Cataract surgery: Everything you need to know
Sometime after age 50, most of us are likely to hear our eye doctor say, "You have cataracts."
Most cataracts are associated with the aging process and are common among older Americans. In fact, according to the National Eye Institute (NEI), 68.3 percent of Americans 80 and older had cataracts in 2010.
And the prevalence of cataracts in the U.S. is expected to grow significantly in the years ahead, due in part to the aging of the population. In 2010, roughly 24.4 million Americans had cataracts, and that number is projected to grow to 50.2 million by the year 2050, according to NEI.
Thankfully, modern cataract surgery is one of the safest and most effective surgical procedures performed today.
More than 3 million cataract surgeries are performed in the United States every year, with the vast majority of these procedures produce excellent visual outcomes.
Cataract Surgery Basics
In cataract surgery, the lens inside your eye that has become cloudy is removed and replaced with an artificial lens (called an intraocular lens, or IOL) to restore clear vision.
The procedure typically is performed on an outpatient basis and does not require an overnight stay in a hospital or other care facility.
Most modern cataract procedures involve the use of a high-frequency ultrasound device that breaks up the cloudy lens into small pieces, which are then gently removed from the eye with suction.
This procedure, called phacoemulsification or "phaco," can be performed with smaller incisions than previous surgical techniques for cataract removal, promoting faster healing and reducing the risk of cataract surgery complications, such as a retinal detachment.
After all remnants of the cloudy lens have been removed from your eye, the cataract surgeon inserts a clear intraocular lens, positioning it securely behind the iris and pupil, in the same location your natural lens occupied. (In special cases, an IOL might be placed in front of the iris and pupil, but this is less common.)
The surgeon then completes the cataract removal and IOL implantation procedure by closing the incision in your eye (a stitch may or may not be needed), and a protective shield is placed over the eye to keep it safe in the early stages of your cataract surgery recovery.
Laser Cataract Surgery
Recently, a number of femtosecond lasers — similar to the lasers used to create the corneal flap in all-laser LASIK — have been approved by the FDA for use in cataract surgery performed in the United States.
These lasers have gained approval for the following steps in cataract surgery, reducing the need for surgical blades and other hand-held tools:
Creating corneal incisions to allow the surgeon access to the lens
Removing the anterior capsule of the lens
Fragmenting the cataract (so less phaco energy is required to break it up and remove it)
Creating peripheral corneal incisions to reduce astigmatism (when needed)
Laser cataract surgery (or, more accurately, laser-assisted cataract surgery) is fairly new and significantly increases cataract surgery cost, primarily because the laser can cost from $300,000 to $500,000 for a surgeon to purchase and there are other significant costs associated with the use and maintenance of this technology.
While studies have shown that lasers can improve accuracy during certain steps of cataract surgery, they may not necessarily improve cataract surgery safety, recovery time and visual outcomes in every case.
For the latest information about laser cataract surgery, ask your eye doctor during your preoperative eye exam and cataract surgery consultation.
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Preparing for Cataract Surgery and Choosing an IOL
Prior to cataract surgery, your optometrist and/or ophthalmologist will perform a comprehensive eye exam to check the overall health of your eyes, evaluate whether there are reasons why you should not have surgery and identify any risk factors you might have.
A refraction also will be performed to accurately determine the amount of nearsightedness, farsightedness and/or astigmatism you have prior to surgery. Additional measurements of your eyes will be taken to determine the curvature of your cornea and the length of your eye.
These measurements are essential to help your cataract surgeon select the proper power of the intraocular lens and give you the best vision possible after surgery.
Today you have many types of IOLs to choose from for your cataract surgery, depending on your specific needs. In addition to IOLs that correct nearsightedness and farsightedness, there are now toric IOLs that correct astigmatism as well.
If you don't mind wearing glasses after cataract surgery, a monofocal lens implant usually is used. Often, only part-time use of reading glasses is needed after cataract surgery with monofocal IOLs. But if prescription eyeglasses are needed (which often is the case if you only need cataract surgery in one eye), your eye doctor typically will prescribe new glasses for you approximately one month after surgery.
If you like the idea of being less dependent on glasses after cataract surgery, one way to correct presbyopia and reduce your need for reading glasses is to have your cataract surgeon adjust the power of one of your monofocal IOLs (assuming you have cataract surgery performed in both eyes) to give you a monovision correction, similar to monovision with contact lenses.
Another option is to choose one of a variety of advanced presbyopia-correcting IOLs to improve your reading vision without sacrificing your distance vision. Presbyopia-correcting IOLs include accommodating IOLs and multifocal IOLs; both types are designed to provide a greater range of vision after cataract surgery than conventional monofocal IOLs.
Be aware that not everyone is a good candidate for these premium IOLs, and choosing a presbyopia-correcting IOL will increase the out-of-pocket cost of your cataract surgery, since the added cost of these advanced lens implants is not covered by Medicare or other insurance plans.
Prior to cataract surgery, in addition to discussing the different types of IOLs, you will be advised about what to expect before, during and after your procedure. This information — which may be presented orally, in writing, via a video presentation or a combination of all three — is meant to help you make an informed decision about whether to proceed with surgery.
If you have any questions or concerns about cataract surgery, be sure to discuss them with your eye doctor and cataract surgeon prior to signing "informed consent" documents authorizing surgery.
Also, discuss with your eye doctor all medications you are taking, including non-prescription ("over-the-counter") formulations and nutritional supplements. Some medications and supplements can increase your risk of cataract surgery complications and might need to be discontinued prior to surgery. Ask your doctor for details.
Cataract Surgery Recovery
An uncomplicated cataract surgery typically lasts only about 15 minutes. But expect to be at the surgical center for 90 minutes or longer, because extra time is needed to prepare you for surgery (dilating your pupil; administering preoperative medication) and for a brief post-operative evaluation and instructions about your cataract surgery recovery before you leave.
You must have someone drive you home after cataract surgery; do not attempt to drive until you have visited your eye doctor the day after surgery and he or she tests your vision and confirms that you are safe to drive.
You will be prescribed medicated eye drops to use several times each day for a few weeks after cataract surgery. You also must wear your protective eye shield while sleeping or napping for about a week after surgery. To protect your eyes from sunlight and other bright light as your eye recovers, you will be given a special pair of post-operative sunglasses.
Also, many centers require someone to be with you after cataract surgery if you received anesthesia. Be sure to ask about this requirement prior to your cataract procedure so you are prepared for surgery day.
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 that would expose your healing eye to dust, grime or other infection-causing contaminants.
Your cataract surgeon may give you other instructions and recommendations for your cataract surgery recovery, depending on your specific needs and the outcome of your procedure. If you have any questions at any time after cataract surgery, call your eye doctor for advice.
If you need cataract surgery in both eyes, your surgeon typically will prefer that you wait one to three weeks between procedures, so your first eye has healed sufficiently and you have good vision in that eye before the second surgery is performed.
Eyeglasses After Cataract Surgery
Unless you choose presbyopia-correcting IOLs, it's likely you will need reading glasses after cataract surgery to see near objects clearly. Even people who choose these premium IOLs often find reading glasses are helpful for certain near tasks and seeing very small print.
In the event you have some mild refractive errors present after surgery (this is common), you may want to wear eyeglasses with progressive lenses full-time after your surgery to attain the best possible vision at all distances.
Even people who have an excellent visual outcome and can see well without glasses after cataract surgery often choose to wear eyeglasses full-time after their procedure to protect their eyes and because they feel more like themselves wearing eyeglasses after surgery if they have worn glasses most of their life.
If you choose to wear glasses after cataract surgery, lenses with anti-reflective coating and photochromic lenses are highly recommended for the best vision, comfort and appearance. Ask your eye care professional for details and to demonstrate these lenses.
Alternatives to Cataract Surgery
Cataract surgery is proven to be safe and effective, with a low risk of serious complications. But wouldn't it be great if eye drops could dissolve cataracts without the need for costly surgery? For one thing, maybe they could help people who live in areas without surgeons or affordable health care.
In a recent study of congenital cataracts (meaning, cataracts that are present from birth), University of California San Diego researchers found that a molecule called lanosterol prevents cataract-causing proteins from adhering to each other, keeping the human lens clear. But if the molecule is abnormal because of a gene mutation, the proteins will adhere and make the lens cloudy.
The researchers created eye drops containing lanosterol, tested them in rabbit eye lenses and found the lenses were clearer after a few days. In live dogs' eyes the drops also reduced the effect of their cataracts.
The drops don't work as well as surgery, because they don't eliminate the cloudiness in the lens — they only reduce it. Further testing may produce a more effective formula, but that will take time.
Still, the potential exists for cataract-dissolving drops to be used routinely someday not just in animals, but also in humans. — L.S.
Cataract Surgery After LASIK
Researchers in Japan discovered something interesting about people having cataract surgery after having had LASIK: they may need cataract surgery sooner.
In the retrospective study, three groups of patients were evaluated:
LASIK Group: Forty consecutive patients scheduled for cataract surgery who had previously undergone LASIK.
Control Group 1: A group of 606 patients having cataract surgery who did not previously have LASIK, but whose eyes were matched to the LASIK group for axial length (front-to-back length of the eyeball, a factor in the degree of myopia).
Control Group 2: A group of 3,642 patients having cataract surgery whose eyes were not matched to those of the LASIK group for axial length.
The mean age at cataract surgery for patients who previously had LASIK was 54.6 years — about 10 years younger than those in control group 1 (matched axial length) and about 15 years younger than those in control group 2 (unmatched for axial length).
Also, 70 percent of patients in the LASIK group were men, a significantly higher percentage than in the control groups. And the rate of corneal higher-order aberrations was significantly higher in the LASIK group than in the control groups.
The study authors concluded that patients with longer-than-average eyeball length (associated with higher myopia) and an increase in corneal higher-order aberrations might need to have cataract surgery performed earlier if they have previously undergone LASIK surgery.
A report of the study appeared in February 2015 in Journal of Cataract & Refractive Surgery. — G.H.
Notes and References
Cataracts. National Eye Institute website. Accessed September 2014.
*Prevalence of cataract and pseudophakia/aphakia among adults in the United States. Archives of Ophthalmology. April 2004.