Cataract Surgery

Information about Cataract Surgery Success and Complications

This information has been prepared both to give you figures for success rates of surgery and to help you understand the potential problems associated with cataract surgery and lens implantation.

Introduction

A cataract is the natural lens inside the eye, which has become cloudy (see figure below). It is situated behind the pupil but in front of the vitreous jelly and retina. Removal of the cataract is usually performed when this significantly affects the eyesight.

Following cataract surgery the eye would be out of focus, but this is usually overcome by placing an intraocular lens (IOL) inside the eye at the time of the operation. Once a lens implant is in position no further surgical treatment is usually required (except for laser surgery – see below).

After the surgery, eye medications are usually given for 4 weeks but may need to be continued for longer. Once the eye has stabilised (normally at 3 weeks after surgery) it is often necessary to make small adjustments to the focus of the eye, to provide the best vision, by changing your spectacle lens.

What is the likelihood of your vision improving?

With cataract surgery there is approximately:

95% chance of better vision (better if you have no other problems such as macular degeneration)

90% chance of good (6/12) vision

85% chance of excellent (6/7.5) vision

1 % chance of no improvement or deterioration in vision due to complications of surgery

What are the complications of cataract surgery?

Major complications, requiring further surgery, occur in about 1 patient in 100 operations and, of these complications, retinal detachment is the most common. Most of these patients will retain some useful vision although 1 in 1000 may lose their sight.
To expand there is a:

1 % chance of retinal detachment (higher in very short sighted patients about 3%)

0.1% (1:1000) chance of infection

0.1% (1:1000) chance of blindness, generally as a result of unsuccessful treatment of retinal detachment or severe infection

Others are: haemorrhage in the eye, vitreous loss, wound leak, loss of corneal clarity (corneal decompensation), dislocation of the lens implant.

Minor complications occur in about 1 in 20 patients (resulting in temporary, but rarely permanent, loss of vision and the need for extra visits and medications. The most common of these are:

Swelling of the retina (cystoid macular edema) – resulting in blurred vision that may last days, weeks or occasionally months. About 2-5 % of those who have cataract extractions will experience decreased vision due to CME during the first post-operative year, usually from one to four months after surgery. The risk is higher in diabetic patients or those patients with a history of uveitis in the past. It often responds to anti-inflammatory eye-drops but occasionally must be treated with an injection of drugs intravitreally (in the eye).

Inflammation always occurs after cataract surgery (uveitis) but may persist for longer than the 3-4 weeks for which it is usually expected.

A droopy upper lid (ptosis) may occur but can be corrected with surgery.

Dry eye.

Health Insurance companies presently only cover the surgeon’s operation fee. Pre- and post-operative examinations are not covered by any health insurance companies. Rarely, extra clinic visits and investigations may be required if post-operative complications develop and these may result in further costs to the patient.

Common changes in vision (as opposed to complications) after cataract surgery

Glasses: Your glasses will need to be changed after surgery. Bifocal lens implants and lenses to correct pre-existing astigmatism are now available and may lower the chance of needing glasses after surgery (see below). In most cases you will still need spectacles for “best vision” either for distance or reading although 80% of patients will be able to manage without glasses for either distance or reading. Also 20% of patients will have an end result that will not permit good vision without glasses due to pre-existing astigmatism or imprecision in the measurements taken to determine implant power.

There is no guarantee that you will not require glasses after cataract surgery, even if you never needed them prior to surgery.

After phacoemulsification surgery temporary glasses can be obtained 2-3 days after surgery but these will only be of value until your permanent spectacle prescription is given at 3 weeks after surgery.

Other changes in vision: Floaters are much easier to see or may develop after cataract surgery. Although these may irritate they do not affect the sharpness of vision and most patients soon learn to ignore them.

Laser Treatment

Laser treatment is only used for treatment of the posterior capsule (or after cataract). This is the membrane that is left behind to support the implant. There is a 10% chance per year of requiring YAG laser treatment to the posterior capsule (the membrane); this risk may be less with modern implants at least in the first 1-2 years after surgery.

Anaesthetic Procedures

Local anaesthesia, where the patient is awake during the operation, is the method of choice for most patients as it allows rapid recovery with minimal risk to your general health whilst providing good operating conditions. Different techniques are available. Usually the eye to be operated on is made numb with eye-drops or gel (95% of cases).

General anaesthesia, where the patient is put to sleep for the operation, is a safe procedure. It is normally only now used for nervous patients or those likely to be unable to cooperate with a local anaesthetic.

Intra-ocular lens (IOL) choice fall into 3 main categories:

Conventional Monofocal IOLs

Conventional lenses have a uniform focus and provide excellent image quality, but have a limited range of focus. I usually aim for good distance vision in the first eye to be operated on. Glasses are required after surgery to allow good reading vision.

Multifocal IOLs

A variety of different types of multifocal lens have been implanted in cataract surgery over the last 20 years. These lenses produce both clear distance and near vision, and approximately 80% of patients are completely spectacle free after implantation. But you do not get something for nothing optically: many patients are aware of light scatter symptoms (such as haloes around lights), especially in the early period after surgery. Modern multifocal IOLs such as the Rayone Trifocal, Zeiss Asphina 839MP Trifocal, Zeiss Lara or Tecnis Symfony IOL are designed to minimise these optical side effects. Light scatter symptoms after implantation are usually mild and tend to improve with time. But a second operation to exchange the multifocal IOL for a monofocal IOL is occasionally necessary (less than 2% of patients). An accurate distance focus is also required to get the best out of multifocal implants, and LASIK refractive surgery may be beneficial to fine tune focusing after implantation in up to 1 in 5 patients after multifocal IOL implantation (20%). Finally, whilst intermediate and distance vision is usually sharp, some patients prefer to wear spectacles to get the sharpest focus for some near vision activities such as reading (especially in dim light). Despite these limitations, multifocal IOLs are highly effective in promoting freedom from spectacles for most activities after surgery, and are an increasingly popular choice in cataract patients.

Many cataract surgeons exchanging ideas in trade journals indicate that an extreme perfectionist is the very worst kind of candidate for a multifocal or presbyopia-correcting intraocular lens of any kind. While these lenses are high tech marvels, they are unlikely to produce absolutely crisp vision at multiple distances at all times and in all circumstances.
Particularly with multifocal IOLs, you must be prepared for the possibility of at least some visual distortions — particularly in the form of glare and halos around light sources at night. These distortions rarely would prohibit night driving.

Toric IOLs

Some patients with pre-existing astigmatism (the eye is egg-shaped rather than football-shaped) will require glasses after surgery unless they have a special toric IOL inserted. About 15% of the cataract population may benefit from this type of lens.

At present health insurance companies cover the cost of the conventional IOL but do not cover the cost of special lenses such as the multifocal and toric IOLs. Patients will be charged the excess cost of these by the hospital on the day of surgery.

The Zeiss Trifocal will cost €650.

The Zeiss Toric IOL will cost between €350-€575 depending on the degree of astigmatism.

Cataract surgery is a day case procedure: you do not need to stay in hospital overnight after surgery. We do not normally operate on both eyes at the same session. Special order lenses including multifocal and toric IOLs require that biometry is performed at a separate visit in advance of the day of surgery.

Time off work

Although the visual recovery after cataract surgery is rapid: you can expect to see quite well within 2 days of surgery, we advise a week off work after each procedure. This is not obligatory, and provided you are able to put drops in 4x per day, a return to work on the Monday after surgery will not damage the eye. Dusty environments are unlikely to damage the eye, but may be irritating, and should be avoided for 1 week after surgery.

Other limitations on activity

You can be as active as you like after modern cataract surgery. Bending over and lifting light weights are no problem, and flying is permissible from the day after surgery. The main limitations are: no swimming for 1 week after surgery and no eye make up for one week after surgery. Driving is fine once you can read a number plate at 70 feet. Driving with good vision in only one eye is legal, but you should obviously exercise caution until you feel confident, and initially drive short distances by day in familiar surroundings.

Self-Paying fee for Cataract Surgery (If no health insurance cover):

Many patients without insurance opt to have cataract surgery performed privately in Blackrock Clinic rather than waiting for an appointment in public hospitals.

Blackrock Clinic fee €995; Surgeon fee €1000; Anaesthetist fee €400; Pre and Post-op Visit €350 (€200/150); A scan Biometry to measure lens size required €95 (both eyes are measured);

Total for single eye cataract surgery €2840 (€2272 Net after Tax rebate from Revenue)

If a premium lens is required by the patient this will result in an additional fee of €350 for toric lenses up to 3.5D of astigmatism and €575 for toric lenses up to 8D of astigmatism. If the patient requires or chooses a multifocal lens to allow some near vision as well as distance vision then the additional cost of this lens will be between €450-600.