Cataracts         

 

 

The preoperative details

Prescriptions and written instructions are given at your preoperative visit. We will give you explicit written instructions about where to report and at what time on the day of your surgery.

On the day before your surgery, you will take eye drops to prevent infection and inflammation. You cannot have solid food after midnight on the day before your surgery. There is a health questionnaire to be filled out before you report. It’s a good idea to bring along your medications to the outpatient center. There is no need to change any medications you take to “thin” the blood. Medications used for cardiovascular reasons are taken the morning of surgery with a sip of water.

 

No diabetic medications are taken. We will usually schedule diabetic patients early in the day in order to get them back on their normal diet and medications promptly that morning.

 

We will ask you to arrive at the hospital outpatient reception desk two hours before your scheduled surgery time.

 

 

On the day of surgery

After you check in at the reception area, you are taken back to the preoperative area where your nurse will introduce herself and gather your medical information. She will help you change into a stylish gown.  Just your clothes up top are removed, and an IV is started.

 

The anesthesiologist will stop by to review your medical history and tell you what to expect from the intravenous sedation. It is not common for additional lab testing like EKGs or blood work to be obtained, but it may be requested at the anesthesiologist’s discretion.  

The IV sedation used works extremely well with people of all ages, with all kinds of medical conditions, with all degrees of anxiety about having surgery on their eye. If you have had a colonoscopy, you probably have experienced this type of sedation already. It is quick in onset, and is quick to dissipate.  Rarely, people will have some nausea afterward, but truly uncomfortable or serious adverse reactions are rare. The usual agents used are Versed and Fentanyl.

 

 

The Cataract Procedure

Right before the cataract surgery, the eye is dilated and then a surface anesthetic jelly is applied. With no injection of anesthetic into the crowded space around the eye, there is no danger of bleeding behind the eye or poking some pretty important structures. Especially in people on any type of blood thinner-- for example, warfarin (Coumadin), aspirin, Plavix, Aggrenox, etc.—there is no need for them to stop these important medications before or after surgery.

You are taken to the OR, where a topical disinfectant, Betadine, is applied around the eye, even to the inside of the lids, then rinsed after an appropriate “dwell” time. This has been shown in studies to significantly reduce the number of bacteria that might cause infection. Even people who are sensitive to iodine used in intravenous studies, or who are allergic to shellfish, do fine with Betadine prep.

The gentle intravenous medication is given, which induces "twilight sleep”.  Many people do not remember the surgery, which takes ten minutes, on average.

At the start of your cataract surgery, the eye lashes and edges of the eyelids are isolated behind sterile plastic sticky drapes, to help prevent infection.  An instrument called a speculum props the eyelids open. There is no need for the patient to concentrate on keeping his eyes open, or even staring straight ahead. 

After the lid speculum is in place, the operating microscope is brought over the eye. This is sometimes annoying for the patient, at first, but then the photoreceptors in the retina adapt. Patients report that they see fascinating, brilliant colors and moving shadows. Generally, they do not feel anxious or frightened. If they voice any concerns, the nurse anesthetist sitting at their side provides more sedation.

 

Dr. Smith uses phacoemulsification, that is, ultrasonic liquefying of the cataract. This is done through a 3 mm incision, about half the width of a pencil. If the incision is beveled properly, it is self-sealing in the large majority of cases and will not require any stitches.

Dr Smith makes two incisions in the far peripheral cornea to access the cataract inside the eye, just behind the iris and through the pupil. There is a capsule or casing around the cataract that is opened at the start, before the lens is removed. Then a combination of ultrasound and vacuum removes the cloudy natural lens, under high magnification.

 

Phacoemulsification, the official name of the surgery, comes from the ultrasonic emulsification or liquefying of the phakos, Greek for lens.

 

The work is accomplished under the clear cornea of the eye (think of how you put together a salad under the Plexiglas at a salad bar!). Great care is taken not to work near the back surface of the cornea, where the single coating of cells can be easily injured. A clear protective gel is placed at the very start of the case just to protect these non-renewable cells. More of this very slimy, protective gel is placed after the cataract is out the before the lens implant is placed in the eye.

Once the IOL is in the eye, the protective gel (viscoelastic, technically) is removed.  I put a dilute solution of antibiotic directly into the eye as the last step, and then check meticulously for any leaks.

 

 

Your cataract is gone! After the surgery...

When you come out of the OR, your eye has a clear shield over it to remind you not to rub it while you are recovering from the sedation. In the recovery area, another wonderful nurse will check your vital signs, provide some exquisite soda and crackers, and go over the explicit written instructions for medications and activities.

You will continue the same eye drops you took the day before surgery.  After you have recovered from the sedation, there are no restrictions to your activities, except underwater swimming.

 

You will have my mobile phone number to call if you need more than Tylenol for pain, since the discomfort after the “sutureless” cataract operation is typically described as “an eyelash in the eye” or scratchy. I will ask you to wear a shield on the eye just when you are sleeping for two more days after the day of surgery, to guard against rubbing the eye in your sleep or on awakening.

 

I see all my postoperative patients the day after surgery, with very rare exceptions.  I want to see myself how you are doing, make sure the medications are correctly taken, and answer any questions you might have. Your next checkup is at two weeks post-op. If it is appropriate, we can discuss if the other cataract needs surgery, based on your function.

 

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