Cataract Surgery Sees Improvement

By Brigitte Rozario

IF you live long enough, you will get cataracts. It is something that typically occurs to people over the age of 55 when their natural eye lens becomes cloudy, making it harder for them to see clearly. If the eye is not operated on, the person can eventually go blind. 

That is the bad news. 

The good news is that the technology involved in such surgeries is getting more and more advanced. Twenty years ago, cataract surgery involved making a 10mm incision on the cornea to remove the cataract. Today, the cataract can be removed through a mere 2.2mm incision and a 2.75mm lens can be implanted through that same incision.  

Dr Aloysius Joseph Low, consultant ophthalmic surgeon, explains: “During the days when I was undergoing training in the 1980s, we used to do cataract surgery using the ECCE (Extracapsular Cataract Extraction) technique. This involved making an incision of about 10-12mm in order to extract the cataract. As time progressed, the incision became smaller and smaller. So from 10mm it became 5mm, 3.2mm, then 2.75mm, and now it’s 2.2mm. 

“The smaller wound means faster healing. And obviously because the wound is small, the chance of getting an infection is less. In addition, when you make a big wound you are actually inducing astigmatism. So, if you can reduce the size of the wound, then the amount of surgically-induced astigmatism can be reduced. The main thing is that we want to ensure safety and, here, the smaller the wound, the better it is.”  

How it’s done 

This procedure, called Cataract 2.2, is only now available locally because it involves the use of a special machine as well as lens. Once the 2.2mm incision is made, then the modified ultrasound with an oscillating phaco tip goes through the incision.  

Dr Low says this modified ultrasound is a breakthrough because only the oscillating phaco tip can go through such a small incision.  

After the tip is inside the eye, it oscillates to break up the cataract into fragments and simultaneously the machine is able to suck out the fragments.  

He explains that previously, surgeons were using a conventional ultrasound, which produced heat that would damage adjacent healthy tissue. With the modified ultrasound, the amount of heat that is produced is negligible.  

According to Dr Low, the advantages of using this modified ultrasound is that it doesn’t produce a lot of heat and it has the ability to break down even hard cataracts.  

After the cataract is removed, the surgeon typically would polish the capsule at the back of the eye. Not all surgeons do it though because there is a risk of breaking the capsule, and when that happens, you can’t implant the plastic lens.  

However, if the capsule at the back of the eye is not polished after the cataract is removed, then the patient might develop a secondary cataract, which is also known as posterior capsule opacification.  

What happens is that the capsule opacifies and blocks the patient’s view. In such cases, the patient would then have to go for laser surgery to make a hole in the capsule so that the patient can see clearly. This is usually done six months to a year after the cataract surgery.  

The power of the lens 

After polishing the capsule, the surgeon would need to implant the plastic lens. 

Dr Low explains that if the wound is too small, implanting the lens would pose a problem because the lens is bigger than the wound. And, if the surgeon then made the incision bigger just to insert the lens, then it would defeat the purpose of making a small incision in the first place. 

Fortunately, lens technology has also advanced over the years. While previously a 2.75mm lens could not be implanted through a 2.2mm incision, it can now be done because the lens can be folded, inserted and then unfolded inside the eye.  

Dr Low says that not all lenses can be folded and inserted through the incision.  

So, whether all cataract patients can go for the Cataract 2.2 surgery also depends on the patient’s choice of lens. 

In addition, those with extremely hard cataracts are not advised to go for this procedure because it will take a very long time to remove the cataract. It would be easier to use the old technique of ECCE if the patient is old and it’s going to take a long time.  

Normally the procedure for Cataract 2.2 takes about half an hour. With a rock hard cataract it might take one hour.  

The Cataract 2.2 surgery is conducted under just topical anaesthesia, which is just eye drops. There is no injection. Dr Low says he expects the patients to be able to watch TV in a few hours after the surgery and usually by the next day the wound would have closed. 

There are follow-up visits to the doctor and antibiotics must be applied. All precautions should also be taken to ensure the patient does not scratch the eye and re-open the wound. 

The second eye can be operated on a week to a month after the first eye. Usually patients won’t feel balanced after one eye is done because one side is clear and the other is blurry, and they would want to operate on the second eye as soon as possible.  

Cataract 2.2 was first done in 2005 by Japanese surgeon Dr Takayuki Akahoshi. Dr Low informs that Dr Akahoshi is now doing 1.9mm incisions. Although the size of the incision is expected to get smaller with time, the challenge remains in how to insert the lens through such a small incision. 

Hopefully lens technology will also improve to allow implantation through such small incisions.