June 9, 2012

YAG Capsulotomy after Cataract Surgery - Details, Costs

I had cataract surgery on my left eye and posted a detailed article on this blog about my experience: Cataract Surgery - What to Expect, Details, Costs. That was in 2006. My vision in that eye has become fuzzier, especially during the last few months. I suspected the membrane capsule that holds the artificial lens had thickened, thus reducing my vision. The doctor had made me aware of this possibility prior to my original surgery. The Good Hope Hospital in the United Kingdom uses a good animation to demonstrate cataract surgery and the follow-up surgery that is sometimes required. Click on each label on the left.

The word used to describe a lens sac becoming cloudy is "opacification" (i.e. becoming opaque). When the lens capsule becomes so cloudy that reduced vision interferes with someone's life, then a procedure called "Nd:YAG Capsulotomy" may be performed. The full name of the procedure would be "neodymium:yttrium-aluminum-garnet laser posterior capsulotomy". "Neodymium:yttrium-aluminum-garnet" specifies the type of laser and "posterior capsulotomy" means removal of the rear of the lens capsule. WebMD has a good page about the procedure: Nd:YAG laser posterior capsulotomy for cataracts. The laser is used to burn holes in the back of the lens sac, sort of like the perforation holes around a postage stamp. The membrane tears apart along the perforations, pieces break off, and the pieces become loose inside the eye. The new opening in the lens sac lets light through restoring good vision.        

In the remainder of this post I will describe each appointment and the associated costs. I do not have medical insurance so the costs shown are the actual charges I paid.

First Appointment – examination
April 4, 2012

I arrived at 1:50 for a 2:00 o'clock appointment and was called from the waiting room at 2:29. A lady refractionist asked me to look at charts while wearing my distance glasses so she could determine my current corrected vision in each eye. Then I removed my glasses and she tried different lens until she found the best lens for each eye. My vision with my current glasses and the best vision they could get with new lenses, were so close that no new prescription was needed. My right eye (which has an untreated cataract) was 20/40. My left eye (which has an artificial lens from cataract surgery six years ago) was 20/60. We were interrupted four times during the refraction process.

After completing the refractive tests the lady put yellow drops in my eyes for the glaucoma test. I do not know the name of the drops. They numbed my eyeballs so that I would not feel the tonometry test to determine the pressure in each eye. The drops contained yellow dye that glowed under blue light. I sat with my chin in a machine while the lady slowly made a device touch my eyeball to measure the pressure. Pressure in my right eye was 18. My left eye was 17. According to Wikipedia's article on "Intraocular pressure", normal eye pressure is 10-20 mmHg. Then the lady put drops in my eyes to dilate my pupils. I think she said the name of the drops was Mydriacyl. She led me to an interior waiting room at 2:57.

The doctor came and got me at 3:36. He asked me a series of questions to assess the negative impact my current vision problem is having on my life. He asked if bright lights bother me, if I have any trouble driving at night, if I see white flashes at the edges of my vision, if I see flickering, and more. Then he examined each eye thoroughly using a machine that shown a bright light into my eye. Occasionally he asked me to look a certain direction. He took a lot of notes, I assume to record his observations, and asked me to follow him to another room. There I sat with my chin in another machine. The doctor lined the machine up with my left eye and told me to look at the center of a screen in the machine. Red lights moved in lines forming rays with the center. Then more red lights showed a circle. The lights kept changing and moving around until a picture of my retina was taken. The doctor used a computer to control the machine and I assume his computer screen showed him the picture that was taken. The doctor repeated the process three or four times. He said the cloudiness of my lens capsule prevented him from getting a good picture of the retina. He said he had intended to compare a current picture with the picture he took in 2006 to see if the epiretinal membrane visible in 2006 had grown. He was not able to make the comparison and could not say definitively whether the epiretinal membrane is a problem. He said he thinks I am a good candidate for a YAG capsulotomy. He said there's about a 1% chance of retinal detachment. Then he said actually the risk is a little higher for people who are nearsighted, as I am, but he thinks the risk is low and acceptable. He recommends the procedure. He asked if I had any questions. I had several, which he answered. (Of course, since then I have thought of several more questions which I guess I'll only ask if they become relevant later. If my retina detaches, what happens then? If the epiretinal membrane has grown and does present a problem, what do we do?)

It was time to make a decision. I told him I want to do the YAG capsulotomy. He said he does them on Tuesday mornings at the nearby surgery center, the same place he had performed my cataract surgery. He said the surgery only takes about ten minutes. My eye will be numbed and dilated, but otherwise I will not be anesthetized or medicated. He said about two hours after the surgery I will need to come back to his office where a technician will check the pressure in my eye. Then I will need to come back again a few weeks later for a final check of the eye and my vision. He turned me over to his staff to work out the details. It was 4:07. I was with the doctor for 31 minutes.

I may have had to sign a form or two. A lady asked me a lot of questions about my medical history – medicines, allergies, operations, hospitalizations, etc. We scheduled the surgery for a date about twenty days later. She gave me a sheet of instructions. She asked if I could go directly from there to PreOps at the surgery center. I said I could. She called ahead, made sure it wasn't too late in the day, and told me they were expecting me. She drew a little map for me showing me where to go. She told me the doctor's fee for the surgery would be $324.00. Then she handed me off to another lady who wanted money for that day's services. The charge was $225.00. I paid by check. She gave me a receipt, a pair of rolled up sunglasses to put on before going out in the daylight, and said we were done.

First Appointment – part 2, PreOps
April 4, 2012

I drove to the nearby surgery center and after a couple of missteps I found PreOps. A lady took me into her office and spent the next 15-20 minutes updating my information in their computer system, explaining forms to me, getting my signature and initials many times, and making copies for me of all the forms I signed (at my request). When she confirmed my social security number I asked her to delete it. (They only need my social security number if insurance is involved and I don't have insurance.) She ignored my request and continued. I let it go. She told me the surgery center's facility fee would be $1,027.00. She said if I prepaid, the fee would be $514.00, which is a 50% discount. She asked if I wanted to pay right then or if I wanted to pay when I came for the surgery. I said I had only brought one blank check and I had used it to pay my ophthalmologist, so I would have to wait and pay the facility fee on the morning of the surgery. She smiled and said actually I needed to pay right then. I reluctantly gave her my credit card. Before I left she made sure I was aware that the facility fee was an estimate and might be different at the time of my surgery. When we were done I left with the following papers:

Handwritten receipt for $514.00
Machine-printed receipt for $514.00
Brochure about the surgery center
Patient Registration form
Financial and Collections Policy
Authorization for Surgery / Other Procedures and Anesthesia Services (2 pages)
Acknowledgment: Receipt of Notice of Privacy Practices

(I received no Notice of Privacy Practices, although I had to sign saying I had. I didn't notice I had no such document until I was writing this blog entry.)

As I was walking to the car in the rain I realized no one had told me where to go on the day of surgery. I walked back to PreOps, got someone's attention, and asked where to report for the surgery. A lady told me. I left PreOps at 4:55.

Second Appointment – surgery
April 24, 2012

The PreOps instructions sheet said I could eat and take my normal medications before surgery. I arrived at the surgery center front desk at 9:50 for my 10:00 o'clock appointment. After checking me in and making sure their paperwork was in order, the receptionist directed me to the waiting room. I stood for a few minutes watching a real-time cataract operation on a monitor hanging from the ceiling. I also conversed with another man waiting. A nurse called my name at 9:59.

I followed the nurse to a little room where she double-checked several facts – my full name, my birthdate, the procedure I was there for, which eye, and which doctor. She also asked some other questions. I remember one was whether I had any allergies. She went over a page of discharge instructions with me and made me sign the page. She gave me a little yellow circle with a sticky back which she asked me to put on my forehead over the eye to be operated on. She left the room to ask the doctor which drops to give me. When she returned she separated three bottles from the four she had out. At 10:07 she put two numbing drops in my left eye, then one dilation drop, and finally one drop to control pressure. I did not ask her the names of the drugs. She said the doctor would be with me in about twenty minutes, after the dilation drop had taken effect and after the doctor had finished his current cataract surgery. Then she left.

The room was fairly small with cabinets, a counter, the chair I was sitting in, and a small stand in the center of the room with a machine on it. There was a stool on each side of the machine. I got up and read the name of the machine. It was a "YC-1400 Ophthalmic YAG Laser System". The Nidek company has a newer model that looks almost the same, the YC-1800. (A larger picture with specifications is available by clicking the view button near the bottom of this page beside YC-1400.) The nurse returned to check on me at 10:25. She said the doctor would be a little bit longer.

The doctor arrived at 10:37. He had the nurse put two more numbing drops in my eye. The nurse asked me to move to the stool beside the machine. The doctor squeezed a drop of what looked like a gel onto a small device on the counter. The device reminded me of a microscope's eyepiece. He asked me to put my chin in the chin cup on the machine and to press my forehead against the forehead rest. He sat on the opposite stool. He reached around the machine with the small device in his hand and pressed it onto my eye. I asked him later if he had put a contact lens on my eye and he said he had. He asked me to stare straight ahead. I saw two vertically aligned red lights. I think I could also see a faint reflection of my lens capsule. The doctor took aim and began clicking something that shot laser pulses into my eye. The lights moved around as he aimed and fired the laser. He asked me to look left. He fired the laser several times. He asked me to look right and fired several times. After the first few shots I started counting. I think the doctor fired the laser 78 times, plus or minus a couple. Throughout the process I could see the membrane he was shooting and I could see bits of it falling away now and then.

Suddenly he was done and told me I could sit back. He squirted liquid into my eye as he held tissues around my eye. I assume he was rinsing off the gel he had put in my eye. He said I might see floaters and my eye would feel scratchy and crusty for a few hours. He said if I saw light flashes, had pain, or noticed anything else obviously wrong to call his office. He wrote a prescription for eye drops and told me to use them four times a day for one week. He said I could fill it at Walmart for $4.00. The prescription was for Pred Forte. He said I could also use other drops to irrigate my eye today if needed. He told me to go to his office at 12:00 so they could check my eye pressure. He said they would also make an appointment to examine my eyes in two weeks to see if I need a new glasses prescription. Then he asked if I had any questions.

I asked the doctor if the device he put on my eye at the beginning was a contact lens. He said it was. I asked him if he had shot laser pulses around the membrane until it fell loose. He said he had made an X across the middle. When the flaps didn't peel back off of the lens on their own he fired shots at the bases of the flaps until each piece fell free. I asked him how long I would probably see the new floaters – hours or days? He responded noncommittally by saying some floaters never go away. He said I might be most likely to see them in the morning when I first sit up. He reminded me that the retina's image is upside down and reversed, which may mean sinking floaters appear to move upward. I am uncertain how that works. Finally, I asked about paying him. No one had asked me for payment yet. He said his office would bill my insurance. I told him I don't have insurance. He said they would handle payment at his office. We were done. The nurse gave me a copy of the discharge instructions I had signed earlier. I left at 10:45. The doctor had been with me for only 8 minutes and my entire time at the surgery center was only 55 minutes.

Second Appointment – post-operation check
April 24, 2012

I arrived at the ophthalmologist's office at 11:59 for the follow-up pressure check. They called me into the back before I had even sat down in the waiting room. A lady took me into a room and asked me if I wear glasses to drive. I said yes. She asked me to put them on. I told her I had left them in the car because I had thought she was just going to check my eye pressure. I reminded her that my eye was still dilated. She said she wanted to check my vision and my pressure. I went back to the car for my glasses. My left eye's vision with my glasses was 20/40 -2, which means I could identify all but two letters on the 20/40 chart line. Three week's ago my left eye's vision with my glasses was 20/60. Even though my eye was still dilated I could see better than I saw three weeks ago. The lady put two yellow numbing drops in my eye for the pressure test. After the test I asked her what the pressure was. She said it was 7. I said a few weeks ago it was either 17 or 18. She tested it again less than a minute after the first test. The second time the pressure was 10. I don't know if the test is inaccurate or if eye pressure changes that much in a minute, but the difference does not encourage confidence in the test. I couldn't help but wonder if she wrote down both readings or just the second one. I asked her what the normal healthy range is. She said 8 to 22. The reason eye pressure is tested after a YAG capsulotomy is because sometimes the eye pressure increases too much after surgery. Obviously I didn't have that problem. I made an appointment for two weeks later and wrote a check to pay for the surgery. The fee was $324.07. The technician gave me my receipt and I left at 12:15.

I drove to Walmart and got the prescription filled. The bottle of generic Prednisolone Acetate Ophthalmic Suspension (substituted for Pred Forte) was $17.46 (not $4.00 as the doctor said it would be). I put the first drop in my eye at 1:25. Prednisolone Acetate is a steroid that reduces swelling in the eye.

I felt bad for the rest of that day and the next day. My left eye felt scratchy and irritated. I had a headache. I felt slightly nauseous. I saw more floaters than usual in my left eye. I felt slightly feverish and experienced occasional chills and sweats. Prednisolone Acetate showed me how connected my eye socket and mouth are. Soon after putting a drop in my eye I tasted it in my mouth. The taste was bad. The taste lingered, sometimes until time for the next drop about six hours later. I think the eye drops were what made me feel slightly nauseous. I felt better the second day after surgery. The feverishness had disappeared and the floaters had noticeably decreased, although they were still distracting. The drops still tasted bad.

On the afternoon of the day after the procedure I got a telephone call from a nurse at the surgery center. She asked me if I had experienced much redness or swelling in my eye. I said I had not. I told her I had a lot of floaters. She asked if I was satisfied with the service they had provided. I said I was. In retrospect, I wish I had told her that their service was too expensive.

Third Appointment – post-operation follow-up
May 8, 2012

I arrived at 2:15 for a 2:15 appointment. They called me at 2:57. A technician tested my eyes with my distance glasses from 2:57 to 3:04. At 3:06 the doctor came in, examined my left eye, checked my left eye's vision with charts and lenses to see if a new prescription was needed, put yellow drops in my left eye, and measured the eye's pressure. The pressure was 12, which was good. The doctor was satisfied with everything and said the new prescription was so similar to my current glasses' prescription that there was no need for new glasses. He was with me for eight minutes and left at 3:14. When I checked out I was told today's examination was "post-op" and there was no additional charge. The only paperwork I received was a card with my new prescription.

I am quite satisfied with the results of the YAG capsulotomy. When there is no floater in the way my left eye's vision is very sharp at 15 inches. My artificial lens is fixed so there is only one optimal focus distance. The only time my left eye has seen this well was after my cataract surgery in 2006.

Here are the costs rounded to the nearest dollar. Costs are what I was charged and what I paid. No insurance was involved.

Cost Recap

$225 ophthalmologist examination
$514 surgery center facility fee
$324 ophthalmologist's surgery fee
  $17 prednisolone acetate ophthalmic suspension
$1,080 grand total

I am posting this on June 9, one month after my last eye examination. I still have floaters, but they are not as distracting as they were a month ago. My guess is that I have become accustomed to the floaters, plus there are fewer of them. Sometimes a floater will be right in the middle of my vision, causing me to tilt my head and roll my eyeball around until the floater floats to a new position. When there is no floater in the way my vision is sharp. I am very satisfied with the operation.

Here's a link to my 2006 blog entry with details of my cataract surgery: