Although surgery is the only remedy for cataracts, it is almost never an emergency. Most cataracts cause no problem other than reducing a person's ability to see, so there is no harm in delaying surgery.
Early cataracts may be managed with the following measures:
Progression of Cataracts. Patients and their families usually have plenty of time to carefully consider options and discuss them with an ophthalmologist. There is no constant rate at which cataracts progress:
Cataract removal is the one of the most common type of eye surgeries performed in the United States, especially for people over age 65. In the past, cataract surgery was not performed until the cataract had become well developed. Newer techniques, however, have made it safer and even more efficient to operate in earlier stages. Cataract surgery improves vision in up to 95% of patients and prevents millions of Americans from going blind.
Nevertheless, cataract surgery may be performed more often than needed. In general, even if cataracts are diagnosed, the decision to remove them should be based on the patient's own perception of vision difficulties and needs and the effect of vision loss on normal activity. The patient should also be aware of all the risks and costs of surgery.
In general, surgery is indicated for people with cataracts under the following circumstances:
These guidelines are general, however. Whether surgery is appropriate or not further depends on the cataract patient's specific condition and needs. Some examples include:
Because of the risks, albeit small ones, of poorer vision or blindness, no one should be forced to have cataract surgery if they don't want it or are not strong enough to have the procedure. If there are any doubts about whether or not to have cataract surgery, consider a second opinion.
Treatment Decisions for Cataracts in the Second Eye. If a person has a cataract in a second eye, the issues for decision making are the same as for the first eye. The timing of the procedure in the case of two cataracts is unclear. Doctors have long recommended postponing surgery on the second eye until the first eye has healed and the results are known. However, many patients have trouble reading and performing ordinary tasks while waiting for a second surgery. Patients with double cataracts should discuss all options with their surgeon.
The patient should ask the ophthalmologist the following questions before agreeing to cataract surgery:
Cataract surgery is usually done as an outpatient procedure under local anesthesia and takes less than an hour. Preoperative preparations may include:
All cataract procedures involve removal of the cataract-affected lens and replacing it with an artificial lens.
Phacoemulsification. Phacoemulsification (phaco means lens; emulsification means to liquefy) is the most common cataract procedure performed in the United States.
The procedure generally involves:
Phacoemulsification requires only local anesthesia. Newer methods for administering local anesthesia produce few complications. Most phacoemulsification procedures now take about 15 minutes, and the patient is usually out of the operating room in about an hour. There is little discomfort afterward, and visual rehabilitation takes about 1 - 3 weeks.
Phacoemulsification is sometimes combined with glaucoma surgical procedures, for patients who have both glaucoma and cataracts.
Extracapsular or Intracapsular Cataract Extraction. Extracapsular cataract extraction, the original standard procedure, is now generally used only in patients who have an extremely hard lens. It typically involves the following steps:
It takes about 2 - 4 weeks to completely restore vision.
With the clouded lens removed, the eye cannot focus a sharp image on the retina. A replacement lens or eyeglasses are therefore needed:
Intraocular Lenses (IOLs). In about 90% of cataract operations, an artificial lens, known as an intraocular lens (IOLs), is inserted. Most IOLs are made out of acrylic, although other materials, such as silicon, are also used.
IOLs are designed to improve specific aspects of vision. The choices include:
The patients and the doctor must make these decisions based on specific visual needs. Many patients also need eyeglasses after cataract surgery for reading or to correct astigmatism.
Modern cataract surgery is one of the safest of all surgical procedures. Most complications, even if they occur, are not serious. They can include:
Phacoemulsification does have some specific complications, although they are rare, particularly with experienced eye surgeons. They include:
In about 30% of cases patients develop secondary cataracts within 1 - 5 years after either procedure. Therefore, these patients need different treatment choices.
Preventing Infection and Reducing Swelling. The ophthalmologist may prescribe the following medications after surgery:
Factors that Increase Risk for Complications. The risks of complications are greater for the following people:
Returning Home and Follow-up Visits.
Protecting the Eye. Postoperative protection of the eye typically involves:
Avoiding Glaucoma. Cataract surgery can cause glaucoma, a condition in which the pressure of fluids inside the eye rises dangerously. It is very important to minimize any activity that increases internal eye pressure. Postoperative cataract patients take the following precautions:
Cataracts and Glaucoma. For patients with both glaucoma and cataracts, doctors recommend:
Cataracts and Corneal Disease. Patients with both cataracts and corneal disease may have one of the following procedures:
Although less common than with phacoemulsification, about 30% of patients who have extracapsular cataract surgery develop a secondary "after-cataract" called posterior capsular opacification. Posterior capsular opacification generally occurs because of the following events:
Secondary cataracts are more likely to occur in younger patients, in those with diabetes, or when cataract surgery is combined with vitrectomy (clearance of debris from the fluid in the eye).
Treatment for Posterior Capsular Opacification. Researchers are investigating methods that may help prevent posterior capsular opacification. The standard treatment is laser surgery known as a YAG capsulotomy. (Capsulotomy means cutting into the capsule, and YAG is an abbreviation of yttrium aluminum garnet, the laser most often used for this procedure.)
Complications. Laser surgery has become so commonplace that some ophthalmologists use it after cataract surgery to prevent later clouding. However, laser surgery has its own risks and possible complications, similar to those of cataract surgery itself, and can also lead to poorer vision or blindness. About 1% of laser surgery patients develop a detached retina, a risk that is much higher than the original cataract surgery.
In some people, particularly those with glaucoma or who are severely nearsighted, the pressure in the eye may spike after laser surgery. Certain drugs used for treating glaucoma, such as dorzolamide (Trusopt) or apraclonidine (Iopidine), may help prevent this occurrence. It is strongly recommended, however, that this surgery be performed only if the lens capsule clouds up again, not to prevent a secondary cataract.
Infants. Treatment of infants first depends on whether one or both eyes are affected:
Toddlers and Older Children. Intraocular lens replacement is now standard treatment for children 2 years and older.
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