Cataract Eye Surgery: Everything You Need to Know Before and After Surgery

The majority of my career as an ophthalmic technician was spent specializing in cornea, cataracts and corrective laser surgery. I especially enjoyed helping patients get ready for surgery. So, here is everything I know about the subject from my 16 years in ophthalmology.

Behind the iris, the color part of the eye, is the lens. This structure is densely packed with cells inside a bag known as a capsule. This capsule is suspended by little filaments called zonules that are attached to the ciliary body or muscle. These filaments allow the lens to bend and flex in order to focus on objects at different distances. This is how we are able to read. As we age (again with the aging), the lens hardens and yellows. This causes cloudy vision, an inability to read and vision that is dimmed. The yellowing can also cause changes in color vision; however, the changes happen so slowly that they go unnoticed. The cataract starts to form between the ages of 40 and 50, when we typically start to need reading glasses. Most ophthalmologists will not call it that however. In essence, when the lens starts to harden, a cataract is forming.

Glasses will improve vision in the beginning of this process. When the lens starts to yellow, and is no longer able to focus at all on its own, glasses will no longer improve vision adequately. At this point, surgery is required.

Surgery is very simple. After anesthesia (this is a conscious sedation) is administered, an incision is made in the limbus, the junction between the cornea and the sclera. (If you are looking in the mirror, this junction is where the color part meets the white of the eye.) The hardened lens, or cataract, is removed by a process called phacoemulsification. This is a fancy, medical term for using a sonic wave to break up the cataract and then vacuum it out. The capsule is left intact in order to hold the implant, also known as the intraocular lens implant (IOL).

IOLs have come a long way. The intraocular lens implant was discovered in the 1940s, by a man named Harold Ridley. Ridley was an ophthalmologist who became a member of the Emergency Medical Service, after serving a year in the Royal Navy. During WWII, specifically the Battle of Britain (Germany’s air attack), Ridley saw Royal Air Force pilots with eye injuries involving fragments of the cockpit canopy of their planes. The canopy was made of a material known as polymethylmethacrylate, or PMMA, a very hard plastic. The PMMA shards caused no symptoms of rejection in the injured eyes. This gave him the idea for the implant. The first intraocular lens was implanted in February 1950. Lenses were attached to the iris inside the pupil, called an iris clip, up until the late 1970s. These served their purpose, but unfortunately, the eye could not be dilated or the lens would rip the iris and fall back into the vitreous. This led to the haptics we use today. Haptics allow the IOL to be placed inside the capsule, and prevent movement. IOLs can also be placed in the anterior chamber (in front of the iris); however, this usually only occurs if the capsule is damaged in some way, or the ophthalmologist feels the capsule won’t hold the lens sufficiently.

There are several different types of lenses on the market today. Let’s take a brief look at each lens.

The Standard Monofocal Implant

The standard implant only corrects vision at distance, requiring the patient to use reading glasses, or readers, for any type of near work. Some patients will need correction for distance as well, especially if they have astigmatism (irregular corneas) or the pre-surgery measurements were not done correctly.

Multifocal Implants

Multifocal implants allow patients to read at distance, intermediate and near ranges. There are several different types of these lenses. I’ll discuss briefly each lens.

• Restor multifocal lens: This lens is designed like the Monofocal lens, however the center of the implant has a concentric ring pattern that allows for reading at intermediate and near distances. This lens had issues with glare at night when it originally came out. Alcon says it has resolved this issue with it's new aspheric Restor Lens.
• ReZoom multifocal lens: This lens is similar to the Restor lens with the exception that it has five concentric rings at varying distances for intermediate, near, distance and night driving vision. This lens is better for patients who do things at an intermediate distance regularly.

Lenses for Night Driving

• Technis Lens: This lens was designed for patients who frequently drive at night. Studies have shown the Technis lens gives an extra ½ second of reaction time at night because the patient can see a few feet farther than a traditional Monofocal lens.

Accommodating Lenses

• Crystalens: I’m a bit biased on this one. The Crystalens is an accommodating lens implant. This means it uses the eye’s natural muscle to focus the lens at all distances. Why am I biased? The theory behind the lens is sound, and it allows for a greater range of distances compared to the multifocal lens. There is also no chance for issues with glare at night because there are no concentric rings to create halos. This is as close as we can humanly get to the original lens Mother Nature gave us. There are a couple of drawbacks to this lens. For the first week after surgery, the patient is not allowed to read. In fact, the eye will usually stay dilated for a week after surgery to prevent possible accommodation. This is to allow the lens to seat properly in the capsule. If the patient were to read the first week, the lens could bow forward and stay there, causing the patient blurry vision at all distances and the benefit of the lens will be lost completely. The other drawback is the zonules, the little muscles that focus the lens, have atrophied since the formation of the cataract. It takes up to six months to build these muscles back up and realize the full value of the Crystalens.

Toric Lenses

• Toric lenses: These lenses correct astigmatism. Astigmatism is a fancy medical term for an irregular or bumpy cornea. This lens allows patients, who would otherwise have to wear glasses to correct this, see things at distance without glasses. There is no multifocal version of this lens as of yet.

After one of these lenses is implanted in the eye, the patient is taken to the recovery area for about 30 minutes to let the anesthesia wear off. Typical cataract surgery requires no stitching or patches after the procedure. There are times when these are required, but your physician should be able to tell you prior to surgery if this will be necessary.

Recovery time is usually about four weeks. During the first week, the patient is not allowed to wash their hair, or lift anything over ten pounds. Patients really shouldn’t bend over to pick anything up for at least 3 days after surgery. Swimming is not allowed for three weeks. Rigorous exercise is generally limited the first week, I always told my patients that when they can resume swimming, they will be able to get back to their exercise regimen (better to be safe than sorry.) Eye drops will be used for the duration of recovery.

The first week an antibiotic to prevent infection and a steroid to help prevent the body’s natural immune response are given to the patient to administer four times a day. The antibiotic will usually be Vigamox or Zymaxid, but it varies from doctor to doctor. The steroid is almost universal. It is a form of Prednisolone Acetate, either generic or brand name. Some physicians add a non-steroidal anti-inflammatory (NSAID) such as Nevanac three times a day to help alleviate any pain from possible inflammation. The antibiotic and NSAID will usually last about a week. The second week the physician will start to taper the steroid so that by the fourth week all drops are discontinued. At this point, the patient will be tested for eyeglasses if needed. If a second eye is to be done, it is typically done a week or more after the first eye.

That is almost everything I know about cataracts (with exception of all the advanced medical lingo, etc). I hope this helps anyone who is considering surgery. Remember, if you have any questions, don’t hesitate to ask your ophthalmologist. Not all of these lenses will work for everyone. Be sure to check with your physician to see which lens, if any, is right for you.

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