Seeing clearly again

Seeing clearly again

HOW would the world look like if we had cataracts in both eyes?

We can find out by looking at digitally altered images to mimic its blurring effect on our vision, or by comparing French Impressionist painter Claude Monet's later works in the 1910's to his earlier paintings.

At least, that is what Stanford University ophthalmologist Dr Michael Marmor thinks after he recreated, with computer simulation and his own medical knowledge, the images of some of the masterpieces of French impressionistic painter Claude Monet.

Monet's documented descriptions of his symptoms were typical. In 1912, at age 72, Monet's reduced vision had prompted him to consult eye doctors, who diagnosed him with cataracts in both eyes.

However, as he was worried that his colour perception may be affected by surgery, he refused treatment even though the surgery was already well established and relatively safe at the time.

Even when Monet continued to work while he struggled with cataracts, his vision deteriorated in the following years.

He slowly lost his ability to distinguish between colours. It was 11 years after his symptoms started that he finally agreed to cataract surgery.

At that time, his eyesight was so bad he could only paint during certain hours of the day when the lighting was optimal.

"The blurring of vision did not seriously alter his basic Impressionistic style, but his cataracts severely changed and challenged the marvelous qualities of colour in his works," Marmor wrote in his 2006 paper, Opthalmology and Art: Simulation of Monet's Cataracts and Degas's Retinal Disease.

While some may argue that Monet might just had been trying out a new style, it is not likely so because after his surgery, Monet destroyed many of his late canvases, and refined one of his most famous series of paintings, Water Lilies, to resemble his earlier style.

Cataract 101

Cataract 101

Almost a century after Monet's high-profile and well-documented case, cataract remains a common cause of visual impairment and blindness in many parts of the world, especially outside developed countries.

In Malaysia, cataract has become a leading cause of preventable blindness, causing 39% of reported blindness in the country.

"On average, people get cataracts around the age of 58 in Malaysia," says ophthalmologist Dr Aloysius Joseph Low.

Besides symptoms like blurring of vision, the fading of colours, and the reduced ability to see in low lighting Monet described, people with cataract also commonly experience glare (light sources like headlights and lamps may appear too bright), see halos around lights, and have poor night vision.

"Also, one of the things we often observe in people with cataract is the frequent changes in the (correction) "power" of their (prescription) eyeglasses or contact lenses," says Dr Low. As the formation and progression cataract can change the shape of our lens, its focal power may be altered.

Although many people think of cataract as the growth of a membrane that covers parts of the eyes, it is actually the clouding of our lens within the eye.

This may be caused by the clumping of proteins in the lens as we grow older or when we suffer damage to our eyes.

Much like the way a fog can cloud a glass window, cataract formation can reduce the amount and direction of light that passes through our lens, making it difficult for us to see.

Treatment options

Treatment options

While eye doctors in Monet's time mostly relied on their observations and their patients' description of their failing vision, eye specialists (opthalmologists) today have more tools at their disposal to detect early cataract, even when changes in their patients' vision are not yet noticeable.

Routine eye checks is thus useful to detect eye problems as we age.

According to the US National Institutes of Health, the symptoms of early cataract may be improved with new eyeglasses, brighter lighting, anti-glare sunglasses, or magnifying lenses. When these do not help, surgery is the only effective treatment.

However, if detected early, many do not need immediate surgery. Some people with cataract may not even need surgery for the rest of their lives. "Many of our patients always ask us, 'when is my cataract ripe for surgery?'," notes Dr Low.

"But the rule is, if your cataract doesn't affect your daily activities, then you do not need immediate surgery. We can start with yearly follow-ups to monitor your condition first," he adds.

"Many do not realise that a large part of cataract treatment involves the observation and monitoring of the patient's condition."

Like any chronic condition, the formation and progression of cataract depend on many factors. In its fact sheet about cataracts, the WHO includes the reduction of cigarette smoking, ultraviolet light exposure, and alcohol consumption as ways people may prevent, or rather delay the development of cataract.

Diabetes mellitus, hypertension, and high body mass index are identified as additional risk factors.

It also depends on the patient's exposure to radiation and the amount of free radicals he/she generates and consumes, for instance, from food and stress, says Dr Low.

"You can actually delay or slow down cataract formation by taking more antioxidants like vitamin A, C, and E in your natural diet, and wearing sunglasses, but it doesn't slow down the progression," Dr Low explains, "because most cataracts are age related - if you live long enough, you will get it," he notes.

Meeting visual needs

Meeting visual needs

If you have lived long enough to get cataracts, you can also be consoled that today, the choices available to you are significantly more than the options Monet had a century ago.

While surgical techniques during Monet's time had required eye doctors to cut across the outer lining of their patients' cataract-ridden eyes to remove the lenses, eye surgeons today can remove them by making one or two small incisions at the side of the eye (via extracapsular cataract extraction and phacoemulsification respectively).

And while patients who opted for surgery two decades ago had to be in hospital for at least three days, patients today can return home shortly after the 20 minute procedure, although they may be required to wear protective eyewear for about a week.

In an article titled The Evolution of Cataract Surgery: The most common eye surgery in older adults, University of Manitoba department of ophthalmology chairman Lorne Bellan also described the advancement in lens replacement technology.

"Originally, no intraocular lens implants were used following cataract surgery, and patients had to rely on 'Coke bottle'-thick hyperopic glasses," he wrote.

But when artificial lenses (called intraocular lenses or IOLs) were invented (in the 1950s) and subsequently improved, patients now can rely on normal reading glasses after they undergo cataract surgeries.

There are currently three types of IOLs - monofocal, multifocal, and accomodating lenses, explains Dr Low.

The monofocals, the first generation of IOLs, helps the patient see distant objects clearly. The second generation of IOLs - the multifocals - helps the patient to see near distant objects clearly.

As both lenses do not help patients with their intermediate vision (needed to read), patients who have these two types of IOLs surgically inserted into their eyes will still need reading glasses.

The latest generation of IOLs, the accomodating lenses, helps the patient see objects that are near, far and of intermediate distance, says Dr Low. "It mimics the natural accomodative functions of the eye," he explains.

Unlike monofocal and multifocal lenses, the accommodative lens have flexible hinges on its sides to allow the patient's eye's muscles to move its position according to current visual needs.

For instance, when the eye focuses on an object far away, the lens can be moved to rest back in the eye to help the patient see it clearly.

Patients who have accomodative lens inserted, however, are often required to wear reading glasses for at least two weeks to allow the eye to heal and resume its normal accomodative functions.

Regardless of the type of lens inserted, the cataract surgery required to insert it is the same. "It is one of the safest and most common surgeries in the world," says Dr Low.

But the type of lens you need may differ according to your visual needs and the affordability of the lens (newer generation lenses are more expensive than older ones).

A retiree who does not mind reading glasses, for instance, may have different visual needs compared to an executive of who is still required to use computers and handheld devices that require intermediate vision on a daily basis.

"The goal is to meet the patient's visual needs," says Dr Low.

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