that early clear lens extraction provides significant advantages over laser peripheral iridotomy (LPI), the previous standard of care. Key findings showed that CLE offers:

---

CLE for Less Advanced Angle-Closure

For patients with early or less advanced angle-closure disease, the widespread use of clear lens extraction remains an ongoing research priority. However, CLE may still be considered on an individual basis, depending on:

• Anatomical suitability
• Risk of disease progression
• Patient age and refractive status
• Potential benefits versus risks

These decisions should be made in consultation with Suresh Marpuri who is a specialist ophthalmologist experienced in angle-closure management.

---

CLE in the Presence of Cataract

In patients who also have a cataract, lens extraction is widely accepted as an appropriate and effective treatment option. Removing the lens helps open the anatomical drainage angle while also improving clarity of vision.

---

Further Guidance

The Royal College of Ophthalmologists provides comprehensive information through its:

• “Management of Angle-Closure Glaucoma” Clinical Guideline Summary
• Patient information leaflets

These resources can be accessed through the official RCOpth website.

On occasion, the clear vision achieved after cataract surgery can become blurred. YAG laser treatment is a non-invasive procedure used to correct this.

Cataract surgery is a surgical procedure to remove and replace your natural lens with a new plastic one. This new plastic lens is placed inside the lens membrane (called the bag or capsule).

Over the course of time this lens membrane can thicken and become scarred. Vision can become misty and sensitive to glare as the cloudy capsule interferes with light reaching the back of the eye.

A YAG laser capsulotomy is a simple, common procedure to restore the vision to the level achieved after the original cataract surgery.

Suresh Marpuri uses a special lens to apply a laser beam that creates a small hole in the centre of the capsule. Light can then pass through to the back of the eye and vision clears. The treatment is painless as anaesthetic drops are used to numb your eye before the laser and takes less than 10 minutes.

You may notice floaters after capsulotomy which settles in 4 to 6 weeks. Rarely your eye pressure may raise following laser.