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Cataract surgery – What happens before during and after surgery

This article explains what you need to know about the process of cataract surgery and how I will make it as convenient and stress-free for you as possible.

The pre-operative consultation

This takes place in the outpatients clinic where I will ask about your symptoms and examine your eyes to fully assess their health. Various measurements are made with several sophisticated devices. These enable me to select the lens implant that is correct for you. Read ‘Customised cataract surgery’ for more information. After the examination I will discuss the best treatment with you and there will be ample opportunity to ask any questions you wish. The examination may require the use of eyedrops that will blur your vision for a few hours, so please bring someone with you to drive you home.

Before and after cataract eye surgery
I will also discuss the anaesthetic with you- there are two types. If you have a general anaesthetic you will be asleep during the operation or alternatively you may prefer a local anaesthetic in which case you will be awake. There are two ways of giving the local anaesthetic. Usually powerful anaesthetic eyedrops are used. Alternatively a numbing injection may be given gently into the tissues around the eye, but not into the eye itself. This is similar to the injection given by a dentist before a filling. Either way there will be no pain during the operation and you will not ‘see the operation’, although there is slightly more ‘awareness’ if the anaesthetic eyedrops are used. The effectiveness of either type of local anaesthetic may be enhanced by intravenous sedation, given by an anaesthetist.

I invite patients to choose their anaesthetic but I sometimes suggest a particular method, for example a local anaesthetic may be preferable for patients with heart problems. I will also advise you which type of local anaesthetic will work best for you – the majority of operations are performed using drops alone as this is the most gentle method.

Making the arrangements

My secretary will call you after the consultation and schedule a convenient date for your operation. She will also make the necessary arrangements with your private health insurance if applicable.
Before the operation

If you are having either type of local anaesthetic you may eat and drink as normal and take all your normal medication at the usual time, including anticoagulants and medication for diabetes. If you are having a general anaesthetic you may eat and drink until SIX HOURS before admission, after which you must be ‘nil by mouth’. If you are on medication, take it no later than six hours before admission or wait until after the surgery. If you are diabetic please let my secretary know. She will pass the information to the anaesthetist who will advise whether any changes should be made on the day of the operation to your normal diabetes treatment.

Contact lenses may cause infection. The contact lens worn on the eye to be operated must be removed four days prior to surgery. You may continue to wear the other contact lens as usual, including during the operation.

You will need to arrive at the hospital about one hour before the operation. The exact time will be confirmed beforehand. Eyedrops will be applied by a nurse to prepare the eye for the operation by dilating the pupil. You may wear your normal glasses until this time. Ladies may wear eye make up as usual. I will see you before the operation and you will have an opportunity to ask any questions you wish. The anaesthetist will assess you and discuss the anaesthetic. You will be asked to sign a consent form.

During the operation

You will be taken to the anaesthetic room. If you have chosen it, a general anaesthetic will be administered and you will be asleep. Alternatively you may have a local anaesthetic and remain awake, in which case you will receive either anaesthetic eye drops (most patients) or an injection.

Next you will be taken into the operating theatre. The skin around your eye will be cleaned with an antiseptic and a sterile covering placed around your head. The other eye is covered so it cannot see the operation. I will then perform the phaco-emulsification cataract procedure which takes about 15-20 minutes.

From time to time during the operation I will reassure you that all is well. There will be a hissing noise from the phaco-emulsification machine and you will hear me giving instructions to the nurses. Patients who are having a local anaesthetic are sometimes concerned that they may accidentally do something untoward such as blink, cough or move suddenly. My advice is not to worry. The eyelids are kept open by a small clip, so you will not be able to blink. Very few patients actually make any movement and a cough should cause no difficulty although if you can it is best to warn me that you want to do it.

A cover will be placed on your eye to protect it at the end of the operation. If you had a general anaesthetic you will go to the recovery room to sleep it off before returning to your room. Alternatively if you had a local anaesthetic you will return directly to the ward after your blood pressure has been checked.

After the operation

Going home

I will see you before you go home. Someone must drive you or alternatively we will arrange a taxi. There is normally no need to remain overnight in hospital after your surgery but you may do so if you wish. It is best to book the room in advance – my secretary will make the necessary arrangements if you ask her to do so.

The eyeshield

The shield placed over your eye after the operation will be removed before you leave. Alternatively remove it yourself at home – this does not need to be done by a nurse as it is perfectly safe for you or a relative to do it. Discard the gauze which will be soiled but retain the plastic eyeshield. For one week after the operation the eyeshield should be taped over the eye whenever you sleep or nap. A roll of medical tape will be provided for this purpose. If you misplace the tape, purchase more from a chemist or use sellotape – this works just as well although it is not as gentle for your skin. The eyeshield stops you accidentally rubbing or pressing on your eye whilst you are asleep. Stop using the eyeshield after a week. You may wash it with soap or detergent if you wish. There is no need to wear the eyeshield during the day as the eye will come to no harm from wind, smokey environments, sunshine, cooking fumes etc. Similarly, sunglasses are not needed to protect the eye although you may of course wear them on a sunny day as you normally would.

The eyedrops

Begin using the post-operative eyedrops as soon as you remove the eyeshield – see ‘How to use your eyedrops’ below.

How your eye will look

If you had a local anaesthetic injection your eye will be closed and will feel numb for a few hours after the operation. You may also have some double vision – if this happens, replace the eyeshield until it passes. The eye surface may be bruised after the surgery. Do not be concerned. The bruising is on the surface of the eye, not inside it, and will do no harm. Expect it to disappear after one or two weeks. After a local anaesthetic injection there is occasionally also mild bruising of the eyelids which will disappear after the same time. Bruising is more common if you take aspirin or anticoagulants such as Warfarin.

Your vision will be quite blurred for about a day. Although recovery after cataract surgery is very quick, please allow a week or so for your sight to sharpen fully. Also remember that you may need glasses to enjoy the best possible sight. This is discussed in ‘Will you need glasses after cataract surgery?’.

How your eye will feel

Many patients notice a scratchy sensation from the operated eye. This is normal and usually disappears after a week or two, although it sometimes lasts longer. You will be given local anaesthetic eyedrops to use if necessary – read ‘How to use your eyedrops’ below.

How to use your eyedrops

You will be given eyedrops called MAXITROL. Please begin using them on the day of the surgery. Apply one drop to the operated eye as soon as you get home and last thing at night and once or twice in between depending on the time. Take a common sense approach and expect to apply the Maxitrol 2 – 4 times on the day of surgery. Subsequently put one drop on the operated eye FOUR TIMES A DAY FOR THE FIRST TWO WEEKS AND TWICE A DAY FOR THE SECOND TWO WEEKS unless I ask you to do otherwise. After four weeks you may stop using the Maxitrol. Space the drops at approximately equal intervals ie: breakfast, lunch, dinner and bedtime. They do not require refrigeration. Maxitrol is a combined antibiotic/steroid formulation intended to prevent infection and promote healing. It or similar agents are sometimes required for longer than four weeks.
Your eye may feel sore. You will be given a supply of local anaesthetic eyedrops – usually TETRACAINE, alternatively PROXYMETACAINE or BENOXINATE. You may use these as often as you wish, with two qualifications:

  • If overused they may slow healing, so use them only when necessary.
  • If you suffer severe pain, rather than a scratchy sensation, you may have an infection requiring prompt intervention. In this case PLEASE CONTACT ME IMMEDIATELY.

The local anaesthetic is dispensed in small resealable containers which may be used until empty, provided you replace the cap. Discard the container, once opened, after 24 hours. They do not need to be refrigerated before or after opening.

Applying the eyedrops (a nurse will show you how to do this before you go home)

  1. Before and after eye surgery - eye dropsLook in a mirror, if necessary a magnifying mirror such as a shaving or make-up mirror.
  2. Pull the lower eyelid down to form a pocket.
  3. Place one drop into the pocket formed. If you are not sure that the drop has gone in, instil another as it is important to be sure that you have had the medication and you will not come to any harm from an extra drop.
  4. You may find it helpful to rest your hand on your nose to steady it.
  5. Close the eye for about one minute to help absorption.

You may prefer to ask someone else to instil the eyedrops. It does not matter if you accidentally touch your eye with the tip of the bottle, but obviously you must take care not to poke the eye hard.

If you use eyedrops for other reasons eg: glaucoma, you must continue these as normal. Wait about 3 minutes between the different types of eyedrops. It does not matter in what order they are applied.

Do’s and don’ts after the operation

Modern phaco-emulsification cataract surgery enables you to return to a normal life almost as soon as you wish.

DON’TS: The golden rule is not to knock or rub the eye for a month until the operation has completely healed. However you will be reassured to know that only a hard knock etc, is likely to do any harm. Please do not go swimming for two weeks in case you get sea or pool water in your eyes. Strenuous activities such as jogging or aerobics should also be postponed for one week.

DO’S: Most normal activities are acceptable immediately after surgery and will not harm the eye, for example shopping, housework, gardening, going to the cinema, climbing the stairs, watching TV and reading. Bending over to pick something up is perfectly safe. Coughing, sneezing and blowing your nose are not harmful. Leisurely exercise such as walking is recommended straight away. You may shower, bath, wash your face and shampoo your hair as normal immediately after surgery. When drying off, try to pat around the eye. If you do get soap in your eye, do not rub it! Just keep it closed until the stinging stops. Ladies may wear make-up immediately after the surgery.

Driving is permissible as soon as your eyesight satisfies the legal requirements. There is no risk to the operated eye from driving so the safety of the eye is not a consideration. Generally patients may expect to resume driving the day after surgery but this does depend on your individual circumstances which I will discuss with you.
You may return to work as soon as you wish.

Follow-up

I check patients just after the operation and then once more about a month later. Extra follow-up visits are sometimes necessary.

Phaco-emulsification cataract surgery is usually done without stitches. However it is occasionally necessary to use one non-dissolving stitch. This is removed during a follow-up consultation. Removal takes only a few seconds and causes no discomfort.

What to do about your glasses immediately after surgery

Remember that you may need glasses to enjoy the best possible vision after surgery. Read the chapter on ‘Customised cataract surgery’ and the article below titled ‘Will you need glasses after cataract surgery?’ for more information. If this is your first cataract operation there may be an imbalance between the two eyes after the surgery that will disappear when the second eye is done.

You should wait about a month before obtaining glasses from your optician as it takes this long for the eye to fully heal and until then the prescription will not be accurate. The optician will prescribe a new lens for the operated eye and leave the other lens until it is appropriate to change it.

During the month before you obtain new glasses try the following options. None will cause any harm to your eyes.

  1. Not wearing distance glasses at all. For reading you may wish to buy inexpensive ‘ready-made’ reading glasses from a chemist or supermarket.
  2. Wearing your old distance and reading glasses. In this case you will be reliant on the unoperated eye since the old glasses will probably be the wrong strength for the recently operated eye.
  3. Have your optician remove the glasses lens in front of the operated eye, leaving the frame empty or replacing it with a blank lens. Leave the lens in front of the unoperated eye in place. This works best for patients with weak glasses prescriptions.
  4. If you normally wear contact lenses, continue with the lens on the unoperated eye (but remember to remove it four days before surgery on this eye as it is an infection risk). Do not wear the contact lens on your operated eye.

Will you need glasses after cataract surgery?

Cataract surgery and distance glasses

Modern cataract surgery minimises dependence on distance glasses after the operation for activities such as driving or watching television. In fact you may not need them at all even if you have worn distance glasses for many years. Long and short sight and astigmatism are correctable. Please understand however that it is not possible to guarantee freedom from distance glasses and that you may need to wear them after the operation even if they were not required before. If they are necessary, new distance glasses may be obtained from an optician one month after surgery.

Cataract surgery and reading glasses

You will need reading glasses after the operation even if you do not need distance glasses. This is true even if you have not worn reading glasses before. However there are three ways around this which work for some patients -

Multifocal lens implants

You may choose a type of lens implant called a ‘multifocal’. This focuses light from close as well as distant objects, reducing and often abolishing dependence on both reading and distance glasses. It also corrects astigmatism. By contrast the standard type of lens implant is called a ‘monofocal’ – this focuses light from either distant or close objects, but not both. Multifocals are an important technological advance, but have drawbacks. First, they do not guarantee freedom from reading glasses. Second, they sometimes cause haloes around car lights when driving at night, although this is not normally a severe problem and the haloes often disappear after a while. Third, the vision provided by multifocals may be slightly less sharp than by monofocal implants although the difference is usually too small to be noticeable. In summary, patients are usually delighted by the independence from glasses provided by multifocal lenses but they are not appropriate for everyone.

Monofocal lens implants

Monofocal lens implants may be intentionally focused for clear near vision, aiming for freedom from reading glasses. The drawback is that you will need distance glasses. This is the opposite of the usual way of using monofocal lens implants, when the eyes are focused for clear unaided distance vision but need reading glasses. I only recommend this method to those who prefer wearing distance rather reading glasses. These are usually short sighted patients who have never needed reading glasses but who are accustomed to distance glasses.

Monovision lens implants

In ‘monovision’ one eye is focused for distance and the other for near vision with monofocal lens implants – both distant and near objects are seen without glasses. However monovision is a compromise and works in only a minority of patients.

What are the risks of cataract surgery?

I believe this subject should be discussed even though you may find it unsettling. You will be reassured by the knowledge that in experienced hands the risk of modern cataract surgery is very low. In medicine some risk must always be accepted to achieve a cure, but fortunately in cataract surgery the balance is heavily weighted in favour of a happy outcome.

The most serious complications requiring further surgery and sometimes causing permanent loss of vision include infections, retinal detachment, clouding of the cornea and retention of part of the cataract.

Other problems include haloes when driving at night, dependence on glasses postoperatively even if they were not needed pre-operatively and drooping of the upper eyelid. Macular oedema (swelling of the retina) is quite common and causes blurred vision, although it usually responds quickly to the eyedrops used to treat it. Many patients develop a posterior vitreous detachment and notice a flickering light in the peripheral visual field, followed by a ‘floater’ seen as a mobile black speck. Temporary redness, watering, scratching and tenderness are common after cataract surgery.

What if there are other eye problems as well as cataract?

Sometimes there are other eye problems in addition to the cataract, such as macular degeneration or glaucoma. In this case cataract surgery may not restore perfect vision. However if there is a significant cataract it is usually worthwhile removing it in order maximise vision. If this circumstance is relevant, I will discuss it fully with you during the consultation.

What is secondary cataract?

Cataract removal is always permanent. However you should be aware of a common condition called ‘secondary cataract’. This is the formation of a thin, opaque layer on the surface of the lens implant causing blurring of vision. It may occur at any time after cataract surgery. Fortunately secondary cataract is easily cured. This is done in outpatients with a laser, takes only a few minutes and causes no discomfort.