Cataract Surgery

In cataract surgery, the cloudy natural lens is removed from the eye. In most cases, the focusing power of the natural lens is restored by replacing it with a permanent intraocular lens (IOL) implant.

When to have cataract surgery often is a subjective decision, based on how well you are able to see while engaging in 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 also begin to look faded. If your functional vision is impaired significantly and it becomes difficult for you to visually perform your normal daily activities, it may be time 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 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 using a regular single-vision (monofocal) intraocular lens or a presbyopia-correcting (multifocal) intraocular lens for replacement of your eye's natural lens. 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 during surgery.

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.

Cataract surgery is usually 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 for surgery, you will be given eye drops and perhaps medications 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 mechanically remove your cloudy lens (i.e., 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.

A plastic or silicone IOL will be inserted inside the eye to replace the natural lens that was removed.
 

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.

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.

Note that lasers currently are not used to remove cataracts, although ongoing research means this method may be possible in the future.

After a period of time following cataract surgery, some people may need a simple laser procedure to clear up cloudiness within a membrane (posterior capsule) that is the back surface of the eye's original natural lens. The intraocular lens is positioned on top of this membrane, which is purposely left in place during cataract surgery.

Occasionally, this membrane becomes cloudy (called a posterior capsular opacity) and causes symptoms similar to those that were present with the original cataract. When a cloudy membrane causes compromised visual acuity, a high energy YAG laser is used to open up the membrane. This procedure is simple and painless and need be done only once in a lifetime if the membrane becomes cloudy following cataract surgery.

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. (Photo courtesy of National Eye Institute, National Institutes of Health)

You will need to administer eye drops, as prescribed by your surgeon, several times daily during the next few weeks after the procedure. 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 after surgery, 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, make sure you 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 instructions depending on the outcome of your surgery. Always follow your surgeon's specific postoperative instructions, which are given to you prior to your discharge from the outpatient facility.

Glaucoma or a buildup of pressure within the eye (intraocular pressure) also sometimes occurs 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.

Bruising or a black eye can result from cataract surgery, if an injection is used to numb the eye.

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.

Retinal detachments also are possible in up to 3.6 percent of people following cataract surgery (Ophthalmology reference book, 2004), particularly if you have unusually long eyes associated with nearsightedness. Some eye surgeons dispute this direct association with cataract surgery (EyeWorld, November 2004), because highly nearsighted people already are at risk of retinal detachments with or without cataract surgery.

If you notice fading vision similar to a curtain moving across your field of view or flashes of light, immediately seek medical help for a possible retinal detachment. Retinas can frequently be reattached and vision restored, but only if action is taken promptly.

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 (Ophthalmology Clinics of North America, December 2006).

However, even serious complications of cataract surgery often can be resolved with appropriate follow-up treatments.

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.

Remember that sight-threatening complications often are associated with individuals who already have poor underlying health affecting how their eyes heal. Also, some individuals 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 individuals 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.