Introduction

Few decisions in life are more impactful than the choice to undergo cataract surgery—and how to have it done. Because cataract surgery is so common, many patients don’t realize it involves important decisions that can affect their vision for the rest of their lives. Modern technology has introduced new options for how the surgery is performed and what type of lens implant is used. These choices matter.

Before we explore the available options, it’s important to first understand what a cataract is and the role of the natural lens in our vision.

The Lens of the Eye

Behind the pupil sits the eye’s natural lens. When we’re young (typically under age 40), this lens is flexible and able to shift focus to help us read and see clearly at all distances. It also contributes about 20% of the eye’s focusing power.

As we age, this lens gradually becomes stiffer—often starting in our 40s—leading to difficulty seeing up close. This is why people begin to need reading glasses or bifocals. Over time, the lens also becomes cloudy, reducing the quality of vision even with glasses. When this happens, it’s called a cataract.

Cataract surgery is one of the most successful and common procedures in the world. It involves replacing the cloudy natural lens with a clear artificial lens implant.

Lens Replacement Surgery: More Than Just Cataract Removal

During cataract surgery, we remove the clouded lens and replace it with a new, clear one. Some lens implants restore clarity but still require glasses—often trifocals—to help patients see far away, up close, and at intermediate distances (like a computer screen).

Other advanced lens implants do much more. They restore both clarity and a full range of vision, often giving patients the ability to read, work, and drive without glasses—similar to the visual range they had in their 30s.

It’s important to understand:

· Insurance typically covers the standard lens that restores clarity only.

· Advanced lens implants, which restore clarity and reading range, involve an additional investment by the patient.

· Both options are good—but which is best depends on the patient’s lifestyle, eye health, and visual goals. Your consultation with your eye doctor and surgeon helps with these important decisions. 

Some people choose to have Lens Replacement Surgery even before their cataract fully forms, especially if they’re in their 40s to 60s and want to eliminate their need for reading glasses or bifocals. This is called Refractive Lens Exchange and the patients who do it never need to worry about developing a cataract and they are not dependent on reading glasses or bifocals anymore. 

Surgical Technique: Manual vs. Laser Lens Capsule Opening

The natural lens is housed in a thin, clear membrane called the capsule—imagine a grape inside a grape skin. During surgery, the surgeon must create a round opening in the front of the capsule, about 5.0 mm in diameter, perfectly centered over the lens. This allows the lens to be removed and the new implant to be placed in the capsule.

After surgery, the capsule naturally “shrink-wraps” around the new lens implant. This process, called capsule contraction, helps hold the lens in place for the rest of the patient’s life—and does this the best if the opening overlaps the edge of the implant for 360 degrees.

Achieving this ideal overlap is a key to long-term stability of the implant.

There are two main methods for creating the capsule opening:

1. Manual method – done with handheld forceps and typically quite accurate.

2. Laser method – uses a femtosecond laser guided by advanced imaging (OCT) to precisely place and shape the opening.

The laser method can:

· Provide a near-perfectly round and centered opening.

· Improve the chances of 360° overlap, which enhances lens stability.

· Use imaging to determine the exact center of the natural lens—something that can be more difficult to judge manually.

Both manual and laser methods are highly respected and can lead to excellent outcomes. However, the laser approach involves an additional cost and is generally considered more precise. Patients should weigh these benefits with their doctor when deciding which approach is right for them.

Conclusion

When considering cataract surgery—or elective lens replacement—patients should be informed about:

· Implant choices: standard (clarity only) vs. advanced (clarity and range of vision).

· Surgical techniques: manual vs. laser-guided lens capsule opening.

Understanding these options empowers you to have meaningful conversations with your eye surgeon and make the best decision for your vision and lifestyle.

Richard P. Holm, MD passed away in March 2020 after a battle with pancreatic cancer. He is founder of The Prairie Doc®. For free and easy access to the entire Prairie Doc® ® library, visit www.prairiedoc.organd follow Prairie Doc® on Facebook. Vance Thompson, MD is an internationally recognized specialist in refractive cornea, phakic IOL and lens replacement surgery.