Should I get “refractive” or “standard” cataract surgery?

While they’re equally safe, refractive and standard cataract surgery are different in a few key ways. “Refractive” means the goal is to get you out of glasses.

Joel Hunter, MD
Joel Hunter, MD
Refractive Surgeon, Hunter Vision Updated 10/31/18 12:15 PM

When considering Refractive Cataract Surgery vs. Standard Cataract Surgery, most people approach this choice with the same question: what does refractive mean? The most helpful definition is that it means the goal is to get you out of glasses. Since this is such a simple definition, which also ignores the textbook optics definition, it can seem misleading. In all honesty, the reason the definition is simple and accurate is that it contains exactly the reason refractive surgery exists. The whole idea is to get people out of glasses. That’s all anyone is asking when they want to know what makes refractive cataract surgery and standard cataract surgery different. A basic textbook definition of what it means to refract—changing the direction of a ray of light—is less helpful. This is because there’s no reason to care about how something works before we know what it does.

True story: one time someone fell asleep while I was talking to them in clinic. I made the mistake of explaining how refractive surgery is possible when they only wanted to know what was possible. I’ll tell you what’s not possible: figuring out a good way to wake up someone in that situation without it feeling awkward in the room.

The possibilities of Refractive Cataract Surgery

The idea of refractive cataract surgery pivoting on the tenet of getting someone out of glasses adds a layer of honesty to the process. Without the goal of glasses-free vision, it’s much better to avoid going down that road in the first place. When we can assume within reason that there’s a way to get someone out of glasses, refractive cataract surgery is the road that gets us there. What decides whether or not it’s an option? We find out if it’s medically possible for the patient to end up without the need for glasses. The refractive option is also sometimes available for those who know they’ll need readers, but want to ensure they’ll be out of distance glasses.

One of the most important parts of fixing cataracts is being honest about what to expect with standard cataract surgery. A few times a week, imaging will show that a patient would most likely have glasses-free distance vision with standard cataract surgery. But this same patient won’t be able to get reading vision without glasses. In those cases, it’s never a question about what procedure we tell them to get. If they’ll likely have the same vision with standard or refractive cataract surgery, we will tell them to go with standard cataract surgery. It has equal safety, equal results, and is the more affordable option of the two. That’s pretty great news when we get to give it. The goal of standard cataract surgery may be clear vision with glasses instead of glasses-free vision, but when the stars align to allow honesty in what to expect from standard cataract surgery, it’s especially fun.

The key differences in Refractive vs. Standard Cataract Surgery

When we’ve determined that refractive cataract surgery can help someone get out of glasses completely, a candidate will usually ask, “What’s involved in that procedure compared to standard cataract surgery?” While they’re equally safe, refractive is different in a few key ways.

First, even small amounts of astigmatism need to be corrected for you to become glasses-free. This requires careful planning. Specific measurements and procedural approaches are necessary.

Second, each eye has to have the correct prescription not only for that eye, but in coordination with the other eye. This has to be exact for the procedure to work. It’s amazing to see it all come together! There are now diagnostics and imaging scans before and during surgery to make all of this possible in a way it wasn’t a few years ago.

Last, because everything has to be so exact, there needs to be a safety net to make sure we don’t end up missing the goal. There’s an inherent level of variability in human healing and anatomy, so it’s possible to do everything right and still end up shy of the goal. It’s unlikely—but possible. While it’s uncommon to need glasses in these cases, the goal is still to make the vision as good as it can possibly be. In those rare cases, a few months later when everything is confirmed to be stable, we perform a 10-minute LASIK procedure to maximize the vision for that eye.

Refractive and standard versions of cataract surgery are different in that one aims to get you out of glasses and the other doesn’t. But they are both the same where it matters most: the vision ends up dramatically clearer than it was with the cataract. You end up needing glasses in one version, and in the other you don’t—but the results are equally clear. And both refractive and standard cataract surgery are identical when it comes to safety. If one was safer, we’d stick to that one without a second option. Since vision is clear and the procedure is safe with either choice, it all comes down to that first helpful and simple definition of refractive: Do you want to get out of glasses?

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