Modern Cataract & IOL implantation surgery

A cataract is an opacity in the natural lens in the eye reducing the vision. Aging is the commonest cause. Cataract is not contagious, and is not a layer that grows on the eye as many people consider. Also, it cannot be treated by peeling off this layer. Cataract cannot be treated with drops, injections or even a Laser. It needs a surgery which is extremely sophisticated. The natural lens in the eye is much more sophisticated than a camera lens, and focuses an image on the retina. The retina converts light into electricity, which is conducted to the brain through the optic nerve and it is actually the brain which sees what ever the eye captures & relays! Apart from senile cataract, there are other types. Secondary cataract is due to an eye surgery, diabetes, use of steroids etc. Traumatic cataract follows an eye injury, sometimes many years later. Congenital cataract occurs often in both the eyes and may be due to metabolic diseases, consanguinity, viral infections etc. Radiation cataract is due to exposure to irradiation. Smoking, alcohol, malnourishment, prolonged exposure to sunlight, a family history of early cataract etc. are known to predispose development of cataract.

Wearing sunglasses and a hat are known block the ultraviolet sunlight and delay onset of cataract, especially in those who work outdoors for long hours and where UV light is abundant like in seashores, beaches, mountain tops etc. Good nutrition rich in protein, anti-oxidants and vitamin C can help reduce the risk or delay age-related cataract. After the age of 40 , you should have comprehensive eye examinations at least once every two to three years. In addition to cataract, you need to look out for age-related macular degenerations, glaucoma, diabetic and hypertensive retinopathy and other vision disorders. Early treatment at the right time could save sight. The most common symptoms of a cataract are painless, progressive blurring of vision. Colors may appear faded. Headlights & lamps may appear too bright or glaring. A halo may appear around lights.Night vision may be poor. Vision may be defective in bright lights Double vision or multiple images may appear. Frequent changes in eyeglasses may be needed. Sometimes reading vision may improve and you will be able to read without glasses! This so called second vision is a temporary phenomenon and is due to cataract. Cataract does not cause headache, watering or redness. If the cataract is there in only one eye, you may be totally unaware of it! Visual acuity test, slit lamp examination, pupillary reactions, dilated retinal assessment,

Tonometry, status of the lacrimal sac etc are some of the tests done when you reach an eye hospital.

Treatment The symptoms of early cataract may be improved with a new pair of glasses, bright lighting, antiglare sunglasses etc. If they dont help, surgery is the only effective treatment. Surgery involves surgical removal of the lens and replacing it with an artificial lens. When the vision loss interferes with day to day activities, such as cooking at home, office work, hobbies, driving, reading, or watching TV etc. it is time to get surgery done. You can time the surgery to suit your convenience, as delaying cataract surgery will not cause damage to the eye or make the surgery more difficult, unless you have a mature cataract with total blindness. You do not have to rush into surgery but plan it to suit your convenience. Sometimes a cataract might have to be removed at an early stage, like when it prevents assessment or treatment of another eye problem, like in age-related macular degeneration or diabetic retinopathy. If you have cataracts in both the eyes, the surgery will be performed on each eye at separate times, and the gap between the two surgeries can be as early as 1 day, in case you are hard pressed for time. Pre operative investigations, control of other diseases, post operative medications and follow ups will be easy if both the eyes are operated in a short interval. In several centers, simultaneous cataract IOL surgeries on both eyes are being performed, especially on children where they have to be taken under general anesthesia. You will also have better 3 D vision, better depth perception and better multi-focality by this way. There are many different techniques of cataract surgeries, and it is best to leave the selection to the surgeon, as he can chose the technique that best matches your type of cataract. 1. Phacoemulsification. Three very small incisions are made on the side of the cornea. Your doctor inserts a tiny probe into the eye. This device emits ultrasound waves that soften or breaks up the cataract so that it is removed by suction. MICS or Microincision cataract surgery aims at performing the same with even smaller incisions, but does not suit all types of cataracts. As any energy used in excess inside the eye is harmful, in recent days, more and more mechanical and hydro forces are used, and the use of ultrasound is minimized.

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Small incision cataract surgery Here a tiny incision is made and the cataract is broken into smaller pieces mechanically, and removed from the eye. This technique is the preferred method for majority of surgeons, and is particularly useful in difficult cases of cataract surgery. 3. Phacosection is a modification, wherein the nucleus & epinucleus of the cataract are broken into two pieces, and removed through a single tiny incision. Ultrasound device is not necessary for this technique, & the procedure extremely safe for all types of cataracts. Phacoemulsification and Phacosection do not significantly alter the corneal curvatures, and hence toric and multifocal IOLs can be implanted. 4. Extracapsular surgery & intracapsular surgery are older techniques, which need larger incisions and suturing. They are generally not employed these days. What are the risks of cataract surgery? As with any surgery, cataract surgery has risks, such as infection, bleeding, inflammation, glaucoma etc. Before cataract surgery, please give the list of all your illnesses, and the treatment you are taking. Your doctor may have to temporarily stop certain medications that increase the risk of bleeding during surgery. Inform about Diabetes, high BP, previous surgeries, enlarged prostrate & the medicines you are taking for them, cough, infections, heart diseases, allergies, past history of the eye, esp. any sudden loss of vision etc. to the surgical counselor. After surgery, you must keep your eye clean, wash your hands before touching your eye, and use the prescribed medications properly. With todays modern surgery, you could return to your work and all household tasks the very next day. As the surgery is safe & painless, there is no need for an anesthetic injections, no need for stitches to close the tiny incision, and no bandage! High myopia and those with weak retina need regular follow ups. In them, retinal detachment can occur suddenly with symptoms of flashes or floaters. Floaters are little "cobwebs" or specks that float in your vision. If you notice them see your eye doctor immediately, as retinal detachment is an emergency. Those who have diabetic or any other progressive retinopathy need periodic assessments.

. After the natural lens is removed, an artificial lens called an intraocular lens (IOL) is inserted. An IOL is a clear synthetic lens that requires no care and becomes a permanent part of the eye. Today, most IOLs can be injected through a tiny incision using a cartridge. They are made of acrylic material, and can by hydrophilic or hydrophobic. Both are very popular.Light is focused by the IOL onto the retina, improving your vision. You will not feel or see the new lens, and it serves you for life time. It never needs a replacement! Newer lenses have aspherical surfaces like the lens of an young adult, and this increases the quality of vision. Few IOLs have a slight yellow tint, to match the natural lens There are many kinds of IOLs, some are monofocals, and few are multifocals. With monofocals, you would need glasses for some of your work tasks. The monofocals can be focused for near, distance or for intermediate distances. Discuss about your needs with the doctor or surgical counselor. You could chose monofocal for distance in your dominant eye and for near in the other eye. If you have astigmatism, it can be corrected by Toric IOLs. Multifocal IOLs make you see both distance and near without glasses, and gives maximum visual independence. They do cause some haloes around lights. Multifocal Toric IOLs were introduced recently. Keratometry & Biometry are used to measure the curve of the cornea and the size of your eye, and appropriate IOL power is calculated. If you have been wearing high powered glasses before, the new IOL will drastically reduce the spectacle power after surgery. Two birds with one stone!! Lasers are not used for cataract surgery, although some patients call it as Laser surgery! While all other Lasers tried in the past have been abandoned, research is going on for

the development of Femtosecond Laser based equipment to perform some steps of cataract surgery like making incisions, capsulotomy and nucleus softening. Few equipment models have been released into the market recently. But surgery to remove the cataract from the eye and to implant the IOL cannot be avoided. Research towards prevention or reversal of cataract is in still going on, without any headon results. How is the cataract surgery done? Cataract removal is one of the most common operations performed on the human body. It also is one of the safest and most effective type & technologically the most evolved form of surgery. Surgeons skills are equally important. Dont take it lightly although the technology has made it appear too simple a surgery! In over 95 percent of cases, people who have cataract surgery have much better vision. Several tests are done before surgery and these minimize the risk factors. When you arrive at the hospital for the surgery, few eye drops are put into your eye to dilate the pupil, to disinfect and to numb the eye. The area around your eye will be washed and cleansed. The operation usually lasts less than fifteen minutes and is painless. You will be awake during surgery and can talk to the surgeon if needed. You could cough or sneeze or move during this modern surgery, but do inform the surgeon before doing it! After the operation, instruction will be given about the care and medications. You can return home in about half an hour, once you are feeling quite well. You can eat normally, both before and after the surgery. Mild discomfort, watering and glare are normal after cataract surgery. Some fluid discharge is also common. Your eye may be sensitive to light and touch. If you have more discomfort or pain, call your doctor for advice. After one or two days, moderate discomfort should disappear. You need to use some eye drops for about a month after surgery. You will be taught as to how to use your eye drops, how often to use them, and for how long. You will need to wear an eye shield at night & eyeglasses to help protect your eye. Avoid rubbing or pressing on your eye. Dont keep on wiping your eye with kerchiefs or tissues. Dont touch the eye with dirty hands. You can wash your face with soap and water right from the next day after surgery. Avoid splashing the eye with water with the eyes open. You could use all cosmetics, but avoid Khajal and eye make up. At home, you can bend to pick up objects on the floor, lift moderate weights, can walk, climb stairs, and do household chores.

Can problems develop after surgery? Problems after surgery are rare, but they can occur. These problems can include infection, bleeding, inflammation (pain, redness, and swelling), decreased vision, double vision, and high or low eye pressure. These may be the new ones or pre existing. With prompt medical attention, many of these problems can usually be treated successfully. Many people who need cataract surgery also have other eye conditions, such as age-related macular degeneration, diabetic retinopathy or glaucoma. Then the vision recovery may not be complete, and this may be expected before itself or may come as a surprise. After several years of good vision, the capsule of the lens that encloses the IOL may become hazy & blur your vision. This condition is called Posterior capsular opacity or PCO. This can be treated with a Nd YAG Laser capuslotomy, a painless outpatient procedure. Todays cataract surgery with IOL implantation is a very safe procedure, and if you are advised to go through it, there should be no reason to hesitate. Most of the insurance and TPA companies reimburse the cataract IOL surgery completely, and the cashless facilities will give you a very good package. If you cannot afford surgery at a good private hospital, there are many charity institutions supported by government and philanthropists who perform cataract IOL surgery free of cost. As most hospitals do offer subsidized services for poor, discuss about monetary issues with the counselor. If you can afford some payment, avoid mass eye surgery camps, where the risks

are little higher. Due to logistics of performing many surgeries, there may be compromise in the hygiene or surgical protocols. Enjoy vision, enjoy nature and enjoy life with the modern cataract IOL surgery. This is vastly different from how Sushrutha practiced cataract surgery centuries ago.

Cataract surgery was pioneered in the 8 century BC by Shushruta, who discovered that the sight could be restored by pushing the cataract out of the pupillary zone.He did this by poking a needle into the eye! The patient sat opposite on the ground so that the doctor was at a comfortable height for doing the operation on the patient's eye. After having taken bath and food, that patient had been tied so that he could not move during the operation. The doctor warmed the patient's eye with the breath of his mouth. He rubbed the closed eye of the patient with his thumb and then asked the patient to look at his knees. The patient's head was held firmly. The doctor held the lancet between his fore-finger, middle-finger and thumb and introduced it into the patient's eye towards the pupil, half a finger's breadth from the black of the eye and a quarter of a finger's breadth from the outer corner of the eye. He moved the lancet gracefully back and forth and upward. There was a small sound and a drop of water came out. The doctor spoke a few words to comfort the patient and moistened the eye with milk. He scratched the pupil with the tip or the lancet, without hurting, and then drove the 'slime' towards the nose. The patient got rid of the 'slime' by drawing it into his nose. It was a matter of joy for the patient that he could see objects through his operated eye and the doctor drew the lancet out slowly. He then laid cotton soaked in fat on the wound and the patient lay still with the operated eye bandaged.

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