Cataract Surgery

How are cataracts diagnosed?

Cataracts are detected by the finding of lens opacification during a medical eye examination by an eye-care professional. The abnormal lens can be seen using a variety of specialized viewing instruments. Using a variety of tests, Dr Joseph is able to tell how much a cataract may be affecting your vision. Usual eye tests include testing visual acuity, glare sensitivity, colour vision, contrast sensitivity, and a thorough examination of all other parts of the eye. Dr Joseph will make sure vision loss is not due to other common eye problems, including diabetes, glaucoma, or macular degeneration.

Most cataracts associated with aging develop slowly, and many patients may not notice visual loss until it is fairly advanced. Despite being told that you have cataracts, it is not imperative to have surgery to remove them until they begin to affect your vision. The development of cataracts is unpredictable; some cataracts remain less dense and never progress to the point where they cause cloudy vision and require treatment, while others progress more quickly. Thus, the decision and timing to proceed with cataract surgery is individualized for each patient. Dr Joseph will be able to tell you how much of your vision loss is due to cataracts and the type of visual recovery that may be expected if surgery is chosen.

Who is a candidate for cataract surgery?

Dr Joseph may mention during a routine eye exam that you have early cataract development even if you are not yet experiencing visual symptoms. Although he will be able to tell when you first begin to develop cataracts, you will generally be the first person to notice changes in your vision that may require cataract surgery. Clouding of the lens may start to be seen at any age, but it is uncommon before the age of 40. However, a large majority of people will not begin to have symptoms from their cataracts until many years after they begin to develop. Cataracts can be safely observed without treatment until you notice changes in your vision.

Surgery is recommended for most individuals who have significant vision loss and are symptomatic secondary to cataract. If you have significant other eye disease unrelated to cataracts that limits your vision, Dr Joseph may not recommend surgery. Sometimes after trauma to the eye or previous eye surgery, a cataract may make it difficult for your eye-care professional to see the retina at the back of the eye; in these cases, it may still be appropriate to remove the cataract so that further retinal or optic nerve evaluation and treatment can occur. The mode of surgery can be tailored to individuals based on coexisting medical problems. Cataract surgery is generally performed with minimal sedation and typically takes less than 30 minutes. Therefore the surgery does not put significant strain on the heart or the lungs.

Prior refractive surgery such as LASIK is not a contraindication to cataract surgery.

A cataract is a medical condition, falling under the category of prescribed minimum benefits(PMB’s) and insurance companies usually cover part or all of the cost of cataract surgery, including pre- and postoperative care.  Please therefore ensure with your medical aid that you are reimbursed in full for your cataract surgery, once it has been done.

Corneal imaging: an essential tool in LASIK work-up and evaluating corneal pathology prior to insertion of premium intraocular lenses

What are the different types of cataract surgery?

The standard cataract surgical procedure is performed in a hospital. The most common form of cataract surgery today involves a process called phacoemulsification. With the use of an operating microscope, Dr Joseph will make a very small incision in the surface of the eye in or near the cornea. A thin ultrasound probe, which is often confused with a laser by patients, is inserted into the eye and uses ultrasonic vibrations to dissolve (phacoemulsify) the clouded lens. These tiny fragmented pieces are then suctioned out through the same ultrasound probe. Once the cataract is removed, an artificial lens is placed into the thin capsular bag that the cataract previously occupied. This lens is essential to help your eye focus after surgery.

There are three basic techniques for cataract surgery:

  1. Phacoemulsification: This is the most common form of cataract removal as explained above. In this most modern method, cataract surgery can usually be performed in less than 30 minutes and usually requires only minimal sedation. Numbing eyedrops or an injection around the eye is used and, in general, no stitches are used to close the wound. An eye patch is usually required after surgery for 24 hours.
  2. Extracapsular cataract surgery: This procedure is used mainly for very advanced cataracts where the lens is too dense to dissolve into fragments (phacoemulsify). This technique requires a larger incision so that the cataract can be removed in one piece without being fragmented inside the eye. An artificial lens is placed in the same capsular bag as with the phacoemulsification technique. This surgical technique requires a various number of sutures to close the larger wound, and visual recovery is often slower. Extracapsular cataract extraction usually requires an injection of numbing medication around the eye and an eye patch after surgery.
  3. Intracapsular cataract surgery: This surgical technique requires a wound  of similar size used in extracapsular surgery, and the surgeon removes the entire lens and the surrounding capsule together. This technique requires the intraocular lens to be placed in a different location, in front of the iris, or fixated behind the iris. This method is rarely used today but can still be useful in cases of significant trauma.


What are the different types of intraocular lenses implanted during cataract surgery?

As the natural lens plays a vital role in focusing light for clear vision, artificial lens implantation at the time of cataract surgery is necessary as a replacement for the natural lens to yield the best visual results. Because the implant is placed in or near the original position of the removed natural lens, vision is restored, and peripheral vision, depth perception, and image size are not affected. Artificial lenses usually remain permanently in place, require no maintenance or handling, and are neither felt by the patient nor noticed by others.

There are a variety of intraocular lens styles available for implantation, including monofocal, toric, and multifocal intraocular lenses.

  1. Monofocal lens: These lenses are the most commonly implanted lenses today. They have equal power in all regions of the lens and can provide high-quality distance vision, usually with only a light pair of spectacles. Monofocal lenses are in sharpest focus at only one distance. They do not correct pre-existing astigmatism, a result of irregular corneal shape that can distort vision at all distances. Your surgeon may correct the astigmatism at the time of cataract surgery by making one or two additional incisions in the periphery of the cornea. This does not make the surgery more dangerous. People with significant astigmatism require corrective lenses for sharpest vision at all distances. Patients who have had monofocal intraocular lenses implanted usually require reading glasses.
  2. Toric Intraocular Lenses: Toric lenses have more power in one specific region in the lens to correct astigmatism as well as distance vision. Due to the difference in lens power in different areas, the correction of astigmatism with a toric lens requires that the lens be positioned in a very specific configuration. While toric lenses can improve distance vision and astigmatism, the patient still will require corrective lenses for all near tasks, such as reading or writing.
  3. Multifocal Lenses: Multifocal intraocular lenses are one of the latest advancements in lens technology. These lenses have a variety of regions with different power that allows some individuals to see at a variety of distances, including distance, intermediate, and near. While promising, multifocal lenses are not for everyone. They can cause significantly more glare than monofocal or toric lenses. Multifocal lenses cannot correct astigmatism, and some patients still require spectacles or contact lenses for clearest vision.
  4.  Monovision: If your cataract surgery involves both eyes, you might consider monovision. This involves implanting an IOL(intra-ocular lens) in one eye that provides near vision and an IOL in the other eye that provides distance vision.

Usually people can adjust to this. But if you can’t, your vision may be blurred at both near and far. Another problem is that depth perception may decrease because there is less binocular vision — meaning, your eyes aren’t working together as they once did.

People who do best with this method already are accustomed to monovision with contact lenses, which is a common way of correcting presbyopia (age related loss of reading vision). If you can’t adjust to monovision after your cataract surgery, you may wish you had tried a multifocal or accommodating IOL instead. Dr Joseph may trial-fit a cataract patient in monovision contact lenses prior to inserting monovision IOLs.

Mixing multifocal lenses is another method of achieving a type of modified or “blended” monovision by using one type of IOL that emphasizes distance vision and another that emphasizes intermediate vision.

 

What should one expect after the cataract surgery?

Following surgery, you will need to return for visits within the first few days and again within the first few weeks after surgery. During this time period, you will be using several eyedrops which help protect against infection and inflammation. Within several days, most people notice that their vision is improving and that they are able to return to work. During the several office visits that follow, Dr Joseph will monitor for complications. Once vision has stabilized, Dr Joseph will refer you to your optometrist to be fitted with glasses if needed. The type of intraocular lens you have implanted will determine to some extent the type of glasses required for optimal vision. 

What are potential complications of cataract surgery?

While cataract surgery is one of the safest procedures available with a high rate of success, rare complications can arise. Your ophthalmologist will discuss the specific potential complications of the procedures that are unique to your eye prior to having you sign a consent form. The most common difficulties arising after surgery are persistent inflammation, changes in eye pressure, infection, or swelling of the retina at the back of the eye (cystoid macular edema), and retinal detachment. If the delicate bag the lens sits in is injured, then the artificial lens may need to be placed in a different location. In some cases, the intraocular lens moves or does not function properly and may need to be repositioned, exchanged, or removed. All of these complications are rare but can lead to significant visual loss; thus, close follow-up is required after surgery. If you have pre-existing macular degeneration or floaters, these will not be made better by cataract surgery.

In some cases, within months to years after surgery, the thin lens capsule may become cloudy, causing blurred vision after cataract surgery. You may have the sensation that the cataract is returning because your vision is becoming blurry again. This process is termed posterior capsular opacification, or a “secondary cataract.” To restore vision, a laser is used in the office to painlessly create a hole in the cloudy bag. This procedure takes only a few minutes in the office, and vision usually improves rapidly.

 

How to care for your eye after surgery

First 24 hours post-operative:

  • You may experience a mild discomfort or pain after the surgery-this is completely normal and you will be supplied with pain medication if you need to take as required.
  • You will be discharged home with tablets called Diamox– you must please take one tablet three times per day until the following day where you will be seen at the clinic.
  • You will be discharged with an eye-shield covering the operated eye. Please do not remove this shield at home – it will be removed the day after surgery in the eye clinic.

Day 1 to week 1 post-operative:

  • After removing the shield and you have been examined, you will be required to instill Spersadex Co eyedrops( bottle with a green top), one drop, four times a day or during the waking hours. It is not necessary to wake up at night to instill the drops, unless otherwise specified by your specialist.
  • Please note that your spectacles you were using prior to the surgery will not be effective on the operated eye.
  • You will require a pair of reading spectacles after surgery-the surgery does not correct both your distance and your near vision, unless you have had a multifocal lens inserted.
  • Please note that you may be light sensitive-feel free to wear sunglasses-preferably with 100% UVA and UVB blockout.
  • Please ensure you are aware of your time and date for the 1 week post op visit. 

Week 1 to week 6 post-operative:

  • You must please continue to instill the Spersadex Co 1 drop four times per day, unless your specialist informs you otherwise.
  • Your vision should improve daily and if there is any discomfort this should decrease too.
  • We will review your eye 6 weeks after the surgery and thereafter you may get a pair of reading spectacles.
  • Once again, please do not wear your old pair of spectacles after surgery-they will blur your vision.
  • Please avoid lifting heavy objects and getting water in your eye for the first week post-op.
  • A week after surgery, please feel free to go to Clicks and try on spectacles for reading which will see you through until 6 weeks post-op. You may try anything from +1 to +3 and buy any one that feels comfortable. You cannot damage your eyes if the strength isn’t perfect. This is just an economical way to allow you to read until a prescription pair of spectacles is made.

If you experience severe pain, swelling or a sudden decrease in vision, please contact the Eye Centre immediately

 

Important info prior to surgery

  • Please ensure that you make your eye specialist aware of all medication that you use, as some may adversely affect surgery, or result in the delay or cancellation of surgery.
  • If you are on the following medication, please alert your specialist:
    • Warfarin
    • Disprin
    • Flomax
    • Plavix
    • Clopidegrol
    • Prodaxa
  • Please have your blood pressure, blood glucose (if you are diabetic), and your urine checked prior to admission. This must be done at least a day before surgery.
    • If any of these parameters are abnormal, your surgery may be cancelled and you will need to go to your general practitioner to normalize them.
    • If you are on Warfarin, Plavix, Clopidegrol or Prodaxa,we will need to draw blood the day before or week before surgery to see how thin it is, and depending on the result, we will inform you whether it is adequate for surgery.
  • The evening before your surgery and the morning thereof, you may eat and drink fluids as per normal. Only if you are having a general anaesthesia will you be required to fast from midnight the evening prior to your surgery.(You will be informed of this.)
  • Chronic medication, including eye drops must be used as indicated prior to your surgery, unless otherwise advised by your eye specialist.
  • If you have shortness of breath, are unable to lie flat, are claustrophobic, or are asthmatic, please inform us prior to admission.
  • Please inform us if you have any open/septic wounds on any part of your body prior to admission.
  • If you have been using treatment for infection of the eyelids and lashes, please continue using treatment, including the morning of the operation.
  • Please make sure you have someone to take you to and fetch you from the hospital on the day of your surgery.