Preparing for Cataract Surgery
Cataract surgery is usually done as an outpatient procedure under local anesthesia and takes less than an hour. Preoperative preparations may include:
- Having a general physical examination is important for patients with medical problems such as diabetes. Diabetes can cause damage to the blood vessels of the eye’s retina, a condition called diabetic retinopathy. If you have diabetes, discuss with your doctor how your blood sugar level may affect the surgery.
- Reviewing all medications with the ophthalmologist. In particular, men who take tamsulosin (Flomax, generic), or similar drugs for prostate problems, require special surgical techniques to prevent complications.
- The ophthalmologist will use a painless ultrasound test to measure the length of the eye and determine the type of replacement lens that will be needed after the operation.
- Topical antibiotics (such as ofloxacin or ciprofloxacin) may be applied preoperatively to protect against postoperative infection.
- Most healthy patients receive either a local injection or topical anesthetic. They may also receive a sedative. Some patients may need general anesthesia.
All cataract procedures involve removal of the cataract-affected lens and replacing it with an artificial lens.
Phacoemulsification. Phacoemulsification (phaco means lens; emulsification means to liquefy) is the most common cataract procedure performed in the United States.
The procedure generally involves:
- The surgeon makes a small incision.
- A thin probe that transmits ultrasound is used to break up the clouded lens into small fragments.
- The tiny pieces are sucked out with a vacuum-like device.
- A replacement lens is then inserted into the capsular bag where the natural lens used to be.
Phacoemulsification requires only local anesthesia. Most phacoemulsification procedures take about 15 minutes, and the patient is usually out of the operating room in about an hour. There is little discomfort afterward, and visual rehabilitation takes about 1 - 3 weeks.
Phacoemulsification is sometimes combined with glaucoma surgical procedures, for patients who have both glaucoma and cataracts.
Extracapsular Cataract Extraction. Extracapsular cataract extraction, the original standard procedure, is now generally used only in patients who have an extremely hard lens. In this procedure, the surgeon leaves intact the posterior capsule, which adds structural strength to the eye. A replacement lens is then inserted. .
Replacement Lenses and Glasses
With the clouded lens removed, the eye cannot focus a sharp image on the retina. A replacement lens or eyeglasses are therefore needed:
Intraocular Lenses (IOLs).An artificial lens, known as an intraocular lens (IOLs), is usually inserted after the cataract is extracted. Most IOLs are made out of acrylic, although other materials, such as silicon, are also used.
IOLs are designed to improve specific aspects of vision. The choices include:
- Lenses that address a single fixed focal point. Such lenses are suitable either for reading or distance vision, but not both. If a distance lens is implanted, the surgeon prescribes glasses or contact lenses for reading. If a reading lens is implanted, lenses for seeing distances will be prescribed.
- Lenses that address multifocal points. Multifocal lenses can focus at different points for both reading and distance vision. However, contrast may be reduced, and some patients experience glare and halos, particularly at night.
- Lenses are available to correct astigmatism after cataract surgery.
The patients and the doctor must make these decisions based on specific visual needs. Many patients also need eyeglasses after cataract surgery for reading or to correct astigmatism.
Complications of Cataract Surgery
Cataract surgery is one of the safest of all surgical procedures. Most complications, even if they occur, are not serious. They can include:
- Swelling and inflammation can occur in the days or weeks following surgery. Risk is about 1%. This complication can be particularly harmful for patients with existing uveitis (chronic inflammation in the eye, which can be due to various medical conditions).
- Retinal detachment. In rare cases, the retina at the rear of the eye can become detached.
Glaucoma. This is an eye condition in which the pressure of fluids inside the eye rises dangerously. Risk is very low, but patients should be sure to avoid activities after surgery that increase pressure.
- Infection. This is very rare (0.2%) but may be significant if it does develop.
- Bleeding can develop inside the eye.
- Posterior capsular opacification is one the more common complications of cataract surgery.
Preventing Infection and Reducing Swelling. The ophthalmologist may prescribe the following medications after surgery:
- A topical antibiotic may protect against infection.
- Corticosteroid eyedrops or ointments are often used to reduce swelling, but they can pose a risk for increased pressure in the eye.
- Nonsteroidal anti-inflammatory drugs (NSAIDs), such as diclofenac, ketorolac, naproxen, and voltaren, also reduce swelling and do not have the same risks as steroids. Newer NSAIDs approved to treat pain and swelling after cataract surgery include bromfenac (Xibrom) and nepafenac (Nevanac).
Factors that Increase Risk for Complications. The risks of complications are greater for the following people:
- Patients who have other eye diseases.
- People with diabetes. Intracapsular and extracapsular cataract extraction can pose a high risk for the development or worsening of retinopathy, a known eye complication of diabetes.
- People who have taken tamsulosin (Flomax, generic) or other alpha-1 blocker drugs. Tamsulosin is a muscle relaxant prescribed for treatment of several urinary conditions, including benign prostatic hyperplasia (BPH). Tamsulosin may cause intraoperative floppy iris syndrome (IFIS), a loss of muscle tone in the iris that can cause complications during eye surgery. Problems have been reported both for patients who were taking the drug during surgery as well as those who had stopped taking the drug weeks or months before surgery. Men who have taken tamsulosin or similar drugs should inform their eye surgeon. The surgeon may need to use different techniques to minimize the risk of IFIS and other complications.
Returning Home and Follow-up Visits.
- Patients usually leave the surgical site within an hour of surgery. Cataract surgery almost never requires an overnight hospital stay.
- Patients need someone to drive them home and stay with them for a few days until their vision improves.
- The patient is usually examined the day after surgery and then during the following month. Additional visits occur as necessary.
- Vision usually remains blurred for a while but gradually clears, usually over 2 - 6 weeks. (It can take longer.)
- When the doctor decides the condition has stabilized, the patient will receive a final prescription for glasses or contacts.
Protecting the Eye. Postoperative protection of the eye typically involves:
- The ophthalmologist usually tapes a bandage over the eye to protect it during the healing process.
- When changing the bandage, the eye can be cleaned gently using a washcloth dipped in warm water without soap. A new bandage can then be positioned and taped.
- It is very important not to press or rub the eye during this procedure.
- An eye shield may be placed over the bandage at night.
Avoiding Glaucoma. Cataract surgery can cause glaucoma, a condition in which the pressure of fluids inside the eye rises dangerously. It is very important to minimize any activity that increases internal eye pressure. Postoperative cataract patients should take the following precautions:
- Minimize vigorous exercise.
- Put on shoes while sitting and without bending over.
- Kneel instead of bending over to pick something up.
- Avoid lifting.
- Limit reading since it requires eye movement (watching television is all right).
- Sleep on the back or on the unoperated side.
Treatment of Posterior Capsular Opacification (Secondary “After Cataract”)
About 15% of patients who have cataract surgery develop a secondary "after-cataract" called posterior capsular opacification. Posterior capsular opacification is a clouding of the lens capsule that was left behind when the original cataract was removed. It generally occurs because after surgery there are still some natural lens cells left behind that proliferate on the back of the capsule.
The standard treatment for posterior capsular opacification is a type of laser surgery known as a YAG capsulotomy. (Capsulotomy means cutting into the capsule, and YAG is an abbreviation of yttrium aluminum garnet, the laser most often used for this procedure.) This procedure can help improve vision and reduce glare.
- This is an outpatient procedure and involves no incision.
- Using the laser beam, the ophthalmologist makes an opening in the clouded capsule to let light through.
- After the procedure, the patient remains in the doctor's office for an hour to make sure that pressure in the eye is not elevated.
- The doctor will usually prescribe anti-inflammatory eyedrops for the patient to take at home.
- Most patients will find that their vision improves within a day.
- An eye examination for any complications should follow within 2 weeks.
Complications. YAG laser capsulotomy is generally a safe procedure. Serious complications are rare, but can include retinal detachment.