What Is Cataract Surgery?

Cataract surgery is an elective surgical procedure performed by an ophthalmologist (an eye specialist) in an outpatient surgical center or in hospital.

During cataract surgery, a patient's cloudy lens is broken into pieces and removed. The surgeon then replaces the removed lens with an artificial one called an intraocular implant, or IOL.

Since cataract surgery is performed under local anesthesia, patients go home after the procedure; they do not require care overnight in a hospital. While the surgery itself usually takes less than 30 minutes to complete, patients can expect to be at the center or hospital for several hours, due to preoperative checks and postoperative recoveries.

If a person has cataracts in both eyes, they will usually undergo one surgery at a time, generally a few weeks apart. This is done to minimize any possible complications and give the first eye operated on proper time to heal.

Cataracts are rare in children but may be treated with surgery under general anesthesia.

Various Surgical Techniques

There are a few main cataract surgery techniques. Your surgeon will choose the best one for your procedure based on factors like the size and location of your cataract.

Traditional Cataract Surgery With Phacoemulsification

Phacoemulsification is the most common technique used to remove a cataract. With this technique, a surgeon uses a surgical blade to make a small incision (ranging between 2 to 3 millimeters) in the cornea. Then, another incision is made in the capsule (the clean, thin bag that holds the lens). Through a process called phacoemulsification, an ultrasound device is placed through the incision, emitting highly focused sound waves into the eye to break the cloudy lens (the cataract) into tiny pieces.

The pieces of the lens are then removed using gentle suction from a vacuum attached to the device. At this time, the artificial lens can be inserted into the capsule. The incision is closed with a special liquid; stitches are not usually needed.

To summarize, ophthalmologists often explain traditional cataract surgery like this: Think of an M&M candy inside an eye: the goal is to create an opening in the top shell, scoop out the dark, cloudy chocolate, and then put in a lens between the two shells.

Extracapsular Cataract Extraction

This is a less commonly used technique and involves the surgeon making a larger incision (10 mm) in the eye to remove the lens in one piece. Suction may be used if additional pieces remain. As with phacoemulsification, once the lens is removed, an IOL can be placed. The incision is closed with several sutures or stitches.

Intracapsular Cataract Surgery

This procedure involves removing the entire lens and capsule through a large incision.
Intracapsular cataract surgery is rarely performed. This technique may result in more complications and slower healing than surgeries that involve a smaller incision.

Laser-Assisted Cataract Surgery

Laser-assisted cataract surgery involves using an optical coherence tomography image to help the surgeon create precise and specific laser incisions in the cornea and the capsule. The laser then softens the cataract and breaks it up into small pieces.

After the pieces are removed, a new intraocular lens can be implanted into the capsule.
Laser cataract surgery can also simultaneously correct an eye condition called astigmatism.
While more investigation is required, there does not appear to be a major difference in safety or visual outcomes when comparing traditional cataract surgery with phacoemulsification to laser cataract surgery.

Contraindications

While there are no absolute contraindications to undergoing cataract surgery, possible ones include:

• Vision can be managed well with temporary measures: Since cataract surgery carries risks, you should only go through with the procedure when other non-invasive measures have been exhausted. These temporary measures may include obtaining a new eyeglass prescription for a stronger lens or getting anti-reflective coatings on your eyeglass lenses.
• Potential for visual improvement is limited: Certain coexisting conditions, such as age-related macular degeneration (AMD) or a history of stroke involving the visual pathways in the brain, may make any visual improvement with surgery marginal. 
• Anatomic challenges: Certain anatomic eye issues or conditions (e.g., small pupils or glaucoma) can make cataract surgery more challenging to perform and/or increase the risk of complications during surgery. Additionally, having only one good eye is a primary risk; a conservative approach is generally recommended for those with one seeing eye, and surgery is only when the benefits of surgery outweigh the risks. Additional risk factors include restless leg syndrome or an inability to lie still and flat. These issues are not necessarily contraindications, but they do require careful attention and an experienced surgeon.

Potential Risks

All surgeries carry some potential risks or complications, and cataract surgery is no exception. That said, these complications are generally very preventive and many can be addressed if treated promptly. Complications of cataract surgery include:

• Swelling of the cornea: This complication may cause blurry vision the day after surgery. If significant, steroid eye drops can help bring down the swelling.
• Increased pressure inside the eye (elevation of intraocular pressure): This complication is generally temporary and transient within the hours right after surgery. In some people, though, the pressure persists and/or worsens, requiring treatment with a pressure-lowering medication.

• Posterior capsular rupture: This complication refers to a tear in the posterior capsule (back part) of the natural lens. It occurs during the surgery and is fixed intraoperatively with various surgical techniques.
• Posterior capsular opacification: This complication occurs when the capsule behind the new lens implant thickens and becomes opaque (cloudy or hazy) following cataract surgery. As a result, your vision can become significantly blurry, similar to what it was before surgery. A simple laser procedure known as Yag capsulotomy can be performed to remove this hazy capsule.
• Rare complications include:
• Bleeding in the eye (suprachoroidal hemorrhage): This occurs as a result of the sudden tearing of blood vessels in the suprachoroidal space, which sits between the sclera and the choroid. This occurs (and is treated) during the surgery and is signaled by the loss of the red reflex, and increased IOP, with firming of the eye.
• Infection inside the eye (endophthalmitis): Though rare, but one of the most serious and devastating complications of cataract surgery. It causes severe eye pain, redness, and vision loss.
• Retinal detachment: This causes a sudden, painless increase in seeing floaters (tiny spots in your vision) or light flashes. Retinal detachment occurs more commonly in nearsighted people or in those who have had a prior retinal tear or detachment.
• Dislocation of the implanted lens: This occurs when the lens moves out of place. It may occur days to years after surgery and can cause symptoms like blurry vision, double vision, and seeing the edge of the artificial lens implant.

Purpose of Cataract Surgery

The overall purpose of cataract surgery is to replace a person's cloudy lens with a clear, artificial one in order to improve their vision.

Cataract surgery is mostly indicated when a person's cataracts and associated vision symptoms are negatively impacting their ability to perform daily functions, like reading and driving.

Less commonly, the presence of another eye condition, like diabetic retinopathy or macular degeneration, may be an indication for cataract surgery. This is because removing the cataract may be necessary in order for the other eye condition to be visualized and managed properly.

If you and your healthcare provider are considering cataract surgery, you will undergo several diagnostic tests, such as a refraction test, slit lamp exam, and optical coherence tomography (OCT).

These tests allow your healthcare provider order to thoroughly understand your visual function, look for coexisting eye diseases that may affect your candidacy or complicate the surgery, and determine the refractive (focusing) power for your artificial lens.

How to Prepare

Once you and your ophthalmologist have made the decision to move forward with cataract surgery, and you have completed all of your pre-operative tests and thoroughly reviewed all the potential risks, you can begin to prepare for your surgery.

Preparation for cataract surgery involves reviewing the following logistics with your healthcare provider and their surgical staff:

• Arrival time for your surgery and what you need to bring (e.g., insurance card)
• Cost of the surgery (cataract surgery is often covered by insurance, but you may have a deductible, co-payment, or additional costs depending on the specific lens you have implanted)
• Whether you need to stop taking any of your medications prior to surgery, and if so, when
• When to stop eating and drinking prior to surgery (usually at least six hours)
• Specific instructions for taking eye-drop medications before the surgery

You will also want to arrange for a family member or friend to drive you home after the surgery.

What to Expect on the Day of Surgery

On the day of your cataract surgery, you will arrive at either the outpatient surgical center or the hospital. You may fill out some forms at this time, including a consent form.

Upon entering the operating room, you may be given an anti-anxiety medication to help you relax.

Next, the following steps will be performed by your surgeon or their surgical staff. The surgery usually takes less than an hour to complete.

1. Your eye will be numbed with eye drops or an injection around the eye.
2. The skin around your eye and eyelid will be cleaned and sterilized.
3. A sterile drape will be placed over your head and around your eye, and your eye will be properly exposed using a lid speculum.
4. Your surgeon will look through a special surgical microscope and make tiny incisions in the peripheral part of your cornea.
5. Next, the capsule is opened with a small needle to gain access to the lens.
6. A small ultrasonic probe will be inserted into your eye if the phacoemsulfication technique is being used.
7. A new, clear lens implant will then be inserted into your eye through the same small incision and positioned into place.
8. The incision will be self-sealing and most often will not require stitches.

Right after surgery, your surgeon will do a quick examination of your eye and cover it with an eye shield. You will then be taken to a recovery room where you will rest for about 15 to 30 minutes.

Recovery

During your immediate recovery from cataract surgery (i.e., the first 24 to 48 hours), your eyes may feel itchy and appear red. Other initial common complaints include soreness, irritation, burning, or stinging. Your vision may also be blurry, which is normal. Eye itchiness usually resolves within a couple of days, while blurry vision may take up to a week.

In addition to keeping tabs on your symptoms during recovery, it's also important to follow your surgeon's instructions, which will include:

• Avoid touching or rubbing your eyes.
• Use your eye drops as advised.
• Sleep with a protective eye patch at night to avoid accidentally poking or hitting yourself. Your healthcare provider may also ask that you wear eyeglasses or a shield during the day to protect your eye.