What should I know about cataract eye surgery?
With age, the world can get a little fuzzier. Many older Americans commonly develop cataracts – a fogging of the lens of the eye. Around 25 million Americans 40 and older have cataracts, according to the National Eye Institute, part of the National Institutes of Health. And the likelihood a person will develop cataracts increases sharply as one ages.
Vision difficulties resulting from cataracts can raise the risk for accidents and injuries. “In a practical sense, cataracts really increase the risk of car accidents and falls,” says Dr. Mitchell Brinks, an assistant professor of ophthalmology at the OHSU School of Medicine and chair of Vision 2020/USA, a national coalition of eye care organizations focused on blindness prevention.
Rarely, people under 40 can also develop cataracts as well. Some kids are born with cataracts or develop them in childhood (congenital cataracts). In other cases, cataracts may result from eye injury or taking some medicines like steroids. Younger people with cataracts are also potential candidates for surgery.
Given the common nature of the problem and the great impact it can have on daily life, cataract surgery is quite common. The minutes-long procedure replaces the clouded lens with a clear artificial one – called an intraocular lens – so more light can reach the retina and improve vision. According the NIH, by age 80 more than half of all Americans either have a cataract or have undergone cataract surgery to fix it. Well over 3 million cataract surgeries are done annually in the U.S., making it the most common elective surgery.
While many are still reluctant to have any surgery involving their eyes, experts say for the vast majority, the procedure improves vision and quality of life. Additionally, the risks are minimal, clinicians say, while still stressing that every patient should talk through whether the procedure is right for them and if the benefits outweigh the risks.
Symptoms of cataracts may include:
- Blurry or dim vision.
- Colors may seem faded or what you see may become more yellow- or brown-tinged.
- Sensitivity to light and glare, or seeing halos around everything from headlights or lights in a home.
- Double vision.
- Trouble seeing at night.
- Frequent changes in the prescription of glasses or contacts.
The typical age-related cataract is akin to a window in a home that for 65 years has never been cleaned, describes Dr. Ranya Habash, medical director of technology innovation at the Bascom Palmer Eye Institute at the University of Miami Miller School of Medicine, where she also serves as an assistant professor of ophthalmology. “So it’s totally normal for it to be fogged up,” says Habash, who is also an assistant professor of ophthalmology at UM.
But she and other clinicians emphasize that doesn’t mean you should just live with the consequences of this natural process.
As an elective procedure, there is no one-size-fits-all model that determines who will or won’t undergo cataract surgery. Rather, much of that is determined individually by patients with their ophthalmologist. If cataract symptoms impact your life and what you’re able to do, experts say it’s worth at least discussing with an ophthalmologist whether cataract surgery might be appropriate for you.
“Anybody who has that fogging and is having visual disturbances,” Habash says, “like they feel uncomfortable driving at night, they’re having a lot of glare … halos, trouble focusing, their glasses keep changing – those are all the patients who are candidates for surgery.”
Experts say the majority of people with cataract are candidates for cataract surgery. A key determination is how significant the clouding of the lens has become, and along those lines, the extent to which it affects a person’s function and quality of life.
Cataract surgery is a fairly standardized procedure, and eye surgeons say that’s one reason for consistently high success rates. Still there’s some variation with cataract surgeries.
There are two main types of cataract surgery performed today:
- Phacoemulsification, or phaco.
- Extracapsular cataract surgery.
Phaco is the most common cataract procedure: A surgeon uses a handheld, pen-shaped probe – inserted through a small incision in the cornea, the front surface the eye. That device transmits ultrasound waves to break up the lens with the cataract. The eye is irrigated and then the pieces of the lens are suctioned out. A clear replacement lens is then inserted.
With extracapsular surgery, an incision is also made in the cornea. But it’s through that scalpel or laser cut, which the entire lens with the cataract is removed. (Anything that remains is also suctioned out.) This method is considered effective as well, but because phaco allows the lens to be removed through a smaller incision than with extracapsular surgery, it’s typically the preferred method in the U.S. today.
Certain technologies, such as lasers, may also be used in an attempt to enhance surgery. But traditional cataract surgery success rates that hover around 98% or 99% are still considered comparable to rates of success seen with laser-assisted cataract procedures.
For example, laser-assisted surgery may be recommended for cataract procedures when the patient also has astigmatism. With this condition, the eye isn’t perfectly round but instead is irregularly shaped, causing blurred vision. For patients who want to get this corrected during cataract surgery, the laser can be used to create incisions that help reshape the eye to fix astigmatism.
A laser may also be used to precisely map the eye and place a specialized lens, like a multifocal lens that allows the patient to see far and near more clearly. That often eliminates the need for glasses or contacts.
Multifocal lenses – much like bi- or tri-focal glasses – allow a person to focus at different distances – like for driving, working at a computer or reading. However, the downside is it can take some adjustment, and may cause visual difficulties. “That’s not how your natural eye works, to have two images in the same eye. So people can get some glare or kind of halos around lights more commonly with those,” Brinks says. “So we’re pretty careful in who we put those in, because they’re difficult to take out if they cause problems.”
For lens options, a monofocal is the standard, used to restore vision for a single area of focus – typically distance vision. In such a case, glasses may still be needed for reading.
In addition, cameras may boost precision with another approach called intraoperative aberrometry. “We have the ability to use camera systems to redo measurements that we often do before surgery,” says Dr. Mitra Nejad, a cataract surgeon at the UCLA Stein Eye Institute and a clinical instructor at the university’s David Geffen School of Medicine. “We can basically use this technology during surgery to kind of double-check and fine-tune our measurements. These are measures for the lens implant that we’re going to place in the eye.”
Eye doctors say cameras used in this way to assist with cataract surgery help with selecting the properly sized replacement lens for the patient and placing that lens. Similarly, laser-assisted surgery can correct astigmatism and be useful for implanting specialized lenses.
Experts differ, however, on how widely used these technologies should be, their cost effectiveness and how much impact they may have on outcomes versus traditional cataract surgeries for the majority of patients. But on a case-by-case basis, some eye surgeons say they may enhance results and should be discussed as options.
While the rate of complications is low, as with any procedure, cataract surgery carries risks, which can affect the eye or vision. Those include:
- Swelling or inflammation.
- Retinal detachment.
- Damage to the eye.
- Vision loss.
- The artificial lens can shift or move out of position.
Need for secondary surgery to correct issues from the first, like a procedure called a vitrectomy to remove parts of the original lens left in the eye.
Minor complications or side effects like prolonged dry eye requiring drops after surgery or prolonged cloudy vision may occur in around 1 in 100 cases. While vision loss or other serious complications, such as retinal detachment or bleeding or hemorrhage, are far rarer. Post-cataract surgery: “Maybe 1 in 1,000 have worse vision than they did before,” Habash says.
Often patients experience some pain or discomfort immediately after the procedure, particularly in the hours following cataract. In some cases, however, pain may persist for weeks afterward. Talk with your doctor before cataract surgery about options, including pain relievers, to address pain, and what should be done if it continues.
A patient’s own medical history, like having diabetes or diabetic eye disease, can increase risk. Previous retinal problems or trauma in the eye, glaucoma, macular degeneration, which is the leading cause of vision loss in older adults – “those are all things that can impact the surgical results too,” Habash says.
Besides reducing risk for falls and automobile accidents, correcting cataract can greatly improve a person’s overall quality of life, eye surgeons emphasize. “It’s kind of discouraging and frustrating for people not to function like they used to,” Brinks says.
Removing a fogged lens and replacing it with one that allows light to pass through unabated can improve clarity of vision, depth perception and contrast sensitivity, which is important to be able to see things at night or at dusk. The surgery can also enhance a person’s abilities to see color again. That’s something Brinks hears patients comment on a lot. “That dress is so red, or the flowers are so yellow, the sky was so blue – and they’re almost as excited about that as the improved clarity.”
Results vary and some vision limitations – like a need to wear glasses for certain things, depending on the surgery and individual patient – may remain. But improvements help many older adults push back against an age-related limitation that clinicians say doesn’t have to be.
Where to Have Surgery
Regulation and again standardization of cataract procedures mean that patients should expect a consistently high rate of effectiveness with the surgery most anywhere they have it done.
Still, what shouldn’t be ignored is the number of procedures done at a particular health care facility and especially by an eye surgeon. Some eye surgeons emphasize, too, the importance of updated equipment, such as to calculate the right prescription for a lens. But that’s a supplement to, not a replacement for, doing a high volume of cataract surgeries.
Compared with other surgeries, eye surgery especially takes much repetition to hone skills. “It’s a much more complex surgery, even though it’s so fast,” Habash says. “So you have to go to someone who does a lot of these.”
Habash didn’t suggest a baseline number of procedures that a surgeon should have done, but she and others stressed how key experience is. So in seeking an eye surgeon consider their experience with the procedure.
Questions to Ask
Before you proceed with cataract surgery, make sure you know what to expect to determine if the procedure is right for you. Here are some questions to ask:
- How do the risks and benefits compare for me?
- If I am a potential candidate, when is the right time for me to have cataract surgery?
- How much experience do you have performing cataract surgery?
- What type of approach – e.g. traditional or laser-assisted – do you recommend and why?
- What are my options for artificial lenses?
- What will be the cost, and will it be covered by insurance?
- How should I prepare for surgery?
- What will recovery entail?
- Will I still need to wear glasses after cataract surgery?
In addition, if you have cataracts in both eyes, you’ll want to know how the surgeon would like to proceed. Typically, surgery is performed on one eye at a time, to provide separate time for recovery with each eye.
What to Expect Before Surgery
Prior to any cataract procedure, you’ll be assessed by your eye doctor. You’ll have measurements taken that will be used for your artificial lens prescription. Your ophthalmologist should also look for other eye diseases, like glaucoma.
You may also be seen by your primary care doctor to check on your general health for surgery. If you have diabetes or other issues like high blood pressure, it’s important to ensure those are controlled before surgery to lessen any associated risks going into the procedure.
You’ll discuss what to expect before, during and after surgery. For the procedure itself, the eye being operated on will be numbed, but you’ll likely be awake for the procedure. However, if you feel uncomfortable staying awake during the procedure, you can discuss with your doctor whether mild sedative medication to help calm you during the surgery is appropriate.
How to Prepare for Surgery
Make sure to closely follow any instructions from your eye surgeon leading up to your cataract procedure. This typically include using eye drops to prevent infection and reduce inflammation in preparation for surgery. You’ll also likely need to abstain from eating or drinking anything for a short period – perhaps after midnight through the morning of your procedure.
Don’t wear makeup of anything kind the day of your procedure.
Check about what medications you may be able to continue taking and if you’ll need to stop any. Unlike with other surgeries, you likely will not need to stop taking blood thinners.
It’s generally advised that you arrange to have a ride to and from surgery.
You’ll be asked to use eye drops after surgery as well. Make sure to follow your surgeon’s post-operative instructions.
Don’t rub your eyes after surgery. For a first week afterward, stay out of swimming pools and generally avoid activities, like gardening, where you may get water, dirt or other debris in your eye to prevent infection.
Don’t bend over right after your procedure, and be careful not to strain and avoid heavy lifting or strenuous activity for a couple weeks after cataract surgery. Too much pressure on the eye can increase the risk for complications.Taking it easy for one to two weeks after surgery will help allow your eye to heal.
Overall, it’s important to follow your doctor’s specific recommendations closely after your cataract surgery for best results.
It will likely take some time to adjust to your new intraocular lens. Immediately after the procedure, it’s normal to have some blurry vision. But usually patients are able to resume most activities within a day or so after cataract surgery. Ask about any restrictions after the procedure in advance, like when you can resume driving.
Some inflammation right after surgery is normal. And it can take weeks for your eyes to adjust, but you should be fully recovered within a month. “Typically over the first week patients experience an improvement in their vision every day,” Habash says.
Make sure to note how your recovery is going in any follow-up visits with your eye surgeon, and to flag any concerns or possible side effects or complications you’re experiencing.