What Are Cataracts?
A cataract is a clouding of the normally clear lens of the eye. The lens, which lies just behind the pupil, helps the eye to focus. When the lens becomes clouded, the passage of light to the back of the eye is partially blocked, and a person’s ability to see is reduced. This clouding of the lens of the eye is called a cataract. Thus, a cataract is not a growth or a tumor, but a change in the clarity of the lens.

Cataracts may form in the eyes of people of any age, but they are most common in older adults. In fact, after age 65, many people have a cataract. It is important to remember that if you have a cataract, you may not necessarily require an operation because many people have some minor clouding of the lens that does not affect vision. An operation to remove the cataract becomes necessary only if the patient’s vision and ability to function become impaired. If you do need an operation to remove a cataract, you should know that advances that have been made in cataract operations in recent years have made cataracts one of the most treatable of eye disorders.

This article will explain:

* Why you may need to have a cataract operation
* How a cataract surgical procedure is usually performed
* What to expect before and after the operation

Remember, as common as cataract surgery is — more than a million and a quarter such operations are performed in the United States each year — no two people undergoing the procedure are alike. The reasons for and the outcome of any operation depend on your overall health, age, the severity of lens opacity (cloudiness), and any other abnormalities of the eye or existing health conditions. This article is not intended to take the place of the professional opinion of your ophthalmologist (a surgeon who specializes in diseases and abnormalities of the eye and who is trained to perform surgical procedures on the eye). Rather, the information that is presented here can help you understand the basics of this surgical procedure. Read this material carefully. If you have any questions, discuss them openly with your ophthalmologist.
What Causes Cataracts?

Most people who develop cataracts are older adults. Almost everyone over the age of 65 has a cataract in one or both eyes that interferes with vision. Diseases, such as diabetes, and the long-term use of some medications, such as corticosteroids, can contribute to the formation of cataracts. Physical injuries, such as a puncture wound to the eye, and injuries caused by chemicals hitting the eye or by exposure to excessive X-rays, intense heat or, possibly, too much sunlight also can cause cataracts. In addition, smokers tend to have a higher occurrence of cataracts than non-smokers.

Cataracts may take years to form, or they may worsen rapidly in a few months. Furthermore, cataracts can affect both eyes at the same time, but they may develop at different rates. People with cataracts often experience one or more of the following symptoms:

* Blurred or hazy vision
* Poor vision at night or in very bright light
* Difficulty driving, especially at night because of glare from headlights of oncoming cars
* Seeing “ghost” images
* Change in color vision
* Loss of contrast
* Poor distance vision

Many people do not need to have an operation for a mild cataract. But when a cataract begins to interfere with your ability to carry out desired tasks — for instance, if you have difficulty reading a newspaper or you experience difficulty driving — it is time to discuss the option of a cataract operation with your ophthalmologist.

Can Cataracts Be Treated Non-Surgically?

Cataracts do not go away on their own or with the use of medication. The only way to treat cataracts is to have them removed surgically. However, there are a few things that can be done to provide temporary relief from the symptoms of cataracts until an operation can be performed. Eyedrops that widen the pupil of the eye may help you to see better if the cataract is small and near the back of the lens; your surgeon will be able to determine the exact location of the cataract and whether eyedrops may be a temporary option for you. Wearing sunglasses or other special types of glasses will protect your eyes from sunlight, and readily available Polaroid® sunglasses may help reduce the glare further in bright sunlight. Wearing a visor to prevent light from shining directly into the eyes is often helpful. Also, using standard 60- or 100- watt light bulbs or brighter instead of fluorescent lighting may help you to see better indoors.

When Should Your Cataract Be Removed?

A surgical procedure to remove a cataract is usually recommended when your vision becomes poor enough to interfere with your daily activities. The decision to remove a cataract is usually based on factors such as your lifestyle, age and occupation. Sometimes, your surgeon may recommend that an operation be performed immediately to avoid other eye complications. Immediate removal wasn’t always the standard treatment for cataracts, however. Years ago, surgeons advised patients to let the cataract “ripen” or grow to totally obscure vision before they would remove the cataract. Now, however, with advances in surgical technology, surgeons no longer recommend waiting to remove a cataract, because waiting could make the procedure more difficult to perform. In addition, today’s cataract removal procedures are safer and more successful than operations that were used in the past.

Surgical Removal of Cataracts

Studies have shown that cataract surgery is successful more than 95 percent of the time. Virtually all cataract patients now have an intraocular lens (IOL) implanted at the time that their cataract is removed. In rare cases, it may be inappropriate for the ophthalmologist to implant an IOL during the operation. In such cases, the ophthalmologist may need to consider alternatives, such as having the patient fitted for a contact lens. Sometimes an IOL may be implanted during a later operation. Glasses also may be an option in such rare cases. However, these glasses are thick and heavy, and they distort peripheral (or side) vision. You should discuss these issues with your ophthalmologist to determine if wearing cataract glasses or cataract contact lenses may be an option for you.

Because the operation can be performed in several ways, you should discuss with your surgeon which option is best for you. The patient usually receives a local injection of anesthetic solution around or behind the eye. In the most common method of cataract removal, the surgeon looks through an operating microscope and makes a small incision with a scalpel in or near the cornea. An opening is then made through the capsule of the lens so that the cloudy contents can be broken up with ultrasound waves and then removed. Rarely — less than 1 percent of the time — the surgeon may choose to remove the entire lens. Until recently, the most common surgical treatment for cataracts was to remove the center (nucleus) of the lens through a larger incision. Currently, there is a trend toward removing cataracts with a small incision and ultrasound.

Nearly all cataract operations are scheduled on an outpatient basis. When patients have cataracts in both eyes there is usually an interval of several months between operations. However, an operation on the second eye is not always necessary, and the need for it must be determined on an individual basis.

Most sutures (stitches) that are sewn during the procedure do not have to be removed. Some newer types of incisions are not sutured at all; therefore, these procedures are often referred to as “stitchless cataract surgery.”

Recovery

You may experience some swelling of the eye area immediately after the operation. If you do, it can be treated with eyedrops that contain anti-inflammatory medication. Fortunately, infection is rare after a cataract operation. Nonetheless, an antibiotic ointment or eyedrops may be applied directly to the eye for several weeks to ensure that no infection develops.

You should be up and walking soon after the operation. However, you may find that exposure to bright light is uncomfortable. Sunglasses and eyedrops can relieve most discomfort you may experience. Your level of activity will depend on your surgeon’s instructions. Usually, you can resume normal, nonstrenuous activity on the first day after the operation. You also may be asked to wear eyeglasses, both indoors and outdoors, for seven-to-10 days following the operation. In addition, to prevent scratching or irritating the healing wound, you may be asked to sleep with a protective eye shield until the healing process is well under way.

Are There Any Complications?

As with any surgical proceed there may be complications that occur during or following cataract removal. Although complications are rare, those that occur most commonly are:

* Inflammatory reaction. Your eye and the area around it may swell and be tender or painful. You will be treated with an antibiotic and/or anti-inflammatory drugs in drops, by local injection, or through the bloodstream. Very rarely, if the infection progresses, small amounts of an antibiotic may be injected into the eye.
* Fluid in the retina (or macular edema). This complication occurs more commonly in people who have certain conditions, such as diabetes. Although the problem usually clears up by itself, eyedrops or pills are sometimes used to help remove the fluid.
* Other serious, but less common complications, that may occur following cataract surgery include: dislocation of the lens implant, infection, retinal detachment and excessive bleeding. You should discuss these unlikely difficulties with your ophthalmologist if you are concerned about them.

Life After Surgery

Once a cataract has been removed, light can once again pass undistorted through the cornea and the IOL to the retina (back of the eye). However, your vision will not be clear unless the light is focused directly on the retina; eyeglasses provide that focus, so you may be required to wear glasses to see more clearly. In addition, the artificial implanted lenses or IOLs cannot change shape the way the eye’s natural lens did when you were younger, and you will most likely need to wear bifocal lenses or reading glasses in order to see clearly at close range. It is important to note that you may need to have your eyeglass prescription changed following a cataract operation.

At times, a cataract can be successfully removed, but vision is not improved because of other conditions or diseases of the eye. One such disease is macular degeneration. In this condition, the central part of the retina — the area that is critical for “fine” seeing — is damaged. Often this condition cannot be diagnosed prior to the cataract operation because the presence of the cataract may prevent the ophthalmologist from seeing the macula in sufficient detail. Early diagnosis of macular degeneration is vital to successful treatment of retinal diseases.

In addition, other pre-existing conditions of the eye can limit vision after the operation, such as diabetes and glaucoma. All such preexisting conditions limit the eye’s ability to regain normal vision, even if the cataract operation is successful. It is important to remember, however, that cataract removal has a high success rate. It is more than likely that your vision will be better than it has been, and that you will be able to do things that you were not able to do before the operation.

Surgery by Surgeons

A fully trained surgeon is a physician who, after medical school, has gone through years of training in an accredited residency program to learn the specialized skills of a surgeon. One good sign of a surgeon’s competence is certification by a national surgical board approved by the American Board of Medical Specialties. All board-certified surgeons have satisfactorily completed an approved residency training program and have passed a rigorous specialty examination. The letters F.A.C.S. (Fellow of the American College of Surgeons) after a surgeon’s name are a further indication of a surgeon’s qualifications. Surgeons who become Fellows of the College have passed a comprehensive evaluation of their surgical training and skills; they also have demonstrated their commitment to high standards of ethical conduct. This evaluation is conducted according to national standards that were established to ensure that patients receive the best possible surgical care.

Reviewed by:

Ronald M. Burde, M.D., F.A.C.S.,
Monteflore Medical Center,
The University Hospital for the Albert Einstein College of Medicine, Bronx, NY

David E. Eifrig, M.D., F.A.C.S.,
Department of Ophthalmology,
University of North Carolina, Chapel Hill, NC

Manus C. Kraff, M.D., F.A.C.S.,
Kraff Eye Institute, Chicago, IL

George L. Spaeth, M.D., F.A.C.S.,
Wills Eye Hospital, Department of Ophthalmology,
Jefferson Medical College, Philadelphia, PA

George W. Weinstein, M.D., F.A.C.S.,
Department of Ophthalmology,
West Virginia University, Morgantown, WV