Cataract surgery is the most common surgery that Singaporeans encounter in our adult life.
In general, as we age, we will all develop cataracts. Yes. Let me repeat that. EVERYONE WILL GET CATARACTS. It’s a matter of how mild or severe the cataract formation is.
Typically, people develop cataracts at around 50 to 70 years of age. However, certain things can cause you to get them at a much younger age:
- Trauma: Any prior injury including a blunt hit to the eye can cause cataracts.
- Excessive sunlight UV exposure
- Overuse of steroid medication in the forms of oral steroids, nasal steroid sprays or steroid eyedrops.
- High degree of myopia or short-sightedness
- Any prior eye laser or eye surgery
How do you know if you have cataracts?
Cataracts will give you symptoms such as blurring of vision, double vision, shadowy vision and darkening or dimming of vision.
Early stage cataract has no symptoms, except for mild changes in your spectacle degree, brought about by the changes in shape or thickness of the lens.
This also causes the most dangerous misconceptions about eyesight in Singapore.
Everyone has that old uncle or auntie who tells you “Oh. My short-sightedness is getting better now. My degree is going down”.
Sorry uncle (or auntie). But your eye-sight is NOT improving. It’s an early sign of cataract development.
"I ONLY need to check for cataracts, right?"
Your eye is a very complex organ. When you feel that something is wrong with our eyes, it could be due to floaters, cataracts, glaucoma, hazy corneas or even more severe things like retinal tears and epiretinal membranes.
The mistake many patients make is to simply get a check for cataracts, when they should be getting their overall eye health checked.
You don’t want to test negative for cataracts and walk out of the clinic happy, not knowing that you are suffering from glaucoma (which can make you blind).
For example, if you have an epiretinal membrane or macular hole on top of cataracts, having a cataract surgery alone will not give you clear vision.
Instead, the epiretinal membrane could be removed at the same time as the cataract surgery to give you an improved visual outcome.
Therefore a cataract check should only be a small part of a proper eye check up.
How does your eye doctor check for cataracts?
As part of a complete eye check up, here are 3 ways to check specifically for cataracts in Singapore:
1. Slit Lamp Method
All eye doctors examine patients at the slit lamp, and grade the severity and type of cataract by inspecting the lens.
This method relies heavily on the doctor’s judgement, experience, skill and care taken. It’s a very subjective measure.
That is why different doctors may grade cataracts slightly differently. (Similar to how the colour turquoise may be considered as "green" to some people and "blue" to others.)
2. Cataract Photography
A photograph of the lens with a cataract can be taken while you are at the slit lamp. The colour and density of the cataract can be recorded, and it's progression can be monitored.
Not all clinics in Singapore have the ability to carry out cataract photography because it is an additional or surplus function (good-to-have as opposed to must-have), which drives up the cost to the clinic substantially.
Hence not all clinics are willing to invest in this extra utility.
Personally, I feel it is an essential part of my examination because it allows me to illustrate the condition to my patients, and allows them to understand better what they have or why they need treatment.
Doctors note the colour of the cataract and presence of white opacities in the lens as seen centrally in the lens nucleus.
3. Cataract Density Imaging
There are a few machines that can demonstrate or measure the density of a cataract, simply by taking a picture of your eye. It is non-invasive and easy to perform.
Again, this is a good-to-have, not a must-have for most clinics.
Cataract density imaging can supplement cataract photography, but it is not a critical tool for the clinically experienced doctor.
I like to be able to image the density of the cataract. This helps me to give patients reassurance about their cataracts in an objective manner.
- Box A – Dense cataract as seen by white appearance of the nucleus centrally
- Box B – Moderate cataract as seen by the less white, semi-translucent shadow centrally
- Box C – Minimal to no cataract as seen by translucency (lack of white) within nucleus
How much does eye screening cost in Singapore?
Broadly, the costs of eye screening can be divided into consultation fees and pre-consultation eye tests.
|Public Hospitals||Private Clinics|
|Process to get appointment||Polyclinic referral||Private GP referral||Direct|
|Waiting time for appointment||3-6 months||1-2 months||Within 1 week|
This surprises most people: private rates at public hospitals are similar to private clinics, depending on which clinic you choose. If you have insurance coverage, you may be able to enjoy up to full coverage even at private clinics, depending on your policy or Medishield riders.
Those who have a Community Health Assist Scheme (CHAS) or Pioneer Generation (PG) card can enjoy even higher subsidies at public hospitals.
However, do note that if you are a subsidised patient, you cannot choose which doctor you will be seeing as it varies at every visit. Your doctor could be a trainee medical officer, registrar, associate consultant, consultant or senior consultant.
Waiting time can also be longer at public hospitals (for both subsidised and full-cost patients).
"Can I leave my cataract alone if I'm scared of surgery?"
The risks of cataract surgery such as bleeding, infection and blindness are extremely low at 1 in 10,000 to 100,000 – lower than a plane crash.
Still scared? Well, the good news is you don’t always need surgery right away. In fact, cataracts are known to progress slowly, so you can actually delay your surgery for a bit.
My personal advice is to opt for surgery when your vision is bad enough to make undergoing surgery worth the risk.
I usually ask my patients:
- Can you still drive at night with ease?
- Can you still read the newspapers?
- Can you still see your Excel spreadsheet?
- Can you still see the ball when you play golf?
If there are any deficiencies which significantly affect your quality of life, then it would be prudent to take the next step to regain your full visual potential, and in turn achieve full quality of living.
What are non-surgical options for treating your cataract?
In some cases, if your cataract is very mild and you wish to delay its progression, you may use eyedrops. These eyedrops suppress the progression of senile cataracts by altering the lens proteins and preventing lens degeneration.
It’s applied 4 times a day and has no side effects. However, these eyedrops cannot reverse or cure a mature cataract.
In the interim period when your cataract is not severe enough to warrant surgery, you can get a pair of prescription glasses to improve your vision.
Since the cataract frequently changes the degree of your eyesight, it's helpful to make a new pair of glasses at least once a year to keep your prescription up to date.
I have seen many patients with mild cataracts who manage well with eyedrops and/or yearly changes in spectacles. They are able to maintain functional vision for 3-5 years without needing to go for surgery.
What happens during cataract surgery?
Cataract surgery takes only 30 minutes, and is usually done as a day surgery. There's no need to stay overnight.
Some surgeons like to perform cataract surgery on their patients with as little anaesthesia as possible.
This means that patients are lightly sedated so they may be aware of what’s going on during the procedure and are able to ‘co-operate’ with their surgeons’ instructions to keep still.
Personally, I prefer to have my patients fully sedated and completely asleep so that they are unaware of the procedure and fully comfortable.
What kind of lenses are placed in your eye during cataract surgery?
During cataract surgery, we implant an intraocular lens in your eye to correct your vision. It’s like your spectacle lens. Except, we put it into your eye.
And just like with spectacles, it’s all about the lens. There are 3 main types of methods and lenses:
1. Monovision method
During cataract surgery, when we implant a new lens in the eye, we can choose a lens that allows you to see far in one eye, and near in the other eye (this method is known as monovision).
Your eyes are then able to adapt after some time, so that the brain can see both far and near without glasses.
2. Using multifocal lens
Another method is to implant a specialised lens which allows you to see both near and far (this lens is known as the multifocal lens).
The use of multifocal lens may result in lower contrast vision. This may not be suited for every individual’s requirements, nor appropriate for people with other pre-existing eye problems. Your eye doctor will be the best person to tell you if you are suitable or not.
3. Premium implants
We can even correct astigmatism by using toric intraocular lenses (premium implants) which are placed at the steepest axis required.
There are many different types of premium implants (toric, multifocal, trifocal, extended range of vision) that can be offered to you. Bear in mind that not all implants are suitable for everybody.
Your eye surgeon should be able to have a detailed discussion with you about which would suit you best.
What are the different methods for cataract surgery?
1. ECCE for hard and dense cataracts
In the old days, cataract surgery was performed by creating a large 12 mm wound. This was known as ECCE. During this surgery, the entire lens would be removed, and 7-8 stitches would be used to close the wound. That is why the old saying was to ‘wait for your cataract to be ripe’ before taking it out.
We no longer perform cataract surgery this way. Do NOT wait for your cataract to be too ‘ripe’ as it makes the surgery more complicated. If your lens is too ‘ripe’ or hard, it gets difficult to crack and aspirate.
Nowadays, ECCE is reserved for extremely hard or dense cataracts that are not amenable to the modern-day phacoemulsification surgery (‘phaco’ for short). No one would choose to have an ECCE done because the recovery is longer and more painful.
2. Phacoemulsification surgery
These days, we create a very small 2mm incision and insert a small probe which cracks and aspirates (similar to a vacuum) the cataract. There is no need to stitch the wound up at the end.
Phaco is the gold standard for cataract surgery nowadays - the cataract is removed using ultrasound energy through a tiny 2 mm wound.
Because the wound is so small, recovery is usually very quick, painless and easy.
With the advent of femtosecond laser technology, phaco can now be assisted by this laser instead of relying on the surgeons’ scalpel or blade - henceforth the so-called ‘bladeless’ cataract surgery.
What will your recovery be like after cataract surgery?
After surgery, your operated eye will have an eye shield for 1 day.
There is usually little to no pain on the eye at all. Eye redness and swelling is mostly minimal after my surgery.
You may proceed with a normal diet and general activity, but you should stay away from strenuous exercise, swimming, and dusty environments.
Once removed, cataracts do NOT come back - this is yet another cataract myth. Read about 7 major cataract myths in my other article here.
How much does cataract surgery cost in Singapore?
Subsidized patients in public hospitals may be charged up to $1300 for a single eye cataract surgery.
This cost does not include the pre and post-surgery visits, and because it is a subsidised rate, you'll not be able to choose your desired ‘premium’ implants.
Unsubsidised (private) patients in public hospitals may be charged as much as $3,500 to $4,000 for a single eye cataract surgery. Again, this rate does not include pre- and post-surgery visits.
However, unsubsidised patients CAN choose certain premium lenses, although the cost may go up higher than that stated, depending on the type of lens chosen.
When a premium lens is chosen, the cost rises to $4,500 to $6,000 for single eye cataract surgery.
Private hospitals charge a range from $3,500 to $7,000 for single eye cataract surgery.
This rate includes the surgeon fee, premium lenses costs, and may also include pre- and post-surgery visits depending on the package offered by the surgeon.
How can you save money on your cataract surgery in Singapore?
1. Medisave and insurance claims
For Medisave claims, you can expect to claim $2,450 off the cost of the surgery for both public and private hospitals.
For insurance claims, depending on your policy and medishield riders, you may be able to claim up to the full amount, including the pre-surgery and post-surgery visit.
2. Public vs private hospitals
Private hospitals have shorter waiting times, better service quality from all the supporting staff and more personalised care from your eye doctor.
The upside of public hospital is: it’s cheaper and there’s always a backup doctor in case yours goes on holiday.
3. Non-premium lenses
If you really want to be thrifty about it, you could choose a non-premium lens (which saves you about $500 to $1,000 depending on where you do it) and opt to use spectacle correction after cataract surgery.
To be clear, this is NOT something I encourage, because I believe that since you are going for a surgery already, you might as well use the opportunity to get the full correction done so that you have greater spectacle independence.
One thing that I would encourage is for you to try saving costs in other non-eye related ways. For example, giving up cigarette smoking (which helps to saves your sight as well).
How can you pick the best doctor for your cataract surgery in Singapore?
How to choose the best doctor for your cataract surgery? You know you can trust your doctor when he/she is:
1. Upfront and honest with you. If you have a cataract, your doctor will be able to tell you the extent of your cataract or show you through cataract imaging and pictures. Don’t just take his/her word for it, you can see it for yourself.
2. NOT pushing you to go for surgery. Cataracts are not something that cause blindness overnight. You can take some time to mull over it and decide when to go for surgery. Your doctor shouldn’t be hard-selling you to go for surgery immediately.
3. Knowledgeable about the advances in technology in the eye field. Older is not always wiser. If your doctor is a ‘dinosaur’ and isn’t updated about modern and advanced treatments, you could be getting outdated treatments which don’t work as well.
4. Experienced and well-trained. If your doctor has more than 10 years of experience in the eye field and has performed THOUSANDS of cataract surgeries, you know you are in safe hands.
5. Approachable and patient with you. Most importantly, you need to feel comfortable with the doctor who is going to operate on you. You should feel comfortable enough to ask all the questions you have, and the doctor should be patient enough to address all your concerns. You don’t want a doctor who brushes you off because he/she has no time for you. You shouldn’t be afraid to ask as many questions as you want.
What are the most important questions to ask your eye doctor if you are considering cataract surgery?
Here’s a useful list of questions you can ask your eye doctor when you send in your free enquiry:
1. What will the surgery process be like? Will you be comfortably sleeping or will you be awake?
If you don’t want to know what is going on, don’t be afraid to let your doctor know.
Some patients think you have to be awake for your cataract surgery. This might be because they think that some doctors prefer their patients to be awake, but that’s not true. Cataract surgery can be done under perfectly comfortable conditions with the patient fully asleep.
2. Which intraocular lens is most suitable for you, and why?
You need to tell your doctor your preferences in terms of when you prefer to use glasses, what sports you like to do etc. Your doctor should be able to match an intraocular lens to your lifestyle.
3. What happens in the event of an unlikely complication when the cataract falls to the back of the eye?
Ask if your doctor will be able to manage the complication immediately, or whether there will be a delay because your doctor needs to call in another doctor to fix the situation.
Sometimes, if your eye doctor is not retina-trained, he/she may need to call in a retina-trained doctor to deal with the unforeseen situation. Although rare, it does mean that there will be a slight delay in treatment and your surgery may take longer than you like, which will affect your recovery process.
This rare complication will also result in a sudden ballooning in the cost of your surgery due to costs from additional equipment needed, and the involvement of another doctor. So just be sure to ask beforehand what the provisions would be for such an unlikely event.
Dr Claudine Pang is a Consultant Ophthalmologist who graduated with a Distinction and Gold Medal in Medical Ethics. With more than 13 years experience, her forte is in cataract surgery, myopia prevention, macular and retinal diseases. She has 2 cheekily cute kids and spends almost all her time outside work with them. Her hobbies are dancing, golfing and baking.
- Davis G et al. The Evolution of Cataract Surgery. Mo Med. (2016)
- Lawless M et al. Reviewing the visual benefits of femtosecond laser-assisted cataract surgery: Can we improve our outcomes? Indian J Ophthalmol. (2017)