Cataract Surgery

What to Expect During Cataract Surgery?

Sandra Lora Cremers, MD, FACS

Any surgery can be nerve racking, but surgery in your eye, can cause even the most austere to be more than a little anxious.

Cataract surgery remains the most commonly performed surgery in the world and has the least complications by percentages of all major surgeries.

There is usually minimal discomfort felt during surgery. The amount of discomfort or pain depends on what type of anesthesia a patient requests and the patient’s pain threshold

Anesthesia Options:

1. Topical: lidocaine or proparacaine/tetracaine drops &/or gel.

-Used by majority of surgeons around world since no increased risk of using this from the anesthesia itself.

-Discomfort/pain during the surgery is possible if given just topical anesthesia. Often eye surgeons use intravenous (iv) sedation to help patient’s perception of pain during the procedure.

2. Peribulbar: anesthesia given around the eye:

-a long needle is used to inject anesthesia around eyeball and not behind it.

-low risk of complications from anesthesia but include, retrobulbar hemorrhage (blood behind eye that needs to be treated), damage to optic nerve (rare), damage to eyeball (rare).

-this provides good anesthesia but is not used as often as in past given risks.

-may limit patient’s ability to move eye and close eyelid, so eye usually is taped shut for first 24 hrs after cataract surgery/peribulbar anesthesia.

3. Retrobulbar: anesthesia given behind the eye:

-a longer needle is inserted through the skin of the lower eyelid and directed under the eyeball and through the orbital septum and behind the eye.

-risk of complications from anesthesia is higher than a peribulbar injection but include, retrobulbar hemorrhage (blood behind eye that needs to be treated), damage to optic nerve, damage to eyeball and its contents (rare).

-this provides very good anesthesia but is not used as often as in past given higher risks.

-may limit patient’s ability to move eye and close eyelid, so eye usually is taped shut for first 24 hrs after cataract surgery/retrobulbar anesthesia.

4. General Anesthesia:

-rarely used in adults unless patient cannot stay still, eye movement is excessive, or patient cannot follow directions or is at risk for significant movement during the surgery.

-General Anesthesia has a very safe risk profile but the usual risk of general anesthesia apply: this is not limited to, risk of aspiration, pneumonia, risk of stroke, heart attack (rare), risk of life threatening condition (very rare), risk of death (very rare).

-General anesthesia is used for all pediatric cases.

During cataract surgery you may also feel the following:

1. You will be asked to lie flat on a stretcher. All paperwork will be checked and you may be asked to sign more paperwork.

2. Drops will be put into your eyes.

3. Often an IV line will be placed: some patients have told me this was the worst part of the whole procedure.

4. You may be given a pill or two to swallow prior to or after your surgery.

5. You may feel a blood pressure cuff on your forearm go on from time to time during the surgery: try not to be alarmed as this is normal.

6. If you have Laser Cataract Surgery: the Femtosecond Laser cuts the cataract into pieces making its removal less traumatic to the eye; astigmatism correction can also be done with the Laser.

a. you may be asked to sit up straight so a mark can be placed on the cornea if having your astigmatism corrected.

b. You will be asked to look at three flashing lights within a cone. Take deep breaths throughout the process.

c. A lid speculum will be placed in the eye, which can be slightly uncomfortable but does not usually cause any pain.

d. A suction cup will be placed onto the eye. You may feel pressure in the eye during the laser part of the procedure, which usually lasts less than 1-2 minutes. Continue to take deep breaths throughout the process.

e. The suction cup is then released, a contact lens may be removed then from the eye, and the lid speculum will be removed: all of which do not usually cause any pain.

7. You will be asked to close your eyes before the cataract surgery begins.

8. Once in under the microscope for the cataract removal:

a. A lid speculum will be placed in the eye, which can be slightly uncomfortable but does not usually cause any pain.

b. More drops for anesthesia will be placed.

c. You might feel the eye being moved around and pressure from time to time which is normal.

d. You will be asked to look ahead look straight ahead in the center of four lights under the microscope and to move your eye down sometimes, which should not be stressful and done with ease.

e. Some patients will see lights and flashes during the process if surgery done under Topical Anesthesia.

f. You will feel pressure and some discomfort from time to time. If at any time you feel significant pain, tell your surgeon and more anesthetic can be given.

g. Most uncomplicated cataract surgeries take 15-20 minutes or less. If the vitreous gel in the back of the eye comes forward or if the back part of the capsule breaks open during surgery, the surgery can take longer though still usually less than 30-50 minutes.

h. You may feel more pressure at the end of the cataract removal when the implant is being placed. This usually lasts for 2-5 seconds.

9. ORA: Intraoperative Aberrometry allows the surgeon to fine tune the planned implant power:

a. You will be asked to look at central blinking lights under the microscope and your head may be moved by the surgeon. There is usually minimal discomfort during this part.

10. The lid speculum is removed.

11. More drops are given and a clear shield is placed.

12. You may have foreign body sensation, scratchiness, tearing, discomfort after the surgery which is normal. This can last for a few days to weeks afterwards if the cornea was cut during the surgery which can be normal. If you have any worsening pain, vision, worsening of flashing lights, a burst of black floaters, or you see a dark curtain coming down over your vision EVER, contact your eyeMD asap as this can be an emergency.

The below is a good summary by a colleague: Dr. Vance Thompson.

More information on Cataracts:

Most of us after age 50, have a change in our lens which technically is called a Cataract. Sometimes an EyeMD will state “You have cataracts.” Not all cataracts require or will require surgery.

A cataract is a clouding of the lens inside the eye, causing vision loss that cannot be corrected with glasses, contact lenses or corneal refractive surgery like LASIK.

As frightening as cataracts might sound, modern cataract surgery usually can restore vision lost to cataracts — and often can reduce your dependence on eyeglasses as well.

Most cataracts are associated with the aging process and are common among older Americans. In fact, according to the National Eye Institute (NEI), the percentage of Americans with cataracts by age group in 2010 were as follows:

And the prevalence of cataracts in the U.S. is expected to grow significantly in the years ahead, due in part to the aging of the population. In 2010, roughly 24.4 Americans had cataracts, and that number is projected to grow to 50.2 million by the year 2050, according to NEI.

Thankfully, modern cataract surgery is one of the safest and most effective surgical procedures performed today. More than 3 million cataract surgeries are performed in the United States every year, with the vast majority of these procedures produce excellent visual outcomes.

Please click here for a video on how cataract surgery works.

Watch this video about how cataract surgery works.

Cataract Surgery Basics

In cataract surgery, the lens inside your eye that has become cloudy is removed and replaced with an artificial lens (called an intraocular lens, or IOL) to restore clear vision.

The procedure typically is performed on an outpatient basis and does not require an overnight stay in a hospital or other care facility.

Most modern cataract procedures involve the use of a high-frequency ultrasound device that breaks up the cloudy lens into small pieces, which are then gently removed from the eye with suction.

This procedure, called phacoemulsification or “phaco,” can be performed with smaller incisions than previous surgical techniques for cataract removal, promoting faster healing and reducing the risk of cataract surgery complications, such as a retinal detachment.

After all remnants of the cloudy lens have been removed from your eye, the cataract surgeon inserts a clear intraocular lens, positioning it securely behind the iris and pupil, in the same location your natural lens occupied. (In special cases, an IOL might be placed in front of the iris and pupil, but this is less common.)

The surgeon then completes the cataract removal and IOL implantation procedure by closing the incision in your eye (a stitch may or may not be needed), and a protective shield is placed over the eye to keep it safe in the early stages of your cataract surgery recovery.

Laser Cataract Surgery

Recently, a number of femtosecond lasers — similar to the lasers used to create the corneal flap in all-laser LASIK — have been approved by the FDA for use in cataract surgery performed in the United States.

These lasers have gained approval for the following steps in cataract surgery, reducing the need for surgical blades and other hand-held tools:

Creating corneal incisions to allow the surgeon access to the lens
Removing the anterior capsule of the lens
Fragmenting the cataract (so less phaco energy is required to break it up and remove it)
Creating peripheral corneal incisions to reduce astigmatism (when needed)

Laser cataract surgery (or, more accurately, laser-assisted cataract surgery) is fairly new and significantly increases cataract surgery cost, primarily because the laser can cost from $300,000 to $500,000 for a surgeon to purchase and there are other significant costs associated with the use and maintenance of this technology.

While studies have shown that lasers can improve accuracy during certain steps of cataract surgery, they may not necessarily improve cataract surgery safety, recovery time and visual outcomes in every case.

For the latest information about laser cataract surgery, ask your eye doctor during your pre-operative eye exam and cataract surgery consultation.

Preparing for Cataract Surgery and Choosing an IOL

Prior to cataract surgery, your optometrist and/or ophthalmologist will perform a comprehensive eye exam to check the overall health of your eyes, evaluate whether there are reasons why you should not have surgery and identify any risk factors you might have.

Cataract surgery with phacoemulsification

Phacoemulsification in cataract surgery involves insertion of a tiny, hollowed tip that uses high frequency (ultrasonic) vibrations to “break up” the eye’s cloudy lens (cataract). The same tip is used to suction out the lens.

Cataract surgery with phacoemulsification

After the eye’s natural lens is removed during cataract surgery, an artificial or intraocular lens is implanted to take its place.

A refraction also will be performed to accurately determine the amount of nearsightedness, farsightedness and/orastigmatism you have prior to surgery. Additional measurements of your eyes will be taken to determine the curvature of your cornea and the length of your eye.

These measurements are essential to help your cataract surgeon select the proper power of the intraocular lens and give you the best vision possible after surgery.

Today you have many types of IOLs to choose from for your cataract surgery, depending on your specific needs. In addition to IOLs that correct nearsightedness and farsightedness, there are now toric IOLs that correct astigmatism as well.

If you don’t mind wearing glasses after cataract surgery, a monofocal lens implant usually is used. Often, only part-time use of reading glasses is needed after cataract surgery with monofocal IOLs. But if prescription eyeglasses are needed (which often is the case if you only need cataract surgery in one eye), your eye doctor typically will prescribe new glasses for you approximately one month after surgery.

If you like the idea of being less dependent on glasses after cataract surgery, one way to correct presbyopia and reduce your need for reading glasses is to have your cataract surgeon adjust the power of one of your monofocal IOLs (assuming you have cataract surgery performed in both eyes) to give you a monovision correction, similar to monovision with contact lenses.

Another option is to choose one of a variety of advanced presbyopia-correcting IOLs to improve your reading vision without sacrificing your distance vision. Presbyopia-correcting IOLs includeaccommodating IOLs and multifocal IOLs; both types are designed to provide a greater range of vision after cataract surgery than conventional monofocal IOLs.

Be aware that not everyone is a good candidate for these premium IOLs, and choosing a presbyopia-correcting IOL will increase the out-of-pocket cost of your cataract surgery, since the added cost of these advanced lens implants is not covered by Medicare or other insurance plans.

Prior to cataract surgery, in addition to discussing the different types of IOLs, you will be advised about what to expect before, during and after your procedure. This information — which may be presented orally, in writing, via a video presentation or a combination of all three — is meant to help you make an informed decision about whether to proceed with surgery.

If you have any questions or concerns about cataract surgery, be sure to discuss them with your eye doctor and cataract surgeon prior to signing “informed consent” documents authorizing surgery.

Also, discuss with your eye doctor all medications you are taking, including non-prescription (“over-the-counter”) formulations and nutritional supplements. Some medications and supplements can increase your risk of cataract surgery complications and might need to be discontinued prior to surgery. Ask your doctor for details.

Cataract Surgery Recovery

An uncomplicated cataract surgery typically lasts only about 15 minutes. But expect to be at the surgical center for 90 minutes or longer, because extra time is needed to prepare you for surgery (dilating your pupil; administering pre-operative medication) and for a brief post-operative evaluation and instructions about your cataract surgery recovery before you leave.

You must have someone drive you home after cataract surgery; do not attempt to drive until you have visited your eye doctor the day after surgery and he or she tests your vision and confirms that you are safe to drive.

You will be prescribed medicated eye drops to use several times each day for a few weeks after cataract surgery. You also must wear your protective eye shield while sleeping or napping for about a week after surgery. To protect your eyes from sunlight and other bright light as your eye recovers, you will be given a special pair of post-operative sunglasses.

Also, many centers require someone to be with you after cataract surgery if you received anesthesia. Be sure to ask about this requirement prior to your cataract procedure so you are prepared for surgery day.

While your eye heals, you might experience some eye redness and blurred vision during the first few days or even weeks following the procedure.

During at least the first week of your recovery, it is essential that you avoid:

Strenuous activity and heavy lifting (nothing over 25 pounds).
Bending, exercising and similar activities that might stress your eye while it is healing.
Water that might splash into your eye and cause infection. Keep your eye closed while showering or bathing. Also, avoid swimming or hot tubs for at least two weeks.
Any activity that would expose your healing eye to dust, grime or other infection-causing contaminants.

Your cataract surgeon may give you other instructions and recommendations for your cataract surgery recovery, depending on your specific needs and the outcome of your procedure. If you have any questions at any time after cataract surgery, call your eye doctor for advice.

If you need cataract surgery in both eyes, your surgeon typically will prefer that you wait one to three weeks between procedures, so your first eye has healed sufficiently and you have good vision in that eye before the second surgery is performed.