Senile cataract is an age-related, vision-impairing disease characterized by gradual, progressive thickening of the lens of the eye.
Lens extraction is the definitive treatment for senile cataract.
It can be accomplished via the following procedures:
- Small incision cataract surgery or SICS- where the wound heals by itself and there are no sutures
- Extra Capsular Cataract Extraction (ECCE)-conventional method with sutures- It involves removal of the lens nucleus through an opening in the anterior capsule, with retention of the integrity of the posterior capsule.
- Phacoemulsification –an ultrasonically driven needle is used to fragment the nucleus of the cataract through an opening in the anterior capsule; the lens substrate being then removed through a needle port.
Intraocular lens implantation/IOL is done along with each of these procedures. IOLs can be chosen on the basis of
- Quality of lens
- Refractive outcome expected by patient
- Other coexisting conditions affecting the eye like DM / uveitis / any congenital eye conditions.
Foldable IOLs are better.
Hydrophobic lenses are better than hydrophilic lenses. Also the surgeon’s charges increase with the cost of the lens. Hydrophobic lenses are thinner and easier to place and have a lesser incidence of complications.
Hydrophilic lenses are not approved by US FDA but are commonly and justifiably used here as cost is less.
Multifocal and monofocal lenses both are used depending on the surgeon’s and patient’s preference.
With multifocal lenses most patients do not need to wear glasses. Minor night time discomfort while driving is not a deterrent.
With monofocal lenses one has to wear glasses but vision quality is superior. Cost, of course, is less.
Within lenses, foldable lenses are costlier than rigid; multifocal costlier than monofocal; toric lenses (that correct astigmatism) costlier than non-toric.
There is no perfect lens like there is no perfect spouse or perfect child!
- Cost of surgery– Most patients think that the type of lens is the single most important factor! In a non-affording patient, his non affordability is the most important factor. Otherwise, the surgeon’s expertise, the overall services, the phaco machine quality and lastly the lens cost determine the expense.
- When operating on patients on aspirin/clopidogrel one need not ask them to discontinue as topical anesthesia is used and the corneal incisions are bloodless.
- When a patient is on alpha blockers for conditions like benign prostate enlargement Intraoperative Floppy Iris Syndrome/IFIS is a complication that can occur. It is a disaster if the surgeon is not prepared with the iris hook or a pupil dilator; the surgery can get messy and some surgeons keep an iris retracting device called the Malyugin ring ready to tackle this problem.
For more details see the chapter on Alpha antagonists and IFIS.
- The commonest significant complication seen is a painful red eye.
- Nausea, vomiting indicates raised intraocular pressure.
- Hazy cornea and dropping vision are two things a family physician can pick up and immediately refer.
- Early infection / inflammation (presenting as red eye with sticky discharge and swelling) and decreasing vision are two conditions the GP can easily diagnose in the operated patient.
- The commonest complication is an unhappy patient despite an excellent surgery!