Cataract surgery

Some people try to make up for their vision loss using eyeglasses or contact lenses at first. This can be effective for a while if the cataracts progress slowly and vision is only slightly impaired.

If your eyesight gets a lot worse, surgery is the only treatment that can improve vision in the long term. There are no effective medications for the treatment of cataracts.

Whether and when to have surgery is a personal decision. It will greatly depend on how much your vision loss is affecting your everyday life. The following factors might play an important role: How good does your eyesight have to be for you to be able to do your job? Are there certain things that you can no longer do, such as reading and sports? Do you have problems finding your way around when you're out and about? Is it becoming too dangerous for you to drive a car?

As long as there are no problems, surgery isn't necessary – even if doctors find that the lens has started to become cloudy. If you’re not sure about surgery, it might help to get a second opinion from a different doctor.

Your vision will typically improve after surgery – even if the cataract is at an advanced stage. But the surgery is more difficult if the cataract is very advanced. It is then harder to measure the eye accurately in preparation for the new lens. So it's a good idea to have your eyes examined regularly by an eye doctor (an ophthalmologist). You can then talk to them about the right time for having surgery.

If both eyes are affected by cataracts, one eye is operated after the other.

Another factor that is important for the decision is whether or not you have other (eye) conditions that could influence the outcome of surgery. For example, some people also have glaucoma, age-related macular degeneration (AMD) or eye damage from diabetes. Then the surgery often doesn’t improve their vision.

Although most operations do not lead to complications, problems can arise. Your eye doctor should thoroughly inform you about the possible pros and cons of surgery before it is carried out. Because cataracts progress slowly and are not an emergency, there is no need to rush into any decisions about whether or when to have surgery.

Cataract surgery involves removing the cloudy lens and replacing it with an artificial lens. To make sure you don't feel any pain during the operation, your eyes will first be numbed using drops, a gel or an injection. You can also ask to be given a sedative – or general anesthesia. During the operation, your eyelids are held open with an eye speculum.

At the beginning of the operation, the doctor makes a small cut at the edge of the cornea (the clear covering of the eye) using a scalpel. Next, the membrane around the lens is opened at the front. The inner core and outer cortex of the lens are then broken up into small pieces using ultrasound and sucked out through the small cut (a procedure called phacoemulsification). Once the old lens has been removed in this way, an artificial lens is implanted. The artificial lens can normally stay in your eye for the rest of your life. Stitches are usually not needed at the end of the operation because the cuts are so small that they normally heal quickly on their own.

Phacoemulsification is the standard procedure in Germany and is paid for by public health insurers. But some doctors offer to do the operation with a laser instead (femtosecond laser). Here, the laser is used to make the cuts and break the lens up into small pieces. This laser-assisted cataract surgery has no health-related advantages: The procedure with a scalpel and ultrasound is just as safe and effective. But you have to cover some (or all) of the costs of laser surgery yourself. It costs around 700 to 2,100 euros.

Cataract surgery takes about 20 to 30 minutes. You can usually go home on the same day, being picked up a few hours after the procedure is over. If more intensive care is needed (for example, if you have other medical conditions), the surgery may be done in a hospital.

During cataract surgery, the eye can usually be numbed enough using only a local anesthetic in the form of eye drops or a special gel. It can also be numbed by injecting the anesthetic next to the eye.

Research has shown that people who have the injection feel somewhat less pain during the surgery. But you can usually only feel slight pressure or slight pain when the eye is numbed with eye drops or the gel.

Eye-drop-related complications occur in less than 1 out of 100 procedures. The injections often lead to minor complications such as bruising, or swelling of the conjunctiva (a protective membrane in the eye). But this doesn't usually have any lasting effects. Serious anesthesia-related complications are very rare.

Anesthetic eye drops don't affect the eye muscles, so you can still move your eyes during the surgery. For this reason, people are asked to look in one direction and keep their eyes still throughout the procedure. Because you need to be very focused and calm to do this, anesthetic eye drops aren't the right option for everyone.

The type of anesthesia doesn't affect your ability to see after the operation.

About 9 out of 10 people can see better after surgery than before: they have sharper vision with more contrast. They can see near and far away objects better again, and they can see more in dim light. But depending on the type of lens used, you may still need glasses after the operation.

Cataract surgery can improve your quality of life and make everyday activities easier. Many people are able to do things that were no longer possible, or were difficult, before the surgery – like driving a car, reading and working at a computer screen. Research suggests that older people who get a new lens have a lower risk of falling. But it can take a few weeks or months for your eyesight to improve to the fullest extent.

The artificial lens will usually last for a lifetime and won't wear out or become cloudy. This means that it probably won’t need to be replaced.

But sometimes a secondary cataract (also known as posterior capsule opacity) develops. Then the part of the lens capsule behind the artificial lens becomes cloudy in the months or years after the operation, causing your vision to worsen again. It is estimated that 25 to 40 out of 100 people develop secondary cataracts within five years of initial cataract surgery. Secondary cataracts can be treated with a laser. The laser treatment only takes a few minutes and you can go home afterwards. You do not need to have surgery again.

Cataract surgery does not usually cause complications. But inflammations, injuries, bleeding and wound-healing problems are possible. This can lead to vision problems that need to be treated.

The most common problems that occur during the surgery are

• damage to the lens capsule (in about 2 out of 100 people) and
• damage to the iris or eyeball (in less than 1 out of 100 people).

The most common problems that occur after the surgery are

• swelling of the retina (in about 2 out of 100 people),
• lens dislocation, where the lens moves out of place (in about 1 out of 100 people),
• retinal detachment (in about 1 out of 100 people) and
• an infection inside the eye, known as endophthalmitis (in less than 1 out of 100 people).

Complications like swelling and bruising are more likely if the eye is numbed using an injection. The risk of complications is also higher in people who have other eye conditions too. For example, the risk of retinal detachment is higher in people who have severe myopia (are very nearsighted).

Although most complications do not have any lasting effects, they can lead to temporary problems such as worse vision or slower wound healing. You might have to take medication for a while, or further eye surgery might be needed.

The most dangerous complication is an infection inside the eye. This happens when germs get deeper into the eye and multiply there. Signs include pain, swelling, a red eye and your eyesight becoming a lot worse. If these kinds of symptoms occur in the days and weeks following surgery, it is important to go to an eye doctor immediately. The infection may lead to blindness or loss of the eye, so it needs to be treated with antibiotics as soon as possible. To reduce the risk of this kind of infection, the surgeon often puts antibiotics into the eye towards the end of the procedure. You also get a prescription for antibiotic eye drops to be used daily after the operation.

Bleeding in the eye can lead to vision problems, too. But this happens in much less than 1 out of 100 people – making bleeding even less common than infections inside the eye.

Artificial lenses are also known as intraocular lenses (IOLs). They can greatly improve your vision in certain ways – even though no artificial lens can adjust its focus between near and far objects as flexibly as a natural lens can. There are different types of artificial lenses:

• Monofocal lenses: This type of lens allows clear vision at one distance only. In other words, you have to decide beforehand what kind of monofocal lens you would like, depending on whether you would prefer sharper vision when looking at things that are far away, at medium range, or nearby. Wearing glasses can help you see things at the other distances more clearly. For instance, if you choose a lens that allows you to see things that are far away clearly, you would need to wear glasses to read a book.
• Multifocal lenses: This type of lens makes it possible to see both near and far objects clearly. So you might not need to wear glasses. But your vision may still remain blurred at some distances. You can see slightly less contrast with multifocal lenses than you can with monofocal lenses. People with multifocal lenses are also more likely to be dazzled by light, for example when driving at night.
• Extended-depth-of-focus (EDoF) lenses: Like multifocals, this newer type of lens allows clear vision both when looking at things that are far away and nearby. But the latter is only possible when looking at things at "computer screen distance" – you still need glasses to read books, for instance. They're less susceptible to glare than multifocal lenses are, though.
• Toric lenses: This type of lens is especially suitable for people who have astigmatism. Their shape is individually adapted to the shape of the eye's cornea in order to correct a refractive error. There are monofocal and multifocal toric lenses.
• Blue-light-blocking lenses: These lenses filter out blue light with the aim of better protecting the retina. But they weren't proven to have this effect in studies. There are monofocal and multifocal blue-light-blocking lenses.

Multifocal lenses, toric lenses, blue-light-blocking lenses and EDoF lenses are more expensive than monofocal lenses. You have to pay for the extra costs yourself. So it's a good idea to carefully consider the pros and cons of the different types of lenses. It might be helpful to get a second opinion from a different eye doctor. Your health insurer can provide information about cost coverage.

Getting a well-fitting lens with the right strength (refractive power) is more important than the lens type. The eye doctor will do the necessary tests before the operation.

You should wear an eye patch for the first 24 hours after surgery. Your eye might itch or hurt a little, and it may feel like you have something in it. These problems usually go away again after a few days. It is important to not rub or push against your eye if you have just had surgery. But it is alright to carefully touch the eye. For the first few days after the surgery, take care to keep water, shampoo and soap out of the operated eye when you take a shower or wash your hair.

You can return to most everyday activities as usual after a few days, apart from driving a car. You also shouldn't read anything (be it a book, a newspaper or something on a screen) for one week – or do any sports activities that involve vibrations (like jogging or cycling) for up to two weeks. It is okay to watch television, though. It is best to discuss further details with your eye doctor. They will also let you know when your eyesight is good enough for you to start driving a car again. This is usually possible after a few weeks.

Depending on the kind of work you do, you will be able to return to work within one to two weeks. People who have an office job can usually go back sooner than those who have a physically demanding job.

The doctor will prescribe various eye drops for the time after the surgery. These prevent infections, reduce inflammation and moisturize the eye. You will also be given appointments for follow-up care at the eye doctor's. Because your eyesight still changes a bit after the surgery, glasses should only be adjusted after several weeks.