Cataract Surgery
Cataract Surgery
In cataract surgery, the cloudy natural lens must be removed from the eye. After that, in most cases a permanent intraocular lens (IOL) implant replaces the natural lens to restore focusing power.
When to have cataract surgery often is a subjective decision, based on how well you are able to see during routine activities. You might be able to drive, watch television and work at a computer for quite a few years, even after you are first diagnosed with cataracts.
However, if you have cataracts, you may eventually start to notice "ghost" images and declining visual clarity, which can't be corrected with glasses or contacts. Colors may begin to look faded, too. If your functional vision is impaired significantly and it becomes difficult for you to perform your normal daily activities, it may be time for cataract surgery.
Preparing for Cataract Surgery
Once you and your eye doctor have decided that you will have your cataract removed, the eye surgeon will examine you. For the immediate time period before and after cataract surgery, ask your surgeon if you should continue your usual medications and nutritional supplements.
As an example, a common drug that treats men with enlarged prostates — Flomax and similar medications known as alpha-blockers — could cause problems associated with intraoperative floppy iris syndrome (IFIS) during cataract surgery. Patients on Flomax or similar medications should notify their eye surgeon before undergoing cataract surgery.
You may be given a choice of implantation with a regular single-vision (monofocal) intraocular lens or a presbyopia-correcting intraocular lens for replacement of your eye's natural lens.
Determining the right IOL for you can be based on many factors, including your lifestyle and ability to pay. If you are interested in correcting presbyopia, which all people have beginning at around age 40, you potentially could restore your ability to see at all distances with a multifocal IOL or accommodating IOL.
However, you must consider that extra cataract surgery costs do occur with "premium" IOLs, even though they may reduce or eliminate dependency on eyeglasses.
Before cataract surgery, your eye will be thoroughly measured in a preliminary eye exam to determine the proper power of the intraocular lens that will be placed in your eye. If you choose a premium IOL, you may need extra tests to make sure measurements are exact and that you don't have other vision problems that might hamper the performance of the IOL.
If you need cataracts removed from both eyes, surgery usually will be done on only one eye at a time. An uncomplicated surgical procedure lasts only about 10 minutes. However, you may be in the outpatient facility for 90 minutes or longer, because extra time will be needed for preparation and recovery.
At least a few days to weeks typically will be needed between surgeries, so that your first eye has the chance to heal and be evaluated in a follow-up exam for any possible problems.
What Happens During Cataract Surgery?
Cataract surgery usually is done on an outpatient basis. You may be asked to skip breakfast and avoid drinking liquids, depending on the time of your surgery. Also, do not wear eye makeup on the day of surgery. Upon arrival at the facility, you will be given eye drops to dilate your pupils and perhaps a sedative to help you relax. A local or topical anesthetic will make the operation painless.
The skin around your eye will be thoroughly cleansed, and sterile coverings will be placed around your eye and head. Under an operating microscope, at least one small incision is made into the eye. The surgeon will then remove your cloudy lens (the cataract).
This procedure can be performed using an ultrasound-driven instrument that "sonically" breaks up the cataract (phacoemulsification) as it is suctioned (aspirated) out of the eye.
In another surgical method, special instruments are used to mechanically break up the cloudy lens into small pieces (phacofracture) and remove them directly from the eye through a small incision.
The surgeon will insert a plastic or silicone IOL inside the eye to replace the natural lens that was removed.
Most incisions used for cataract surgery are self-sealing. However, on occasion, incisions may need to be sutured. When stitches are used, they rarely need to be removed.
Cataract Surgery Recovery
When the operation is over, the surgeon will usually place a protective shield over your eye. After a short stay in the outpatient recovery area, you will be ready to go home. Plan to have someone else drive you home.
A protective patch will be placed over your eye following cataract surgery.
You will need to administer eye drops, as prescribed by your surgeon, several times daily during the next few weeks. You also will need to wear your protective eye shield while sleeping or napping, for about a week after surgery. You will be given sun shades to help protect your eye in bright light.
During at least the first week of your recovery, it is essential that you avoid:
• Strenuous activity and heavy lifting (nothing over 25 pounds).
• Bending, exercising and similar activities that might stress your eye while it is healing.
• Water that might splash into your eye and cause infection. Keep your eye closed while showering or bathing. Also, avoid swimming or hot tubs for at least two weeks.
• Any activity (such as changing cat litter boxes) that would expose your healing eye to dust, grime or other infection-causing contaminants.
Although the basic postoperative instructions are similar among most eye surgeons, each surgeon may have specific recovery instructions depending on the outcome of your surgery. Always follow your surgeon's specific instructions, which you will receive prior to your discharge from the outpatient facility.
Complications of Cataract Surgery
Glaucoma or a buildup of pressure within the eye (intraocular pressure) also occurs sometimes after cataract surgery. If your eye pressure remains high, you may need additional treatment such as eye drops, a laser procedure, pills or additional surgery.
Phacoemulsification in cataract surgery involves insertion of a tiny, hollowed tip that uses high frequency (ultrasonic) vibrations to "break up" the eye's cloudy lens (cataract). The same tip is used to suction out the lens.
After the eye's natural lens is removed during cataract surgery, an artificial or intraocular lens is implanted to take its place.
Far more rarely, you might experience problems such as a decentered intraocular lens that might need to be repositioned or replaced in a second surgery.
Various complications, ranging from minor to serious, also can take place as a direct result of the surgical procedure, including tearing of the posterior capsule holding the intraocular lens in place.
Detached retinas also are possible in a small percentage of people who have undergone cataract surgery, particularly if they have unusually long eyes associated with higher degrees of nearsightedness.
Some eye surgeons dispute this direct association with cataract surgery, because highly nearsighted people already are at risk of getting a detached retina with or without cataract surgery. Cumulative rates of detached retinas occurring in highly myopic general populations who underwent cataract surgery or refractive lens exchange are roughly 1 percent in some studies, which is about the same risk if you never underwent a procedure.
However, a common complication that creates a "secondary cataract" may require a YAG laser capsulotomy procedure. A high myope who undergoes both cataract surgery and a subsequent YAG laser capsulotomy may have a significantly greater risk of developing a detached retina.
Endophthalmitis causing widespread inflammation or infection of the eye can be a serious side effect of cataract surgery that can lead to permanent vision loss and even blindness. Various studies indicate that endophthalmitis occurs in about one out of every thousand cataract surgeries. Endophthalmitis also is more likely to be seen in people with compromised immune systems associated with conditions such as diabetes.
However, even serious cataract surgery complications often can be resolved with appropriate follow-up treatments.
Cataract Surgery Outcomes
A comprehensive study reported in Archives of Ophthalmology in 1994 noted that 95.5 percent of healthy eyes achieved 20/40 uncorrected vision (legally acceptable for driving) or better outcomes following cataract surgery. Of the more than 17,000 eyes evaluated, fewer than 2 percent had sight-threatening complications.
Bruising or a black eye can result from cataract surgery, if an injection is used to numb the eye.
Remember that sight-threatening complications often are associated with individuals who are much older or who already have poor underlying health affecting how their eyes heal. Also, some people have complications because their cataracts are far more advanced or "hardened" at the time of surgery, making them difficult to remove.
A Swedish study published in the British Journal of Ophthalmology in November 1999 found that self-reported outcomes among people who had undergone cataract surgery were less satisfactory when other eye problems were present. Younger people undergoing cataract surgery reported the highest satisfaction levels.
The British journal also reported study results in December 2000 indicating that people in their 60s undergoing cataract surgery were 4.6 percent more likely to achieve 20/40 uncorrected vision or better than people in their 80s.
Laser-Based Cataract Surgery
Laser-based cataract surgery may become much more common in the near future.
In September 2009, LenSx Lasers Inc. (Aliso Viejo, Calif.) was granted FDA clearance to market femtosecond laser technology for capsulotomies, which involve making incisions into the eye. The incisions allow the eye surgeon access for removal of a cloudy lens (cataract), which then is replaced with an artificial lens.
Another femtosecond laser system currently under development ultimately could provide "all-laser" cataract surgery, according to LensAR CEO Randy Frey of Winter Park, Fla.
Frey's company is investigating use of the femtosecond laser system for all aspects of cataract surgery, including precise "laser cuts" into the eye. The system also can "break up" a cloudy lens to allow easy aspiration of the fragments from the eye.
Frey said femtosecond lasers potentially can be used to create limbal relaxing incisions (LRIs) for astigmatism correction as part of a cataract procedure.
Depending on FDA approval, LensAR femtosecond laser systems for cataract surgery could be available as early as 2010.
Optimedica Pascal System (Santa Clara, Calif.) is another femtosecond laser system currently under development for use in cataract surgery.
When to have cataract surgery often is a subjective decision, based on how well you are able to see during routine activities. You might be able to drive, watch television and work at a computer for quite a few years, even after you are first diagnosed with cataracts.
However, if you have cataracts, you may eventually start to notice "ghost" images and declining visual clarity, which can't be corrected with glasses or contacts. Colors may begin to look faded, too. If your functional vision is impaired significantly and it becomes difficult for you to perform your normal daily activities, it may be time for cataract surgery.
Preparing for Cataract Surgery
Once you and your eye doctor have decided that you will have your cataract removed, the eye surgeon will examine you. For the immediate time period before and after cataract surgery, ask your surgeon if you should continue your usual medications and nutritional supplements.
As an example, a common drug that treats men with enlarged prostates — Flomax and similar medications known as alpha-blockers — could cause problems associated with intraoperative floppy iris syndrome (IFIS) during cataract surgery. Patients on Flomax or similar medications should notify their eye surgeon before undergoing cataract surgery.
You may be given a choice of implantation with a regular single-vision (monofocal) intraocular lens or a presbyopia-correcting intraocular lens for replacement of your eye's natural lens.
Determining the right IOL for you can be based on many factors, including your lifestyle and ability to pay. If you are interested in correcting presbyopia, which all people have beginning at around age 40, you potentially could restore your ability to see at all distances with a multifocal IOL or accommodating IOL.
However, you must consider that extra cataract surgery costs do occur with "premium" IOLs, even though they may reduce or eliminate dependency on eyeglasses.
Before cataract surgery, your eye will be thoroughly measured in a preliminary eye exam to determine the proper power of the intraocular lens that will be placed in your eye. If you choose a premium IOL, you may need extra tests to make sure measurements are exact and that you don't have other vision problems that might hamper the performance of the IOL.
If you need cataracts removed from both eyes, surgery usually will be done on only one eye at a time. An uncomplicated surgical procedure lasts only about 10 minutes. However, you may be in the outpatient facility for 90 minutes or longer, because extra time will be needed for preparation and recovery.
At least a few days to weeks typically will be needed between surgeries, so that your first eye has the chance to heal and be evaluated in a follow-up exam for any possible problems.
What Happens During Cataract Surgery?
Cataract surgery usually is done on an outpatient basis. You may be asked to skip breakfast and avoid drinking liquids, depending on the time of your surgery. Also, do not wear eye makeup on the day of surgery. Upon arrival at the facility, you will be given eye drops to dilate your pupils and perhaps a sedative to help you relax. A local or topical anesthetic will make the operation painless.
The skin around your eye will be thoroughly cleansed, and sterile coverings will be placed around your eye and head. Under an operating microscope, at least one small incision is made into the eye. The surgeon will then remove your cloudy lens (the cataract).
This procedure can be performed using an ultrasound-driven instrument that "sonically" breaks up the cataract (phacoemulsification) as it is suctioned (aspirated) out of the eye.
In another surgical method, special instruments are used to mechanically break up the cloudy lens into small pieces (phacofracture) and remove them directly from the eye through a small incision.
The surgeon will insert a plastic or silicone IOL inside the eye to replace the natural lens that was removed.
Most incisions used for cataract surgery are self-sealing. However, on occasion, incisions may need to be sutured. When stitches are used, they rarely need to be removed.
Cataract Surgery Recovery
When the operation is over, the surgeon will usually place a protective shield over your eye. After a short stay in the outpatient recovery area, you will be ready to go home. Plan to have someone else drive you home.
A protective patch will be placed over your eye following cataract surgery.
You will need to administer eye drops, as prescribed by your surgeon, several times daily during the next few weeks. You also will need to wear your protective eye shield while sleeping or napping, for about a week after surgery. You will be given sun shades to help protect your eye in bright light.
During at least the first week of your recovery, it is essential that you avoid:
• Strenuous activity and heavy lifting (nothing over 25 pounds).
• Bending, exercising and similar activities that might stress your eye while it is healing.
• Water that might splash into your eye and cause infection. Keep your eye closed while showering or bathing. Also, avoid swimming or hot tubs for at least two weeks.
• Any activity (such as changing cat litter boxes) that would expose your healing eye to dust, grime or other infection-causing contaminants.
Although the basic postoperative instructions are similar among most eye surgeons, each surgeon may have specific recovery instructions depending on the outcome of your surgery. Always follow your surgeon's specific instructions, which you will receive prior to your discharge from the outpatient facility.
Complications of Cataract Surgery
Glaucoma or a buildup of pressure within the eye (intraocular pressure) also occurs sometimes after cataract surgery. If your eye pressure remains high, you may need additional treatment such as eye drops, a laser procedure, pills or additional surgery.
Phacoemulsification in cataract surgery involves insertion of a tiny, hollowed tip that uses high frequency (ultrasonic) vibrations to "break up" the eye's cloudy lens (cataract). The same tip is used to suction out the lens.
After the eye's natural lens is removed during cataract surgery, an artificial or intraocular lens is implanted to take its place.
Far more rarely, you might experience problems such as a decentered intraocular lens that might need to be repositioned or replaced in a second surgery.
Various complications, ranging from minor to serious, also can take place as a direct result of the surgical procedure, including tearing of the posterior capsule holding the intraocular lens in place.
Detached retinas also are possible in a small percentage of people who have undergone cataract surgery, particularly if they have unusually long eyes associated with higher degrees of nearsightedness.
Some eye surgeons dispute this direct association with cataract surgery, because highly nearsighted people already are at risk of getting a detached retina with or without cataract surgery. Cumulative rates of detached retinas occurring in highly myopic general populations who underwent cataract surgery or refractive lens exchange are roughly 1 percent in some studies, which is about the same risk if you never underwent a procedure.
However, a common complication that creates a "secondary cataract" may require a YAG laser capsulotomy procedure. A high myope who undergoes both cataract surgery and a subsequent YAG laser capsulotomy may have a significantly greater risk of developing a detached retina.
Endophthalmitis causing widespread inflammation or infection of the eye can be a serious side effect of cataract surgery that can lead to permanent vision loss and even blindness. Various studies indicate that endophthalmitis occurs in about one out of every thousand cataract surgeries. Endophthalmitis also is more likely to be seen in people with compromised immune systems associated with conditions such as diabetes.
However, even serious cataract surgery complications often can be resolved with appropriate follow-up treatments.
Cataract Surgery Outcomes
A comprehensive study reported in Archives of Ophthalmology in 1994 noted that 95.5 percent of healthy eyes achieved 20/40 uncorrected vision (legally acceptable for driving) or better outcomes following cataract surgery. Of the more than 17,000 eyes evaluated, fewer than 2 percent had sight-threatening complications.
Bruising or a black eye can result from cataract surgery, if an injection is used to numb the eye.
Remember that sight-threatening complications often are associated with individuals who are much older or who already have poor underlying health affecting how their eyes heal. Also, some people have complications because their cataracts are far more advanced or "hardened" at the time of surgery, making them difficult to remove.
A Swedish study published in the British Journal of Ophthalmology in November 1999 found that self-reported outcomes among people who had undergone cataract surgery were less satisfactory when other eye problems were present. Younger people undergoing cataract surgery reported the highest satisfaction levels.
The British journal also reported study results in December 2000 indicating that people in their 60s undergoing cataract surgery were 4.6 percent more likely to achieve 20/40 uncorrected vision or better than people in their 80s.
Laser-Based Cataract Surgery
Laser-based cataract surgery may become much more common in the near future.
In September 2009, LenSx Lasers Inc. (Aliso Viejo, Calif.) was granted FDA clearance to market femtosecond laser technology for capsulotomies, which involve making incisions into the eye. The incisions allow the eye surgeon access for removal of a cloudy lens (cataract), which then is replaced with an artificial lens.
Another femtosecond laser system currently under development ultimately could provide "all-laser" cataract surgery, according to LensAR CEO Randy Frey of Winter Park, Fla.
Frey's company is investigating use of the femtosecond laser system for all aspects of cataract surgery, including precise "laser cuts" into the eye. The system also can "break up" a cloudy lens to allow easy aspiration of the fragments from the eye.
Frey said femtosecond lasers potentially can be used to create limbal relaxing incisions (LRIs) for astigmatism correction as part of a cataract procedure.
Depending on FDA approval, LensAR femtosecond laser systems for cataract surgery could be available as early as 2010.
Optimedica Pascal System (Santa Clara, Calif.) is another femtosecond laser system currently under development for use in cataract surgery.
Label: Cataract
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