Cataracts - Treatment

Phacoemulsification does have some specific complications, although they are rare, particularly with experienced eye surgeons. They include:

• Rupture of the lens capsule.
• Loss of the lens nucleus into the eye fluid. (This will require removal by a specialist and may result in poorer vision.)
• Flying fragments of the lens can damage the cornea or threaten the retina.
• Pre- and postoperative changes in blood pressure, which are generally not a problem, should be observed carefully, since in some cases the changes may be extreme.

In about 30% of cases patients develop secondary cataracts within1 to5 years after either procedure, which require different treatment choices.

Preventing Infection and Reducing Swelling. The ophthalmologist may prescribe the following medications:

• A topical antibiotic (neomycin or, more effectively, gentamicin). Thisdrug protects against infection.
• Corticosteroid eyedrops or ointments are often used to reduce swelling. Corticosteroids (commonly called steroids) are potent anti-inflammatory drugs. However, they also pose a risk for pressure in the eye and infection. One study reported less visual sharpness with the use of steroids compared to antibiotics. Some newer steroids such as rimexolone, loteprednol, and fluorometholone may pose a lower risk for abnormal pressure.
• Nonsteroidal anti-inflammatory drugs (NSAIDs), such as diclofenac, ketorolac, naproxen, and voltaren, also reduce swelling and do not pose the same risks as steroids. Newer NSAIDS that have been approved to treat pain and swelling after cataract surgery include bromfenac (Xibrom) and nepafenac (Nevanac).

In one study, applying an ice pack for2 hours immediately after phacoemulsification improved comfort level and reduced inflammation, even days after the operation. This simple procedure has no adverse effects and patients should discuss it with their surgeons before the operation.

Factors That Increase Risk for Complications. The risks of complications are greater for the following people:

• Patients who have other eye diseases.
• People with diabetes. Intracapsular and extracapsular cataract extraction are known to pose a high risk for the development or worsening of retinopathy, a known eye complication of diabetes. Experts have hoped that phacoemulsification would pose a lower risk, but a 2001 study reported a high percentage of retinopathy progression after this procedure. The amount of experience a surgeon has plays a role in whether or not a patient has this complication.
• People who have taken tamsulosin (Flomax) or other alpha-1 blocker drugs. Tamsulosin is a muscle relaxant prescribed for treatment of several urinary conditions including benign prostatic hyperplasia (BPH). In 2005, a leading ophthalmologic association and the FDA warned that tamsulosin may cause intraoperative floppy iris syndrome (IFIS), a loss of muscle tone in the iris that can cause complications during eye surgery. Problems have been reported both for patients who were taking the drug during surgery as well as those who had stopped taking the drug weeks or months before surgery. Men who have taken tamsulosin or similar drugs should inform their eye surgeon. The surgeon may need to use different techniques to minimize the risk of IFIS.

Postoperative Care

Returning Home and Follow-up Visits.

• Patients usually leave the surgical site within an hour of surgery. Cataract surgery almost never requires an overnight hospital stay.
• They need to have someone drive them home and stay with them for a few days until their vision is acclimated.
• The patient is usually examined the day after surgery and then during the following month. Additional visits are made as required.
• Vision usually remains blurred for a while but gradually clears, usually over a 2 to 6 week period. (It can take longer.)
• When the doctor decides the condition has stabilized, the patient will receive a final prescription for glasses or contacts.

Protecting the Eye. Postoperative protection of the eye typically involves:

• The ophthalmologist usually tapes a bandage over the eye to protect it during the healing process.
• When changing the bandage, the eye can be cleaned gently using a washcloth dipped in warm water without soap. A new bandage can then be positioned and taped.
• It is very important not to press or rub the eye during this procedure.
• An eye shield may be placed over the bandage at night.

Avoiding Glaucoma. Cataract surgery can cause glaucoma, a condition in which the pressure of fluids inside the eye rises dangerously. It is very important to minimize any activity that increases internal eye pressure. Postoperative cataract patients take the following precautions:

• Minimize vigorous exercise
• Put on shoes while sitting and without lifting up the feet
• Kneel instead of bending over to pick something up
• Avoid lifting
• Limit reading since it requires eye movement. Television is all right.
• Sleep on the back or on the unoperated side

Treatment for Patients with Accompanying Eye Conditions

Cataracts and Glaucoma. For patients with both glaucoma and cataracts, experts recommend:

• In patients with cataracts and poorly controlled glaucoma, a two-step procedure for both eye conditions is needed. The patient first receives a trabeculectomy for glaucoma, followed by cataract surgery. Fluid leakage and the presence of blood in the back chamber of the eye are potential complications of this combined procedure. Phacoemulsification has improved success rates and reduced high complication rates of the double procedure compared with extracapsular cataract extraction. New advances that replace trabeculectomy with nonpenetrating glaucoma surgery may prove to be beneficial.
• In patients who have cataracts plus either closed-angle glaucoma or open angle glaucoma that is stabilized with medication, the cataract may be able to be extracted and medication continued for the glaucoma.
• Amajor 2002 analysis suggested that the combined approach generally offers better control over eye pressure for patients with both cataracts and glaucoma. The best surgical procedure, however, is still uncertain.

Cataracts and Corneal Disease. Patients who have both cataracts and corneal disease may undergo one of the following:

• Combination Procedure. A single operation that combines three procedures. The combined procedure has been used since the late 1970s and employs extracapsular cataract extraction and intraocular lens insertion with corneal transplantation (called penetrating keratoplasty).
• Sequential Procedure. An operation that uses two procedures sequentially. The sequential option performs the cataract procedures and the corneal transplantation separately.

Recovery of vision is usually much more rapid after the combined procedure than after the sequential procedures. Performing the procedures sequentially may also carry a higher rejection rate of the implant, although a 2003 study found no differences in failure rates between the two approaches after a year.

In any case, many experts recommend that for most patients the sequential procedures may be the better option because it appears to have fewer of the following complications than with the combined procedure:

• Posterior capsule rupture
• Eye fluid loss
• Postoperative refractive errors, which result in abnormal distribution of light patterns

The rate of these errors still depends on the skill of the surgeon and the power of the implanted lens no matter what approach is used.

Secondary Cataracts (Posterior Capsular Opacification) and Their Treatments

About 30% of patients who undergo extracapsular cataract surgery develop a secondary "after-cataract" called posterior capsular opacification. Posterior capsular opacification generally occurs because of the following events:

• After surgery, there are still some natural lens cells left behind that proliferate on the back of the capsule.
• The capsule gradually becomes cloudy and interferes with clear vision the same way the original cataract did.

According to a 2001 study, the probability of developing a secondary cataract was 6% at1 year, 15% at2 years, 23% at3 years, and 38% at9 years. The risk is lower with phacoemulsification. Secondary cataracts are more likely to occur in younger patients, in those with diabetes, or when cataract surgery is combined vitrectomy (clearance of debris from the fluid in the eye).

Preventing Posterior Capsular Opacification. Studies suggest that acrylic lenses pose the lowest risk for posterior capsular opacification. A number of substances to prevent posterior capsular opacification are under investigation, including tranilast eyedrops, new lens materials, special capsular rings inserted during phacoemulsification, and new coatings on the implanted lens (e.g., thapsigargin, a plant-derived substance). One interesting investigative approach is called bag-in-the-lens implantation, which involves inserting the lens capsule into the IOL, rather than the other way around. In one small study, no patients developed secondary cataracts after this procedure.

Treatment Decisions for Cataracts in the Second Eye. If a person has a cataract in a second eye, the issues for decision making are the same as for the first eye. The time of the procedure in the case of two cataracts is unclear.Doctors have long recommended that surgery on the second eye should be postponed until the first eye has healed and the results known (about a year).

One study has called this recommendation into question. It was conducted in England, where for budgetary reasons, there are long waits for second-eye cataract surgeries. In the study, patients who waited7 to 12 months for the second-eye surgery reported significant difficulty in reading and performing ordinary tasks during the waiting period. Only 1% of patients who had the second surgery within 6 weeks reported having trouble seeing. In addition, 70% of those who waited experienced problems in depth perception, which can cause difficulty in walking and driving; only 12% who didn't wait reported this problem. Patients with double cataracts should discuss all options with their surgeon.

Treatment for Posterior Capsular Opacification. The standard treatment is laser surgery known as a YAG capsulotomy. (Capsulotomy means cutting into the capsule, and YAG is an abbreviation of yttrium aluminum garnet, the laser most often used for this procedure.)

• This is an outpatient procedure and involves no incision.
• Using the laser beam, the ophthalmologist makes an opening in the clouded capsule to let light through.
• After the procedure the patient should remain in the doctor's office for an hour to be sure that pressure in the eye is not elevated.
• An eye examination for any complications should follow within2 weeks.

Complications. Laser surgery has become so commonplace that some ophthalmologists use it after cataract surgery to prevent later clouding. However, laser surgery carries its own risks and possible complications, similar to those of cataract surgery itself, and can also lead to poorer vision or blindness. About 1% of laser surgery patients develop a detached retina, which is much higher than the risk from the original cataract surgery.

Click the icon to see an image of a detached retina.

In some people, particularly those with glaucoma or who are severely nearsighted, the pressure in the eye may spike after laser surgery. Certaindrugs used for treating glaucoma, such as dorzolamide (Trusopt) or apraclonidine (Iopidine), may helpful for preventing this occurrence. It is strongly recommended, however, that this surgery not be performed to prevent a secondary cataract, but only if the lens capsule clouds up again.

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