Jane Styche

Good evening everyone, I hope you're all well and welcome to our webinar on cataract surgery. My name's Jane and I’m your presenter this evening. Our expert presenter is Mr Wallace Poon, Consultant Ophthalmic Surgeon at Benenden Hospital.

His presentation will be followed by a Q&A session. If you'd like to ask a question, please do so via the Q&A icon which is at the bottom of your screen. This can be done with or without giving your name.

Just to remind you that this webinar is being recorded, although the other attendees won't know that you're taking part unless you give your name when asking a question. If you prefer not to be recorded now is your opportunity to leave the webinar.

I’ll now hand over to Mr Poon and you'll hear from me from me again shortly. Thank you.

Mr Wallace Poon

Thank you, Jane, for the kind introduction. Good evening everyone, welcome to the webinar on cataracts. I am Wallace Poon, one of the 12 consultant eye surgeons practicing at Benenden. When I was asked to prepare a talk on cataracts, I think it is very fitting that I approach the subject from your perspective, as my dad just had his cataract surgeries done in the US a few months ago. The discussion we had was very useful for his decision-making process.

So, a few things about myself. I received my medical training at King's College, London, then I did my eye training in London and the south east. I then did a vitreo-retinal fellowship at St Thomas's Hospital, London. What that means is a more advanced surgical training to deal with the retina. I was then appointed as a Consultant vitreo-retinal surgeon at East Kent Hospitals.

I specialise in trauma of the eye, retinal detachment, complicated cataract surgeries, cataract surgery complications. Now on average I do around a thousand plus cataracts per year, a total of more than 12,000 cataracts to date.

I’m also an honorary lecturer at the University of Kent, supervising post-PhD students on clinical application of medical imaging. I’m also the UK examiner for the European board of Ophthalmologists.

Now this is the list of questions my dad addressed, which I borrowed for this talk and hopefully you'll find the answers useful at the end of the webinar.

So, number one - most importantly - what is a cataract? Different types of cataract, what causes cataracts, do I have cataracts, if I do have cataracts do I need surgery, what can I expect after the surgery, what happens during the surgery, what can go wrong with the operation and where and which surgeon to do my operation?

In the left-hand diagram, you see here, is the frontal view of the eye. The right, where the arrow is pointing, is the cross section of the eye; that means cutting the eye into half. This is the front; this is the back.

The cornea is a transparent structure there; you can see through. That shows the colour of the iris and, in the centre, that's the aperture called the pupil and behind the pupil is the natural lens which is inside a capsule.

I like to tell my patients that the eye works like a camera. The image of the light comes through the eyes, focused by the lens and the cornea onto the retina. The retina functions like the film of the camera as you can see here.

So, what is a cataract, then? Cataract means the natural lens has lost its transparency. In the left diagram, you can see the image was very sharply focused on the retina but in comparison to the right the rays are going everywhere, and you can see the image is compromised.

There are many reasons why people suffer from cataracts. Congenital means you're born with the cataract. It could be traumatic; what that means is - for example - a patient with a penetrating eye injury punctures the capsule and the cataract can be formed within days. It could be related to systemic diseases, for example diabetic patients tend to have cataracts sooner rather than later. It could be drug-related if you're on long term oral or topical steroid eye drops, that can cause a cataract. But by far the commonest cause is age-related.

There are different types of cataract. Nucleus sclerosis, cortical lens opacity, posterior subcapsular cataract, posterior polar cataract. And we're going to look into them in more detail.

On the right side, you can see a well-dilated pupil with the lens behind with a yellowish colour. This is a typical nucleus sclerosis cataract. What that means is the lens material gets denser and that's why it become yellow. It can progress quite slowly. Commonly this is age-related and, what you may find out, is the vision becomes blurry and the colour starts to fade - especially in the blue spectrum of the colour.

Cortical lens opacity looks different. On the right-hand side here, you can see the spoke line appearance of the lens. The opacity tends to appear in the anterior part – or the front part - of the lens. Typically, patients suffering from cortical lens opacity notice a lot of glare.

This is posterior subcapsular lens opacity. Now if I can convince you, you're looking at the back of the lens. This is the shape of the lens - this is the front, that's the back - but this time the cataract tends to progress quite quickly and it's more common in younger patients especially if they're diabetic.

Posterior polar cataract is different. You can see here the opacity is right in the middle and at the back of the lens so, on the cross section, it will be right down there. This tends to be congenital and gets worse with time. The cataract itself can be fused with the capsule which is holding it and that increases the risk of complications during surgery.

So, do I have a cataract then? If you notice that colour starts to fade, things become blurry, oncoming traffic lights cause a lot of glare or you keep changing your glasses -  getting more and more short-sighted -  or you’ve got double vision with one eye closed, it’s quite likely you do have a cataract.

What is next? Go to see your Optometrist. They're highly qualified professionals; they're the first line of defence of your eye health. They'll find sight-threatening disease and refer you to the hospital eye service. For example, cataracts, retinal detachment, wet macular degeneration - and some of the opticians also manage chronic eye diseases with their doctors. For example, the community glaucoma network where you do have glaucoma, you see the Optician and then the eye Consultants will see a result remotely and then you'll manage not necessarily going to the hospital at all.

Some of the Opticians also manage what we call the minor eye emergency service in conjunction with the hospital eye service, so you don't need to go into the eye casualty to be seen as you’re seen by your local Optometrist.

So, what will the Optometrist do to make the diagnosis? First of all, they will check your visual acuity. Hopefully your eyesight will not be as poor. They will check your refraction; that means finding out how long or short-sighted you are and whether you've got astigmatism. And they will perform a slit lamp examination, which is the bright light on the machine that allows us to see a magnified image of your eye. It will check the pressure in the eye to see whether you've got glaucoma and then they will put some drops into your eye, then examine the back of the eye.

Some Opticians are more equipped, and they might have got other fantastic machines that will help the diagnosis or taking a record. One they can do is fundal photos. That means taking picture of the back of the eye. Or there are special scans now which allow us to see the detailed structure of the macula. The macula is the centre of the retina responsible for all the detailed vision.

And I think the Optician quite likely will start discussing what to expect after surgery. They’ll probably talk about refractive outcome and the choice of lens implants you can have, mainly the monofocal or special lenses. And then you will be referred to the Ophthalmologist for further assessment.

Now what can I expect after surgery? As I mentioned earlier, we will talk about the lens implant and the refractive outcome. Mind you, this is quite a difficult concept to understand.

My own experience with my dad is not the most encouraging. We spent half an hour talking about the lens implant and things and, at the end of the conversation, I asked him “So what do you think?” and he said “Whatever your choice is” and then I said “So do you understand what I’m saying?” and he said “Not really”! So, I hope you will do better, and I’ll try my best again to explain to you.

Monofocal lenses - that's the commonest lenses we put inside the eye after cataract surgery. Mono means ‘one point of focus only’. That is either good for distance vision when you're driving or watching the television or just for near vision when you're reading or sewing - but not for both. That means you will need glasses one way or the other.

Astigmatism is not corrected. You might think “What is astigmatism?”. That means the surface of the cornea ideally should be like a football. However, a lot of people were shaped more like a rugby ball, and this will not be corrected with the monofocal lenses. The monofocal lens implantation is performed by most ophthalmologists either under the NHS or as a self-pay patient.

Special lenses are different. They have got the toric elements to correct astigmatism and the multifocal lenses is a bit like ‘internalising the varifocal glasses’. So, rather than wearing it, they internalise it. And what that means is it will be able to provide good distance and near-functional vision without the use of corrective lenses.

However, patients can have glare or reduced contrast sensitivity with this type of lens, so it is not suitable for everyone and especially patients with certain conditions for example irregular astigmatism, glaucoma or disease at the back of the eye. It is performed - or should be performed - by ophthalmologists which specialise in refractive surgery and unfortunately this is not available under the NHS.

Just a quick graphic summary: the left-hand side picture you can see the monofocal lenses, so you need glasses for distance and/or near. NHS patients, self-pay patients or Benenden member patients can all have the monofocal lenses.

But the multifocal or toric lenses, you can see here you’ve got this nice, very fine groove. And most likely you will not need glasses for distance and it's only available as a self-pay package.

So, you'll be referred to the Ophthalmologist for further assessment. You can choose to go to the NHS with only monofocal lenses available or you can consider if you want special lenses as a self-pay patient.

Some interesting facts with the COVID pandemic. According to the March reports from the Royal College of Ophthalmologists this year, before the COVID pandemic in the UK we performed around 450,000 cataracts per year. But this dropped by 44% to nearly 200,000 cases during the COVID period.

As a result, there's a long waiting time even for appointments. Of course, that depends on which part of the country; for example, my colleagues in London tell me at their CCG they've got over 2,000 patients waiting more than 18 months to have an appointment.

Certain parts of Kent, for example in East Kent, where they've got community providers for cataracts the waiting times tend to be less - but however the waiting time is a bit longer than what it used to be. There is extra government funding, but I think it will still take time for the process to go through because the number of patients will compound as the time goes by.

So do I need a cataract operation? There are clinical reasons why I will encourage you to have cataract surgery: for example, if you’ve got angle closure glaucoma. What that means is the cataract becomes so big it blocks the drainage pathway in the eye and, as a result, there's a risk the pressure in the eye can go sky high and you can go blind very quickly.

Or this could be part of a vitreo-retinal procedure. What that means is as I have to do an operation in the back of the eye, I might just as well remove your cataract otherwise you will need surgery sooner rather than later.

Or the cataract is affecting the quality of fundal image. If you're diabetic, you probably will have fundal images by the diabetic screening service. If you have a cataract it blocks a light entering and they cannot take a decent picture to grade your diabetic disease.

Do you think you need cataract surgery? Only if it's affecting your daily life; if you're not seeing well to cook, to shop or you start driving with hesitancy because of the glare affecting you or you might actually not reach the government required legal standards or you start changing your glasses very frequently because you're getting more short-sighted or if it's affecting your hobbies, for example you're playing golf in sports you can't find a ball again or if you enjoy painting especially if you're a famous painter like Claude Monet.

I think you all know he's a French impressionist; he was diagnosed with cataracts in 1912, his symptoms getting worse and worse over the next 11 years. He was very hesitant to have surgery because, in 1912, the surgery was not as advanced as we have today.

He was describing his garden becoming very yellow and very murky and the red became very dull and the blue became darker and indistinct. It is very obvious in his paintings in the different years of the Japanese footbridge. As you can see in this picture, this was drawn in 1899 – a very clear image; the colour is vivid. The same footbridge was drawn in 1922; you can see the image is quite indistinct and he used very dark colours, if I can convince you this is actually the bridge.

So what happens during cataract surgery? Now, in the old days, couching was the method of choice. Now you can see here, a needle or lancet was inserted into the eye and the cataract kind of wiggled a bit and fell to the back of the eye.

The other picture shows you this patient's well prepared for surgery as he's strapped to their chair securely.

It is interesting to know that the payments were made to the Surgeon since 1750 however, if the patient died or lost vision, the Surgeon's finger would be chopped off. Now I’m very pleased to tell you that all my fingers and thumbs are intact!

So modern day cataract surgery is very different. You can see my younger self there operating. This is the operating microscope which provides precision and also a magnified three-dimensional image of the eye. The phacoemulsification machine allows a controlled micro-environment for the surgery to be performed and also you can see here the micro-instruments are very robust, very reliable.

And the most important thing is the development and the continuous advance in the intraocular lens implant. It was first introduced by Sir Harold Wrigley at St Thomas's Hospital and first inserted in November 1949.

Things have moved on a lot and now the lens is much smaller and is foldable allowing micro-incision. So, when I do the operation, the insertion is around 2.1 millimetres. As a result, you don't need any more stitches, it's self-sealed. And the advance of special lenses especially now enables nearly complete visual rehabilitation; that means allowing you to see distance and near.

So, the gold standard in the UK is a phacoemulsification and intraoctal lens implant. This is one of the most commonly performed surgical interventions worldwide with a very high success rate. In the UK, according to the data from the Government, 90.6% of patients will reach driving vision. There are patients which have got other coexisting diseases which, of course, will hamper their recovery.

So, what happens on the day of surgery at Benenden? I will advise you to wear comfortable and dark colour clothing, have a light meal and definitely no alcohol. You will be surprised I do have patients who are so intoxicated I have to cancel the surgery! Make sure you arrive on time, make sure you follow the latest COVID protocol.

When you arrive, we will check your blood pressure and glucose. We will put in more drops to dilate the pupil and will give you overall sedation if you're very nervous. The surgeon who comes to see you will check you're the right patient, check the consent, make sure the lens selection is correct and then mark the side for surgery.

Then you'll be led by a nurse into the eye theatre. There will be the surgeon there, a scrub nurse and also the runner - so it's not going to be overcrowded. You'll be sat on the operating chair, you'll put a cap to pull back all your hair from the face so it won't interfere with the operation, we'll have gauze to cover your ear on the side of the surgery, we advise you to take your hearing aid out on that side and then we'll cover that to make sure no water will go into your ear during the operation.

We will again check your identity and then we'll put a small pulse oximeter on your finger just to make sure your heart is beating and the oxygen content inside your body is adequate. The operating chair will then move backwards, we'll make sure you're comfortable. We’ll put a pillow underneath your knees because I want you to be comfortable, so you won't start wiggling.

We'll put more local anaesthetic and iodine solution in the eye now. You'll notice that because of the iodine solution everything turns a bit brown. That's to be expected.

Then I will clean the eye and then put a drape across. Now what we mean by a drape is a surgical, sterilised piece of plastic which covers the surgical area. It will cause a bit of claustrophobia but can be lifted away from your face.

We’ll then insert a speculum - you can see the metallic things on here - to keep your eye open. You might notice a tiny bit of pressure, but it should not be painful. And then you'll be asked to stare at the operating microscope light which will be three bright dots. Make sure you have both eyes open and you can blink normally. You can listen to the music, but no singing or dancing!

So what will I do then? The different surgical steps. We’ll make a small incision on the cornea - as I said around two millimetres - to go inside the eye.

We'll do what I call the capsulorrhexis to peel off the top of the capsule which surrounds the cataract itself and then the phacoemulsification. What that means is an ultrasonic needle that we’ll insert into the eye, sending ultrasonic waves to break the cataract and then, during that period, you will hear some high-pitched noises.

Once the cataract is removed, we'll do what we call irrigation and aspiration to making sure the whole back will be cleaned. Again, you'll hear some noise. And the lens implant will be put inside the eye, antibiotics will be given and that will seal the wound and then you'll be covered with a transparent shield which you can see through but is blurry. The whole process takes around 10 to 15 minutes.

How I want to show you a bit about a surgery at the stage we call the capsulorrhexis. As you can see here, we are peeling off a very small area of the capsule and I also want to draw attention to the space here. It’s very, very small to manoeuvre. The total length of the eyeball is around 24 to 25 millimetres and the area we are operating on has got only a two to three-millimetre depth - hence any sudden movement can be devastating.

That's the phacoemulsification. You can see the phaco needle inserted into the eye, an ultrasonic wave emulsifies the cataract pieces and cleans it all out and then we'll put the lens implant in. You can see here the lens inside the cannula is folded, goes through a small wound and it opens up. Operation done!

So what can go wrong? There could be complications during the operation. The commonest is what we call posterior capsule rupture. As I explained to you, the lens is inside a capsule. In one in a hundred cases, when we do the operation the capsule can be broken. But what that means is we might need to do an extra procedure to clear the vitreous, which is the jelly structure, moving forward and then put the lens implant in.

Now it might not actually affect the outcome whatsoever, but that means a slightly longer operation.

If the capsule rupture is a lot bigger, part of the cataract can drop to the back of the eye as you can see here. This is a picture taken at the back of the eye. This happens around 1 in 150 cases, so it's not common - but that means you will need further surgery to remove the cataract at a later stage.

The thing we worry about most with any eye surgery is endophyhalmitis. This happens post-operatively and happens in around one in 1,200 cases.

As you can see in the picture, here the eye is quite red, and you can see there's a white line. Now that is white blood cells (or we say pus) inside the eye. Because of the bacteria entering the eye, the whole eye becomes infected. We can still treat it; however the outcome might not be as favourable and - very rarely, one in ten thousand - patients can permanently lose their sight and lose the eye.

And this is why, unless necessary, we do not want to perform an operation in your eye. And you can see here, if I can convince you, the cornea lost its transparency a bit. This is due to swelling or what we call corneal oedema following a cataract operation. It is not uncommon; it happens around one in a hundred cases and the majority of the swelling will clear with time or with some eye drops. However, one in a thousand patients might need further surgery to clear that.

Postoperatively, you can also have what we call cystoid macular oedema. This is the OCT scan I mentioned earlier. This is looking at the anatomy of the back of the eye. This is the macula. This is what a normal macula should look like, nice and smooth with the dip in the centre. And you can tell here the back of the eye is swollen. It happens to 1.2% to 3.4% of patients having a cataract operation. Some of them are so mild it won't even affect your vision; the majority of patients again will recover with some eye drops.

Following the surgery, even months to years later, patients can have capsular thickening. What that means is the capsule that was holding the lens implant has grown thicker. And this is the result here, if I can convince you. You can see this opacity which is causing a problem again and blocking the light entering the eye.

It happens to five to ten percent of cases that undergo cataract surgery, but it can be easily dealt with, with some laser - what we call YAG laser capsulotomy. If I can convince you the same patient here had the opening created by the laser treatment and because the light can go through your vision should return to normal

So, the next question is: where and which surgeon to do your surgery? In America, my father is under a very different health system but - in the UK - there are a few choices. You can decide to go as a self-pay patient; there will be a fee incurred but it allows you to have a much shorter waiting time and you choose your own time, you choose your own Consultant to see you, operated on and you can choose to have monofocal or special lenses.

Benenden members, the cataract surgery is free of charge, medium waiting time, you’re allocated a time to be seen/operated on, you are still consulted and operated on by your own choice of Consultant. But you have to pay for the special lenses.

If you're keen to have that, for NHS patients of course it’s free of charge however as I mentioned earlier, the waiting time can be very long. You’re allocated a time to be seen and quite likely will be seen by one doctor and operated on by a different surgeon and you can only have monofocal lenses.

I am now only practicing cataract surgery exclusively at Benenden. My reason is the Eye Department is located in a brand new £53 million facility, there's plenty of parking space - I know it's quite trivial and it is sometimes very important especially in the very tranquil environment - and you don't feel like you’re rushed and Benenden has got the latest investigative and surgical equipment.

What is also important? I’m working with a team of 12 experienced eye Consultants. Every day of the week there is a clinic and surgical sessions.

What is important is we cover each other. That means, if I’m going on holiday there will be someone looking at your eyes if you’ve got a problem. And my colleagues cover most eyes specialties from oculoplastic (which is to do with the skin of the eye) or to do with the medico-retinal side or vitreo-retinal surgery. And we've got four refractive Surgeons dealing with special lenses implantation.

What is also very important behind the scene is the hard work by our lead clinician the Matron – Jane - the senior management team, CEO, the Medical Director, they instil a very strong clinical governance culture. What I mean by that is that complications, complaints, surgical outcomes are scrutinised. Not to mention we've got a dedicated team of ophthalmic nurses and administrative staff and they’ve created a very well-designed cataract patient pathway.

Why is that important? This is what we call the ‘one stop cataract clinic’ either for monofocal lenses or special lenses. When you come, the nurses will take your history, your blood pressure, check your visual acuity, check your pressure in the eye and then we've done all the investigations. Biometry means to measure the shape of your eyes, so we know what lens implant we have to choose.

If you're in the special lenses clinic they do a special scan of the front part of the eye, you will do the OCT scan, they will sort out your COVID protocol and then you come to see me. That means by the time you see the Consultant all I need to do is concentrate during the eye examination. I can look at the results then I can talk to you and discuss what lens implant is suitable for you.

Other places I work are very different. What I mean by that is that there’s not a linear process. You'll come to see me in one establishment and I’ll say “Oh you need a scan”, and you might end up in an optician doing a scan because some of the establishments don't even have a scan. And then you come back to see me and then I’ll say “Yes you need surgery” and then you'll go to have the biometry measures and then you come back to me and then we talk about the lenses and then we haven't got the lenses in place and they need to be specially ordered.

Benenden is very different in the sense that you only come once. We get all these things done, we get you consented, and I can tell you if you’re a self-pay patient, most likely you'll have your surgery done within three weeks. Also, what is important is after the surgery you will have 24 hours post-surgery hotline so anything you're concerned, you're not happy with, ring the number - there will be someone to answer your call.

So ‘where’ is an obvious choice for me, because that's where I’m going to practice my cataract surgery. Which Consultant – that would depend. It could be your friend’s or family recommendation, it could be subspecialty-related (for example if you want to have special lenses and I recommend you should have the operation done by reflective surgeons) or you have got previous retinal detachment or other things which might be more appropriate for certain Consultants to consult you and operate on you.

Any of our 12 eye Consultants at Benenden are experienced, they're trustworthy and we practice to a very high standard with your interests at heart.

Now these are the list of the questions in the beginning. I hope I’ve managed to answer that. Just a message to take home. If you’ve got the symptoms of cataracts, go to see an optometrist if the following apply which is:

• You want to see and operated on speedily by one of our 12 experienced eye Consultants
• If you want special lenses
• You want a streamlined service
• You want a 24-hour hotline following the surgery

All you need to do is ask your Optometrist for a copy of the referral letter and then you can call the Benenden Private Team if you're a Benenden Member or self-pay patient. This is the number for our Private Patient Consultation team (01580 363158).

So, ring this number if you're interested in seeing us.

And now it's the Q&A session so please ask me any questions if you want to.

Jane Styche

Thank you so much for that, Mr Poon, it was really interesting. I’ve worked in eyes for 12 years and I’ve learned something so that's always worth it!

So, I do have some questions for you. So, I’m just going to start at the top and work my way down. We have a lady that's got sight only in one eye and on the other eye she has already had cataract surgery, but she wonders whether this could be done again but with special lenses?

Mr Wallace Poon

I would recommend not to have special lenses because you will like the two eye functions in junction to each other. So, I think, unfortunately, if you have one monofocal lens put in it would be better to have the similar property of lens to be implanted.

Jane Styche

Okay, so quite a common question that we get: what is the criteria for cataract surgery? People talk about ripeness and size; could this please be explained?

Mr Wallace Poon

Yes, as I mentioned earlier, the most important thing is – is the cataract affecting your daily life? For example, I mentioned is it compromising your vision, are you driving, if you're driving are you having symptoms that are causing you to lose your confidence because of the glare or are you actually reaching the Government standard or is it affecting your hobbies?

Those are the things you need to consider. Cataracts can be done earlier or later - depends what your living style is.

Jane Styche

So, I have a question regarding glaucoma. So, I have glaucoma for which I take two eye drops. How does this affect my cataract operation?

Mr Wallace Poon

Well first of all it depends on how advanced your glaucoma is. If you've been told by your glaucoma specialist you've got advanced glaucoma, you'll be better off if the surgery is done by himself/herself or their colleague.

The reason for that is when you perform cataract surgery there will be fluctuation in the pressure inside the eye during the operation and there's a very small chance that can damage the optic nerve further. So, if you are on two eye drops that means you might have slightly advanced glaucoma.

We are still able to do the cataract surgery for you providing we have got all your medical notes to find out how advanced your glaucoma is, so we can advise you accordingly.

Jane Styche

So, another very common question: can the procedure be done under general anaesthetic because I am totally terrified of the prospect of having it done whilst awake?

Mr Wallace Poon

Yes, it can be done under general anaesthetic but, unfortunately, at Benenden we only perform the surgery under local anaesthetic. Generally speaking, in the UK, nowadays over ninety five percent of cataract surgery is under local anaesthetic.

Of course, if you're very terrified, or you're so nervous you can't keep still, general anaesthetic might be the only option forward.

Jane Styche

Okay I have a question: I’ve heard that people have been fitted with monofocal lenses, one for long sight and one for short sight. Is that a possibility and would you recommend it?

Mr Wallace Poon

Yes, it is possible, and this is why I said the refractive outcome is quite difficult to explain and to understand.

What basically is happening is you will have one eye for long distance and one eye for short distance, that means for reading. So, at any moment, you're only utilising one eye to perform the function.

Now this is not necessarily suitable for everyone because two eyes have got what we call reflective difference. So, because one is long, one is short, some patients might find it very difficult to cope.

What we will advise is you might be better to see an Optician before you contemplate what to have. We call this monovision might be to try the lenses or try contact lenses and see whether you can cope with the different distances before we actually contemplate doing surgery. Because once the lens implant is put in, it can be reverted, but it's better not to because that means there's more operations and risk of complications or you might end up still wearing contact lenses afterwards which will defeat the object.

Jane Styche

So, I have a retinal vein occlusion in my right eye. Am I still able to have cataract surgery in both eyes?

Mr Wallace Poon

The answer is yes, and I think if you've got retinal vein occlusion in one eye, I think we'd suggest not to have the special lenses but have the monofocal lenses.

But sure, you can still have cataract surgery.

Jane Styche

So, can a toric and monofocal be combined if paid for?

Mr Wallace Poon

Yes, with special lenses is you can do two things. You can correct your astigmatism which is the toric lenses, or it can have the multifocal capability. Those two characters can be combined, or you can just have the toric lenses with the monofocal lenses combined together.

Jane Styche

So, I have an occasional chronic cough. Is it necessary to remain very still during surgery? If so, what do I do if I need to cough?

Mr Wallace Poon

Yes, you will need to keep still during surgery. The reason as I explained earlier is, we have got a very confined space to operate only. You can certainly see that movement can cause devastating effects.

However because you're awake I will tell you, if you have got tendency to cough, we will say before you cough raise your hand so if I’ve got instruments inside the eye I can withdraw them quickly and then you can cough.

Of course, this is not the ideal situation, but I’ve been operating on patients who do have coughing episodes and we safely have the operation performed.

Jane Styche

So, I have an attendee that has glaucoma and has had laser for the glaucoma in the past and I wonder whether this would affect cataract surgery.

Mr Wallace Poon

That would depend on what type of laser surgery the patient had, because you can have laser to create a hole in the iris. Sometimes that will make the surgery a bit more challenging because, after the laser is performed, it will induce inflammation in the eye and the pupil can get stuck and not dilate well.

It is still possible to have the operation done but it might need extra tools to help us to dilate the pupil. But the answer is yes it can be done.

Jane Styche

So, I have an attendee that asks: if you need further correction for your vision can you wear contact lenses after cataract surgery?

Mr Wallace Poon

The answer is yes, you can wear contact lenses and sometimes even glasses will be sufficient

Jane Styche

An attendee doesn't currently have cataracts, but would a special lens replacement prevent cataracts developing in the future?

Mr Wallace Poon

As I mentioned earlier, any surgery carries a risk that things can go wrong. You can have what we call clear lens extraction that means you have got the normal lenses but - because of your lifestyle - you don't want to wear glasses, and that procedure can be performed. And of course, once the natural lens has been removed and replaced with the lens implant, you will not develop cataracts in the future.

Jane Styche

We have an attendee that has cataracts forming and has done for several years but they're not actually affecting the quality of life yet. So, they seem quite comfortable that they should wait a little bit longer. Would you agree with that?

Mr Wallace Poon

Yes, I would. That's what I told my dad. I think if you're not bothered with the symptoms and you're coping with your daily life, leave it for now.

Jane Styche

And the final question I believe, which I may be able to answer a little bit better is: what is the cost for special lenses?

That varies, so when you come for a special lens assessment the Consultant will be with you for a long time talking about the variety of lenses which would be suitable for you, at which point once the lens is chosen then we will let you know how much they cost.

But for a private patient you're looking at approximately about three and a half thousand pounds per eye, depending on lenses (price correct at the time of recording – please check our pricing page for up to date costs).

Oh I’ve had another question pop up - one moment! Post-op activities: what should be avoided, Mr Poon?

Mr Wallace Poon

Now traditionally, cataract surgery involved quite a large incision and you might have got stitches in the eye. We tend to ask the patient to refrain from any physical activities, even not to bend down. Not that because when you bend down the wound will burst open, we are more concerned when you bend down you're not aware you have the cataract surgery done and you might bang your eye into the corner of the table or - when you go gardening - there might be something you're not aware of.

So, for example, we will ask the patient to refrain from any physical or contact sports for at least a month and no swimming for a month. But if you're engaged in just your hobbies of watching television or walking, there should not be any problem whatsoever.

Mind you, however, following the cataract operation you will be given some eye drops to use so it is more for your own convenience how much activity and how comfortable are you to perform those activities.

Jane Styche

Perfect! Well I’d like to thank everybody for asking such helpful questions. I think people have the same questions but don't always like to ask. And thank you Mr Poon for answering the questions and for a really, really interesting session.

You'll shortly receive a survey and I’d be very grateful if you could spare a few minutes and let me have your feedback on today's webinar.

So, on behalf of myself, Mr Poon and the team here at Benenden Hospital I’d like to say thank you very much for joining us today and we look forward to seeing you all again at the next webinar.