Cataract and Refractive Lens Surgery

Cataract-Team

Narayana Nethralaya is fully equipped with the most modern technology for performing sutureless cataract surgeries. The Department of Cataract has made tremendous progress in the last years. Four new dedicated state of the art operation theatres have vastly increased our capacity and the patient turnover time has been significantly reduced. We also have increased the capacity in our out-patient department with streamlined systems for consultation & investigation.

Cataract is the leading cause of decreased vision and blindness in our country. It can be cured by a simple cataract extraction microsurgery, which, these days is performed using advanced technology in a short time.

We are one of the few institutions in the world to have the 3 top platforms for cataract surgery – the Infinity, the Signature and the Stellaris. All these machines can be used for the latest Micro-Coaxial Cataract Surgery (MICS), or removal of the cataract through a 2mm (or less) incision with the implantation of foldable intraocular lenses (IOLs). We offer our patients the latest in IOL technology including the accommodative Crystalens HD, the ReSTOR & Tecnis multifocal IOLs and the astigmatism correcting Toric IOLs. We offer the latest generation of multifocal IOLs with astigmatism correction and the Implantable Collamer Lens as an option in correcting refractive errors. To minimize calculation errors in the implanted IOLs we now have the Immersion Biometry and the non-contact Lenstar which works by the laser interferometry principle. We perform upwards of 10,000 surgeries annually, with a large number of them being MICS with high end IOLs.

What is cataract?

  • It is clouding (opacification) of the natural lens, which prevents light rays from reaching the retina.
  • Early on, a change in glass power may help.
  • Later on, it progressively affects vision, till finally, only the perception of light remains.
Immature Cataract

Immature Cataract

Hypermature Cataract

Hypermature Cataract

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What are the causes of cataract?

Ageing is the most common cause of cataract. Every person gets it sooner or later, especially people over 60yrs of age. Other causes include diabetes, injury, usage of certain medications, and secondary to other eye diseases such as uveitis and glaucoma. Cataracts can occur early in diabetes, myopia (short sight) and as a hereditary predisposition.

What are the symptoms of cataract?

  • Painless, gradually progressive blurring of vision.
  • Double vision or seeing multiple images.
  • Trouble with seeing in poor light conditions and sometimes in excessive sunlight.
  • Becoming sensitive to glare, making night driving difficult.
  • Difficulty in distance vision and in reading.

When does one go in for surgery?

  • To a large extent is depends on the person undergoing surgery.
  • Whenever the cataract affects vision to a degree that it hampers the person’s daily activities (reading, driving, playing golf etc.), surgery should be considered.
  • During surgery the normal lens of the eye is removed and replaced with an intra-ocular lens which lasts for the entire lifetime.

Surgical Options

  • Surgery can be performed manually through 5- 6 mm wounds called SICS (Small Inscision Cataract Surgery).
  • Phacoemulsification is at present universally accepted as the standard of care for cataract surgery.
  • Ultrasound energy is used in phacoemulsification to break up the cataract (emulsify) into microscopic fragments which can be sucked out of the eye.

Cataract1
What is MICS?

  • The surgical wounds have progressively become smaller and now the latest technique is “Micro-coaxial Phacoemulsification” or MICS.
  • MICS is phacoemulsification of the cataract through a wound of 2.2 mm or less, with implantation of an intra-ocular lens through the same wound.
  • Wound healing and refractive stabilization is faster in MICS than in traditional phaco.

Options in Intra-ocular Lenses (IOLs)

  • The majority of the IOLs implanted are mono-focal.
    They can focus light rays from one particular distance only.
    Normally distance objects are clear and one needs glasses for reading.
  • Intra ocular lens can be rigid or foldable. Foldable lens will need smaller wounds to insert.

Cataract2

What about multifocal IOLs?

  • Multifocal IOLs have different segments built onto the same lens which allows clear distance & near vision with spectacle freedom for most activities.

What about toric IOLs?

  • Traditionally used monofocal IOLs correct only the spherical refractive error. Patients with pre existing astigmatism will need spectacle correction for distance vision and near. Toric IOLs reduces the need of glasses for distance.
  • Recently multifocal IOLs have also been introduced with this option, thus correcting for distance, near and cylindrical error.

Trifocal IOLs

  • A limitation of standard multifocal IOLs is that they provide good distance and near vision but have a somewhat compromised intermediate vision. This is the distance used for working on computers. Trifocal IOLs provide excellent vision not only for near and far, but also for intermediate distances.

Toric Multifocal IOLs

  • Astigmatism is a refractive error in which the curvature of the cornea is different in different meridia. The shape is more akin to an American football rather than a regular football. People with astigmatism were earlier not suitable for multifocal IOLs. Now with the introduction of Toric Multifocal IOLs, it is possible to correct this astigmatism and also provide good near vision to this group of people.

IOL power calculation
Biometry (IOL power calculation) is done by trained personnel and every endeavour is made to ensure accurate results. It requires measurement of the axial length (length of the eyeball) and corneal keratometry (power of the cornea). Axial length measurements are done using both laser and ultrasound technologies using different machines. This is done to avoid errors as much as possible. Corneal keratometry measurements prior to cataract surgery is calculated using a host of equipment including

  • Orbscan
  • Pentacam
  • Galilei
  • OPD 3
  • iTrace

This also allows us to manage complex cases such as patients coming for cataract surgery after having undergone keratorefractive surgery (LASIK, PRK etc) or those with Keratoconus.

Biomechanical imaging of the cornea prior to cataract surgery is possible using: Corvis & Ocular Response Analyzer.

What are the pre-op procedures?

  • One needs to be in fairly good general health.
  • Diabetes, hypertension, cardiac problems (if any) need to be controlled before surgery.
  • One needs to do a detailed check up of the eye and a dilated examination of the retina.
  • Specific to the eye ones need to undergo scans of the eye to find out the curvature and the length of the eye to decide on the model and power of the intraocular lens to be implanted.

What happens on the day of Surgery?

  • Surgery is a “walk in- walk out” procedure.
  • Surgery is mostly done under topical anaesthesia.
    Anaesthetic drops numb the surface of the eye and the surgery can be comfortably and painlessly performed. The eye remains open after surgery.
  • Some patients may require an anaesthetic injection before the surgery.
  • A routine surgery lasts approximately 10 minutes with the preparation time being of similar duration.
  • Pre-operatively dilating drops are applied which take between 1 – 1.5 hours to act.
  • One could expect to spend half a day at the hospital on the day of surgery.

FAQ on Post-Operative Care

Is there much discomfort after surgery?
Cataract surgery is pretty much painless and so is the post-operative period. There is mild irritation (or foreign body) sensation for a few days. There may be mild redness & watering of the eyes which again subside in a few days.

What do I do after surgery?
There is no need for bed rest after surgery. One can walk, eat normally, watch TV and be normal around home on the day of the surgery. One needs some protective glasses only when outdoors.

What about the post-operative treatment?

  • There is a graded schedule for eye drops after surgery.
  • No tablets / injections are used.
  • One would start with 3 types of eye drops, which would be stopped over a period of 6 weeks.

When can I resume my normal work?

  • One can resume work even the day after surgery.
  • One could either work from home or office, but one should remember to apply the drops as advised.
  • Normally till the glass correction is given 4-6 weeks after surgery, reading may be difficult, but this is much better after implantation of a multifocal IOL.
  • Temporary glasses can be given the day after surgery.
  • One could resume routine exercise, yoga & sports like golf 2-3 days after surgery.

What about post-operative restrictions?

  • One should avoid water from directly getting into the eyes for 10 days after surgery.
  • One could sponge the hair and face properly even the day after surgery.
  • Normal bathing (taking precautions for the eye) can be resumed the day after surgery.
  • After 10 days one can be completely normal.
  • Bending down, chewing food or lifting moderate weights are not at all a problem after surgery.
  • One can be pretty much normal after surgery.

When will I see well?

  • The vision will be bright and pretty much clear the day after surgery.
  • Full vision will be restored gradually in a few days time.
  • Objects may appear excessively bright & blue in colour for some days. This is because the cataract was not allowing light to reach the retina and most of the blue light was being cut off. The brain gets disused to seeing blue. All these complaints are temporary.

Will I need glasses after surgery?

  • We use highly specialized equipment (Immersion A-Scan, Optical Biometry, corneal topography etc.) to predict the IOL power to be implanted.
  • Even then, there is a small possibility of a minor error in the IOL power. This leaves a residual spectacle power which would need to be corrected with glasses.

How do I clean my eye after surgery?

  • One would not normally need to specifically clean the eye after surgery.
  • Mopping the face with a wet towel (with the eyes closed) should suffice.
  • If there are deposits of medicines on the eyelids or lashes one could use fresh ear buds, moisten them with an antibiotic eye drops and clean the outside of the eyelids (and lashes) with them.

Can I travel after surgery?

  • One would not normally need to specifically clean the eye after surgery.
  • Any amount of travel is absolutely fine provided one remembers to apply the eye drops.
  • Timings will be given for the application of the eye drops, but an hour this way or that does not cause any problem.

Equipment

Our operation theatre has a stainless Steel modular design with laminar air flow and HEPA filters. We have state of the art equipment for performing cataract surgery some of which are:

  • Centurion (Alcon): Is the only intelligent phaco platform that dynamically optimizes cataract removal.
  • Infiniti (Alcon)
  • Stellaris (Bausch and Lomb)
  • Signature (AMO)

We are fully equipped to take up complex paediatric surgeries under general anaesthesia. All this is constantly monitored by team of anaesthetists, nurses and supporting staff.

Cataract-NN1

Femtosecond laser cataract surgery

The femtosecond laser is the latest breakthrough in advanced cataract surgery as a means to providing precision and safety to crucial steps of the surgery. These include creation of surgical incisions, circular opening on the lens surface (capsulotomy), and fragmentation of the human lens. The additional advantage of this laser is that it is accurate enough to plan incisions in the peripheral cornea to aid in the correction of pre-existing corneal astigmatism (cylindrical power).

How is it better than standard phacoemulsification?

In standard phacoemulsification, the corneal incisions are made with a metal blade. The circular opening in the lens capsule from which to remove the cataract and place an artificial lens is made using a sharp bent needle. The surgeon then divides the lens manually to aid its removal after emulsification with ultrasound energy.

In bladeless cataract surgery, the Femtosecond laser replaces all three steps. The entire process is automated using the machine’s integrated OCT guided imaging system. Since the surgery is done with laser, the incisions are more precise and the capsular opening is perfectly centred and round.As the laser divides the lens into small fragments, the amount of ultrasound energy used to remove the cataract is greatly reduced, which in turn helps in early visual recovery.

Phakic IOLs

Phakic posterior intraocular lens implantation is currently an excellent option for high myopes who desire spectacle independence but are not good candidates for LASIK or photorefractive keratectomy (PRK).
Facilities available for planning ICLs include

  • Ultrasound biomicroscopy (Quantel): 50 MHz UBM probe is the tool of choice for studying the mechanisms and critical relationships between the iris, the lens and the cilary body in patients undergoing ICL surgery.
  • Anterior segment OCT (Tomey, RTVue)

Other facilities

Surgical skill and equipment to deal with complicated cataracts such as

  • Post traumatic cataracts
  • Displaced cataractous lenses/Intraocular lenses

Doctors of Cataract and Refractive Lens Surgery

@Rajajinagar

Dr. K Bhujang Shetty
Dr. Mathew Kurian
Dr. Naren Shetty
Dr. Hemamalini M.S.
Dr. Keya Barman
Dr. Aishwarya
Dr. Luci Kaweri
Dr. Tejal SJ

@Narayana Health City

Dr. Adrian Sandeep Braganza
Dr. Lubna Zameer

@Castle street, Ashok Nagar

Dr. Colin A.S.Nazareth
Dr. Ridhima Bhagali

@Bannerghatta Road

Dr. K Bhujang Shetty
Dr. Naren Shetty
Dr. Narendra KP
Dr.Rashmi Krishnamurthy
Dr.Chaithra Aroor