Ординатура / Офтальмология / Английские материалы / The Eye Book A Complete Guide to Eye Disorders and Health_Cassel, Billig, Randall_2001
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with no sutures (or one suture) really help patients recover faster. There’s also less chance for unwanted postoperative astigmatism due to sutures being too tight or too loose. On the other hand, procedures involving a larger surgical incision must be closed using many more sutures. Recuperation from these procedures is usually longer, with a greater chance for astigmatism.
At the end of surgery, you’ll probably receive an antibiotic medication in the eye; then a light eye patch and shield will be placed over it. You’ll be taken to a recovery area where—finally—you can break your surgical fast. Eat, drink, and be merry, for the operation is over!
After Surgery
You’ll be able to go home shortly after the operation, but somebody else must drive you, because you’ll still be drowsy. (Even if you think you’re fully alert, have someone drive you anyway.) You’ll probably need someone to drive you again for your first follow-up appointment, the next day. Overall, most people don’t find the surgery difficult; many patients report that it was painless and not nearly as taxing as they had expected.
You’ll go back to your eye surgeon and/or your referring eye care provider for several postoperative visits. These are generally scheduled as follows: the day after surgery, and then at one week, three weeks, and six to eight weeks afterward. You may need to be seen more frequently if you have any complications or an unusual postoperative course.
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Rest and relaxation are the marching orders during the first twenty-four hours after cataract surgery. For most patients the evening of the operation usually includes some mild eye discomfort and headache, which can be treated with over-the-counter analgesics. Lingering postoperative drowsiness, an effect of the anesthesia, is not uncommon. (Note: Immediately report any severe pain, nausea, vomiting, or other unusual symptom to your eye surgeon.) The next day you’ll go back to your surgeon and have the eye patch and shield removed (if you were given them after surgery). Many patients notice an immediate improvement in vision; lights are brighter, colors are more vivid, even objects are better defined. Your vision will continue to improve gradually over the next several weeks.
The old restrictions—in which patients were warned not to lift or bend after cataract surgery—are becoming passé. Stories of patients dislodging implant lenses or tearing open their cataract wound as they bent over to tie their shoes or brush their teeth now belong to cataract folklore. Today most cataract patients resume their normal activities—including reading, driving, and work- ing—almost immediately after surgery. Recommendations regarding showering, bathing, and visiting the beauty parlor have also been changed. (However, it’s a good idea to discuss these activities, as well as the resumption of golf, tennis, swimming, bowling, or gardening, with your doctor beforehand.) Common sense is usually your best guide to resuming normal activities after cataract surgery.
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You’ll probably need to wear some covering over the operated eye for one to two weeks after surgery, either your old eyeglasses or a lightly tinted pair of sunglasses. This will help protect the eye from an accidental finger (your own or a grandchild’s), foreign object, bump on the eye, or other form of trauma. At night you’ll probably wear an eye shield to keep you from inadvertently rolling onto the operated eye or rubbing it during sleep. Antibiotic and anti-inflammatory eye drops are commonly prescribed after surgery to prevent eye infections and eliminate swelling and discomfort.
Complications
Complications of cataract surgery are generally mild, but it’s important for you to be aware of the warning signs.
Cystoid macular edema, a common problem, is a swelling that occurs in the retina after the surgery. Fluid accumulates in small spaces in the area of the retina responsible for central or straight-ahead vision. This swelling can cause blurred vision during the weeks immediately following the operation. The edema usually goes away in one to two months without causing any damage to the retina or eye, but occasionally it can remain much longer and may require medical treatment.
Postoperative eye infection is another well-recognized complication of cataract surgery. The most severe form, which occurs in the eyeball, is called endophthalmitis. It is very difficult to treat, and the earlier it’s diagnosed and treated, the better the chances for minimizing the dam-
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age from this potentially devastating complication. Endophthalmitis often causes the eye to become very red and painful, with an associated decrease in vision. It usually occurs within the first week after surgery. Although the problem isn’t nearly as common today as it once was —thanks to sterile surgical techniques, plus the use of antibiotics—it’s definitely something you should be aware of, so that you can seek treatment as soon as possible. Other, less serious postoperative infections such as bacterial conjunctivitis, allergic reactions to topical medications, and suture abscesses also may cause milder degrees of inflammation, discomfort, and alterations in vision.
Retinal detachment is another potentially serious postoperative complication. If there’s any weakness in the retina at the time of cataract surgery, the retina can become loosened or detached by the procedure. The tricky thing is that this may not happen immediately after surgery but may occur weeks or even months later.
If you’ve ever had cataract or any other form of eye surgery, contact your surgeon immediately if you notice the sudden onset of floaters, flashing lights, or a “curtain” that seems to be blocking part of your vision. These may be signs of a retinal tear or detachment, and they should be evaluated immediately. The quicker this is discovered and treated, the better the chances for repair and a good visual outcome.
Other problems that may arise after cataract surgery include a marked change in your eyeglass prescription, making it difficult for you to adjust to your new vision
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after surgery. Healing can also lead to unwanted astigmatism in the eye (a complication that, fortunately, is much less common with smaller incisions). Double vision is also not uncommon, especially within the first two weeks after surgery. The brain has to get readjusted to the change in vision between the two eyes. When double vision persists or develops several weeks or months after the surgery, this may be due to a problem with someone’s ability to turn the images from each eye into a single picture. (This is best evaluated with special testing and may require a “prism” correction in your eyeglasses to help your eyes work together. For more on this, see chapter 2.) Corneal damage—much less common today with mi- crosurgery—is another potential problem. This can lead to prolonged visual blurring after the surgery and, very rarely, may require a corneal transplant.
Other fairly common complications are spontaneous anterior chamber bleeding from the cataract wound and recurrent postoperative inflammation—both easily treated if promptly brought to the attention of the eye surgeon. Annoying floaters and intermittent flashing in the operated eye are also frequent postoperative complaints. These are related to a change in the vitreous dynamics in the back of the eye after surgery and should be brought to your eye doctor’s attention, since they may be the first sign of a retinal tear or detachment (see chapter 15).
Although many patients worry about them, implants rarely slip out of place after surgery, and sutures very seldom come loose. Again, we’ve come a long way from the days when these were common postoperative problems.
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As potentially devastating as these complications can be, if they’re caught early and tended properly, in most cases there’s still an excellent chance that the eye can heal normally and you can have better vision than you had before surgery—even if you need a second surgery soon after the first to correct a particular postoperative problem. Unfortunately—although it doesn’t happen often— there is a chance that if an infection gets out of control, a retina becomes badly detached, or a complication does not respond to treatment or management, you may end up with worse vision in the eye than you had before. Some patients have even lost their vision or their eye after cataract surgery. Although the local anesthesia we use today has significantly lower risks than general anesthesia, there have also been extremely rare instances in which patients have died during the procedure.
This is why, even though you may feel fine, your doctor will want to monitor you closely after the operation. It’s also why you should call your doctor immediately at the first sign of unusual discomfort or a sudden change in vision. But again, for the vast majority of patients, serious complications are rare, and the benefits of cleared sight often far outweigh the risks of surgery.
How Will This Improve Your Life?
Realistic Expectations
People have different expectations after cataract surgery, some realistic and others not. Most people still need to wear glasses to fine-tune their vision after cataract surgery. Although we’ve all heard of people who swear they
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no longer need glasses after cataract surgery, most surgeons would agree that these fortunate souls are the exceptions rather than the rule. Remember, implant lenses are artificial, and they’re only so good at replacing the eye’s focusing power. The more active you are, and the more you depend on good eyesight for activities such as driving and reading, the more likely you are to need corrective eyeglasses or contact lenses after surgery.
Patients who have had cataracts removed almost universally notice that colors are brighter and more vivid after the surgery. Since the cataract acts like a dirty window, removing it allows more light to pass to the back of the eye. (A particularly happy patient once returned after cataract surgery to tell us that she had been prepared to redo the wallpaper in her dining room. After the surgery she realized that the wallpaper was fine, as bright and colorful as she remembered it being when she bought it; it had only seemed faded because of her cataract.) Night driving is easier and so is reading, especially in dim light. Occasionally the increase in light makes people rely more on sunglasses when they go outside than they did before the operation.
The Second Eye
Now that you have had one cataract removed, what should you do as the cataract in the other eye continues to advance? The criterion for surgery on the second eye is generally the same as that (discussed above) for the first eye—mainly, visual acuity of 20/50 or worse. However, a surgeon may operate on the second eye in other
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situations—for example, if someone has severe discomfort due to the visual imbalance resulting from the presence of a remaining cataract. This is particularly common when the cataract has been removed from a nondominant eye; suddenly the nondominant eye has better vision than the dominant eye, and the brain becomes “confused.” This conflict can cause visual discomfort until the cataract is removed from the dominant eye and binocular vision is restored.
No two operations are ever the same, and so it is with cataract surgery. Many patients feel that the second operation took longer, hurt more, or otherwise did not go as well as the first. Rarely do they report that it was a better experience. But as with childbirth, recollections of the event fade with time, making a comparison very difficult. (Note: This applies to listening to friends’ experiences, too. When it comes to cataract surgery, improved eyesight often seems to cloud the memory.) Be cautiously optimistic about the surgery, and you’ll have a better chance of being pleasantly surprised.
The “Second Cataract” behind the Implant Lens: Lasers in the Management of Cataracts
Lasers—highly sophisticated instruments that harness energy and release it on demand at a specific point— have greatly improved our ability to treat eye disease. A question we’re regularly asked by patients contemplating cataract surgery is, Do you do the laser cataract surgery? Well, we all do, yet we all don’t. Confused? So are the patients. Much of the bewilderment stems from mar-
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keting campaigns by ophthalmologists hoping to convey the idea that they’re one step ahead of the competition. The bottom line is that all ophthalmologists basically perform the same cataract extraction operations with implantation of intraocular lenses. So where do lasers come in?
Remember, we treat the cataract surgically by removing the hazy lens, as described in detail above. But lasers don’t work that way; we can’t simply use a laser to cut a clear zone through the lens.
But we can still use lasers to treat cataracts—kind of. Sometimes, with time, the back portion of the lens bag that was left in the eye, and now is located behind the intraocular implant lens, becomes very cloudy. This “second cataract,” or opacified posterior capsule, can cause a gradual decrease in vision even though the cataract has been removed. In the past an eye surgeon needed to insert a needle into the eye to open this cloudy membrane. Ophthalmic scientists later developed lasers (YAG lasers) able to open these membranes with less risk than the needle technique. This outpatient procedure is virtually painless and usually provides immediate improvement in a patient’s vision.
So this is how we explain it to our patients who ask if we perform laser cataract surgery: Cataract surgery initially requires removing the cataract lens from the eye. A laser can be used later, if necessary, when a cloudiness develops behind the implant lens.
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Special Eyeglass Considerations after
Cataract Surgery
Most people who have had cataract surgery eventually need some form of eyeglasses to maximize their distance or reading vision. As discussed previously, this has a lot to do with a person’s own visual demands and level of activity.
No two patients are the same; everyone heals at a different rate, and each surgery may cause a different amount of postoperative swelling. Most patients get their “final” eyeglass prescription about six weeks to three months after surgery. But as your eye continues to heal over the first year, your prescription may change again at six months to a year later; even after this, you may still require slight alterations in your prescription from time to time.
What kind of eyeglasses will you need after cataract surgery? Again, much depends on you. Important considerations include the style of glasses you wore before the operation, your particular visual needs after surgery, and how much you want to spend. Bifocals, trifocals, and no-line progressive lenses are popular options, because these are usually what patients wore before surgery, and they continue to provide corrected vision at various distances after surgery. Occasionally patients require only single-vision distance or reading glasses after cataract surgery. Some patients are even fortunate enough to be able to use inexpensive premade drugstore reading glasses. Contact lenses can even be worn after cataract