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 customise the lens implant for you. Read ‘Customised cataract surgery’ for more information.
After the examination I will discuss the best treatment for you and there will be ample opportunity to address any
questions you have. The examination may require the use of eyedrops that blur your vision for a few hours, so please bring someone to drive you home.
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 sometimes suggest a particular method, for example a local anaesthetic may be preferable for patients with heart problems and a general anaesthetic for claustrophobes.
Making the arrangements
My secretary will call you after the consultation and schedule a convenient date for your operation. She will also help 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 your normal medication at the usual time. 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 or take anticoagulants or Flomax (Tamsulosin) please let me know so I may advise whether any changes should be made to your normal 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, except during the operation.
You will need to arrive at the hospital at least an hour before the surgery. The exact time will be confirmed beforehand. Eyedrops or a pellet will be applied to prepare the eye for the operation by dilating the pupil. 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. If applicable 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. You may have a local anaesthetic and remain awake. Alternatively if you have chosen it, a general anaesthetic will be administered and you will be asleep.
In 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. 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. Be assured that you cannot ‘see’ the operation.
A cover will be placed on your eye 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. You must not drive yourself. There is no need to remain overnight in hospital. Depending on your circumstances it may be best if someone accompanies you home and is with you for the first day or two.
The eyeshield
The shield placed over your eye after the operation will be removed before you leave. Alternatively take it off 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 secured over the eye at night. A roll of medical tape will be provided for this purpose. 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, smoky environments, sunshine, cooking fumes etc. Similarly, sunglasses are not needed to protect the eye but you may choose to wear them if you are light sensitive for a while after the surgery, which is common.
The eyesight
If you had a local anaesthetic injection your eye will be closed for a few hours after the operation. You may also have some double vision - if this happens, replace the eyeshield until it passes.
Your vision will be quite blurred for a day or two. Although recovery from cataract surgery is very quick, you should allow a week or so, sometimes longer, 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 look
The eye may be bruised after 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. Bruising is more common if you take aspirin or anticoagulants. Your eyelids may be sticky or even stuck together in the morning for a few days. If necessary, clean them with cotton wool and saline or freshly boiled, cooled water.
How your eye will feel
Eyes are often scratchy after surgery. 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 to take, MAXITROL or DUCRESSA or alternative agents. 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 them 3 - 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 them unless I advise otherwise. Space the drops at approximately equal intervals ie: breakfast, lunch, dinner and bedtime. Refrigeration is unnecessary. They are a combined antibiotic/steroid formulation intended to prevent infection and promote healing.
Your eye may feel sore. You will be given a supply of local anaesthetic eyedrops - Proxymetacaine, Benoxinate or Tetracaine. You may use these when you wish, up to six times daily, 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 reused, 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
- Look in a mirror, preferably a magnifying mirror.
- Pull the lower eyelid down to form a pocket.
- Place one drop into the pocket. 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.
You may prefer to ask someone else to do 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 immediately.
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. Strenuous activities such as jogging or aerobics should also be postponed for two weeks and ladies should be circumspect about eye make up for the same period.
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, don’t rub it! Just keep it closed until the stinging stops.
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 a few days after surgery but this does depend on your individual circumstances which I will discuss with you.
You may return to most kinds of non-manual 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 a 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
After your first cataract operation there may be a focusing imbalance between the two eyes. This will disappear when the second eye is done. In between try the following options, none of which will harm your eyes (a) not wearing distance glasses at all. For reading you may use inexpensive ready readers (b) wearing your current glasses. In this case you will be reliant on the unoperated eye since the glasses will probably be the wrong strength for the recently operated eye (c) have your optician remove the glasses lens in front of the operated eye, so the frame will be empty or replace it with a blank lens. Leave the lens in front of the unoperated eye in place. This may cause a feeling of imbalance and usually only works for patients with a weak glasses prescription (d) if you use contact lenses, continue them on the unoperated (but not the operated) eye and wear ready readers when needed.
If cataract surgery has been done for one eye but none is planned for the other, initially follow this advice. After about a month you may update your glasses if you need to – you should wait as it takes this long for the eye to fully heal, until when the prescription will not be accurate.
After your second cataract operation, wearing ready readers if required and managing without distance glasses normally works best. Your old glasses will probably be the wrong power. If you still need glasses, wait at least a month before getting them.
Modern cataract surgery technology has the capacity to reduce or altogether abolish your need for glasses. This applies even if you have depended on them all your life. Short and long sight, astigmatism and reading glasses are correctable. Read ‘Customised cataract surgery’ for more information.
Please understand however that it is not possible to guarantee freedom from glasses and that you may need to wear them after the operation even if they were not required before. If they are necessary, new glasses may be obtained from an optician a month or so after 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, damage to the cornea and tearing of the lens capsule which may lead to retention of part of the cataract. Issues affecting the lens implant may include malposition, internal lens reflections causing the perception of a peripheral dark crescent or restriction of peripheral vision and the late development of opacification of the plastic from which the device is made.
Other problems include haloes when driving at night, dependence on glasses post-operatively 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 especially in those who suffer from blepharitis.
You may wish to read the information for patients on cataract surgery, its benefits and risks, on the Royal College of Ophthalmologists website.
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 to maximise vision. If this circumstance is relevant, I will discuss it with you during the consultation.
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 back 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.
