Published: 20 June 2023

You’ve been diagnosed with a cataract and you’ve been told you should have cataract surgery. The surgeon is also telling you that you should consider paying out-of-pocket for certain features. Where did this come from? Why should you have to pay out-of-pocket for cataract surgery? Shouldn’t your health insurance just cover it? In trying to answer these questions, you will first need a little history of both cataract and refractive surgery, which corrects errors of refraction such as nearsightedness, farsightedness, and astigmatism. Radial keratotomy (RK) was the first widely used refractive surgery for nearsightedness. It was invented in 1974 by Russian ophthalmologist Svyatoslav Fyodorov, and it was the primary refractive procedure done until the mid-1990s. Then it was surpassed by the laser procedure called PRK and then, eventually, LASIK; they are still the predominately pure refractive surgeries done today. Cataract surgery has its origins all the way back to at least 800 BC in a procedure called couching. In this procedure, the cataract was pushed into the back of the eye with a sharp instrument so the person could look around the cataract. Medically that is all that was done with cataracts until around 1784 when a cataract was actually removed from the eye. The next big advance was implants to replace the removed cataract. The invention of implants was spurred by Harold Ridley, who recognized that injured Royal Air Force pilots could retain shards of their canopy made out of a substance called PMMA in their eye without the body rejecting it. Implants became commonplace after the FDA approved them in 1981. The implants have improved over the years and most implants today are foldable, enabling them to fit through tiny incisions of around 3 millimeters. Medicare and most other insurances cover the cost of MEDICALLY NECESSARY cataract surgery. This means they will cover the surgery when someone has symptoms of visual trouble that is interfering with their normal daily activities AND the cataract is the cause of those visual disturbances. There is no reason to remove a cataract just because it is there. It needs to be causing a problem to make it medically necessary to remove it. Medicare and most other insurance do not cover refractive surgery (LASIK, PRK, etc.). The general perception of refractive surgery by the insurance industry is that it is not MEDICALLY NECESSARY. You can correct the refractive errors in almost all cases by non-surgical means, such as glasses and/or contact lenses. Today there are methods of doing additional procedures, or using special implants, at the time of cataract surgery to correct more than just the cataract alone. This is where the two types of surgeries, refractive and cataract, have merged into a single operation that tries to take care of both problems. The merging of cataract and refractive surgeries is why there are now options to not only get your cataract removed, but also to correct your astigmatism (irregular shape to cornea) and/or presbyopia (the inability to see well up close that hits nearly everyone in their 40’s). This is where the "paying for cataract surgery" comes in. Surgery to correct astigmatism and presbyopia are not considered MEDICALLY NECESSARY because they can be corrected with eyeglasses or contacts. Your cataract, once it hits a certain point, cannot be corrected with glasses or contacts and therefore it is MEDICALLY NECESSARY and your insurance will pay for that component of your surgery. What it won’t pay for is any additional amount that is charged to correct your astigmatism or presbyopia. If you want to address your astigmatism and/or presbyopia at the time of cataract surgery in order to be less dependent on wearing glasses after surgery, then paying for those components is going to be an out-of-pocket payment for you. Article contributed by Dr. Brian Wnorowski, M.D.

Published: 21 May 2023

More middle-aged and older adults are wearing soft contacts than ever. And one of the biggest reasons they stop wearing contacts is the difficulty they face reading with their contacts after presbyopia begins to set in around the early 40’s. Presbyopia is the diminished ability of the natural lens in our eyes to focus up on close objects. It begins with the occasional medicine bottle being a struggle to read and then over time more and more gets blurry. It can be very frustrating to stare at something up close and have it be blurry regardless of what you do. So there are three basic choices a contact lens wearer can do to aid their reading while still wearing contact lenses. Reading Glasses Initially, the use of an over-the-counter reader or prescription reading glass for occasional use works well for people in the early stages of presbyopia. They are worn over distance contact lenses so there is little adjustment and vision is clear near and far. However, they need to be with you, not left in the car or at work, and oftentimes people end up just wearing readers all day since it is just that much clearer. Monovision This fitting technique can be used with any type of contact lens. The brand of lenses you are currently wearing can often be used to fit you with monovision. Your dominant eye is determined. Then the non-dominant eye prescription is adjusted to compensate to make it a reading contact lens. So once fitted you have one eye for distance and the other for reading. Yes, it sounds really crazy, but it can actually work quite well. Your brain initially has to adjust to using each eye individually to obtain the sharpest vision, but once this is achieved, year-to-year adjustments can be made to the reading eye to allow comfortable distance and reading vision for many years. Monovision fits are not always successful. Some people just cannot adjust to it regardless of motivation or desire. It seems to work best when someone has had some difficulty with reading and they are noticing more and more that they need their readers. At that point, they can appreciate the ability to read and their brain seems to adapt more readily. When I wear my contacts this is the option I have used for myself. Multifocal Contacts Another option is multifocal contact lenses. Most major manufacturers of soft contact lenses have some type of disposable multifocal lens available. They do not work like multifocal glasses. They use a technique called simultaneous viewing where you are actually looking through all the powers at once. To visualize this, imagine a vinyl record with the label in the center and the various tracks extending outward. Most of the lenses are made with the strongest reading power located in the center where the label would be, then each ring further out gradually becomes weaker until you reach your full distance power. So essentially you are looking “around” the reading part for distance then through the center for reading. It works, sort of. Multifocal lenses work better on younger patients, say 40-50 years old, for help with reading. There is no adaptation period to these lenses like monovision. What you see is what you get. But if you have any significant amount of astigmatism or if you wear a toric contact that corrects for astigmatism, multifocal lenses are not for you. And because the reading is central in the lens, if you make it too strong for reading then you blur the distance vision too much, so oftentimes a multifocal lens wearer after age 50 faces the dilemma of either wearing reading glasses to boost their reading needs or changing to monovision. Conclusion In conclusion, while none of the options are perfect, they all may present some level of relief in your quest to continue to wear contacts into middle age, retirement, and beyond. But some options may better serve you at a certain point in your life or career than others. Talk to your eye doctor to see what choices are best for you. Article contributed by Eugene Schoener O.D.