Cataract surgery
Introduction
Cataracts are cloudy patches in the lens of the eye that can make your vision blurry and may eventually lead to blindness if it is left untreated.
Cataracts can develop in one or both eyes, and over time the size of cataract can get bigger until the whole lens is covered.
The lens of each eye should be clear in order for your eyes to work properly. The clear lens allows light to reach the retina at the back of the eye, which enables you to see things. With a cataract, less light can reach the retina, so your vision is affected.
A cataract can be present for a while before you notice you have one. However, having regular eye tests can spot cataracts in their early stages, so it's important to keep up to date with eye examinations. Ideally, you should have your sight checked by an optician every two years, although people over 60 years old may be required to have eye tests every year.
If you have a cataract, it will continue to develop. The only way to restore your vision is by having the cataract removed by surgery.
Cataract surgery is one of the most common and quickest surgeries performed, and many people are able to return to their usual daily routine after 24 hours.
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When should it be done?
If the cataract is getting in the way of your daily business and affects your ability to drive or read, you may need cataract surgery.
Surgery to remove a cataract can now be done at any stage of development. In the past, people with cataracts were encouraged to wait until the condition was so bad that they could hardly see. Now, cataract surgery can be performed from an early stage to prevent further eye conditions developing, such as macular degeneration or diabetic retinopathy. If you are at risk of developing an eye condition caused by cataracts, your GP may recommend having cataract surgery.
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How is it performed?
Surgery will be needed to remove any cataract you may have. If you have cataracts in both eyes, they will be operated on at separate occasions so the first eye has time to heal and allow your vision to return.
A majority of cataract operations are performed with keyhole surgery and are usually performed as day surgery, meaning you can go home afterwards. You will need someone to look after you for the first 24 hours.
Before your operation, your optician or GP will refer you to a specialist eye doctor (ophthalmologist or ophthalmic surgeon) who will assess your eyes and your general health. This is called a pre-operative assessment.
During this assessment, measurements of your eye will be taken, to prepare for the artificial lens that will replace your natural lens.
An appointment will probably be made for your operation to take place in a separate visit.
There are three types of cataract surgery. They are:
- phacoemulsification,
- extracapsular cataract surgery, and
- intracapsular cataract surgery.
Since cataract surgery is so common these days, these operations can often be completed with 45 minutes. Phacoemulsification usually takes between 15-30 minutes, although extracapsular and intracapsular operations can take longer.
Phacoemulsification
Phacoemulsification is the most common cataract procedure.
The surgeon puts drops into your eye to dilate (widen) your pupil. You will also be given a local anaesthetic, which can be applied as drops. Although sometimes injections in the tissue around the eye may also be used.
The surgeon then makes a tiny cut (incision) on the front surface of the eye (the cornea). A small probe is inserted into the cornea which releases ultrasounds that help to break up the cataracts into tiny pieces. The ultrasound probe is removed and a new probe is inserted which sucks out the cataracts.
Once the entire cataract has gone, the surgeon inserts a small plastic lens through the incision in the cornea. The lens sits in the lens capsule, behind the pupil. The replacement lens is folded in half when it is inserted so it can fit through the incision in the cornea. When it is in place, it unfolds itself and adopts the natural position of the old lens.
Extracapsular cataract surgery
If your doctor thinks your lens is too awkward to remove by phacoemulsification, they may suggest extracapsular extraction.
The surgeon will need to make a larger incision in the cornea and through to the lens capsule in order to remove the whole lens in one piece. Once the lens is removed, an artificial lens (such as those used in phacoemulsification), is inserted into the lens capsule.
Intracapsular cataract surgery
This form of cataract surgery is very rarely carried out, but is sometimes needed if the zonules (which support the lens) are too weak.
Intracapsular cataract surgery involves the removal of the entire lens, including the lens capsule. An artificial, plastic lens is then inserted through the incision where it sits over the pupil.
The replacement lens
There are three types of replacement lens available. Your doctor will help you decide which one will be the best for you. The types of lens are:
- fixed strength lenses (monofocal) - set for one level of vision, usually distance vision,
- multifocal lenses - allow two or more different strengths, such as near and distance vision, and
- accommodating lenses - allow the eye to focus on both near and distant objects, in a similar way to the natural human lens.
Multifocal and accommodating lenses are not normally available through the NHS. NHS funding for these types of lens will depend on your local Health Board (HB). Ask your GP, or ophthalmologist, what lenses are available in your area. If NHS funding is not available for these types of lenses, you may be able to pay to have them fitted on a private basis.
After the operation
You will usually have a pad or dressing over your eye after surgery. This helps avoid any infection and will keep your eye rested. Occasionally an eye shield will need to be worn.
In a majority of cases, vision is noticeably improved upon straightaway, but it is not uncommon for vision to take a few weeks until it is functioning completely.
The incision made in phacoemulsification is usually so small that it does not need stitches and it will heal on its own. It is likely that extracapsular and intracapsular operations will require stitches. These may be dissolvable or you may need to return to your GP or specialist to have them removed at a later date.
It is important to note that after your operation you will probably still need to wear your glasses to see things that are far away (distance vision), or close to you (near vision).
Your eye prescription will probably change, but you will have to wait several weeks before having your eyes tested. The optician will then be able to give you a new prescription, if necessary.
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Risks
Cataract surgery is very common and the risks are very low. However, no surgery is risk-free. It is estimated that a complication occurs in 2% of cataract surgeries.
The most common risk is developing a condition called posterior capsule opacification. This is caused when a part of the lens capsule thickens and becomes cloudy. This condition can be treated, usually with laser surgery.
Other complications in the eye after cataract surgery can include:
- infection,
- bleeding,
- inflammation,
- rupture of the back of the lens capsule, and
- damage to other parts of the eye, such as the cornea.
It is usually possible to treat any complications. However, occasionally, your vision may be worse than before or there may be permanent damage to the eye causing loss of sight. But this is very rare.
If a severe cataract is not treated, there is the possibility that loss of sight may be permanent.
Childhood cataract surgery
There are slightly more risks involved with childhood cataract surgery. They include:
- increased pressure inside the eye (glaucoma),
- squint (strabismus),
- abnormalities affecting the pupil in the eye,
- vision becoming cloudy again (visual axis opacification or posterior capsule opacification),
- separation of the retina from the inner wall of the eye (retinal detachment), and
- infection - for example, a rare bacterial infection (endophthalmitis).
If childhood cataracts are left untreated, the child may become blind. Even if cataracts are removed, visual impairment or blindness can remain.
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Recovery
You should be able to see an improvement with your vision almost immediately after surgery. Although it will take 1-2 months in total for your vision to settle. It is not unusual for the eye to be slightly inflamed, itchy, sticky, reddened, or occasionally bruised.
After surgery, you must arrange for someone to collect you and take you home as you will not be allowed to drive yourself. Your surgeon will tell you when you can start driving again. You should also arrange for someone to take care of you for the first 24 hours after surgery.
You will probably have a protective pad or shield over your eye which you should keep on for the first 24 hours. If you need to keep it on for longer your surgeon will tell you.
You will also be prescribed steroidal eye drops to help reduce inflammation, and antibiotic eye drops or cream to prevent infections.
If you experience moderate pain or discomfort, taking painkillers, like paracetamol, should help ease the pain. If your eye becomes very painful, drastically redder, and your sight worsens, contact your GP immediately.
Do not rub or touch your eyes as this can cause infection.
To make your recovery easier, it is a good idea to light each room so you can see clearly. If you have visual problems with the eye that was not operated on, you may need some assistance for longer than 24 hours.
Other advice for recovering from cataract surgery suggests that you should:
- avoid strenuous exercise as it may increase eye pressure,
- avoid getting soap or shampoo in your eye,
- avoid lifting anything heavy, and
- wear sunglasses if it is sunny as your eyes may be extra sensitive to bright light, or if it is windy to avoid any debris getting in the eye.
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Results
Most people see an improvement with their sight almost immediately after surgery.
It is important to remember that your vision will be improved to the level it was at before the cataract developed, not to 20/20 vision. Cataract surgery does not restore vision; it simply removes the cataract that blocks vision.
It will take several weeks after the operation for your vision to settle down before your optician can give you a new prescription, if necessary.
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