Cataract surgery

The only treatment for cataracts is surgical removal and replacement of the cloudy lens to restore the transparency of the visual axis. The modern surgical technique is extremely safe with very few serious complications, and the intraocular lens allows the rehabilitation of one eye so that it matches the vision in the other eye that has not yet undergone cataract surgery.

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Cataract surgery

Under normal conditions, humans are born with a natural intraocular lens which is usually transparent and focuses the light rays optimally for the rest of the eye’s systems. When cloudiness appears in the lens (usually with age) then a cataract is actually formed.

What is cataract surgery?

Cataract surgery – surgical treatment

The only treatment for cataracts is surgical removal and replacement of the cloudy lens to restore the transparency of the visual axis.
The modern surgical technique is extremely safe with very few serious complications, and the intraocular lens allows the rehabilitation of one eye so that it matches the vision in the other eye that has not yet undergone cataract surgery.

Surgical techniques – the operation is usually performed on a day-hospital basis under local anesthesia provided topically (drops), using a block (injection in the eye area) or injection of an analgesic substance into the anterior chamber of the eye.

Sometimes controlled sedation is used. General anesthesia is only necessary for patients who cannot reliably cooperate with local anesthesia (eg, cognitive impairment or other communication barrier) or perhaps those who have had a complication of local anesthesia in the other eye.

Experienced surgeons can perform the surgery itself in 10 to 20, but patients typically spend 30 to 60 minutes in the operating room for positioning, sterile drape, additional preparations, and settling the patient after surgery.

The two techniques that are most widely used for cataract surgery are:
Phacoemulsification, which is performed in over 99% of surgeries in reformed countries, and extracapsular cataract extraction, which is still very popular in third world countries.

Choice of lens in cataract surgery

Most patients in reformed countries will have artificial intraocular lenses (IOL) implanted during cataract surgery, except in some forms of intraocular inflammation (uveitis), in some cases of high myopia, and in case of unusual intraoperative complications.

An intraocular lens can be implanted secondarily in a subsequent operation.
The alternatives to lens implantation are aphakic glasses or contact lenses.
However, patients are often not satisfied with these solutions and therefore in over 99% of surgeries an intraocular lens is implanted during surgery.

Intraocular lens implantation

Broadly speaking, there are four types of intraocular lenses (in reality there are hundreds of different types):
monofocal, multifocal, accommodative and toric.
In general, monofocal and multifocal lenses are equally effective in improving distance vision.

Multifocal intraocular lenses contain optical properties that generally allow some of the light rays to be focused for distant vision and some of the light rays to be focused for vision from closer distances.
Therefore, these lenses can have unwanted effects.

Patients with multifocals report side effects such as glare or halos.
Toric lenses can reduce or eliminate the need for astigmatism correction with glasses or contact lenses.
Multifocal, accommodative and serial lenses are more expensive than monofocal lenses and are usually offered as “premium” lenses.

The additional expense is usually paid by the patient because these lenses, which reduce dependence on glasses, are not covered by insurance in most countries of the world.

A 2014 review based on four studies in the UK, Italy and Germany, which compared accommodative lenses with monofocals, found moderate-quality evidence of a modest improvement in near vision after six months.
Therefore, these lenses did not “conquer the market”.

Overall, more data are needed to determine the relative merits of monofocal, multifocal, accommodative, and toric lenses.
Since these lenses are offered to patients at a higher price, it is advisable to have a conversation with the patient before the operation in order to make sure that the patients’ expectations are realistic.

The analysis process

Phaco-emulsification (“phaco cataract surgery”)

Paco cataract surgery is also called small-incision cataract surgery and has become the most common form of cataract removal technique in high-resource reformed countries.
The lens is removed using a probe (handpiece) with a tip with a diameter of 1 to 3 mm inserted through a small incision.

This tip, also known as a phaco probe, contains a needle that vibrates and produces ultrasonic energy to split the hard central part of the lens together with an irrigation and aspiration sleeve.
The softer cortex is then suctioned out and the lens capsule is left behind and intact (except for an anterior opening in the anterior box).

A collapsible plastic or silicone lens can be threaded through the small incision (which is usually the case).
In special situations, the cutout can be widened if necessary to accommodate a larger, more rigid plastic lens.
It may not be possible to perform phaco in an advanced cataract where the lens nucleus may be very difficult, but this is a rare phenomenon in skilled hands.

The small incisions through which the surgery is performed are self-sealing, which means that most of the time (over 90%) no suture is needed to close the incision.
Phaco cataract surgery has the advantage of faster recovery of visual acuity due to the small size of the incision and the decreased likelihood of astigmatism (cylinder) induced by incision or suture.

Extracapsular Cataract Extraction

Extracap cataract surgery involves removing the lens nucleus in one piece.
The lens shell is suctioned from the eye and the lens capsule is left behind to support and contain an intraocular lens.
A rigid plastic lens is inserted through the same incision and placed on the capsule or behind the iris.

There are modifications of this method that offer a smaller incision, almost the same size as the incisions in phaco cataract surgery but still larger.
Nowadays in Israel this surgery is hardly performed because of the advantages and the good results with phaco cataract surgery.

After the surgery

Prevention of infections after cataract surgery

One of the most worrying complications after cataract surgery is an intraocular infection known as endophthalmitis, but fortunately this is a rare phenomenon (around 1 in 3000 eyes). The instillation of diluted Polidine (at a concentration of 5-10%) on the surface of the eye as part of the surgical preparation of the operative field, has been shown to decrease the incidence of post-operative endophthalmitis. It is a treatment that is cheap, available and effective and therefore has become an integral part of cataract surgery in Israel.

Prophylactic use of topical antibiotics (eye drops) before and after cataract surgery is common, despite little evidence to support this practice.
In contrast, the use of antibiotics during surgery (injection of antibiotics into the anterior chamber) appears to be effective in reducing the low risk of postoperative endophthalmitis, with or without the addition of topical antibiotics.

However, it is recommended not to use intraocular vancomycin during surgery, because of the risk of retinal vasculitis.

Results after cataract surgery

In general, cataract surgery is considered one of the safer surgeries. But as with any surgery in medicine, there are risks and possible complications. The results often depend on the presence or absence of visible morbidity. For example, improvement in vision may be limited by an underlying retinal problem related to age, complications of diabetes, trauma, or amblyopia. Additionally, intraoperative challenges and complications may limit the final outcome.

A 2013 report from Europe found that a corrected visual acuity (CDVA) of 0.5 (20/40) or higher and 1.0 (20/20) or higher was achieved in 94.3 percent and 61.3 percent of the cases respectively.

Complications from cataract surgery

Because of the frequency with which cataract surgery is performed, even rare complications affect a large number of people.
As with most surgical procedures, side effects are lower among surgeons who perform more procedures (experienced surgeons).
Cataract surgery is a low-risk procedure, but the surgery is usually performed in a relatively older population and multiple medical morbidity increases the risk of any procedure.

Immediate complications after cataract surgery – these complications may limit vision at the end of the recovery period and occur in the first days or weeks after surgery:

Treatment after cataract surgery

There may be mild pain during the first 24 hours after surgery, usually relieved by over-the-counter analgesics.
Patients can resume normal activities such as reading, walking, eating and watching TV on the evening of surgery.

Some surgeons put a bandage on the eye after the operation, usually depending on the type of anesthetic used.
After surgery, all medications can be resumed immediately, including anticoagulants/antithrombotics, assuming there were no concerns about bleeding during surgery.

The eye is usually examined the day after the first operation, although some surgeons forego this visit in routine cases and are content with telephone contact with patients. Patients are usually seen a week and a month after surgery to check that there are no complications and that there is proper healing.
Nonsteroidal or steroidal anti-inflammatory drugs are often prescribed after surgery to reduce pain, inflammation, and the likelihood of macular edema, an inflammatory complication that can limit vision recovery.

They usually start infusing two to four times a day and usually start reducing about a week after the surgery depending on the choice of the surgeon, the drug and the nature of the surgery the patient underwent.
The available evidence suggests that NSAIDs may be more effective than steroids in preventing macular edema after cataract surgery.

Suturing of incisions is less common in this era of phaco cataract surgery but if they were needed, they are usually removed after one to six weeks.

The recommendations on limiting physical activity vary greatly among surgeons depending on their confidence in the technique used.
Patients with large incisions are generally advised not to perform heavy lifting or strenuous activity for several weeks.

Today, we tend to limit heavy lifting or strenuous activity to a period of a few days.
Most patients are able to return to work in about a week, unless driving or heavy lifting is required of them. There is no flight restriction after the surgery.

The final glasses prescription is determined about a month after the surgery. Patients are usually required to wear reading glasses after cataract surgery.
Some patients may notice the improvement in vision as soon as the day after surgery and others may not appreciate the full effect until updated glasses are prescribed a month after surgery.

Endophthalmitis (a bacterial or fungal infection in the eye), a complication that can cause a significant decrease in vision and usually leaves some impairment. With the help of intraocular injections of antibiotics at the end of the surgery, the risk of such a complication is about 1 in 3000. An increased risk has been reported at a younger age, combined eye surgery and anterior vitreectomy.
Corneal edema, usually passes after a few days but may be prolonged and may reduce vision and cause pain in approximately 0.3 percent of patients.
Displacement of the intraocular lens over the years (about 1.1 percent).
Cystoid macular edema (thickening and edema in the macula, approximately 0.5 to 2% of cases). Risk factors include diabetes, previous eye surgeries and a complex surgical procedure.
Toxic anterior segment syndrome (TASS) is an inflammation of the anterior segment of the eye that usually occurs within 24 hours of surgery and is associated with noninfectious toxic substances from equipment, solutions, or other substances used during the procedure. Clusters of cases have been attributed to poor preparation of sterilization equipment.

Late complications after cataract surgery – these complications may limit vision at the end of the recovery period and occur months/years after surgery:

Retinal detachment, which usually requires intervention in the form of laser, cryotherapy or surgery (0.7 percent). It can cause significant vision loss and moderate impairment, although it can sometimes be treated without vision loss. A population-based study suggested that the risk of retinal detachment is increased up to 20 years after cataract surgery. In one longitudinal study of 9400 patients the cumulative rate of retinal detachment was 2.3 percent at eight years. Eyes with high myopia seem to be at a particularly high risk of retinal detachment after cataract surgery.
Risk of macular degeneration - concerns have been raised that patients who have undergone cataract surgery may be at increased risk of age-related macular degeneration of the retina. Proposed mechanisms include increased postoperative sensitivity to light damage, inflammatory changes secondary to surgery, or induction of angiogenesis. However, this association could be due to overlapping risk factors for the two conditions, or the fact that macular degeneration may be detected after cataract surgery and thus may represent an earlier disease that was not detected due to lens opacity. A 2017 systematic review concluded that no reliable conclusions can be drawn from the available data as to whether cataract surgery is beneficial or harmful in people with age-related macular degeneration.
Opacity of the posterior capsule, which occurs in approximately 20% of cases, can be successfully treated using an yttrium-aluminum (YAG) laser capsulotomy and is therefore not considered a complication by many surgeons. The procedure, which is usually done in an outpatient clinic, is not painful and yields an improvement in vision almost immediately. YAG capsulotomy does increase the risk of retinal detachment and cannot be considered completely benign. In a meta-analysis it was found that biological materials and the design of the end of the intraocular lens may affect the formation of secondary opacities in the posterior capsule; The incidence was lower for acrylic or silicone lenses and for those with sharp optical edges.

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Questions and answers

What is a cataract?

A cataract is a clouding or turbidity in the lens of the natural eye. The lens consists of proteins that are arranged so that the lens is transparent and thus can fulfill its function. When the lens becomes opaque or yellowish, its function is impaired and the condition is called a cataract. The only way today to treat cataracts is by replacing the natural lens with an intraocular artificial lens through cataract surgery.

What are the symptoms of cataracts?

Cataracts develop slowly and gradually, so that at first you may not notice its existence. Over time, the cataract develops and becomes more cloudy and at this stage it will be possible to feel changes in vision such as blurred vision, flashes or halos around bright lights, difficulty driving especially at night or a feeling of “faded colors”. The type of cataract you suffer from will affect the type of symptoms you will experience and how quickly they develop.

When is the best time to undergo cataract surgery?

Once the cataract is formed, it continues to develop, but as mentioned, initially it is not noticeable. The level of visual impairment varies from person to person. The degree of interference to vision and lifestyle is usually what will determine the time of intervention in the case of cataracts. It is important to consult the attending ophthalmologist in order to determine the best time for cataract surgery.

Is there an age too young or too old to undergo cataract surgery?

The treatment is offered according to the severity of the symptoms and the development of the cataract, not according to age. There is a congenital cataract or a cataract that appears in childhood and requires early surgical intervention to prevent the formation of a “lazy eye”.

How is cataract surgery performed?

During cataract surgery, the cloudy lens of the eye is removed and an artificial intraocular lens (IOL) is implanted in its place. To do this, the surgeon will make a small incision in the cornea through which the cataract can be broken up and removed. Today, more and more cataract surgeries are performed with a laser, which allows the softening of the lens before its disassembly and also allows cuts to be made in a more delicate and precise manner.

Is it possible to undergo cataract surgery in both eyes?

Yes, but usually each eye will be operated on in a separate operation, when they have a few weeks to recover.

Can I undergo cataract surgery if I have undergone LASIK surgery to remove glasses?

Even if you have had various eye surgeries in the past, you may still be a good candidate for cataract surgery. It is important to update the attending physician on general and specific medical history so that he can make decisions according to your personal situation.

What are intraocular lenses (IOL)?

When the cataract (the cloudy natural lens of the eye) is removed, the eye remains like a camera without a lens – the image will be blurry. Therefore, everyone who undergoes cataract surgery is implanted with an artificial intraocular lens (IOL), which will take the place and function of the cloudy lens that was removed. The artificial lens is permanent and does not require maintenance, it cannot be felt and does not become cloudy over time. It is important to adapt the lens personally to the patient and his needs, and thus the shape, design, material and prescription will be chosen personally by the ophthalmologist.

What types of artificial intraocular lenses (IOL) are there?

After a thorough examination and evaluation, you will be presented with various lens options.

Monofocal lens – the traditional lens. Assists in carrying out activities for a predetermined distance (near, medium or far) and the rest of the time it is necessary to use eyeglasses.

Multifocal lenses – the development of technology has led to the development of advanced lenses that allow vision at varying distances and reduce the dependence on eyeglasses.

Toric lenses – reduce or eliminate astigmatism (cylinder) and improve far vision.

How long does cataract surgery last and is it painful?

Cataract surgery usually lasts about half an hour, but with the organization it can take one and a half to two hours. The operation is performed under local anesthesia (except for exceptional cases that require general anesthesia) so the patient should not experience pain during it, and is awake in order to alert if he feels pain or discomfort. After the surgery, painkillers can be used as needed during the recovery period.

Is cataract surgery considered a safe surgery?

Cataract surgery is among the most common surgical procedures with a low rate of complications. However, any procedure has the potential for complications or side effects. Potential complications of cataract surgery include infection, retinal detachment, glaucoma, and macular edema. Less than 2% of patients who undergo cataract surgery will suffer from complications, and most of them are treatable. Therefore, it is very important to attend the follow-up appointments after the surgery, which enable early detection of complications if they exist and treatment accordingly.