I seem to be seeing more one-eyed cataract patients lately (e.g., one eye that is 20/400 or worse from age-related macular degeneration [AMD] and untreatable, and the other eye with a cataract that is 20/80, 20/70, 20/60, etc.).

These patients are often very symptomatic and want the cataract out of the ‘good’ eye.

How good an eye would you operate on—20/80, 70, 60, 50, 40, 30, or 25?

Steve Slade, M.D.
Houston

That is a good question. I tell one-eyed patients that in general they fall into two categories: those who, due to apprehension, wait longer than they would if they had two good eyes and those who want surgery earlier because a cataract in their only good eye creates a greater impairment. This seems to help them sort out their thoughts.

Douglas D. Koch, M.D.
Houston

While it is challenging, I see a larger number of one-eyed patients for cataract evaluation, and I apply the same indications as [I do] for the two-eyed patients—namely, a level of visual function that interferes with patients’ ability to function at a level compatible with their needs in the presence of a cataract that is the likely cause of the reduced visual function. Depending on the cause of the monocular status, I may use additional precautions.

Sam Masket, M.D.
Los Angeles

In these cases, I usually recommend doing the ‘[good’ eye first so [patients] get something in the way of improved vision with their first experience. Even a well-counseled patient often backs out of the second eye when the first eye goes perfectly, but the retina prevents any dramatic change in vision. I think that if they are in the 20/40 range or better, or if they have posterior subcapsular cataract or cortical changes that make them glare down more, they would be good candidates in your expert hands.

Jeffrey Whitman, M.D.
Dallas

Over the years, I have gravitated to the following method: The first day I see them I usually will not schedule them. I tell them that I have operated on many patients with one eye and that the doctor and patient should be more cautious-that their anxiety and yours is higher. My analogy is: “This is like taking a car trip with no spare in the trunk.” You decide when to drive and you drive more cautiously. That doesn’t mean you don’t take the trip.

When they are frustrated enough with their vision, I tell them we will take the trip together, and feel they will do well.

I have found that one-eyed patients in today’s world don’t let their vision go below 20/30 or 20/40, as they want to drive—they are bothered more by the same amount of blurriness, as they have no other eye compensation.

I then tell them to think about it and that we are ready to help them when they are ready to take the trip. I give them a four-month appointment and tell them we will recheck then and if they want something done beforehand, they know where we live.

Dr. Slade, you and I have completely different practices and locations, so that will make a difference. The point is that I don’t use visual acuity; I use function. I do warn them as they approach 20/40 that they are approaching vision that may inhibit their driver’s license renewal.

J.E. “Jay” McDonald II, M.D.
Fayetteville, Ark.

Dr. McDonald, I agree with you and have been focusing on function with more pre-op counseling. So far, 20/40 is my limit.

Steve Slade, M.D.

I wonder if we could shift the discussion to whether or not one should perform cataract surgery first on the eye with poor visual potential (let’s say 20/200 potential vision in an eye with AMD).

My thought has always been that patients can get an idea of what cataract surgery is like with the first eye (even though the visual potential is poor). If they are pleased with the process and feel comfortable, they can move forward to surgery in their better seeing eye. 

Perhaps the surgeon can learn something from operating on the first eye as well.

Obviously, patient counseling is critical because despite a perfect surgical technique, infection, retinal detachment, and other post-operative complications can still occur.

Bill Trattler, M.D.
Miami

Both approaches have merit and concerns. As a result, I share the decision- making process with the patient. I explain that surgery for the poorer prognostic eye is a good idea for those who need to ‘get their feet wet,’ even if the outcome will be underwhelming. 

Generally, those patients who are very anxious about a procedure on their better eye will take that option. But I explain further that if I could operate for only one eye, it would be because a better chance of making a significantly positive impact on lifestyle exists. 

Sharing the decision with the patient takes considerable pressure off me to make the decision, as I do sense that it should be patient oriented.

Regarding one-eyed patients, I didn’t mention chair time, which can be extremely long. I often spend significantly more time discussing the problem than doing the surgery. 

I know that I have no chance, but I hope to have the code for complex cataract expanded to include one-eyed patients, in particular those who have lost their first eye to cataract surgery. There is always the difficult balance of having the patient let the cataract get too dense and increasing surgical risks versus having surgery at a stage when he can function, albeit at a reduced level.

Samuel Masket, M.D.

Both approaches make full sense. I always explain to the patient that doing the better eye brings a much better visual outcome. Doing the worse eye, on the other hand, may bring disappointment (we all know that many patients hear what they want to hear, not what you tell them). Nevertheless, if a patient insists on having the bad eye done, I do that. I fully agree with you in this case. Once they are pleased with the process, they are more open to having surgery on the better eye.

Igor Benenson, D.O., M.D.
Philadelphia

I agree with most of the comments here. If patients are bothered by a cataract in their only seeing eye, I will take the risk with the patient and help him regardless of visual acuity. Many patients with cortical spokes, posterior subcapsular cataracts, or polar cataracts will see 20/20 on the chart but are severely handicapped in the real world. If this bothers them and they are willing to risk their only eye, then I’m willing to help them if clinically indicated. 

I never sell surgery, and I also am cautious of patients who take things in too cavalier a manner. But ultimately, I think patients are much better off doing their surgery when they are a bit younger and more straightforward than waiting until they hit a tree with their Chevy or have 4+ nuclear sclerosis, pseudoexfoliation, and are taking Flomax (tamsulosin hydrochloride, Boehringer Ingelheim GmbH, Ingelheim, Germany) with marked drusen at the macula.

Steven G. Safran, M.D.
Lawrenceville, N.J.

This has been an excellent discussion. What a great forum! Where else can you ask a question and get responses from a past president of ASCRS, the head of the cataract section of ASCRS, the head of the listserv, and one of the best and busiest cataract surgeons in my own state within minutes? I have operated in both ways—worst eye first and best eye first—patients such as the ones you all present, and I can see advantages and disadvantages with both methods. I like to spend a lot of time talking to these patients. I personally like the idea of operating first on the worst/low potential vision eye (low expectations and risk), but I find that most patients want the best eye operated on first and to leave the worst eye for a ‘spare’ if it has little potential, so I usually end up operating on the good eye.

Steve Slade, M.D.

I do the opposite. I like to work on the eye with better potential first. If the worse eye is done first, then patients typically feel that the surgery was unsuccessful and wonder if it was done correctly. It’s impressive how they completely forget the pre-op discussion about the bad eye—they completely forget why it went blind (not cataract) and have unrealistic hopes of restoring perfect vision. They often refuse to even consider the second eye until the first eye is ‘fixed.’

Now I do the better eye first, have a good result, then I do the eye with the poor prognosis. There may be no improvement, yet they feel it is no problem and that all went well. They are completely happy because of the first eye. Perception is an odd thing.

Dan Eisenberg, M.D.
Las Vegas

I’ve been following this discussion with mixed emotions, but I’m prepared to change my approach from doing the worst eye first.

Have you noticed, as I did today, that the patients can be more anxious for the second eye than they were for the first? It’s astounding to me how frequently the patients misremember our discussions about most anything.

Al Dorfman, M.D.
Huntingdon Valley, Pa.