The first time I heard my grandmother describe her upcoming cataract surgery, I was confused by the expression she used. She told me the right eye was "ready for surgery, but the left eye still needed to ripen." I have heard the term so often since then that I long assumed it was a valid concept, endorsed by ophthalmologists, and that it referred to a process of maturation that was necessary to make a surgical remedy possible. As it turns out, the need for a cataract to "ripen" before surgery is a myth.
A cataract is a clouding of the lens that prevents light from passing through it; because the lens focuses images on the retina (which then carries visual signals to the brain), it is vital to vision that the lens be clear.
The condition is common. Of an estimated 30 million persons with blindness worldwide, cataracts are estimated to account for half. Although the most common cause of cataract in developed countries is advanced age, the lens can lose its clarity in a number of other ways, including injury, infection, inflammation, certain medications, a genetic disorder or radiation (as with treatment of a tumor). Fortunately, surgical removal of the cloudy lens and insertion of a plastic or silicone lens has become rather routine and is generally considered minor surgery with a remarkably high success rate.
But there is no need to wait for the cataract to "ripen" — in fact, cataract surgery can be successfully performed at any time during the process of cataract development. As with any other intervention, the timing of surgery depends on the balancing of risk vs. benefit. For example, if a cataract is tiny and does not affect vision, the anticipated benefits of surgery are small or nonexistent, and the operation should be delayed. The cataract may worsen so slowly that surgery may not be required at all. On the other hand, proceeding directly to surgery may be appropriate if a cataract significantly reduces vision, especially if the other eye is not perfect either. Decisions about surgery are also affected by the person's overall health, lifestyle and individual preferences. The same degree of cataract might be well-tolerated by one person and disabling in another.
When cataract surgery was a riskier operation, it was delayed longer, until symptoms were severe; this waiting period was likened to fruit ripening on the tree. The notion, as with many myths, likely comes from an incomplete understanding about the underlying condition and from terminology that is appealing but inaccurate. With the advent of safer procedures, the concept is even less appropriate.
In most cases, an early cataract is watched over time, and when it causes enough problems, surgery is recommended. To think of the cataract as "ripening" over that waiting period does not usually get in the way of proper care. But there may be occasions when referral to or follow-up with an ophthalmologist is delayed because of this mistaken concept — in those circumstances, it is important to identify the myth for what it is. A lens, or a cataract within it, has little in common with fruit and does not ripen — in fact, it only worsens — over time.
Robert H. Shmerling, M.D. is associate physician at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School. He has been a practicing rheumatologist for over 20 years at Beth Israel Deaconess Medical Center. He is an active teacher in the Internal Medicine Residency Program, serving as the Robinson Firm Chief. He is also a teacher in the Rheumatology Fellowship Program.