The only way to guarantee that you'll never get cataracts is to die young. They are as much a part of life as gray hair, wrinkles, and liver spots. But cataracts, unlike other signs of advancing age, can be permanently removed, and the vision they once clouded can be restored.

A cataract occurs when the lens of the eye grows thicker, becoming cloudy and opaque. The aging process gradually turns the normally clear and transparent crystalline lens white or yellowish brown. Because this murkiness reduces the amount of light that can enter the eye, it also reduces your vision.

If you could watch the whole process through a microscope, you'd see that the lens of your eye is made up of cells and transparent fibers, which continue to grow throughout your entire life. With time, however, the fibers become compact and lose their transparency. As with other parts of your body, the eyes also can retain fluid, causing the lens to thicken or swell. All of these changes contribute to a loss of visual clarity.

These changes take time. It normally takes years to develop a cataract. And just as the timing may vary from person to person, so can the severity.

Cataracts can be so small that they have virtually no effect whatsoever on your vision. Many people live out their lives without doing anything about them. Conversely, however, they can leave you virtually blind.

While the aging process is responsible for most cataracts, there are other causes. These include injury, inflammation, and medication, especially cortisone.

Some babies are born with cataracts because of an inherited disease or problems during pregnancy. Mothers who contract rubella during the first trimester of pregnancy, for example, may give birth to babies with cataracts, hearing defects, and abnormalities of the heart. But thanks to the development of the rubella vaccine, "rubella babies" are no longer very common.

Studies also show that there may be a direct link between cataracts and excessive exposure to sunlight. Studies show that there appears to be a higher incidence of cataracts in geographic areas where sunlight—especially the UV light portion—is intense.

Does this mean that taking a holiday in the sun will doom you to looking at the world through cloudy eyes? No. What it does mean is that wearing sunglasses made to block out potentially harmful UV light rays is a wise precaution.

But once you have cataracts, it really doesn't make any difference what caused them. Just as an arm broken while rescuing a fair young damsel from distress will hurt as long and as much (and also take as long to heal) as one broken after a slip on an icy patch of pavement, the cause of a cataract has little if anything to do with the cure.

Options in a Blurry World

As cataracts develop, several things usually occur. The most common complaint is blurred vision. Activities that require sharp vision, such as reading and driving, become more difficult. Driving at night may become hazardous due to the glare of approaching headlights.

Other common complaints include sensitivity to light, actually feeling as if there is a film over your eyes, noticing a change in color of the pupil of your eyes, and needing frequent changes in glasses. Some people simply report that the world "looks dull."

When Clearer Vision Signals Trouble

It's one thing for senior citizens to feel that they're getting their youthful strength back. But if they feel they're getting their vision back, they could be in for trouble.

Older people sometimes think that this is happening to them because they find that they can do close work—such as reading the paper or even a phone book—without their reading glasses. What's really happening is that they are getting more nearsighted. And that can be an early sign of cataract development.

Of course, any or all of the above can also be signals that other eye problems are developing—problems such as macular degeneration. The important thing to remember is that these symptoms indicate that you need to check with your eye doctor.

Let's say that you've gone to your doctor and the verdict is cataracts. What do you do next?

Well, maybe the answer is ... nothing.

Living with cataracts can be compared to living with teenagers. Their potential to drive you absolutely, positively bonkers is ever present. The problem is always there, like a volcano quietly burping in the background. But some people live their entire lives without ever having their neighboring volcano or their in-house teenagers explode. Similarly, even though cataracts can lead to loss of vision, it is nearly always the kind of visual loss that can be reversed. And in other cases, cataracts develop so slowly that they never cause a major reduction in vision. An operation is unnecessary.

But just what is a major reduction in vision? That depends on you. Some people are quite willing to put up with a little blurred vision. Their occupation, attitude, and lifestyle let them live comfortably with their cataracts and the limits they place on their lives.

On the other hand, even a minor reduction in vision can be a major catastrophe for some people. Accountants, airline pilots, athletes, artists, machinists, and surgeons might find life and livelihood threatened by even a slight reduction in vision. They might need an operation at the first sign of a cataract.

So the decision to have surgery is a very personal one, based on how well you are functioning and how satisfied you are with the way things are. It is only rarely that a lens becomes so swollen that it absolutely, positively has to be removed. Often a change in glasses, or the regular use of eyedrops to dilate the pupils to let more light into the eyes, can forestall surgery for months—even years.

But if you decide that cataracts are imposing too many limits on the way you live and work, the only real solution is surgery. It would be nice if there were some sort of pill or potion we could take that would dissolve cataracts and make surgery unnecessary. There is currently a great deal of research in that very area. And there are numerous products on the market today that are supposed to delay cataract formation or even reverse it. The key words here are supposed to. These claims have been made about specific vitamins, amino acids, hormones, and even aspirin.

A Role for Vitamins C and E?

Even though there is no guarantee that anything will prevent cataracts from forming, or even delay them, there are indications that some vitamins may be able to help some people.

One research study showed that people who took 300 to 600 milligrams of vitamin C or 400 international units of Vitamin E daily for five years before turning 60 were less likely to develop cataracts after age 60. This is just one study, however, and more research needs to be done before any definite conclusions can be drawn.

Special "secret" or "wonder drug" injections, pills, and eyedrops have also been tried. So far, however, there is no compelling evidence to show that any of them can actually prevent cataracts from forming or reverse them once they have formed. At best, these chemicals and compounds might be harmless. At worst, they could damage what vision is left, or cause other serious medical problems.

This is not to say, however, that there will never be an anti-cataract pill or potion. There is a lot of research being done, and there have been some encouraging results. When rats are made diabetic, for example, they often develop cataracts. Drugs that inhibit an enzyme known as aldose reductase seem to prevent such cataracts from forming. This may or may not lead to successful drug treatment for human cataracts, but even if it does, the availability of such a drug is years away.

Surgery, however, does work, and it is available now. The surgeon will, as a rule, do only one eye at a time. Although cataracts usually develop in both eyes, one eye is usually worse than the other. The surgeon will often do that one first. After the first eye heals, you may be left with unbalanced vision until the second cataract is removed. When the second one heals, you can expect to once again have good binocular vision.

Restoring the Focus

In the operation, the surgeon removes the clouded lens. The good news is that a barrier to crisp, clear vision is gone. The bad news is that a powerful lens has been removed with it. Without the lens, light rays that enter your eye will not focus on the retina, but somewhere behind it, just as they do in a farsighted eye.

This leaves three corrective choices: special eyeglasses called cataract glasses, special contact lenses, or a new lens that can be surgically implanted in the eye. This new lens is called an intraocular lens (IOL) for the simple reason that intraocular means "inside the eye."

We'll go into all three alternatives in more detail shortly. But first, keep this is mind: Whatever method you choose depends on a number of circumstances, including your age, the presence of other eye diseases, the vision of your other eye, your ability to wear and manipulate a contact lens, and last but far from least, the skill of the surgeon performing the operation.

Now let's look at the three alternatives in more detail.

Glasses

Wearing special cataract glasses is the safest, simplest, least expensive, and oldest postsurgical solution. The main disadvantage is that there can be problems adjusting to them.

They are usually heavier and thicker than conventional eyeglasses. In fact, they look a lot like the bottom of a soda pop bottle. And they can produce visual distortion.

What you see through cataract glasses is usually enlarged. Straight lines appear somewhat curved, and peripheral vision is blocked out. As a result, objects off to one side may suddenly loom into view. Not only do they appear "out of nowhere," (the "jack-in-the-box" effect), they loom about 25 percent larger than life when they do.

Contact Lenses

Contact lenses are also quite safe, but they too can be difficult to adjust to. It's hard enough for a young person to learn how to use and manipulate contact lenses. For older people—and they are the ones who need them—the task can be almost insurmountable when combined with arthritis or other ailments.

But many older people decide it's worth the aggravation and effort, because contact lenses are such an improvement over cataract glasses. 'There is practically no enlargement of the image or loss of peripheral vision.

Since handling contact lenses can be the major problem for elderly people, extended-wear lenses—which need to be removed, cleaned, and replaced only about once a week—avoid many of the difficulties and much of the bother of daily-wear lenses.

As with any other contact lenses, however, you should be alert for and aware of unusual redness of the eye, excessive watering, light sensitivity, or any eye pain. If problems do occur, check with your doctor immediately.

Intraocular Lenses (Implanted Lenses)

Intraocular lenses, or IOLs, represent one of the most beneficial developments in the field of eye surgery. These plastic lenses are about the size and shape of normal, plastic, hard contact lenses, but they have tiny flexible feet, or "haptics," attached to the edges to hold them in place inside the eye. They are permanently inserted in the eye when the cataract is removed. They require no cleaning, replacement, or other maintenance and offer the patient virtually natural vision.

Intraocular lenses are manufactured with high precision and are ordered based on measurements of the length and curvature of the eye. Because any corrective power can be ordered, the ophthalmologist may select lenses that will correct the eye either for distance vision or near vision. Bifocal IOLs are not yet available (except in certain research studies), and their advantage over regular IOLs has not been established.

Sometimes the lens implant is not a perfect match, and a patient will still need corrective lenses—glasses or contact lenses—after the surgery. While it might seem odd at first, a patient can wear contact lenses over an implanted lens. That's because the implanted lens is underneath the surface of the eye and does not touch the contact lens.

Intraocular lenses were first developed in Europe and have been popular in North America since the mid-1970s. The results are generally quite good, and as surgeons become more experienced and lens-making technology improves, they will be even better.

Not everyone with a cataract is a candidate for an implant. People with certain preexisting eye problems, such as uveitis, might have to learn to live with conventional contact lenses or cataract glasses. Also, small children, whose eyes are still growing, are not good candidates. The size and power of their eyes may change as they get older.

Types of Cataract Surgery

Now that we have an overview of what can be done, let's take a more detailed look at the surgery itself. There are two main techniques for cataract surgery: intracapsular and extra-capsular. In addition, some doctors now prefer a third procedure, phacoemulsification.

Intracapsular

With intracapsular surgery, the entire cataract and its surrounding capsule are removed. An incision is made in the upper part of the eye where the white and colored parts meet. The cornea is gently folded back. A freezing probe, a cryoextractor, is placed on the cataractous lens. The stiff, frozen lens is gently and carefully removed from the eye, and the incision is closed carefully with very fine stitches.

Extracapsular

The extracapsular method is similar to the intracapsular procedure except that the back part of the lens capsule, the clear membrane between the lens and interior of the eye, is left in place. An incision is made just as it would be for the intracapsular technique. The anterior, or front, surface of the lens is cut with a fine needle. Then the hard center of the lens (the nucleus) is carefully squeezed out with a gentle pressure and any remaining fragments of the cataractous lens (the cortex) are sucked out of the eye with a small suction device.

The posterior, or rear, of the capsule is left intact to prevent the vitreous, which is located behind the lens, from moving forward. The posterior capsule also provides some support for a lens implant. Within months of the original surgery, however, the posterior capsule might begin to cloud up, reducing vision once again.

In that case, the capsule can be opened with a knife or, even simpler, a laser beam. The type of laser used for this procedure is the neodymium-YAG laser (YAG stands for yttrium-aluminum-garnet), named for the material that produces the energy source of laser light. The laser procedure, which is not painful, is done in the doctor's office and takes only a few minutes.

Phacoemulsification

Phacoemulsification is a relatively new technique developed in the early 1970s. A special kind of probe—a phacoemulsifier—is used. The business end of the probe features a hollow titanium needle that vibrates about 40,000 times per second, breaking the cataract up and virtually liquefying it with ultrasonic vibrations.

The phacoemulsifier also functions as a vacuum cleaner, sucking the liquefied cataract from the eye.

The incision needed for the process is slightly smaller than the one used in a conventional extracapsular operation, so advocates of this procedure believe the healing process is a little faster.

Although it is a bit more difficult for the surgeon to learn, the technique is probably no better or worse than the other techniques. But those surgeons who are comfortable with it seem to prefer it.

Implanting the New Lenses

Once the cataract is removed, there is room for an intraocular lens to be permanently inserted. While there are hundreds of different types of IOLs that can be implanted, most of them fall within two broad categories: anterior chamber implants and posterior chamber implants.

Anterior chamber implants are placed just in front of the iris, while posterior implants are placed just behind it.

Although both techniques seem to work quite well, in recent years surgeons have seen more complications with anterior chamber lenses. This may be because they can rest on the iris and their haptics, or feet, come into direct contact with the drainage system for the fluid that percolates throughout the interior of the eye.

Posterior chamber implants are slightly more difficult to insert, but there are fewer complications, possibly because they do not come in direct contact with any of the critical structures inside the eye.

Anterior chamber implants can be used whether your surgeon is using the intracapsular or extracapsular surgical technique. Posterior chamber implants can be used only if your surgeon uses the extracapsular procedure.

Most cataract surgeries performed today utilize the extra-capsular approach coupled with posterior chamber implants. As a rule, there are few complications and the patient comes out of it with good vision.

Foldable lenses are a relatively new implant variation. Their advantage is that they can be folded, much like a taco shell, and inserted through a smaller incision. Such incisions would be expected to heal quickly and not cause much astigmatism. The "taco style" lenses seem to have good potential, but they are still being perfected.

If You're Facing Surgery, Here's What to Expect

Every operation, every surgeon, every patient, and every situation is different. But these general guidelines usually apply.

Most cataract surgeries are treated as outpatient procedures and done under local anesthesia, using the same type of numbing medication used by dentists. This anesthetic is injected in back of the ear or around the temple and then underneath the eye. Some patients and some doctors prefer a general anesthetic. Sometimes the decision is left to the patient.

The anesthetic performs three functions.

• It numbs the eye so you don't feel any pain.
• It prevents eye movement.
• It "shuts off" the vision in the eye so you can't see the surgeon or the scalpel he uses.

Depending on your surgeon and your situation, you might be asked to use antibiotic eyedrops or ointment for a few days prior to the surgery.

Special drops to dilate the pupil will usually be put in when you are being readied for the surgery. Dilating—expanding—the pupil makes it easier for the surgeon to see the cataract. You may also be given a mild tranquilizer to calm the nerves. You may be asked to take nothing by mouth for several hours before the operation. This is a standard precaution used before most types of surgery. If you do use regular medication or drink alcohol excessively, you should discuss this with your doctor in advance.

The skin around your eyes will be scrubbed with soap and alcohol, and a sterile cloth or paper drape will be put over your head and body. A tube is used to blow fresh air under the drape to make breathing easier.

All of these preparations can take as long as an hour. The operation itself—including the lens implant—usually takes less than an hour.

If you aren't spending the night in the hospital, and most people don't, make sure you have someone to drive you home. You will be wearing an eye patch covered with a metal shield to protect the eye from accidental injury. You might also have some discomfort, so the eye doctor may prescribe some pain pills or ask you to take over-the-counter pain medication for the first few days after the operation. Make sure you discuss in advance any other medication you might be taking. Keep in mind that drinking alcohol while taking pain pills could be dangerous.

The doctor will probably want to see you within a day or two of the operation and probably every one or two weeks for the next six weeks after that. Eyedrops will be used during this period to provide comfort, to speed the healing process, and to prevent infection. Glasses or a shield should be worn during the day to protect the eye from injury, and you should sleep with the shield on for the same reason.

Get plenty of rest and don't do any heavy lifting, straining, or other exercising until the doctor gives you permission. Too much strain could pop a blood vessel in your eye. It's usually okay to take a shower and wash your hair, but try to keep soap and water out of the convalescing eye.

You should be able to resume normal activities after about six weeks. At that time you should have your eyes checked for a new prescription for glasses or contact lenses.

Possible Complications

No surgical procedure comes with a 100 percent guarantee. Even though cataract surgery is usually a highly successful and trouble-free procedure, complications can and do occur. You should be aware of them.

Any time an incision is made in the eye, small blood vessels are cut. If the bleeding cannot be controlled, the eye may fill with blood and permanent damage may result.

Infection is also a rare possiblity. If bacteria enter the eye through an incision, endophthalmitis, the blinding infection can develop.

Sometimes, even though the operation is a success, the patient doesn't see as well as expected. When this happens, it is often because of fluid that collects in the center of the retina, the part responsible for central vision. This condition—known as cystoid macular edema—will sometimes clear up by itself, or after cortisone has been injected around the eye. Sometimes, however, it can't be cured, and the patient is left with good peripheral vision but poor central vision.

Retinal detachment, a rare but potentially blinding complication, can occur months or even years after cataract surgery. Retinal detachments seem to be less common when an extracapsular procedure is done, but the condition occurs so rarely for all types of cataract surgery that it is difficult to be sure.

All of these complications are scary. And while they are not likely, they are possible. If you keep them in mind and weigh them against the potential—and much more likely—benefits, you will be better able to make an intelligent decision about whether or not to undergo cataract surgery.

Eric Rost

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