Cataract Surgery - What to Expect (post 2 of 3) - Day of Surgery

Continuing my series of posts covering what to expect around the time of cataract surgery: today I will describe what I tell my patients to expect the day of surgery. Remember, this is what I tell my patients to expect - other surgeons will differ in what they tell their patients to expect depending on technique and preferences.

Day of Surgery:

1) When you arrive at the surgery center there will be some minimal additional paperwork to fill out.

2) You will change out of your clothing into a hospital gown (note: some surgery centers do not require this).

3) A mark will be made on your forehead indicating which eye is to have cataract surgery. This may be done in the "pre-op" area or in the operating room depending on which surgery center is used.

4) During the time you are in the surgery center you may be asked multiple times “what eye are you having surgery on?” This is not because the staff don’t know but because they check and double check that we are operating on the correct eye. This is for your protection.

5) Multiple drops will be placed in your eye multiple times. Although the drops you use at home must be spaced at least five minutes apart, the drops in the hospital will be given to you one right after the other. This is OK.

6) It may take 45 minutes to two hours for your eye to dilate enough to safely perform surgery. The doctor will check your pupil once you are in the operating room. Do not worry about the dilation - if needed there are techniques your doctor can use during surgery to sufficiently dilate your pupil.

7) An IV will be placed in your arm either in the pre-operative holding area or in the operating room. Once in the operating room the anesthesiologist will give you something through the IV to relax you. One of the effects of this medication is short-term amnesia. So, if you are having your second eye done, don’t be surprised if you don’t remember all of these things being done when you had your first cataract surgery. This is a very common feeling.

8 ) A blood pressure cuff will be placed on your other arm. This is necessary for monitoring this critical vital sign. Periodically this will inflate and give you a sense of pressure. Just relax and the pressure will go away.

9) Some doctors (myself included) feel that music works both to relax you and assist with the rhythm of surgery. If you have a particular type of music you would like to be played during the surgery, let your surgeon know. Note: not all surgeons accept requests, but I do (my iPod has over 9,000 songs so I can honor almost any request except country music - closest I have on my iPod is Johnny Cash, but I'll even listen to country music if you bring the CD).

10) During the actual surgery you will hear buzzing and bells. There may be a sense of pressure in the eye and you may feel fluid running down the side of your face. This is all normal.

11) You should not feel pain during the surgery (but you will feel pressure and sometimes a sense of "tugging"). If you do feel pain or discomfort, let your surgeon know and he will give you additional anesthetic.

12) You will be in the operating room for about 45 minutes to an hour. About half of this time is spent preparing for the actual surgery.

13) After surgery a shield will be placed over your surgery eye. you will then be transferred to a recovery area for and hour or so while the nurses check your vitals and confirm that you have recovered from the anesthetic.

14) The entire process from the time you arrive to the time you leave the hospital can take from three to five hours.

Afternoon and Evening of surgery:

You may have the sense that there is something in your eye like a grain of sand. This is normal and will be relieved by using the drops that you have been instructed to use. If needed, you may take Tylenol for relief. You should not have significant pain. If you do, call your surgeon's office as soon as possible.

Note: find out who will be taking call for your surgeon. Will it be the surgeon or another ophthalmologist or optometrist? Will you be able to get through 24 hours a day, seven days a week? Or, will you be forced to go to the emergency room after hours if there is a problem? Practices vary, but I take my own call except for every third weekend when my partner, Dr. Richard Kratz, takes call for me. Even then, he can get in touch with me as I carry my cell phone everywhere I go (I will even give my personal cell phone number to my patients who have had cataract surgery - though the fastest way to get in touch with me is actually through my answering service which picks up the phone whenever my office is closed - no answering machine or voicemail here).

Next post: what to expect after surgery...

© 2009 David Richardson, MD

Cataract Surgery - What to Expect (post 1 of 3) - Before Surgery

Over the course of this blog I will try to address all of the common questions I get asked by my patients. Many of these questions have to do with expectations. The next few posts will be about the mundane activities that surround cataract surgery: the stuff you can do, the stuff you should do, and the stuff you should not do.

Note: these posts will reflect my personal preferences. Other surgeons will have their own set of expectations. Each surgeon creates a set of guidelines based on his or her experience, training, techniques, and understanding of the literature. Additionally, I will modify these guidelines based on the needs or health of an individual patient.

So, assuming you have already chosen a surgeon and he or she has confirmed that you have a cataract and you would benefit from cataract surgery, what can you expect Prior to Cataract Surgery?

If you are a contact lens wearer you will need to stop wearing the lens in the eye that will have surgery for at least three weeks prior to surgery. You may need to return to the office multiple times to have your corneal curvature measured prior to surgery.

You will need to coordinate pre-operative medical clearance from your internist or family physician. This may include blood testing, an EKG, and a physical exam. This should be done at least two weeks (but not more than a month) prior to surgery.

You will need to come into the office for additional testing of the eye and to complete the necessary paperwork prior to surgery. Please make sure to bring your consent and filled out questionnaire with you. Expect to be in our office for two to three hours.

Expect a call from us about two to three days prior to surgery to let you know what time you need to arrive at the surgery center.

You will be using drops in the eye that will be operated on beginning three or four days prior to surgery. These drops function to protect the eye from infection and inflammation. We may have samples of some of the drops, but you will have to go to the pharmacy to pick up the others.

You can eat the night before surgery. After midnight, however, you should not eat or drink anything.

Next post: What to Expect the Day of Surgery

© 2009 David Richardson, MD

Why Cataract Surgery Might Not Be a "Piece of Cake" with Diabetes

While it is true that for most people cataract surgery is a "piece of cake," for surgery to go well it helps to have an otherwise healthy eye. If someone has any eye disease in addition to the cataract this will increase the risk that the final vision will be limited after surgery.

Unfortunately, the general experience of most people who have had cataract surgery does not apply when there is a history of diabetic retinopathy. People with otherwise healthy eyes might note that their vision was better before they even left the operating room. However, most of these people do not have diabetic retinopathy (for more on diabetic retinopathy visit my practice website and search for "diabetic retinopathy" - a list of articles and educational animations will be visible).

A history of diabetic retinopathy increases the risk of surgery. Eyes with a history of retinopathy are at higher risk of macular edema (swelling of the retina), and infection. Treating these conditions can be challenging.

Additionally, decreased night vision is often a result of the laser treatment for proliferative retinopathy (that's still better than the alternative of no treatment - loss of central and overall vision). Cataract surgery may help by allowing more light into the eye, but it will not completely improve it - there will still be some permanent limitation of night vision.

The most important thing someone with Diabetes can do to limit these additional risks of cataract surgery is to maintain good control of the blood sugar.

© 2009 David Richardson, MD

So then, How is Cataract Surgery done? (post 9 of 9)

All right. Here we are. The final installment. All that's left now is to 'close' and double-check:

The incisions were then hydrated...

One method of closing the incision is to hydrate' it. Essentially, a sterile salt solution is injected into the cornea. This results in a local swelling around the incision forcing the incision closed. Often this acts as a substitute for suturing the incision. The problem is that we really don't know how long this swelling lasts. Will it keep the incision closed long enough to protect the eye from infection? For this reason I will often add a suture (see last post).

...and the anterior chamber was formed to physiologic pressure (confirmed by intraoperative tonometry) at which pressure the incisions were checked and felt to be watertight and of good integrity.

Basically, sterile saline is injected into the eye through the paracentesis (small 1mm incision) to bring the pressure in the eye back up to a 'normal' pressure. The incisions are then checked for leaks.

The lid speculum and drapes were then removed followed by placement of Vigamox drops in the fornices on the left.

Remember the bent-paperclip-like device used to keep the eye open? We don't need that anymore as the surgery is over. As a final step to protect from infection a drop of antibiotic is placed on the surface of the eye. Some surgeons inject an antibiotic into the eye at the end of surgery. To date there is no agreement in the US as to which provides more protection. There is a recently published European study that supports using an injection. However, the antibiotic used in the European study is not readily available for intraocular use in the USA. Therefore, most North American surgeons feel the risks of using a 'compounded' antibiotic (made by hand) out weights the potential protection it might provide. As mentioned in my last post, I have not had an episode of acute endophthalmitis in over 2,000 cases of cataract surgery using topical, not intraocular antibiotics. As this rate is similar to that experienced with the European method there does not seem to be a convincing reason to change. Again, using the wisdom of my father, 'If it's not broke, don't fix it.'

A shield was then placed over the left eye which the patient was instructed to keep on the eye except during placement of Nevanac, Vigamox, Omnipred 1% drops which she is to use including the day of surgery.

With topical anesthetic there is no need to patch the eye. A shield with little holes in it is sufficient to protect the eye from rubbing when the patient is sleeping. Additionally a shield is easier to take on and off than a patch. This is important in order to get the antibiotic and anti-inflammatory protection of the prescription drops.

She was instructed to avoid any heavy exertion...

Basically, I tell my patients not to pick up anything over 20 pounds, avoid swimming, gardening, high-impact aerobic activities, and "jerking" activities such as roller coaster riding, bungee jumping, skydiving, and the like. Most standard daily activities are just fine.

...and is to follow up in my office the day after surgery.

It is also acceptable to follow-up the day of surgery.

She tolerated the procedure well.

This is an understatement. Most people find cataract surgery to be a painless procedure and look forward to having surgery on their second eye shortly after their first eye has healed from surgery.

© 2009 David Richardson, MD

So then, How is Cataract Surgery done? (post 8 of 9)

We're almost done. Believe it or not, however, these last steps can take up almost a third of the total time of surgery:

A single 10-0 Vicryl suture was then placed in the temporal corneal incision and the knot was buried in the corneal stroma.

These sutures are incredibly thin (about as thick as a strand of blond baby hair), difficult to work with (ever tried tying a knot of thin hair?), and expensive (about $15 per suture). Thus, suturing the incision is skipped by many surgeons.

No doubt you've seen advertisements for 'no-stitch' cataract surgery. It's sexy not to place a suture. And, it probably isn't necessary every time. If I am convinced beyond a doubt that the incision is watertight without the need for a suture then I won't place one either.

There are many reasons given for not placing a suture as it (1) may result in irritation; (2) can result in surface bleeding aka a 'sub-conjunctival hemorrhage;' (3) might have to be removed in the office. Certainly no surgeon wants his or her patients to have a beet-red eye after surgery because a suture was placed. And, a sub-conjunctival hemorrhage can look awful: 'what happened to your eye!' is another phrase surgeons don't want their patients to hear (it makes for bad advertising).

Additionally, as mentioned above, suturing is time consuming and expensive. Placing a suture can add five minutes to the time of surgery. This may not sound like much, but consider this: my average cataract surgery without placing a suture lasts 12-14 minutes. By placing a suture I have just increased my surgery time by almost 40%. Believe it or not, with the downward pressure on cataract surgery reimbursement (it is now about 1/10th of what it was in the 1970s) the only way for a surgeon and surgery center to make ends meet is to be efficient.

I like performing surgery and insurance companies know that most cataract surgeons would do this as a hobby. Thus, as long as I am not losing money on my surgery I'll keep doing it. And, as long as my surgery center allows, I'll keep placing a suture when I think it is needed. Why? Because placing a suture may decrease the risk of infection. I mentioned earlier that infection is one of the few things that can result in a loss of vision (or even blindness). If I can reduce the risk of infection from 1 in 500 to 1 in 1,000 or 2,000 then I will.

To date I have performed over 2,000 cataract surgeries without a single case of acute endophthalmitis (early infection of the eye). Most published studies on endophthalmitis report rates of 1 in 500 to 1 in 1,000. I believe part of the reason my patients have avoided this complication is my meticulous attention to incision closure and use of a suture when I feel it would benefit the integrity of the incision.

One more post to go...

© 2009 David Richardson, MD

So then, How is Cataract Surgery done? (post 7 of 9)

Continuing my series on what happens during cataract surgery, we have so far removed the cataract, but still have to place the new lens in the eye.

Provisc was then injected into the anterior chamber and capsular bag...

After phacoemulsification of the cataract and aspiration of the cortex, there is little remaining viscoelastic. In order to safely place the new intraocular lens (IOL) in the eye this gel must be replaced. This step also functions to open up the capsular bag and make it easier to position the IOL inside the bag. As much as possible we try to leave things as they were. What better place for the new lens than where the old lens (cataract) was: in the bag?

...following which the lens was inspected for proper power and good integrity.

I personally check the model and strength of the IOL before surgery and just before implantation in the eye. Although not all surgeons personally do this, I feel that this is something I should not delegate to someone else. Which IOL is placed in the eye determines the final vision after surgery. Pretty important step, wouldn't you agree?

The lens was placed in the insertion device which was used to insert the lens through the temporal incision,...

Not all lenses have to be placed in the eye using an inserter. Most lenses can also be folded. However, something must be done to the IOL in order to get it through the incision. Remember that the incision is only 2.2-3.6mm wide. Most IOLs have optics (round lenses) that are 5.5-6.0mm in diameter. Thus, they must be rolled, folded, or otherwise deformed in order to fit them through the corneal incision. Because they must be flexible, most modern IOLs are made of malleable materials such as silicon or acrylic.

...guiding the leading haptic into the capsular bag. The trailing haptic was positioned in the capsular bag using a lens manipulator.

The 'haptics' are flexible loops that stick out from the optic. These act to hold the lens in place and center it in the bag.

The remaining viscoelastic was then removed using automated irrigation and aspiration, taking care that no residual viscoelastic was trapped behind the optic.

Now that the cataract has been removed and the new lens is in the eye it is time to remove the protective gel. If it is left in the eye it will clog up the drainage system resulting in a high intraocular pressure after surgery. Many times, even with diligent removal of the viscoelastic material the pressure will still 'spike' up in the first 24 hours after surgery. However, this is often easily controlled with drops or by letting some of the fluid out of the eye through the paracentesis created at the beginning of the surgery.

Because the more advanced viscoelastics (which are thought to be more corneal protective) are more likely to remain in the eye after surgery I will go 'behind the lens' in order to remove as much as I can. Many surgeons choose not to take this extra step because it is risky without proper technique and difficult to do without a bi-manual irrigation and aspiration setup.

We are almost done. Next post: placing the suture.

© 2009 David Richardson, MD

So then, How is Cataract Surgery done? (post 6 of 9)

Finally, it is time to remove the cataract:

Hydrodissection and hydrodelineation were then completed with a visible fluid wave and good nuclear mobility noted.

'Hydrodissection' is a technique used to free the cataract from its attachments to the capsular bag. Without freeing the lens, all surgical forces that act on the lens would be translated through the capsule to the zonules (the delicate cables that hold the lens in place). If these zonules are damaged during surgery then there will not be sufficient support to place a clear new lens in the eye.

During hydrodissection fluid is injected between the capsule and lens. This fluid travels around the lens creating a space between it and the capsule. If this step is not completed the remaining steps of catarct removal are more difficult and dangerous to perform.

Hydrodelineation is very similar to hydrodissetion except the layers separated are those of the lens nucleus (hard, central part of the cataract) and epi-nucleus (softer outer part of the cataract). This step does not have to be performed unless the surgeon uses an advanced technique call 'phaco-chop' (more on that next).

Phacoemulsification of the nucleus was then completed using a horizontal chop phacoemulsification technique requiring 0.6 minutes of phacoemulsification at 24% power.

Phacoemulsification is the ultrasound technology currently used by the majority of US surgeons. Essentially, a hollow tip vibrates at an extremely high frequency (faster than the speed of sound) breaking up the cataract into small pieces. These fragments are then vacuumed through the central opening of the tip and out of the eye. Other methods of breaking up the cataract do exist including laser and pulses of water. However, neither of these has really caught on in the US as the ultrasound works so well for most types of cataracts.

There is, however, a downside to ultrasound. If the tip of the ultrasound handpiece touches the capsule, the bag will tear allowing vitreous (the gel behind the capsular bag) to come forward. This is the main thing all cataract surgeons try to avoid as it often significantly complicates the surgery. Additionally, as discussed earlier, the ultrasound energy is not only absorbed by the cataract, but also by the cornea resulting in swelling. An advanced technique such as phaco-chop can reduce the total amount of ultrasound time used (compared to older and more basic techniques such as 'divide and conquer') and thus limit the amount of corneal edema.

The remaining cortex was then removed using bimanual automated irrigation and aspiration.

The cortex is that part of the catarct still adherent to the capsular bag. It has a stringy, tenacious character to it and is usually still present even with hydrodissection. It must be removed or the bag will not be optically clear resulting in blurred vision and inflammation. However, the capsule is very delicate an tears with any significant traction on it. To get an idea of what this is like lay out some cheap plastic wrap (the stuff you use to cover leftovers before you put them in the refrigerator) and stick some painter's tape on it. Now try to remove the tape without stretching or tearing the plastic wrap.

As you can imagine, this is another step in cataract surgery which has a high risk of 'capsular rupture,' resulting in 'vitreous loss,' or tearing of the capsule allowing the vitreous gel to come forward.

In order to decrease this risk I use a technique called 'bi-manual' irrigation and aspiration. This requires the simultaneous use of two instruments (rather than one) allowing me to obtain better control in the eye. Not every surgeon, however, uses the bi-manual technique as it requires (1) expensive handpieces that many surgery centers will not pay for (I own my bi-manual handpieces); (2) phacoemulsification equipment with excellent fluidics (a topic that would require its own post); (3) is technically more challenging to perform; (4) takes longer to complete than with 'co-axial' or one-handed irrigation and aspiration.

Next post: placing the new lens into the eye

© 2009 David Richardson, MD