Fig. 1: Visually significant cataract.

As you know by now (see Cataract Basics), a cataract is a clouding of the natural lens of the eye. To some extent, it is a normal aging process, and simply having a cataract does not necessarily mean that you need to have surgery.

That being said, over 1.5 million cataract surgeries are performed annually in the United States alone, and almost 19 million worldwide (2010), for visually significant cataracts. (Fig 1)

So, how do you know if and when your cataracts are ready for surgery? In other words, how visually significant are they? (I say “they” because cataracts tend to develop bilaterally, and usually fairly symmetrically, though one eye is often more dramatically affected.) Sometimes, your ophthalmologist will tell you, especially if your lenses have gotten so dense that it is hard for your doctor to see into the eye, and to examine you for diseases like glaucoma, macular degeneration, diabetic eye disease, or other important eye conditions.

However, often times the decision is up to you. You need to ask yourself how much impact your vision is having on your life. Are you still doing the things you enjoy, or is your degraded visual quality slowing you down? Can you drive at night comfortably, or is glare from oncoming headlights becoming an issue? Can you still read your newspaper or sew, or does even the brightest lamp not provide enough light? Have people accused you of ignoring them in the street, when in fact you could not see their faces due to glare from the sun? Have you changed your glasses prescription three times in two years, and still not achieved the clarity you seek? If you’ve answered yes to some or all of these problems, then your cataracts are probably ready for surgical intervention.

Now that you and your ophthalmologist have agreed that cataract surgery is warranted, and have discussed which eye to do first, your doctor will discuss with you details about the surgery. Simply put, the surgeon removes the cataract and puts a prosthetic lens in its place, which will stay there for the rest of your life.

There are a few aspects of lens implants that you will likely discuss with your surgeon. One is the type of lens—single-vision or multifocal.

•Single vision lenses, which have been around for decades, restore your vision in a fixed distance. In other words, most people choose to have their distance vision corrected as clearly as possible without glasses, with the knowledge that they will still need reading glasses for near vision.

•Multifocal lenses, which are a newer technology, can technically correct visual acuity at all distances.

Both of these technologies have their plusses and minuses (the need to wear glasses for the single-vision lens implants; the risk of haloes and visual aberrations with multifocal lens implants, among others) that  you will need to review with your surgeon in more detail. Many surgeons have a lens that they traditionally use and are comfortable with, but all should be able to at least discuss options. No matter what type of lens implant you will be getting, your surgeon will also do special preoperative measurements of your eyes, in order to determine what power lens implant to place. (Fig 2)

Fig. 2: Intraocular lens implant.

Cataract surgery is done in an operating room of either a hospital or surgery center, and is usually ambulatory; in other words, you leave the hospital or surgical center soon after the procedure. It is generally done under local anesthesia, with some intravenous sedation, and you are breathing on your own the whole time while being monitored by an anesthesiologist or trained nurse anesthetist.

The surgery itself, which is on only one eye at a time, takes anywhere from 20 minutes to over an hour, depending on its complexity and you need to be able to lie still under drapes for the duration of this time. Since it is a surgery, and does require anesthesia, you will most likely be asked to see your medical doctor for a simple preoperative clearance. This usually involves an EKG, and maybe some blood work, depending on your age and other medical conditions like diabetes, or if you are on medications that can affect your bleeding risk (like Coumadin).

How you otherwise prepare for the surgery varies by surgeon, but there are a few general precepts most surgeons follow. Most will ask you to stop aspirin, Plavix, or other blood thinners 10 days to two weeks prior to surgery, in order to minimize the risk of intraoperative bleeding. Input may be required from your medical doctor regarding the use of more potent anticlotting medications like Coumadin, and you may be asked to alter your dosage of this for several days prior to your planned operation.

To prepare the eye itself for surgery, you will most likely be instructed to use antibiotic drops 1 to 3 days prior to surgery. This may be accompanied by special lid scrubs to further debride the eye of potential contaminants. In addition, you may also be asked to start preoperative anti-inflammatory drops, and/or dilating drops in the days leading up to surgery. For the morning of surgery itself, you will be advised not to eat or drink anything in the morning hours before surgery, taking only your usual morning medications (like blood pressure pills) with a sip of water. Lastly, you should be reminded that you will need someone to pick you up after the surgery, since most, if not all, surgical centers will not release you alone after cataract surgery.

Now the big day has arrived, and you have come to the operating center with an empty belly, and probably some butterflies. Once the staff have confirmed the surgical site with you, drops will be given to dilate your pupil and to numb your eye. An intravenous line will be started in the preoperative holding area, and you will then be brought into the operating room, where you will lie down on a surgical table. You may receive some mild sedation at this time, while your eye is sterilely cleansed for the last time. You will then be covered with a surgical drape, and a speculum (a specialized wire device) will be inserted under your lids in order to keep your eye open during the surgery.

Once the surgeon is ready, and the microscope in place, the cataract operation begins. The surgeon will make an incision in the eye, and remove the cataract in one of two ways. One way is via a very small incision, and uses ultrasound waves to emulsify the lens. This is known as phacoemulsification. A second method involves removing the lens as a whole, via a larger incision; this is known as an extracapsular cataract extraction. The surgical approach is up to the surgeon, and may be influenced by a number of factors, including density of the cataract, visibility of the cataract, and other anatomic aspects of the eye. Either way, your lens implant will be placed after the cataract has been removed, and the area cleansed of its remnants. You may require sutures depending on the size of the incision; these may remain for weeks to months, or even longer, as per surgeon’s protocol, and are generally not problematic to the patient. (see Fig 3 and 4)

Fig. 3: Phacoemulsification cataract extraction.

During the surgery, depending on how sleepy you are, you may be aware of lights and shadows, and may hear your surgeon and the staff speaking. You should not have any pain, though you may have some pressure sensations, and may also feel your surgeon moving around your eye and face. Generally, patients are very comfortable and relaxed during the procedure; many fall asleep, though may be intentionally awakened by the surgeon if they start to move around or snore!

Before you know it, the surgery will be finished and the drapes removed. Your eye will be covered with a protective shield, and you will be brought to a postoperative recovery room. You may be given a light snack, and will likely be sent home with your designated pickup person within an hour if you are feeling well.

Expect to visit your surgeon the next day for a post operative check. Your vision and eye pressure will be checked, and your schedule of postoperative instructions will be reviewed. This usually includes the sameantibiotic drop you used preoperatively, and an anti-inflammatory drop. You may also be given additional drops for pressure control or other issues, and may be asked to wear the protective shield at night for the first week. You will probably be asked to see your surgeon again the following week, and then again 3 to 4 weeks later, or as per your surgeon’s protocol.

Fig. 4: Completed cataract surgery with lens implant in place.

Visual recovery after cataract surgery tends to vary a little in timing among patients, due to a host of factors including your age, other coexisting ocular conditions, and complexity or duration of surgery. Your vision may be very blurry when your eye patch is first removed in the surgeon’s office the first day. This is very normal, and usually no cause for alarm. After all, your delicate eye has just sustained a bit of an operative assault, and needs a little time to adjust. It is also normal for your eye to feel a little irritated or scratchy for the first few days. Generally, vision improves rapidly over the course of the first week, and by your postoperative visit on week 2, your visual improvement should be well on its way. After this visit, you will likely be advised to taper your postoperative meds, and on the final postoperative visit 3 to 4 weeks later, you will be given a new prescription for glasses, if needed.

Now that I’ve discussed cataract surgery, let me touch for a moment upon the risks and benefits of the surgery, which your surgeon will also discuss with you. There is over a 98 percent success rate in cataract surgery, and the benefits are myriad: improved clarity and quality of vision, crisper color vision, less reliance upon glasses, and less glare. It is indeed a surgery, however, and with every surgery comes its attendant risks and complications. These risks include infection; bleeding; prolonged inflammation; prolonged elevation in eye pressure; prolonged corneal swelling; retinal tears or detachment; and loss of best-corrected vision. A piece of cataract may also be dislocated into the eye during surgery, requiring a second procedure to retrieve it. While these problems can often be addressed successfully, they may necessitate a prolonged recovery period, during which you and your surgeon will work together to achieve the best possible outcome.