How to really treat Cataract?

Introduction The opacification of the normal transparent lens is called cataract. The Latin word 'cataracta' means 'waterfall'. Imagine trying to peer through a sheet of falling water or through a frosted or fogged-up window.
Dr. Niteen Dedhia’s talk on Cataract Treatment

History of Cataract treatment

Cataract11The earliest surgery treatment began in India. It was known as 'couching'. The sclera was incised. The lens was then dislocated backward into the vitreous and out of the optical axis.This procedure was performed for more than two thousand years until the mid-eighteenth century. Great progress in cataract surgery has been made in recent years with the introduction of micro-surgical instruments, microscope and modern surgical techniques like phaco-emulsification.
In the early stages of cataract development, all that is needed to correct your vision with glasses is a change in prescription. As the cataract develops and begins to affect your lifestyle, it needs to be removed. Cataract surgery, the most commonly performed surgery, is safe and effective in 95% patients with enhancement in vision.
Methodology The procedure of cataract surgery by Phacoemulsification technique Phacoemulsification
  • During this procedure, the surgeon will first create a small incision with an advanced diamond blade.
  • The surgeon will then peel off the front layer of your lens capsule.
  • Using ultrasound from small sophisticated instruments, the surgeon will break up your cataract into minute fragments.
  • The instruments then use gentle suction to extract these fragments out of the eye.
  • An intra-ocular lens is implanted to replace your natural lens.

Classification of cataracts

Cataracts are classified as per their morphology (form and structure) and as per their maturity.
  • Capsule
  • Cortex
  • Nucleus
The primary function of the bi-convex lens is to refract and focus light on the retina while remaining transparent. This transparency depends on the maintenance of structural (anatomic) & functional (physiologic) integrity. The lens is 66% water,the least hydrated organ of the body. The remaining bulk is composed mainly of protein. It is devoid of any blood supply and derives its nourishment from the surrounding aqueous and vitreous. a)Morphological types
  • Capsular : Focal thickening of lens capsule
  • Sub-capsular
  • Cortical : Opacification of cortical fibres
  • Nuclear Cataract
b) According to maturity
  • Immature : Scattered opacities are separated by clear zones.
  • Mature : Cortex and nucleus become totally opaque.
  • Intumescent : The lens becomes swollen by absorbing water.
  • Hyper-mature Cataract : Mature cataract, which has become smaller and has a wrinkled capsule as a result of leakage of water out of lens.
  • Morgagnian Cataract : A Hyper-mature cataract, in which total liquefaction of cortex allows the nucleus to sink inferiorly.

Causes of cataract

opaqueAge-related cataract : The cataract occurs as a result of the natural aging process of lens fibres which become opaque over a period of time.
Traumatic cataract
  • Due to a direct penetrating injury.
  • Concussion- Electric shock and lightning.
  • Ionizing radiation to ocular tumours.
  • Surgical trauma
Metabolic cataract : Defect in body metabolism
  • Diabetes
  • Galactosaemia -inborn error of metabolism
  • Calcium disorders
  • Toxic cataract
Steroid-induced cataract This occurs as a result of excess intake of oral steroid or putting steroid drops in the eye. Other cataract inducing drugs: Chlorpromazine, Miotics, Busulphan, Amiodarone, gold Secondary cataract Here, cataract develops as a result of some other primary ocular disease such as chronic inflammation due to any cause. Development of cataract It varies from person to person but as a general rule, most cataracts develop slowly over a period of time. A cataract can take months or even years to reach a point where it adversely affects vision.

How do cataracts affect normal lifestyle?

One may not be aware that a cataract is developing if the size and location of the cloudy areas in the lens are not in the pupillary area. As the cataract progresses, there is deterioration of distant and near vision. life-style
  • One may experience hazy, fuzzy and blurred vision.
  • The eye may also be more sensitive to light resulting in glare and making night-driving difficult.
  • There may be a need to change the eye-glass prescription in the early stages, which may help temporarily.
  • As the cataract develops further, stronger glasses would no longer improve the vision.
  • This can lead to imbalance between the two eyes, which may cause headaches.
  • One may also experience poor night-vision, poor depth-perception, e.g. difficulty in getting downstairs.

Methods of evaluation of cataract

Visual acuity : Checking vision of both eyes unaided, aided with glasses and correlate it to the severity of cataract. Intra ocular pressure - If intra-ocular pressure increases secondary to cataract as in intumescent cataracts, surgery is needed to prevent further complications. Slit-lamp examination - To know the type of cataract along with the extent of opacity, morphology or any associated ocular pathology. Direct and indirect ophthalmoscopy: : Fundus examination to rule out any pathology that may limit visual outcomes following surgery, Dense (may prevent retinal evaluation) A-scan biometry - To calculate the AL and IOL power for implantation. In cases of mature cataract the posterior segment of the eye is evaluated using B-scan USG.

Treatments for cataract

No presently available medical treatment can prevent cataracts or reverse them once they develop.
  • The only treatment for cataract is their surgical removal.
  • The decision to operate is taken by the patient and the doctor together.
  • This decision is based on the degree to which the cataract is impairing vision and the effect it has on patient's lifestyle.
  • It is the decision only the patient and the doctor can make, as based on needs of the individual.
  • With modern advances in cataract surgery, one should not wait for the cataract to mature. Surgery should be undertaken when the opacity impairs vision significantly.

Various treatment options available for cataract extraction

  • Extra-Capsular Cataract Extraction (ECCE): is a conventional technique. It requires
  • requires an incision of 10-12mm
  • The doctor removes the clouded lens in one piece piece following which a non-foldable IOL is implanted.
  • Multiple stitches are required.
  • This results in increased chances of post-operative cylindrical power (astigmatism).
  • Micro-incision cataract surgery: Phaco-emulsification is a modern technique.
liquifiedPhaco-emulsification is the latest technology in cataract surgery.
Methodology
  • It is a micro-incisional stitch- less operation.
  • The ultra-sound energy emulsifies the cataract.
  • It is liquefied and sucked through the phacoemulsifier probe.
  • Then the surgeon implants a foldable intra-ocular lens in the eye permanently.
It is the least traumatic form of cataract surgery with early rehabilitation and recuperation. Vision restoration is possible in a short period of time.

Advantages of phaco-emulsification

  • The operation is atraumatic to the eye.
  • It is a day-care procedure without the requirement for overnight hospitalization .
  • In most cases, the surgeon performs the surgery by administering local anaesthetic drops without giving any injection .
  • Hence no patch is necessary after the surgery in most cases.
  • Least chances of infection.
  • Quicker healing and recovery.
  • The patient gets good quality vision within 24-48 hours.
  • Minimum post-operative precautions.
  • The patient can resume professional work in the shortest possible time.
  • One may need to wear glasses only to fine-tune one's vision, although glasses may be needed for clear near-vision depending on the type of IOL implanted.
  • One can reimburse the cost for the surgery through Mediclaim.

Lens implants

During cataract surgery, the natural lens of the eye that has turned opaque is removed, resulting in loss of focusing power of the eye. When the natural lens of the eye is removed an artificial implant is placed in the eye.

Intra-Ocular Lens (IOL)

Intra-ocular lenses may be rigid or flexible. The flexible IOLs are made from either Silicone or Acrylic so that they can be folded to allow insertion through a much smaller incision as compared to rigid IOLs. SofPort® AO Lens with Violet shield Technology
softportDescription The new SofPort AO lens with violet shield technology is designed to be aberration free and thus reduces spherical aberration for better vision quality relative to standard spherical IOL's.

Indications for cataract surgery

Visual improvement.
  • Medical indications in which the presence of a cataract adversely affects the health of the eye e.g. lens-induced glaucoma.
  • Cosmetic indications: A mature cataract in an otherwise blind eye is removed to restore a black pupil.

How do I decide whether to have a cataract surgery?

After you inform the doctor about how your cataract affects your vision and your life, you and your doctor can decide about the corrective course of action.
  • My glasses do not help me see well enough.
  • Driving is a problem – there is too much glare from the sun during the day-time and headlights at night.
  • I do not see well enough to do my best at work.
  • I do not see well enough to do things I need to do at home.
  • I do not see well enough to do things I like to do (e.g. watch T.V, sew, play cards, go out with friends)
  • I am afraid I will bump into something or fall.
  • I am not as independent as I would like to be.
  • My eyesight bothers me a lot.

Benefits of cataract surgery

Cataract surgery gives you back the ability to drive, read and continue work. You can also get back to your social activities and hobbies. Risks of cataract surgery : Some of the possible complications are
  • High pressure in the eye.
  • Blood collection in the eye.
  • Infection.
  • RD (Retinal Detachment).
  • Swelling / clouding of the cornea.

Instructions for Surgery

What you should know or do before going for surgery
  • Know your general health status.
  • Treatments related to other active diseases before surgery.
  • Pre-operative investigations like blood tests, ECG and glucose levels should be recorded.
  • Carry out the pre-operative instruction as per the scheduled date and time as given by your doctor.
Pre-operative instructions
  • Have light breakfast four hours before arriving at the hospital.
  • Use the eye drops as instructed- one starting three days prior to the date of the surgery and the second on the day of surgery in the eye which is to be operated.
  • Take the dose of regular medication which you are already taking for the systemic illness if any.
  • Take a head bath and dress comfortably.
  • Visit the clinic accompanied by one or two persons at the most.
  • Carry your case papers, reports, sunglasses and necessary medication.
  • Register at the reception counter for admission.
  • Read and sign the consent form for the operation and take instructions from the optometrist.
  • If for some reason you have any questions, the doctor or one of the optometrists will answer them before the surgical treatment is begun.
  • Stop taking blood-thinning or anti-inflammatory medications including Aspirin three days prior to the day of your surgery, after consulting your physician.
  • Plan to have someone drive you home following surgery.
  • Plan to have a parent or legal guardian with a disabled person.
  • If there is any change in appointment, call up at the centre and inform a day prior to the date of surgery.
  • Do not apply make-up or wear jewellery.
  • Do not carry expensive goods with you.

Area of operation

The assistant will take you to the area where you would be prepared for the surgery. You will change into surgical clothes, cap, etc. Pre-operative medication will be administered by way of anaesthetic drops, injections or sedatives if necessary. One person will help you to enter the operating room and lie down on the operation table. You will always have somebody by your side to assist and help you during the surgery. Surgical wash The two eyelids will be carefully cleaned with the anti-bacterial solution and drops will be instilled to clean the eyes and to make the area sterile during the surgical procedure. After surgery An assistant will help you to leave the operation theatre and go to the recovery room where you may rest for some time. After this, the person accompanying you, can take you home to rest. Good vision is necessary to enjoy your life to its fullest extent!