On the bright side

Both eyes fogged with cataracts that left him essentially blind and one failed surgery behind him, Edwin Smith decided to come to the United States, joining relatives from the Marshall Islands in Spokane to get his vision restored.

Now, after a second surgery, his right eye is clear and bright. His left eye, on which surgery in the Marshall Islands failed, remains clouded.

A former teacher who wrangled single classrooms full of kindergartners through eighth-graders, he wants to return home someday. For now, Smith, 65, lives in a tiny, sparsely furnished apartment on Spokane’s North Side.

But, at least with one eye, he can see. And that’s everything.

Without your sight, Smith said, “You cannot do anything. If we lost our eyes, maybe we would die. We cannot do anything.”

Cataract surgery can be life-changing for older people, helping to preserve independence – and, according to a study published this month in the Journal of the American Medical Association, reduce their chances of hip injuries sustained in falls, which can be devastating.

It’s not rare for people with cataracts or other vision problems to be misdiagnosed with Alzheimer’s disease, said Dr. Eric Sohn, a geriatrician who serves as medical director for six nursing homes in the Inland Northwest.

Along with hearing loss, vision loss contributes to head injuries, depression and relationship problems among older populations.

“There’s a whole lifestyle cascade that follows,” Sohn said.

But, especially for the oldest patients who remember the days of extended hospitalization and thick “cataract glasses,” the idea of eye surgery may still be daunting.

In other cases, vision problems that could be corrected may go undetected by physicians or accepted as a fact of aging by elderly people, Sohn said.

Before his successful surgery, Smith relied on his wife, Bira, to guide him, to keep him safe.

“If I want to go to hospital, she lead my hands,” Smith said. “Now I can take care of myself.”

‘Like a dirty windshield’

The oldest patients may avoid surgery for several reasons, said Kim Calnan-Holt, an optometrist who sees cataract patients before and after surgery at Pacific Cataract and Laser Institute’s Spokane office. She measures the length of patients’ eyes and the curvature of their corneas to help determine the implant lens they need after the one they were born with is removed.

“The 80- and 90-year-olds – they get more worried about any surgery at that age,” Calnan-Holt said. “And they have the memory of what it used to be like.”

As recently as the 1960s, cataract patients were hospitalized, their heads held in place after surgery with sandbags. While a patient’s cloudy lens these days is replaced with a synthetic implant, patients used to wear thick “cataract glasses” after surgery.

But in many cases, the oldest patients’ reluctance is rooted in fear of losing their independence. It’s a catch-22, Calnan-Holt said: They fear a complaint about their failing vision will lead to a revocation of their driving privileges or a perception that that they’re handicapped. So they don’t seek help, their vision worsens and they truly do become handicapped.

A cataract is a clouding that develops in the lens of the eye. And everybody’s lenses get cloudy as they age, although other factors – such as high-dose steroids or a blunt-trauma injury – can contribute to cataracts, too. Calnan-Holt’s office recently treated a patient who’d been hit in the eye 15 years ago with a champagne cork.

When an eye doctor diagnoses a cataract, she said, it means the lens has gotten so cloudy it’s significantly affecting the patient’s vision. Some people get cataracts in their 40s and 50s. But most are in their 60s or older by the time their reduced vision bothers them enough to get surgery.

People on the young end of that range, eager to continue living active lives, rarely hesitate, Calnan-Holt said. For many baby boomers, she said, cataract surgery is just another rite of aging.

Regardless of age, many patients are amazed when they get their vision back within days of the surgery, she said.

“It’s like a dirty windshield,” she said. “You don’t realize how dirty it was until you clean it.”

Reducing fall risk

According to the JAMA study, the oldest cataract patients stand to gain the most from surgery.

The study examined a random sample of 1.1 million Medicare patients 65 and older who were diagnosed with cataracts from 2002 to 2009. Those who underwent cataract surgery had lower odds of hip fracture within a year of surgery compared with patients who hadn’t had surgery. Overall, cataract patients who had surgery suffered 16 percent fewer hip fractures.

But researchers found the results varied when broken down by age.

People ages 65 to 69 actually sustained more hip fractures. The researchers suggested some possible reasons, including that those younger people may be more active and have surgery on just one eye, which could affect depth perception.

Patients ages 80 to 84 saw the most significant benefit, suffering 28 percent fewer hip fractures. For elderly people hip fractures can lead to life-threatening complications.

One out of five hip fracture patients dies within a year of their injury, according to the Centers for Disease Control and Prevention. Hip fractures usually require surgery and hospitalization and are often followed by admission to a nursing home.

Improved vision through cataract removal improves elderly people’s chances of avoiding all that, the study suggests.

“If you can’t see it, you can’t navigate it well, and there’s a higher chance of having a fall,” Calnan-Holt said.

Sight and sound waves

Smith said his right-eye cataract was so severe it took his surgeon more than 2 hours to remove.

Normally, the outpatient procedure usually performed under local anesthetic takes a few minutes. After numbing the area around the eye, the surgeon uses high-pitched sound waves to break up the lens in a patient’s eye. The pieces are removed through suction.

A folded implant – a manmade replacement lens – is inserted through a tiny incision in the eye, where it unfolds once inside.

While a cataract can’t form on the new lens, some people get “secondary cataracts” on the part of the lens that isn’t removed, Calnan-Holt said. To treat that, doctors use a laser to make a small opening that allows light to pass through.

For Alvin Wilson, 82, of Spokane, cataract surgery was painless and easy. Wilson was not one of those older people who hesitated before getting it.

“They just give you a dark pair of glasses, and you go home,” he said. “It was the best thing I ever had done.”

Suffering from severe arthritis, his main hobbies had become reading and watching television, his wife said. New glasses failed to improve his vision before he was diagnosed with cataracts in both eyes.

“Even with a magnifying glass he was getting to the point where he couldn’t read the newspaper,” Christine Wilson said.

Post-surgery, he still wears glasses, but he can see. Said his wife: “It’s life-changing.”