cataract surgery

What is cataract surgery

Cataract surgery is an eye surgery performed under local anaeshetic to replace the lens inside your eye that has become cloudy with an artificial lens (called an intraocular lens, or IOL) to restore clear vision. Cataract eye surgery typically is performed on an outpatient basis and does not require an overnight stay in a hospital or other care facility. 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.

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.

Cataract eye surgery 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 (IOL), 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 eye 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.

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 U.S. Food and Drug Administration (FDA) for use in cataract surgery performed in the United States.

In laser cataract surgery, the surgeon creates a precise surgical plan for the corneal incision with a sophisticated 3-D image of the eye called an OCT (optical coherence tomography). The goal is to create an incision with a specific location, depth and length in all planes, and with the OCT image and a femtosecond laser, it can be performed exactly without the variable of surgeon experience.

This is important not only for accuracy but also for increasing the likelihood that the incision will be self-sealing at the end of the procedure, which reduces the risk of infection.

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)

For the latest information about laser cataract surgery, ask your eye doctor during your preoperative eye exam and cataract surgery consultation.

According to the National Eye Institute, 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 the National Eye Institute.

A cataract needs to be removed only when vision loss interferes with your everyday activities, such as driving, reading, or watching TV. Sometimes a cataract should be removed even if it does not cause problems with your vision. For example, a cataract should be removed if it prevents examination or treatment of another eye problem, such as age-related macular degeneration (AMD) or diabetic retinopathy.

Talk with your eye care professional about cataract surgery and make sure it’s right for you. Most eye doctors suggest considering cataract surgery when your cataracts begin to affect your quality of life or interfere with your ability to perform normal daily activities, such as reading or driving at night.

It’s up to you and your doctor to decide when cataract surgery is right for you. For most people, there is no rush to remove cataracts because they usually don’t harm the eye. But cataracts can worsen faster in people with diabetes.

Delaying cataract eye surgery generally won’t affect how well your vision recovers if you later decide to have cataract surgery. Take time to consider the benefits and risks of cataract surgery with your doctor.

If you choose not to undergo cataract surgery now, your eye doctor may recommend periodic follow-up exams to see if your cataracts are progressing. How often you’ll see your eye doctor depends on your situation.

What do you want from cataract surgery?

For some people, simply replacing a cloudy lens with a clear implant and wearing glasses for some activities is perfect. For others, achieving the best possible vision without glasses after cataract surgery is the goal. Your vision needs and expectations can help you and your ophthalmologist decide the best surgical option for you.

How long does cataract surgery take?

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.

Is cataract surgery painful?

No. You’ll receive local anesthetics to numb your eye and you may be given a sedative to help you relax. If you’re given a sedative, you may remain awake, but groggy, during surgery.

How much does cataract surgery cost?

Cataract surgery costs are generally covered by Medicare if you are Medicare eligible. Private insurance usually covers cataract surgery as well.

Medicare will cover your costs if your vision tests at a certain level of acuity or clarity. Private insurance plans may have similar vision requirements. If your surgery is covered you may still have some costs. Special types of IOLs will cost more. Choosing to have cataract surgery before your vision has deteriorated enough will cost more.

In certain cases, it might be possible to get coverage before you meet the age or vision requirements. Talk with your ophthalmologist if you are considering having early cataract surgery.

Extra costs associated with laser cataract surgery are unlikely to be covered by Medicare or private health insurance. Fees vary from one cataract surgeon to another, but it is likely you would pay a few hundred dollars extra per eye out-of-pocket for a laser-assisted procedure.

People who do not want to invest out-of-pocket money in laser cataract surgery can still feel confident about the traditional approach.

But if you want the best possible vision, laser cataract surgery is appealing. A more accurate incision, capsulotomy and astigmatic correction may help you achieve your goal of less dependence on glasses after cataract surgery.

To decide if laser cataract surgery is the best choice for you, ask your cataract surgeon for more information about this exciting technology during your preoperative exam and consultation.

What do you do if you don’t have Medicare or private insurance coverage?

You may still be able to reduce and manage the cost of cataract surgery. Ask about payment plans through your doctor’s office. See if your employer offers flexible spending accounts that can help. Your ophthalmologist can help you learn more about costs of cataract surgery. Discuss your options for affording the procedure.

Who can be offered laser-assisted cataract surgery?

Under today’s Medicare guidelines, only certain patients may be offered laser-assisted cataract surgery.

Specifically, your ophthalmologist can offer it if you have astigmatism diagnosed during your cataract consultation and would like to have that refractive error corrected during cataract surgery. In this situation, the laser is used to create specific incisions in the cornea to reshape it, treating the astigmatism.

You may also be offered laser cataract surgery if you choose to have a premium lens implanted, such as an astigmatism-correcting toric intraocular lens (IOL) or a multifocal intraocular lens (IOL). Ophthalmologists who use laser cataract removal technology explain that it allows them to see and map the lens capsule better and place the opening in the capsule more precisely, allowing for better centering of the intraocular lens (IOL).

Can you choose to have laser-assisted cataract surgery if you don’t have either of the conditions above?

Current Medicare guidelines say that a surgeon may not offer and charge for the laser-assisted cataract surgery unless one of the two conditions above is met.

Which type of cataract surgery has a shorter recovery time?

The recovery period for both laser-assisted cataract surgery and traditional cataract surgery is the same. Some people can see clearly almost immediately, while others may find their vision clears within about a week or two. Remember that it takes about 3 months to fully recover from cataract surgery.

What benefits does laser cataract surgery offer that traditional cataract surgery does not?

Using a laser to do cataract surgery allows the surgeon to make very precise incisions in less time. It can improve accuracy and consistency in the surgical steps. And in some cases, laser-assisted cataract surgery can provide a higher degree of correction for a refractive error, such as astigmatism, than traditional cataract surgery.

However, it is important to be aware that studies have not shown that laser-assisted cataract surgery results in fewer complications or better visual outcomes than traditional cataract surgery. With any type of cataract surgery, your outcome depends in large part on the skill and experience of your eye surgeon.

What is cataract

Cataracts are when the lens, a small transparent disc inside your eye, develops cloudy patches (see Figures 2 and 3). Inside your eyes, you have a natural lens. The lens bends (refracts) light rays that come into your eye to help you see. The lens should be clear, like the top lens in Figure 1 and 2.

Cataracts usually appear in both eyes. They may not necessarily develop at the same time or be the same in each eye.

When you’re young, your lenses are usually like clear glass, allowing you to see through them. As you get older, they start to become frosted, like bathroom glass, and begin to limit your vision.

If you have a cataract, your lens has become cloudy, like the bottom lens in the illustration. It is like looking through a foggy or dusty car windshield. Things look blurry, hazy or less colorful with a cataract. Over time these patches usually become bigger causing blurry, misty vision and eventually blindness.

How quickly the cataract develops varies among individuals and may even be different between the two eyes. Most age-related cataracts progress gradually over a period of years.

Cataracts more common in older adults and can affect your ability to carry out daily activities such as driving.

Cataracts can also affect babies and young children.

  • Cataracts are a very common reason people lose vision, but they can be treated. You and your ophthalmologist should discuss your cataract symptoms. Together you can decide whether you are ready for cataract surgery.

Types of cataracts

Cataract types include:

  • Cataracts affecting the center of the lens (nuclear cataracts). A nuclear cataract may at first cause more nearsightedness or even a temporary improvement in your reading vision. But with time, the lens gradually turns more densely yellow and further clouds your vision.

As the cataract slowly progresses, the lens may even turn brown. Advanced yellowing or browning of the lens can lead to difficulty distinguishing between shades of color.

  • Cataracts that affect the edges of the lens (cortical cataracts). A cortical cataract begins as whitish, wedge-shaped opacities or streaks on the outer edge of the lens cortex. As it slowly progresses, the streaks extend to the center and interfere with light passing through the center of the lens.
  • Cataracts that affect the back of the lens (posterior subcapsular cataracts). A posterior subcapsular cataract starts as a small, opaque area that usually forms near the back of the lens, right in the path of light. A posterior subcapsular cataract often interferes with your reading vision, reduces your vision in bright light, and causes glare or halos around lights at night. These types of cataracts tend to progress faster than other types do.
  • Cataracts you’re born with (congenital cataracts). Some people are born with cataracts or develop them during childhood. These cataracts may be genetic, or associated with an intrauterine infection or trauma. These cataracts also may be due to certain conditions, such as myotonic dystrophy, galactosemia, neurofibromatosis type 2 or rubella. Congenital cataracts don’t always affect vision, but if they do they’re usually removed soon after detection.

There are other types of cataract:

  • Secondary cataract. Cataracts can form after surgery for other eye problems, such as glaucoma. Cataracts also can develop in people who have other health problems, such as diabetes. Cataracts are sometimes linked to steroid use.
  • Traumatic cataract. Cataracts can develop after an eye injury, sometimes years later.
  • Congenital cataract. Some babies are born with cataracts or develop them in childhood, often in both eyes. These cataracts may be so small that they do not affect vision. If they do, the lenses may need to be removed.
  • Radiation cataract. Cataracts can develop after exposure to some types of radiation.

How a cataract forms

The lens, where cataracts form, is positioned behind the colored part of your eye (iris). The lens focuses light that passes into your eye, producing clear, sharp images on the retina — the light-sensitive membrane in the eye that functions like the film in a camera.

As you age, the lenses in your eyes become less flexible, less transparent and thicker. Age-related and other medical conditions cause tissues within the lens to break down and clump together, clouding small areas within the lens.

As the cataract continues to develop, the clouding becomes denser and involves a bigger part of the lens. A cataract scatters and blocks the light as it passes through the lens, preventing a sharply defined image from reaching your retina. As a result, your vision becomes blurred.

Cataracts generally develop in both eyes, but not evenly. The cataract in one eye may be more advanced than the other, causing a difference in vision between eyes.

Clear-and-Cloudy-Lenses

 

Figure 1. Normal eye anatomy

human-eye-anatomy

Figure 2. Structure of the human eye

human eye anatomy

Figure 3. Eye cataract

Eye cataract

Cataract Risk Factors

Besides aging, other cataract risk factors include:

  • having parents, brothers, sisters, or other family members who have cataracts
  • having certain medical problems, such as diabetes
  • having had an eye injury, eye surgery, or radiation treatments on your upper body
  • having spent a lot of time in the sun, especially without sunglasses that protect your eyes from damaging ultraviolet (UV) rays
  • smoking
  • obesity
  • high blood pressure
  • previous eye injury or inflammation
  • previous eye surgery
  • prolonged use of corticosteroid medications
  • drinking excessive amounts of alcohol

If you have any of these risk factors for cataract, you should schedule an appointment with your ophthalmologist.

Cataract Prevention

Protecting your eyes from sunlight is the best way to do this. Wear sunglasses that screen out the sun’s ultraviolet (UV) light rays. You may also wear regular eyeglasses that have a clear, anti-UV coating. Ultraviolet light from the sun may contribute to the development of cataracts. Wear sunglasses that block ultraviolet B (UVB) rays when you’re outdoors.Talk with your eye doctor to learn more.

No studies have proved how to prevent cataracts or slow the progression of cataracts. But doctors think several strategies may be helpful, including:

  • Have regular eye examinations. Eye examinations can help detect cataracts and other eye problems at their earliest stages. Ask your doctor how often you should have an eye examination.
  • Quit smoking. Ask your doctor for suggestions about how to stop smoking. Medications, counseling and other strategies are available to help you.
  • Manage other health problems. Follow your treatment plan if you have diabetes or other medical conditions that can increase your risk of cataracts.
  • Choose a healthy diet that includes plenty of fruits and vegetables. Adding a variety of colorful fruits and vegetables to your diet ensures that you’re getting many vitamins and nutrients. Fruits and vegetables have many antioxidants, which help maintain the health of your eyes. Studies haven’t proved that antioxidants in pill form can prevent cataracts. But, a large population study recently showed that a healthy diet rich in vitamins and minerals was associated with a reduced risk of developing cataracts. Fruits and vegetables have many proven health benefits and are a safe way to increase the amount of minerals and vitamins in your diet.
  • Reduce alcohol use. Excessive alcohol use can increase the risk of cataracts.

Types of cataract surgery

You may be offered a choice of two cataract surgical options: traditional cataract surgery or laser-assisted cataract surgery.

Traditional cataract surgery is one of the most common surgeries in the world. It is recognized as being safe and effective. Laser cataract surgery, which is not covered by most insurance plans, costs more than traditional cataract surgery and may provide some advantages in terms of precision and consistency—in the proper situation. So how do you decide which type of cataract surgery to have?

Here are some things you should understand about both kinds of cataract surgery. Talk with your ophthalmologist (and get another ophthalmologist’s opinion as well, if you prefer) to determine the best type of surgery for you.

Traditional cataract surgery

Traditional cataract surgery is one of the most frequently performed surgeries and also one of the most safe and effective, with predictable outcomes. It is highly dependent on surgeon skill, volume and experience. The first step in cataract surgery is making an incision in the cornea. With traditional cataract surgery, called phacoemulsification, the eye surgeon creates a small incision in the side of the cornea in the area where the cornea meets the sclera by hand-held metal or diamond blade. This incision allows the surgeon to gain access to the interior of the eye to break up and remove the cataract, which is a clouding of the eye’s natural lens that is located right behind the pupil. An instrument is inserted through this incision into the area behind the pupil where the eye’s lens sits in a capsule or bag. The surgeon uses the microsurgical instrument to create a circular opening in the lens capsule. Then a special pen-shaped probe is inserted through that opening to apply sound waves (ultrasound) to break up the cloudy center of the lens. Then the broken-up pieces of lens are suctioned out of the eye. An artificial intraocular lens (IOL) is implanted to replace the cloudy natural lens. The side walls of the corneal incision will be filled with a special liquid and self-seal after surgery, so most commonly stitches are not needed.

Laser-assisted cataract surgery

In laser cataract surgery, an advanced femtosecond laser replaces or assists use of a hand-held surgical tool for the following steps in cataract surgery:

  • The corneal incision
  • The anterior capsulotomy
  • Lens and cataract fragmentation

Use of a laser can improve the precision, accuracy and reproducibility of each of these steps, potentially reducing risks and improving visual outcomes of cataract surgery.

With laser-assisted cataract surgery, a camera/ultrasound imaging device is placed over your eye to map its surface and gather information about the lens. The device sends detailed information to a computer that programs the laser for the exact location, size and depth of the incisions. The surgeon uses the laser to make the corneal incision and the opening in the lens capsule. Energy from the laser may also be used to soften the cataract. Then the ultrasound probe used in traditional cataract surgery is used to break the lens into pieces and suction them out of the eye. The IOL is implanted. As with traditional cataract surgery, the corneal incision usually does not require stitches.

Laser cataract surgery systems

A number of medical device companies offer laser systems for performing laser cataract surgery. Systems that have attained FDA approval and are currently available for laser-assisted cataract surgery performed in the United States include:

  • LenSx. The LenSx system (Alcon) was the first femtosecond laser system to gain FDA approval for cataract surgery performed in the U.S. The LenSx system is approved for corneal incisions, capsulotomies and lens (cataract) fragmentation and has been used in more than 400,000 cataract refractive procedures worldwide, according to Alcon.
  • LensAR. The LensAR Laser System (LensAR, Inc.) is approved for corneal incisions, capsulotomies and lens (cataract) fragmentation. The “AR” stand for “Augmented Reality,” which refers to proprietary imaging technology that collects an unprecedented spectrum of biometric data and then reconstructs a sophisticated 3-D model of the anatomy of each patient’s eye, according to the company.
  • Catalys. The Catalys Precision Laser System (Abbott Medical Optics) also is FDA-approved for the three primary steps prior to IOL insertion in laser cataract surgery (corneal incision, capsulotomy and lens fragmentation). The Catalys system also features a liquid optics interface that provides gentle docking of the laser to the eye, reducing risks associated with high eye pressure during laser cataract surgery, according to AMO.
  • Victus. The Victus Femtosecond Laser Platform (Bausch + Lomb) also is FDA-approved for corneal incisions, capsulotomy and lens fragmentation in laser cataract surgery. The Victus system features proprietary Advanced Docking Technology that minimizes the possibility of eye tilt or distortion and enables precise alignment designed to maintain the natural shape of the eye during laser-assisted cataract surgery, according to the company.
  • Femto LDV Z8. This femtosecond laser system, produced by Ziemer Ophthalmics, offers a number of distinct advantages according to the company, including a higher repetition rate of the laser beam for faster procedures, low energy per laser pulse for gentler treatments, and overlapping laser spots for high precision and predictability.

All FDA-approved laser systems for laser cataract surgery have shown excellent outcomes in clinical trials. The laser your surgeon has chosen for his or her practice is a matter of personal preference, based on specific features and other factors. Typically, the skill of your surgeon is more important than the brand of laser used for the laser-assisted steps of your cataract procedure.

Who can be offered laser-assisted cataract surgery?

Under today’s Medicare guidelines, only certain patients may be offered laser-assisted cataract surgery.

Specifically, your ophthalmologist can offer it if you have astigmatism diagnosed during your cataract consultation and would like to have that refractive error corrected during cataract surgery. In this situation, the laser is used to create specific incisions in the cornea to reshape it, treating the astigmatism.

You may also be offered laser cataract surgery if you choose to have a premium lens implanted, such as an astigmatism-correcting toric IOL or a multifocal IOL. Ophthalmologists who use laser cataract removal technology explain that it allows them to see and map the lens capsule better and place the opening in the capsule more precisely, allowing for better centering of the IOL.

Can you choose to have laser-assisted cataract surgery if you don’t have either of the conditions above?

Current Medicare guidelines say that a surgeon may not offer and charge for the laser-assisted cataract surgery unless one of the two conditions above is met.
Which type of cataract surgery has a shorter recovery time?

The recovery period for both laser-assisted cataract surgery and traditional cataract surgery is the same. Some people can see clearly almost immediately, while others may find their vision clears within about a week or two. Remember that it takes about 3 months to fully recover from cataract surgery.

What benefits does laser cataract surgery offer that traditional cataract surgery does not?

Using a laser to do cataract surgery allows the surgeon to make very precise incisions in less time. It can improve accuracy and consistency in the surgical steps. And in some cases, laser-assisted cataract surgery can provide a higher degree of correction for a refractive error, such as astigmatism, than traditional cataract surgery.

However, it is important to be aware that studies have not shown that laser-assisted cataract surgery results in fewer complications or better visual outcomes than traditional cataract surgery. With any type of cataract surgery, your outcome depends in large part on the skill and experience of your eye surgeon.

Cataract surgery procedure

The entire cataract surgery takes about an hour to perform. Before beginning, you may be given a mild sedative to help you relax. Your eye then is dilated with eye drops and the area is numbed with a local anesthetic. It’s possible that you might remain awake during cataract surgery or you may drift off.

Your eye surgeon uses one of two methods to remove your cloudy lens:

  • By removing the lens in one piece after making an incision in your eye
  • By suctioning the lens out in pieces after breaking it up with an ultrasound probe

During cataract surgery, your eye surgeon will remove your eye’s cloudy natural lens. Then he or she will replace it with a clear artificial lens. This new lens is called an intraocular lens (IOL), is positioned in the same place as your natural lens. It remains a permanent part of your eye. When you decide to have cataract surgery, your doctor will talk with you about IOLs and how they work.

An intraocular lens (IOL) is a tiny, artificial lens for the eye. It replaces the eye’s natural lens that is removed during cataract surgery.

Intraocular lenses (IOLs) come in different focusing powers, just like prescription eyeglasses or contact lenses. Your ophthalmologist will measure the length of your eye and the curve of your cornea. These measurements are used to set your IOLs focusing power.

What are IOLs made of?

Most intraocular lenses (IOLs) are made of silicone or acrylic. They are also coated with a special material to help protect your eyes from the sun’s harmful ultraviolet (UV) rays.

Monofocal IOLs

The most common type of lens used with cataract surgery is called a monofocal IOL. It has one focusing distance. It is set to focus for up close, medium range or distance vision. Most people have them set for clear distance vision. Then they wear eyeglasses for reading or close work.

Multifocal IOLs

Some IOLs have different focusing powers within the same lens. These are called multifocal and accommodative lenses. These IOLs reduce your dependence on glasses by giving you clear vision for more than one set distance.

These IOLs provide both distance and near focus at the same time. The lens has different zones set at different powers. It is designed so that your brain learns to select the right focus automatically.

Accommodative IOLs

These lens move or change shape inside your eye, allowing focusing at different distances.

Toric IOLs

For people with astigmatism, there is an IOL called a toric lens. Astigmatism is a refractive error caused by an uneven curve in your cornea or lens. The toric lens is designed to correct that refractive error.

As you plan for your cataract surgery, talk to your ophthalmologist about your vision needs and expectations. He or she will explain IOL options for you in more detail.

However, for some people, other eye problems prohibit the use of an artificial lens. In these situations, once the cataract is removed, vision may be corrected with eyeglasses or contact lenses.

Cataract surgery is generally done on an outpatient basis, which means you won’t need to stay in a hospital after the surgery. During cataract surgery, your eye doctor uses local anesthetic to numb the area around your eye, but you usually stay awake during the procedure.

If you need cataract surgery in both eyes, your doctor will schedule surgery to remove the cataract in the second eye after you’ve healed from the first surgery.

What to expect with cataract surgery

Before cataract eye surgery

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.

The day of cataract eye surgery

Your ophthalmologist may ask you not to eat any solid food at least 6 hours before your surgery.

Cataract removal surgery may be done in an outpatient surgery center or in a hospital. Here is what will happen:

  • Your eye will be numbed with eye drops or with an injection around the eye. You may also be given a medicine to help you relax.
  • You will be awake during surgery. You may see light and movement during the procedure, but you will not see what the doctor is doing to your eye.
  • Your surgeon will enter into the eye through tiny incisions (cuts, created by laser or a blade) near the edge of your cornea (the clear covering on the front of your eye). The surgeon uses these incisions to reach the lens in your eye. Using very small instruments, he or she will break up the lens with the cataract and remove it. Then your new lens is inserted into place.
  • Usually your surgeon will not need to stitch the incisions closed. These “self sealing” incisions eventually will close by themselves over time. A shield will be placed over your eye to protect it while you heal from surgery.
  • You will rest in a recovery area for about 15–30 minutes for observation to make sure there isn’t any sign of trouble, such as bleeding or a reaction to the anesthesia. Then you will be ready to go home.

Cataract eye surgery process

The Corneal Incision

Traditional cataract surgery is one of the most frequently performed surgeries and also one of the most safe and effective, with predictable outcomes. It is highly dependent on surgeon skill, volume and experience.

The first step in cataract surgery is making an incision in the cornea. In traditional cataract surgery, the eye surgeon uses a hand-held metal or diamond blade to create an incision in the area where the cornea meets the sclera. This incision allows the surgeon to gain access to the interior of the eye to break up and remove the cataract, which is a clouding of the eye’s natural lens that is located right behind the pupil. Next, an intraocular lens (IOL) is inserted and implanted, to replace the cloudy natural lens.

The corneal incision is made in special way so it will self-seal when surgery is complete, without any need for stitches.

In laser cataract surgery, the surgeon creates a precise surgical plan for the corneal incision with a sophisticated 3-D image of the eye called an OCT (optical coherence tomography). The goal is to create an incision with a specific location, depth and length in all planes, and with the OCT image and a femtosecond laser, it can be performed exactly without the variable of surgeon experience.

This is important not only for accuracy but also for increasing the likelihood that the incision will be self-sealing at the end of the procedure, which reduces the risk of infection.

The Capsulotomy

The eye’s natural lens is surrounded by a very thin, clear capsule. In cataract surgery, the front portion of the capsule is removed in a step called an anterior capsulotomy, to gain access to the cataract.

It is very important that the remainder of the lens capsule that remains intact in the eye is not damaged during cataract surgery, because it must hold the artificial lens implant in place for the rest of the patient’s life.

In traditional cataract surgery, the surgeon creates an opening in the capsule with a small needle and then uses that same needle or a forceps to tear the capsule in a circular fashion.

In laser cataract surgery, the anterior capsulotomy is performed with a femtosecond laser. Studies have shown that capsulotomies performed with a laser have greater accuracy and reproducibility.

Studies also have shown that laser capsulotomies enable better centering of the intraocular lens, and IOL positioning is a significant factor in determining final visual outcomes.

Lens And Cataract Fragmentation

After the capsulotomy, the surgeon now has access to the cataract to remove it. In traditional cataract surgery, the ultrasonic device that breaks up the cataract is inserted into the incision. During this phacoemulsification procedure, the ultrasound energy can lead to heat buildup in the incision, which sometimes can burn the incision and negatively affect the visual outcome by actually inducing astigmatism.

An incision burn also has a higher chance of leaking and sometimes needs multiple sutures to close. The smaller the incision we use, the more this issue is important to consider.

The laser, on the other hand, softens the cataract as it breaks it up. By breaking up the cataract into smaller, softer pieces, less energy should be needed to remove the cataract, so there should be less chance of burning and distorting the incision.

Laser cataract surgery may also reduce the risk of capsule breakage. After the calculation of the proper implant power, there is no step more important for visual outcome than preservation of the capsule that the natural lens sat in. This capsule is as thin as cellophane wrap and it’s important that the the portion that is left inside the eye after cataract surgery is undamaged, so it can hold the IOL in the proper position for clear, undistorted vision.

The reduced phacoemulsification energy required in laser cataract surgery may also make the procedure safer to the inner eye, which reduces the chance of certain complications, such as a detached retina.

Astigmatism Correction At The Time Of Cataract Surgery

To reduce the need for prescription eyeglasses or reading glasses after cataract surgery, it is important that little or no astigmatism is present after implantation of presbyopia-correcting multifocal IOLs and accommodating IOLs.

Astigmatism usually is caused by the cornea being more curved in one meridian than others (in other words, it’s shaped somewhat like an American football). To reduce astigmatism, small incisions can be placed in the periphery of this more curved meridian; as the incisions heal, this meridian flattens slightly to give the cornea a rounder, more symmetrical shape (like a baseball).

This procedure is called limbal relaxing incisions (LRI) or astigmatic keratotomy (AK). Surgeons can perform LRI or AK manually with a diamond blade, and it is quite effective in reducing astigmatism.

During refractive laser-assisted cataract surgery, the OCT (optical coherence tomography) image can be used to plan laser LRI or AK incisions in a very precise location, length and depth. This increases the accuracy of the astigmatism-reducing procedure and increased the probability of good vision without glasses after cataract surgery.

Cataract surgery recovery

Post cataract surgery

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.

While your eye heals, you might experience some eye redness and blurred vision during the first few days or even weeks following the procedure.

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.

Cataract surgery recovery time

  • After the procedure, you’ll have some discomfort for a few days.
  • Healing generally occurs within eight weeks.

Cataract surgery aftercare

Days or weeks after surgery:

  • You will have to use eye drops after surgery. Be sure to follow your doctor’s directions for using these drops.
  • Avoid getting soap or water directly in the eye.
  • Do not rub or press on your eye. Your ophthalmologist may ask you to wear eyeglasses or a shield to protect your eye.
  • You will need to wear a protective eye shield when you sleep.
  • Your ophthalmologist will talk with you about how active you can be soon after surgery. He or she will tell you when you can safely exercise, drive or do other activities again.

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

Vision after cataract surgery

According to American Society of Cataract and Refractive Surgery, studies show that 95 percent of patients who choose a standard intraocular lens (IOL) for cataract surgery have their vision fully restored to its pre-cataract state, and if you choose a premium intraocular lens (IOL) your vision may be even better than it was before.

If you have any problem with sensitivity to sunlight after cataract surgery, eyeglasses with photochromic lenses, which darken automatically to UV rays, often can provide relief. Also, for residual refractive error and presbyopia after surgery, progressive lenses with anti-reflective coating often can sharpen your vision for activities like night driving and reading.

People whose vision fails to improve after cataract surgery often have underlying eye disorders, such as age-related macular degeneration (AMD), diabetic retinopathy and other eye conditions. Some of these individuals may benefit from other procedures or from low vision aids.

Cataract surgery side effects

Cataract surgery complications are few, and cataract surgery is among the most common and most successful surgical procedures performed today.

According to the American Society of Cataract and Refractive Surgery, 3 million Americans undergo cataract surgery each year, with an overall success rate of 98 percent or higher.

Also, a study of more than 200,000 Medicare beneficiaries who underwent cataract surgery between 1994 and 2006 found that 99.5 percent of patients had no severe postoperative complications and the risk of severe complications has decreased with advances in surgical tools and techniques.

Cataract surgery complications

Cataract surgery is generally safe, but it carries a risk of infection and bleeding. Cataract surgery increases the risk of retinal detachment.

Some cataract surgery complications occur quite a while later. For example, a detached retina can occur months or years after a perfectly successful cataract procedure.

Most patients with retinal detachment have a good outcome if they see their ophthalmologist when symptoms first begin and treatment is done immediately. However, a small percentage will have substantially and permanently reduced vision.

Be sure to report floaters, flashes of light and a curtain-like vision loss to your ophthalmologist immediately, as these symptoms may indicate a retinal detachment has occurred.

Like any surgery, cataract surgery carries risks of problems or complications. Here are some of those risks:

  • Eye infection
  • Eye inflammation
  • Bleeding in the eye.
  • Droopy eyelid (ptosis)
  • Ongoing swelling of the front of the eye (cornea) or inside of the eye.
  • Swelling of the retina (the nerve layer at the back of your eye).
  • Macular edema (swelling of the central retina)
  • Detached retina (when the retina lifts up from the back of the eye).
  • Damage to other parts of your eye.
  • Pain that does not get better with over-the-counter medicine.
  • Vision loss.
  • Intraocular lens dislocation – the intraocular lens (IOL) implant may become dislocated, moving out of position.
  • Posterior capsule opacity (PCO)
  • Light sensitivity
  • Photopsia (perceived flashes of light)
  • Ocular hypertension (elevated eye pressure)

Your ophthalmologist will talk with you about the risks and benefits of cataract surgery. When cataract surgery complications do occur, most are minor and can be successfully treated medically or with additional surgery.

Posterior capsular opacification

One of the most common cataract surgery complications is a posterior capsule opacity (also called posterior capsule opacification or PCO). Your vision could become cloudy or blurry weeks, months or years after cataract surgery. This is not unusual. Posterior capsular opacification (PCO) is also called “secondary cataract” or “scar tissue.” It’s not like a scar you get on your skin. Posterior capsule opacification occurs because lens epithelial cells remaining after cataract surgery have grown on the capsule. But because it happens after the eye has healed from cataract surgery, some people think of it as a scar. In some cases, if the condition progresses significantly, your vision may be worse than it was before cataract surgery.

During cataract surgery, your surgeon will remove the cloudy natural lens of your eye (cataract) and replace it with an intraocular lens (IOL). Much of the thin clear membrane that surrounds the natural lens (called the lens capsule) is left intact during surgery and the IOL usually is implanted within it.

When the cataract is removed, your surgeon makes every attempt to maintain the integrity of the lens capsule, and normally your vision after cataract surgery should be very clear. However, in about 20 percent of patients, the posterior portion of the capsule becomes hazy some time during cataract surgery recovery or even months later, causing PCO.

Posterior capsular opacification (PCO) happens when a membrane called the posterior capsule becomes cloudy. It might help to think of the posterior capsule as a transparent pocket. It holds your intraocular lens (IOL) in place. It also once held your eye’s natural lens (what became the cataract) in place. If you notice cloudy vision again, you might need to have a laser procedure. The laser creates an opening in the cloudy capsule and is called a posterior capsulotomy (or a YAG laser capsulotomy). This procedure helps restore clear vision.

YAG laser capsulotomy involves just a few simple steps:

  • Usually the eye is dilated before the procedure, with dilating eye drops.
  • A laser removes the hazy posterior capsule from your line of sight without making an incision or “touching” the eye.
  • Many ophthalmologists recommend anti-inflammatory eye drops following the procedure.

The procedure takes only a few minutes and is entirely painless; nor does discomfort occur post-operatively.

You must remain still during the procedure, however. Very uncooperative patients, such as children and mentally disabled people, may require sedation.

Following a YAG laser capsulotomy, you may resume normal activities immediately. You may experience some floaters afterward. These will likely resolve within a few weeks.

Most people can expect their vision to improve within a day. As with any eye procedure, however, call your eye doctor immediately if vision worsens or fails to improve.

Because the YAG laser removes the central zone of the cloudy posterior capsule behind the intraocular lens, the condition cannot return. So only one laser treatment is required to permanently eliminate vision loss caused by posterior capsule opacification after cataract surgery.

YAG Laser capsulotomy risks

Although a YAG laser capsulotomy poses slight additional risk, overall the procedure is extremely safe. The most important risk is that the retina can become detached from the inner back of the eye.

Statistics suggest that the lifetime risk of a detached retina as a cataract surgery complication in the United States is about 1 percent. That number rises to about 2 percent after YAG laser capsulotomy. It is important to be aware of this cataract surgery risk.

Dislocated Intraocular Lenses

Another example of cataract surgery complications is malpositioned or dislocated intraocular lenses (IOLs). You may see the edge of the lens implant, or you may even develop double vision. If the intraocular lens becomes too badly dislocated, your visual acuity could decrease substantially.

How can an IOL become malpositioned or dislocated?

In most cataract surgeries, the intraocular lens is placed inside the “capsular bag,” which contains the cloudy natural lens or cataract of the eye.

Ophthalmologists make every attempt to maintain the integrity of the capsular bag so that the intraocular lens can be positioned correctly within it. But the capsular bag is extremely thin — approximately the thickness of a single red blood cell — and can sometimes rupture or break.

Also, the capsular bag itself may dislocate due to weakness or breakage of the fibers (zonules) that hold it in place, resulting in a condition known as zonular dialysis. This condition places you at risk of malpositioning or dislocation of the lens implant.

Even without underlying complications, intraocular lenses can still dislocate — especially if one of the springy “arms” holding the lens in place is positioned improperly inside the capsular bag or becomes malpositioned later on.

When an intraocular lens implant is malpositioned or dislocated, your cataract surgeon can probably reposition it in a second procedure. In some cases, the lens implant must be sewn in place, or another type of lens must be implanted.

If IOL dislocation occurs following a recent cataract surgery, repositioning the lens should be done soon. This is because lens implants begin to “scar” into place approximately three months after original implantation and can become much more difficult to remove.

If you do experience a malpositioned or dislocated intraocular implant, your chances of a good outcome following a second procedure are very good if you and your surgeon take action promptly.

Also, a recent Mayo Clinic study of more than 14,000 cataract surgeries performed between January 1980 and May 2009 found that the risk of late IOL dislocation after cataract surgery was very low: At 10 years after surgery, the cumulative risk was 0.1 percent; at 20 years, it was 0.7 percent; and at 25 years, it was 1.7 percent.

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