Date

I had cataract removal surgery this year. Twice: My left eye was done in May 2016, and my right eye in October.

Since most people I know have no experience of this and are curious about it, I wrote up a description of the experience as a Q&A.

Aren't you kind of young for that?

Yes. Cataracts are common in people in their 70s. I'm ... not quite there yet. Nobody knows why I had these. Sometimes it's genetic, but nobody else in my family had them at a young age. Sometimes it's associated with steroid abuse.... yeah, not relevant. Sometimes people have them from birth ... nope. Sometimes it's from excessive UV light exposure. Maybe? Occasionally, people just develop them earlier than usual for unknown reasons. That's me!

What are cataracts anyway?

Cloudy tissue inside the eye, behind the lens.

How did you get them?

Nobody knows. An optometrist first noticed them when I was in my early twenties. They said "huh, that's weird. Well, they're not giving you much trouble, so we'll just keep an eye on them for now." And I got the same response at every eye exam from then until now.

What changed this year?

In the spring of 2016 I was suddenly complaining of my right eye being unable to focus. It was like somebody was jiggling my eye up and down. So I couldn't focus both eyes on the same thing when it was happening. It was maddening. It wouldn't happen all day, but would last for a few minutes, many times a day, off and on for weeks.

After a couple days I scheduled an appointment with an ophthalmologist and they could not find anything wrong except the longstanding cataracts. It didn't seem like the eye was actually physically jiggling. The cataract specialist believed it was caused by my cataracts getting worse and my brain was trying and failing to compensate - basically trying to see around the cataract and not finding a good focus.

Just for good measure they sent me to a neurologist, who sent me to to get an MRI, and then a followup (that's another three medical appointments if you're keeping track), all with negative results - no indication of any neurological problems at all.

So it was finally time to get the cataracts out.

What did the cataracts do to your vision?

They make things generally more blurry, so they made my nearsightedness worse, and glasses couldn't fully compensate since the blurring happens inside the eye behind the lens. My distance vision has not been great for a long time.

But the most surprising part about this was something that I wasn't at all aware of. It turns out the cloudy cataracts also caused a sort of reduction in contrast, where back-lighting would wash out anything in front of a light source. I think this was because light entering the eye would bounce around internally. So if you were standing in front of a daylit window, I'd just see your silhouette. Other people would be able to make out your features. I had no idea I wasn't seeing normal contrast until after the first surgery.

Here's a simulated example I made based on a creative-commons-licensed photo by M.Angel Herrero.

On top is an altered version meant to represent my pre-surgery vision without glasses. On bottom is the original photo, meant to represent someone with 20/20 vision.

Two photos of camels against a bright sky. The first is blurry and low contrast, the second is sharp and high contrast.

I can't say this is a precisely accurate representation, but it gives the general idea: note how much detail is lost not just by the usual nearsighted blurring, but by loss of color contrast. For example, the camel saddle clearly visible in the second photo was totally lost in the silhouette of the first photo.

My old glasses would fix much of the blurring, but none of the loss of contrast. And I had no idea.

So you got LASIK surgery?

No. Lasik, as I understand it, consists of using lasers to re-shape your eye's natural lens. Done at a young age, if your lens still has some flexibility, I gather that you can get close to 20/20 vision.

What's the difference between LASIK and cataract removal?

Cataract surgery means removing the lens from your eye, along with the cloudy tissue, and then inserting an artificial lens into your eye.

Creepy!

I thought so!

Were you awake during the surgery?

Yep. But somewhat sedated.

Did it hurt?

Not at all on the first eye. The second eye was rather uncomfortable; I don't think they sedated me as much. But it was over quickly, and frankly the long periods of waiting in various hallways and waiting rooms bothered me a lot more than the actual surgery.

What did it look like while it happened?

Just a bunch of blurry weird colors and bright lights. I really couldn't tell what they were doing.

So you have 20/20 vision now, right?

Nope.

The artificial lens is not as flexible as a real one. So it's kind of like having a head start on what happens to everybody as they age - the natural lens loses flexibility, so you have a narrow depth of field - you can't focus both near and far, and that's why you start needing reading glasses and/or bifocals or progressive lenses.

What I do have is nearly perfect vision at the chosen distance.
After some discussion with the doctor I chose 18". (Actually a bit less on the left eye, so I can see a bit closer with my left eye and a bit farther away with my right.)

Wait, after all that you still need glasses??

Partly! So I basically had to choose a fixed distance at which to get really good vision, and need glasses for anything else.
I can now work, read (mostly), and socialize at meals, etc. without needing glasses at all. I couldn't do any of that for decades!

I can also walk around the neighborhood or a store pretty well, but signs get hard to read. Definitely need glasses for driving, and I usually prefer to have them on when I'm out walking.

I've also found that I can't read tiny print up close any more. If it's too small to read at 18", then I have to bring it closer, but that just makes it more blurry. So I need reading glasses for very small, fine details.

I might eventually get progressive lenses.

So if you still need glasses, what's the point?

It's way better than what I had before! Getting rid of the contrast problems was unexpectedly amazing.

Also, my distance vision with glasses is way, way better than anything I have experienced for decades. It's kind of startling. I can make out individual bricks on buildings many blocks away. This is a totally new experience. It's like my distance vision just went from a cruddy youtube video to HD.

Also, I can buy thinner and lighter glasses without getting the most expensive high-index lenses anymore. That's kinda nice.

I'm also significantly less nearsighted at medium distance, and see nearly perfectly around one to three feet, so I no longer put my glasses on the second I wake up. They usually don't go on until I go out.

Any unexpected results?

I am not used to needing to remember where my glasses are. They always lived on my head the entire time I was awake. Now, I keep having to remember where I last put them down. This is surprisingly hard.

Insurance woes

Before having all this done, I checked that my insurance plan covered cataract surgery; it does.

Unfortunately, it turns out that such a simple answer is totally inadequate to the way US health care actually works.

I knew that I'd have to meet my deductible, and I knew that I'd owe some "coinsurance" for part of the cost above the deductible. What I did not know, and nobody could tell me, was how much it would end up costing total.

First of all, it's not just one bill. Aside from all the pre-op doctor visits (there were many: I think five at the eye doctor, two at the neurologist, one at the MRI, one at my regular doctor to get an EKG and get certified that I was healthy enough (for a 10-minute outpatient procedure) ... which were mostly the usual doctor visit co-pay (and the MRI which was 100% covered thankfully))... aside from all that, the actual surgery for the first eye involved three bills, where I had naively expected one. One from the ophthalmologist who did the surgery; one from the anesthesiologist; one from the clinic where the surgery was done.

The clinic bill was the worst, because there was $470 of mystery uncovered expenses on it. This was a nightmare to sort out, because first I couldn't even figure out what they were. The Explanation of Benefits (EOB) from the insurance company had about 20 line items with no description or procedure code; each had one word, "SURGERY". I got a bill from the clinic, which listed what everything was, but the number of items and the amounts listed were different than on the EOB! Eventually, by painstakingly trying different combinations of sums, I was able to figure out which items on the bill corresponded to which on the EOB, and thus which ones were not covered. Then I had to start the long process of calling the doctor, the insurance company, and the clinic trying to figure out why these were uncovered and what could be done about it. Much buck-passing ensued.

It turned out the $470 was for four different medicated eyedrops that were administered during the procedure. I was given maybe one or two drops of each. Does $470 sound absurdly excessive for about six drops of medication? (Which, some googling suggests, can be obtained at a much lower retail price for a full bottle?)

In the end, I finally found a very helpful person at the billing department of the clinic who was aware that this amount was egregious and just removed those items from my bill. But it took months to find that person.

That's why it took so long to do the second eye - I was trying to sort out the billing for the first eye!

Did the same thing happen on the bill from the second eye? You bet. I still haven't got the final bill from the clinic yet, but the EOB looks the same.

I can only imagine how hard this kind of thing must be for people with more expensive medical conditions who can't figure out how to navigate this crazy system. It's really broken. Imagine if you had a cognitive impairment and didn't have adequate help? It's insane.


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