Cataract Extraction – All You Need to Know

This article is written for patients in ordinary language and it is for anyone who wishes to know the basic facts about this very important ophthalmic surgery. Lack of proper information and management can result in permanent loss of vision either in one or both eyes. If there are issues which are not clear please feel free to contact your ophthalmologist, general practitioner or local hospital.

Pathophysiology:

Cataract is clouding of the eye’s lenses; it can be unilateral or bilateral. Generally cataract formation is age related. Most patients do not even realize that they have cataracts as the process is slow and grows on the patient. After a number of years vision becomes impaired and the eyes look milky. Eventually cataracts become dense and affect vision and the quality of life. At this time surgery is the only choice but there are many “vendors of medications” which are of debatable benefit. The author would not be buying any such medication.

Healthy human lenses are clear and transparent (65% water). Light travels through them easily and is focussed onto the retina of the eye. The lenses do not have a blood supply. New cells are made continuously throughout our lifetime but some factors cause the lens to become opaque, hard, and dense. When this happens the “ripe cataracts” will need to be extracted so that light can transmit a clear picture to the retina where it can be processed and sent through the optic nerve to the brain. In ideal conditions our vision is 20/20.

Each year thousands of surgeries of this type are performed. This article is to help patients look after themselves after surgery. It will also be useful reading for family members looking after a loved one and for student nurses in years one and two of their training.

Picture of Eye with Cataract.

Types of Cataracts.

Cataracts are of many different types but the following four groups are commonly recognised.

1. Congenital. These types of cataracts are rare but some newborns do have them or develop them within the first year of life.
2. Traumatic Cataracts. These are due to eye injury which may have taken place years ago. Many patients may have forgotten that an eye injury did occur.
3. Secondary Cataracts. These are caused by medications like prednisone or other corticosteroids. Sometimes they may be secondary to diabetes. Diabetics are 10 times more likely to develop cataracts than non diabetics.
4. Age-related Cataracts. These are the most common types of cataracts. Generally three subdivisions are recognised. These are based on the anatomical location of the cataract. These are nuclear, cortical and posterior sub-capsular.

Preparing for Cataract Extraction.

Cataract extraction may be done using local or general anaesthetic to prevent pain during the procedure. A local anaesthetic numbs a local area whereas a general anaesthetic renders the patient unconscious and makes him free of pain. Nowadays, most surgeons prefer to use local anaesthetics because they have fewer post operative complications.

For the purposes of extracting the cataract the surgeon will make a small incision in the ball of the eye and remove the cloudy lens. One of the following procedures will be used to remove the lens.

In nuclear expression the lens is removed in one piece. The other procedure is called Phacoemulsification and in this procedure sound waves are used to break the lens into small pieces and the pieces suctioned out with a narrow hollow tube.

After the cataracts have been extracted plastic lens are put in place and sometimes a stitch is inserted at other times it is not stitched but a patch is placed over the eye.

Length of Stay in a Hospital. Most cataract extractions are done as day procedures and therefore hospital stay is not necessary. However, if the patient is in a hospital for some other condition then his discharge will be contingent upon the other condition.

Generally, cataract extractions are done and the patient is sent home on the same day. Patients are booked to show up in the hospital where the procedure is to be performed a few hours before scheduled time. If this is the case then the patient must have been given the preparation (pre-operative) instructions a few days before the surgery.

The Surgery:

A Registered Nurse will see the patient prior to the procedure to do a general check to make sure that all preoperative checks have been done. At this point the nurse may go through a check list of things which she is required to check

After the preoperative formalities are completed an Intra Venous Cannula will be inserted in the patient’s non-dominant hand if the procedure is to be done under a general anaesthetic. This cannula will be used to administer the anaesthetic. The cannula is removed before the patient goes home.

An identification bracelet is often placed on every patient so that the patient can be correctly identified each time for medication administration and procedure performance purposes.

The patient is made to lie on his back and once the anaesthesia is applied or given then the surgeon will perform cataract extraction. After reversal of anaesthesia and appropriate observations the patient will be sent back to the ward or discharged home.

scores the left side before inserting the gastroscope. In this position the inflated stomach sits evenly on the “operating table”.

This is a complex procedure and can last from one to two hours. The patient is generally administered oxygen via a ventilator if the patient is on life support. Oxygen administration may be continued briefly after the procedure.

Post Cataract Extraction.

The patient wakes up quickly after the anaesthesia has been reversed. He will need help maintaining his airway. A Registered Nurse is always in attendance, just in case things go wrong.

Initially the patient will be drowsy, sleepy and be disorientated to time, person and place. As he wakens he will be able to maintain his airway. He may have had a local anaesthetic applied into his eyes.

Many patients complain of itchy eyes. This is normal Eyelids may be sticky. This too is normal. There may be a mild discomfort for about three days after cataract surgery. Sometimes there is a fluid discharge. Again this in normal and common.

The patient’s surgeon or doctor may prescribe a non aspirin pain reliever every 4 to 6 hours (aspirin can cause bleeding). All discomfort normally stops after two to four days.

Introduce the patient to fluids and soft foods slowly. Do not do anything which will stimulate the cough reflex. Coughing may cause the cataract to prolapse and the patient will sight from that eye.

After a head to toe assessment, if everything is satisfactory, then the patient will be allowed to go home. A patient is not allowed drive or do any lifting for fear of relapse.

If the patient is in pain then appropriate medications will be given. Others will feel excessively sleepy. Generally, the patient can be discharged home about two hours.

Arrange for an ambulance or a relative to take the patient home. This will obviously depend upon the patient’s living conditions.

Try to sleep on the side away from the surgery. This will reduce pressure and trauma to the operated eye.

Do not wash your hair or allow dirty water of any type to enter the eye.

Use all eye medications as ordered. The patient will be ready for his first pair of glasses after about one month following surgery.

Home help is advisable. The patient or carer must be instructed to use a protective plastic eye patch during the night. This is to protect against accidental rubbing the eye. During the day an eye pad will suffice.

Most hospitals will dispense the medications which need to be applied to the eye and specific instructions will be given. When both eyes are involved then the carer must be given specific instructions.

Complete healing takes about three months.

Discharge Home & Follow up.

Patients should be clearly instructed NOT to do any household work until instructed by the surgeon. One week is the usual complete rest period.

Exercises are strictly forbidden. Stooping and any activity which results in the patient having to bend forwards are discouraged.

Cough should be controlled. It is good practice not to drive or operate machinery for two to three weeks.

Consumption of alcohol is discouraged because it results in higher risks behaviour.

A light sedative may be prescribe to help sleep. During the first week home a friend or relative should stay with the patient. Take the patient back to the hospital back if there are any difficulties.

The Follow-up.

The surgeon will see the patient after the procedure and again by agreement. This is generally one week after the extraction. If there are no complications, the next appointment will be a month later. At this time it is important for the patient to ask any specific questions he may have.

The surgeon often sends a report to the patient’s general practitioner by mail or fax depending upon local policies and procedures. A list of medications is often sent.

The patient may be placed on a bland diet or other food restrictions for the first seven to ten days. The patient is instructed to see his GP or specialist if there are complications.

The Risks.

Cataract extraction is a low risk procedure but because most patients are old they tend to have many co morbidities. The specific risks of this procedure are:

1. Infection: This risk can be minimized by appropriate use of antibiotics
2. Bleeding: Low risk but it is a risk nevertheless
3. Inflammation, pain, redness, and swelling
4. Glaucoma: High intraocular pressure
5. Retinal detachment: If this happens the patient may become partially or totally blind
6. Need for additional surgery: Sometimes the cataracts regrow
7. Loss of vision may occur but it is rare

The Benefits:

The patient will have nearly normal vision for the rest of his life if there are no other complications. Many patients will require reading glasses, those with internal lenses will not require them.

This information is non-specific and should not be used for diagnostic or treatment purposes. Only qualified and registered medical practitioners are authorised to treat and diagnose patients. Registered Nurses can do assessments and look after patients following surgery.