(January 28, 2009 - Insidermedicine) Dr. Scott Greenstein, MD, FACS, a specialist in cataract surgery, discusses what he would do if he were 70 years old and had blurred vision. Dr. Greenstein, a Comprehensive Ophthalmologist at Massachusetts Eye and Ear Infirmary and an Instructor in Ophthalmology at Harvard Medical School, has been practicing Comprehensive Ophthalmology for over 20 years. He was most recently Chief of Ophthalmology at both Waterbury Hospital and Griffin Hospital in Connecticut.
On a recent trip to Boston, we caught up with Dr. Scott Greenstein, a comprehensive ophthalmologist at Massachusetts Eye & Ear Infirmary and an instructor in Ophthalmology at Harvard Medical School. Dr. Greenstein has been practicing comprehensive ophthalmology for over 20 years and was most recently chief of ophthalmology at both Waterbury Hospital and Griffin Hospital in Connecticut. His specialty is cataract surgery.
How Might a Cataract Affect a Patient’s Vision?
Dr: Greenstein: Typically, a seventy year old patient with blurred vision who has already been diagnosed with a cataract who comes in to see us here, would be found to have a reduction in their visual acuity. It could be anywhere from 20/25 to counting fingers. But to go back for a minute, we need to be sure who has diagnosed the cataract and to what level the cataract has developed.
A cataract is a clouding of the lens in the eye. It will give the effect, in many cases, as if a person is looking through a dirty window – the light is not getting through the lens in sufficient amounts to be focused clearly on the retina. Most of us are born with a completely clear lens and over time, in adulthood, this tends to opacify. I reserve the word for a patient that has a clouding of the lens that interferes with their vision, and interferes with their ability to function, whether it’s driving, reading, watching television or any activities of daily living. We would want to confirm the diagnosis and we start off by doing what is called a refraction. A refraction determines the best corrected vision, and we go from there.
How Else is the Level of Visual Impairment Assessed?
Dr: Greenstein: There is a questionnaire that many practitioners use in order to asses the level of a person’s visual impairment. It specifically addresses the issues of trouble with things like driving, reading or watching television. We want to take a detailed history, we want to know if a patient is on certain medications. There’s an increased incidence of cataract formations among patients who have diabetes, patients who have taken steroid medications and ultimately, in terms of management, we’re very concerned with patients who have taken medicines called Alpha-blockers, particularly a medicine called Flomax used in men with prostatic hypertrophy. There are other medicines, Cardura and Hytrin, which can also have an impact on the eye and a cataract patient. We want to know also about hypertension, as sometimes a person with uncontrolled hypertension is a poor risk for eye surgery.
We take a complete medical history, review of systems, again we want to know about the patient’s symptoms of visual loss and then we proceed as I mentioned with a determination of their best possible vision, with or without glasses. We then want to check the cornea – the clear tissue on the front of the eye to be sure that there is no scaring or inflammation of the cornea. The patient would need a dilated examination in which drops are instilled to open the pupil (the opening in the eye) behind which sits the lens. We then look with a slit lamp, or a biomicroscope and directly view the degree of clouding of the lens. As comprehensive ophthalmologists, we look at the entire health of the eye, but in this case we are particularly focused on whether there is a clouding of the lens and to what degree.
When is a Cataract Surgery Recommended?
Dr. Greenstein: The indication for cataract surgery is vision that does not meet a person’s needs, as I’ve called it previously, functional visual impairment. There is no absolute number of visual acuity, but we do find that patients who cannot see well enough to drive a car legally in most states ,which is 20/40, vision less than that is typically what we’re operating on.
Is There Medical Management for Cataracts?
Dr. Greenstein: There is no medical management of cataract. Many years ago when I was training there was some ophthalmologists, when surgery was not nearly as successful as it is now, who would prescribe dilating drops for patients in the attempt or hope that if you dilated the pupil and let more light in around the cataract that these patients might see better. Unfortunately, in some patients that makes them more symptomatic. I’ve heard radio advertisements for certain drops that can somehow treat cataracts. This is absolutely false and there is no drop or medical management to get rid of cataracts, they must be fixed surgically.
If I Had a Cataract at Age 70 and Had Blurred Vision…
Dr. Greenstein: If I was age 70 and was complaining of poor vision in one or both eyes and felt that I may have a cataract, hopefully I would have been seeing a primary ophthalmologist routinely every year or two and we would have some indication as to whether a cataract had been growing slowly before. But in any case if I noticed visual loss I would get to my comprehensive ophthalmologist. I would want to be refracted carefully to see what was my best correction with glasses. I would want to know if I had elevated pressure in the eye that could be causing glaucoma. I would want to know if I had pseudoexfoliation of the lens capsule. I would want to know if there was any problem with the cornea – a dystrophy of the cornea that could be causing clouding in front of the lens. Of course, is there a cataract? What type is it? Is there any age related macular degeneration? Is there epiretinal membrane formation? Is there fluid in the macula, macular edema? Is there a vein occlusion or an artery occlusion in the retina? Is there blood in the vitreous? Is there a retinal tear? So all of these things I would want to know.
If indeed there was a cataract that was giving me sufficient reduction in vision such that there was a likelihood that removing the cataract would restore me to my usual vision and there were no contraindication or other problems, I would want this done by an eye surgeon who has done a lot of these, who does probably hundreds a year, not three or four dozen on one day, but enough that they’re skillful and compassionate and have enough time to spend with me to reasonable expectations, to see me post operatively, to be able to handle any complications that might arise – however rare, who might by able to handle any complications that may arise intraoperatively. So a seasoned person who has the time and compassion to get me through this.