Putting a knife to the eye sounds pretty horrific, like some sort of method of “enhanced interrogation.” In fact, the eyeball is such a sensitive, squeamish part of the body that there are even websites listing horror movies with the worst eyeball-involving scenes (Google it!). Ommetaphobia aside, a scalpel in the right hands can provide sight-restoring, quality-of-life-redeeming treatment to an eye affected by cataract.

What are cataracts?
Cataracts are an opacity or clouding of the anatomical lens inside the eye. Light is focused through this lens to reach the sensory retina at the back of the eye, just one step in the process we know as vision. To allow clear vision, this lens must be optically clear and transparent. However, for various reasons such as disease, trauma, or most commonly, age, this lens loses its transparency, with the resultant cataract physically blocking and scattering light as it comes through the eye. Because everyone ages, age-related cataract is considered to be one of the most common eye diseases. In the year 2000, an estimated 20.5 million Americans had a cataract in at least one eye with this number projected to increase to 30.5 million by the year 2020 and 50.2 million by 2050, partly due to our aging population and longer lifespans.

When is the right time for cataract surgery?
There’s no straight-cut answer for this one (no pun intended). One of the most important factors to consider is how significantly the cataract is affecting your quality of life. As vocation, hobbies, and favorite activities vary widely from individual to individual – a birdwatcher or painter has a much higher demand on their vision than, say, a swimmer or metalworker – the best person to decide when your vision is no longer up to scratch is you! In some cases, cataract surgery may be recommended before you necessarily feel ready, such as when your vision no longer meets the requirements of the DMV to hold a driver license.

What’s involved in cataract surgery?
Technology has come a long way in improving the safety and visual outcomes in cataract extraction. We now have two main techniques used in modern cataract surgery – the conventional phacoemulsification method or the newer femtosecond laser assisted surgery (FLACS).

Firstly, you can expect to be given a local anesthetic or nerve block around your eye – this is no horror movie! General anesthesia is typically not used during cataract surgery to allow the surgeon to communicate with you during the procedure and to avoid the unnecessary risks of general anesthetics. Certain patients, such as those with significant anxiety or ommetaphobia (it is not often that we get to use this word!), or patients with medical conditions that inhibit them from lying still on the operating table for a short time, will be indicated for general anesthesia. In other cases, light sedation can be administered intravenously during the procedure to help with comfort.

Phacoemulsification (PCS) vs. Femtosecond Laser-assisted Cataract Surgery (FLACS)
Traditional cataract surgery, or phacoemulsification, is considered safe and effective. The eye surgeon creates a small incision on the side of the cornea then inserts a microsurgical instrument to create a circular opening in the lens capsule. After that, an ultrasound probe is inserted which breaks up (emulsifies) the cloudy center of the lens. Those broken up pieces are then suctioned out of the eye. To replace that cloudy lens, the eye surgeon implants an artificial intraocular lens (IOL) made of acrylic or silicone which restores the clear transmission of light through this structure of the eye and even potentially corrects your refractive error and the need for spectacles. Stitches are typically not needed if the surgeon can apply a self-seal liquid. An uncomplicated procedure should require no more than 10 to 15 minutes on the operating table.

Femtosecond Laser-Assisted Cataract Surgery, or FLACS, is deemed to be more precise because it uses a laser to determine the location, size and depth of the corneal incision and it’s the laser that actually makes the incision and then proceeds to soften the cataract. From there, it’s just like traditional cataract surgery: an ultrasound probe emulsifies the lends and it’s suctioned out of the eye. The IOL, or artificial intraocular lens, is implanted and a safe-seal liquid is applied to close the incision.

The debate between phacoemulsification surgery and FLACS is still ongoing and the numerous studies conducted have not been unanimous in finding that one provides consistently better outcomes than the other. Your eye doctor is the best person to discuss the benefits and disadvantages of each technique for your specific situation. In all cases, FLACS will be a significantly more expensive than phacoemulsification and may not be available to all patients.

What are the options for IOL implants?
There are various options for intraocular lens implants, with the best choice often largely dependent on your lifestyle and visual needs. Monofocal IOLs are the most common implant and usually correct for either long distance or near vision, meaning you will still require spectacles. Some patients are a good candidate for what is known as monovision, with one eye implanted with a long distance IOL and the other with a near vision IOL.

Multifocal or accommodative IOLs address both far and near vision as they can provide a wider depth of focus. While this greatly reduces dependency on spectacles, you may still prefer glasses for specific tasks, such as night-time driving or long periods of reading.

As can be expected, there are advantages and disadvantages of all types of IOLs and not all patients will be suitable for all options.

What happens after the operation?
You will be given an eye shield to protect your eye during the early stages of recovery and advised against certain activities, such as exposure to unsterile water sources or heavy lifting. You will also be put on a regime of anti-inflammatory and antibiotic eye drops for the following 3 to 4 weeks. More specific instruction will be given by your surgeon and you can expect to have a few more review appointments to ensure the eye is healing properly and to address any side effects you may be experiencing.

Your vision will be clearer almost immediately after the cataract has been removed; however, the eye will still need time to heal and during this time the vision is likely to change.

After approximately 4 to 6 weeks the vision should have settled and by this time you will be able to determine whether you still require spectacles to help with certain tasks, such as night-time driving, reading and computer work, or watching horror movies!

About 2 million cataract surgeries are performed each year in the US so if you’re considering undergoing this procedure yourself, know that you’re in good company. Just make sure you avoid watching any ommetaphobic horror movies before your appointment.

References
Cataract in Adults. https://www.uptodate.com/contents/cataract-in-adults
Cataract Surgery. https://www.allaboutvision.com/conditions/cataract-surgery.htm
Vision Conditions. https://www.dmv.ca.gov/portal/dmv/detail/dl/driversafety/vision_cond
Are you awake during cataract surgery? https://www.allaboutvision.com/conditions/faq-cataract-surgery-awake.htm
A Review of Laser-Assisted Versus Traditional Phacoemulsification Cataract Surgery. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5449299/
Is Femto Cataract Surgery Here to Stay? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4398800/
15 Things You Need to Know About Cataract Surgery. https://visioneyeinstitute.com.au/eyematters/15-things-need-know-cataract-surgery/
IOL Implants: Lens Replacement After Cataracts. https://www.aao.org/eye-health/diseases/cataracts-iol-implants
Cataract Surgery Infographic. https://www.aao.org/eye-health/news/cataract-surgery-infographic