Dear Cyndy, You wrote: Forgot to say I saw the retina man yesterday and asked him 1) was the vasculitis related to the bleeding in the retina, and 2) did the cataract surgery last year precipitate the wet macular degeneration? He did not scoff, thank heavens. He said 1) that it was possible, and 2) that there was a lot of argument in the profession about that Q. He personally thought that both cataracts and M.degeneration were conditions of Old Age, and could easily be simultaneous but not causal. What think you? ================== 1) Retinal vasculitis has an unmistakable signature on fluorescein angiography. No such signature was apparent on the pictures you sent me. In the absence of such conclusive diagnostic fluorescein angiographic evidence, treatment for retinal vasculitis should not be administered, because such treatment (sytemic steroids) is itself a cause of potentially life threatening illness. 2) The retina man's answer "He personally thought that both cataracts and M.degeneration were conditions of Old Age, and could easily be simultaneous but not causal," begs the question which is not whether cataract "is the cause" of macular degeneration, but whether the surgical removal of the cataract can precipitate or accelerate the development of macular degeneration in an eye disposed to that disease. I'm pleased by the retina man's comment: "that there was a lot of argument in the profession about that Q." because I haven't heard such argument. It has been my impression that this obvious question has been swept under the rug by the cataract extraction industry, which has become a multi-billion dollar business. My own experience is inconclusive. I know many patients, including my father, my sister, my wife and myself, who have undergone cataract surgery and survived for years (14 years in my own case) without serious macular disease. On the other hand, I've had many patients over the years in whom macular degeneration has developed soon after cataract surgery. The macula is among the tissues of the body, one of the most delicate and vulnerable, with the teleologic explanation that although it has a high rate of metabolism and requires proportionately much oxygen and nutrients, it lacks bloodvessels the presence of which would interrupt the optical image that the macula transmits to the brain. That's the weakness which is the structural basis of macular disease. There are contradictory considerations with respect to cataract surgery and macular degeneration. Arguably removal of a dense cataract permits the (early) diagnosis of macular disease, which would otherwise be masked. In the presence of dense cataract it's not possible to tell to what extent, if at all, macular disease contributes to visual impairment. At the same time, the macula is inaccessible to inspection and angiography. On the other hand, there's no denying that cataract surgery is trauma, which stresses all the tissues of the eye, of which the macula is most vulnerable, a circumstance which places on the cataract surgeon the burden of proof that he is doing no harm. Not only has this proof not been brought. The need for such proof is not even recognized. A second consideration is that the natural lens, especially when it is cataractous, serves as a filter which screens the macula from the radiant energy, especially of low wavelengths (blue, violet and ultraviolet light). Hence after cataract extraction especially blue colors appear much brighter. When I was in ophthalmology training in the sixties, we were taught that aside from gazing directly at the sun, one could not damage ones eye by exposure to light. The error of this teaching became embarrassingly apparent when, subsequent to the development of microscopic surgery in the 70's and 80's, eyes were exposed during twenty or so minutes of surgery to unusually bright illumination, and macular damage from even a short exposure to bright light became apparent. I infer that cataract extraction exposes the eye to potential injury from light, and I recommend to my patients that they wear dark glasses under such circumstances, especially when gazing onto a field of snow or onto a surface of water from which light is reflected. My conclusion has been to recommend to my patients to defer cataract surgery in the cataractous eye until the vision in the BETTER eye is so impaired (from whatever cause) that they can no longer read or drive. I practice what I preach. My own left eye has been blind from cataract for years, and monocular vision seems to have had no adverse consequence for my carpentry, for my plumbing, for my ophthalmology or for my reading. The disadvantage of postponing surgery, in addition to the masking of hypothetically treatable macular disease, is the loss of ocular alignment. The eye which is not used tends to drift outward, making the patient "wall-eyed". Cataract surgery when it is finally done, will be complicated initially with double vision, a potentially very annoying but not unmanageable symptom. I bet, that's far more than you wanted to read. Stay well, and give my best to Ned. Jochen PS: I append the full text of the Appeals Court decision.