Cataract Surgery Methods: Which Is Right for You?

The only proven treatment for cataracts is lens replacement surgery. The natural crystalline lens of the human eye that has become opaque or cloudy is replaced with an artificial intraocular lens. Two primary surgical techniques are used today with phacoemulsification being the predominant choice. The third technique is an evolution of one of the techniques and is popular in developing countries.

Key takeaways:

Most cataract surgeries are performed under local anesthesia with mild sedation and patients go home the same day. This article discusses the different options for cataract surgery and which might be best for you.

Types of cataract surgery

There are three main types of cataract surgery that are widely used today. One is really a modification of the main two types.

Phacoemulsification (Phaco)

Phacoemulsification is the most commonly recommended surgical method for cataract surgery today. It involves the phacoemulsification or “phaco” of the natural lens or the breaking down of the lens into small pieces to remove it by suction. In almost all surgeries, an artificial intraocular lens (IOL) replaces the natural lens.

Phacoemulsification constitutes over 90% of cataract surgeries worldwide today and is considered the standard of care. The surgery boasts low complication rates and great vision results. It is a minimally invasive procedure that is fast with a quick post-operative recovery.

The incision is usually no more than 2–3 mm (0.08–0.12 inches). The artificial IOL is foldable so it fits through without the need for any sutures for closure. Foldable IOLs are made of silicone, hydrophobic, or hydrophilic acrylic material with different refractive powers available for implantation. Sometimes a rigid polymethyl methacrylate or PMMA lens is used which is rigid and requires a larger incision.

Phacoemulsification is performed with a machine with an ultrasonic handpiece equipped with either a surgical steel or titanium tip which vibrates at 40 kHz or in the ultrasonic frequency range. The result is the natural lens tissue is emulsified.

Your surgeon will then use an instrument called a “chopper” or “cracker” that will break up the hard cataract nucleus into finer pieces. Suction is then employed to aspirate the cortical material or the soft parts of the lens surrounding the nucleus.

The final step of the surgery is to use a dual irrigation-aspiration (I-A) probe or a bimanual I-A system to remove any remaining lens or peripheral material. The choice of IOL is carefully planned with your doctor since there are many options.

Extracapsular cataract extraction (ECCE)

In extracapsular cataract extraction (ECCE), the lens is removed from its capsule and extracted whole or in large pieces. This surgical technique is also called manual extracapsular cataract extraction. It involves the removal of almost the entire natural lens in a single piece, leaving the elastic posterior capsule intact.

In this surgery, the incision is substantially larger, 10–12 mm (0.39–0.47 inches), in the sclera or cornea. The natural lens is manually removed. Stitches are necessary for closure.

ECCE is preferred for patients who have very hard cataracts or in other clinical situations when phacoemulsification may not be possible. Another reason your doctor may use the ECCE surgical method is to avoid permanent corneal damage. One potential drawback of ECCE is a higher incidence of astigmatism compared to phacoemulsification.

In developing countries where phacoemulsification equipment is not yet available, ECCE has become a popular option. In fact, there is a modification of ECCE which has been adopted called manual small incision cataract surgery or MSICS where no sutures are required.

Manual small incision surgery (MSICS)

Using MSICS, the surgeon makes a self-sealing incision with a tiny tunnel. The incision is larger than used in phacoemulsification, but smaller than used in ECCE. MSICS has become the standard of care in developing countries because of the excellent outcomes, no sutures, lower costs, and fewer incidences of astigmatism. MSICS is also easy for surgeons to learn and master.

MSICS is a preferred option in places where there are few resources. In many developing countries, a phacoemulsification machine is hard to come by so surgeons have learned the MSICS technique as a way of adapting.

Many of the vision results of MSICS in these poor countries are excellent. Without MSICS, the vast majority of people with cataracts would go untreated, leading to a higher incidence of blindness.

What to expect before, during, and after cataract surgery

The anticipation of having any surgery may cause anxiety. The good news is that cataract surgery is safe, effective and most people find the recovery easy. Vision results after surgery are excellent.

Pre-op planning

Your eye doctor will perform a thorough eye exam to confirm the presence and characteristics of the cataract. The choice of IOL will be discussed since there are multifocal intraocular lenses that can replace bifocal or trifocal eyeglasses.

It is essential to review the surgery completely. This will avoid unrealistic expectations, patient dissatisfaction, or the need to replace the IOL later.

In order to be a good candidate for cataract surgery, the patient must:

  • Be evaluated for age-related macular degeneration and glaucoma.
  • Have normal eye pressure or their glaucoma be under control with medications or other surgery.
  • Have an adequately dilated pupil using drops.
  • Be evaluated for retinal detachment since they would need additional surgery to correct that.

Prospective patients must also avoid using a popular treatment for benign enlarged prostate called tamsulosin since taking this drug may cause a surgical complication called intraoperative floppy iris syndrome which can lead to posterior capsule rupture and vision loss.

During the surgery

Your doctor will administer antibiotics before, during, and after surgery. These will include topical corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs).

Expect your doctor to do the procedure with local anesthesia and sedation. You will likely not remember any of the surgery, but technically you will be awake without the need for breathing support.

After the surgery

Almost all cataract surgery is done as outpatient surgery. You will go home the same day.

Most patients will go home with an eye patch for the rest of the day and while sleeping. You will be instructed on the use of anti-inflammatory and antibiotic eye drops after you go home. Many patients experience only mild discomfort unless additional surgery was performed such as for glaucoma.

Most surgeons can perform the planned surgery using phacoemulsification or MSICS. In some cases, it may be necessary to convert the surgery technique to ECCE to better handle a cataract that is more troublesome than anticipated.

Complications after cataract surgery are rare but can be serious so close follow-up is necessary with your surgeon. It is also uncommon for the IOL to need to be exchanged, removed, or repositioned.

Things to consider

After cataract surgery, many patients expect instant results. The reality is that the healing process generally takes about four to six weeks.

It is common for patients to have the following temporary symptoms:

  • Eye-watering
  • Grittiness
  • Blurred vision
  • Double vision
  • Eye redness

It is important for patients to avoid getting water in their eyes which means no swimming for at least a few weeks. Many patients return to normal activity within just a few days after surgery.

All surgery centers will require you to have a designated driver to take you home after the surgery. And, it is likely your doctor will ask you not to drive for about 24 hours after surgery. Some patients will experience pupil dilation for a day or so and that will necessitate wearing sunglasses to avoid glare.

There is no special care needed for the small incision with phacoemulsification. Other procedures may necessitate waiting for the incision to heal before any heavy lifting or straining so the stitches stay intact.

Almost all cataract patients have improved visual acuity after cataract surgery. It is one of the most successful surgical procedures worldwide. Patients should carefully discuss cataract surgery options with their eye doctor. The decisions regarding surgery are typically straightforward such as using phacoemulsification and what type of artificial lens will suit their lifestyle and vision needs.

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