Cataract surgery has changed dramatically over the past decades. Patients who once presented were told that their cataract had to be “ripe enough” to safely remove. Now with the reduced risks and excellent post-operative refractive outcomes of cataract surgery, this manner of thinking has somewhat changed. While I am concerned when patients present for second opinion because another ophthalmologist told them that this “dangerous cataract” had to be removed immediately, I do feel that early intervention is beneficial in certain circumstances.
Pseudoexfoliation syndrome: There have been several debates as to whether cataract surgery may accelerate develop of glaucoma in psuedoexfoliation patients who undergo cataract surgery. This is largely unsubstantiated, and most would agree that cataract surgery in the majority of patients results in a small decline in intraocular pressure. Also, most ophthalmologists are not excited when a patient presents to their office with a 4+ brunescent lens and significant pseudoexfoliation. As the crystalline lens becomes more dense, the capsular bag may become more frail. Additionally the zonules may provide less support with time. Pupillary dilation may also be worse as the patient ages. By removing cataracts in these patients at an earlier time, it may result in a lower risk of intra- and post-operative complications.
Fuchs dystrophy: Physicians are often reluctant to operate in patients with cataracts and fuchs dystrophy. While central corneal thickness may be less than 600, we are often left to wonder if the cataract is the primary cause of visual compromise or perhaps subclinical corneal edema is present. Futhermore, the threat of pseudophakic bullous keratopathy (PBK) concerns many ophthalmologists from attempting cataract removal. While new technologies have reduced our endothelial cell loss and increased our threshold for choosing phacoemulsification alone over combined cataract/transplant procedures, any intracameral phacoemulsification results in endothelial cell loss. To that extent, removal of a softer lens will be tolerated better by the cornea. If in fact the patient later on develops PBK, a second staged transplant procedure may result in a better outcome since there will be less inflammation than from a combined procedure.
Ultimately, the decision to proceed with cataract surgery lies with the patient. Certainly if the patient is happy with their level of vision, surgical intervention should not be recommended. However, for those patients with pseudoexfoliation or fuchs dystrophy I suggest we do not let them “over ripen”.
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