Cataract surgery 1

Cataract surgery
Cataract surgery is the removal of the natural lens of
the eye (also called "crystalline lens") that has
developed an opacification, which is referred to as a
cataract. Metabolic changes of the crystalline lens
fibers over the time lead to the development of the
cataract and loss of transparency, causing impairment
or loss of vision. During cataract surgery, a patient's
cloudy natural lens is removed and replaced with a
synthetic lens to restore the lens's transparency.[1]

Following surgical removal of the natural lens, an

artificial intraocular lens implant is inserted (eye
surgeons say that the lens is "implanted"). Cataract Cataract in Human Eye- Magnified view seen on examination with a
surgery is generally performed by an ophthalmologist slit lamp

(eye surgeon) in an ambulatory (rather than inpatient)

setting, in a surgical center or hospital, using local anesthesia (either topical, peribulbar, or retrobulbar), usually
causing little or no discomfort to the patient. Well over 90% of operations are successful in restoring useful vision,
with a low complication rate.[2] Day care, high volume, minimally invasive, small incision phacoemulsification with
quick post-op recovery has become the standard of care in cataract surgery all over the world.

Types
Currently, the two main types of cataract surgery extraction performed by the ophthalmologists are
phacoemulsification (phaco) and conventional extracapsular cataract extraction (ECCE). In both types of surgery
an Intraocular lens is usually inserted. Foldable lenses are generally used when phaco is performed while
non-foldable lenses are placed following ECCE. The small incision size used in phacoemulsification (2-3mm) often
allows "sutureless" wound closure. ECCE utilises a larger wound (10-12mm) and therefore usually requires
stitching, although sutureless ECCE is also in use.
Cataract extraction using intracapsular cataract extraction (ICCE) has been superseded by phaco & ECCE, and is
rarely performed.
Phacoemulsification is the most commonly performed cataract procedure in the developed world. However, the high
cost of a phacoemulsification machine and of the associated disposable equipment means that ECCE remains the
most commonly performed procedure in developing countries.
Cataract surgery 2

Types of surgery
Extracapsular cataract extraction involves the removal
of almost the entire natural lens while the elastic lens
capsule (posterior capsule) is left intact to allow
implantation of an intraocular lens[3] . There are two
main types of cataract surgery:
• Phacoemulsification (Phaco) is the preferred
method in most cases. It involves the use of a
machine with an ultrasonic handpiece equipped with
a titanium or steel tip. The tip vibrates at ultrasonic
frequency (40,000 Hz) and the lens material is
emulsified. A second fine instrument (sometimes
called a cracker or chopper) may be used from a
Cataract surgery, using a temporal approach phacoemulsification
side port to facilitate cracking or chopping of the probe (in right hand) and "chopper"(in left hand) being done under
nucleus into smaller pieces. Fragmentation into operating microscope at a Navy medical center
smaller pieces makes emulsification easier, as well
as the aspiration of cortical material (soft part of the
lens around the nucleus). After phacoemulsification
of the lens nucleus and cortical material is
completed, a dual irrigation-aspiration (I-A) probe
or a bimanual I-A system is used to aspirate out the
remaining peripheral cortical material.

• Conventional extracapsular cataract extraction

(ECCE): It involves manual expression of the lens
through a large (usually 10–12 mm) incision made
in the cornea or sclera. Although it requires a larger
incision and the use of stitches, the conventional Cataract surgery recently performed, foldable IOL inserted. Note
method may be indicated for patients with very hard small incision and very slight hemorrhage to the right of the still
dilated pupil.
cataracts or other situations in which
phacoemulsification is problematic. Microincision
cataract surgery involves a technique by which a cataract can be reached through an incision of 1.5 millimeters or
less.

• Intracapsular cataract extraction (ICCE) involves the removal of the lens and the surrounding lens capsule in one
piece. The procedure has a relatively high rate of complications due to the large incision required and pressure
placed on the vitreous body. It has therefore been largely superseded and is rarely performed in countries where
operating microscopes and high-technology equipment are readily available[3] . After lens removal, an artificial
plastic lens (an intraocular lens implant) can be placed in either the anterior chamber or sutured into the sulcus.
Cryoextraction is a form of ICCE that freezes the lens with a cryogenic substance such as liquid nitrogen[4] . In this
technique, the cataract is extracted through use of a cryoextractor — a cryoprobe whose refrigerated tip adheres to
and freezes tissue of the lens, permitting its removal. Although it is now used primarily for the removal of subluxated
lenses, it was the favored form of cataract extraction from the late 1960s to the early 1980s[5] .
Cataract surgery 3

Intraocular lenses
• Intraocular lens implantation: After the removal of the cataract, an intraocular lens (IOL) is usually implanted
into the eye, either through a small incision (1.8 mm to 2.8 mm) using a foldable IOL, or through an enlarged
incision, using a PMMA (polymethylmethacrylate) lens. The foldable IOL, made of silicone or acrylic material of
appropriate power is folded either using a holder/folder, or a proprietary insertion device provided along with the
IOL. The lens implanted is inserted through the incision into the capsular bag within the posterior chamber
(in-the-bag implantation). Sometimes, a sulcus implantation (in front or on top of the capsular bag but behind the
iris) may be required because of posterior capsular tears or because of zonulodialysis. Implantation of
posterior-chamber IOL (PC-IOL) in patients below 1 year of age is controversial due to rapid ocular growth at
this age and the excessive amount of inflammation, which may be very difficult to control. Optical correction in
these patients without intraocular lens (aphakic) is usually managed with either special contact lenses or glasses.
Secondary implantation of IOL (placement of a lens implant as a second operation) may be considered later. New
designs of multi-focal intra-ocular lens are now available. These lenses allow focusing of rays from distant as well
as near objects, working much like bifocal or trifocal eyeglasses. Pre-operative patient selection and good
counselling is extremely important to avoid unrealistic expectations and post-operative patient dissatisfaction.
Acceptability for these lenses has become better and studies have shown good results in selected patients. Brands
in the market include: ReSTOR (R), Rezoom (R) and Technis MF (R).
In addition, there is an accommodating lens that was approved by the US FDA in 2003 and made by Eyeonics,[6]
now Bausch & Lomb. The Crystalens (R) is on struts and is implanted in the eye's lens capsule, and its design allows
the lens' focusing muscles to move it back and forth, giving the patient natural focusing ability.

Preoperative evaluation
An eye examination or pre-operative evaluation by an eye surgeon is necessary to confirm the presence of a cataract
and to determine if the patient is a suitable candidate for surgery. The patient must fulfill certain requirements such
as:
• The degree of reduction of vision due, at least in large part, to the cataract should be evaluated. While the
existence of other sight-threatening diseases, such as age-related macular degeneration or glaucoma, does not
preclude cataract surgery, less improvement may be expected than in their absence.
• The eyes should have a normal pressure, or any pre-existing glaucoma should be adequately controlled on
medications. In cases of uncontrolled glaucoma, a combined cataract-glaucoma procedure
(Phaco-trabeculectomy) can be planned and performed.
• The pupil should be adequately dilated using eyedrops; if pharmacologic pupil dilation is inadequate, procedures
for mechanical pupillary dilatation may be needed during the surgery.
• The patients with retinal detachment may be scheduled for a combined vitreo-retinal procedure, along with
PC-IOL implantation.
• In addition, it has recently been shown that patients taking tamsulosin (Flomax), a common drug for enlarged
prostate, are prone to developing a surgical complication known as intraoperative floppy iris syndrome (IFIS),
which must be correctly managed to avoid the complication posterior capsule rupture; however, prospective
studies have shown that the risk is greatly reduced if the surgeon is informed of the patient's history with the drug
beforehand, and has appropriate alternative techniques prepared.[7] .
Cataract surgery 4

Operation procedures
The surgical procedure in phacoemulsification for removal of cataract involves a number of steps. Each step must be
carefully and skillfully performed in order to achieve the desired result. The steps may be described as follows:
1. Anaesthesia,
2. Exposure of the eyeball using a lid speculum,
3. Entry into the eye through a minimal incision (corneal or scleral)
4. Viscoelastic injection to stabilize the anterior chamber and to help maintain the eye pressurization
5. Capsulorhexis
6. Hydrodissection pie
7. Hydro-delineation
8. Ultrasonic destruction or emulsification of the cataract after nuclear cracking or chopping (if needed), cortical
aspiration of the remanescent lens, capsular polishing (if needed)
9. Implantation of the artificial IOL
10. Entration of IOL (usually foldable)
11. Viscoelastic removal
12. Wound sealing / hydration (if needed).
The pupil is dilated using drops (if the IOL is to be placed behind the iris) to help better visualise the cataract. Pupil
constricting drops are reserved for secondary implantation of the IOL in front of the iris (if the cataract has already
been removed without primary IOL implantation). Anesthesia may be placed topically (eyedrops) or via injection
next to (peribulbar) or behind (retrobulbar) the eye. Oral or intravenous sedation may also be used to reduce anxiety.
General anesthesia is rarely necessary, but may be employed for children and adults with particular medical or
psychiatric issues. The operation may occur on a stretcher or a reclining examination chair. The eyelids and
surrounding skin will be swabbed with disinfectant. The face is covered with a cloth or sheet, with an opening for the
operative eye. The eyelid is held open with a speculum to minimize blinking during surgery. Pain is usually minimal
in properly anesthetised eyes, though a pressure sensation and discomfort from the bright operating microscope light
is common. The ocular surface is kept moist using sterile saline eyedrops or methylcellulose viscoelatic. The
discission into the lens of the eye is performed at or near where the cornea and sclera meet (limbus = corneoscleral
junction). Advantages of the smaller incision include use of few or no stitches and shortened recovery time.[3] [8] . A
capsulotomy (rarely known as cystotomy) is a procedure to open a portion of the lens capsule, using an instrument
called a cystotome[9] . An anterior capsulotomy refers to the opening of the front portion of the lens capsule, whereas
a posterior capsulotomy refers to the opening of the back portion of the lens capsule. In phacoemulsification, the
surgeon performs an anterior continuous curvilinear capsulorhexis, to create a round and smooth opening through
which the lens nucleus can be emulsified and the intraocular lens implant inserted.
Following cataract removal (via ECCE or phacoemulsification, as described above), an intraocular lens is usually
inserted. After the IOL is inserted, the surgeon checks that the incision does not leak fluid. This is a very important
step, since wound leakage increases the risk of unwanted microrganisms to gain access into the eye and predispose to
endophathalmitis. An antibiotic/steroid combination eye drop is put and an eye shield may be applied on the
operated eye, sometimes supplemented with an eye patch.
Antibiotics may be administered pre-operatively, intra-operatively, and/or post-operatively. Frequently a topical
corticosteroid is used in combination with topical antibiotics postoperatively.
Most cataract operations are performed under a local anaesthetic, allowing the patient to go home the same day. The
use of an eye patch may be indicated, usually for about some hours, after which the patient is instructed to start using
the eyedrops to control the inflammation and the antibiotics that prevent infection.
Occasionally, a peripheral iridectomy may be performed to minimize the risk of pupillary block glaucoma. An
opening through the iris can be fashioned manually (surgical iridectomy) or with a laser (called YAG-laser
iridotomy). The laser peripheral iridotomy may be performed either prior to or following cataract surgery.
Cataract surgery 5

The iridectomy hole is larger when done manually than when performed with a laser. When the manual surgical
procedure is performed, some negative side effects may occur, such as that the opening of the iris can be seen by
others (aesthetics), and the light can fall into the eye through the new hole, creating some visual disturbances . In the
case of visual disturbances, the eye and brain often learn to compensate and ignore the disturbances over a couple of
months. Sometimes the peripheral iris opening can heal, which means that the hole ceases to exist. This is the reason
why the surgeon sometimes makes two holes, so that at least one hole is kept open.
After the surgery, the patient is instructed to use anti-inflammatory and antibiotic eye drops for up to two weeks
(depending on the inflammation status of the eye and some other variables). The eye surgeon will judge, based on
each patient's idiosyncrasies, the time length to use the eye drops. The eye will be mostly recovered within a week,
and complete recovery should be expected in about a month. The patient should not participate in contact/extreme
sports until cleared to do so by the eye surgeon.

Complications
Complications after cataract surgery are relatively uncommon.
• Some people can develop a posterior capsular opacification (also called an after-cataract). As a physiological
change expected after cataract surgery, the posterior capsular cells undergo hyperplasia and cellular migration,
showing up as a thickening, opacification and clouding of the posterior lens capsule (which is left behind when
the cataract was removed, for placement of the IOL). This may compromise visual acuity and the ophthalmologist
can use a device to correct this situation. It can be safely and painlessly corrected using a laser device to make
small holes in the posterior lens capsule of the crystalline. It usually is a quick outpatient procedure that uses a
Nd-YAG laser (neodymium-yttrium-aluminum-garnet) to disrupt and clear the central portion of the opacified
posterior lens capsule (posterior capsulotomy). This creates a clear central visual axis for improving visual
acuity.[10] . In very thick opacified posterior capsules, a surgical (manual) capsulectomy is the surgical procedure
performed.
• Posterior capsular tear may be a complication during cataract surgery. The rate of posterior capsular tear among
skilled surgeons is around 2% to 5%. It refers to a rupture of the posterior capsule of the natural lens. Surgical
management may involve anterior vitrectomy and, occasionally, alternative planning for implanting the
intraocular lens, either in the ciliary sulcus, in the anterior chamber (in front of the iris), or, less commonly,
sutured to the sclera.
• Retinal detachment is an uncommon complication of cataract surgery, which may occur weeks, months, or even
years later.
• Toxic Anterior Segment Syndrome or TASS is a non-infectious inflammatory condition that may occur following
cataract surgery. It is usually treated with topical corticosteroids in high dosage and frequency.
• Endophthalmitis is a serious infection of the intraocular tissues, usually following intraocular surgery, or
penetrating trauma. There is some concern that the clear cornea incision might predispose to the increase of
endophalmitis but is no conclusive study to corroborate this suspicion.
• Glaucoma may occur and it may be very difficult to control. It is usually associated with inflammation, specially
when little fragments or chunks of the nucleus get access to the vitreous cavity. Some experts recommend early
intervention when this condition happens (posterior pars plana vitrectomy). Neovascular glaucoma may occur,
specially in diabetic patients. In some patients, the intraocular pressure may remain so high that blindness may
ensue.
• Swelling or edema of the central part of the retina, called macula, resulting in macular edema, can occur a few
days or weeks after surgery. Most such cases can be successfully treated
• Other possible complications include: Swelling or edema of the cornea, sometimes associated with cloudy vision,
which may be transient or permanent (pseudophakic bullous keratopathy). Displacement or dislocation of the
intraocular lens implant may rarely occur. Unplanned high refractive error (either myopic or hypermetropic) may
Cataract surgery 6

occur due to error in the ultrasonic ecobiometry (measure of the length and the required intra-ocular lens power).
Cyanopsia, in which the patient sees everything tinted with blue, often occurs for a few days, weeks or months
after removal of a cataract. Floaters commonly appear after surgery.

History
Cataract surgery was known to the Indian physician
Sushruta (6th century BCE), who described it in his
work the Sushruta Samhita. This text describes an
operation called "couching", in which a curved needle
was used to push the lens into the rear of the eye and
out of the field of vision. The eye would later be soaked
with warm clarified butter and then bandaged. Sushruta
claimed success with this method but cautioned that
this procedure should only be performed when Slit lamp photo of IOL showing Posterior capsular opacification

absolutely necessary.[11] [12] This method may have visible few months after implantation of Intraocular lens in eye, seen
on retroillumination
been brought to the West by Greek travelers from India
and the Middle East.[11] The removal of cataract by
surgery was also introduced into China from India.[13]

In the Western world, bronze instruments that could have been used for cataract surgery have been found in
excavations in Babylonia, Greece, and Egypt. The first references to cataract and its treatment in the West are found
in 29 AD in De Medicinae, the work of the Latin encyclopedist Aulus Cornelius Celsus, which also describes the
couching operation.[14]
Couching continued to be used throughout the Middle Ages and is still used in some parts of Africa and in
Yemen.[15] [16] However, couching is an ineffective and dangerous method of cataract therapy, and often results in
patients remaining blind or with only partially restored vision.[16] For the most part, it has now been replaced by
extracapsular cataract surgery and, especially, phacoemulsification.
The lens can also be removed by suction through a hollow instrument. Bronze oral suction instruments have been
unearthed that seem to have been used for this method of cataract extraction during the 2nd century AD.[17] Such a
procedure was described by the 10th-century Persian physician Muhammad ibn Zakariya al-Razi, who attributed it to
Antyllus, a 2nd-century Greek physician. The procedure "required a large incision in the eye, a hollow needle, and
an assistant with an extraordinary lung capacity."[18] This suction procedure was also described by the Iraqi
ophthalmologist Ammar ibn Ali of Mosul, in his Choice of Eye Diseases, also written in the 10th century.[18] He
presented case histories of its use, claiming to have had success with it on a number of patients.[18] Extracting the
lens has the benefit of removing the possibility of the lens migrating back into the field of vision.[19] A later variant
of the cataract needle in 14th-century Egypt, reported by the oculist Al-Shadhili, used a screw to produce suction. It
is not clear, however, how often this method was used as other writers, including Abu al-Qasim al-Zahrawi and
Al-Shadhili, showed a lack of experience with this procedure or claimed it was ineffective.[18]
In 1748, Jacques Daviel was the first modern European physician to successfully extract cataracts from the eye. In
the 1940s Harold Ridley introduced the concept of implantation of the intraocular lens which permitted more
efficient and comfortable visual rehabilitation possible after cataract surgery. The implantation of foldable
intraocular lens is the procedure considered the state-of-the-art.
In 1967, Charles Kelman introduced phacoemulsification, a technique that uses ultrasonic waves to emulsify the
nucleus of the crystalline lens in order to remove the cataracts without a large incision. This new method of surgery
decreased the need for an extended hospital stay and made the surgery ambulatorial. Patients who undergo cataract
surgery hardly complain of pain or even discomfort during the procedure. However patients who have topical, rather
Cataract surgery 7

than peribulbar block, anesthesia may experience some discomfort.

According to surveys of members of the American Society of Cataract and Refractive Surgery, approximately 2.85
million cataracts procedures were performed in the United States during 2004 and 2.79 million in 2005 [20] .
In India, modern surgery with intraocular lens insertion in Government- and Non Government Organisation
(NGO)-sponsored Eye Surgical Camps have replaced older surgical procedures.

See also
• Eye surgery
• Africa Cataract Project

References

Bibliography
• Finger, Stanley (2001). Origins of Neuroscience: A History of Explorations Into Brain Function. US: Oxford
University Press. ISBN 0195146948.
• Lade, Arnie & Svoboda, Robert (2000). Chinese Medicine and Ayurveda. Motilal Banarsidass. ISBN
812081472X.

External links
• Keith P. Thompson (inventor). "Near Vision Accommodating Intraocular Lens with Adjustable Power" [21]
(PDF). U.S. patent No. 5,607,472. Retrieved 2007-02-04.

References
[1] U.S. News and World Report, December 17, 2007, page 64.
[2] University of Illinois Eye Center. "Cataracts." (http:/ / www. uic. edu/ com/ eye/ LearningAboutVision/ EyeFacts/ Cataracts. shtml) Retrieved
August 18, 2006.
[3] Extracapsular Cataract Extraction - Definition, Purpose, Demographics, Description, Diagnosis/preparation, Aftercare, Risks, Normal results,
Morbidity and mortality rates, Alternatives (http:/ / www. surgeryencyclopedia. com/ Ce-Fi/ Extracapsular-Cataract-Extraction. html)
Encyclopedia of Surgery: A Guide for Patients and Caregivers
[4] Cryotherapy for cataracts. (http:/ / www. surgeryencyclopedia. com/ Ce-Fi/ Cryotherapy-for-Cataracts. html) Encyclopedia of Surgery
[5] Meadow, Norman B. Cryotherapy: A fall from grace, but not a crash (http:/ / www. ophthalmologytimes. com/ ophthalmologytimes/ article/
articleDetail. jsp?id=186750). Ophthalmology Times. October 15, 2005.
[6] New Device Approval - CrystaLens Model AT-45 Accommodating IOL - P030002 (http:/ / www. fda. gov/ cdrh/ mda/ docs/ p030002. html).
U.S. Food and Drug Administration.
[7] Charters, Linda Anticipation is key to managing intra-operative floppy iris syndrome (http:/ / www. ophthalmologytimes. com/
ophthalmologytimes/ article/ articleDetail. jsp?id=339794). Ophthalmology Times. June 15, 2006.
[8] Surgery Encyclopedia - Phacoemulsification for cataracts (http:/ / www. surgeryencyclopedia. com/ Pa-St/ Phacoemulsification-for-Cataracts.
html)
[9] Capsulorhexis using a cystotome needle during cataract surgery (http:/ / www. medrounds. org/ bookstore/ ProductDetail.
php?product_id=79)
[10] Surgery Encyclopedia - Laser posterior capsulotomy (http:/ / www. surgeryencyclopedia. com/ La-Pa/ Laser-Posterior-Capsulotomy. html)
[11] Finger, page 66
[12] p. 245, A History of Medicine, Plinio Prioreschi, volume 1, 2nd ed., Omaha, Nebraska: Horatius Press, 1996, ISBN 1888456019.
[13] Lade & Svoboda, page 85
[14] Cataract history (http:/ / www. mrcophth. com/ Historyofophthalmology/ cataracthistory. htm)
[15] PCLI: Cataract - History (http:/ / www. pcli. com/ cataract/ history. html)
[16] ‘Couching’ for cataracts remains a persistent problem in Yemen (http:/ / www. escrs. org/ Publications/ Eurotimes/ 05September/ pdf/
couching. pdf), EuroTimes, September 2005, p. 11.
[17] Factors influencing the genesis of neurosurgical technology, William C. Bergman, M.D., Raymond A. Schulz, M.Sc., and Deanna S. Davis,
M.S., P.A.-C., Neurosurgical Focus 27, #3 (September 2009), E3; doi:10.3171/2009.6.FOCUS09117.
Cataract surgery 8

[18] Emilie Savage-Smith (2000), "The Practice of Surgery in Islamic Lands: Myth and Reality", Social History of Medicine 13 (2), pp. 307-321
[318–9], doi:10.1093/shm/13.2.307
[19] Finger, Stanley (1994), Origins of Neuroscience: A History of Explorations Into Brain Function, Oxford University Press, p. 70,
ISBN 0195146948
[20] American Academy of Ophthalmology reference (http:/ / www. aao. org/ news/ academy_express/ 20060405. cfm)
[21] http:/ / www. ott. emory. edu/ share/ technologies/ descriptions/ 92008. pdf
Article Sources and Contributors 9

Article Sources and Contributors

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