There are 3 sets of fees involved: hospital fees (room, operating theatre, lens implant cost and medical supplies, etc.), anaesthetist fees and surgeon's fees:
- Surgeon's fees in London are usually of the order of £600 - £900.
- Anaesthetist fees vary at around £300-£400.
- Hospital fees in Central London are between £1,500 and £2,000 (which usually includes a standard lens). There will be an additional fee of £600 or thereabouts if femtosecond laser is used.
- The lens implant cost can also vary significantly depending on the type of lens implant used.

Insurance companies will usually cover the cost of standard implants to allow set for distance or monovision. However, insurers usually won't cover high cost of implants such as toric implants or multifocal implants.

Note: that all these costs are for one operation only – normally each eye is operated on separately, so two operations will be needed.

This will vary enormously depending on your policy. Insurers have been trying to contain the costs of cataract operations for some time, as it’s such a commonly performed operation. Hospital fees are usually fully covered. Many insurers have “capped” the amount they’re willing to pay for the surgeon’s and anaesthetist's fees, so you may need to pay any extra (known as shortfall). Some insurance companies will cover the whole cost of the operation, including these fees – others put forward only a nominal sum, to the point where there is really only minimal cover for this procedure.

Note: some insurers/policies limit your choice of surgeon and you will only be allowed to see one of a small number of surgeons who have agreed to keep their fees very low. This practice by the insurance company effectively limits your choice of surgeon on purely financial grounds, rather than quality, and we would always encourage you to discuss your choice of surgeon with your optometrist or GP.

Removing the cloudy lens and replacing it with a new one allows us to correct certain aspects of a patient’s vision. In many cases it’s possible to significantly reduce a patient’s dependence on glasses. We’ve outlined a number of options below. However, please don’t worry if it all seems complex – Mark will guide you through the options before the operation, based on his extensive experience and your specific visual needs. For example, an avid golfer would want excellent distance vision, whilst an academic would need good reading vision – although we do find that many people just want to minimise their use of glasses!

As the name would suggest, this sets the operated eye for distance vision. This means that you should achieve very good unaided vision, although you may require a weak prescription to get the sharpest vision for driving and long-distance work (e.g. at the cinema). You will, however, need to have reading glasses to be able to read small print and for computer work.

Many patients use varifocals or bifocals before surgery. You can continue to use these types of glasses after surgery, but the prescription will need to be changed.

When patients have cataracts in both eyes, we can set one eye (usually the dominant eye) for distance vision as described above, and the other eye for reading. Whilst this sounds daunting, the brain automatically switches to the eye with the clearest image. This means that you may not require glasses for reading menus in restaurants, or prices in shops.
It does not guarantee that you will be independent of glasses, but it will markedly reduce your dependence on reading glasses. You would still require glasses to get the best reading vision, particularly in poor light.

This “Monovision” is usually well tolerated and can work very well. You may already have tried it before surgery, as many opticians do this with contact lenses. If not, it is sometimes worth using contact lenses to stimulate monovision for a day as a trial before surgery.

Following cataract surgery using monovision, most patients (92-98% in recent studies) adapt quickly to this spread of focus. Very rarely, a patient may feel that the eyes are imbalanced, but this can be corrected with contact lenses, glasses, or a corrective surgery procedure (LASIK - "laser" surgery). If you choose "monovision" the insurance company will cover this lenses implant, as a standard one is used, and there is no need to get both eyes done within a short period of time (unlike multifocals).

The options describe above are fixed focal length implants. Whilst excellent results are obtained with these implants, the patient will be dependent on additional glasses for some tasks. The glasses will usually be reading glasses with separate glasses for computing, or varifocal glasses.

Multifocal lens implants are designed to reduce dependency on glasses after cataract surgery. These lenses are designed to send light to the retina in 3 defined focal lengths - distance, intermediate, and near. Distance tasks are driving, watching TV, recognising people's faces, and walking around. Intermediate tasks are those at middle distance - usually a visual task with the object held at arms' length and a typical distance would be 60 em. Good examples of intermediate visual tasks would be computing, using a smart phone or tablet, reading prices in shops, and looking at briefings in meetings. Near tasks include close up reading -for example reading a book. We now recognise that modern life places great demands on intermediate visual tasks- just think how many times a day you might use your smart phone or use a computer. Many patients justifiably do not want to be dependent on glasses to perform these visual tasks after cataract surgery. Multifocal lens implants with a trifocal lens are a way to address these demands. Example lenses include the PanOptix trifocal (Alcon) and the Zeiss trifocal.

Am I suitable for a multifocal (trifocal) lens implant?

A Multifocallens implant can really only be considered if you fulfill all of the following criteria:

1. You have confirmed cataracts in both eyes and you are willing to have cataract surgery in both eyes within a short time interval - usually a few weeks apart.

2. You are aged over 60 years.

3. There is no history of other eye disease.

4. You do not have very high glasses prescription or astigmatism.

Conversely multifocallenses do not work well and usually would not be considered in the following cases:

1. You only have cataract in one eye.

2. Younger patients -e.g. 40s and 50s.

3. You have other diseases -for example glaucoma, a lazy eye, eye injury, previous eye surgery, diabetic retinal disease, or a history of retinal detachment.

4. You have have had previous laser refractive surgery to correct myopia.

5. You have a high glasses prescription.

What to expect if we use a multifocallens?

The benefits

Patient who have had a PanOptix lens implants generally report high levels of satisfaction.

The majority of patients don't need additional glasses for distance or intermediate tasks. However, studies show that about 33% of patients need glasses for some near tasks, and of these about half (17%) used their glasses some of the time.

Side effects

Even if suitable, there are some important side effects of multifocal lenses that you must be aware of.

Firstly, most patients (about 70%) notice haloes or coloured rings around point sources of light and these are evident immediately after surgery. These effects are more prominent at night and most patients would notice haloes around headlights whilst driving at night. Although they can be a nuisance, these visual effects usually do not affect the ability to perform the visual task.

In addition, most patients learn to tolerate these side effects once they understand that they are an inevitable side effect of this style of lens. However, you would not want to use this lens if you were an astronomer and needed to see the night time sky, or you enjoyed night time photography. Patients also report some glare around bright sources of light.

What if I am one of the patients who notices significant glare and haloes and am very troubled by this?

About one in 100 patients are very troubled by the side effects of multifocal lenses and report constant glare and haloes under most lighting conditions. If it is in the early post operative period, it can be worth waiting to see if these side effects settle. In many cases the effects can improve significantly over about 6 months. However if the side effects don't settle then the only solution is to exchange the lens implant for a fixed focal lens implant and accept reading glasses. In my experience about 1 in 100 patients would require this. This necessitates a return to theatre and the surgery can be performed successfully under local anaesthesia. However there are rare risks involved. In addition, there is a cost implication, as you would have to pay for the surgery and theatre costs involved. Be advised that the insurance companies generally not cover this.

Astigmatism occurs primarily when the front of the eye (cornea) is shaped like a rugby ball,rather than a football. It's very common, and your optometrist can correct this with special glasses or contact lenses. For mild astigmatism, the degree of astigmatism can be reduced during cataract surgery,in order to reduce the strength of glasses needed after  surgery. The femtosecond laser is an ideal way  of correcting low astigmatism.

Moderate and severe astigmatism can be corrected by using a special astigmatic lens implant during cataract surgery,called a toric lens. This works very well and Mark strongly recommends it in all cases of moderate to severe astigmatism (greater than 1.25 dioptres). However,insurance companies generally won't pay for the cost of toric lens implants (the cost of the Acrysof Toric IOL is about £500). You may also need to have an additional measurement of the cornea prior to surgery (topography). Multifocallenses can also be ordered as a toric lens.

This option is occasionally used. It particularly suits patients who have always been short-sighted (myopic) who habitually take their glasses of in order to read. it really only applies if cataract surgery is planned in both eyes. The idea is to use a lens implant set for reading in both eyes. In this sense it differs from monovision. it is appealing to patients who spend a lot of their working lives reading, for example academics or historians. It might also appeal to those who do a lot of detailed close work, for example jewellers and engravers. The downside is that if both eyes are set for reading after cataract surgery, then without glasses correction the distance will be blurred - for example walking around, crossing roads and driving. Of course the distance vision can be corrected by a pair of distance glasses or varifocals.

There has been a recent development in cataract surgery - the use of the femtosecond laser.  

What is femtosecond laser

Until recently, a surgeon would create incisions in the eye through the cornea using fine instruments under a microscope. Through these incisions, the surgeon would then manually open a small 5 mm window in the front part of the membrane (called the anterior capsule) that surrounds the cataract. Whilst surgeons are very skilled in doing this, we now have the technology to use a laser (femtosecond laser) to cut a perfectly circular window. The laser can create an opening that is perfectly round and centred within the eye, to a degree of accuracy that cannot be replicated by any surgeon anywhere in the world.   Using a laser to create a perfectly circular window in the capsule allows the surgeon to implant the lens in a more precise location so that it is perfectly centred within the eye. The laser also splits and softens the cataract, making extraction more straightforward. Having said that, large studies have not shown a significant benefit of femtosecond cataract surgery over conventional surgery, and this is because most patients already achieve excellent results with conventional surgery.  

Some possible benefits of femtosecond laser surgery

There are good reasons for proposing several probable benefits of using femtosecond laser in phacoemulsification cataract surgery,however we do not currently have enough evidence to support all of the below. This may change in the future as new studies are reported.  

Treating astigmatism

If you have astigmatism and you are keen to minimise the need for glasses after your cataract surgery then femtosecond laser is more likely to improve your odds of achieving this. The laser can create precise cuts in the cornea - this is an excellent way to treat low astigmatism. For medium to high astigmatism,a TORIC lens implant is a better option.  

Reducing the complexity of the surgery

Mark feels that the laser can be particularly useful in certain challenging cases of complicated cataract.  

Reducing the amount of energy needed dissolve the cataract

During cataract surgery, we use ultrasound energy to liquidise the cataract within the eye (phacoemulsification or phaco). With femtosecond laser,we use the laser to soften the cataract prior to the phaco. This allows us to use less energy within the eye. This is beneficial, as excess energy is associated with potential damage to the cornea,and inflammation in the retina.

Risks
As with conventional phacoemulsification cataract surgery, the usual risks of surgery apply, for example,the risk of infection. Reassuringly,there is no evidence of an increased risk of infection following femtosecond laser surgery. These risks are detailed above.

The question is whether there are additional risks over and above the standard operation? Large studies from the US show that femotsecond laser is safe and that the risk of complications is very low. However complications can occur.

In terms of serious complications, very rarely the laser can weaken or break the capsule supporting the cataract to the extent that the cataract nucleus falls into the vitreous jelly. This complication is also a rare occurrence with conventional surgery. This complication can be remedied, but there is an increased risk of visual loss as it requires an additional operation to remove the cataract,usually with the assistance of a vitreoretinal surgeon.

Availability and cost
Moorfields Eye Hospital was one of the earliest hospitals in the UK to have a femtosecond laser machine. Mark has been performing femtosecond laser assisted surgery on our private patients,for those who want it, since 2013. He was one of the first UK surgeons to adopt this technology alongside a small number of Moorfields colleagues, and has helped to train other surgeons in the technique.

At present, femtosecond laser machines are still relatively uncommon in the UK. Currently femtosecond laser assisted cataract surgery is generally not available under the NHS outside the research environment. The laser is a very high cost machine. As a resuIt,there is an additional hospital fee for the use of the laser, and the hospital will levy this fee to the patient for use of the laser. However, Mark does not charge any more in terms of his surgical fee in order to use the laser. Insurers recognise and accept the technology, but generally do not cover the additional charge for laser at present. However the level of cover varies enormously between different companies and policies, and we would generally advise patients that there is little to be lost by asking. In the interim, we can advise on the extra cost.