CATARACT SURGERYChristopher L.B. Canny, MD,

FRCSC

Head, Division of Ophthalmology, SKMC

Cataract SurgeryCataract SurgeryObjectivesObjectives

to explain what a cataract isto explain what a cataract is to describe indications for cataract to describe indications for cataract

surgerysurgery to describe post operative symptoms to describe post operative symptoms

requiring urgent re-examinationrequiring urgent re-examination to describe ICD-9, DRG, and CPT to describe ICD-9, DRG, and CPT

codes in relation to cataracts and codes in relation to cataracts and cataract surgerycataract surgery

Cataract SurgeryCataract SurgeryThe Lens and CataractThe Lens and Cataract

Crystalline lens focuses a clear image on Crystalline lens focuses a clear image on retinaretina

Suspended behind iris by filamentous zonulesSuspended behind iris by filamentous zonules Flexible and changes shape with contraction Flexible and changes shape with contraction

of ciliary muscle permitting focusing of imageof ciliary muscle permitting focusing of image

Cataract SurgeryCataract SurgeryThe Lens and CataractThe Lens and Cataract

Consists of elastic capsule, cortex and nucleusConsists of elastic capsule, cortex and nucleus Grows throughout life compressing nucleusGrows throughout life compressing nucleus A cataract is any opacity or discoloration of lens A cataract is any opacity or discoloration of lens

(366)(366) Described in terms of zones of lens involvedDescribed in terms of zones of lens involved Described in terms of color change – brunescentDescribed in terms of color change – brunescent Described in terms of development – immatureDescribed in terms of development – immature

Cataract SurgeryCataract SurgeryLens and CataractLens and Cataract

A cataract is described in terms of zones of lens A cataract is described in terms of zones of lens involved, colour change, and developmentinvolved, colour change, and development Infantile, nuclear cataract (366.04)Infantile, nuclear cataract (366.04) Senile nuclear sclerosis with brunescens (366.16)Senile nuclear sclerosis with brunescens (366.16) Cortical senile cataract (366.15)Cortical senile cataract (366.15)

Cataract SurgeryCataract SurgeryLens and CataractLens and Cataract

A cataract is described in terms of zones of lens A cataract is described in terms of zones of lens involved, colour change, and developmentinvolved, colour change, and development Infantile, nuclear cataract (366.04)Infantile, nuclear cataract (366.04) Senile nuclear sclerosis with brunescens (366.16)Senile nuclear sclerosis with brunescens (366.16) Cortical senile cataract (366.15)Cortical senile cataract (366.15) Total or mature (senile) cataract (366.17)Total or mature (senile) cataract (366.17) Hypermature (senile) cataract – Morgagni cararact (366.18)Hypermature (senile) cataract – Morgagni cararact (366.18) Anterior subcapsular traumatic cataract (366.21)Anterior subcapsular traumatic cataract (366.21)

Cataract SurgeryCataract SurgeryLens and CataractLens and Cataract

A cataract may be primary or secondaryA cataract may be primary or secondary Primary usually refers to opacification of the lens proper and includes Primary usually refers to opacification of the lens proper and includes

congenital (743.3), infantile (366), senile (366.1), cataract secondary to congenital (743.3), infantile (366), senile (366.1), cataract secondary to ocular disorders (366.3), diabetic cataract (366.41), toxic (366.45), etcocular disorders (366.3), diabetic cataract (366.41), toxic (366.45), etc

A secondary cataract usually refers to a so-called after-cataract (366.5) A secondary cataract usually refers to a so-called after-cataract (366.5) and is really opacification of the posterior capsule following cataract and is really opacification of the posterior capsule following cataract surgerysurgery

Most common cause is age-relatedMost common cause is age-related Other causes include trauma, inflammation, diabetes, corticosteroidsOther causes include trauma, inflammation, diabetes, corticosteroids

Cataract SurgeryCataract SurgerySymptoms of CataractSymptoms of Cataract

Usually very slow onset Usually very slow onset of symptomsof symptoms

Image blur progressing Image blur progressing to visual failureto visual failure

‘‘second sight’ due to second sight’ due to increasing myopiaincreasing myopia

Double or multiple Double or multiple imagesimages

‘‘starbursts’ around lightsstarbursts’ around lights Colour discrimination Colour discrimination

decreasesdecreases

Cataract SurgeryCataract SurgerySymptoms of CataractSymptoms of Cataract

Rarely a swelling lens can Rarely a swelling lens can cause an acute rise in cause an acute rise in intraocular pressure by intraocular pressure by closing the anterior closing the anterior chamber angle and/or chamber angle and/or causing severe causing severe inflammation from an inflammation from an immune reaction to immune reaction to leaking lens proteins in leaking lens proteins in the aqueousthe aqueous

Indicated by sudden Indicated by sudden onset of pain, redness, onset of pain, redness, and rapid change in and rapid change in visionvision

Cataract SurgeryCataract SurgeryPre-operative Ophthalmic Pre-operative Ophthalmic

EvaluationEvaluation Comprehensive evaluation by operating Comprehensive evaluation by operating

surgeonsurgeon A-scan biometry for intraocular lens A-scan biometry for intraocular lens

calculationcalculation Supplemental ophthalmic testing (not routine)Supplemental ophthalmic testing (not routine)

Contrast sensitivityContrast sensitivity Glare testingGlare testing Potential acuityPotential acuity Specular microscopySpecular microscopy Corneal topographyCorneal topography B-scan ultrasonography (only if fundus not visible)B-scan ultrasonography (only if fundus not visible)

Cataract SurgeryCataract SurgeryPre-operative Medical EvaluationPre-operative Medical Evaluation

Internal medicine evaluation Internal medicine evaluation indicated for patients with COPD, indicated for patients with COPD, recent myocardial infarct, unstable recent myocardial infarct, unstable angina, poorly controlled diabetes, angina, poorly controlled diabetes, poorly controlled hypertensionpoorly controlled hypertension

Routine medical testing (blood tests, Routine medical testing (blood tests, EKG) do not increase the safety of EKG) do not increase the safety of cataract surgerycataract surgery

Cataract SurgeryCataract SurgeryNonsurgical ManagementNonsurgical Management

Operating ophthalmologist Operating ophthalmologist explaining to patient the symptoms explaining to patient the symptoms of cataract and the risks benefits, of cataract and the risks benefits, and alternative treatmentsand alternative treatments

Stop smokingStop smoking Refraction and prescribing of Refraction and prescribing of

glasses when appropriateglasses when appropriate

Cataract SurgeryCataract SurgeryIndications for SurgeryIndications for Surgery

Cataract associated visual loss that Cataract associated visual loss that negatively affects quality of life by negatively affects quality of life by limiting ability to drive safely, read, limiting ability to drive safely, read, participate in sports, etc.participate in sports, etc.

Secondary glaucoma or lens induced Secondary glaucoma or lens induced uveitisuveitis

Cataract inhibits optimal management of Cataract inhibits optimal management of posterior segment disease such as posterior segment disease such as diabetic retinopathydiabetic retinopathy

Cataract SurgeryCataract SurgeryContraindications to SurgeryContraindications to Surgery

The patient does not desire surgeryThe patient does not desire surgery Glasses or visual aids provide vision that meets Glasses or visual aids provide vision that meets

the the patient’s needspatient’s needs Surgery will not improve visual functionSurgery will not improve visual function The patient’s quality of life is not compromisedThe patient’s quality of life is not compromised The patient cannot safely undergo surgeryThe patient cannot safely undergo surgery Informed consent cannot be obtained from patient Informed consent cannot be obtained from patient

or surrogateor surrogate Appropriate post-operative care cannot be Appropriate post-operative care cannot be

arrangedarranged

Cataract SurgeryCataract SurgerySurgical TechniquesSurgical Techniques

Infection prophylaxisInfection prophylaxis 5% povidine iodine in conjunctival sac prior to 5% povidine iodine in conjunctival sac prior to

surgerysurgery Topical broad spectrum antibiotic prior to Topical broad spectrum antibiotic prior to

surgerysurgery Extracapsular cataract extraction by Extracapsular cataract extraction by

phacoemulsification preferred methodphacoemulsification preferred method Standard extracapsular technique may be Standard extracapsular technique may be

required in extremely hard cataractsrequired in extremely hard cataracts

Cataract SurgeryCataract SurgerySurgical technique – Lens removalSurgical technique – Lens removal

Common lens (cataract) removal techniques Common lens (cataract) removal techniques include:include:

Intracapsular (total) extraction (DRG* 13.19)Intracapsular (total) extraction (DRG* 13.19) Extracapsular (partial) extractionExtracapsular (partial) extraction

Nuclear delivery (DRG 13.59)Nuclear delivery (DRG 13.59) Phacosection (DRG 13.42)Phacosection (DRG 13.42) Phacoemulsification (DRG 13.41)Phacoemulsification (DRG 13.41)

* DRG = Diagnosis Related Groupings

Cataract SurgeryCataract SurgerySurgical technique – Technical Surgical technique – Technical

ElementsElements

Successful cataract Successful cataract procedures include:procedures include: Capsular fixation of a Capsular fixation of a

posterior chamber IOL posterior chamber IOL (DRG 13.71)(DRG 13.71)

Little or no trauma to Little or no trauma to corneal endothelium, iris corneal endothelium, iris and other ocular tissuesand other ocular tissues

Incision design that Incision design that minimizes surgically minimizes surgically induced astigmatisminduced astigmatism

Watertight closure of the Watertight closure of the incision, self-sealing or incision, self-sealing or suturedsutured

Cataract SurgeryCataract SurgeryIntraocular Steps of Intraocular Steps of PhacoemulsificationPhacoemulsification

Self-sealing incisionSelf-sealing incision shelvingshelving 1 – 3 mm1 – 3 mm

Paracentesis Paracentesis incisions (2)incisions (2)

Staining of anterior Staining of anterior capsulecapsule

CapsulorhexisCapsulorhexis Opening of anterior Opening of anterior

capsulecapsule

Cataract SurgeryCataract SurgeryIntraocular Steps of Intraocular Steps of PhacoemulsificationPhacoemulsification

HydrodissectionHydrodissection Separation of Separation of

nucleus from cortex nucleus from cortex by jet of waterby jet of water

Nuclear Nuclear disassemblydisassembly Loosened nucleus Loosened nucleus

quartered and/or quartered and/or chopped, liquified chopped, liquified and aspiratedand aspirated

Cataract SurgeryCataract SurgeryIntraocular Steps of Intraocular Steps of PhacoemulsificationPhacoemulsification

Complete removal Complete removal of epinucleus and of epinucleus and cortexcortex

Implantation of Implantation of centered IOLcentered IOL

Cataract SurgeryCataract SurgeryIntraocular Steps of Intraocular Steps of PhacoemulsificationPhacoemulsification

Watertight closure of woundWatertight closure of wound

Cataract SurgeryCataract SurgeryComplicationsComplications

Dropped nucleus 1% (15% Dropped nucleus 1% (15% residents) residents)

Infectious endophthalmitis Infectious endophthalmitis 0.13% (0.06-0.17%)0.13% (0.06-0.17%)

Expulsive choroidal Expulsive choroidal hemorrhage 0.3% (0.1-0.5%)hemorrhage 0.3% (0.1-0.5%)

Cystoid macular edema 1.4% Cystoid macular edema 1.4% (1.2-1.6%)(1.2-1.6%)

Retinal detachment 0.7% (0.6-Retinal detachment 0.7% (0.6-0.8%)0.8%)

Corneal edema 0.3% (0.2-Corneal edema 0.3% (0.2-0.4%)0.4%)

Dislocated IOL Dislocated IOL Posterior capsule opacification Posterior capsule opacification

19.7% (19.1-20.319.7% (19.1-20.3))

Cataract SurgeryCataract SurgeryOutcomesOutcomes

Cataract surgery is highly successfulCataract surgery is highly successful Post-operative visual acuity reached Post-operative visual acuity reached

20/40 or better in 90% of all cases of 20/40 or better in 90% of all cases of cataract surgery and in 95% of cases cataract surgery and in 95% of cases without pre-surgical co-morbiditywithout pre-surgical co-morbidity

Cataract SurgeryCataract SurgeryPostoperative CarePostoperative Care

Responsibility of operating Responsibility of operating ophthalmologistophthalmologist

Operating ophthalmologist obliged to Operating ophthalmologist obliged to inform patient about:inform patient about: signs and symptoms of possible complicationssigns and symptoms of possible complications eye protectioneye protection activitiesactivities medicationsmedications required visitsrequired visits how to access emergency carehow to access emergency care

Cataract SurgeryCataract SurgerySymptoms Requiring Prompt Symptoms Requiring Prompt

AttentionAttention

Decreasing visionDecreasing vision Increasing painIncreasing pain Progressive rednessProgressive redness Periocular swellingPeriocular swelling Discharge from the Discharge from the

eye (not tears!)eye (not tears!) New floatersNew floaters Photopsias (light Photopsias (light

flashes)flashes) Field defectsField defects