Cataract Removal: Getting A Clearer View

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Whether we like it or not, one by-product of aging is the deterioration of our eyes' focusing ability, which starts about the time we turn 40. In the middle of an eye exam, the eye doctor may mention reading glasses or even- gasp! - bifocals. While this may be a taste of age-related things to come, it's nothing too serious. On the other hand, some problems of the aging eye require more than prescription eyewear. One is cataract, the progressive clouding of the eye's lens. Cataract affects more than half of all Americans 65 and older and results in 1.5 million surgeries each year in the US.

In normal vision, light rays are focused by the lens of the eye onto the retina, a layer of light-sensitive cells at the back of the eye. The retina sends visual images to the brain via the optic nerve. Cataract occurs when proteins in the lens clump together and turn the lens opaque - in much the same way cooking transforms raw egg whites. Cataract symptoms include blurred, dim, double, or distorted vision; poor night vision; increased nearsightedness; and heightened or halo-like glare from headlights or lamps.

Surgery is the only effective way to cure cataract. It involves removing the cloudy lens and usually replacing it with an artificial lens.

Should I Have Surgery?
Cataract surgery is one of the most common, successful, and safest surgeries performed in the US today. Still, as with any surgery, the risk of complications does exist. In rare instances, surgery can cause infection, which can result in loss of vision in the eye or even loss of the eye itself. Other possible complications include a detached retina; swelling of the cornea or of the macula; bleeding within the eye; and displacement of the newly implanted lens.

In up to half of all cataract operations, a membrane from the cataract -left behind to anchor the new lens - thickens, causing blurred vision. Fortunately, this secondary cataract or after-cataract can easily be treated on an outpatient basis with a laser.

Your ophthalmologist will discuss the risks and benefits of cataract surgery with you, but the final decision is yours. If only the periphery of your vision has become clouded, you might postpone surgery for a while. If the cataract interferes with your central line of sight, you may want earlier intervention. It's probably time for surgery if you find your vision problems are interfering with activities such as reading, driving a car safely, or performing your work.

Sometimes a cataract will harden over time, making it more difficult to remove. Your ophthalmologist can tell you whether this is true in your case and whether you should have surgery sooner. If you have cataracts in both eyes, your ophthalmologist will most likely operate first on the one that is worse, then wait until the eye is healed before removing the cataract in the other eye.

Finally, cataract is sometimes accompanied by other eye conditions, such as glaucoma or age-related macular degeneration. If you have such a coexisting condition, expect your ophthalmologist to play a larger role in your decision-making about cataract surgery.

What Happens During Surgery?
Cataract surgery (see illustration) is performed by an ophthalmologist, a physician trained in the medical and surgical care of the eyes and visual system.

Phacoemulsification is the most common type of cataract surgery. With the aid of a magnifying microscope, the surgeon makes a small incision -about 3 mm long - through the side of the cornea, the clear, dome-shaped surface at the front of the eye. The surgeon then inserts a probe called a phacoemulsifier to break up the cataract with high-frequency ultrasound. The pieces of cloudy lens are then sucked out through a small tube, leaving behind the lens capsule.

If a cataract is particularly dense or hard, a surgeon may do extracapsular surgery, rather than phacoemulsification. In this procedure, the incision is larger, and the healing time may also be longer. On rare occasions, when a cataract has become dislocated due to injury or disease, the doctor may perform intracapsular surgery in which both the lens and the capsule are removed.

The next step is to replace the original lens. Prior to surgery, the surgeon will have made detailed measurements of the curvature of the cornea and the length of the eye and chosen the right replacement lens, called an intraocular lens. The intraocular lens is made of either silicone or acrylic and is folded to fit through the same small incision made for the phacoemulsification phase of the operation. The new lens unfolds as it enters the capsule. Tiny plastic loops attached to the implanted lens hold it in place. Once the lens is in place, the surgeon closes the incision, usually without stitches. The entire procedure takes no more than 30 minutes.

The intraocular lens becomes a permanent part of the eye and will generally restore a patient's vision to what it was before the cataract developed. Occasionally, problems during surgery or coexisting eye conditions will rule out use of an intraocular lens. In these cases, contact lenses or eyeglasses are prescribed.

Getting Ready for Surgery
You may be asked to avoid aspirin and other anticoagulants for several days before the procedure. You also will be told to abstain from eating or drinking anything for about six hours before your surgery.

In preparation for surgery, you will be given a mild sedative. After the area around your eye is cleaned, you will receive an injected or topical local anesthetic to numb the eye and drops to dilate the pupil and keep it from moving. Although you'll be aware of your surroundings during the procedure, you will not feel any pain or even know whether your eye is open or closed. However, if you're very nervous or have a limited ability to cooperate, the procedure can be done under general anesthesia.

What Happens After Surgery?
After surgery, the doctor will place a bandage or shield over your eye that can be removed about four hours later. After resting in the recovery area, you may go home (you will need someone to drive you). The doctor will prescribe antibiotics and anti-inflammatory drugs to take following the surgery to help healing and, if necessary, to control pressure in the eye. To avoid complications, you need to follow your doctor's instructions precisely.

For the first few days, your eyes may feel itchy or sticky, tear a bit, and be sensitive to light. This is normal. But if you experience severe pain or a drastic change in vision, contact your doctor. During recovery keep your eye clean, removing any discharge from around the eyelid. Avoid jarring head movements and do not touch or rub your eye. Your doctor will give you an eye shield to guard against unintentional rubbing during the night. Finally, when you are outdoors, wear UV-blocking sunglasses.

Your ophthalmologist will want to see you for several follow-up visits to make sure your eye is healing properly. The first visit takes place the day after surgery, with additional appointments after one week, three weeks, and six to eight weeks.

Some people notice improvement in their eyesight within an hour of surgery. For others, it takes up to several weeks for their vision to return to normal. After living with cataracts for some time, you may need a while to adjust to vision through clear lenses. Colors, in particular, may appear more luminous. Eyeglasses will not be prescribed until your vision fully stabilizes, generally three to six weeks after surgery.

How Can I Lower My Risk for Cataract?
The biggest risk factor for cataracts is age. While you can't slow the passage of time, you can do a few things to reduce your level of risk:

Stop smoking. Smoking has been consistently linked with the development of cataracts.
Wear sunglasses. Cataracts also have been linked to exposure to the sun's ultraviolet B (UVB) rays, which also cause sunburn and skin cancer. Sunglasses approved for "general purposes" by the American National Standard Institute can block 95% of UVB rays.
If you are diabetic, control your blood sugar. Uncontrolled diabetes can lead to several eye problems, including cataracts.
Get your antioxidants. Several epidemiologic studies have found fewer cataracts among people who have a high intake of antioxidants, which are thought to block oxygen free radical damage to the eyes' lenses. Results from the randomized Age-Related Eye Disease Study (AREDS) are due next year and should shed some light on the role of antioxidants in preventing cataracts. Eating several servings of fruits and vegetables daily is always a good idea and will provide you with plenty of antioxidants.
Resources
• American Academy of Ophthalmology

P.O. Box 7424

San Francisco, CA 94120-7424

www.eyenet.org

National Eye Institute
2020 Vision Place
Bethesda, MD 20892

(301) 496-5248

www.nei.nih.gov

• A special report, "The Aging Eye," is available for $16 from:

Harvard Health Publications

P.O. Box 421073

Palm Coast, FL 32142-1073

E-mail: harvardpro@palmcoastd.com

PHOTO (BLACK & WHITE): Cataract Surgery

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