Cataract

Cataract is a common condition affecting the adult eye. One study found visually significant cataracts to be present in 14% of men and 24% women aged 65 to 74, and in 39% of men and 46% of women aged 75 years and older.

Cataract has been found to be the leading cause of blindness (although curable) in people over 40 years, and millions of cataract procedures are performed in this country annually. However, not all cataracts need to be removed. This section discusses adult cataract and cataract extraction.

Cataract Evaluation and Treatment by Richmond Eye Associates

All of the physicians (M.D.'s) of Richmond Eye Associates perform comprehensive eye examinations to determine if a patient has cataracts, if the cataracts are the cause of vision loss, and if it is safe for the patient to undergo cataract surgery. All of the surgeons of Richmond Eye Associates perform cataract surgery using modern, small incision techniques using state-of-the-art surgical equipment with highly trained operating room nurses and staff.

While the primary goal of cataract surgery is to restore the patient's best possible vision by removing the cataract, it is also possible to minimize the need for glasses or contact lenses by choosing the best possible lens implant for the patient.  While lens implants mainly correct for farsightedness and nearsightedness, there are also astigmatism-correcting lens implants as well as lens implants that improve near vision and near focusing after surgery.  Surgical treatment of astigmatism and residual refractive error at the time of surgery and after surgery may also be available, depending on the surgeon and the health of the eye.  These options should be discussed with the operating surgeon at the time of the cataract evaluation so that all necessary tests can be done preoperatively to insure the best possible post-operative result.

The next sections discuss general information about cataracts, symptoms of cataracts, possible causes of cataracts, and more details about the surgical removal of cataracts.

What is cataract?

Cataract is a clouding of the natural lens within the eye. Usually both eyes are affected, although one may be more severe than the other. Nearly everyone will develop some clouding of the lens by age 60, but the vision may not be affected.

Since light must pass through the lens to reach the retina, visual disturbances are the main symptoms of cataract. Cataract within the lens of the eye distorts and blurs visual images.

Possible symptoms include:

• A usually gradual blurring of the vision at distance or near which may not be correctable with glasses.
• A shift in the eye's refractive error (or glasses prescription), often toward nearsightedness. Some people experience "second sight", or the ability to read without glasses at near due to the nearsightedness caused by cataract. With time, however, this temporary improvement in near vision will worsen as the cataract becomes more advanced.
• Glare symptoms, sometimes worse at night (headlights), other times worse during the day. This causes a sensitivity or aversion to light, but not pain.
• Halos around lights and double vision (through one eye - double vision can also be caused by misalignment of the eyes, but if one eye is closed the double image disappears).
• Worsening color vision, although this may be so gradual that it is not appreciated.

Cataract does not cause pain (except is very advanced cases), or redness or scratchy feelings, and a cataract is not a "skim growing on the surface of the eye".

Different types of cataract include:

• "Nuclear" cataract - this is a gradually worsening haziness in the nucleus, or center of the lens. This tends to change very slowly, and my cause a change in glasses prescription.
• "Cortical" cataract - this is a clouding just inside the front surface lens (the lens capsule), and may cause glare symptoms.
• "Posterior subcapsular" cataract - this is a granular clouding near the back surface of the lens. This tends to affect the vision more rapidly, and is more common in younger eyes (under 60 especially).
• Many cataracts may have varying degrees of all of the above types mixed together.

What causes cataract?

It is not fully understood what causes cataract, why one eye is often worse than the other, and what can be done to slow the worsening of cataract. Ongoing research is being directed in these areas. Some known causes of cataract include:

• A change in the lens due to normal aging processes. By a certain age, it may be normal to develop some cataract in the lens, although the vision may not always be affected. There may be a family tendency to develop certain types of cataract at certain ages.
• Association with certain medical problems, especially diabetes.
• Association with certain medications, such as long term or high dose steroids.
• There has been established an increase risk for cataract in men who smoke, and an increase risk for cataract extraction in women who smoke.
• Cataract can occur after ocular trauma (sometimes very rapidly in severe trauma), and after intraocular inflammatory problems (iritis).

When does cataract need to be removed?

A cataract does not need to be removed just because it is present; there needs to be a visual impairment present to warrant surgery. Less emphasis now is being placed on a required loss of visual acuity (20/50 vision or worse, in the past), and instead more emphasis is now placed on a loss of functional ability related to visual tasks. A cataract does not have to be "ripe" before is can be removed. In other words, one does not have to wait until they have a complete loss of vision before a cataract can be removed.

It is important to have a complete, dilated eye examination, preferably by the operating ophthalmologist, in order to determine if cataract is present, and if it is causing any loss of vision.

The examining physician will ask vision related questions regarding daily activities, such as difficulty driving, reading, working, enjoying hobbies, or trouble with glare. These questions help the ophthalmologist to understand the exact nature of any visual problems that the patient is having.

In many instances, a simple change in glasses prescription can substantially improve the vision, and cataract surgery can be deferred. However, quality of vision problems, such as glare, may remain in spite of new glasses.

After the complete examination, if there is an uncorrectable loss of vision (a glasses update will not help) and the ophthalmologist determines that the cataract is the cause of the loss, it can be discussed whether or not removing the cataract would help to restore the vision. Other eye problems such as corneal disease, glaucoma, retinal problems, or optic nerve problems may limit a full recovery of vision. Sometimes, other tests are needed to help to sort this out.

Cataract surgery can be recommended if a loss of vision is caused by the cataract, and if it seems that improvement would result from the surgery. Generally, if a loss of vision, or other cataract related visual side effects (such as glare) are interfering with a person's lifestyle, cataract surgery is considered. A careful explanation of the risks and potential benefits need to be explained to the patient by the surgeon prior to surgery.

How are cataracts removed, and what are the risks?

Cataract extraction is a highly refined and successful surgical procedure using state-of-the-art technology. The goal of the surgery is to allow a return of vision as fast as possible and without restricting a person's lifestyle during the recovery period.

Cataract surgery is done as an outpatient operation in a operating room. A person has dilating drops placed in the eye prior to surgery. Anesthesia is usually a combination of sedation with local anesthesia. A person does not have general anesthesia for the operation, but many patients will fall asleep during the operation. There are specific cases where general anesthesia is recommended.

The operation usually takes less than 30 minutes to perform. The cloudy portion of the lens (the cataract) is removed from the eye using a technique known as phacoemulsification. This uses ultrasound to break apart the lens, which is then aspirated using fluid suction. Lasers are not commonly used to remove a cataract at this point. There are a few laser cataract systems available which automate some parts of the cataract procedure. Ultrasound still needs to be used even when laser is used. A lens implant is then placed back into the eye into the lens capsule, which supports and helps to center the implant. This implant is a plastic lens of a particular power to help to minimize the need for glasses after the operation. The implant does not need to be exchanged or removed, except in extremely rare circumstances. The opening through which the surgery is done (millimeters in size) may or may not need to be closed with fine absorbable sutures.

The patient usually returns home within one to two hours after the completion of surgery, often with a patch or shield covering the eye. This is removed the same day by the patient, or the next day in the office, and eye drops are prescribed to help with the healing process. These eye drops are tapered over a period of time. At about a month after the operation, glasses can be prescribed, if needed. If the second eye needs to be operated on, this is usually done 2-4 weeks at the earliest after the first operation.

Generally, cataract surgery is highly successful. However, there are some risks:

• With any surgery, there is risk of infection and bleeding. This is very rare with cataract surgery.
• There is risk that the eye may not be able to see as well as predicted, due to an addition problem with the eye not previously seen.
• There is risk that an unexpected glasses prescription will result, although this is becoming rarer with improved equipment used to determine the power of the lens implant.
• There is a chance that the membrane that the lens implant rests on in the eye may become cloudy with time. If this cloudiness begins to affect vision, this membrane can be opened using a laser in a 5-10 minute procedure done outside of the operating room or in the ophthalmologist's office.
• There is a low (about 1%) risk of retinal detachment after cataract surgery. There is also a slight risk of a usually temporary swelling of the retina after surgery.
• There may be other risks in people with diabetes, glaucoma, macular degeneration, and other eye conditions. These need to be discussed by the ophthalmologist.