Will delaying treatment of my cataracts make the outcome worse?

There’s a fine balance when it comes to deciding the perfect timing for cataract surgery.

You are right that we shouldn’t delay too long because in some cases, if the cataract progresses too rapidly, it will become too dense or hard; and may make the surgery more complicated or difficult, which in turn may affect visual outcome.

Having said that, very often if the cataract is progressing rapidly, it will likely affect your vision significantly, and you would be able to sense it.

On the other hand, we do not want to rush into having surgery when your vision is hardly affected.

A key consideration before surgery is how much of your vision is affected by the cataract. Remember that every surgery has some risks albeit low, so we do weigh the benefits of doing surgery against any potential risks.

I would definitely encourage surgery if your diminished vision is affecting your quality of life; however if you are functioning very well and happily at the moment, then there would be no need to rush into surgery.

In your case, because you mentioned that your vision is not affected much yet, it would be reasonable to monitor your cataracts for now.

You should visit your eye doctor regularly at least 6-monthly to check on the cataract progression.

In addition, visit your eye doctor immediately if you should experience any noticeable deterioration in your vision.

I hope this was helpful to you.

Yours truly

Cataract is a condition in which the natural lens in your eye gradually turns cloudy. For most, the progression is gradual. At the earliest stages of cataract, vision is not affected to a significant degree. With the passage of time, patients may notice reduction in some aspects of their vision including night vision, contrast and colour vision. At the later stages, patients suffer from blurring of vision which cannot be corrected with spectacles.

Where patients are often confused is deciding when is the optimum time to have cataract surgery. Many of the older folks used to remember their eye doctors telling them to wait till the cataract would fully “ripen” like a fruit before having surgery.

That would have been at least 20 or more years ago. In those days, the surgery required a far larger wound and was considered to have greater risks of infection or bleeding and the recovery could take as long as 3 months.

Fast forward to today, cataract surgery is now performed via keyhole methods with incisions smaller than 2mm. Recovery is now within a month, with many patients returning to work within a week after surgery. Rarely do we now wait for a cataract to fully “ripen” as these cataracts may pose a challenge to the keyhole methods of surgery resulting in higher rates of complications.

In addition, newer lens implants for cataract surgery now have the potential to help patients gain spectacle independence for both far and near distances thereby significantly reducing the need for glasses for far and for reading.

The consideration of when to have cataract surgery can be basically boiled down to one question: Has your vision reached a stage whereby your quality of life has become affected? ( e.g. work, sports and hobbies).

If the answer is no, then it would be appropriate to observe the situation. If however your vision prevents you from maintaining your daily routine then it may be time to have a deeper discussion with your ophthalmologist on the best timing for your cataract surgery, including the various lens implants available to help you be spectacle independent.

Understand that different individuals will have different visual demands and as a result, the advice on the timing of cataract surgery will also be dependent on the patient’s current lifestyle and occupational needs.

If you are told that you have minor cataract, most likely you would be able to wait until the cataract gets more mature.

Nonetheless, you should continue to schedule regular visits to your eye doctor for follow-up review of the maturity of your cataract.

If your cataract is already mature, it is not wise to delay going for cataract operation as the cataract will be harder in composition and also be of a larger volume, making the surgery more complicated as well as increasing the risk of glaucoma.

Hope that you found this helpful.

Yours sincerely,

Dr Tony Ho

Whether or not one should delay cataract surgeries when vision does not seem to be significantly affected depends on a few factors:

1) MOST IMPORTANTLY, WHAT IS YOUR RISK OF ANGLE CLOSURE GLAUCOMA

It can be terribly confusing to many, including to some eye doctors themselves, but cataracts are associated with a type of glaucoma that is more common in Asians called angle closure glaucoma. And in case you have not heard about glaucoma before, it is an irreversible eye disease often referred to as the thief of sight, that is best prevented rather than cured, as damage done cannot be reversed.

If you have long-sightedness (as opposed to short-sightedness and presbyopia) you are at higher risk of angle closure glaucoma. Long-sighted eyes are generally eyes with smaller internal dimensions and the lens thickening that comes with aging are more prone to crowding the outflow channels in these eyes versus eyes with larger internal dimensions (axial length).

Quoting the 2017 edition of the Principles of Preferred Practice in Cataract Surgery published by the APACRS (pardon all the jargon): "Removal of the clear or early cataractous lens in primary angle closure/primary angle closure glaucoma reduces the forward bulge on the iris and leads to deepening of the anterior chamber, opening up of the angles and improving the long-term control of intraocular pressure (IOP) in these eyes".

Ask for a "gonioscopy" which is an examination of the outflow angles of your eyes. If they are very narrow you are better off having your cataract surgery sooner rather than later.

2) Are your daily activities affected by your drop in visual function? If yes, it is fair to consider a cataract surgery already

3) This may not sound diplomatic at all, but although the success rate of cataract surgery is generally high in Singapore, skills may vary between surgeons, and results also depend on what type of intraocular lens implants one chooses.

Ask about the size of wound of the proposed surgery, the smaller the size (it can be as small as 1.8mm) in general the faster the recovery will be. Also, pricier lens implants (e.g. multifocal or extended range lenses) are able to deliver a wider range of good vision, possibly eliminating the need for glasses afterwards.

I suggest finding out more about your eyes, and when the time comes for cataract surgery, do discuss your visual requirements with your doctor.