What is a Cataract?
A cataract is a cloudy area in the lens of the eye. A normal lens is clear and focuses light into the back of the eye (see right photo). When a cataract develops some of this light is blocked out and or scattered. As this cataract develops, it becomes harder for a person to see.
Cataracts are a normal part of aging. About half of Americans ages 65 to 74 have cataracts. Over 90 percent of those age 75 and over have this condition.
Most people with cataracts have a cataract in both eyes. However, one eye may be worse than the other because each cataract develops at a different rate.
Some people with cataract don’t even know it. Their cataract may be small, or the changes in their vision may not bother them much. Other people who have cataracts cannot see well enough to do the things they need or want to do.
What Are the Symptoms of a Cataract?
Here are some signs of a cataract:
- Cloudy, fuzzy, foggy, or filmy vision.
- Changes in the way you see colors.
- Problems driving at night because headlights seem too bright.
- Problems with glare from lamps or the sun.
- Frequent changes in your eyeglass prescription.
- Double vision.
- Better near vision for a while only in farsighted people.
These symptoms also can be signs of other eye problems.
How is a Cataract Diagnosed?
A regular eye exam is all that is needed to find a cataract. Your eye care professional will ask you to read a letter chart to see how sharp your sight is. You probably will get eye drops to enlarge your pupils (the round black centers of your eyes). This helps the doctor to see the inside of your eyes. The doctor will use a bright light to see whether your lenses are clear and to check for other problems in the back of your eyes.
Other eye tests may also be used occasionally to show how poorly you see with a cataract or how well you might see after surgery:
- Glare test.
- Contrast sensitivity test.
- Potential vision test.
- Specular photographic microscopy.
Only a few people need these tests.
How is a Cataract Treated?
A change in your glasses, stronger bifocals, or the use of magnifying lenses may help improve your vision and be treatment enough. With time glasses will no longer work. The way to surgically treat a cataract is to remove the lens and replace it with an artificial lens called an implant (See photo).
Just because you have a cataract does not mean it must be removed immediately. Cataract surgery should be put off until you are no longer satisfied with the way you see. We don’t do cataract surgery on eyes that see well. With an eye examination your eye doctor can tell you if your decreased vision is due to a cataract on another underlying cause. For example, there may be other problems behind the cataract.
Video of cataract surgery:
This video by Dr. Matthew Niemeyer is a good example of the most current cataract surgery being performed to date. Although many will disagree, I feel cataract surgery has become a specialty. The surgeons who are performing over 10 surgeries per day develop a very high level of skill that seems to translate into less postoperative problems, less trauma induced, and corrections coming out more accurate. Angeles Vision Clinic prefers to use cataract specialists as our surgeons of choice. Dr. Niemeyer with Northwest Eye Surgeons does most of our cataract surgery here at Angeles Vision Clinic and we have been extremely pleased with the level of care our cataract patients are receiving
How Do I Decide Whether To Have Surgery?
Most people have plenty of time to decide about cataract surgery. Your doctor cannot make your decision for you, but talking with him can help you decide if you are ready for surgery on not.
Tell your eye care provider how your cataract affects your vision and your life. If your vision becomes to much of a disability removal should be considered. Circle the statements below that apply to you and share this list with your doctor:
- I need to drive, but there is too much glare from the sun or headlights.
- I do not see well enough to do my best at work.
- I do not see well enough to do the things I need to do at home.
- I do not see well enough to do things I like to do (for example, read, watch TV, sew, hike, play cards, go out with friends.
- I am afraid I will bump into something or fall.
- Because of my cataract, I am not as independent as I would like to be.
- My glasses do not help me see well enough.
- My eyesight bothers me a lot.
You may also have other specific problems that you want to discuss with your eye doctor.
What Should I Know About Surgery?
Your doctor will discuss the options with you before choosing the best kind of cataract removal and lens replacement for you. He or she will also explain how to prepare for surgery and how to take care of yourself after it is over.
People do not need to stay overnight in a hospital to have cataract surgery. You will go to an outpatient center or hospital, have your cataract removed, and leave when the doctor says you are fit to leave. However, you will need a friend or family member to take you home.
It takes a few months for an eye to heal after cataract surgery but most people are seeing well within the first few days. Most patients have minor discomfort for a day or two only. Your eye doctor should check your progress closely during this time making sure your eye recovers fully.
Removing the Lens
There are three types of surgery to remove lenses that have a cataract:
- Extracapsular surgery. The eye surgeon removes the lens, leaving behind the back half of the capsule (the outer covering of the lens).
- Phacoemulsification (pronounced FAY-co-ee-mul-sih-fih-CAY-shun). In this type of extracapsular surgery, the surgeon softens the lens with sound waves and removes it through a needle. The back half of the lens capsule is left behind.
- Intracapsular surgery. The surgeon removes the entire lens, including the capsule. This method is rarely used.
Replacing the Lens
A person who has cataract surgery usually gets an artificial lens or implant at the same time. A plastic disc, called an intraocular lens, is placed in the lens capsule inside the eye. Other choices are contact lenses and cataract glasses. Your doctor will help you to decide which choice is best for you.
Can a Cataract Return?
A cataract cannot return because all or part of the lens has been removed. However, in about half of all people who have extracapsular surgery or phacoemulsification, the lens capsule becomes cloudy. This cloudiness of the lens capsule, if it occurs, usually develops a year or more after surgery. It causes the same vision problems as a cataract does.
The treatment for this condition is a procedure called YAG Capsulotomy. The doctor uses a laser (light) beam to make a tiny hole in the capsule to let light pass. This surgery is painless and does not require a hospital stay.
Most people see better after YAG capsulotomy, but, as with cataract surgery, complications can occur. Your doctor will discuss the risks with you. YAG capsulotomies should not be performed as a preventative measure.
Is Cataract Surgery Right for Me?
Most people who have a cataract recover from surgery with no problems and improved vision. In fact, serious complications are not common with modern cataract surgery. This type of surgery has a success rate of 95 percent in patients with otherwise healthy eyes. But no surgery is risk free. Although serious complications are not common, when they occur they could result in loss of vision.
If you have a cataract in both eyes, experts say it is best to wait until your first eye heals before having surgery on the second eye. If the eye that has a cataract is your only working eye, you and your eye care doctor should weigh very carefully the benefits and risks of cataract surgery.
You will be able to make the right decision for yourself if you know the facts. Ask your doctor to explain anything you do not understand. There is no such thing as a “dumb” question when it comes to your health.
Here are some questions you might ask:
- Do I need surgery right away?
- If not, how long can I wait?
- What are my personal risks?
- What benefits can I expect?
- If I choose surgery, which type is best for me?
- Which lens replacement is best for me?
- What are the chances of developing cloudiness in the lens capsule after cataract surgery?
- What are the benefits and risks of YAG capsulotomy?
You may wish to write down other questions to ask your doctor to help you make an informed decision about treatment.
Benefits and Risks of Cataract Surgery
Improvements in Activities
- Everyday activities
- Moving around
- Social activities
- Blood collection inside the eye
- Infection inside the eye
- Artificial lens damage or dislocation
- Drooping eyelid
- Retinal detachment
- Severe bleeding inside the eye
- Swelling or clouding of the cornea
- Loss of the eye
The Cataract Surgery
1. The process begins with the creation of a micro incision with a diamond knife.2. A round opening is then made in the skin of the natural lens, which is like a grape, with a skin and a softer interior.
3. Next, using a special probe with suction, the interior of the natural lens is removed, leaving only the skin. This technique is called phacoemulsification (see below)and uses ultrasound to remove the cataract. Lasers are not used to remove the cataract but may be used after the surgery.
4. The lens capsule is carefully cleaned and polished, providing a natural location for the new lens (the intraocular lens) that will be inserted into the eye to correct vision. The lens is flexible and actually fits through the tiny initial incision, opening inside the eye into the “skin” of the natural lens. Over time, the capsule contracts, “shrink-wrapping” the lens in place and making it a permanent part of the eye.5. The new lens becomes so well integrated into the eye that even severe trauma will not dislodge it.
- A small 1/8 inch opening is created with a specific self sealing technique. The new technique places the incision into the cornea just next to the sclera.
- Ultrasound is used to gently break up (or emulsify) the cloudy lens into tiny pieces which can be removed through the tip of the “phaco” probe instead of a wide incision.
- An intraocular lens (IOL) is then implanted through the smaller incision. The size of the IOL is smaller than a dime.
- The final replacement lens is shown in place. The small “No Stitch” incision does not require sutures.
Using new surgical techniques, the removal of the cataract is a safe and straightforward process. It is performed without sutures through a micro incision in the eye and takes 7 to 15 minutes.
No discomfort is experienced during and none or minimal after the procedure due to complete local anesthesia.
PRE-OP CATARACT SURGERY DIRECTIONS
DAY OF SURGERY:
- Generally, it is recommended that aspirin be avoided for at least ten days prior to your cataract surgery. Your doctor will advise you regarding the products containing aspirin.
- Many eye care providers prefer that food intake be avoided at least eight hours prior to surgery. If you are allowed to eat breakfast on the morning of your surgery, keep the meal light (ie. tea or coffee and toast). Orange and grapefruit juices may increase the effects of anesthesia — check with your doctor beforehand.
- Take your medications and eye drops (as advised by your doctor). If you have diabetes, your doctor will tell you the dosage of insulin or oral diabetic medications and the diet you should follow. Bring all medications in their original containers with you and give them to the nurse.
- Leave valuables, such as jewelry (rings, etc.), at home on the day of surgery.
- Wash your face well. Do not wear any face or eye make-up, shaving lotion, or perfume..
- Register at the Registration/Admitting desk at the hospital on the date and time specified by the doctor’s office. From there, you will be escorted to the day surgery area where you will change from your street clothes into a hospital gown.
- After surgery, you will return to the hospital recovery area for a short time. You will be given an appointment to see the doctor within 36 hours. You will be able to return home with your family or friend. DO NOT DRIVE YOURSELF.
FOLLOWING THE DAY OF SURGERY:
- The doctor will remove the dressing and examine your eye. Your vision will be tested, and eye drops will be instilled. It is normal for vision to be slightly blurred in the operated eye. It is not uncommon to experience some double vision. This should gradually improve over the next few days.
- Glasses should be worn at all times to help keep your operated eye protected during the healing process. Please remember that the eyeglass prescription will no longer be correct in the lens corresponding with your operated eye. In about 3-6 weeks, you will be given a new prescription for glasses.
- It is not uncommon for many patients to experience a slight increase in light-sensitivity (photophobia) following cataract surgery. This may cause increased tearing and eye irritation. Lightly dab tears away from eyelids without touching the eye directly. Avoid rubbing, poking, or applying pressure to the eye.
- Do not lift over 30 lbs. for two weeks. Avoid lowering your head below the level of your heart (ie. bend at your knees, and not at your waist).
- Avoid getting soap or water in your eyes. You may shower, but do not get the operated eye wet. During the first two weeks, hair can be washed with the head tilted backwards (ie. hairdresser-style). No swimming for two weeks.
- Apply a protective shield over the operative eye at bedtime (your doctor will instruct you how to apply).
- You may have some discomfort or mild pain after eye surgery which should be relieved by acetaminophen (Tylenol).
- If you experience severe pain, any decrease in vision, or discharge from the eye, call your eye care provider immediately.
*Please note: The above guide is to be used for reference only. Please follow the specific medical advice of your doctor.
Yag Laser Capsulotomy
In approximately 50-80 percent of people that have undergone cataract extraction, an additional procedure involving the use of a laser may be required to “tweak” the vision. This procedure is called a Yag Laser Capsulotomy.
To understand this procedure we will review the anatomy of the crystalline lens. Remember that the lens has two main layers: the inner nucleus layer and the outer cortex.
The lens is enclosed by the third structure termed the capsule which is almost like a “plastic” wrap around the lens. In modern cataract procedures, the capsule’s anterior surface is removed allowing the lens to be extracted (extracapsular) or broken up by ultrasound (phacoemulsification). The posterior portion of the capsule is left intact which provides a structure for the implant to be placed. Usually with in the first two years after surgery, this posterior capsule begins to cloud up. Prior to the onset of laser surgery, this clouding of the capsule was termed a second cataract which required another trip to the operating room to remove. With the advent of the Yag laser, this capsular membrane can be painlessly broken up within the eye by laser energy thus restoring clear vision.