Cataract Surgery is THE most common surgical eye procedure performed in our adult population in Singapore. Since nobody is immune to cataract formation, and it is more likely than not that our parents or grandparents would need cataract surgery at some point in their lives, it is probably in our best interest to know more about it. Here are the what, when, how and who’s of modern cataract surgery in about 1800 words.

Healthy eye and eye with cataract

What is a Cataract?

Our eye works very much like a camera and we have a lens in our retina that allows us to focus images for our brain. A cataract is the clouding, opacification or thickening of that natural crystalline lens in our retina, due to the natural process of ageing or age related macular degeneration. The process of cataract formation and deteriorating eye health may be unknowingly accelerated by other environmental factors, such as trauma, medications, UV-exposure, etc.

Who will get Cataracts?

In general, as we age, we will all develop eye conditions like cataracts. It’s a matter of how mild or severe the cataract formation is. The typical age to develop cataracts in Singapore is 50 to 70 years old. Certain predisposing factors may quicken this process:

  1. Trauma: Any prior injury including a blunt hit to the eye can cause cataracts.
  2. Excessive sunlight UV exposure
  3. Overuse of steroid medication in the forms of oral steroids, nasal steroid sprays or steroid eyedrops.
  4. High degree of myopia or short-sightedness
  5. Any prior eye laser or eye surgery

How do I know whether I have Cataracts?

Cataracts will give us vision changes symptoms such as blurry vision, double vision, shadowy vision, poor night vision and reading vision and darkening or dimming of vision. If the cataract is very early or mild, they may be little or no symptoms except for mild fluctuations in our spectacle degree, brought about by the changes in shape or thickness of the lens. That is why you would have heard about how older people with what you would have expected as stable spectacle degrees, suddenly develop a ‘decrease’ in their spectacle degree. They always assume that their eyes are ‘improving’ however it is actually the development of an early cataract.

As your eye doctor and ophthalmologist, I would be able to detect cataract formation while viewing your eye through the slit lamp. There are also imaging techniques that allow me to measure the density of the cataract and quantify its severity.

What do I need to consider if I have cataracts?

Firstly, there’s no need to get anxious about it. Remember that I said EVERYONE gets cataracts at some point in their lives, it’s really a matter of time.

Cataract surgery

The important questions to ask would be:

  • Do I need surgery now?

We don’t always need an operation right away. In fact, your eye doctor or ophthalmologist will tell you that cataracts are known to be slowly progressive, so don’t worry, you have some time to play with.

Since every and any surgery is not without risk, we want to be absolutely sure that we need cataract removal surgery before committing to one. By that, we need to be certain that our cataracts are impairing our vision enough to make undergoing surgery worth the risk.

So ask yourself: How has my decrease in vision impacted my life? Depending on what your usual daily activities are, I would ask my patients a series of questions revolving around that. For example: Can you still drive at night with ease without much blurry vision? Can you still read the newspapers? Can you still see your Excel spreadsheet? Can you still see the ball when you golf?

If there are any deficiencies which significantly affect your quality of life, then it would be prudent to take the next step of treatment to regain your full visual potential and in turn achieve full quality of living.

Beautiful young woman
  • Do I have any co-existing conditions that may need to be addressed?

As your eye doctor and ophthalmologist, I must tell you that many people think that they require treatment for cataracts only, and fail to consider their entire eye in a holistic manner. Know that it is not possible to have good visual outcome if there are co-existing retinal problems, glaucoma etc. During your pre-surgery eye assessment with me, I will be able to explain to you whether you have any other eye conditions that need to be treated. Often, these eye problems can be treated in the same setting.

For example, if you have an epiretinal membrane or macular hole, having laser cataract surgery alone will not give you the best vision you could have. Instead, the epiretinal membrane could be removed at the same time as the cataract surgery to give you an improved visual outcome. Likewise, if you have concurrent glaucoma, having a combined glaucoma procedure at the time as the cataract surgery may improve your glaucoma.

Lastly, if you have extremely troublesome floaters that are disturbing your daily living and worsening your quality of life, I would be able to discuss with you the pros and cons of having these annoying floaters removed during your cataract surgery.

  • What sort of vision correction do I want after surgery?

We take the opportunity during cataract surgery when we are going to implant an intraocular lens implant (IOL lens) in your eye to correct your vision to suit your daily needs. First, we need to understand that having cataract surgery leads to loss of accommodation which is the inability to focus on both distance and near without any prescription glasses. This is similar to the ‘Lao Hua’ or presbyopia phenomenon that all of us experience as we get older.

Some of us like to see far without the use of glasses or lenses and don’t mind wearing spectacles for reading near work. Some of us prefer to wear spectacles or lenses for distance vision, then be able to remove the spectacle lens to see clearly for near reading. Yet some of us prefer not to wear spectacles or lenses at all for both distance and near and are willing to accept a slight compromise in the sharpness or quality of vision.

Depending on the patients’ preference, we are able to offer artificial lens such as mono-focal lenses which correct vision to one desired distance or multifocal lens which corrects to multiple distances, although at a lower visual quality. We can even correct astigmatism by using artificial lens i.e. toric IOL lenses which are placed at the steepest axis required. These are known as ‘premium’.

There are many different types of premium implants (toric, multifocal, trifocal, extended range of vision) that can be offered to you although not all types are suitable for everybody. Your ophthalmologist will match the best implant to each patient according to their personality, occupation, hobbies and daily visual needs.

What are the risks of surgery?

The risks of cataract surgery such as bleeding, infection posterior capsule, retinal detachment and blindness are extremely low; and quoted at 0.01% to 0.001% (1 in 10,000 to 100,000). That is even lower than getting hit by a car or being in an aeroplane disaster. Thus it is generally a safe procedure.

Generally, we feel comfortable proceeding with surgery when the benefits (improvement to vision) clearly outweigh the risks.

What can I expect before surgery?

Before your surgery, your eye doctor or eye specialist would assess your entire eye and visual concerns in a detailed manner. After a detailed discussion on the type of vision that best suits you, accurate measurements of your eye are made in order to prepare the perfect IOL artificial lens for your eye. Your surgeon will hand you pre-surgical eyedrops which will include antibiotic and anti-inflammatory components which primes your eye into the best environment for surgery.

How is cataract surgery done?

Cataract surgery is usually done as a day surgery procedure, which means that the whole process usually takes half a day and there is no need to stay overnight. The surgery itself only takes less than half an hour.

In the old days, cataract surgery was performed by creating a large 12 mm wound in the cornea, expulsion of the lens in the eyes as a whole piece and putting in 7-8 stitches at the end. That is why the old saying was to ‘wait for your cataract to be ripe’ before taking it out.

We no longer perform cataract surgery this way. Instead, we use ultrasound energy. We create a very small 2mm wound in the front of the cornea, insert a small ultrasound probe which cracks and aspirates (similar to a vacuum) the cataract, and negate having to stitch the wound at the end. Hence, it works against us if the lens is too ‘ripe’ or hard as that makes it difficult to crack and aspirate. So, please do NOT wait for your cataract to be too ‘ripe’ as it inadvertently makes the surgery more complicated and even risk eye infection.

Your surgeon might perform laser assisted cataract surgery too. Laser assisted cataract surgery uses femtosecond laser technology for extra precision and accuracy instead of traditional hand-held surgical tools.

What can I expect during surgery?

Some surgeons like to perform the cataract operation on their patients with as little anaesthesia as possible. This means that patients are lightly sedated so they may be aware of what’s going on during the procedure and able to ‘co-operate’ with their surgeons’ instructions to keep still. 

I, on the other hand, prefer to have my patients fully sedated and completely asleep so that they are unaware of the procedure and fully comfortable. Most of my patients comment that going for surgery is like going for a spa treatment, where they have a good sleep and wake up after the procedure is all over. 

What can I expect after surgery?

After the operation, your operated eye will have an eye shield for 1 day as part of the recovery process to prevent infection. There is usually little to no pain on the eye at all. Eye redness and swelling is mostly minimal after my surgery. You will be given post-surgery eye drops according to a regime that we will carefully go through with you. The eye drops must be administered as told. We always review your progress at day 1, week 1 and month 1 after surgery as a package.

You may proceed with normal diet and normal activity except we encourage you to stay away from strenuous exercise, swimming, or dusty environments. We will provide you with a tinted or clear protective eyewear (according to your choice) which protects your operated eye.

Woman making an eye test

What is the cost of cataract surgery? 

Thanks to the Ministry of Health website, the cost of cataract surgery in public (restructured) and private hospitals are no longer a mystery.

Subsidized patients in public hospitals may be charged as high as $1300 for a single eye cataract surgery. This cost does not include the pre- and post-surgery visits and because it is a subsidized rate, patients are unable to choose their desired ‘premium’ implants.

Unsubsidized patients in public hospitals may be charged as high as $3,500 to $5,500 for a single eye cataract surgery. Again, this rate does not include pre- and post-surgery visits. With this rate, patients are able to choose certain premium lenses although the cost may go up higher than that stated, depending on the type of lens chosen.

Private hospital charges can range from $6,000 to $12,000 for single eye cataract surgery. This range is so wide depending on the type of intraocular lens, the type of anaesthesia, and which private hospital is chosen. This rate includes the surgeon fee and may also include pre- and post-surgery visits depending on the package offered by the surgeon.

It may seem more economical to have cataract surgery done at public hospital, however, when you look at the cost breakdown, it may not necessarily be so. With the added advantage of less waiting-time, more consult-time, more premium lens choices, and more individualized care, it might be more value for your money to consider private hospital for your cataract surgery.

Suggested Readings:

  1. Allen D, Vasavada A. Cataract and surgery for cataract. BMJ. 2006;333(7559):128‐132.
  2. Alkharashi M, Stark WJ, Daoud YJ. Advances in cataract surgery. Expert Rev Ophthalmol 2013;8(5):447-56.
  3. Lee RM, Thompson JR, Eke T. Severe adverse events associated with local anaesthesia in cataract surgery: 1-year national survey of practice and complications in the UK. Br J Ophthalmol 2016;100(6):772-6.
  4. Day, A., Donachie, P., Sparrow, J. et al. The Royal College of Ophthalmologists’ National Ophthalmology Database study of cataract surgery: report 1, visual outcomes and complications. Eye 29, 552–560 (2015). 
  5. Wang W. et al. A Global View on Output and Outcomes of Cataract Surgery With National Indices of Socioeconomic Development. Investigative Ophthalmology & Visual Science July 2017, Vol.58, 3669-3676.
  6. Aristodemou, Petros et al. Evaluating Refractive Outcomes after Cataract Surgery. Ophthalmology, Volume 126, Issue 1, 13 – 18

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