Cataract Surgery: All the Things to Know

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How cataract surgery is performed

Cataract surgery consists of removing the cataract and inserting an artificial lens inside the eye. In the eye there is a lens called Crystalline which allows images to be focused. When this lens becomes opaque it is called a cataract. The only cure for cataracts is surgery which consists of extracting the cataract and replacing it with an artificial lens made of plastic material called an intraocular lens or IOL (Intra Ocular Lens). Here are the main phases of the intervention:

1. Cataract Removal

Cataracts can be removed in several ways. The most advanced techniques for cataract removal are laser surgery and phacoemulsification . In both cases, a small microincision of approximately 2 mm is made on the cornea and a gelatinous substance called viscoelastic is injected inside the eye which protects the cornea. The capsule containing the cataract is then opened and through this opening called capsulorhexis the cataract is fragmented and aspirated using the Laser and the Phacoemulsifier.

2. Insertion of the Intraocular Lens

Once the cataract is removed it is replaced by an intraocular lens. The type of intraocular lens that is implanted in the eye determines the outcome of the surgery . There are various intraocular lenses today, the most innovative or premium ones allow the correction of myopia, astigmatism, presbyopia and hyperopia along with cataracts. It is also possible to improve the vision of those suffering from cataracts and maculopathy . The intraocular lens is inserted inside the capsule that contained the cataract

3. Closing the Incision

After inserting the intraocular lens inside the eye, the viscoelastic that was inserted at the beginning of the operation is aspirated and the surgical incision is closed by simply hydrating it. No stitches are applied because the incision is so small that it closes on its own . The location of the incision is usually lateral but can also be superior. The operation lasts approximately 10 minutes. Cataract surgery performed with the most advanced techniques allows you to drive, work on the computer, read everything without glasses in just 24 hours after the operation .

Advanced Techniques: Laser and Phacoemulsification

Laser Cataract Surgery

Phacoemulsification of Cataract The laser for cataract removal is called Femto-Laser or Femtosecond Laser and has been used since 2012. It allows cataract surgery to be made more precise and safe in selected cases. Below is a list of the main benefits of Cataract surgery with Laser :

  1. The incisions made with the Laser on the cornea are extremely precise and allow the astigmatism present together with the cataract to be corrected.
  2. The laser increases precision during the delicate phase of capsulorhexis. In this phase the capsule containing the cataract is opened and the intraocular lens is introduced through the opening. A well-performed capsulorhexis allows for safer surgery and the use of more innovative intraocular lenses.
  3. The laser allows the cataract to be fragmented using little energy and in this way it is less traumatic than the surrounding structures of the eye. This is especially true for very mature cataracts or in eyes with other diseases such as Cornea Guttata.

The laser in cataract surgery is a valid tool, indispensable in some complex cases , unusable in other cases such as when there is poor dilation of the pupil or opacities of the cornea. Only the experience of a good ophthalmologist will be able to advise you whether laser surgery is indicated or not in your specific case. Scientific literature confirms that Laser and Phacoemulsification are equivalent. Here are some important scientific articles on the subject .

Phacoemulsification

Phacoemulsification is the most used technique in the world for cataract removal. Cataract surgery is carried out using a sophisticated ultrasound instrument called a Phacoemulsifier which fragments and aspirates the cataract. The use of a latest generation phacoemulsifier is essential for performing good cataract surgery . The most modern instruments allow the amount of energy used to remove cataracts to be minimized. Thus, just a few hours after the operation, the eye shows no signs of inflammation and the patient sees well without any discomfort. The most modern phacoemulsifiers also allow the pressure inside the eye to be kept constant during the operation with great benefit for patients suffering from glaucoma , this allows the risks to be greatly reduced during the operation. Finally, let us remember how the phacoemulsifier is often used during laser cataract surgery to remove some fragments of the cataract. The invention of this technique dates back to an American eye surgeon Charles Kelman who thought of using ultrasound to remove cataracts while observing his dentist use ultrasound to remove gum tartar. His studies were carried out at the prestigious Wills Eye Hospital in Philadelphia USA where Doctor Badalà learned these and other innovative techniques.

Intraocular lenses

Once cataracts have been removed with Phacoemulsification or Laser , a lens is always inserted inside the eye. This lens called an intraocular lens or IOL (Intra Ocular Lens) is inserted inside the capsule that contained the cataract. The intraocular lens is made of acrylic or silicone plastic material. There are different types, the main differences concern the shape of these lenses, to simplify, there are standard intraocular lenses and more innovative lenses also called premium lenses, let’s discover them together:

  • Standard intraocular lenses: They make you see well far or near. However, in conditions of low contrast or night vision, the quality of vision is not optimal.
  • Aspheric intraocular lenses: Compared to standard intraocular lenses, they offer better quality of vision at night and in foggy conditions and greater contrast sensitivity.
  • Toric intraocular lenses: They allow you to correct astigmatism and cataracts. They offer the same quality of vision as aspheric lenses after cataract surgery.
  • Introcular lenses with increased depth of field : They allow you to see well both from afar and at the computer without glasses, but to read small characters such as newspapers the patient requires additional glasses.
  • Trifocal Introcular Lenses : allow you to drive, use the computer, cell phone and read even the smallest print, all without glasses.
  • Hi-Tech Intraocular Lenses : They can be customized after surgery thanks to sophisticated computerized light irradiation, they allow you to correct all vision defects: myopia, astigmatism, presbyopia and hyperopia. Mostly useful after refractive surgery
  • Intraocular lenses for maculopathy : There are various intraocular lenses for maculopathy , some models are inserted into the eye at the time of cataract surgery, other models are inserted at a later stage. They work by focusing the images on peripheral parts of the macula where the damage of the maculopathy is reduced or absent.

The quality of vision after cataract surgery depends on the type of intraocular lens that is implanted in the eye . Choosing the most suitable intraocular lens for each patient requires in-depth examinations and great experience of the ophthalmologist surgeon.

We are at your disposal to evaluate together the intraocular lenses best suited to your needs .

Anesthesia for Cataract Surgery

There are different types of anesthesia for cataract surgery with relative advantages and disadvantages. Let’s discover them together:

Topical Anesthesia

A few drops of an anesthetic eye drop (based on lidocaine or novesine) are instilled and the perception of pain disappears. The eye continues to see and can move . The advantage of this type of anesthesia is that the patient can already see immediately after the operation. The disadvantage is that you may be bothered by the light used during the procedure. It is the most common anesthesia for cataract surgery . The patient leaves the operating room with a pair of sunglasses or a protective eyecup and therefore usually without wearing a bandage.

PeriBulbar, RestroBulbar, Subtenonian Anesthesia

An injection of an anesthetic drug is given near the eye to numb the eye and its muscles. The patient does not see or hear anything and also cannot move his eye for approximately 4-5 hours if the drug carbocaine is used or for 10-12 hours if naropin is used as an anesthetic. This technique is indicated for complex cataract operations or when the patient is photosensitive or anxious. With this type of anesthesia the patient wears a protective bandage for approximately 4 hours after the operation.

General Anesthesia

Rarely used for cataract surgery, it can be indicated in cases of claustrophobia or in patients who are uncooperative due to other diseases or disorders.

Convalescence and Risks of Cataract Surgery

The course after cataract surgery is very favorable but it is important to follow a few simple indications to minimize the risks. Here is all the useful information on what to do after the surgery.

Convalescence

You do not feel pain either during or after cataract surgery , it is usually normal to expect a slight discomfort like a grain of sand in the eye for a couple of hours after the operation, an annoyance that gradually becomes less noticeable as time passes. reduces quickly. Convalescence It is essential to never touch the operated eye in the first hours after cataract surgery , touching the eye can cause serious problems in the first hours. Touching the recently operated eye can in fact cause an infection or move the intraocular lens that has been inserted inside the eye itself. It is good practice to wear a protective shell while sleeping for the first few days after surgery. The sight improves already on the afternoon of the operation although it is reasonable that only the next day you will be able to see well and no longer have any discomfort. Watching television, driving and using the computer is usually possible the day after cataract surgery , but the ophthalmologist who performed the surgery will give the green light for these activities. You should avoid getting shampoo or soap in the eye for at least a week , so it may be advisable to shampoo at a hairdresser for the first few days after surgery. Sports activities such as running or swimming can be resumed one month after surgery, while walking or cycling can be resumed as early as one week after surgery, obviously following a positive opinion from the treating ophthalmologist. Avoiding crowded or dirty environments such as public transport is a good idea in the first days following the operation. Similarly , close contact with pets should be avoided in the early stages. The risk is in fact that of developing an infection which could be a very serious complication.

Risks

Cataract surgery is today an extremely safe operation but it also presents some risks. The most important risk is that of infection . For this reason it is essential to follow the antibiotic therapy prescribed by the ophthalmologist and to use common sense hygiene rules, such as avoiding dirty environments immediately after the operation, avoiding touching the eye, using a protective eyecup during the night of the intervention, common sense rules that are provided by the ophthalmologist and which are fundamental for the success of the operation. In the presence of very high myopia, cataract surgery can lead to an increased risk of retinal problems such as retinal detachment , therefore the risk/benefit ratio must be carefully evaluated and possibly correct predisposing factors before surgery. Risk of infection after surgery In those who take anticoagulant drugs or suffer from severe arterial hypertension, there may be risks of bleeding associated with cataract surgery, for this reason those who are being treated with anticoagulant or antihypertensive drugs must ensure that the underlying pathologies are well controlled before undergoing to the intervention. Finally, particular care must be taken by those who suffer from Glaucoma and undergo cataract surgery because the surgery or subsequent therapy could lead to changes in eye pressure. Those who suffer from Glaucoma must undergo careful monitoring of eye pressure in the vicinity of the operation and never spontaneously suspend Glaucoma therapy after Cataract surgery. In the testimonials section of this site you will find the stories of patients operated with the most advanced. We think the experience of those who have already undergone this treatment journey at our center is the best way to respond to the emotions, fears and curiosity of those who have to begin an innovative treatment experience.

Cataract and Myopia surgery

Cataracts and Myopia are frequently associated. Worsening myopia in old age may be a sign of cataract progression. High myopia often accompanies an early-onset cataract. Cataract surgery allows you to correct myopia, however in high myopes it must be performed with some precautions. Those with high myopia already have a higher than normal risk of having retinal complications such as myopic maculopathy or retinal detachment. These risks of complications are increased by cataract surgery , therefore surgery in these subjects should only be taken into consideration in cases of moderate or advanced cataracts. To minimize these risks , careful evaluation of the retina before and after surgery at close intervals is required . The choice of the optimal intraocular lens in high myopes may present some additional difficulties, therefore in-depth examinations and an experienced surgeon are necessary. The risk of intraoperative complications is generally higher in high myopes, especially in cases of concomitant use of antiplatelet or anticoagulant therapy . They are in fact exposed to a higher risk of choroidal hemorrhage during surgery. A rare but very serious complication. However, the correction of high myopia with cataract surgery allows a notable improvement in vision, generally proportional to the amount of myopia that is corrected.

Cataract and Maculopathy surgery

Maculopathy often affects older people and is therefore frequently associated with cataracts . Maculopathy causes a reduction in central vision making it difficult to drive, read and recognize faces. 4231_LEHP_iolAMD_2415 In the presence of cataracts and maculopathy it is advisable to first treat the maculopathy and then the cataract because the damage produced by the maculopathy is not reversible while that produced by the cataract is. The sight that is lost due to maculopathy is difficult to regain. The sight that is lost due to cataracts is regained after surgery. Today there are intraocular lenses dedicated to those suffering from maculopathy and cataracts. They also allow you to improve your vision significantly by enlarging the image and moving it to the healthy part of the retina. In Maculopathy, in fact, the central part of the retina called the macula is diseased but the surrounding part of the retina is healthy. By moving the image onto the healthy retina with these intraocular lenses, vision improves. We have introduced important innovations in this regard in Italy with the EyeMax intraocular lens since 2015. This lens can be implanted in the eye at the time of cataract surgery or subsequently, allowing a notable improvement in vision in selected cases. For further information, here are some scientific literature articles on the subject

Depending on the severity of the disease, the patient may also start driving again after this operation. This operation to treat maculopathy and cataract together is comparable to a normal cataract operation. It lasts about 10 minutes and is performed with topical anesthesia using only eye drops as an anesthetic. You can learn more with the testimonies of patients operated on at our Clinic.

Cataract and Glaucoma surgery

Cataracts and glaucoma can coexist, in fact it often happens that eye drops used to treat glaucoma can accelerate the formation of cataracts. Some types of cataracts can cause the onset of glaucoma, a disease characterized by an increase in eye pressure.

  1. Cataract with Pseudoexfoliation of the Capsule (also called PEX) causes Glaucoma over time. The cataract exfoliates, that is, it gradually loses pieces of the outermost layer. This exfoliation of the cataract obstructs a filter inside the eye (the trabecular meshwork), causing an increase in eye pressure typical of glaucoma. In these cases it is advisable to do cataract surgery at an early stage to avoid the risk of developing serious glaucoma.
  2. Hypermature cataract in hyperopic subjects. The eyes of those suffering from hyperopia are smaller than normal and a very mature cataract can cause narrow-angle glaucoma in these cases. The mature cataract produces an obstacle to the escape of the liquid present inside the eye, contributing to raising the pressure in the eye. Removing the cataract and replacing it with an artificial lens creates more space inside the eye . This allows for better intraocular fluid dynamics followed by an improvement in eye pressure.

Cataracts and Glaucoma can be treated together with cataract surgery combined with glaucoma surgery. The glaucoma procedure most frequently associated with cataract surgery today is the i-stent inject procedure. This operation performed in Milan for the first time in our clinic in June 2019 often allows you to get rid of the need to instill eye drops for glaucoma. Istent Inject is an intervention for those suffering from initial or moderate glaucoma and is not suitable for those suffering from advanced glaucoma. In any case , cataract surgery in glaucoma sufferers often improves eye pressure. Added to this is that after cataract surgery a laser treatment for Glaucoma called SLT or selective laser trabeculoplasty can be done more easily . This laser treatment widens the mesh of the trabecular meshwork and allows the liquid inside the eye to escape more easily. After cataract removal, the trabecular meshwork is more easily visible and treatable. In cases of advanced glaucoma, cataract surgery can be combined with a filtering operation to lower eye pressure called Trabeculectomy or with the implantation of a draining valve (Ahmed, Baerveldt) .