How This Surgeon is Revolutionizing Eye Sight Saving Procedures

Well, it’s very different to when Mr Kirkpatrick started his career back in the Eighties. “When I was a young surgeon patients were typically given a general anaesthetic and had to spend two or three nights in hospital, and the team was doing well if we managed five cases in a morning list. Today, thanks to advances in both technology and technique, cataract operations have been transformed, not least because the procedure is much quicker and nearly always done with the patient awake using nothing but local anaesthetic eye drops. • Patients get sight back in a day in new NHS cataract surgery “If all goes to plan it can take less than ten minutes with patients sometimes heading back home within an hour of arriving at the clinic, meaning we can treat many more, often 30 in a single day. And the end result is much better too, with 95 per cent achieving near perfect vision — although most will still need glasses for some tasks.” What is a cataract and why do so many of us develop them? Cataracts are caused by degradation of proteins in the lens sitting behind the coloured part of your eye (the iris) causing it to turn cloudy. They can develop at any time — indeed, very rarely, babies can be born with them — but they typically start to become a problem from middle age. The average age of people Mr Kirkpatrick operates on is about 75, “but we do see a significant number who are younger — in their fifties or sixties, and occasionally even in their forties”, he says. “Nearly all of them are referred directly by their high street optometrist after an eye test [patients can choose which unit they are referred to under the NHS in England] with common complaints including being dazzled by oncoming headlights at night, and increasingly blurred vision that means they have difficulty with day-to-day tasks even with frequent changes to their glasses or contact lens prescription.” Not all cataracts cause symptoms. The National Institute for Health and Care Excellence (Nice) estimates that about 1 in 6 people in their forties and fifties will have some degree of cataract but most won’t be aware of it. However, by their sixties a similar proportion will have significantly impaired vision, rising to nearly three quarters of those over 85. Age remains the biggest risk factor but clouding of the lens can also be accelerated by other things. Genes play a role, with cataracts being more likely in people with close relatives who have also been affected. They can also develop after eye injuries and are more common in people who are short-sighted, have diabetes or high blood pressure, are overweight, who smoke and/or drink heavily, or have to take long-term steroids. • Read more expert advice on healthy living, fitness and wellbeing When should cataracts be treated and what is involved? Who should be offered surgery and when remains a controversial area in the UK — at least on the NHS. People living in England tend to have the best access and shortest wait times compared to other parts of the UK but there is regional variation here too with some regions imposing higher eligibility thresholds than others. However, Mr Kirkpatrick is clear — if your cataracts are affecting your ability to do day-to-day tasks like driving and reading then you should be eligible for treatment. “Nice guidance on cataracts in England basically says: if you’ve got symptomatic cataracts, understand that you can have surgery for it and are prepared to accept the small risk of an operation, then you should be offered surgery.” There is no need, or benefit, in waiting for them to get worse, or “ripen”, as many patients believe — indeed leaving them too long can complicate surgery. “Severe cataracts in someone who has lost a lot of their vision can pose significant technical challenges for surgeons like me, and increase the risk of complications and a poor result. So I always encourage people to act, particularly if they are starting to struggle with their vision. And the tipping point is often when it impacts on their ability to drive,” says Mr Kirkpatrick. Once you have troublesome cataracts, surgery is the only option. Research is continuing into non-surgical options like medication but there have been no breakthroughs so far (although one UK study did suggest that high doses of vitamin C can slow progression). Waiting times vary considerably across the UK. Mr Kirkpatrick’s patients typically wait a few weeks to be seen for their initial consultation and another two to four months before they have their operation. However, much longer waits are common and, outside England, can be more than a year. • No NHS cataract op after six years … in England I’d have waited weeks The operation No one likes the idea of someone operating on their eye, particularly when they are wide awake, but it’s a painless and quick procedure. After the local anaesthetic eye drops have numbed the eye, the surgeon makes two tiny tunnelled incisions (2.2mm to 2.4mm wide) and introduces two instruments to break down the cloudy lens — it’s a similar in size and consistency to a small Jelly Tot — and gently wash out/suck out the debris. A synthetic lens is then inserted in its place. The new lens is bigger than the incisions — 6mm across — but is rolled into a scroll to pass through the outer eye and into the cavity left by the old lens, where it unfurls to its full size. Job done. No stitches are normally required as the incisions are self-healing and Mr Kirkpatrick has “only resorted to a stitch twice in the last year”. Then it’s off home with some eye drops and a protective patch. Vision improves immediately but it takes a few days for the eye to heal properly and for everything to settle down, so it’s important to take it easy during this period. Follow-up is typically a month later with your optometrist, by which time your vision should be as good as it is going to get, but the surgeon will see you again if there are any problems. Mr Kirkpatrick prefers to do one eye at a time in the unlikely event that the operation doesn’t go to plan or the patient develops complications — something you wouldn’t want to affect both eyes at the same time, although bilateral surgery is becoming more common these days. Waiting before doing the second eye also gives the surgeon an opportunity to fine-tune their selection of the second lens to get the best overall result by complementing the outcome from the first eye. Choosing the right lens requires complex pre-operative assessment and, as with glasses and contact lenses, the wrong choice can give poor results. There are myriad options available. The standard offering on the NHS is a monofocal lens that aims to give normal or near normal middle and long distance vision, so you may still need reading glasses. More complex types — like multifocal lenses — can mean you don’t need any glasses at all, but these cost more than ten times as much (prices vary but they tend to start at about £500) and are only available privately. And, no, you can’t pay your NHS surgeon a bit extra for a better lens. If you want one of these you will need to go privately and probably budget for about £3,000 per eye. The surgery may sound simple but it requires a steady hand — and a steady eye. During the op you will be asked to keep your stare fixed on a light to keep your eye still. You can’t blink because your eyelids are held gently open with retractors and thanks to the local anaesthetic you won’t feel the need to. And because the surgeon rests their hands on your head, if you do inadvertently move, their hands will go with you. So relax. • The London professor bringing eyecare to remote areas of the world What can go wrong? As with all surgery, a cataract operation carries risks but serious complications are very uncommon. Mr Kirkpatrick warns his patients that “while nearly everyone will sail through the operation and end up with a pretty good result, there is a 1 in 200 chance of being left with a significant loss of vision — defined as losing three lines or more of vision on an eye chart — as a consequence of damage to the chamber the lens sits in, or other possible complications like post-operative infection and inflammation.” Not all patients will end up with perfect vision and some may still need correction, particularly for specific tasks like reading, watching TV or driving. “But this is a group of people who have often been wearing specs for at least 15 to 20 years before surgery so they often don’t regard this as a major issue. Another potential problem is hazing of the lens capsule, which can occur anywhere from six months to many years later, but this is easily remedied with outpatient laser treatment. The risk depends on the type of lens used but we see this type of hazing in about 1 in 20 of our patients.” The quest for a glasses-free future Recent advances in lens technology, as well as improved and safer surgical techniques, have meant that implants are increasingly being used in people who do not have significant cataracts. These include people who want to ditch their glasses or contact lenses, not just for distance vision, but for close work too. Refractive surgery of this type is nothing new and the most popular choice — using a laser to reshape the cornea at the front of the eye — has been common practice for three decades or more. However, unless you have one eye treated for close vision and the other for distance (not everyone can cope with this) it doesn’t deal with the age-related focusing issue (presbyopia) that affects people from their late forties on so you will still need reading glasses. Replacing the lens with a multifocal one can give you perfect vision for close work like reading as well for looking at things on the horizon. I say perfect vision but, despite the latest advances, most users will tell you it’s not quite normal vision in that they tend to notice a ring around bright lights, including oncoming headlights. And, of course, it also carries all the risks of conventional cataract surgery. There is another issue. Using lens implants in younger people does increase the risk of future problems with the delicate light sensitive membrane (retina) at the very back of the eye. Retinal tears and detachments — which, while treatable, can threaten sight — are much more common after early cataract surgery, particularly in men and those who are very short-sighted, with rates of detachment as high as 1 in 20, compared to 1 in 200 for most of us. Put it this way, at my age (63) if I really couldn’t live with my glasses I would opt for lens replacement over laser surgery, but if I was 30 I would be choosing the laser. However, the two are not mutually exclusive and laser is sometimes used to fine-tune vision after multifocal implants. You can’t tell if someone has had laser surgery but Mr Kirkpatrick admits to looking closely for the telltale signs of lens implants when he sees suspiciously spectacle-free older celebrities and politicians being interviewed on television. So what does he look for? “An artificial lens can sometimes give its presence away by twinkling in the light.” And who wouldn’t want a bit more twinkle in their eye?