About Dr Brian Ang

Cataract Surgery Steps: From Start to Finish

What is a cataract and why is it important?

A cataract simply means that the natural lens inside your eye has become cloudy. In a normal eye, the lens is the middle window that separates the front and back compartments of the eye. It’s job is to focus light entering the eye onto the retina so you can see more clearly.

Over time, the lens becomes gradually more cloudy with age. As the cataract develops, less light becomes focused onto the retina. Your eyesight gradually becomes more blurry and your visual acuity decreases. You’ll also start to notice glare, especially during a bright day or at night when driving. Sometimes, you may also notice double vision.

(Image adapted from the internet)

Cataract is important because it is the leading cause of preventable blindness worldwide. The numbers are truly enormous. Approximately 20 million people worldwide are blind from this, with 400,000 people becoming visually disabled every year from the United States alone.

Cataract surgery is unsurprisingly the most common day case procedure in the world. Nevertheless, it remains a major global health issue, particularly for developing countries where there is poor access to eye healthcare.

I have been told that I have a cataract. Do I need to have an operation now?

All my patients with cataract ask me this question. And the answer is always the same: it depends.

The decision to have cataract surgery depends on your circumstances. The most important consideration is whether or not you are experiencing vision problems from the cataract.

So ask yourself the following questions:
– Is your vision interfering with your quality of life, such as with driving?
– Is your vision affecting the way you manage your day-to-day activities?
– Are you having difficulties seeing well enough to feel safe?
– Is your vision bad enough for you to accept the risks of surgery?

If the answers to the above questions are all no, then you can probably wait.

If you visit an ophthalmologist and you feel pressurized to undergo surgery, my advice is to seek a second or even third opinion. High pressure tactics usually only benefit the surgeon financially, not the patient undergoing surgery.

Unfortunately there are some eye specialists who employ high pressure tactics to convince you to have surgery even though you may not need it.

My cataracts are really affecting me. What should I do?

Read the cataract surgery patient information sheet here.

The first step is to see an ophthalmologist for a cataract assessment.

When I see a patient referred for cataract surgery, I take a full history to include the questions above. I also test the visual acuity, check the refraction, and perform a comprehensive eye exam to confirm the suitability of the eye for surgery. I always look out for other eye diseases that may impact on the outcome of surgery, such as glaucomamacular degeneration, and diabetic eye disease.

Sometimes, it may be appropriate to combine the cataract surgery with stent implantation (such as the iStent or Hydrus microstent) or injection of a special medicine into the eye (intravitreal injection).

I pay particular attention to features that may make the surgery more difficult and complex, such as a small pupil, dense and wobbly cataract, small eye, and inability to life flat for surgery.

At this point, I will also discuss the vision needs at length so that I can plan appropriately, manage unrealistic expectations, and avoid dissatisfaction later on.

Do I need to undergo any special tests before surgery?

Yes. There are a few special tests that will need to be performed to give your eye the highest chance of a successful visual outcome. These are all usually conducted during your cataract assessment visit.

A-scan biometry is performed to measure the curvature of the cornea and length of the eyeball, among other things, so that the optimum intraocular lens can be calculated for your eye. A-scan biometry therefore needs to be as accurate as possible.

If you are wearing contact lenses, you will need to leave them out for at least 2 weeks before the scan. This is because contact lenses can affect the curvature of the cornea.

Optical coherence tomography (OCT) scan is performed to detect any macular disease such as macular degeneration, epiretinal membrane, and diabetic macular edema.

Corneal topography scan may be performed if there is irregularity of the cornea, such as in keratoconus or after pterygium surgery.

B-scan ultrasound may be performed if the cataract is so dense and opaque that the back of the eye cannot be visualized clinically. The B-scan will be able to detect diseases affecting the back of the eye, such as retinal detachment and tumors of the eye.

I have now been scheduled to have cataract surgery. Please walk me through what happens on the day of surgery step by step.

When you arrive at the day surgery center or hospital for surgery, there will be 4 distinct stages: preadmission, anesthetic bay where you receive the anesthetic, operating bay where you will undergo the actual surgery, and the recovery area.

The whole process will take about 3 to 4 hours. The actual surgery itself takes around 15 to 45 minutes, depending on the complexity of the case.


The day surgery center or hospital will have already advised you on fasting arrangements and what to do you with your medications.

In general, you will need to fast for at least 6 hours prior to surgery.

This is what will happen at preadmission:
– History-taking by nurse to confirm surgical procedure and drug allergies
– Measurement of blood pressure, pulse, and oxygen saturation levels
– Eye drops to dilate the pupil for surgery
– Local anesthetic eye drops to numb the surface of the eye

When ready, you will be moved to the anesthetic bay.

Anesthetic bay

The anesthetist or anesthesiologist will have already discussed with you about the different anesthetic options and risks involved.

This is what will happen in the anesthetic bay:
– You will lie down on a trolley
– Time out to confirm site and type of procedure to be performed
– Intravenous cannula inserted into the back of your hand
– Sedating medication is given to make you drowsy
– Local anesthetic injection around the eye to fully numb the eye
– If appropriate, general anesthetic may be administered instead of local

Once anesthetic has been given, you will be moved to the operating bay.

Operating bay

Before commencing surgery:

– Time out to confirm site and type of procedure to be performed
– Cleaning of the eye with antiseptic (povidone iodine or chlorhexidine)
– Sterile drape over the eye
– Opening the lids and exposing the eyeball with a lid clip (speculum)

During surgery:

– 3 incisions into the eye with a micro-incision blade (up to 3 mm)
– Viscoelastic into the eye to maintain the shape and pressure of the eye
– Capsulorrhexis to create a round opening at the front of the bag containing the cataract. This provides access to the cataract.

(Image adapted from the internet)

Steps in phacoemulsification cataract surgery: corneal wound incision to allow entry into the eye (left), and capsulorrhexis to create an opening at the front of the capsular bag (right)

– Hydrodissection to separate the cataract from the capsular bag
– Phacoemulsification to fragment the cataract into pieces using ultrasound
– Intraocular lens implantation into the empty capsular bag

(Image adapted from the internet)

Steps in phacoemulsification cataract surgery: phacoemulsfication ultrasound sculpting of the cataract into little pieces to allow easy removal (left), and implantation of the intraocular lens into the capsular bag (right)

– Removal of viscoelastic
– Wound hydration to seal the wound. Sutures are rarely needed.
– Antibiotic (usually cefazolin) into the eye to prevent infection

At completion of surgery:

– Eye is cleaned
– Pad and shield placed over the eye
– Final check to confirm that surgery has been successfully completed

Recovery bay

After surgery, you will be moved to the recovery area. This is what will happen in the recovery area:
– You’ll be given around 30 minutes to regain your bearings
– Measurement of blood pressure, pulse, and oxygen saturation levels
– You’ll finally get some food and drink!
– Postoperative instructions about eye care and use of eye drops
– Discharge from day surgery center or hospital. You will need a family member or friend to accompany you home.

If you are interested to learn more about the specifics of cataract surgery, below are a selection of books and other items that you may find helpful.

What happens after cataract surgery?

The pad and shield can be removed the next day, and you can start your normal postoperative eye drops, usually a steroid anti-inflammatory eye drop (Prednisolone or Dexamethasone) and an antibiotic (Chloramphenicol) 4 times daily for 3 to 4 weeks. You will need to continue your other usual eye drops (if any).

Over the next few days, you may experience blurriness, discomfort, sensitivity to light, with blood and swelling around the eye. This will gradually improve with the eye drops. You may take paracetamol to help control any discomfort.

It can take a week or two before you notice any improvement in your vision. You will usually be reviewed 2 to 4 weeks after surgery. There is usually no need to be seen the next day unless there is a specific concern about the surgery.

Around 4 to 6 weeks after surgery, you can see your optometrist for new glasses to further sharpen your focus.

I recently had cataract surgery but I am worried about the pain and swelling in my eye. What should I do?

If at any time, you are concerned about anything about the eye after surgery, please get in touch with your surgeon.

If you encounter a complication, it is far better to have the complication treated earlier rather than a week later.

Most complications are relatively minor can be easily treated with drops or laser. Rarely, sight threatening complications such as retinal detachment  and  endophthalmitis (severe infection of the eye) can still occur and require early treatment for best outcomes.

See Related: 

Complications occurring early after cataract surgery

Complications occurring late after cataract surgery

Have a story about your eye surgery?

Have you recently had eye surgery? Was it how you thought it would be, or was it totally not what you expected? Why not share your experience of surgery with other readers?


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