Treatment:

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:

• Stronger eyeglasses or contact lenses
• Use of a magnifying glass during reading
• Strong lighting
• Medication that dilates the pupil. (This may help some people with capsular cataracts, although glare can be a problem with this treatment.)

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:

• Some cataracts develop to a certain point and then stop.
• Even if a cataract does progress, it may be years before it interferes with vision.
• Very rarely do people need immediate cataract surgery.

Choosing Cataract Surgery

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.

Indications for Surgery

In general, surgery is indicated for people with cataracts under the following circumstances:

• The Snellen eye test reports 20/40 or worse, with a cataract being responsible for vision loss that cannot be corrected by glasses.
• Performing everyday activities has become difficult to perform to the point that independence is threatened, or the patient is at risk for accident or injury.

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:

• Even if the criteria for surgery are met, a very sick, elderly person in a nursing home may have less need for sharp vision than an active younger adult. Among very elderly patients (85 years and older), especially those with serious health problems, there are also higher risks for complications during surgery and poor outcomes afterward. Nevertheless, these cautions should not prevent the elderly from having this procedure; vision improvement rates are still over 85%.
• Even if the criteria for surgery are not met, some people with eye tests of 20/40 or better might want surgery because of problems with glare, double vision, or the need to have an unrestricted driver's license.
• Even if the criteria for surgery are not met, if retinal disease is also suspected (usually a complication of diabetes), the doctor may perform cataract surgery in order to have a clear view of the eye.

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.

Questions for the Ophthalmologist

The patient should ask the ophthalmologist the following questions before agreeing to cataract surgery:

• Is my cataract surgery an emergency?
• Are the cataracts the only cause of my poor vision?
• How much experience do you have with this procedure?
• Do I have other eye diseases that might complicate surgery or reduce my benefit?
• Do I have other health problems that might further complicate eye surgery?
• What type of lens will you implant?
• What type of procedure will you use?
• Afterwards, what are my chances of having poorer vision or becoming totally blind in that eye?
• How well should I ultimately be able to see out of the operated eye?
• How long will it take to heal?
• What precautions should I take during the healing process?
• How long will it take to achieve my best eyesight?
• Will I have to wear glasses or contact lenses after surgery?
• When will I get my final eyeglass prescription?
• How soon after surgery will I be able to see well enough to go back to work? Drive a car? Return to full activity?

Preparation for Surgery

Cataract surgery is usually done as an outpatient procedure under local anesthesia and takes less than an hour. Preoperative preparations may include:

• Having a general physical examination is important for patients with medical problems such as diabetes. Diabetes can cause damage to the blood vessels of the eyeâ ' s retina, a condition called diabetic retinopathy. Recent research suggests that patients who have diabetic retinopathy and poor blood sugar control should not have their blood sugar rapidly corrected before cataract surgery. Correcting blood sugar too quickly before surgery may cause vision problems after surgery.
• The ophthalmologist will use a painless ultrasound test to measure the length of the eye and determine the type of replacement lens that will be needed after the operation.
• Topical antibiotics (such as ofloxacin or ciprofloxacin) may be applied preoperatively to protect against postoperative infection.
• Most healthy patients receive either a local injection or topical anesthetic. They may also receive a sedative. Some patients may need general anesthesia.

Surgical Procedures

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:

• The surgeon makes a small incision.
• A thin probe that transmits ultrasound is then used to break up the clouded lens into small fragments.
• The tiny pieces are sucked out with a vacuum-like device.
• A replacement lens is then inserted into the capsular bag where the natural lens used to be. In most cases, this is an intraocular lens (IOL), which is foldable and slips in through the tiny incision.
• Because the incision is so small, it is often watertight and does not require a suture afterward, particularly if a foldable lens has been used. A suture may be needed if a tear or break occurs during the procedure or the surgeon inserts a rigid lens that requires a wider incision.

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:

• The ophthalmologist works under an operating microscope to make a small incision in the cornea of the eye.
• The surgeon then extracts the clouded lens through this incision.
• The capsule is left in place, which adds structural strength to the eye and enhances the healing process. (Less commonly in intracapsular cataract extraction, the surgeon removes the lens and the entire capsule. This procedure has greater risks for swelling and retinal detachment.)
• A replacement lens is then usually inserted.
• A small suture is needed to stitch the incision together.

It takes about 2 - 4 weeks to completely restore vision.

Replacement Lenses and Glasses

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:

• Lenses that address a single fixed focal point. Such lenses are suitable either for reading or distance vision, but not both. If a distance lens is implanted, the surgeon prescribes glasses or contact lenses for reading. If a reading lens is implanted, lenses for seeing distances will be prescribed.
• Lenses that address multifocal points. Multifocal lenses can focus at different points for both reading and distance vision. However, contrast may be reduced, and some patients experience glare and halos, particularly at night.
• Lenses are available that will correct astigmatism after cataract surgery.

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.

Complications of Cataract Surgery

Modern cataract surgery is one of the safest of all surgical procedures. Most complications, even if they occur, are not serious. They can include:

• Swelling and inflammation. Risk is about 1%. This complication is particularly harmful for patients with existing uveitis (chronic inflammation in the eye, which can be due to various medical conditions).
• Glare. Patients may experience glare after surgery from light scattering at the edges of the new lens, particularly with square-edged IOLs, which are typically used with posterior capsular cataracts. In most cases, this is a temporary problem that resolves after a few weeks. Sometimes, the problem lasts, and the patient needs another operation.
• Materials used in some lenses trigger an immune response in some patients. This causes inflammation and tiny deposits of tissue in the eye that lead to secondary cataracts -- called posterior capsule opacification.
• Retinal detachment. In rare cases, the retina at the rear of the eye can become detached. Risk is very low (0.1%), and phacoemulsification poses less of a risk for this than older standard surgery.
• Atonia (loss of muscle tone that results in a disturbing glare). (Phacoemulsification poses less of a risk than standard surgery.)
• Glaucoma. This is an eye condition in which the pressure of fluids inside the eye rises dangerously. Risk is very low, but patients should be sure to avoid activities after surgery that increase pressure.

Glaucoma is a condition of increased fluid pressure inside the eye. The increased pressure causes compression of the retina and the optic nerve which can eventually lead to nerve damage. Glaucoma can cause partial vision loss, with blindness as a possible eventual outcome.

• Infection. This is very rare (0.2%) but may be significant if it does develop.
• Blisters on the cornea. There is a higher risk of rupture with phacoemulsification, but the risk is extremely low, particularly for experienced eye surgeons.
• Bleeding can develop inside the eye. Risk is about 1% for minor bleeding and 1 in 10,000 for severe bleeding.
• An implanted IOL can become damaged or dislocated. Risk is very low.
• The surgery itself can produce vision loss or impairment. The risk for this is 1 in 1,000. (Phacoemulsification poses less of a risk than standard surgery.)

Phacoemulsification does have some specific complications, although they are rare, particularly with experienced eye surgeons. They include:

• Rupture of the lens capsule.
• Loss of the lens nucleus into the eye fluid. (This will require removal by a specialist and may result in poorer vision.)
• Flying fragments of the lens can damage the cornea or threaten the retina.
• Pre- and postoperative changes in blood pressure, which are generally not a problem, should be observed carefully, since in some cases the changes may be extreme.

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:

• A topical antibiotic may protect against infection.
• Corticosteroid eyedrops or ointments are often used to reduce swelling, but they can pose a risk for increased pressure in the eye.
• Nonsteroidal anti-inflammatory drugs (NSAIDs), such as diclofenac, ketorolac, naproxen, and voltaren, also reduce swelling and do not have the same risks as steroids. Newer NSAIDS approved to treat pain and swelling after cataract surgery include bromfenac (Xibrom) and nepafenac (Nevanac).

Factors that Increase Risk for Complications. The risks of complications are greater for the following people:

• Patients who have other eye diseases.
• People with diabetes. Intracapsular and extracapsular cataract extraction can pose a high risk for the development or worsening of retinopathy, a known eye complication of diabetes. The amount of experience a surgeon has plays a role in whether or not a patient has this complication.
• People who have taken tamsulosin (Flomax) or other alpha-1 blocker drugs. Tamsulosin is a muscle relaxant prescribed for treatment of several urinary conditions, including benign prostatic hyperplasia (BPH). Tamsulosin may cause intraoperative floppy iris syndrome (IFIS), a loss of muscle tone in the iris that can cause complications during eye surgery. Problems have been reported both for patients who were taking the drug during surgery as well as those who had stopped taking the drug weeks or months before surgery. Men who have taken tamsulosin or similar drugs should inform their eye surgeon. The surgeon may need to use different techniques to minimize the risk of IFIS and other complications.

Postoperative Care

Returning Home and Follow-up Visits.

• Patients usually leave the surgical site within an hour of surgery. Cataract surgery almost never requires an overnight hospital stay.
• Patients need someone to drive them home and stay with them for a few days until their vision acclimates.
• The patient is usually examined the day after surgery and then during the following month. Additional visits occur as necessary.
• Vision usually remains blurred for a while but gradually clears, usually over 2 - 6 weeks. (It can take longer.)
• When the doctor decides the condition has stabilized, the patient will receive a final prescription for glasses or contacts.

Protecting the Eye. Postoperative protection of the eye typically involves:

• The ophthalmologist usually tapes a bandage over the eye to protect it during the healing process.
• When changing the bandage, the eye can be cleaned gently using a washcloth dipped in warm water without soap. A new bandage can then be positioned and taped.
• It is very important not to press or rub the eye during this procedure.
• An eye shield may be placed over the bandage at night.

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:

• Minimize vigorous exercise.
• Put on shoes while sitting and without lifting up the feet.
• Kneel instead of bending over to pick something up.
• Avoid lifting.
• Limit reading since it requires eye movement (watching television is all right).
• Sleep on the back or on the unoperated side.

Treatment for Patients with Accompanying Eye Conditions

Cataracts and Glaucoma. For patients with both glaucoma and cataracts, doctors recommend:

• In patients with cataracts and poorly controlled glaucoma, a two-step procedure for both eye conditions may be used. The patient first receives a trabeculectomy for glaucoma, followed by cataract surgery. Fluid leakage and the presence of blood in the back chamber of the eye are potential complications of this combined procedure. Phacoemulsification has improved success rates and reduced high complication rates of the double procedure compared with extracapsular cataract extraction. New advances that replace trabeculectomy with nonpenetrating glaucoma surgery may prove to be beneficial.
• In patients who have cataracts plus either closed-angle glaucoma or open angle glaucoma that is stabilized with medication, the cataract may be extracted and medication continued for the glaucoma.

Cataracts and Corneal Disease. Patients with both cataracts and corneal disease may have one of the following procedures:

• Combination Procedure. A single operation that combines three procedures, extracapsular cataract extraction and intraocular lens insertion with corneal transplantation (called penetrating keratoplasty).
• Sequential Procedure. An operation that uses two procedures sequentially. The sequential option performs the cataract procedures and the corneal transplantation separately.

Secondary Cataracts (Posterior Capsular Opacification) and Their Treatments

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:

• After surgery, there are still some natural lens cells left behind that proliferate on the back of the capsule.
• The capsule gradually becomes cloudy and interferes with clear vision the same way the original cataract did.

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.)

• This is an outpatient procedure and involves no incision.
• Using the laser beam, the ophthalmologist makes an opening in the clouded capsule to let light through.
• After the procedure the patient should remain in the doctor's office for an hour to be sure that pressure in the eye is not elevated.
• An eye examination for any complications should follow within 2 weeks.

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.

Treating Cataracts in Children

Infants. Treatment of infants first depends on whether one or both eyes are affected:

• For infants born with cataracts in one eye, the American Academy of Ophthalmology recommends surgery as soon as possible, by 4 months or ideally even earlier. The procedure is followed by contact lens correction and patching of the unaffected eye. Although this approach is successful in many cases, some children still become blind in the affected eye. There is also a high risk for glaucoma after surgery.
• In infants with cataracts in both eyes, surgery is not always an option. Sometimes surgery may be performed sequentially, with the second eye operated on a few days after the first. Phacoemulsification appears to pose a much higher risk for secondary cataracts than standard lens removal.

Toddlers and Older Children. Intraocular lens replacement is now standard treatment for children 2 years and older.