Cataracts and Cataract Surgery

Cataracts are now removed by a revolutionary surgical technology called phacoemulsification. A small hole is cut into the eye, and another into the capsule that surrounds the cataract. The cataract is then cut up and vacuumed out of the eye in tiny pieces using phacoemulsification technology. The artificial lens that must replace the cataract (in order to restore vision after surgery) is then placed inside the capsule. All of this is done as day surgery at the hospital.

Cataract surgery is performed safely and expertly by the experienced hands of your eye surgeon. Although there are certain lasers which can be used to do parts of the surgery, this a very expensive technology that is not currently available at Misericordia Health Centre or deemed necessary.

Cataract surgery is done through a very small incision (hole) in the eye. Most of the time, this incision is self-sealing and does not require any stitches. However, if it is leaky, it will be sealed closed with either a dissolvable or a semi-permanent stitch that may or may not need to be removed after surgery. Occasionally, people feel a bit of foreign body sensation or eye irritation when this stitch becomes loose several weeks later, in the case of a dissolvable stitch, or months or even years later, in the case of a semi-permanent stitch. If this happens, contact your surgeon to check your eye and pull out the stitch. This is a simple, painless office procedure that can be done when you visit your surgeon.

The intraocular lens (covered by Manitoba Health) will correct your vision for one distance only. Therefore, most people who get these lenses can see well in the far distance, but will still need glasses to read after surgery (usually over the counter glasses are good enough unless you have significant astigmatism).

If you are a candidate and opt for a premium intraocular lens (explained below), you will be less dependant on glasses for most activities.

Cataract surgery is done under topical anaesthetic (anaesthetic gel and drops) with intravenous (IV) sedation. This means that you are awake during surgery, but will not feel anything during the surgery. At the beginning of the surgery, you will feel your surgeon preparing the area by putting a drape over your face and placing a clip under your lids to hold your eye open. You will be able to see light and colours during the surgery. Cataract surgery will take about 15 to 30 minutes (depending on the maturity of the cataract and/or other challenging factors).

(If you are having cataract surgery as well as glaucoma surgery, the combined procedure usually takes about 1 hour or so and extra freezing will be used around the eye for the glaucoma surgery. The experience will be similar except a bit longer.)

If you are having cataract surgery alone, there is no need to stop your blood thinners.

If you are having cataract surgery combined with a glaucoma surgery, you WILL need to stop your blood thinners before surgery in consultation with your family doctor or specialist (1 week for aspirin or Plavix® (clopidogrel); 3 days for Coumadin® (warfarin) or Xarelto® (rivaroxaban). You will be able to restart them about 3 days after surgery, unless otherwise stated.

Routinely, non-preserved lidocaine anaesthetic is injected into the eye to ensure that the surgery is comfortable.

Flomax (tamsulosin), used for benign prostate hypertrophy, can cause IFIS or "intraoperative floppy iris syndrome". This causes some difficulty in removing the cataract and dilating the pupil. Usually, non-preserved 2.5% phenylephrine (an adrenaline-like drug) is used to help dilate the pupil and keep the iris from billowing into the instruments that are used to take out the cataract. Sometimes, tiny hooks or devices are used to stretch the pupil to make sure the iris is kept out of the way. Overall, problems with Flomax are easily overcome with these maneuvres. Stopping Flomax before surgery will not prevent this problem from occurring, therefore there is no need to stop Flomax. Similar drugs that can also cause IFIS are alfuzosin (Uroxatral) and finasteride (Proscar).

Non-preserved phenylephrine 2.5% may also be used to dilate the pupil more fully by injecting it directly into the eye.

Diluted Moxifloxacin drops (Vigamox®) are injected into the eye at the end of all eye surgeries (except if there is an allergy to this drug). This has been shown to be a safe and effective way to prevent infection.

If you have had a previous surgery for glaucoma called trabeculectomy, or a XEN® or PreserFlo™ implant, you will likely have a superficial or "subconjunctival" injection of Avastin® (bevacizumab 2.5mg) at the end of the surgery. This will sting a bit. This prevents closure of the filtration site, which helps drain fluid out of the eye to lower eye pressure in glaucoma patients. Often, after cataract surgery, particles get flushed through this site and promote scarring and eventual failure of the filter. Avastin® helps prevent this by inhibiting growth of new blood vessels that support newly growing tissue, like scar tissue. This medication is used for chemotherapy in colorectal cancer and also in other eye conditions like proliferative diabetic retinopathy and wet macular degeneration. It rarely can cause closure of blood vessels and compromise oxygen flow causing tiny "strokes" to the area it is used. This is a very rare, potential complication. If this happened, your vision would be much blurrier than expected after cataract surgery. You should call your surgeon's office for a follow-up check as soon as possible or visit Misericordia Health Centre or an emergency department after office hours.

Complications are rare during and after cataract surgery, but can occur. The most common complication during surgery is rupture of the capsule that holds the cataract, possibly causing spillage of cataract material to the back of the eye. If this happens, your surgery may be prolonged, or you may require another surgery afterwards. Also, you may need an anteriorly placed lens, which will require a larger incision, which must be stitched up. If promptly and effectively managed, you should still have a good visual outcome with this complication, although it will take longer to recover.

Capsule rupture can happen more commonly with an eye condition called "pseudoexfoliation" . In this condition, which is often associated with glaucoma, small particles can collect on the fibres (called "zonules"), which hold the capsule in place. This can cause the capsule and cataract to be wobbly and break easily during surgery. You will be advised if you have this condition. Surgery can still be done in this case, but it often takes longer due to special precautions that need to be taken to prevent problems. Sometimes, if the capsule is too floppy and loose, a capsular tension ring is inserted into the capsular bag as well. This helps stent the capsule and provides more support for the capsule and lens. The capsular tension ring and artificial lens are permanently implanted. You will receive a card with information on these implants at the end of the surgery.

Pseudoexfoliation can also prevent proper dilation of the pupil for cataract surgery. If the pupil is not dilated widely enough for various reasons, it may become necessary to use "iris hooks" or a similar iris- stretching device during surgery. After cataract surgery, the pupil may still look slightly stretched and irregular for some time, however this will not affect the vision.

Sometimes after cataract surgery, especially if a patient has glaucoma of any type, the eye pressures can become very high and may require extra medication by mouth or by intravenous to control. Occasionally, a second surgery is required to control the eye pressure.

Other possible complications which could cause problems with your vision or even loss of vision include chronic swelling of the cornea, prolonged inflammation, elevated eye pressure, infection, retinal detachment and hemorrhage (bleeding). These could occur during or days, weeks, months or years after the surgery. Thankfully, these complications are rare. We try our best to identify these problems and treat them as quickly as possible. It is important for anyone who has cataract surgery to get checked promptly (same day) if he/she is experiencing severe pain or headache, worsening redness, decreasing vision, sudden onset of flashing lights (lasting seconds) or new onset floaters. If the problem occurs on an evening or weekend, your surgeon may not be available. For post-surgical emergencies after- hours, call the Misericordia Hospital switchboard at 204-774-6581 and ask for the on call Ophthalmologist or visit Misericordia Health Centre or your nearest emergency room.

Anaesthetic complications are extremely rare but can happen even with the small amount of intravenous medications and local anaesthetics that are used. Most of the time, if a patient is comfortable, no drugs are used. However, if a patient is nervous and needs something to stay relaxed, a small amount of sedatives and painkillers are used in the intravenous. In some patients, use of local anaesthetics in and around the eye can cause decreased vision, bleeding and nerve changes. These effects are usually temporary and resolve with time. Rarely, there can be permanent damage. In rare patients with multiple medical problems, these drugs can potentially cause cardiac or neurological problems, resulting in serious illness or even death. We are certainly vigilant of any concerns with the use of medications in our patients and are prepared to deal with these kinds of emergencies. However, we cannot always predict when a serious drug reaction will occur. Fortunately, these complications are extremely rare with local procedures.

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After the surgery, you will be seen in the office (or Misericordia Health Centre on weekends) later that day or the next day, and sometimes 1 week later. You should see your Optometrist 4 to 6 weeks after (the second eye) surgery to update your glasses. You will need to use 3 different types of eye drops for 4 weeks.

If you are taking eye drops for glaucoma, you will need to continue these in addition to the extra post-operative drops, unless otherwise instructed. If you are having glaucoma surgery combined with your cataract surgery, the glaucoma eye drops will be stopped after the surgery in your operated eye only. Full instructions will be given at the time of surgery. You will also receive a card with information about the implanted lens to keep for your records. Your eye will be covered with a shield when you leave the hospital. You can take the shield off when you get home, and then tape it over your eye at night for 1 week to protect your eye while sleeping. We recommend 3M Transpore® tape available at any drugstore to tape on the shield (hypoallergenic and latex free).

Since we do not use a freezing needle injection around your eye, you will be able to see right after surgery. However, because your eye has been exposed to the bright shining microscope light, phacoemulsification energy and lots of fluid for the duration of the surgery, there will likely be some temporary swelling and inflammation. Expect your immediate post-operative vision to be blurry. Over the course of the next few days, your vision will improve as the swelling and inflammation clears up. It is not usual for your vision to get worse. If you have worsening vision or pain, call your surgeon's office or the Misericordia Health Centre at 204-774-6581.