Small incision cataract surgery with intra-ocular lens correction

General information about cataracts What is a cataract?

What causes cataract?

A cataract is a clouding of the lens of the eye. Your vision becomes blurred because the cataract is like frosted glass, interfering with your sight. A cataract is not a skin that grows over the surface of the eye. Like the lens in a camera, the lens of the eye is inside the eye, towards the front just behind the iris (the coloured part of the eye).

The most common type of cataract is related to ageing of the eye and is most often found in persons 55 years or older. Other causes of cataract include family history, medical problems such as diabetes, injury to the eye, medications especially steroids, and previous eye surgery.

How fast does cataract develop? How quickly the cataract develops varies among individuals and may even be different between the two eyes. Most age-related cataracts progress gradually over a period of years.

How does cataract affect your sight? The most common effect of cataract is blurring or misting of vision. It may seem as if your glasses have become dirty or scratched when they are not. You may notice you need a brighter light to read. You may be dazzled by lights such as car headlamps and sunlight, and you may notice a change of colour vision such that objects may appear washed out or faded.

Other cataracts, especially in younger people and people with diabetes, may progress rapidly over a short time. It is not possible to predict exactly how fast cataracts will develop in any given person.

How is cataract treated? Surgery is the only way a cataract can be removed. However, if symptoms of cataract are not bothering you very much, surgery may not be needed. Sometimes a simple change in your glasses prescription may be helpful.

PAG E 2 | MIDLA N DS EY E C A RE - SMAL L INCISION CATARAC T SURGERY W I T H I N T R A -O C UL A R L EN S C O R R EC T I O N

No medications, dietary supplements or exercises have been shown to prevent or cure cataracts. When should surgery be done? In the past, eye specialists often waited until the cataract became “ripe” and the vision was very poor before the cataract was removed. Nowadays, with modern surgery, the operation can be done as soon as your eyesight interferes with your daily life and your ability to read, to work, or do the things you enjoy. You will probably want to consider surgery if this is the case. If you are a driver you must reach the visual standard required by the Driver and Vehicle Licensing Authority (DVLA) and it may be necessary to have the cataract removed in order to keep your licence. If you have other conditions affecting your vision, such as ageing of the retina at the back of the eye (called Age-Related Macular Degeneration) you may not experience much improvement in vision after cataract surgery. If improvement in your vision is unlikely we may advise you not to have the cataract removed.

W W W. MI D L A N D S EYECA R E. O R G | C O N TAC T US @ MI D L A N D S EYECA R E.ORG | PAG E 3

General information about cataracts What can I expect from cataract surgery? Cataract surgery is now the most commonly performed surgical operation worldwide and more than 96% of patients experience an improvement in vision. Fewer than two per cent of patients have serious, unforeseen complications. Cataract surgery is usually performed under local anesthesia as a day case. The eye surgeon does the operation with the aid of a microscope, through a small incision in the eye. This incision is so small that stitches are not usually necessary. The cataract is broken up with an ultrasound probe and the lens fragments are removed from the eye. In most cases the focusing power of the eye is restored with an intraocular lens implant which remains permanently in the eye. The operation generally takes about 15-20 minutes, although it can last longer. We do not perform cataract surgery with laser, although laser treatment is sometimes needed afterwards if the lens casing (the capsule), which is usually left in place, becomes cloudy.

What is an intraocular lens implant? Most modern intraocular lens implants are made with acrylic or silicone, and can be rolled up inside an inserter or folded so that they can be inserted into the eye through a small incision. Once inside the eye the intraocular lens unfolds and is placed behind the iris, in the same position as the eye’s natural lens. Intraocular lenses can be manufactured to any strength. Measurements of the eye (biometry) taken during the pre-operative assessment determine the strength of the lens to be inserted. Most people prefer to have an intraocular lens that will correct their vision so that they will see clearly in the distance without glasses or with just a small prescription. Reading glasses will still be needed.

PAG E 4 | MIDLA N DS EY E C A RE - SMAL L INCISION CATARAC T SURGERY W I T H I N T R A -O C UL A R L EN S C O R R EC T I O N

Cataract surgery generally takes about 15-20 mins. with 96% of patients experiencing improved vision. Are there different types of intraocular lens implant? There are many different designs of intraocular lens but in general they fall in the following categories: • Single focus intraocular lenses: The most common type of intraocular lens has a single focus (like single vision glasses). If a single focus lens is inserted that corrects the eye for distance, reading glasses (or bifocals or varifocals) must be worn for close work. Conversely an intraocular lens can be chosen that corrects the eye for near, and distance glasses must then be worn. • Multifocal intraocular lenses: In recent years multifocal intraocular lenses have been developed that can focus for distance and near. Ideally a patient with a multifocal intraocular lens does not need to wear glasses at all. In practice some people can have difficulty in adjusting to these lenses and can experience blurring of vision and haloes around lights. • Accommodating intraocular lenses: Another type of intraocular lens, called an accommodating intraocular lens, is designed so that it can move a little forwards and backwards in the eye. As the lens moves forward it increases the focus for near. The advantage of this type of lens is that it does not give rise to

problems with blurring of vision or haloes. Unfortunately the amount of focusing by this type of lens can vary, and for some patients it may not focus for near at all and will function just like a single focus lens. • Yellow filter intraocular lenses: Some intraocular lenses have a yellow filter that reduces the amount of blue light that can damage the retina at the back of the eye. The yellow filter lenses do not affect your perception of colour and they generally do not cost more than a standard lens. Surgeons at Midlands Eye Care Ltd recommend this lens for most patients. • Toric intraocular lenses: These lenses can correct for astigmatism as well as restoring the focussing power of the eye. Astigmatism occurs when the cornea, the clear window at the front of the eye, is rugby-ball shaped and not spherical. Toric intraocular lenses neutralise corneal astigmatism, giving the patient clearer vision without glasses or contact lenses.

Note: Such special lenses are expensive and are not available to NHS patients. Most private insurance companies will require the patient to pay for the additional cost of these lenses. W W W. MI D L A N D S EYECA R E. O R G | C O N TAC T US @ MI D L A N D S EYECA R E.ORG | PAG E 5

About your cataract operation If your consultant ophthalmologist at Midlands Eye Care has advised that cataract surgery will improve your vision and you have agreed to proceed, the following arrangements will be made: Preoperative assessment A week or two before the planned operation we will ask you to attend for a pre-operative assessment. This takes about an hour. It is helpful if you can bring a friend or relative and make arrangements to have somebody take you home. You will be unable to drive yourself, as the pupils will be dilated. We will need to know your current medications so please remember to bring all your medications (or a list) with you.

During preoperative assessment you will have a number of assessments and tests: General assessment: You may be asked about general health issues, home circumstances, support, and after-care. If you have any special requirements or do not have anybody to look after you on the night after the operation, you may need to stay in hospital for one night.

Eye examination and biometry: Your eyes will be examined to see if you have any eye conditions that can affect the outcome of cataract surgery. Measurements of the eye – called biometry – will be undertaken to determine the power of the intraocular lens that is required to focus your eye once the natural lens (cataract) has been removed. Planning the surgery and consent: The doctor will discuss and agree the plan for surgery with you and the type of anaesthetic you will require. He or she will discuss whether you would like to have your eyes focused for near or distant vision, and any options for multifocal or filter lenses. You should read the section in this booklet about complications of cataract surgery and the doctor can give you more explanation if you wish. You will then be asked to sign a consent form. Please feel free to ask questions about any aspect of your cataract operation. You may find it helpful to bring along a list of these questions. Any additional tests (x-ray, blood tests, ECG), if needed, will be scheduled at this time.

PAG E 6 | MIDLA N DS EY E C A RE - SMAL L INCISION CATARAC T SURGERY W I T H I N T R A -O C UL A R L EN S C O R R EC T I O N

Anaesthesia for cataract surgery Local anaesthesia is the preferred form of anaesthesia for 95% of all cataract operations. During local anaesthesia you will be awake but should feel no pain. You must be able to keep still for about 20 minutes. Please, let us know if lying on your back with one firm pillow for 20 minutes is a problem for you. There are different ways local anaesthesia may be administered: 1. Subtenons anaesthesia. The eye is numbed with anaesthetic drops, then an anaesthetic solution is injected through a blunt cannula around the eye. You will feel a sensation of pressure and variable discomfort lasting up to 30 seconds. Following the injection a firm bandage is placed over the eye for a few minutes to spread the anaesthetic. After that the eye is numb and the operation itself will cause no discomfort. The anaesthetic solution also reduces the movement of the eye and therefore you do not need to worry about keeping the eye still. 2. Subtenons anaesthesia with sedation. This option is possible if you are very nervous and would find it difficult to lie still for 20 minutes. A sedative is given as a tablet or intravenous injection to calm you or to keep you lightly asleep for the duration of the operation. 3. Topical anaesthesia. Drops or gel are given to numb the surface of the eye. You will be aware of the small surgical device that keeps the eye open during the operation. You will

still be able to move your eye and the surgeon will therefore ask you to look in certain directions during the procedure. Further anaesthetic solution can be placed inside your eye to reduce any discomfort. Most patients are aware of gentle movements and minor pressure on the eye, and also the irrigating solution feels cool. There are advantages and disadvantages of the different types of local anaesthesia. Subtenons anaesthesia takes several hours to wear off and you may experience transient double vision during this time. Topical anaesthesia wears off after a few minutes but some patients find it difficult to co-operate during topical anaesthesia. General anaesthesia may be necessary in some instances. With general anaesthesia you will be completely asleep during the procedure. If you are very nervous, have difficulty lying still for about 20 minutes or have a head tremor that you cannot control, then general anaesthesia is preferred. Also your surgeon may recommend general anaesthesia if you are very shortsighted or need to have both eyes operated on at the same time.

W W W. MI D L A N D S EYECA R E. O R G | C O N TAC T US @ MI D L A N D S EYECA R E.ORG | PAG E 7

The day of surgery What is a cataract operation? On arrival at the hospital you will be greeted by the nurse who will be caring for you that day. Before going to theatre we will ask you to exchange your top for a clean gown. The eye will be cleaned and drops to dilate the pupil will be instilled at intervals. This takes up to 30 minutes. You will be visited by the anaesthetist who will be administering the local or general anaesthetic. He or she will assess whether you have any special requirements for anaesthesia and will be with you throughout the operation. Your nurse will accompany you to theatre and hand you over to the theatre staff. The anaesthetic will be given in the anaesthetic room and you are then transferred to theatre. For the surgery, which lasts about 20 minutes, your head will be covered with a drape. Fresh air is delivered under the drape, and the drape is lifted away from your nose and mouth so you can breathe normally. During the operation a nurse will sit with you and hold your hand. As we would like you not to speak once the operation has started, the hand is your route of communication. Should you have any difficulties during the procedure, squeeze the hand tightly, and we will attend to it immediately.

You may vaguely see some movement but no details of the operation. Some patients describe seeing a multitude of colours during the operation, but it may be completely dark. The ultrasound machine we use to break up the cataract makes quite a lot of noise, and can sound like a vacuum cleaner, when sucking out the cataract fragments. You may be given an antibiotic injection under the eye at the end of the operation. This may sting a little. Finally an eye pad and shield is placed over the eye. If you have had a local anaesthetic you will be able to leave the hospital about one hour after surgery. Before going home the nurse will give you a packet containing the eye drops we want you to use after the dressing has been removed, some tablets to take to reduce the pressure in the eye, and an eye shield and some tape. You will also be given a card with your intraocular lens implant details which you should keep in a safe place for future reference. Arrangements will be made for your follow-up appointment. The eye pad and shield should be left in place until the following morning. If for any reason it falls off, throw the pad away, wash and dry the shield and replace it over the eye with tape. Please, rest when you get home!

PAG E 8 | MIDLA N DS EY E C A RE - SMAL L INCISION CATARAC T SURGERY W I T H I N T R A -O C UL A R L EN S C O R R EC T I O N

If you have a local anaesthetic you will be able to leave the hospital about one hour after surgery.

Post operative information Immediately after the operation... • Small incision cataract surgery normally allows you to mobilize straight away, but you are advised to rest when you get home. • It is normal for you to feel some discomfort, itching or foreign body sensation when the anaesthetic wears off. Take a mild pain relieving tablet such as Paracetamol as necessary. (2 tablets four-hourly; maximum 6 tablets per day) • Resume your normal diet, but please do not drink any alcohol for 24 hours. • Remove the dressing the next morning after the operation.

Caring for your eye... • It is usual for the eye to be a little sticky particularly in the mornings – and this will improve as healing progresses. • Only bathe the eye if it is sticky or there is discharge. Use cooled boiled water and gently bathe the lids with gauze or lint. Bathe from the nose side outwards using each piece of gauze or lint only once.

• Use your eye drops as directed. The course of drops usually lasts for 4 weeks. If you run short, please ask for more at your follow up appointment or get some from your own doctor. ALWAYS WASH YOUR HANDS before and after you clean the eye or when you use the drops. Don’t allow the tip of the bottle to touch the eye. • Secure the shield over the eye with tape at night for about 7 days. • You may gently wash your face. Do not wash your hair within the first 24 hours. Take care not to get soap, water, or shampoo into the operated eye. • PLEASE DO NOT RUB YOUR EYE. The eye takes about 6 weeks to heal, and pressure on the eye during this time may cause the incision in the eye to open up. This could seriously damage the eye. continued...

W W W. MI D L A N D S EYECA R E. O R G | C O N TAC T US @ MI D L A N D S EYECA R E.ORG | PAG E 9

Post operative information Activities and exercise... • Avoid a dusty atmosphere, heavy lifting or straining, gardening, or strenuous exercise for the first 2 weeks and then gradually increase your activities to normal. Swimming is not recommended for 6 weeks after the operation. • You may read or watch television. It is not harmful to wear your old glasses, if you find them helpful. • You may return to work after 2 weeks. If your job involves heavy manual work wait for 3 weeks. • Before you drive please talk to your Consultant as this will depend on the quality of vision in your other eye. If your vision in the other eye meets the legal requirements you can drive after about 3 days, provided you are comfortable. Dark glasses may be helpful as the eye may be quite light sensitive to start with.

Please contact us if you have any concerns... If your eye becomes painful, red, or your vision becomes more blurred, or if you have any other concerns, please contact us. We can be reached via the following telephone numbers:

Midlands Eye Care Ltd 01283 561320

Burton Clinic Queen’s Hospital, Burton 01283 500660

Nuffield Hospital, Derby 01332 540100

Follow up • Following surgery you will receive one or two further appointments with the Consultant to review the progress of your eye. • Four weeks after the operation you can make an appointment with your Optician to change the lens in your glasses.

PAG E 1 0 | MIDLA N DS EY E C A RE - SMAL L INC ISION CATARACT SURGERY W I T H I N T R A -O C UL A R L EN S C O R R EC T I O N



Complications of cataract surgery Small incision cataract extraction is one of the most successful surgical procedures performed today. However, any surgical intervention carries a risk and therefore surgery should not be undertaken lightly and meticulous aftercare is important. The following are the common or serious complications of cataract surgery. 1. Raised intraocular pressure. This is a common event which may lead to increased pain within the first 24 hours and makes the vision blurred. It can be treated with medication and usually settles within 3 days. 2. Allergic reaction to eye drops. Although every care is taken to avoid known allergies to medication, occasionally an unknown allergic reaction develops to the eye drops. This will manifest itself by increasing soreness, redness and swelling, usually within the first week of exposure. Should this occur, other drops will be prescribed. 3. Sutures to an enlarged incision in the eye. Occasionally it proves impossible to remove the natural lens with the ultrasound probe and the incision in the eye needs to be enlarged. Sutures for the longer incision may need to stay in place for 3 months and cause some distortion (blurring of vision). After removal the eye “straightens” out and glasses can be prescribed. Vision is unaffected in the long term.

4. Infection. Between 1 to 3 patients in two thousand develop a sight threatening infection in the eye. Severe persistent pain and significant loss of vision are the hallmarks of this complication, which may occur within 48 hours or as late as 3 weeks after the operation. Vision may be permanently impaired, and immediate advice should be sought as prompt treatment improves the outcome. 5. Rupture of posterior lens capsule and vitreous loss. The natural lens has an outer envelope called the lens capsule. The back (posterior) part of the lens capsule is left in the eye to support the intraocular lens implant. In a small percentage of operations the capsule can get torn and the vitreous gel at the back of the eye may come forward and need to be removed. In spite of these additional surgical manoeuvers it is usually possible to place the lens implant into the eye. Occasionally it may be necessary to place the lens implant during a second subsequent operation. If the lens capsule is broken, there are more floaters post-operatively and the eye may take a little longer to settle. Vitreous loss increases the risk of subsequent retinal detachment.

W W W. MI D L A N D S EYECA R E. O R G | C O N TAC T US @ MI D L A N D S EYECA R E. ORG | PAG E 1 1

Complications of cataract surgery 6. Dropped nucleus. Rarely, when the lens capsule is torn some of the cataract (the nucleus or fragments of nucleus) can fall into the back of the eye. A second operation is then required to remove the nucleus. Post operative recovery is prolonged, but visual outcome can be good. 7. Retinal detachment. The retina is the sensitive tissue, like the film in a camera, that lines the back of the eye. Any cataract operation increases the risk of a retinal detachment, and that risk is greater if there is loss of vitreous during the operation. The symptoms of retinal detachment are a sudden onset of floaters, flashing lights, and a shadow coming from the edge of the vision. If a retinal detachment is diagnosed at an early stage the detachment can be repaired and vision is preserved.

8. Suprachoroidal haemorrhage. When the eye is opened to remove the cataract there is an abrupt loss of eye pressure. Extremely rarely this may lead to the rupture of a major blood vessel in the eye and massive bleeding. At best this can make it impossible to proceed with the operation, which could be done at a later stage. At worst the haemorrhage can destroy the internal anatomy of the eye with total and permanent loss of vision. 9. Corneal oedema. The cornea is the clear window at the front of the eye. The back surface is lined by cells that pump fluid out of the cornea, keeping it clear. If these cells are damaged during cataract surgery the cornea can become “waterlogged” and hazy. In most instances the cornea will become clear in days or weeks, but rarely the damage will be permanent and a corneal graft may be required.

PAG E 1 2 | MIDLA N DS EY E C A RE - SMAL L INC ISION CATARACT SURGERY W I T H I N T R A -O C UL A R L EN S C O R R EC T I O N

10. Macular oedema. The macula is the centre part of the retina at the back of the eye, and is responsible for our ability to see fine detail. For reasons that are not well understood, fluid can accumulate in the macula after cataract surgery and vision can be mildly or moderately reduced. This problem usually gets better over several weeks or months, but sometimes eye drops or tablets can speed up recovery. 11. Posterior capsular opacification. (“after” cataract) The back, or posterior, part of the lens capsule is left in the eye during cataract surgery to support the intraocular lens. By 2 to 3 years after cataract surgery up to 50% of patients will develop posterior capsular opacification (PCO). The vision becomes increasingly blurred and it can feel as if the cataract is coming back. This is not the case, and laser treatment can clear the capsule and restore vision.

If you have any queries or questions about the complications of cataract surgery please raise these with the doctor at preoperative assessment, or ask your eye surgeon.

W W W. MI D L A N D S EYECA R E. O R G | C O N TAC T US @ MI D L A N D S EYECA R E. ORG | PAG E 1 3

Who can I contact for further information? Royal College of Ophthalmologists 17 Cornwall Terrace, London, NW1 4QW

Telephone: 020 7935 0702 Website: www.rcophth.ac.uk

Royal National Institute of Blind People (RNIB) 105 Judd Street, London, WC1H 9NE

Telephone: 020 7388 1266 Helpline: 0303 123 9999 Email: [email protected] Website: www.rnib.org.uk

Driver and Vehicle Licensing Agency (DVLA) Drivers Medical Enquiries Swansea, SA99 1TU

Telephone: car & motocycle 0300 790 6806 Telephone: bus, coach & lorry 0300 790 6807 Email: [email protected] Website: www.direct.gov.uk/en/Motoring/ DriverLicensing/MedicalRulesForDrivers/index.htm

If you require a copy of this leaflet in larger print, you can download a version off our website at: www.midlandseyecare.org

PAG E 1 4 | MIDLA N DS EY E C A RE - SMAL L INC ISION CATARACT SURGERY W I T H I N T R A -O C UL A R L EN S C O R R EC T I O N

Useful addresses Staffordshire Blind 51 - 63 North Walls, Stafford, ST16 3AD

Telephone: 01785 602177 Email: [email protected] Website: www.staffordshireblind.co.uk

Sight Support Derbyshire 65 - 69 Nottingham Road, Derby, DE1 3QS

Telephone: 01332 292262 Email: [email protected] Website: www.sightsupportderbyshire.org.uk

Vista (Leicestershire Blind Association) Margaret Road (off Gwendolen Road), Leicester, LE5 5FU

Telephone: 0116 249 0909 Email: [email protected] Website: www.vistablind.org.uk

W W W. MI D L A N D S EYECA R E. O R G | C O N TAC T US @ MI D L A N D S EYECA R E. ORG | PAG E 1 5

59 New Street, Burton-on-Trent, Staffordshire DE14 3QY

Tel: 01283 561320 e-mail: [email protected] web: www.midlandseyecare.org