How Is a Cataract Removed?

How is a cataract removed?

A cataract can be removed basically in two ways: “intracapsular,” taking the lens out with its enclosing capsule, or leaving the capsule and only taking the lens out—”extracapsular”.

There are various techniques of taking a lens out with its capsule—either the older suction or forceps or the newer cryoprobe. This is a probe whose tip freezes and on, contact adheres firmly to the lens thus permitting easy removal.

Newer methods are now available using ultrasonics but they are still experimental and are restricted to a few centres in America and Europe.

The surgeon will decide the best method taking each case on its merits. The same surgeon may use different techniques or eve’ a combination of techniques on different cases.

It is best to let the surgeon decide. After all, he wants you to get the best possible results.

Are sutures put in the eye nowadays?

Surgeons all over the world, put in ultra-fine sutures to give stability and safety to the eye. The ultra-fine sutures have led to greater use of an operating microscope to be able to put them in well.

Sutures have the disadvantage that they are not very comfortable and may need removal. However, immediate ambulation instead of having sandbags around the head for 5 days and the security of a well-sutured wound far outweigh any disadvantages. Most modern sutures dissolve by themselves, or are so thin that they can be left indefinitely.

What type of anaesthesia is used for cataract surgery?

There are two types.

(a) General anaesthesia in which the patient is totally unconscious. Usually a mixture of gas (ether, trilene, nitrous oxide) and oxygen is used.

(b) The second type, and the most frequently used, is called local anaesthesia, in which only the organs in the immediate surgical locality (and hence the word local) are anaesthetised, in our case, the eyelids and eyeball.

When is general anaesthesia given? What are its disadvantages?

General anaesthesia is preferable for nervous patients or those who may suddenly move during an operation. All children below 15 are naturally given general anaesthesia. It has, as its advantage, a complete control of the patient’s movement. Unlike a local anaesthesia whose effect may wear off, general anaesthesia can be for any length of time, thus giving greater flexibility to the surgeon.

It however has its disadvantages. It is not safe in very old or weak patients, those with a tired heart or an unhealthy chest. There is also the slight attendant risk, fairly rare in the hands of an expert anaesthetist, of vomiting after an operation.

There is however a safer technique which uses a combination of local anaesthesia, with intravenous sedation. This puts the patient into a deep sleep but he is not unconscious and thus avoids the risk of general anaesthesia. It has however, to be done by a skilled anaesthetist. It is the author’s preferred mode of anaesthesia.

How long do I need to stay in the hospital after the cataract is removed?

It depends on your surgeon and the particular method used by him. Usually if the would is well-sutured and safely secured, the patient can get up the next day and walk around and go home on the first post-operative day. This is one of the advantages of using newer techniques and materials.

Will I need to use dark glasses immediately?

Dark glasses are purely an individual necessity. Some patients do need them and some don’t. There is usually no hard and fast rule. However, if the patient has always felt the need for sun-glasses even before he developed cataracts, then in all probability he will need them now.

For practical purposes the only necessity is of protecting the eye. The colour of the glasses is fairly immaterial.

What activity can be performed at home immediately after surgery?

Assuming you return home immediately on the first day, you can move around, sit and talk with friends, and if the other eye sees adequately, watch TV or read a little.

You can turn on the bed to the unoperated side.

A businessman can carry on his work on the telephone and sign letters.

However, most people generally take it easy for 2-3 weeks.

What activity should not be indulged in immediately after surgery?

The most important cardinal point is not to rub or touch the operated eye. If drops and ointments need to be put in, only the lower lid is touched. The upper lid is out of bounds.

Care should be taken to keep the bowels soft. Straining at stools must be avoided.

Naturally, you must not bend forward or try to lift heavy objects.

A little cooking is acceptable, but excessive exposure to heat must be avoided.

Though the patient may have a bath below the neck daily, he must not bend down to fill his mug/Iota with water.

If the eyes are kept closed (do not squeeze them tight) water may be poured over the head daily, if need be, after 2 weeks. Shampooing, especially for ladies, is best after the fourth week and only after getting permission from your doctor.

Soap or water entering the eye after 2 weeks is not dangerous. However, straining the neck by bending the head backwards unsupported (as is done in ladies’ beauty parlours) is totally forbidden. You may keep your head straight or slightly bent forwards. There must also be no vigorous shampooing of the head. Apply the soap, gently work it in, and wash it out.

Though riding in a car is acceptable, be cautious of getting into crowded buses and being jostled around. A newly-operated eye is a very delicate organ. At least 6 weeks need to elapse for the wound to gain sufficient strength.

When will the sutures be removed?

Depending upon the material used by your doctor, some sutures may never need to be removed and drop off by themselves. Some sutures which are not of the dissolving kind or are the partially dissolving kind, need removal after 3-4 weeks.

It all depends upon your surgeon and partly on how quickly your wound is healing.

When will I get glasses for my operated eye?

On an average they are prescribed a month after surgery. If sutures are used glasses are prescribed usually a week after the removal of sutures.

If both eyes have cataracts then a temporary glass is given by the 5th day after surgery to be used until the final glasses are prescribed.

It is however important to remember that these glasses given after a month will need changing again after 3 months. This is because the number alters as the wound in the eye heals. Subsequent power changes will be 9 months and 18 months after surgery. Usually after the third change the power remains stable.

What is the best time of the year to have cataract surgery?

There was a time when it was desirable to have cataract surgery in early winter or before the spring starts in Bombay. In cold countries, winter was frowned upon, since there was a danger of pneumonia occurring in the chest as movement was restricted following cataract surgery.

Nowadays, with almost immediate ambulation, hardly any restriction to bed and the easy availablity of air-conditioned operating rooms, the season in which to perform the operation is no longer important. Cateract is truly elective surgery (you elect your own convenient time). Except for extreme summer, virtually any time for surgery is perfectly acceptable, as far as the eye is concerned.

Can one return to one’s old job following cataract surgery?

Virtually any activity except for extreme physical jobs can be resumed after cataract surgery.

There are however some restrictions. Standing on the head (shirshasan) is completely forbidden, as is boxing or taking part in violent exertions.

Normal everyday activity—using a bus, taking a walk, a full day at the office, an evening movie or television have no effect on the eye.

True, with the new glasses it takes time for the eyes to adapt themselves but this is purely temporary. After all there are many people who have had cataracts removed and now drive a taxi, serve in the police, do fine painting or even figure work with absolute comfort.

If the cataract is removed from one eye and the other eye is normal and sees perfectly well, what glasses are worn?

The patient has a few alternatives:

(1) He may use a spectacle lens only on the operated eye and wear a glazed glass (non-transparent) over his normal seeing eye.

(2) He may wear his regular glasses over the normal eye and use plain unpowered spectacle lenses over his operated eye. In essence he sees only from the normal eye, and only diffuse images from his operated eye.

(3) He may use a contact lens over his operated eye. Since a contact lens brings the image size back to normal, both eyes may be used toether again. It must be stressed that this is the only way available (unless an implant is done during the surgery for cataract removal) which permits simultaneous use of both eyes with binocular vision.

If cataract is removed from one eye and the other eye sees hazily for distance but cannot read clearly, what can be done?

(1) One may see distance and near with one’s operated eye only and wear glazed glass over one’s normal eye.

(2) One may see distance with one’s normal eye and read with the operated eye.

(3) One may wear a contact lens over one’s operated eye, and see and read with both eyes simultaneously.

What is an after-cataract or secondary cataract? What is needling?

A cataract, as mentioned earlier, is like a lens in an envelope called the capsule. If the capsule and lens are both taken out (called intra-capsular removal) then there is never any need for “needling”.

If the lens is taken out and the capsule left behind, the capsule sometimes tends to thicken or blur vision and may need to be “needled” or cut.

Either way, needling is a very minor procedure and needs no hospitalization, causes no pain, lets the vision return almost instantly and usually is totally without any risk.

There are certain conditions, before and during surgery, in which, for the safety of the eye, the capsule is left behind. There are also surgeons who believe it is always best for the eye to leave the capsule in. Either way it matters little and the choice must always be the surgeon’s.

What are the new “intra-ocular implants” we hear about? Why do we need an implant?

A person operated for a cataract has to wear cataract glasses, which, in essence, are roughly +12 in power. These look like thick magnifying glasses. The problems in vision are many—a tendency to see things magnified more than 30%, distorted vision planes (a tilted building, a straight line seeming curved) and extreme imbalance in the perception of depth or stereopsis (tea poured in the saucer instead of cup; dropping glasses on the table) lead to a fair degree of problems.

A contact lens can solve most of these but brings new problems in its train. A person has to learn to clean and handle an object which is usually only half an inch in size, and continuous care needs to be exercised.

An implant solves all these problems; the vision is normal, as a matter of fact, except for reading glasses, you may not use any glasses for distance. Once inserted, you may forget that they exist at all.

An intra-ocular implants is a plastic replacement for the human lens which has been taken out as it has lost its transparency. Here a plastic lens, permanently clipped to the pupil of the eye, replaces the human lens.

These implants are made of hard or soft plastic, having loops of ultrarefined polypropylene. The actual implant is usually only 4-6 mm in size.

Once an implant is inserted, nothing is visible from outside. The eye looks, and feels, normal and you have done away with the fat glasses which are an optical problem and cosmetic embarrassment.

People in certain occupations, such as pilots, captains of ships, racing drivers or for that matter, even policemen, cannot do with fat glasses or a fragile contact lens especially on exposure to weather. For them, the forgotten implant is best—they have normal vision at all times, in all kinds of weather.

How new are implants?

Implants have been around for a long time. The first implant was done by British surgeon Ridley in September 1960. They however came into vogue only about 12 years ago and since then a fair number have been performed.

In India, implants have been practised for the last 3 years. India has been one of the pioneering countries for research in intra-ocular implant material and patterns.

What are the risks with implants?

With any surgical procedure there are risks which have to be taken, and complications may occur. In a very large percentage of cases implants cause no problems at all. In some cases drops or drugs may be needed. Some eyes do not accept an implant which may need to be removed but there is minimal risk to the eye in the hands of an expert. An implant once fitted is very stable and even a direct blow on the eye may not dislocate an implant.

An implant properly fitted is perfectly safe and more than 1,50,000 implants have been fitted in the world over the last 10 years.

How long does an implant last?

It is supposed to be a permanent device for the life of the patient and may never need removal at all. In medicine, no figure is taken for granted until proved. The patient wearing an implant the longest has been wearing them for 20 years, so the present figure is 20. Next year it will be 21 and so forth. We will only know if they last for 50 years, after 50 years and not before but experimental evidence leads us to believe that they are permanent devices.

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