Cataracts and surgery

The eye functions like a camera.There is a focusing part at the front that produces a sharp image on the retina at the back of the eye. The focusing part at the front of the eye consists of the cornea and the lens.

The pupil is like the aperture in a camera, regulating the amount of light entering the eye. The retina contains special cells called rods and cones that register the light and turn it into electrical impulses that are sent to the brain so that we can see.

Fine vision, such as reading, is performed by a small part in the centre of the retina called the macula.

If you are worried about your eyes or eyesight we advise that you should consult your own medical practitioner or an optician at the earliest opportunity.

Alternatively if you are in England and are feeling ill now, you can call NHS Direct on 0845 4647 for nurse advice.

NHS Direct also operate an online health information enquiry service at http://www.nhsdirect.nhs.uk/.

Please note: The NHS Direct service can only provide information about named health conditions; it cannot provide diagnoses, advice or counselling.

NHS Direct Online’s health information enquiry service is designed for use by residents in England only. If you are not resident in England, they cannot respond to your enquiry.

Cataracts occur when there is cloudiness and opacity within the lens inside the eye. Normally this lens is crystal clear and serves to focus light onto the retina at the back of the eye.

The process of cataract formation is similar to cooking an egg. At the start of cooking the egg-white is clear but steadily becomes more opaque. A similar process occurs in the lens of the eye and is a natural part of aging. Cataracts form slightly quicker if you suffer from diabetes or eye diseases such as uveitis. The cloudy lens will not transmit light clearly onto the retina. A diagram of the eye showing the position of the lens in which a cataract develops.

This picture shows a cataract in the eye. The upper image shows the milky cataract obscuring the dark of the pupil; the bottom image shows a cross section of the cataract behind the iris. The symptoms can occur over a short period of time. They are very common and most people will require surgery for cataracts at some stage during their lives.

Most people notice that they are having problems in their 60′s but they can occur earlier. Cataracts cause problems with vision. These include poor vision whilst driving or watching television, difficulty with close work and reading, glare in bright lights and an increase in the strength of glasses required to see clearly.

How is surgery done?

The cataract is removed from the eye by an operation called ‘phakoemulsification’. A tiny 2mm incision is made in the wall of the eye usually under the upper eyelid. This is about the thickness of a 10p coin. The cataract is dissolved painlessly using a special instrument called a phakoemulsification needle. A new plastic lens is folded in half, gently squeezed through the incision and unfolded inside the eye. The incision is self sealing and does not usually require stitches.

The operation is usually performed whilst you are awake. The eye is numbed with drops.

This lady is awake and comfortable, lying on her back. There are drapes over her eye and there is plenty of space for her to breathe underneath. Mr Ursell is looking at the cataract with a microscope and removing it with phakoemulsification. The nurse is assisting.

What to expect

If you think you have a cataract you will need to arrange an appointment to see Mr Ursell. At this appointment your pupils will be dilated with drops. You will be scheduled for surgery and the operation will be fully explained. Measurements will be taken to calculate the strength of replacement lens required. Do not drive to this appointment.  You will be able to discuss different options for getting rid of glasses following surgery at this stage.

On the day of surgery wear comfortable loose fitting clothes. You will have drops in the eye to dilate the pupil and anaesthetise the eye.

In the operating theatre, light drapes will be placed over the eye and a small instrument is used to open the eyelids.

After surgery which takes between 10 and 20 minutes you can go home once the surgery has been checked.   We aim to have the whole procedure take 2 hours from start to finish.

Following surgery you will be given drops to use 4 times a day for one week, then twice a day for two further weeks. The vision should clear within a few hours of the operation and rapidly improve over the next day or two. Glasses, if required, should be prescribed 4 weeks following surgery.

Why do I need this man-made lens implanted?

The natural human lens, which started out crystal clear in your youth, has now become cloudy. This lens has a certain power to it, the same way that a camera lens has a certain power. When the cataract (the cloudy lens) is removed, it’s like taking the lens out of the camera: you won’t get a good picture until you replace the lens. The lenses are typically made of acrylic (plastic), silicone, or a similar compound and they have been implanted in eyes for more than 50 years. They are designed to last for your lifetime and about 5 million lens implants are done worldwide per year. This lens is implanted in the same position as the human cataractous lens, which was removed. It is behind the iris (the blue, green, or brown part of the eye) and it is not visible to other people looking at your eyes. You won’t feel this lens or even realize that it is implanted in the eye. This lens is NOT like a contact lens. This lens is permanent and is implanted inside your eye. You will not feel it and it will not come out of the eye.

What are the three basic types of lens implants?

There are three types of implant: Standard single focus, toric and accommodating.

Standard Single Focus Implants

The standard lens implant is a single-focus lens with the focal point typically set for distance, with glasses being required for intermediate or near vision. The eye adapts quickly to this lens implant as this type of lens provides the best image quality and most natural vision possible, although just at the single focal point (distance). With the astigmatism treated or managed and a single-focus lens implanted, the distance vision will be excellent without glasses, but glasses will be required for computer use or reading.

Toric Implants

If you have astigmatism and this is less than one dioptre in power, this can usually be fixed by extra incisions performed at the time of cataract surgery. However, if your astigmatism is more than one dioptre in strength, then these incisions are not usually sufficient.   We are now finding that implants with astigmatism added to them, so-called Toric implants, are much more effective at reducing astigmatism and therefore reduce your reliance on glasses following surgery.  The current Toric implants that we are using are fixed distance lenses with an astigmatic component added to them.  You will need to use reading glasses following surgery with a Toric implant.

Premium Implants

In our practice we use the Crystalens, Oculentis M-Plus and Restore Implants, which, unlike a standard IOL, can treat both a person’s cataracts and presbyopia—loss of near and intermediate vision.  You probably noticed in your forties that you started to lose some of your up-close vision and had to start wearing reading glasses.

Premium Implants not only treat your cataracts (a clouding or hardening of your lens), but can also reduce or eliminate your dependence on glasses. It does so by recreating accommodation (the process by which the eye changes from near to distance vision) similar to your eye’s natural lens.  Premium implants can reduce or eliminate glasses for most activities, including: reading a book, working on the computer, and driving a car.
In our hands approximately 80% of patients who have these implants placed in both eyes will be able to function perfectly adequately for near, distance and intermediate tasks without glasses.   Some patients do occasionally need glasses for fine work following surgery, but the majority of patients are extremely delighted with the results of surgery.

Which lens will you put in my eye?

The lens that we will implant in your eye depends on your visual needs and preferences and whether you elect to have a premium lens. All lenses are fully CE approved, are of the highest quality and are from top-name ophthalmic manufacturers. We only use high-end implants with the best optics – the same ones that we would implant in our own family and friends.

The single-focus lenses that we prefer are referred to as aspheric lenses since they address the sharp focusing of the eye as well as the spherical aberration in order to provide a better quality image, similar to a high-end Nikon camera lens. Studies have even shown better driving performance in people who receive these aspheric lenses. If your concern is the best quality of vision and you don’t mind wearing glasses for any intermediate or near work, then this is the best lens for you.

The premium lenses allow a much greater freedom from glasses, with 90% of patients in the official FDA studies never or only occasionally using glasses for distance, intermediate and near vision.
Because the lens is different to your normal focusing, it takes a few weeks for the brain’s visual pathways to adapt.  As the brain adapts, these visual artifacts significantly lessen and the majority of patients are quite happy and state that the benefits of their Premium  lenses far outweigh any other issues. If your concern is good vision and you would like to reduce or eliminate your need for glasses for distance, intermediate and near, then a premium implant is the best choice for you.

How do you calculate what power lens to use?

Since each eye is different, before the surgery, your eyes will be measured with specialised equipment using light-waves or ultra-sound in just a few minutes. Remember that cataract surgery is to correct cataracts and that treating astigmatism or using premium implants are separate procedures and costs.

Will I need glasses after the cataract surgery?

Cataract/Refractive Lens Surgery with a Single-Focus Lens:

Yes, glasses required for distance, intermediate, and near. If you choose cataract surgery alone, with a single-focus lens, then you may have issues with astigmatism after the surgery. You may need glasses to address this astigmatism and you will certainly need glasses to see intermediate distances, such as computer work, as well as to see near points, such as reading fine print. Remember that the primary goal of cataract surgery is to correct cataracts and not to reduce the need for glasses.

Cataract/Refractive Lens Surgery with a Single-Focus Lens + Astigmatism Management:

No glasses for distance, but yes, you’ll need glasses for intermediate and near work.

If you choose cataract surgery with a single-focus lens and astigmatism management/treatment, then you will achieve sharp vision for distance and will likely pass your driving test without glasses. You will have the best quality vision possible with the lowest incidence of visual disturbances. If you are a perfectionist, if you demand the best image quality and if you are willing to use glasses for intermediate and near work, then this is the best option for you.

Cataract/Refractive Lens Surgery with a Premium Implant + Astigmatism Management:
Eliminate or significantly reduce the need for glasses for distance, intermediate, and near work. If you choose cataract surgery with a premium lens and astigmatism management / treatment, then you will regain a more full spectrum of vision, at a variety of focal points. In the official FDA study, 80% of patients with these lenses never used glasses or only occasionally used them. Remember that this type of vision requires a few weeks for the visual system to adapt. If you really hate using glasses, if you are motivated and if you have an easy-going personality, then this may be the best option for you.

The Risks

Mr Ursell maintains a continuous audit of the success of cataract operations.  This can be compared to the UK national average.

National average % achieving driving vision (6/12 ) or better.

Mr Ursell % achieving driving vision (6/12 ) or better.

* Glaucoma, Diabetes, Macular Degeneration, Amblyopia

Post-op refraction (difference from predicted)

Consents

The option of cataract removal has been offered to you as a means of improving your vision.  The decision to operate and the timing are elective.  The cataract is actually the lens within the eye which has become cloudy.  After it is surgically removed, the cloudy human lens will be replaced with an intraocular lens ‘implant’.  The ‘implant’ is a small artificial lens which is permanently implanted into the eye during surgery.  It does not require cleaning or removal (as with contact lenses).  In addition, conventional glasses are usually prescribed to enhance the focus for certain distances.

Risks of Eye Surgery

As with any operation, there are risks to cataract surgery.  Individuals may respond in a unique way to any medical treatment.  Although improved modern techniques have greatly reduced their incidence, complications can and do occur.  Fortunately, severe complications which can cause loss of vision, such as major internal bleeding or infection, are very rare at approximately 1 in 1,000 cases.  Uncommon, but potential ocular complications may also include prolonged elevation of intraocular pressure, corneal clouding, retinal problems such as detachment, and chronic internal inflammation.  All of these conditions may arise in an aging eye without surgery as well.

As with all types of surgery, there can be unpredictable complications of local or general anaesthesia, and adverse reactions to medications.  It is even conceivable that health problems elsewhere -completely unrelated to surgery – can occur during or close to the time of surgery, simply because of your general state of health.

The purpose of this information is not to frighten or upset you.  Rather, it is to ensure that the decision to undergo cataract surgery has been carefully thought out with regard to the benefits and risks.  Fortunately, for most individuals, the chance of success with surgery is over 95%.  Without surgery, the visual loss caused by a cataract cannot be restored, since the cataract will not spontaneously improve.

You will be required to sign a form giving consent to Mr Ursell to proceed with your operation.

At the hospital

Once surgery is complete, additional drops will be placed in your eye to prevent infection, decrease inflammation, temporarily inactivate your eye’s focusing system and keep your pupil dilated.  You will need someone to drive you home.

At home

When you have returned home, it is important to rest for the remainder of the day and avoid any strenuous activities.

You may shower or bathe and wash your hair one day after surgery but avoid getting soapy water into your eye for a few days.

One day after surgery

Start using the drops provided.  At this point, you may resume normal activities, including bending.

Continue eye drops as directed, do not discontinue the drops until directed to do so.

A follow-up visit will also be scheduled for approximately one to two weeks after surgery.

If you experience any unusual pain, unusual discharge or an abrupt change in your vision, please call the mobile number provided immediately.

After surgery, it is normal for the white part of your eye to appear red, this will usually clear in a few days.

Your eye may feel scratchy but you should have no pain.  If you experience pain or increased discomfort, call my secretary, Karen, immediately on 0845 680 2020.

Temporary floating spots and brief flashes are common following surgery, but should disappear.

Your distance vision will usually be very good within a day or two after surgery.  However, your intermediate and near vision may be somewhat blurred for the first one or two weeks.

How to use your eye medication

• In order to keep the eye drops clean, do not allow the bottle tip to touch the eye.
• Do not allow other people to use your eye drops.
• Discard any remaining drops after one month.
• Continue putting the eye drops in as instructed above until the Eye Doctor tells you otherwise.
• If your drops run out before your next clinic visit, please ask your GP for a repeat prescription.

How to apply your eye drops

Always wash your hands before putting in the drops

• Sit or lie with your head tilted backwards and look at the ceiling.
• Place the bottle on the bridge of your nose.
• Squeeze one drop into the eye.
• Close your eye and gently blot excess drops with a clean tissue.

Instructions for after your eye operation

• If you wear glasses, use these if they make your eye feel comfortable.
• Avoid strenuous activity such as contact sports, heavy gardening, swimming, etc. for a few days.
• It is permitted to look and bend down.
• Watching TV and reading will cause no harm.
• If you need advice about driving please ask the nurse before leaving the hospital.
• When washing your face avoid the eye area for a few days.  If necessary, bathe the eye with cooled boiled water and cotton wool.
• If you notice any sudden redness, swelling or intense pain, please call the hospital immediately.