
Cataract Surgery
There are three parts to this information. Click the buttons
on the right. Below is Part A.
YOUR CHOICES ARE...
1. When to have surgery. Are you having trouble with your vision?
2. Where to have surgery. Public or private systems?
3. What lens you wish to have. The types of lenses are described click here.
4. What quality of vision you want afterwards.
5. How do you want your eyes focussed and balanced.
6. How much do you want to wear glasses? This relates to the quality of vision you will have.
7. What compromises you wish to take to get the result you desire.
To learn about cataract surgery at Newcastle Eye Hospital, click the movie below.
​
For patients having surgery, you can read the detailed notes below written by Dr Peter Davies. There is a one-page summary found by clicking here, and a pre-referral checklist of information we like to know, found by clicking here.
​
These instructions are general in nature, and do not replace any advice given to you by your treating eye surgeon.
These notes were written by Dr Peter Davies. These instructions are general in nature, and do not replace any advice given to you by your treating eye surgeon.
​
Topics covered
What is a cataract?
The natural history of cataract without surgery?
When to have cataract surgery.
How do you and we define successful eye surgery?
The process of cataract surgery.
Where to have surgery- public and private health systems
Anaesthesia for cataract surgery.
Same-day surgery at Newcastle Eye Hospital
Which eye should have surgery first?
Glasses use after cataract surgery
Which intraocular lens should you chose?
Results of cataract surgery.
The post-operative period.
Dropless cataract surgery is possible.
When can I drive?
Refractive outcomes after cataract surgery.
What is Mono vision?
Refractive error after surgery
How can we correct refractive error
Truths about vision and glasses after surgery
Common problems
Complications
Cataract surgery techniques – laser versus manual
Commonly asked questions
What is a Cataract
A cataract is when the natural lens inside the eye becomes cloudy. It is not a growth over the eye.
The only way to improve vision is with surgery to remove the cataract and replace it with a clear artificial lens. Without cataract surgery, the vision slowly worsens as the lens hardens, until the eye becomes blind. In Australia we intervene before patients experience severe vision loss.
The operation takes around 5-10 minutes, and is done with local anaesthetic and light sedation as day-only surgery. You will be awake, but you will have light sedation to calm the nerves, which may block your memory of the operation.
A cataract typically develops slowly and can affect one or both eyes. Cataract usually occurs from the age of 60 upwards, although it can occur in younger adults and rarely even in children and babies.
​
Most cataracts are a result of the natural ageing of the eye. From age 40 onwards, metabolic changes start occurring in the crystalline lens that cause it to take on water and become less flexible. The first signs of this are difficulty focusing on near objects – called presbyopia. Presbyopia occurs in everyone after a certain age and is corrected with glasses.
Eventually, these lens changes progress to the point where cloudy opacities develop in the lens which at first can cause difficulty with glare and driving at night, but eventually cause blurring and alteration of colour perception. This can only be improved through surgery.
The aim of all eye surgery is to restore normal eye structure and function. The eye is exactly like a camera. To see clearly, it needs clear lenses (the tear film over the cornea, the cornea and internal lens), a healthy film (the retina), and a clear centre (the vitreous jelly and water). In cataract surgery, the cloudy internal lens is replaced with a clear artificial lens.
However, despite having normal anatomy, the eye will not see clearly if the “optics” are not correct. “Optics” refers to the way the eye focuses light. Just like a camera, the eye needs to focus light clearly on the retina, to capture clear images. The two lenses in the eye are the cornea (fixed focus) and the natural internal lens (variable focus up to middle age but it becomes fixed focus later in life).
Some eyes are short-sighted (myopia). This means the eye cannot see distant objects clearly. Other eyes are long-sighted (hypermetropia), and require glasses BOTH for reading and distance. Eyes can compensate for long-sightedness by increasing the power of the internal lens (focussing achieved by the internal natural lens adjusting its’ shape and changing focussing power). We can correct both these problems with spherical lenses in glasses or contact lenses. Eyes that see normally with glasses or contact lenses, are still considered “normal” eyes.
When we lose the ability to focus the eye as we age, starting after 40 years, we call this “Presbyopia”. Patients notice an inability to read. Reading glasses, bifocals or multifocal glasses are required to correct Presbyopia.
Some eyes have astigmatism. This is usually because the cornea is curved like a rugby football, instead of a soccer ball. Astigmatism is reduced with a toric lens used during surgery.
In the past, all patients required glasses to see clearly after cataract surgery, because it was difficult to exactly predict the power of the artificial lens needed for each patient.
The Natural History of Cataract Without Surgery
Without surgical treatment, cataracts usually worsen over time, leading to gradual vision loss. This can interfere with daily activities such as reading, driving, and recognizing faces. Without surgery, every eye with cataract will go blind eventually. It is not a question of IF you need cataract surgery, but WHEN you do.
AVOIDING BLINDNESS IS THE MAIN REASON WE DO CATARACT SURGERY.
​
When to Have Cataract Surgery
Cataract surgery is typically recommended when the cataract begins to significantly affect daily life and vision. The decision is based on the impact on quality of life, not just the physical presence of the cataract. In Australia we usually recommend intervention when the vision starts to drop. Once the vision drops below the driving standard (6/12), the risk of falls begins to increase.
The time to do cataract surgery usually depends on the patient. Initially we are waiting for the cataract to actually have an affect on the vision. We help patients who have real problems with their vision to overcome these problems.
Once cataracts are starting, it is a question of when to do them, not if they will ever need to be done. They always get worse over time. The natural history of cataract is blindness over time. We do cataract surgery to prevent blindness and to improve the vision.
Each individual patient is the best judge of when to have cataract surgery At the most basic level, if a patient isn’t having a problem with the vision, then they do not need cataract surgery. “If it ain’t broke, don’t fix it.”
Once the vision starts to drop and the cause is due to the cataract, that is when we offer cataract surgery. Usually the patient sees the optometrist 1st to make sure the vision isn’t corrected with a simple update of glasses.
It’s good advice not to delay cataract surgery. The longer patients delay surgery, the lesser the quality of surgical result, and the higher the complication risk. With any severity of cataract surgery, the benefits outweigh the risks. But the longer you wait, The risks increase and the benefits decrease.
The BIG PICTURE of cataract surgery is this…we are doing it to stop you going blind from cataract, which is the natural history over time. Without surgery, eventually, you have a 100% chance of blindness from your cataract. With surgery, almost everyone avoids blindness, and gains vision.
As a bonus, we restore your eyesight, reduce your need for glasses, and allow an updated pair of glasses to give you best possible vision. This is the optical aims of cataract surgery.
How do you and we define successful surgery?
We are most concerned with you the patient being happy with the result of your surgery.
Being happy with the result requires you to understand what success looks like for you.
Take time to think about this, as your criteria for success will determine your happiness with the result. Take time to write down your desires and your definition for success, and please tell your surgeon.
Much of the rest of this information is to assist you in answering for your doctor and yourself – will you be happy with your surgery and what are you specifically wanting the surgery to do for you.
How do we the doctors define success? How does the government and health funds define success? What do the government and health funds actually pay for?
1. Preventing blindness, which is what will happen without surgery
2. Improving best corrected distance vision. This is your vision with the best pair of glasses on.
3. Balancing the vision between both eyes, but only to a point (less than 3 dioptres of defocus).
4. The vision is better than what we started with.
You might add other definitions for success.
1. Driving without glasses. Most of our patients achieve this, but not all.
2. Reading without glasses
3. Both distance and reading without glasses
4. Reduced glare and haze.
5. Never needing glasses
6. Enjoying the process
The Process of Cataract Surgery
We recommend the following schedule.
-
Obtain a referral from your optometrist confirming that you have cataract limiting your vision.
-
Ring the practice for an appointment, stating you have cataract. 49676677
-
Initial clinical appointment with your surgeon.
-
IOLMaster Eye measurements to plan the surgery - these can be done at the initial or subsequent appointments.
-
Pick dates for surgery. You can plan tentative dates for each eye.
-
Arrange your family and friends to be your carer. Prepare for putting drops in your eyes.
-
First eye surgery day
-
First eye day one post-op check
-
Week one check with our optometrist to check the result of the first eye and plan the second eye.
-
Second eye surgery
-
Second eye post-op check
-
Community optometrist check 1-4 weeks after the second eye is done.
Most people have some cataracts in both eyes. Therefore, both eyes need doing for best vision. Usually the two eyes are done fairly close together, often one or two weeks apart. The sooner we get the surgery done, the sooner you are enjoying better vision. The final step is updating the glasses in both eyes. Absolute best vision always comes with an update of glasses.
Cataract surgery is performed as a day-surgery case in a licensed day hospital such as Newcastle Eye Hospital. Usually one eye is done at a time, and we use the result of the first eye to optimise the result of the second eye. So we prefer to do the non-dominant eye first when there is cataract in both eyes. Cataract surgery involves removing the clouded natural lens and replacing it
surgery, a fine ultrasound probe (less than 2mm in diameter) is inserted through a tiny opening in the cornea, and the cloudy lens is sucked out, leaving its’ supporting bag (the capsule) behind. A prosthetic lens which has been custom selected for your eye is then inserted into the bag.
Cataract surgery takes 5-10 minutes using local anaesthetic with light sedation - we call this "twilight anaesthetic" which is most popular in Australia. You stay at Newcastle Eye Hospital for about 2 hours.
After cataract surgery, patients want to judge the quality of vision in the eye straight away without glasses. Do not be hasty in judging the vision. Firstly, the eye takes time to heal. Secondly, best vision without glasses occurs with the eyes working together, once both eyes have had surgery. Thirdly, best vision occurs with the optimal pair of glasses.
Cataract surgery is performed in an operating theatre, under local anaesthetic. You need to schedule half a day, and plan to be in the hospital for 2 hours. The hospital will phone you a few days prior to give you a time to arrive. You may not be able to drive for several weeks whilst your vision settles down. Your Doctor will advise you, depending on your specific situation. If you live alone, please ensure you have a family member or friend close by on the first night. You will need to return to be reviewed, usually one day after the surgery.
You will need to fast for 6 hours prior to surgery. The pupil will be dilated with drops. The anaesthetist will give you light sedation, and numbs the eye with a local anaesthetic injection or topical drops. Injection may result in some bruising around the eye, and there is a very small risk of more severe bleeding, especially if you take aspirin or Warfarin. You should have an INR one week prior to surgery.
DO NOT STOP ANY MEDICATION UNLESS SPECIFICALLY INSTRUCTED.
CONTINUE ALL REGULAR EYE DROPS SUCH AS YOUR GLAUCOMA DROPS.
After surgery, you will be given instructions, and three bottles of post-operative drops. You need to start these the day after the surgery. You will have a pad on the eye. You may take this pad off at any stage if it is uncomfortable. Otherwise, take the pad off and start your drops the morning after surgery.
Instead of using drops after surgery, we can give long-acting anti-inflammatory and antibiotic medicines at the time of your operation. This means you won’t need to remember drops, and your eye is still well protected and comfortable. A few patients, such as those with diabetes or glaucoma will need additional drops. We'll let you know if that’s needed for you.
It is normal for the eye to be scratchy and sore, and these feelings may persist for several weeks. The vision will be blurry initially, and the vision should gradually clear day by day. You may have bloody tears, or excessive discharge surface of the eye has no effect on the outcome of the surgery.
AT NO STAGE SHOULD THE EYE THROB OR ACHE. NOR SHOULD THE VISION GET WORSE. If these happen, call your Doctor. Do not rub the eye, and do not wash the eye out with water.
If you currently wear glasses, the old lens will not be right for you. If the frames allow it, Your Doctor pushes out the old lens on the first post-operative day.
Cataract surgery can make the eye dry, and some patients require regular lubrication for several months. Many patients suffer from “Dry Eye”, and eye surgery can make this worse.
Activities that jerk the head (e.g. jogging, aggressive golf swings) are best avoided for the first week. Avoid opening the eyes underwater for one month. Do not rub the eye. Otherwise, continue life as normal. You may bend down, and lift weights. If in doubt, ask your Doctor about specific activities you wish to do. Plan to have one week off work, although you may require more.
Most patients want the second eye done soon after the first eye. Your Doctor typically plans this for one month afterwards. This allows assessment of the result of the first eye, to be taken into account when planning the second eye. Most patients can get-by in the first month with a simple pair of reading glasses, or “magnifiers” available in chemists, service stations, and other stores. Your optometrist can optimise a pair of reading glasses once the focussing has stabilised.
Costs
All patients will be given an exact quote at the time of booking. The exact cost will depend on your health insurance cover and excess, your pensioner status, the artificial lens type recommend for you, and whether you prefer the advanced laser assisted cataract surgery technique, or the manual technique.
If you do not have health insurance, you can still have surgery at Newcastle Eye Hospital. Our doctors and administration staff will explain the options and costs to you.
​
Where to Have Surgery – Public and Private Health Systems
Patients can choose to have surgery through the public health system or privately. Public surgery may involve longer wait times but is often fully covered. Private surgery offers more flexibility and choice, including lens types, but may involve out-of-pocket costs. Please see the attached information sheet for a detailed comparison of the two systems and your options.
Dr Peter Davies established Newcastle Eye Hospital in January 2009. He was motivated by what he perceived as a lack of quality in the existing hospitals available for his patients. Newcastle Eye Hospital remains the only hospital in the Hunter Valley exclusively devoted to eye surgery. The quality of staff, equipment, and procedures all play a role in contributing to your outcome.
You can access Newcastle Eye Hospital, or any private hospital three ways.
-
Having private health insurance. Your doctor will give you estimates of the out-of-pocket costs, if any.
-
Self- funding your surgery. Your doctor will arrange quotes to give you your options. This will depend on your lens choices, which requires eye measurements to be taken of your eyes. Patients can sometimes access superanuation or other funding channels.
-
Clinical trials are sometimes underway where the patients receive surgery at no cost
-
Charity programs fund surgery for some patients.
For patients without private health insurance the public system works very well. It does not cost you money, but it costs you time as there is typically a one year wait for cataract surgery. Wait times do vary. Also, the complication rate is higher, and it is a training system, meaning that the surgical trainees often do the surgery.
Under rules introduced in 2024, the public health employees will determine your care. They can transfer you to other doctors and other clinics.
Some patients choose to take out private health insurance, meaning that after the one-year wait, they can have the two eyes done fairly close together through the private health system.
Anaesthesia for cataract surgery
Everyone wants painless surgery.
Most of us do not want to remember the surgery either.
We start with an intravenous canula, through which the anaesthetist can give you any and all the sedation you need.
Between “local” and “general” anaesthetic, is a type of anaesthetic known as “twilight” anaesthetic. We use short acting drugs to block your memory and give you light sedation, similar to having a colonoscopy. This is much safer than putting you completely to sleep.
To numb your eye, we can use topical drops and/or injection of local anaesthetic.
Your anaesthetist will consult with you and decide for you the safest option, based on your medical history and preferences.
​
Can we do both eyes cataract surgery on the same day?
Yes we can!
But for most patients, we do not recommend it.
There are large advantages to your long-term permanent vision if we do cataract surgery in a step-wise fashion. We learn from the first eye, and this allows us to adjust the result of the second eye.
Doing both eyes on the same day saves you time, as there are fewer visits. But the final quality result is less, there is a greater requirement for "touch-up" surgery or laser, particularly to fine-tune the refraction result, and we do not think the life-style advantages of same-day surgery outweigh the clinical disadvantages.
Same day bilateral surgery offers faster recovery but carries slightly higher risk if complications arise.
There is also the practical factor of increased cost for bilateral surgery, because the doctor and the hospital are not paid the full amount for the second eye, so we need to pass on higher charges to the patient. Some health funds specifically prohibit this.
Ask your doctor if you want same day bilateral surgery.
Which Eye should have surgery first?
Most patients expect that we do the poorer seeing eye first. However, for almost all patients, there are cataracts in both eyes. For most patients we therefore do the dominant eye second. The first eye surgery is less accurate than the second eye, so we use the results of the first eye to optimise the second eye. This is why we want the dominant eye to be the second eye that we do.
As soon as we do one eye, almost all patients want us to do the second eye straight away. So because of the advantages of doing the dominant eye second, for almost all patients we plan to do the non-dominant eye first. The only exception is when there is no cataract in the non-dominant eye and in those patients we would do the dominant eye first.
It is a good idea to work with your optometrist BEFORE you develop cataract, to determine which eye is your dominant eye.
We prefer to do the non-dominant eye first. We use the refractive result, or the focusing result, from the first eye to then optimise the focusing for the second dominant eye. We measure this usually one week after the first surgery. This gives us the best chance for the clearest distance vision in the dominant eye without glasses.
Some patients have one eye as a “lazy eye”, or weaker eye. We call this “amblyopia”.
We prefer to do the weaker eye first even if it is poorly sighted. There are two reasons for this. First, we usually improve the lazy eye. Second, we obtain very useful information from the first eye surgery, that improves and makes safer surgery for the dominant second eye.
Wearing spectacles after cataract surgery
Let’s be honest. Most of us would like to NEVER need glasses. Me too.
However, there are basic truths about focussing of the eye, cataract and lens surgery, and the need for glasses, that all patients need to understand, if they are to be happy with the outcome of eye surgery.
Please read these notes carefully. Please discuss with your optometrist and family, how you would like to see after eye surgery.
​
There are five zones of functional vision.
1. Distance vision - driving and golf
2. Room vision - watching TV which depends on your TV.
3. Computer work - around 80 centimetres.
4. Reading vision - around 40 centimetres.
5. Close near - threading a needle.
​
No artificial intra-ocular lens perfectly focuses the eye for all zones of vision. This is very important for every patient to understand.
​
The best lens is the natural crystalline lens, which can adjust its' focus for all distances when you are young. It becomes rigid as you age, and you loose the ability to adjust focus. This is called presbyopia. The absolute best vision comes when you are young, and your eye can automatically refocus itself for all viewing distances, using the internal lens. It is like an automatic focussing camera. Optometrists fix this with PROGRESSIVE glasses which can focus the eyes for all zones of vision.
​
The best artificial lens that focuses you through the zones of viewing distances is the spectacle progressive lens from your optometrist. There is no equivalent lens that we can insert into the eye, that progressively refocusses the eye for different viewing distances.
After cataract surgery you cannot have every viewing distance in perfect focus without glasses. There are things that glasses can do that no other method of blur correction can do. Glasses allow us to eliminate almost all refractive error. Glasses are removable, changeable, repeatable, and modifiable.
Focusing the eyes with cataract surgery is like focusing a telescope. A telescope has a gross-focusing knob, and a fine-focusing knob. Eye surgery resembles the gross-focussing knob, and glasses resemble the fine-focussing knob. ​
All eye surgery is good at grossly refocusing the eye. But fine-focusing is performed with updated glasses after eye surgery. After eye surgery, there is always some residual optical blur, that can be improved with glasses, regardless of what lens design the surgeon uses in the eye.
No artificial lens in the eye focuses the eye perfectly.
What this means in practice is this - most patients can drive a car without glasses and do most activities of daily living, such as working on the computer, without glasses. But for fine visual tasks such as knitting, needlework and the like, glasses will give absolute best vision.
With eye surgery, we aim to reduce the need for glasses. But we cannot eliminate the need for glasses for every eye for every visual task for every viewing distance.
Many patients still need glasses after surgery for reading or fine tasks, depending on the type of lens implanted. Some may only need them occasionally, or not at all.
Nowadays we still define successful cataract surgery as “improving vision with the best pair of glasses (corrected vision)”. Most patients will have their absolute best vision with glasses following surgery. But most patients can do their activities of daily living without glasses.
Currently, surgery achieves driving-standard vision without glasses for 98% of all patients, and 70% achieve 20/20 or better without glasses. What that means is that some patients need glasses even to drive. This is not failure of the surgery. You may have cataracts in both eyes. Surgery is only ever done on one eye at a time for two reasons. Firstly, it is safer. Secondly, information gained from the first surgery can improve the outcome for the second eye. Thirdly, surgery to one eye is less disruptive – bilateral surgery will place you in a situation where you are temporarily blind.
When we take the cataract out, we insert an artificial lens to replace it. Before surgery, we measure the eyes on multiple machines in multiple ways, and then we use these measurements in complex mathematical formulas to decide which power of lens to put in the eye, based on where we want to focus the eye. Each lens is customised to a plan for a specific eye.
Your Doctor spends considerable time before surgery planning your vision without glasses. We routinely use the IOLMaster, corneal computerized topography, and the Verion surgical system to measure your eye. This allows us to choose the “perfect” lens for you, reducing the need for distance glasses for most patients.
The focussing of the first eye is usually not as accurate as the second eye. This is because, despite the extensive process above, our ability to measure the eye is not perfect and there is always some error. Usually the error for the first eye is the same as the second eye, but not always.
Therefore we usually aim for the first eye to be slightly short-sighted, or myopic. That way, if there is any drift in focus towards long-sightedness, you end up with better vision rather than worse vision.
WE USE THE RESULT OF THE FIRST EYE TO OPTIMISE THE SECOND EYE. Therefore, for the second eye we usually aim for sharper distance vision.
There are three basic ways to focus the eyes.
-
Emmetropia - Both eyes focussed for distance vision.
-
Monovision - One eye is focussed for reading, and one eye is focussed for distance. Usually it is the non-dominant eye that is focussed for reading. It is sometimes hard to know which is the dominant eye. Which eye is used for telescopes? Which eye is used to look through a camera. When we can be certain of the dominant eye, then we can be more confident to offer monovision.
The best candidate for monovision is someone who already has it. This is common. Patients will often come in with mild cataract, where the cataract has changed the focus of the eye, so that one eye is already focussed for reading.
Potential problems with monovision is that, wherever the patient is looking, one eye is blurry. Monovision relies on the brain to suppress the image of the blurry eye. Some people do this naturally and easily. These patients love monovision as they can function for most of their activities of daily living without glasses. However, if the brain does not suppress the image from the blurry eye, then the patient experiences continual double vision, or ghosting of their image. Also, with monovision, the brain cannot construct a true stereopsis 3-dimensional vision.
3. Blended vision - The eyes slightly blended, so one eye is slightly better for reading, but is still basically a distance eye. The second eye is sharper for distance.
Whatever we as doctors achieve with the focussing of the eye, be it clear distance vision for both eyes, or mild blending of vision, a pair of glasses always gives the absolute best clarity. This is important when you attend a show, a movie, or wish to see in the distance at night, or for very fine near work.
People like to think and talk in terms of “needing glasses”. “Need” is a relative term. When we are talking about driving standard, most of our patients do NOT need glasses. When we are talking about absolute best clarity vision, which is not a legal standard, most of our patients will BENEFIT from glasses. Notice I did not use the term “need” in that second sentence. An individual patient’s perception of need is highly variable between patients and depends on the particular visual activity in which they wish to engage.
Prisms: There is another reason why some patients will need glasses after cataract surgery – prisms for double vision. If you already have prisms in your glasses, you will need to update your glasses and have prisms to reduce your double vision. It will take longer for your recovery, and you cannot drive whilst you have double vision.
​