Cataract surgery

Cataracts, which arise when the natural lens of the eye becomes clouded and cause impaired vision and difficulty seeing clearly, can be treated medically through phacoemulsification, often known as cataract surgery. The clouded lens is extracted during cataract surgery and replaced with an artificial intraocular lens (IOL). Globally, cataracts are the most common cause of reversible blindness, and because current IOLs are so technologically advanced, some patients have better vision than they did before the formation of the cataract (Lam et al, 2015). Cataract surgery is the most common NHS surgical procedure. Spending on cataract surgery by the NHS is estimated to be in the region of £500 million annually (Donachie and Buchan, 2023).
 
Surgery for cataracts has not always been state-of-the-art. One of the first methods of cataract surgery, known as ‘couching’, used a needle or other sharp object to push the clouded lens back into the vitreous chamber of

The key objectives of cataract surgery:  

• Better visual clarity: By removing the hazy lens, light can more accurately focus on the retina (Aaronson et al, 2020)
• Improved quality of life: Brings back the ability to read, drive, and recognise faces independently
• Refractive error correction: Modern cataract surgery frequently involves the implantation of an IOL intended to treat presbyopia, astigmatism, nearsightedness, or farsightedness
• Avoidance of complications: If left untreated, advanced cataracts can result in retinal damage, inflammation, or glaucoma (Liu et al, 2017).

The following list provides a thorough assessment, covering eye health, systemic health, surgical planning, and patient preparation.

• Patient history
• Visual acuity
• Slit-lamp examination
• Intraocular lens (IOL) assessment 
• Tonometry
• Retinal health examination
• Systemic health check
• Anaesthesia assessment
• Patient information and advice
• Pre-operative instructions.

• Surgical microscope – Provides high magnification for precision during surgery
• Phacoemulsification machine – Used to break up and remove the cataract using ultrasound
• Intraocular lens (IOL) – Artificial lens implanted to replace the removed cataract
• Tonometry equipment – To measure intraocular pressure before and after surgery
• Surgical instruments – Includes forceps, scissors, and needles for incision and lens removal
• Instruments for incision (e.g. blade or laser) – To create a small incision in the cornea
• Surgical drapes and sterile covers – For maintaining a sterile environment during surgery
• A-scan ultrasound – For measuring the eye’s length to calculate IOL power
• Eye shield – To protect the eye post-surgery.

There are various types of artificial IOLs. Each type of IOL is chosen based on the patient’s visual needs, eye health, and lifestyle preferences. Below is a short list of IOLs, but not limited to:

• Monofocal IOLs: Provides clear vision at one distance (near, intermediate, or far). Which is

The procedure is usually performed on an outpatient basis, meaning the patient can go home the same day. The procedure is usually done under local anaesthesia (LA), which numbs the eye (NICE, 2017). The LA is given to the patient in topical drop form, the type of drops used is according to the surgeon’s preferences. As in any surgical procedure, surgical preferences on equipment used also varies from surgeon to surgeon and it is the scrub practitioner’s responsibility to prepare the required equipment in advance. An intraocular LA is administered during the procedure, either via a subconjunctival injection or through the surgical incision using a cannula on a syringe. In some cases, general anaesthesia may be used, particularly in children, or patients that are difficult to position. Surgery, dependent on complexity, takes between 15 and 30 minutes.
 
Surgical steps in phacoemulsification (Jaggernath et al, 2013):

• Pre-operative preparation: To improve access to

While rare, possible complications include infection, bleeding, retinal detachment, or increased intraocular pressure. However, most people have successful outcomes without major issues (Aaronson et al, 2020).

Recovery: Most people experience improved vision within a few days, although full recovery can take several weeks. NHS patients receive immediate post-operative care and are given an advice booklet on how to care for their eye on the days following surgery. Patients are advised on signs and symptoms and provided with a contact number to ring in the event of any causes for concerns. This has proven to be a more time-efficient and cost-effective way of managing patients postoperatively (Rush et al, 2023).

Nursing and Midwifery Council: standards of proficiency for registered nurses:

Part 1: Being an accountable professional

1.2 Understand and apply relevant legal, regulatory and governance requirements, policies, and ethical frameworks, including any mandatory reporting duties, to all areas of practice, differentiating where appropriate between the devolved legislatures of the United Kingdom.

1.8 Demonstrate the knowledge, skills and ability to think critically when applying evidence and drawing on experience to make evidence-informed decisions in all situations.

Part 3: Assessing needs and planning care

3.5 Demonstrate the ability to accurately process all information gathered during the assessment process to identify needs for individualised nursing care and develop person-centred evidence-based plans for nursing interventions with agreed goals.

Part 4: Providing and evaluating care

4.8 demonstrate the knowledge and skills required to identify and initiate appropriate interventions to support people with commonly encountered symptoms including anxiety, confusion, discomfort and pain. 

Aaronson A, Viljanen A, Kanclerz P, Grzybowski A, Tuuminen R. Cataract complications study: an analysis of adverse effects among 14 520 eyes in relation to surgical experience. Ann Transl Med. 2020 Nov;8(22):1541. doi: 10.21037/atm-20-845. https://atm.amegroups.org/article/view/42560/html

Donachie PHJ, Buchan JC. Year 7 Annual Report – The Sixth Prospective Report of the National Ophthalmology Database Audit National Cataract Audit. NHS or equivalent Funded Cataract Surgery for the 2021 NHS year: 01 April 2021 to 31 March 2022. 2023. Online. Available at: NOD Cataract Audit Full Annual Report 2023.pdf

Jaggernath J, Gogate P, Moodley V, Naidoo KS. Comparison of cataract surgery techniques: safety, efficacy, and cost-effectiveness. Eur J Ophthalmol. 2014 Jul-Aug;24(4):520-6. doi: 10.5301/ejo.5000413.

Lam D, Rao SK, Ratra V, Liu Y, Mitchell P, King J, Tassignon MJ, Jonas J, Pang CP, Chang DF. Cataract. Nat Rev Dis Primers. 2015 Jun 11;1:15014. doi: 10.1038/nrdp.2015.14.
https://www.nature.com/articles/nrdp201514

Leffler CT, Klebanov A, Samara WA, Grzybowski A. The history of cataract surgery: from couching to phacoemulsification. Ann Transl Med. 2020 Nov;8(22):1551. doi: