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Phacoemulsification Surgery

Phacoemulsification has gained in popularity in recent years, and is now the preferred form of cataract removal. Although this procedure has been available to us for a long time, recent advances and refinements in machine and microsurgical instruments have made it safer and more effective than previously.

What is Phacoemulsification?

The technique of phacoemulsification utilizes a small incision. The tip of the instrument is introduced into the eye through this small incision. Localized high frequency waves are generated through this tip to break the cataract into very minute fragments and pieces, which are then sucked out through the same tip in a controlled manner. A thin 'capsule' or shell is left behind after cleaning up of the entire opaque cataract.

The incision size for phacoemulsification is approximately 3.0 millimeters in width. If a lens implant that can be folded is used following removal of the cataract, this incision may not have to be enlarged. If a lens is used which cannot be folded, the incision must be enlarged to 5.0 or 5.5 mm.

Are the stitches required after Phacoemulsification?

The incision (wound) required for phacoemulsification is small (3 mm) and the wound construction is such that it is self-sealing. Therefore a surgery in which a foldable lens has been implanted through the small 3 mm wound, generally does not require any stitch, as it is watertight. The surgeries in which the wound has been enlarged (5 or 5.5 mm) to put a lens that can not be folded, is likely to require one stitch, because the wound is larger.

In addition, some surgeons simply prefer the safety of having the incision sutured, even if the incision is already watertight. The best procedure for a patient is usually the one with which his or her ophthalmologist feels the most comfortable, since these variations of cataract surgery are all quite effective.

What are the advantages of Phacoemulsification over routine extracapsular surgery?

In a conventional surgery the incision required is larger (10-12 mm) and requires stitches for closing. This larger incision takes 6-8 weeks to heal. Moreover, the stitches can cause distortion of the normal curvature of the cornea (the clear part of eye) and thus lead to astigmatism and blurred vision because of this.

Essentially all the advantages of phacoemulsification are because of small incision, which is self-sealing. The wound is more stable and the chances of wound complications are minimized. The patients can resume their normal activity faster as compared to conventional extracapsular surgery. The wound healing is faster and more predictable, and therefore glasses can be prescribed much earlier as compared to the conventional surgery. The patient requires less follow up visits for checkups. As the incision is small and in many cases stitches are not required, the cornea does not get distorted and therefore the chances of significant astigmatism is minimized. At Visitech, the surgeons routinely perform Phacoemulsification with foldable intra ocular lens implantation.


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Surgeries For Cataract

When should I have the surgery?

Usually, you can decide if, and at what stage to have the operation. The cataract may need no treatment at all if the vision is only a little blurry. A change in your eyeglass prescription may improve vision for a while. If visual impairment interferes with your ability to read, to work, or to do the things you enjoy then you will probably want to consider surgery.

In the past, eye specialists often waited until the cataract became 'ripe' before suggesting you had it removed. Nowadays, with modern surgery the operation can be carried out at any stage of the cataract's development, and in fact, is a little safer to do before the cataract becomes 'ripe'.

What are the surgical options?

Majority of cataracts today are removed by Extracapsular surgery, in which the posterior capsule of the natural lens is left in place to support the IOL, which is implanted at the time of surgery. There are two types of extracapsular surgery.

  • Conventional extracapsular surgery: The nucleus of the lens, which is too hard to simply remove by aspiration, is taken out in one piece, and the softer parts of the lens are then aspirated. The surgeon makes an incision (10-12 mm in size) where the cornea and sclera meet. Carefully entering the eye through the incision, the surgeon gently opens the front of the capsule and removes the hard center, or nucleus, of the lens. Using a microscopic instrument, the surgeon then suctions out the soft lens cortex, leaving the capsule in place.
  • Phacoemulsification: It is a form of extracapsular surgery. In phacoemulsification, the hard nucleus is broken up by ultrasonic fragmentation (using sound waves) within the eye, and can then be aspirated. This allows a smaller incision (3 mm in size) to be used.

The other way of removing cataract is Intracapsular surgery, in which the whole lens is removed in a single piece, without leaving the posterior capsule behind. The patients are rehabilitated with glasses or contact lenses. This form of surgery is being done in a few villages and camp surgeries in India.

What is lens implantation?

The function of the normal lens is to focus the image on the back of the eye (retina) so that it forms a sharp image. Once the opaque lens (cataract) is removed, an artificial plastic lens is implanted inside the eye for this function. This lens is known as Intra-Ocular Lens (IOL).

Lens implants have certain advantages. They usually eliminate or minimize the problems with image size, side vision and depth perception noted by people who wear thick eyeglasses after cataract surgery without IOL implantation. They are also more convenient than contact lenses because they remain in the eye and do not have to be removed, cleaned, and reinserted.

Occasionally the doctor will decide that someone's eye is not suitable for a lens implant. In these cases contact lenses or special glasses will be prescribed instead.


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FAQs Cataract

What can be done to prevent cataract?

It is not yet clear, why the eye's lens changes as we age and develops into a cataract. Research is on for the preventive measures. There is no drug or drops as yet that has been proven to be of value in preventing cataract. Recent studies show that exposure to UV rays (Ultra violet rays) may be a factor in development of cataract. It is now recommended to wear sunglasses and a wide brimmed hat to lessen the eyes' exposure to UV rays from the sun.

Other studies suggest people with diabetes are at risk for developing a cataract, as are users of steroids, diuretics, and major tranquilizers.

Can cataract occur at earlier age or in childhood also?

Yes. Sometimes the child may be born with cataract or may develop cataract in early childhood. The management of these cataracts is different from that in adult patients. Cataract may also occur at an earlier age because of trauma, inflammation of eye, use of medicines like steroids, general medical conditions like diabetes, radiation etc.

Can the cataract be treated by laser surgery?

Despite some public misconception, laser is not an option for removing cataracts at this time. Even the experimental devices are quite different from what one might imagine for use in a laser cataract surgery. In these devices a laser is used to break up the nucleus of the cataract into pieces small enough that they can be aspirated from the eye, in the same manner that sound waves are used in phacoemulsification. Thus, an incision still needs to be made, and the lens material removed from the eye. A very small incision will always be needed to physically remove the cataractous lens material.

The YAG laser may be used following cataract surgery. The posterior capsule of the lens, which supports the lens implant, sometimes turns cloudy (aftercataract) several months or years after the original cataract operation. If this blurs your vision, a clear opening can be made painlessly in the center of the membrane with a laser. This indeed is a procedure in which the patient sits in the chair and the laser, without making any incision quickly clears the vision.

Will I get good vision after surgery?

Your sight will usually improve within a few days, although complete healing may take 4-6 weeks. This is the time when a checkup for any possible change in glasses is advised.

Even if the surgery itself is successful, the eye may still not see as well as you would like. Other problems with the eye, such as macular degeneration (aging of the retina), glaucoma and diabetic damage may limit vision after surgery. Even with such problems, cataract surgery may still be worthwhile. If the eye is healthy, the chances are excellent that you will have good vision following removal of your cataract.

Will I need to use glasses after surgery?

Unfortunately yes, you would need glasses after cataract surgery. But the power of the glasses is not much if the lens has been implanted in your eye during the surgery. As we know, the eye needs to change its power in able to focus objects at different distances (compare from auto focus camera). The artificial lens that is put in the eye does not have capacity to change its power. Therefore it can work only for a fixed distance, and you will require a bifocal lens to be able to see at distance as well as near.

There is a range of bifocal and multifocal artificial lens implants are now available, but these are not yet very popular. Discuss with your ophthalmologist if you are a suitable candidate for it.


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Case Studies - Cataract

Case - 1

A 67 year-old lady presented with complaints of gradual decrease in vision in both the eyes since 2 years. She was unable to carry out her daily activities and could not recognize people at some distance till they came quite close. Watching television and reading were becoming increasingly difficult for her. On examination her vision in the right eye was 6/60, while left eye had 6/36. Anterior segment examination showed normal anterior chambers with normal pupils. Lens had cataract in both the eyes, right eye more than left eye. Fundus examination showed no abnormality and Intraocular Pressure was 14 and 16.

She was diagnosed to have Immature senile cataract both eyes. Since she was having problem in doing her daily work she was advised cataract surgery with Intraocular Lens Implantation. She underwent Phacoemulsification with foldable lens implantation in the right eye first and on the second day postoperatively her vision in the right eye was 6/9 without glasses. She had no significant postoperative pain and was comfortable from first postoperative day. The left eye was operated 3 months later for cataract with similar results. The lady was very happy as she could now read a lot and play cards, which she was missing earlier.


Case - 2

A 43 year – old gentleman came with problem of blurred vision in the left eye. He was a senior Executive in a software company and his work involved a lot of reading and computer work. He had been having this problem for the last 3- 4 months and it was becoming increasingly difficult for him to do his office work now. On examination he had a visual acuity of 6/6 in the right eye and 6/9 part in the left eye. Lens in the left eye showed a small central cataract while right eye was normal. Retinal examination was also normal in both the eyes.

Since the patient’s work involved a lot of fine work like reading and computer work, which was being hampered, he was advised to consider cataract surgery in the left eye. He underwent phacoemulsification in the left eye 4 days later. His post postoperative vision in this eye was 6/5 and he could satisfactorily carry out his extensive daily work.


Case - 3

A 72 year – old lady had diminished vision in the right eye for 4 years. On check up her vision in the right eye was counting fingers 3 meters while left eye was 6/18. Anterior segment examination showed some clouding of the lens in both the eyes. Intraocular pressures were normal. Fundus examination right eye showed a large whitish scar in the macula while left eye showed small pale yellowish dot like lesions in and around the macula. The patient was diagnosed to have Age related macular degeneration in the right eye and Drusen (age related changes) in the left eye with Immature senile cataract both eyes.

She was explained about the irreversible damage to the central part in the left eye and the poor visual prognosis even after cataract surgery. She was told that cataract surgery may help her peripheral vision a little but central vision is not likely to improve. She decided to go ahead with cataract surgery right eye. Post operatively she felt better as she could see the surrounding areas more clearly that helped her in walking and moving around.


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