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Cataracts and Cataract Surgery

Everyone on the planet develops cataracts as they age -- it's a normal part of "growing up" after the age of 60. The human lens becomes cloudy and impairs the eye's ability to focus light, making everything seem less clear. Cataract surgery is the most common surgery in America and can restore sharp vision (often a wide range of vision without glasses) in a matter of minutes. This guide explains more...

Cataracts & Cataract Surgery

Uday Devgan, MD, FACS, FRCS

Private Practice, Devgan Eye Surgery

Los Angeles & Beverly Hills, CA

www.DevganEye.com

1-800-337-1969

Board Certified, American Board of Ophthalmology

FACS: Fellow of the American College of Surgeons

FRCS: Fellow of the Royal College of Surgeons, Glasgow

Chief of Ophthalmology, UCLA Olive View Medical Center

Associate Clinical Professor, Jules Stein Eye Institute

UCLA School of Medicine, Los Angeles

2011 Uday Devgan, MD, FACS, FRCS / All Rights Reserved

Previous Editions: 2000, 2003, 2006, 2008 Uday Devgan, MD

This edition: 2008 Uday Devgan, MD / All Rights Reserved

Copyright Warning: This is an original and copyrighted work of Uday Devgan, MD. Any unauthorized use or plagiarism will be prosecuted to the full extent of the law for both punitive and compensatory damages.

Legal Disclaimer: This information is provided for educational purposes only and it should not be construed as personalized individual medical or surgical advice. This information is not meant to replace or supplement a consultation with a duly licensed ophthalmologist regarding the reader's individual health. Dr. Devgan and all associated persons and corporations disclaim any and all liability for injury or other damages that may result from the use of the information contained herein.

About the Author

Uday Devgan, MD, FACS

Cataract & Refractive

Lens Specialist

Uday Devgan, MD, FACS, is an international expert in ocular surgery, with a special interest in cataract and refractive lens exchange.

Dr. Devgan has more than 10 years of experience in performing the full spectrum of cataract, lens, and refractive surgery. His expertise in the areas of small-incision cataract removal, refractive lens exchange, accommodating and multi-focal lenses will provide patients with more surgical options as well as successful alternatives for LASIK non-candidates.

After graduating as valedictorian of Santa Monica High School, Dr. Devgan accepted multiple scholarships to UCLA where he majored in microbiology and molecular genetics. He earned his M.D. with Highest Distinction at the top of his class at the USC School of Medicine where he was co-president of the Alpha Omega Alpha medical honor society. He trained at the Jules Stein Eye Institute at UCLA, where he won awards for outstanding achievement as well as research.

He is a clinical faculty member at the UCLA School of Medicine and is the only professor to have won the UCLA Jules Stein Eye Institute Faculty Teaching Award twice. Dr. Devgan teaches his techniques of ocular surgery every week in his role as Chief of Ophthalmology at Olive View-UCLA Medical Center.

Why do I need to read this knol?

You're probably reading this knol because you desire better vision for your lifestyle and daily activities, and you're exploring the options for vision correction. One of the options for giving you improved vision is surgery on the natural lens of the eye.

You need to read this knol because it will help to explain some of the concepts of how the eye works and some of the aspects of lens surgery. Understanding these issues will help you to make an informed decision about correcting your eyesight.

The entire knol is written in plain English, in a question and answer format, and it answers, in detail, the most common questions that I'm asked by patients. I encourage you to read this book thoroughly and write down any questions that you may have, so that we can address them at the time of your consultation.

What are the reasons to operate on the lens?

The lens has become opaque and hazy and is not able to focus light well, resulting in impaired vision at all distances.

(2) The lens is still clear but it's dysfunctional

The lens, while still clear, is unable to change its focus for near vision, and your reading/near vision is impaired; or your lens is mismatched for your eye, resulting in an extreme glasses prescription.

For all of these situations, the surgery involves operating on the lens of the eye and replacing it with a clear man-made lens in order to better focus the light and improve your vision.

How does the eye focus light?

The eye is like a camera, focusing light rays onto a film to produce a picture. A camera uses a lens to focus light onto the film. Similarly, the eye uses the cornea and the lens of the eye to focus light on the retina. The lens is behind the blue, green, or brown iris of the eye and it is responsible for the fine focus ability of your vision. When you focus on a distant object, then look at a mid-range computer screen, and finally read fine print, your lens changes its shape and therefore its focal point each time.

What are common focusing/refractive problems?

Myopia (nearsightedness) is the ability to see near points well but distant objects are quite blurred. This near point may be a few inches to a few feet away depending on the severity of the myopia.

Hyperopia (farsightedness) is the ability to initially see distance better than near, however this progresses to the point where both distance and near points are blurred.

Astigmatism is when the focusing structures of the eye (the cornea and lens) have different focusing powers in different meridians. If a cornea is somewhat oval shaped, like a football, it won't focus as well as a cornea that is more spherical like a basketball. Small amounts of astigmatism are present in the majority of the adult population, with some people having very significant amounts.

What's the most common focusing problem?

The most common of all refractive problems is called presbyopia - the inability to focus on small objects held close to the eye. This occurs naturally in ALL people as a result of age, and there's just no way to avoid it. During your 40s it may be possible to just hold things farther away and use a stronger light, but eventually you'll find that your arms aren't quite long enough and the light isn't quite strong enough. At this point, most people use reading glasses, bifocals, or progressive spectacles. Presbyopia is due to the natural age related changes to the lens of the eye and there's no way to avoid it.

How does the lens of the eye change with age?

The lens loses its clarity as well as its focusing power. The lens of the eye is as clear as water when we're young. It's also very flexible and is able to accommodate a great amount. This is why elementary school kids can literally read a book that is two inches in front of their eyes. Every year the lens becomes slightly cloudier (like adding a drop of muddy water to a glass of water) and the lens becomes less elastic and some of its near focusing ability is lost. After age 40, as we progressively lose the near focusing ability due to presbyopia, we tend to hold things further away in order to read them.

Other more complex changes happen as well as the human lens hardens and ages, such as an increase in spherical aberration and other distortions, with a resultant decrease in the image quality. This helps to explain why it's a pleasure to drive at night in your 20s, and much more difficult later in life.

When do you replace the lens of the eye?

There are two main indications where the natural lens of the eye is replaced with a man-made lens: (1) when the lens becomes cloudy/opaque and develops a cataract; and (2) when the lens is dysfunctional and the patient desires better vision.

The replacement man-made lenses have been implanted in eyes for more than 50 years. The technology of the newest lenses is amazing, and some have the ability to correct focusing problems, spherical aberration, and even address presbyopia. However, nothing is as good as being young and having youthful eyes. If the patient's natural lens is cloudy and we replace it with a clear lens, the patient's vision will naturally be better. At the time of surgery, we can also address the refractive problems such as myopia, hyperopia, and astigmatism. We can also implant a premium lens implant that helps the patient see distance as well as near with far less dependence on glasses.

What's the difference between refractive lens surgery and cataract surgery?

Both surgeries refer to the procedure of replacing the human lens with a man-made lens. The difference is when the surgery is performed. If the human lens is relatively clear and the patient elects to undergo lens replacement surgery, then it is considered a cosmetic procedure by most health plans. If the lens is cloudy or opaque (a cataract) and the patient elects to undergo lens-replacement surgery, then most health plans will pay for a large part of the procedure.

If patients undergo refractive lens replacement surgery before developing cataracts, then they will never develop cataracts in their lifetime and therefore never need cataract surgery.

What focusing conditions does Refractive Lens Surgery correct?

The most common reason people seek refractive lens surgery is to treat presbyopia, the age-related change of the lens that impairs near vision. By implanting a premium lens, we can provide sharper vision at near, intermediate, and far distances. By choosing the appropriate lens for implantation, focusing conditions like hyperopia and myopia can also be corrected with refractive lens surgery. Finally, at the time of the lens surgery, all or most of the astigmatism can be addressed as well.

Do I want Refractive Lens Surgery or LASIK?

If your natural lens is clear, and you're under age 60, then you're likely a better candidate for LASIK (Laser Assisted in situ Keratomileusis). This is because your natural lens still has some near focusing ability left, though it may be diminished, and the LASIK surgery can correct your distance vision while you use this near focusing ability of your lens to help see up close. LASIK is a surgery of the cornea, or front surface of the eye, and during LASIK the natural lens is not touched.

If your natural lens is clear, and you're over age 60, then you have already lost most or all of the near focusing ability of your natural lens, and you may start to develop age-related cataracts in the near future. While LASIK surgery may correct your distance vision, your near vision will be impaired unless you use reading glasses. By performing refractive lens surgery and implanting a premium lens, the distance, intermediate, and near vision can be addressed.

In cases of extreme glasses prescriptions, such as high myopia or high hyperopia, refractive lens surgery may be a better option than LASIK, even if you're younger. Since LASIK removes microscopic amounts of tissue from the cornea, there is a limit as to how much treatment can be administered. Even the most extreme glasses prescriptions can be safely corrected with refractive lens surgery. I have successfully treated patients with +18 D of hyperopia on one extreme, all the way to -33 D of myopia on the other.

What exactly is a cataract?

The human lens in the eye is normally crystal clear, but when it becomes opaque, we call it a cataract'. A cataract is NOT a film or growth that occurs in the eye. It is simply a cloudy lens. As the opacity worsens, it prevents light from properly focusing on the retina, the light sensitive tissue lining the back of the eye. Early lens changes or opacities may not disturb vision significantly. But as the lens continues to change, the vision becomes blurred and the person notices glare, haziness, and difficulty with seeing street signs or reading, for example.

The cornea is the clear dome of tissue at the front of the eye that helps focus light (contact lenses sit on the cornea). The lens is located behind the iris, the blue, green, or brown part of the eye. The lens has three parts: the capsule, the cortex, and the nucleus. All parts of the lens are normally clear.

Picture: cross section of the eye

What are the types of cataracts?

There are different types of opacities that cause cataracts. Each is described by its location within the lens. The most common type of cataract is the one associated with aging: the nuclear cataract. Often, patients have features of more than one type.

A nuclear cataract occurs in the center of the lens. Common symptoms include blurring or dimming of your vision, glare, and visual distortion. A nuclear cataract makes the vision seem dimmer and patients typically feel that they need to use strong lights in order to read books or magazines. Everyone starts getting early nuclear cataract changes in their 50s and this may contribute to the need for reading glasses or bifocals.

A cortical cataract begins as wedge-shaped opacities in the cortex of the lens, much like spokes on the wheel of a bicycle. The spokes extend from the outside of the lens to the center. When the spokes reach the center, they interfere with the transmission of light and cause glare and haziness to the vision. A cortical cataract typically develops slowly, but it may impair both distance and near vision so significantly that surgery may be indicated at a relatively early stage.

A subcapsular cataract develops slowly and starts as a small grain-like opacity under the capsule, usually at the back of the lens. Significant visual symptoms may not appear until the cataract is well developed. Typical symptoms are glare and blur. A subcapsular cataract is often found in people with diabetes or high levels of myopia, and in people taking steroids.

Nuclear Cataract

Overall cloudiness of the lens

Cortical Cataract

Spokes of opacities

Subcapsular Cataract

Central grainy opacities

What are the symptoms of cataracts?

• Blurry or hazy vision, or dim vision that requires brighter lights in order to read small print
• Increased glare and sensitivity to light, especially in bright sunlight or while driving at night
• A yellowing of the vision
• Increased nearsightedness, requiring frequent changes in your glasses prescription
• Distortion, double images, or ghosting of the vision

Blurring of the vision Glare and light sensitivity

Yellowing of the vision Ghosting / Double Vision

Clear Vision

After Cataract Surgery

Who gets cataracts?

Like gray hair, cataracts are basically unavoidable. For most people, cataracts in the form of slight lens opacities start to develop in their 50s and surgery is typically performed in their 50s, 60s, and 70s. For nearly all patients, the cataracts are related to age, lifetime sun exposure, and genetics. In the other patients, the cataract may be related to diabetes, steroid use (for asthma, allergies, or immune problems), or trauma. Cataracts are a leading cause of blindness but, fortunately, cataracts are easily treated and cured. Everyone who lives long enough will end up having cataract surgery, and this explains why it is the number one surgery performed in the USA, with about 3 million performed last year.

How are cataracts diagnosed and treated?

You'll need to have a thorough examination of your eyes, including dilation and an attempt at a new glasses prescription. At first, a change in your eyeglass prescription may be all that is needed to temporarily improve your vision. When you feel that your vision affects your daily activities or your lifestyle and you desire better vision, cataract surgery should be considered. Cataracts can only be removed with surgery.

At what point do I need cataract surgery?

There is no single objective test to determine the need for cataract surgery. The final decision for cataract surgery is made by the patient and depends on how much the decreased vision from the cataract is bothersome. My patients are highly intelligent and informed patients, and I prefer to explain their current status in plain English, and have them make their own decisions. Doing cataract surgery at an earlier stage makes for a quicker recovery and a technically easier surgery. Waiting until the vision is very poor can often make the surgery and the recovery more involved. Cataract surgery is an elective surgery and it's up to the patient to decide when to undergo surgery. Similarly, refractive lens surgery is scheduled when the patient would like better vision and less dependence on glasses.

The California Department of Motor Vehicles requires that drivers have 20/40 vision (with or without glasses) in their better eye to qualify for a license. Some patients choose to wait until their vision is approximately at this 20/40 level. However, many active patients who still work, drive, and use computers have higher demands for their vision. These patients tend to choose surgery at an earlier stage.

Some patients choose to have surgery even before they develop vision-blocking cataracts. For these patients, who are typically in their 50s, refractive lens surgery is performed in order to eliminate or reduce the need for glasses and to regain their near vision. With their astigmatism managed and a premium lens implanted, the vast majority (92% in the official FDA study of one premium lens) of these patients saw well at distance, intermediate, and near, and they never or just occasionally use glasses. The remaining 8% also saw quite well, but they used glasses more than just occasionally.

The bottom line is: If you're happy with your vision and it doesn't cause difficulties with reading, computer use, driving, working, or your active lifestyle, then you should postpone the surgery. If you want and need better vision for your activities right now, and would like to see more clearly, then schedule the surgery. They're your eyes, and you decide what's best.

How is cataract surgery performed?

Cataract surgery is a way to replace the cloudy lens with a crystal clear lens, thereby restoring vision. In modern techniques, the posterior capsule of the natural lens is left in place to support the man-made replacement lens that is implanted at the time of surgery.

There are three different ways of performing this surgery:

1. In extracapsular surgery the nucleus of the lens is taken out in one piece through a very large incision, and the softer parts of the lens are then aspirated. The man-made lens is then placed in the eye. This technique always requires many sutures (about 10 sutures is typical), a needle injection behind the eyeball for anesthesia, significant bleeding, and months of recovery. This is the original technique of surgery that has been around for decades, and it's still performed by some ophthalmologists because it's technically easier to learn. Be warned that this type of surgery typically creates a lot of astigmatism and you may never be able to see 20/20 without powerful glasses.

2. In phacoemulsification the hard nucleus is broken up by ultrasonic fragmentation (using sound waves) within the eye, and can then be aspirated. The man-made lens is then placed in the eye. This allows a somewhat smaller incision to be used. Phacoemulsification has gained in popularity in recent years, and is now a more common form of cataract removal in the United States. This procedure has been used for approximately 15-20 years, although recent advances and refinements have made it safer and more effective than previously. This is typically performed using needle-injection anesthesia, one or two sutures, and less bleeding. The recovery time until the vision stabilizes is reduced to approximately 2 months. This surgery can cause an increase in the astigmatism and may require that you wear glasses full-time to correct your vision after the surgery.

3. Clear-corneal phacoemulsification is a more advanced version of the last technique mentioned. In this technique, as performed by me, no needles are used, and the painful anesthetic injection behind the eyeball is not given. Instead the eye is numbed with eye-drops and the patient is given a mild intra-venous relaxing medication by the anesthesiologist. The incision in the eye is ultra-small, approximately 1/8th of an inch or less, and it is made with an actual gem-quality diamond. This creates such a tiny and fine incision, that it is self-sealing, and no stitches are required. The man-made lens is one of the top-of-the line models that can be folded or compressed during insertion, and then opened once inside the eye. The name "clear-corneal" refers to the incision, which is made at the edge of the clear tissue named the cornea. Due to the location of this incision, there is typically no bleeding (not even one drop), and the day after the surgery, the eye won't be red at all. The recovery for this surgery is very quick, with good vision within a day or two. When combined with astigmatism management, the pre-existing astigmatism can be lessened and further post-operative astigmatism can be prevented.

So why don't all surgeons perform this Advanced Clear-Corneal method?

Cataract surgery is not an easy surgery to perform, and no surgeon is born knowing how to perform it well. The surgery is performed while the surgeon looks through an operating microscope that greatly magnifies the view of the eye. This also means that a very steady hand is important. It is easier to perform the older techniques of cataract surgery, rather than to learn the newer techniques. Like any other highly technical task, it requires natural talent and considerable practice, at least a few thousand surgeries. No other ophthalmologist in California performs the surgery quite the same way as I do. Some eye surgeons are sharp and are able to learn some of the newer techniques. However, there are still surgeons who still perform out-dated types of surgery, and uninformed patients don't realize the difference until it's too late.

How is my surgical technique better?

1. No Pain. The vast majority of my patients report no pain and they don't even take a single Tylenol afterwards. I am able to numb the eye with eye-drops, while the anesthesiologist gives a small amount of sedation in the intra-venous line to help you relax. The older techniques require medications to be injected behind the eyeball with a 3 inch needle.

2. No Stitches and No Bleeding. Since my incision is so tiny (less than 1/8th of an inch) and is made with a diamond, it seals by itself. It is placed in such a manner that not even one drop of blood comes from the incision. Other techniques require incisions 2x to 5x larger than this, using a large steel blade or even scissors in the eye. In these older techniques, the surgeon would then place between one and ten nylon stitches to close their larger incision. These nylon stitches are sometimes felt when you blink, and they are often left in the eye for years or even permanently. Recovery after this less advanced type of surgery is months, versus just a week or so after my surgery.

3. The Best Optics. The best vision requires the best optics. This involves choosing the best intra-ocular lens to implant in your eye. The cost of the best lenses is many times more than the cost of the cheaper lenses, and in some surgical centers, corners are often cut. I never cut corners, and I only implant the best lenses. In addition, I perform exacting calculations to determine which power lens to place in your eye. I take the extra time to incorporate as much of your glasses prescription as possible, into the power of the implanted lens. I can even analyze your eye and make my tiny incision in such a manner as to help to reduce your astigmatism. All of this means you'll be far less reliant on glasses after the surgery, and many patients achieve total freedom from glasses.

4. Experience with Advanced Techniques. My focus is state of the art cataract and lens surgery. I perform the most advanced techniques and teach them across the US and internationally - in over 30 countries in the past 3 years alone. In order to make the surgery as gentle as possible, your surgeon should use the most advanced techniques - the ones that I teach and write about in my monthly columns in the eye surgery journals. My improvements on this technique reduce the surgical time and make the surgery very gentle on the eye.

5. No Corners are Cut. I will perform your surgery the same way that I have already performed it on my own family members. These are your eyes we're talking about, and you need to demand the best. At every step, you can rest assured that everything will be the very best and of the highest quality. For example, I use $11, 000 worth of diamonds instead of a $9 steel knife because it gives the best results. Even for my charity surgeries, I only use top-of-the-line equipment and products. I'm a perfectionist, and you'll appreciate that.

What about "The Laser"?

Using a laser is not a viable option for removing cataracts at this time, despite what you may have heard. There are lasers for cataract removal under investigation, but they are different from what you might think. In these machines a laser is used to break up the cataract into pieces small enough that they can be aspirated from the eye, in the same manner that ultrasound waves are used in phacoemulsification. An incision still needs to be made in order to remove the cataract from the eye. Using a laser to zap away the cataract while the patient sits in the office will likely never happen, since a very small incision will be needed to physically remove the cataractous lens material from the eye and to implant the man-made lens.

The "Laser Eye Surgery" frequently advertised on TV and radio is not for the treatment of cataracts. That particular type of laser surgery (LASIK) is performed on otherwise normal eyes, to reduce the need for glasses. I often perform LASIK and other types of refractive surgery for non-cataract patients.

In a small percentage of cases, the YAG laser is used months after the cataract surgery if the posterior capsule of the lens, which supports the lens implant, becomes cloudy. This indeed is a procedure in which the patient sits in the chair and the vision is quickly cleared by the laser in less than 5 minutes. It is not used to remove the cataract itself, however.

What about waiting until the cataract is ripe'?

That's a concept that is outdated in America. With the older techniques of surgery, patients waited until their cataract was ripe' and their vision was so poor that they had nothing to lose. Ripe' cataracts are so advanced that the patient has no useful vision, and most Americans need surgery far before that. Waiting until the cataract is severe (ripe') makes the surgery more challenging and the recovery longer.

If a surgeon mentions ripe' cataracts then he may be planning an antiquated surgery, or perhaps he's talking about the way that charity surgery is performed in third-world countries. Remember, cataract surgery should be performed when YOU, the patient, feel that your vision is not adequate for your daily activities, and you desire better vision to suit your lifestyle and to decrease your dependence on glasses.

What about using eye drops, medications, or vitamins to treat cataracts?

There are currently no eye drops, vitamins, or medications that can reverse or cure cataracts. Certain vitamins may play a role in the prevention and progression of cataracts.

Studies have shown a lower prevalence of cataracts in people who take anti-oxidants like vitamin C (and less so with vitamin E) for many years. Another study indicated that B vitamins such as thiamin (B1) and riboflavin (B2) and niacin reduced the risk of cataracts. These studies show that certain nutrients may play a role in the prevention of cataracts but nothing has ever shown a reversal or cure of cataracts.

The best suggestion is to take one multi-vitamin a day and perhaps supplement that with additional anti-oxidants such as vitamin C and vitamin E. In addition to nutrition, you can help prevent further damage and cataracts by wearing sunglasses that block 100% of ultraviolet (UV) light.

Why do I need this man-made lens implanted?

The natural human lens, which started out crystal clear in your youth, has now become cloudy. This lens has a certain power to it, the same way that a camera lens has a certain power. When the cataract (the cloudy lens) is removed, it's like taking the lens out of the camera: you won't get a good picture until you replace the lens. The lenses are typically made of acrylic (plastic), silicone, or a similar compound and they have been implanted in eyes for more than 50 years. They're designed to last for your lifetime and about 3 million lens implants are done in the US per year. This lens is implanted in the same position as the human cataractous lens which was removed. It is behind the iris (the blue, green, or brown part of the eye) and it is not visible to other people looking at your eyes. You won't feel this lens or even realize that it's implanted in the eye. This lens is NOT like a contact lens. This lens is permanent and is implanted inside your eye. You will not feel it and it will not come out of the eye.

What are the two basic types of lens implants?

The standard lens implants are single-focus lenses with the focal point typically set for mid-distance, with glasses being required for intermediate or near vision. The eye adapts quickly to this lens implant as this type of lens provides good image quality, although just at the single focal point (mid-distance). With the astigmatism treated or managed and a single-focus lens implanted, the distance vision should be good without glasses, but glasses will certainly be required for any computer use or reading. This lens is like the fixed lens found in disposable cameras - it does not have the ability to change focal points.

The premium lens implants allow a much wider range of vision like a premium Nikon camera lens. This wide range of focal points encompasses, distance, intermediate, and near zones. With the premium lens implant, you will see well at a variety of distances without glasses, though it may take some time as the brain and eye adapt to the new vision. The premium lens implants offer the widest range of vision possible, and due to this benefit, they account for 80% of the lenses that I implant.

What are the types of premium lens implants?

The two main types of premium lens implants are multi-focal implants and accommodating lens implants.

The premium multi-focal lens implants allow each eye to see at all distances. Some people may report halos or glare around lights, which significantly decrease with time as they adapt to their new vision. Most people say that their new ability to see near, intermediate, and far without glasses far outweighs any visual side effects associated with a mutli-focal lens. With their astigmatism managed and a multi-focal lens implanted, 92% of the patients in the official FDA trial reported either never or only just occasionally using glasses for distance, intermediate, and near. For the motivated patient, these lens implants are excellent choices and I have implanted them in my own friends and family members.

The premium accommodating lens implants are designed to work just like the natural, youthful human eye. These lenses are designed to slightly, but imperceptibly, move inside the eye in response to your eye's normal focusing muscles. This allows a wider range of vision than the standard lens implants. Patients with premium accommodating lens implants have a very wide range of sharp vision without glasses. The premium accommodating lens implants are not typically associated with any increase in glare/halos. These lenses give a wider range of vision, particularly for distance and intermediate vision, however patients may need glasses for the closest near work such as fine print or sewing. For patients who primarily do intermediate activities such as computer work as well as distance activities such as driving, these lenses are excellent choices. These lenses are the most frequently implanted in my practice and I have implanted them in my own friends and family members.

What decisions do I, as the patient, need to make for cataract / refractive lens surgery?

There are two things to consider:

(1) What are my vision needs?

(2) Do I want a premium lens implant?

Your visual needs will depend on your daily activities. We typically divide daily activities into a few main groups, depending on zones.

Zone 1 (1-2 feet away): newspaper, maps, sewing, fine print

Zone 2 (2-4 feet away): headlines, computer, menus, pricetags

Zone 3 (6-20 feet away): indoors, TV, cooking, cleaning, gym

Zone 4 (20-100 feet away): day driving, roadsigns, golf, tennis

Zone 5 (100+ feet away): night driving, star gazing, movies

With a standard lens implant, only one or perhaps two contiguous zones can be achieved without glasses, which would be required for the other zones. If you have astigmatism or other focusing problems, you may be required to wear glasses for all zones with a traditional lens implant. Additional surgery to correct the astigmatism incurs additional costs.

With a premium lens implant, three or four adjoining zones can be achieved without glasses, thereby providing far greater freedom from spectacles. Due to this increased range of vision, premium lens implants are chosen by 80% of my patients. If you have astigmatism, the cost of correcting it at the time of surgery or shortly thereafter is included at no extra cost.

Will my medical insurance cover the cost of cataract surgery?

Yes. Cataract surgery is a medically necessary surgery which means that it is a covered benefit of most medical insurances, PPOs, Medicare, Medi-Cal, and other plans. The cost is very moderate and the out-of-pocket expense for most patients is typically a few hundred dollars or less. For those patients with Medicare, the fees for basic cataract surgery are fixed by the federal government for all doctors. I focus my efforts on patient care and surgery, but my office staff is glad to answer any insurance related or financing questions.

Cataract surgery is one of the most important surgeries that you will undergo in your lifetime, and it's the most rewarding since it can restore your eyesight. Because costs for cataract surgery tend to be very uniform from doctor to doctor (due to insurance regulations and federal Medicare laws), you can treat yourself to the very best surgery. When it comes to your eyes, your focus should be on the highest quality surgery available.

Will my medical insurance cover the cost of astigmatism treatment?

No. Because the purpose of the astigmatism treatment is to reduce or eliminate the patient's dependence on glasses it is considered a cosmetic surgery. Medicare and most insurance plans therefore do not pay for this procedure.

If you are choosing a premium lens implant, the cost of any procedures to correct astigmatism or other focusing errors at the time of surgery or shortly thereafter is fully included at no extra cost. If you are only selecting the standard lens implant, the cost of the astigmatism correction is additional.

Will my medical insurance cover the cost of the premium lens implant?

No. Medicare and most insurance plans pay only for the standard single-focus lens implant. Since the purpose of a premium lens is to reduce or eliminate the need for glasses, its use is considered cosmetic and is therefore not covered by Medicare or most medical insurance companies. In addition to the premium lens implant, we will perform additional testing and services in order to optimize its function.

We can apply the small stipend that Medicare or your insurance company provides for the traditional single-focus lens towards the cost of the premium lens. It is best to make the decision for a premium lens implant prior to the cataract surgery, since doing a second surgery to exchange lens implants at a later date isn't always possible and can be cost prohibitive.

Which lens will you put in my eye?

The lens that I will implant in your eye depends on your visual needs and preferences, and whether you elect to have a premium lens. All lenses that I use are fully FDA (Food and Drug Administration) approved, are of the highest quality, and are from top-name ophthalmic manufacturers. I only use high-end implants with the best optics - the same ones that I have implanted in my own family members and friends.

The traditional single-focus lenses that I prefer are referred to as aspheric lenses since they address the sharp focusing of the eye as well as the spherical aberration in order to provide a better quality image, similar to a high-end Nikon camera lens. Studies have even shown better driving performance in people who receive these ashperic lenses. If you don't mind wearing glasses for any intermediate or near work, then this may be a reasonable choice lens for you.

The premium lenses allow a much greater freedom from glasses, with patients achieving a far larger range of vision. For premium lenses to work their best, it takes time for the eye, brain, and visual system to adapt - often a few weeks or more. Remember that you've been looking through human lenses for many decades, and now with a brief surgery you are looking through a man-made lens. While you will see rather well right after the surgery, optimal vision and adaptation takes time. If your concern is good vision and you'd like to reduce or eliminate your need for glasses for distance, intermediate, and near, then a premium lens is the best choice for you.

How do you calculate what power lens to use?

This is one of my favorite subjects and I spend time perfecting my calculations. Since each eye is different, prior to the surgery, your eyes will be measured with specialized equipment using light-waves or ultra-sound in just a few minutes. Since cataract surgery is to correct cataracts, treating astigmatism or using premium lenses to reduce the need for glasses are considered separate procedures and incur separate costs.

Will I need glasses after the cataract surgery?

Cataract/Refractive Lens Surgery with a Traditional Lens:

Yes, glasses required for intermediate and near, and if you have significant astigmatism, then for distance as well.

If you choose cataract surgery alone, with a single-focus lens, then you may have issues with astigmatism after the surgery. You may need glasses to address this astigmatism, and you will certainly need glasses to see intermediate distances, such as computer work, as well as to see near points, such as reading fine print. Remember that the primary goal of cataract surgery is to correct cataracts and not to reduce the need for glasses.

Cataract/Refractive Lens Surgery with a Premium Lens Implant: Eliminate or significantly reduce the need for glasses for distance, intermediate, and near work.

If you choose cataract surgery with a premium lens implant, then you can regain a full spectrum of vision, at a variety of focal points. It's been my experience that 95% of patients can achieve freedom from glasses for 95% of their daily activities using premium lenses. A reasonable goal for near vision is reading the newspaper with good lighting. Reading the tiny words on the back of a packet of Splenda or Equal in a dimly-lit restaurant will likely require magnifiers. If you really hate using glasses, if you're motivated, and if you have an easy-going personality, then this is likely the very best option for you.

Can I do Mono-Vision' like I did with my contact lenses?

Yes, mono-vision is a very viable option, particularly in patients who have tried it with prior LASIK or contact lenses. This technique makes each eye see slightly differently so that when used together, the range of vision is expanded. This is done by making the dominant eye see more sharply at distance, while the other eye sees better up close. This arrangement is called mono-vision and it's sometimes done in contact lens patients, where one eye is used to see far and the other eye is used to see near. To optimize the results of mono-vision, implantation of a specialized accommodating lens designed for maximizing the range of sharp vision is used. This allows the patient to see sharply at a distance and still read many things up close without glasses. The benefit of this arrangement is the low incidence of visual glare and halos while still providing a full range of good vision without glasses.

What about pre-existing eye conditions?

If you have other eye problems such as macular degeneration, glaucoma or diabetes, these may limit your vision after surgery. Remember the analogy of the camera: cataract surgery is a way to exchange the cloudy lens for a crystal-clear lens. If the camera has defective film (analogous to a disease of the retina) then changing the lens may make the picture better, but it won't be perfect. Cataract surgery may be beneficial even if you have these pre-existing eye conditions, but a cataract surgery only corrects cataracts. Many people with problems like Macular Degeneration have achieved better vision after cataract surgery. If your eyes are otherwise healthy, the chances of restoring good vision following cataract surgery are excellent. When I examine your eyes we'll talk about all eye conditions in detail, and the extent to which they will affect your final vision.

How successful is cataract/lens surgery?

In my hands, cataract and refractive lens surgery has a success rate of more than 99%. Serious complications from cataract surgery are possible, but are exceedingly rare - typically less than 1 percent. One of the most terrible complications is an infection after the surgery, occurring in about 0.1% of patients. I am very vigilant about infections and I'll have you use special antibiotic eye drops before and after your surgery. In addition, everything is fully sterilized for your protection, and absolutely no expense is spared. Prior to surgery, we'll talk and I'll give you an informed consent' that lists everything in detail. This booklet is not intended to replace the informed consent', which is a more complete explanation of the risks, benefits, alternatives, and indications for the surgery. Each person's surgery is different and the results are individual and may vary. Remember, that this is a real surgery on your eyes, and your success depends directly on your surgeon's skills.

I will perform your surgery the same way that I would perform it on my own family members. Your eyes are your most precious sense, and I treat them as such. Many physicians, surgeons, eye doctors, nurses, and their families have chosen me as their surgeon for this reason. I have been fortunate enough to be chosen to perform surgery on the family members of other eye doctors, including Dr. Robert Maloney's father.

What is the patient's role after the surgery?

My job is to perform an accurate surgery of the highest quality for each patient. Your role as the patient is to do the healing. Since the final visual outcome is determined by both my surgical skill and your healing ability, it's critical to follow the post-op instructions. The primary patient responsibility is using the prescribed eye drops for a few weeks after the surgery and not rubbing the eye. Follow up visits with the surgeon or with your co-managing local eye doctor are vital.

How will my vision be better after the surgery?

We can correct the visual clarity, focusing power, spherical aberration, and distortion of the cataract or dysfunctional lens. Reading letters on a chart is only a measure of visual acuity, but there are other aspects to the quality of the vision: the richness of colors, the brightness of images, the absence of distortion, and the subtleties of contrast. After surgery on the first eye, you will likely notice a dramatic difference between the eyes. It is for this reason that most patients elect to correct the second eye shortly after the first.

What if I don't see perfectly after the surgery?

Cataract and refractive lens surgery results in sharp vision with improved colors, contrast, and brightness for the vast majority of patients. The one variable that I cannot predict is how your eye will heal. If you have an unusual healing response and the lens implant shifts within the eye, then you may need thin glasses to achieve 20/20 vision. For patients that have selected a premium lens implant, any further required treatment such as LASIK, PRK, or an additional lens implant in the post-operative period is included at no additional cost. Your surgery costs are for the evaluation, surgical procedures, and lens implant, and not for a particular result. While my goal certainly is "perfect vision" for you, this cannot be guaranteed.

If your goal is to have absolutely incredible bionic vision and to see like you're 21 years old again, then you're out of luck. There's no fountain of youth, and it's impossible to give a 60-year-old patient the perfect visual function of a teenager.

If your goal is to have great vision, a reduced dependence or freedom from glasses, and better visual performance for your active lifestyle, then you're in luck. During our pre-operative consultation, let me know your expectations so that I can be sure to meet or even exceed them.

How long does cataract surgery take?

In my hands, the surgery itself is approximately five to ten minutes for one eye. You will arrive at the surgery center approximately one hour before the scheduled surgery. The nurses will then prepare you for surgery by placing an IV in your arm, checking your blood pressure, and putting a few drops in your eye. Then 15 minutes prior to the surgery you'll be brought to the operating room where your face will be cleaned with a special solution, an oxygen tube or mask will be placed over your nose, and you'll be covered with a sterilized bed sheet. You will be awake, but relaxed, and perhaps in a twilight state. If you'd like, you may doze off to sleep, though most patients choose not to. The anesthesia is local, in which the eye is numbed - it is not general or total-body anesthesia.

Does the surgery hurt?

No, for the vast majority of patients the surgery does not hurt. You will feel my hands resting against your cheek and you may feel some cool water, but rest assured, you will not feel pain. You may see some bright lights during the surgery but you will not see the surgery being performed on your own eye. After the surgery is complete, you'll be taken to the recovery room'. Here, the nurses will once again check your blood pressure, give you something to eat or drink, and monitor you for about an hour. Afterwards, you'll be sent home. It's requested that you do not drive the day of your surgery since the intra-venous anesthesia medications may make you feel somewhat sleepy.

Patients typically don't have any pain and most don't even take a Tylenol. We'll see you in the office the day after the surgery, at which time the vision will be fairly good. There may be some mild fluctutation in vision as the eye heals, but after about 1 week the eye will be stable and the vision will be excellent.

Do I need to have an eye patch after surgery?

No, it's not required due to the small incision size and minimally invasive nature of my surgery. Minutes after I finish your surgery, you will begin to see again as the eye wakes-up' from the anesthesia. Most patients are able to see the clock on the wall of the surgery center after just one hour.

Where do you perform the surgery?

I always perform cataract surgery in a proper, fully-certified, professionally-staffed operating room and never in a clinic back-room'. This is safer for the patient because of the higher level of sterility and the presence of a board-certified anesthesiologist. On the westside, I use various specialized surgical centers. In each facility, the operating area is specifically designed for eye surgery and has all of the latest top-of-the-line equipment.

Can you re-do the cataract surgery that another doctor performed?

I have had a number of patients who were dissatisfied with the results of cataract / lens surgery performed by other doctors. Depending on the problem, I may be able to improve the vision with additional surgery. Remember, though, that the eye is an extremely delicate structure, and certain types of prior damage cannot be repaired. With cataract / lens surgery it is usually better to do it once, do it right, and not have to do it again.

Can we do surgery on both eyes the same day?

No. It's smarter to perform surgery on one eye at a time. The primary reason for this is the small chance of an infection which could damage the eye. This infection (endophthalmitis') occurs far less than 1% of the time for average surgeons. To prevent an infection, you'll use antibiotic eye drops before and after the surgery. I do not usually perform cataract or lens surgery on both eyes the same day. After you are thrilled with your excellent vision from the first cataract surgery, we can schedule the surgery for the other eye. Most patients choose to have the second eye operated one week after the first eye. Our out-of-town patients usually have the second surgery 48 or 72 hours after the first eye.

What are my restrictions after the surgery?

Right after the surgery, I'd like you to go home and take a nap and use your prescribed eye drops as per our instructions. After the office visit the day after surgery, you will able to resume 95% of your normal activities. For example, if you have surgery on Monday, you'll be seen again on Tuesday, and you're free to resume your normal activities that same day. You can choose to take an extra day or two off from your work, or you can work immediately. In most cases, the eye will not be red and your own family won't be able to tell you've had surgery by looking at your eyes. The primary restriction is that you cannot rub the eye for four weeks. In addition, you'll use eye drops in the eye for a few weeks as well. Note that younger patients (50s & 60s) with milder cataracts tend to heal much faster than older patients (70s & 80s) with more advanced cataracts.

Will the cataract ever come back?

No. The cataract is completely removed except for the fine capsule that supports the man-made lens implant. The cataract therefore, can never come back. In a small percentage of people, the microscopic capsule can become slightly hazy while the man-made lens implant stays perfectly clear. In this case, the patient sits in the chair and the vision is then quickly cleared by a laser in a few minutes without ever touching the eye. People that have refractive lens surgery will never develop cataracts and will never require future cataract surgery.

Will my medical problems prevent me from having surgery? And am I too old for surgery?

Nearly all patients can have my advanced technique of cataract surgery. A week or two prior to the surgery, you will need to make an appointment to see your internist or primary care doctor in order to evaluate your general health (the Pre-Operative Medical Clearance'). Since the surgery is performed with just eyedrops (no injections to the eye) and is bloodless, you can even have the surgery without stopping any blood-thinning drugs such as aspirin or Coumadin. More than 95% of patients will pass the Pre-Operative Medical Clearance'. If your internist thinks that your health is not optimal (for example, if you're having episodes of chest pain), then we will defer the surgery until you're more stable. If you have had a recent cough, a cold, or the flu then we will postpone the surgery in order to help prevent an infection in the eye. If you don't have an internist, I can refer you to a number of excellent ones.

Age is not a limiting factor in cataract surgery. If your internist clears you for surgery and if you are able to lie still for 5-10 minutes, you should be able to have the surgery. I've done surgery on many patients in their 90s and some over 100, and they have done well - they just wished that they had the surgery 20 years earlier. Patients who lead active lifestyles tend to opt for cataract or refractive lens surgery much earlier in life.

What are your credentials and how many surgeries do you do?

Even though I've been performing ocular surgery for more than 10 years, patients often ask me about my age since I have been blessed with a youthful appearance. Rest assured, I'm fully trained and I perform dozens of surgeries per week, with thousands of procedures perfomed in my career. I am in the prime of my surgical career with hands that are dextrous and rock-steady. I feel blessed since eye surgery is not only my passion, but it's also my greatest talent.

My parents are originally from India (hence my unusual name), but I'm a local who grew up in Santa Monica and was valedictorian of my high school class. I then accepted a scholarship to UCLA where I majored in Microbiology and Molecular Genetics. Next, at the USC School of Medicine, I earned my M.D. with Highest Distinction, graduated Summa Cum Laude and was co-president of the Alpha Omega Alpha medical honor society. This was followed by training in internal medicine, and then my ophthalmology residency and eye surgery training at UCLA's Jules Stein Eye Institute (ranked as one of the top 3 programs out of 120 nationwide).

Of course, I'm fully board-certified by the American Board of Ophthalmology, having passed both the written and oral exams in the same year (with a percentile score of 98 out of a maximum of 99 for the cataract and lens sub-section). In addition, I am distinguished as a Fellow of the American College of Surgeons (as noted by the FACS initials after my name).

Do you teach surgery to other surgeons?

Yes, I'm an Associate Clinical Professor for the UCLA Department of Ophthalmology and the Jules Stein Eye Institute, and I teach cataract surgery to the UCLA ophthalmology resident doctors every week. I am the Chief of Ophthalmology at UCLA's primary LA County teaching hospital, the Olive View-UCLA Medical Center in Sylmar. I supervise and teach more than 100 cataract surgeries a year, and every single UCLA resident ophthalmologist will spend time learning from me during the course of their surgical training.

I'm the only UCLA faculty member to have been awarded the Teaching Award twice. In addition, each year at UCLA the best eye surgeon wins the Devgan Award for Excellence in Ophthalmic Surgery. I'm honored and proud to have such a prestigious award bare my name, especially since it focuses on outstanding surgical skills - a mixture of hard work, quick thinking, dexterity, and natural talent.

I also travel extensively to present lectures and perform live surgery at major eye surgery meetings, both in the US and internationally. In the last 3 years, I've taught in 30 countries, on 5 continents. I make professional surgical teaching videos as well as design eye surgical instruments. I enjoy writing regular columns for multiple major eye surgery journals, particularly about the technicalities of cataract and lens surgery.

Do you work with my current eye doctor?

Yes, your current eye doctor knows your ocular status very well and will be able to provide valuable information for my surgical plan. This includes your current and previous glasses prescriptions, the curvature and power of your cornea, details from your previous ocular exams, and how your eye has changed over the past few years.

After the surgery, your current eye doctor will conduct many of the important follow-up examinations. Should you require glasses after your surgery, your current eye doctor will then prescribe and fit them for you.

If you don't have a local eye doctor, we would be happy to recommend one for you or we can perform all of your post-op exams.

Where can I find out more about you?

It's easy, just ask: ask your referring eye doctor, ask our office staff, or ask me. If you're internet-oriented, you can simply enter my name into a search engine like Google, and you'll find out about my many activities in ophthalmology. You can also find more at our institute website: www.UdayDevgan.com or at my teaching website: www.ceiol.com.

My passion is my profession, and I love performing eye surgery to help patients see better. I'm proud of my reputation for excellence, and I take pride in every patient I see and in every surgery I perform.

I have performed cataract surgery on my own father and Dr. Robert Maloney's father, both of whom are retired surgeons with high visual demands. I strive to deliver this same high quality to each of my patients, and it's my test for every surgery I do: What would I do if this patient was my own father, mother, sister, or brother?

What other surgeries do you perform?

My focus is cataract, refractive, and LASIK surgery but I'm fully trained in other aspects of eye surgery. I also enjoy handling the complex and challenging cases that are referred by other doctors in the community. If you have other ocular conditions, please ask me about medical and surgical options at the time of your examination. If I cannot help you with a particular eye problem, I'll happily recommend another physician who can.

What if I have other questions?

Feel free to call us and we'll be happy to answer any questions. My staff can answer scheduling, insurance, or other common questions, while I'm happy to answer the medical and surgical ones. This guide covers certain highlights about cataract and refractive lens surgery, and it's not meant to be the informed consent' that you'll read prior to the actual surgery. You're welcome to have a copy of the informed consent to review in detail at any time. Remember that all surgery has some degree of risk, though it may be very small and very rare.

There may be special considerations for patients with diabetes, glaucoma, high degrees of myopia or astigmatism, and for those over age 75. Please write down any questions that you may have on the last page of this book and bring it with you on the day of your consultation.

What is my next step?

If you have decided to undergo my advanced technique of cataract or refractive lens surgery, please call and schedule a pre-operative consultation. On the day of your pre-operative consultation please bring your glasses, the name and number of your internist/primary care physician, and a list of questions that you'd like to ask me. Keep in mind that my surgical schedule fills up quickly and I'm typically booked at least one month in advance.

Finally, thanks for reading this far - you've proven my point about my patients being highly informed and intelligent!

This is an eye with a very visually significant cataract. The human lens has become quite cloudy and opaque, and therefore the pupil looks yellow or grayish instead of black. This cataract is limiting the patient's vision to 20/100. (To see, this patient must stand 20 feet away from objects that perfect' eyes can see from 100 feet away.)

This is the other eye of the same patient, which has recently had cataract surgery and insertion of a lens implant. This new man-made lens is crystal clear and therefore the pupil looks jet black, like it should. This lens also has corrected this patient's vision so that she does not require glasses for reading, computer work, or even driving.

Picture 2: Lens Implant

List of important questions that Dr. Devgan will ask me, the patient, at my pre-op consultation:

q Does your vision limit your activities / lifestyle? How?

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q Which activities are most important to you in your daily life?

o Reading a newspaper or fine print?

o Cell Phone, Blackberry, Palm Pilot use?

o Computer use?

o Desk / Paperwork?

o Cooking? Household activities?

o Daytime driving?

o Golf / Tennis / Daytime sports?

o Night Driving?

o Other?

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q Are you interested in seeing well at distance without glasses after surgery? Or do you not mind wearing glasses for distance activities, such as driving?

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q Are you interested in seeing well at near / intermediate without glasses after surgery? Or do you not mind wearing reading glasses for near / intermediate work?

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q If you absolutely HAD to wear glasses for one activity, which would it be: Reading Fine Print, Computer Use, or Driving?

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q If you could have good distance, intermediate, AND near vision after surgery without glasses, but the compromise was that would need time to adapt to your new vision, would you be interested?

Glossary of Eye Terms

Astigmatism - a condition where the cornea is steeper in one axis versus another instead of being spherical (i.e., the cornea is more football-shaped than basketball-shaped).

Astigmatism Management - performing special procedures in order to decrease or prevent worsening of astigmatism after cataract or refractive lens surgery to aid sharp vision.

Capsule of the Lens - the thin membrane that holds the cataract and then later, the man-made lens implant, in the eye

Cataract - a cloudiness or opacity of the normally clear human lens. As the opacity worsens, the vision declines.

Clear-Corneal Phacoemulsification - a technique of cataract surgery that is blood-less, pain-less, and suture-less.

Cornea - the clear dome of tissue at the front of the eye that focuses light (contact lenses fit over the cornea)

Cortical Cataract - opacities in the human lens that are similar to bicycle spokes in their appearance. They cause a lot of glare and may progress rapidly.

Diamond Instruments - hand-made microscopic instruments with actual gem-grade diamonds, used in eye surgery because they are far more accurate and gentler than steel instruments

Extracapsular Surgery - older technique of cataract surgery that uses steel scissors to cut the eye wall and then many nylon stitches to put it back together.

Glaucoma - an eye disease where high eye pressure and other factors can cause loss of vision if not treated

Intra-Ocular Lens Implant - the man-made crystal-clear lens that replaces the cloudy cataract after it is removed. Usually made of acrylic or silicone.

Iris - the blue, green, or brown part of the front of the eye that gives the eye its color. The lens is behind the iris.

Lens - the normally clear human tissue that helps to focus light in the eye and create clear vision

Multi-Focal Lens Implant - a man-made lens that is placed in the eye that can eliminate or reduce the need for glasses by focusing multiple zones of light onto the retina at once.

Nuclear Cataract - haziness of the central part of the normally clear human lens. This happens to every eye with age.

Phacoemulsification- a technique of removing the cataract with an ultra-sound probe to make the surgery less invasive

Pre-Operative Medical Clearance - a visit to your internist or primary care doctor a week or two before your surgery in order to make sure that you have no major medical issues (such as an irregular heartbeat, breathing problems, etc)

Presbyopia - the inability to focus on near objects due to age-related changes to the human lens.

Pupil - the round opening of the iris that lets light enter the eye. The pupil is dilated (enlarged) using eye drops during your eye exam so that the entire eye may be examined more easily.

Refractive Lens Surgery - removing a relatively clear, but dysfunctional, human lens and replacing it with a man-made lens that can address focusing problems of the eye

Retina - the tissue deep within the eye upon which the light is focused (analogous to the film in a camera).

Single Focus Lens Implant - a man-made lens that is placed into the eye, typically to focus distance objects onto the retina. Glasses are then used for near and intermediate vision.

Subcapsular Cataract - a type of cataract where the opacity is just under the capsule. Seen more commonly in diabetics and in people taking steroids (corticosteroids).

Vitreous - the clear jelly-like substance inside of the eye behind the lens/cataract and in front of the retina.

Patient's Notes / Questions to ask Dr. Devgan

Please use this section to make any notes or to write down any questions that you'd like to ask me.

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Patient's Notes / Questions to ask Dr. Devgan

Please use this section to make any notes or to write down any questions that you'd like to ask me.

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