Actual Cataracts Surgical Process and Procedure
Who can get surgery?
A patient is deemed a good candidate for cataracts surgery if the cataract has reached a stage where the resulting impaired vision is decreasing the individual!!!s quality of life. Many patients believe that their cataracts must be ripe before surgery can be undertaken. This is not true. Any cataracts can be removed during surgery. In the past, it was preferred that patients wait until the last possible moment in case any problems arose during surgery that might later impede their vision. However, today, where cataracts surgery is done on a routine basis and is one of the most common outpatient surgeries performed; there is no need to wait until the cataracts reaches a particular condition. If the cataracts is impairing vision, it can be removed.
Which power of lens should be used?
Before the actual surgical procedure takes place, the doctor and patient must decide which power of lens will be most beneficial for the patient. With over 65 different powers, there will surely be one that fits best for each individual. The final power will be chosen based on several factors, one of the most important being the type of lifestyle the person leads. Do they need to read up close on a regular basis or is far vision more important? In some cases a patient may opt to have a different power lens placed in each eye. A computer generated print out, based on the criteria that is input by the doctor and patient, will calculate the proper power of lens for each patient. Unlike trying on glasses or contact lenses, there is no way to determine if the power that is chosen is the correct one, as IOL!!!s can not be tried on before surgery. Therefore it is crucial that the doctor and patient both understand exactly what the desired outcome is so that the best choice can be made.
Most surgeons do not require patients to stop or decrease their currently prescribed medication. However, this topic should be addressed and discussed well in advance of surgery. Eye Drops Patients are given special eye drops when they arrive for surgery, some may be given a few days before the procedure while others are administered only a few hours prior to surgeryThe first eye drop, an antibiotic, is applied to decrease the risk of infection by killing off certain strains of bacteria in the eyeball which are known to cause problems in this area. A second eye drop is used to reduce inflammation during and after the surgery. And, finally, a special eye drop is given which dilates the pupil allowing the surgeon to view the working field more clearly.
Different forms of anesthesia, local, topical or regional are available for cataracts surgery. The specific type given to the patient will be based on multiple variables; however, all forms of anesthesia work in such a manner that no pain is felt by the patient. If a topical anesthesia is chosen for surgery it is administered through the use of eye drops. No injection is needed, adding to the benefit of using a topical anesthesia over a local anesthesia where the medication is injected via a small needle. The injection used in a local anesthesia has the potential to have minor side effects such as slight discomfort, swelling or bruising. This is another reason why many patients and doctors now prefer the topical eye drops. Regional anesthesia is almost never given unless the patient needs for some reason to be unconscious during the surgery. Examples include children or patients with mental/nervous disorders who cannot sit still or deal with the mental stress of surgery. Nevertheless, the surgeon and patient should discuss which anesthesia will be most advantageous to the patient, as each type provides both benefits and drawbacks, keeping in mind though that all forms serve the purpose of blocking out pain during the surgery and are extremely efficient in this regard. One note however, is that under normal circumstances, topical anesthesia can only be used with small-incision surgery (please see An In-Depth Look at the Cataracts Surgery Procedure for description of small-incision surgery).
Surgery is Safe, Fast and Easy
Routinely, cataracts surgery is performed as an outpatient procedure. The patient usually arrives one to two hours before the scheduled surgery time. This period is used to prepare the patient for surgery; the required eye drops are administered, the patient is given a verbal explanation of what will occur, patient questions are answered, and the patient is then settled into a comfortable position ready for the surgery. The actual surgery only takes 20-30 minutes. The patient normally remains awake, although in some cases if there is need for sedation such as being overly anxious or fearful, a mild sedative can be given. The patient is asked to remain as still as possible and to inform the physician if any movement, such as an itch or a cough, is to be made. Typically, after surgery several post-op exams are performed to ensure that the lens was placed correctly and that the vision has returned to the eye. The patient is then given instructions for recovery and most often discharged from the facility within an hour or two post-op. Risks of Cataract Surgery Cataract surgery has become one of the most common and well-perfected surgeries performed in North America. Its success rate is extremely high and side effects and risks extremely low. However, as with all invasive procedures, there will always be potential for problems involved.
Possible complications consist of the following:
- Endophthalmitis (an infection of the eye)
- High pressure in the eye
- Drooping eyelid
- Detachment of the retina
- Choroidal hemorrhage (bleeding that occurs behind the retina)
- Small fragments of lens which can become lodged behind the vitreous or back cavity of the eye.
- Potential for loss of sight.
- Loss of the eye
One of the two most common side effects includes an inflammatory reaction in the eye where swelling can occur and the ocular region may be tender for a few days. This is easily treated with an antibiotic or anti-inflammatory drug. The second most common side effect is known as macular edema. This is where there is fluid retention in the retina. Macular edema is more frequently seen in patients who already have a prior health problem such as diabetes. There are treatments for fluid retention as well; however, this problem usually resolves itself. The success rate of cataracts surgery (defined as having no serious complications and resulting in improved vision) with today!!!s advanced methods and ultra-modern equipment is at an astonishing 95%. And, the risk of becoming blind with surgery for cataracts removal is extremely low. 18 For those few patients where surgery does not result in improved vision, there is usually a different underlying ocular condition such as age related macular degeneration (ARMD) or diabetic retinopathy. On the flip side of the coin, there are great advantages in quality of life and safety issues related to the successful treatment of a cataracts. Patients report improved ability to drive, read, walk, and work, practice hobbies, engage in social activities and increase their self-reliance, self-confidence and independence.
What to expect after surgery
In some cases after surgery, the surgeon may require the patient to wear an eye patch for a specified time frame. This mainly occurs with large incision cataracts surgery but is possible with other forms as well. Additionally, most patients will continue with the anti-inflammatory and antibiotic eye drops for several weeks. Patients will return to visit the surgeon for a follow-up appointment within a day or two of surgery to assess the procedure and results. If stitches were needed after surgery they most likely will dissolve on their own requiring no additional appointment to have them removed. A majority of patients are able to return to a full schedule of activity to include physical movement, reading, driving and watching TV within a matter of hours or a few short days. As the best vision resulting from the cataracts surgery won!!!t usually show up until several weeks later (although the time frame varies extremely from individual to individual) the surgeon will more than likely request that the patient wait approximately four to six weeks before obtaining a new eye glass or contact lens prescription. People who have had cataracts surgery are pleased with the results obtained and site improved vision, enhanced views, and brighter colors. Many claim they can see better after surgery than they could before the cataracts ever formed.
Will the cataracts return?
A cataracts cannot return for one simple reason. The natural lens upon which the original cataracts formed is removed during surgery. However, some clouding may take place over a few years within the posterior section of the lens capsule itself. The cloudiness is a result of cells gathering in the middle of the capsule and preventing incoming light from hitting the retina. If this occurs there is a very simple and safe procedure which can be performed. The outpatient process for clearing up this minor problem is called YAG capsulotomy. It is painless and quick. YAG capsulotomy requires the doctor to make a small hole in the capsule with a laser beam to allow light to pass through. In the past, before YAG capsultomoy was used, a small incision had to be made and a tiny knifelike instrument inserted into the eye to cut a tiny hole into the posterior capsule. Today, however, as the hole is cut with a beam of light there are no knives or surgical incisions required. The light beam is directed to the center of the capsule, creates a small opening and clears the cloudiness.
Vision aids after surgery
After surgery is performed many patients will still require glasses or contact lenses to bring objects into completely clear view. This is normal. However, in most cases the power of glasses or contact lenses required is less than what was needed prior to surgery.. It is advised to wait at least a month before obtaining new glasses or contact lenses to give the eyes time to readjust and come back to a new normal. Since some of the new artificial intraocular lenses (IOL) block UV radiation, in some cases it is not necessary to wear sunglasses after cataracts surgery - check with the surgeon. However, many people enjoy wearing sunglasses or feel more comfortable with them on. If this is the case, by all means, wear them.
In rare cases, cataracts may be more complicated to remove than the norm. An experienced and skilled surgeon however, will still be able to perform the cataracts removal surgery with few problems. A complicated cataracts may be one that is referred to as a mature brown cataracts. In this case, the cataracts has progressed to the point that it has hardened and become solid in the center. To remove this type of cataracts more force is required to break the cataracts apart. If the surgeon determines that the risk is too great for a small incision cataracts removal surgery, the large incision method will be considered instead. Cataract Surgery Cataract surgery is one of the most common surgeries performed. It is a very quick and safe surgery and is relatively painless. Two types of anesthetic are generally used, those being an eye drop numbing agent or an injection given near the eye that numbs and blocks all pain in the region of the eye. Before the surgery the physician measures the cornea and the length of the patient!!!s eye to determine the proper power of lens implant needed for successful completion of surgery. Once measurements are completed and the eye region is numb surgery can begin. The old clouded cataracts lens is removed and a new artificial one is implanted. The entire procedure normally takes less than an hour and is an outpatient procedure. Micro surgical techniques have enhanced the outcome of cataracts surgery and enabled recovery time and dependence on post surgery corrective lenses to decrease dramatically. Two types of cataracts surgery are Phacoemulsification and Extracapsular extraction. Phacoemulsification leaves the outer-most layer of the eye!!!s lens capsule in tact and removes the cataracts through a small, approximately 1/8 inch, incision where the cornea meets the conjunctiva. (The conjunctiva is the membrane that covers the white part of the eye and the inner part of the eyelid.) The surgeon then inserts a needle probe and uses ultrasound waves to emulsify (break apart) the cataracts and suction to remove the broken parts. Extracapsular extraction requires a slightly bigger incision and is performed when the cataracts is too hard or advanced to be emulsified by sound waves. The lens capsule is opened and the nucleus is removed in one piece and the softer lens capsule is vacuumed out, leaving the lens capsule in tact for support of the new lens. Once the cataracts has been removed a clear lens is put in its place. This lens is called an intraocular lens (IOL), is usually made of silicone or acrylic, and becomes a part of your eye. Some IOLs are rigid and require sutures, but many are flexible and can be folded and enable the use of smaller, self-sealing incisions. The shape of self-sealing incision takes into account the fluid in the eye, and when the cut is made, the shape of the incision creates a flap and seals itself shut. The benefits of this type of incision are proven by shorter surgery time, less recovery time, less vision adjustment time after lens insertion and less discomfort after surgery. Types of Intraocular Lenses (IOL!!!s) Up to this point, most lenses are replaced with monofocal intraocular lenses. These lenses only provide clear vision at one distance, far or near. With the advent of continued research, a second type of lens, the multifocal intraocular lens, was approved by the FDA in 1997 for use in cataracts surgery. This lens provides the patient with the ability to see both far and near, although far vision is still the clearer of the two. Unfortunately, not all patients are eligible for this type of IOL. The doctor will assess the candidate before choosing the multifocal IOL as a replacement. Additionally, some patients that are eligible and choose this form of lens may still require some minor vision correction aid for certain activities that entail near and extremely crisp, clear vision. Fewer individuals however, need glasses and contact lenses when fitted with a multifocal IOL than if a monofocal IOL had been used. Overall, patients who choose the multifocal over the monofocal intraocular lens have expressed greater satisfaction with the increased quality of living that their cataracts surgery has provided them. Since multifocal IOL!!!s have such great prospects for overall vision, researchers continue looking for a way to produce an IOL that will be ideal for a majority of patients and will correct both distant and near vision with equal success. A current possibility that meets these standards is the accommodating IOL. In 2004, a new type of IOL, referred to as an accommodating IOL, was approved by the FDA for use in cataracts surgery. Candidates for this type of IOL are most often originally farsighted. The goal of this new IOL is to give patients the ability to see both near and far after cataracts surgery without corrective vision aids such as glasses or contact lenses. This lens is not entirely fixed in one position; it is somewhat moveable and changes its position in the eye ever so slightly as the eye attempts to focus on near or far objects. This differs from the monofocal and multifocal IOL!!!s in that they are fixed in the eye and cannot change their focus. And, finally, for those patients who underwent surgery in the past for cataracts but were not fitted with an IOL at the time, there is now secondary surgery will allows for fitting of an IOL after a previous surgery. Depending on where in the eye the IOL is placed, there are several different names. An anterior chamber IOL is placed in front of the iris. Behind the iris there is a capsular bag, if the IOL is placed here it is known as a posterior chamber IOL. In the past, the anterior chamber IOL was the preferred method, however, over time and with increased techniques, the posterior chamber IOL is now the most commonly used. Complications In rare cases there can be complications to cataracts surgery. There can be loss of vision, bleeding, double vision and infection. Inflammation and fluctuating eye pressure can be a side effect of this surgery as well. While instances of side effects are documented it should be said that they happen rarely. Retinal detachment is a condition that occurs when fluid seeps through a tear in the retina. The seepage causes the retina to detach from the back of the eye. Retinal detachment also occurs in patients who have had previous eye surgeries and who are extremely nearsighted. Symptoms of retinal detachment are flashes of light or dark spots in the field of vision. Some of these symptoms occur naturally after cataracts surgery, but patients who experience them should contact their doctors immediately. Another symptom is a shadow that seems to move across part of or the entire field of vision. If this occurs the physician should be contacted immediately. Cystoid macula edema is decreased vision in the central part of the visual field due to swelling in the layer of nerve cells that covers the entire back part of the eye, called the retina. The macula is the part of the retina that responds to light in the central part of the visual field. After a cataracts surgery that has had no complications, the blood vessels in the retina can swell and leak and as the fluid accumulates the macula can swell. As time progresses after a cataracts surgery and the patient notices decreased vision he should contact his doctor and tests can be done, such as ocular coherence tomography, to determine the extent of the swelling. This condition can be treated by anti-inflammatory eye drops or injections of steroids to the back of the eye. In some cases vitrectomy surgery can resolve the problem. Posteriorly dislocated lens material is the rare occasion that fragments of the cataractous lens have fallen into the cavity behind the membrane that surrounds the lens. A procedure called a vitrectomy can remove the particles and reduce swelling. Endophthalmitus is an infection inside of the eye. Symptoms include pain and excessive redness and swelling, sensitivity to light and perhaps loss of vision. Usually these symptoms reveal themselves within the first few days after surgery. Antibiotic eye drops are administered the day of surgery. In spite of this, 1 in 3,000 patients develop endophthalmitis. Choroidal hemorrhage is when the choroid, the web of fine blood vessels that supplies blood to the retina, begins to bleed during surgery. It usually occurs in older patients or patients who have high blood pressure or have glaucoma. A hemorrhage confined to a small area will have very little visual loss but if the hemorrhage is severe then significant visual loss can occur. Modern micro surgical techniques, however, rely on small incisions and so therefore the severity of hemorrhages has reduced dramatically. Secondary cataracts are cataracts that develop years after cataracts surgery. It is a condition that clouds the back of the lens capsule. This is part of the lens that wasn!!!t removed during the first surgery and that supports the lens implant (IOL). This condition can also be called !!!aftercataracts!!! and posterior capsule opafication. The problem is treated quickly and simply with a laser called yttrium-aluminum-garnet, or YAG for short. Cells have grown on the back of the lens and the laser is used to make a small incision in the lens to let light pass through. It is a quick painless procedure that usually takes less than 5 minutes to complete. The patient can resume normal activity within hours.