Cataract Surgery

Cataract Surgery: When Do They Begin and What Is the Ideal Age for Surgery?

What is a Cataract?

A cataract is a clouding of the eye's natural lens, which causes blurred vision, glare, and difficulty reading or driving. It is the leading cause of reversible blindness worldwide.

At What Age Do Cataracts Appear?

Onset: From ages 40–50 (initial changes, but without symptoms).

Progression: They become significant after age 60.

Factors that accelerate their development:

Diabetes.

Sun exposure without UV protection.

Smoking.

Long-term use of corticosteroids.

When Should Cataract Surgery Be Performed?

Surgery is recommended when:

Vision affects your quality of life (difficulty reading, driving, or recognizing faces).

The ophthalmologist confirms that a cataract is the cause (not another eye problem).

There are no medical contraindications (uncontrolled eye infections or diseases).

Average Age for Surgery

50–60 years

Rare. Only if there are early cataracts due to trauma or disease.

60–70 years

More common. Typical age for intraocular lens (IOL) surgery.

70+ years

Very common. Maximum safety and predictable results.

Why Not Wait Too Long?

Very advanced cataracts are more difficult to operate on (higher risk of complications).

Loss of independence (falls, accidents due to poor vision).

Decreased quality of life (difficulty with daily activities).

Cataract Surgery as a Quality of Life Improvement and Refractive Procedure

Cataract surgery not only removes lens opacity to restore vision, but also provides an opportunity to correct refractive errors (myopia, hyperopia, astigmatism, and even presbyopia). Today, it is both a therapeutic and refractive procedure.

Why Does It Improve Quality of Life?

Recovery of Clear Vision:

Eliminates lens opacity that causes blurred vision, glare, and difficulty reading or driving.

Prevention of Blindness:

Advanced cataracts are the leading cause of reversible blindness globally.

Patient Independence:

Reduces dependence on thick lenses or visual aids.

What is a Refractive Procedure?

By replacing the cloudy lens with an intraocular lens (IOL), the following can be corrected:

Myopia/hyperopia: With toric monofocal IOLs.

Astigmatism: With toric IOLs.

Presbyopia ("farsightedness"): With multifocal or trifocal IOLs.

Advanced Techniques:

State-of-the-art biometry (IOLMaster, Barrett Formula): Calculates the exact IOL power.

Femtophaco: Use of a femtosecond laser for incisions and cataract fragmentation (greater precision).

Premium IOLs: Multifocal, EDOF (extended depth of focus), or accommodative.

Additional Benefits of Cataract Surgery

Fast recovery (24–48 hours for daily activities).

Topical anesthesia (drops, no injections).

Outpatient surgery (no hospitalization).

Zeiss Cataract Surgery Explained Video Animation

Cataract surgery is a common ophthalmic procedure that involves the removal of the clouded lens and its replacement with an artificial intraocular lens to restore vision. The typical surgical steps for this procedure are described below:

Anesthesia and pupil dilation: Anesthetic drops are applied to numb the eye, and medications are used to dilate the pupil, facilitating access to the affected lens.

Corneal incision:

The surgeon makes a small incision in the cornea, allowing surgical instruments to enter the eye.

Capsulorhexis:

A circular opening is created in the anterior lens capsule to access the cataract.

Phacoemulsification:

Using an ultrasound device, the clouded lens is fragmented and aspirated.​

Intraocular Lens (IOL) Implantation:

A foldable artificial lens is inserted through the incision and placed in the empty lens capsule, restoring the eye's focusing ability.

Incision Closure:

The incision is self-sealing and generally does not require sutures, allowing for a faster recovery.

This procedure typically takes less than an hour and is performed on an outpatient basis. Most patients experience significant improvement in vision within a few days. It is essential to follow the ophthalmologist's postoperative instructions to ensure optimal recovery.

Medium Difficulty Cataract Surgery

Medium Difficulty Cataract Surgery Video: Surgical Steps and Difficulty Level

This video shows a medium-difficulty cataract surgery, typical of a yellowish-white nucleus (LOCS III Grade II–III). Although no surgical procedure is "easy," this case represents a balance between routine and controlled challenges, unlike advanced (brunescent) cataracts or cataracts with comorbidities (pseudoexfoliation, corneal guttata).

Surgical Steps and Relative Difficulty

1. Anesthesia and Preparation

Technique: Anesthetic drops + light sedation (no peribulbar block required).

2. Corneal Incisions

Main (2.2–2.8 mm) + lateral (for instruments).

3. Continuous Capsulorhexis (CCC)

Objective: 5–5.5 mm circular opening in the anterior capsule.

4. Hydrodissection

Injection of BSS to separate the nucleus and cortex of the capsule.

5. Phacoemulsification

Technique: Divide & Conquer or Stop & Chop (for grade II–III nuclei).

Parameters: Moderate ultrasound energy (20–30%), low flow.

6. Cortex Aspiration and IOL Implantation

Residual cortex: Moderate adhesions (greater care should be taken in the posterior pole).

7. Intraocular lens (IOL):

Implantation in the capsular bag without complications.

8. Hydroseal and Closure

Check for leaks in the incisions.

Why is it "Medium Grade"?

Routine Factors:

Emulsifiable nucleus without the need for advanced techniques (pre-chop).

Intact anterior capsule and dilatable pupil.

Factors that Increase Difficulty:

Reduced visibility (semi-opaque cataract vs. completely transparent).

Increased instrumental manipulation to avoid capsular stress.

Risk Factors That Can Complicate Cataract Surgery

Although cataract surgery has a 95-98% success rate, certain factors can increase the risk of intraoperative or postoperative complications. These include patient conditions, ocular characteristics, and technical challenges.

Patient-Related Factors

1. Previous Ocular Diseases

Advanced glaucoma: Impairs visibility and increases the risk of elevated postoperative intraocular pressure (IOP).

Diabetic retinopathy: Risk of macular edema or hemorrhage.

Chronic uveitis: Increased postoperative inflammation and risk of synechiae.

Pseudoexfoliation syndrome: Zonular fragility (risk of lens or IOL dislocation).

2. Challenging Ocular Anatomy

Small, non-dilatable pupil (<5 mm): Makes lens visualization difficult.

Opaque cornea or corneal edema: Reduces visibility during surgery.

Hypermature cataract (brunescent or white): Increased nucleus hardness, requiring more ultrasound energy.

3. Systemic Conditions

Poorly controlled diabetes: Delays healing and increases the risk of infection.

Anticoagulants/antiplatelet agents: Risk of intraocular hemorrhage (although they are rarely discontinued).

Surgical Factors

1. Intraoperative Complications

Posterior capsule rupture: May require vitrectomy and IOL placement in the sulcus or anterior chamber.

Floppy iris syndrome (IFIS): Associated with drugs such as tamsulosin (used for prostate cancer).

Suprachoroidal hemorrhage: Rare but serious (especially in patients with ocular hypertension).

2. Choosing the Intraocular Lens (IOL)

Premium IOLs (multifocal/toric): Increased risk of dysphotopsia (halos, glare) if not selected appropriately.

Hard Cataracts

Brunescent Cataract

Characteristics of Brunescent Cataract

Color: Dark amber to brown (due to accumulation of oxidized pigments).

Hardness: Grade IV–V on the LOCS III (Lens Opacities Classification System) scale.

Surgical Challenge:

Increased risk of irregular fragmentation.

Requires more ultrasound energy, increasing heat in the cornea.

Possible release of toxic pigments into the aqueous humor.

Risk Factors for Posterior Subcapsular Cataracts

Posterior subcapsular cataracts (PSCs) are a type of lens opacity that forms in the posterior capsule, just in front of the vitreous. Unlike nuclear or cortical cataracts, PSCs typically progress more rapidly and cause significant symptoms even in their early stages (such as glare and poor near vision).

Main Risk Factors

1. Long-Term Use of Corticosteroids

Systemic (oral, intravenous) or topical (eye drops, inhalers).

Mechanism: Altered lens fiber metabolism.

Dose-dependent: Increased risk with chronic use (>15 mg/day of prednisone for years).

2. Eye Diseases

Chronic uveitis: Recurrent inflammation accelerates opacification.

Retinitis pigmentosa: Associated with early PSCs.

Previous eye surgery (vitrectomy, retinal detachment).

3. Radiation Exposure

Radiotherapy (for orbital or brain tumors).

Cumulative UV radiation (especially without protection).

4. Systemic Diseases

Diabetes mellitus: Hyperglycemia promotes sorbitol accumulation in the lens.

Myotonic dystrophy: Genetic disease associated with premature bilateral CSP.

5. Drugs and Toxins

Chlorpromazine (antipsychotic).

Amiodarone (antiarrhythmic).

Belladonna alkaloids.

6. Occupational Factors

Occupational exposure to infrared (glaziers, welders).

7. Age and Genetics

Although they are more common in young and middle-aged adults (vs. senile cataracts), there is a genetic predisposition in some cases.

Typical Symptoms of Posterior Subcapsular Cataract

Blurred vision in bright light (photophobia).

Difficulty reading (decreased near vision).

Halos around lights (especially at night).

Differential Diagnosis

Posterior capsule opacification (PCO): Occurs after cataract surgery (not a true cataract).

Posterior polar cataract: Congenital, nonprogressive.

Management and Prevention

Control of modifiable factors:

Minimize corticosteroid dose and duration.

Use UV400 lenses in patients at risk.

Early cataract surgery:

PSCs usually require surgery earlier than other cataracts due to their rapid visual impact.

Preferred techniques: Phacoemulsification with a capsular bag IOL.

Challenges of Operating on a Cataract with a Non-Dilatable Pupil (Pupillary Miosis)

A cataract with a non-dilatable (miotic) pupil is one of the most challenging scenarios in cataract surgery. The small pupil (<4 mm) limits visibility and working space, increasing the risk of complications. These cases are classified as "highly difficult" and require specialized techniques.

Causes of a Non-Dilatable Pupil

Pseudoexfoliation syndrome (50% of cases).

Chronic use of pilocarpine drops (for glaucoma).

Fibrosis due to chronic uveitis or previous surgeries.

Floppy iris syndrome (IFIS) associated with drugs such as tamsulosin.

Surgical Challenges

1. Limited Visibility

Problem: The closed pupil obscures the lens and anterior capsule.

Solution:

Use of dyes (Trypan blue) to stain the capsule.

Improved coaxial illumination (surgical microscope).

2. Increased Risk of Capsular Rupture

Problem: Reduced space → instruments rub against the iris or capsule.

Solution:

Capsulorhexis with microforceps (instead of standard forceps).

Femtophaco (femtosecond laser for precise capsulotomy).

3. Difficulty Fragmenting the Nucleus

Problem: Lack of space to manipulate the lens.

Solution:

Modified chop techniques (vertical or pre-chop).

Viscoexpanders (e.g., iris hooks, Malyugin rings) to mechanically dilate the pupil.

4. Floppy Iris Syndrome (IFIS)

Problem: Iris collapsing over the phacoemulsification tip.

Solution:

Intracameral medications (1:10,000 adrenaline).

Expandable pupil rings (e.g., Morcher).

Common Complications

Posterior capsular rupture (5–10% vs. 1–2% in normal cases).

Loss of nuclear fragments into the vitreous.

Corneal edema due to increased ultrasound energy.

Iris bleeding (especially in IFIS).

Postoperative Care

Intraocular pressure control (risk of acute glaucoma).

Intensive topical steroids (to prevent inflammation).

Monitoring for macular edema (in diabetics).

Are all cataract patients candidates for surgery? Limitations and Considerations

Cataract surgery is one of the safest and most effective procedures in ophthalmology, but not all patients are immediate candidates. The decision depends on ocular, systemic, and surgical risk factors. Here we explain the situations that may limit or delay surgery:

1. Ocular Limitations

Advanced Corneal Diseases

Severe corneal edema or dense scarring: These impair visualization during surgery.

Decompensated keratoconus: This first requires a corneal transplant.

Severe Retinopathies

Proliferative diabetic retinopathy or retinal detachment: These must first be stabilized with laser or vitreous surgery.

Advanced Macular Degeneration: Cataract surgery will not improve central vision.

Uncontrolled glaucoma

Very high intraocular pressure (IOP) increases the risk of complications.

Active ocular inflammation

Uveitis or infections (e.g., ocular herpes): Should be treated first to prevent exacerbations.

2. Systemic Limitations

Uncontrolled diseases

Decompensated diabetes: Risk of infection or poor healing.

Severe high blood pressure: Increased risk of intraocular bleeding.

Autoimmune diseases (lupus, arthritis): May affect recovery.

Anticoagulant medications

Aspirin, warfarin, etc.: Generally not discontinued, but require monitoring.

Pregnancy

Postponed until after delivery (except in urgent cases).

3. Patient Expectations

If the cataract does not significantly affect quality of life, it may be postponed.

In very elderly patients or those with advanced dementia, the actual benefit is assessed.

4. "Hard" or Complicated Cataracts

Hypermature cataracts (white or brunescent): More technically difficult, but not an absolute contraindication.

Pseudoexfoliation syndrome: Risk of zonular rupture (requires special techniques).

What to do if there are limitations?

Stabilize underlying conditions (glaucoma, diabetes).

Treat infections or inflammation before surgery.

Use adapted techniques:

Femtophaco for hard cataracts.

Tension rings if there is zonular fragility.