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Cataract Surgery Procedure – Treatment for Cataracts

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    Jay Lustbader, MD
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    Jay Lustbader, MD
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Cataract surgery is the removal of the lens inside the eye after it has become cloudy due to aging, an eye injury or other causes. In most cases, the cataract surgeon replaces the cloudy natural lens with an artificial lens implant (also called an intraocular lens, or IOL) to restore vision and eliminate the need for thick glasses after surgery.

Cataract surgery is one of the most frequently performed surgical procedures in the United States and throughout the world. According to Bausch & Lomb, a leading American eyecare company, more than three million cataract surgeries are performed in the U.S. every year, and more than 50 percent of Americans over age 65 have cataracts in one or both eyes.

The number of Americans undergoing cataract surgery is expected to increase significantly over the next 20 years as the United States population ages.

When is Cataract Surgery Needed?

Not all cataracts require surgery. Some lens opacities are mild and/or limited to the periphery of the lens and don't significantly affect vision.

But when cataracts cause vision problems, it's time to have them removed. This is especially true if your cataracts are causing problems with your driving vision and are increasing your risk of an accident.

  • Signs and symptoms of vision problems caused by cataracts include:
  • Blurred vision
  • Poor night vision
  • Colors appearing less vivid or "washed out"
  • Glare and halos around lights at night
  • Sensitivity to light
  • The need for frequent changes to your glasses prescription
  • The need for brighter light when reading
  • Double vision (especially if present with one eye closed)

In many cases, loss of vision from cataracts occurs very gradually, and you may not be fully aware of the extent of vision loss you are experiencing for real-world conditions, such as driving at night. A comprehensive eye exam often will reveal vision loss from cataracts before a person knows they have a problem.

To detect and assess vision loss associated with cataracts, your eye doctor may use a special test called a contrast sensitivity test, and may conduct the test with and without a glare source. According to the American Academy of Ophthalmology Preferred Practice Guidelines, assessing visual acuity with only a standard black-on-white eye chart can underestimate the vision loss caused by cataracts and, in these cases, a contrast sensitivity test may be needed to accurately determine a person's real-world level of vision.

Routine eye exams are extremely important after age 40 to monitor the status of your vision and determine if cataracts are causing vision problems. And if you have been told you have "early cataracts" or you are over age 60 you should have an annual eye exam, says the American Optometric Association.

Types of Cataract Surgery

There are two types of cataract surgery: phacoemulsification (or "phaco") and extracapsular. Of the two, phaco cataract surgery is the more advanced procedure and is more popular than extracapsular cataract surgery.

Phaco Cataract Surgery

Phacoemulsification is the most widely used type of cataract surgery performed in the United States. In phaco, the surgeon makes a small incision (usually less than 3mm, or one-eighth of an inch) on the side of the cornea, and inserts a probe through this opening. The probe emits ultrasonic waves that soften and break up the cloudy lens, which is then suctioned from the eye in small pieces.

A foldable intraocular lens (IOL) is then placed in a tubular device that is inserted into the same incision. The device then gently ejects the IOL into the space the natural lens previously occupied, where it unfolds. The surgeon then positions the lens with a small forceps to complete the surgery.

Due to the small size of the incision used in phaco, the procedure is sometimes called "small incision cataract surgery."

Extracapsular Cataract Extraction

Extracapsular (or "extracap") cataract surgery, also called extracapsular cataract extraction (ECCE), is an older procedure that requires a larger surgical incision than phaco. One instance when an extracap procedure may be preferred over phacoemulsification is when a cataract is very advanced and may be too hard to be successfully broken up with the phaco probe. In some of these cases, the surgery may start out as a phacoemulsification procedure, but must be converted to ECCE due to difficulty in breaking up the cataract with phaco.

Extracapsular procedures also are commonly performed is surgical centers in remote or poor areas where phacoemulsification technology or expertise may not be available.

In ECCE, the surgeon makes a longer incision—usually 6 mm or larger—where the cornea and sclera meet. The dense, cloudy core of the lens is removed in one piece or, in some cases, in two or more pieces. The rest of the lens is removed by suction.

Because extracapsular cataract surgery requires a larger incision, multiple sutures are needed to close the wound and there is greater risk these sutures will pull or distort the cornea and create unwanted astigmatism after surgery. Also, visual recovery is typically slower after ECCE than phaco, and there may be more post-operative discomfort.

Laser Cataract Surgery

New advancements in laser technology are under development that will allow most steps of the cataract surgery procedure to be performed using a laser. Laser cataract surgery is currently an area of intense research. You can learn about breaking news related to this research in the News section of our website.

Other Cataract Surgery Advances

Until recently, nearly all cataract surgery has been done under local anesthesia involving an injection of medicine behind or along the side of the eye to immobilize and numb the eye. Today, many cases of small incision phacoemulsification cataract surgery can be performed without an injection. The entire procedure, which generally takes less than 15 minutes, can be done with the eye being numbed with just medicated eye drops.

This "needle-free" cataract surgery eliminates the discomfort and risks associated with an injection, and it also speeds up visual recovery after surgery. Many patients report seeing better almost immediately after surgery, and usually don't need to wear an eye patch for the ride home after the procedure.

Another advance in cataract surgery associated with small incision, "needle-free' phaco procedures is the use of clear corneal incisions. Phacoemulsification and foldable IOL technology has enabled cataract surgeons to make smaller and smaller incisions. Over the past 20 years, incisions for cataract surgery have been reduced in length from more than 12 millimeters to three millimeters or less.

The small incisions associated with modern cataract surgery have also enabled surgeons to change their location. Instead of being made in the traditional location under the upper eyelid (at the junction of the cornea and sclera), the small incisions can be made entirely within the periphery of cornea, off to the side of the eye.

Smaller incisions are preferred because they cause less trauma to the eye, they allow the surgery to be performed with only eye drop anesthesia, and they induce less post-operative astigmatism compared to larger incisions. And since the cornea has no blood vessels, patients who need to take blood thinners for other medical conditions don't have to stop taking these medications prior to cataract surgery.

Because the clear corneal incisions of modern cataract surgery are so small, they will often seal on their own after the procedure without any need for stitches. For this reason, phaco cataract surgery frequently is called "no-stitch" cataract surgery. In some cases, a small incision may need just one stitch for the wound to be watertight. In these instances, a no-stitch cataract procedure becomes "single-stitch" cataract surgery.

Currently the cost for cataract surgery can vary depending on whether new advancements are incorporated into the surgical procedure.

Cataract Surgery Risks

Modern cataract surgery is safe and effective. According to the American Society for Cataract and Refractive Surgery (ASCRS), approximately 98 percent of cataract surgeries result in improved vision and most patients are very satisfied with their outcome.

However, like any surgical procedure, cataract surgery involves some risks. Unexpected complications and undesired outcomes can occur even when an experienced surgeon performs the procedure flawlessly.

Risks and potential complications of cataract surgery include:

Retinal Detachment

Retinal detachment (or detached retina) occurs when fluid seeps under a tear in the retina. Because the eye is being manipulated during cataract surgery, pressure changes inside the eye can increase the risk of retinal tear and subsequent detachment.

The hallmark symptoms of retinal detachment are flashes of light, a sudden increase in floaters and sudden loss of peripheral vision. Retinal detachments occur after about 1 of every 200 cataract surgeries, according to ASCRS.

Early detection is essential for successful treatment of retinal detachment. Treatment usually requires surgery performed by a retinal specialist.

Endophthalmitis

Endophthalmitis is a serious infection inside the eye. Symptoms include eye pain, redness, sensitivity to light and loss of vision. Symptoms usually occur within the first few days after surgery, but may take longer to develop in some cases. According to ASCRS, endophthalmitis occurs after about 1 of every 3,000 cataract surgeries.

Treatment of endophthalmitis usually involves injection of antibiotics into the eye. In some cases, a surgery called a vitrectomy may be required to remove the gel-like vitreous that fills the interior of the eye and has become contaminated with the infecting bacteria and toxins.

Cystoid Macular Edema

The macula is the most sensitive portion of the retina and contains cells responsible for the vision in our central visual field — the portion we use for reading, recognizing a person's face, seeing road signs, etc.

Cataract surgery can cause blood vessels in the retina to leak fluid into the retina, causing small fluid-filled cysts in the macula and a loss of central vision.

When this problem, called cystoid macular edema (CME), is caused by cataract surgery, symptoms are usually noticed about six weeks after surgery. But in some cases, CME can occur months after surgery.

Treatment usually involves the use of anti-inflammatory eye drops. Some cases may require the use of oral steroid medications, injections of steroids behind the eye or vitrectomy surgery.

For more information about risks and potential complications of cataract surgery, visit a cataract surgeon [link to LSN cataract surgeon directory] for a pre-operative evaluation and consultation.

Before Cataract Surgery

A week or two before surgery, you will be asked to have a physical exam and a comprehensive eye exam.

Be sure to tell your cataract surgeon about any health problems you have and any medications you take, including nutritional supplements and other over-the-counter (OTC) medicines. This is essential to properly assess your risks during surgery.

During your eye exam, your surgeon will discuss with you the many IOL options available — including accommodating IOLs and multifocal IOLs to treat presbyopia and reduce your need for reading glasses after cataract surgery.

Examples of accommodating IOLs include Bausch & Lomb's Crystalens IOLs. Examples of multifocal IOLs include Alcon's ReSTOR and ReZoom IOLs.

If you currently have astigmatism, you may also want to consider a toric IOL that can reduce astigmatism after surgery.

With the availability of accommodating IOLs, multifocal IOLs, toric IOLs and continuously improving surgical techniques, it is possible for today's cataract surgeons to not only to remove the cloudy lens from the eye, but also to reduce the patient's need for eyeglasses after cataract surgery.

When the specific goal of cataract surgery is to reduce or eliminate the need for eyeglasses after surgery, the procedure often is referred to as refractive cataract surgery. Cataract surgeons who also offer refractive surgery procedures—such as LASIK, PRK and phakic IOLs—are the best doctors to approach about refractive cataract surgery.

After Cataract Surgery

Immediately after Surgery

Cataract surgery typically is performed on an outpatient basis. Recovery time for cataract surgery is typically minimal and you can go home the same day, shortly after the procedure. You will be given eye drop medication to help prevent infections and inflammation.

Some discomfort and itching after surgery are normal. This discomfort should go away after a day or two. To protect your eye after surgery, you may be asked to wear an eye shield at bedtime for several days.

Eight Weeks after Surgery

Your vision may be blurred until the eye is fully healed. Generally this takes about eight weeks, at which time eyeglasses are prescribed, if needed.

If you want to reduce your dependence on eyeglasses after cataract surgery, you may want to consider LASIK, PRK or other laser refractive surgery, such as Epi-LASIK or LASEK. To reduce your need for reading glasses, ask your surgeon about multifocal LASIK, such as PresbyLASIK.

For the sharpest vision possible with laser refractive surgery after cataract surgery, many surgeons recommend wavefront LASIK (also called custom LASIK), which can correct minor optical errors called higher order aberrations that standard LASIK cannot address.

Several Months after Cataract Surgery

It is not unusual for some people who have had cataract surgery to experience a delayed complication called posterior capsule opacification (PCO). This occurs when the posterior portion of the lens capsule (which is left intact in the eye during cataract surgery) becomes cloudy.

The symptoms of PCO—blurred vision, glare, sensitivity to light, etc.—are virtually the same as those for a cataract. For this reason, PCO is sometimes called "after-cataract" or "secondary cataract."

Treatment for posterior capsular opacification involves creating a clear hole in the capsule with a special type of laser called a YAG laser. The treatment, called a YAG capsulotomy, takes only a few minutes and is painless. The laser energy passes through the cornea and the IOL without damaging them, and vision is restored nearly instantly.

For the latest information about cataract surgery and other topics described in this article and how they specifically relate to you, schedule a consultation with a cataract surgeon near you.

Note: This information is for general education purposes only. It is not to be used as a substitute for medical advice from your eye doctor or refractive surgeon.

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