Definition

Extracapsular cataract extraction (ECCE) is a category of eye surgery in which the lens of
the eye is removed while the elastic capsule that covers the lens is left partially intact to allow
implantation of an intraocular lens (IOL). This approach is contrasted with intracapsular cataract
extraction (ICCE), an older procedure in which the surgeon removed the complete lens within its
capsule and left the eye aphakic (without a lens). The patient's vision was corrected after
intracapsular extraction by extremely thick eyeglasses or by contact lenses.

There are two major types of ECCE: manual expression, in which the lens is removed through an
incision made in the cornea or the sclera of the eye; and phacoemulsification, in which the lens is
broken into fragments inside the capsule by ultrasound energy and removed by aspiration.

In extracapsular cataract extraction, an incision is made in the eye just beneath the iris, or colored
part (A). The diseased lens is pulled out (B). A prosthetic intraocular lens is placed through the
incision (D), and is opened to replace the old lens (E).

INSTRUMENTS:
 Basic eye procedures tray
 Cataract extraction and lens procedure tray
 McIntyre infusion set with connector and coaxial irrigation-aspiration system
 Phacoemulsification tray
  Handgrips or drape for microscope
 Intraocular lens (IOL) implant
 Use the eye drops and medicines as prescribed
 Avoid rubbing or squeezing your eye
 Protection: As advised by your doctor, you may wear the protective eye shield at night
for first week. Dark eyeglasses may be worn during the daytime, especially outdoors, to
avoid any discomfort that you may have from bright light and also to prevent any injury
to eye.
 Face wash: For the first few days, avoid splashing water directly into the eye. You may
use a clean, soft, wet towel to wipe your face.
 Shaving: Shaving of the beard is permitted after the operation.
 Bathing: Body bath (below the neck) may be resumed after the first day, but avoid taking
a shower or a bath in the bathtub for the first week after surgery.
 Head bath: One may wash the hair with the head tilted backwards to avoid any water
splashing into the eye.
 Games: Normal daily activities including walking, reading and watching television may
be resumed soon after the operation. However avoid strenuous activities like jogging,
lifting weights, swimming, gardening, aerobics, contact sports etc. for 1-2 months.
 Sex: You can resume your sex life a week or two after the operation after consulting your
doctor.
 Makeup: Avoid eye makeup for 6 weeks.
 Diet: There are no dietary restrictions and you may take your routine diet. However, the
restrictions as per you pre-existing medical problems, if any, are to continue. Avoid
constipation by taking high fiber diet and plenty of fluids.
 Driving: Avoid driving unless the surgeon permits you.
 Job: You may get back to your job in 1-4 weeks after surgery depending on your
profession. Ask your surgeon about this.
 Normal symptoms: The following symptoms are normal and are not a cause for alarm.
These are slight redness, mild watering, mild irritation, glare and slight drooping of upper
eyelid. These will remain to some extent for 6-8 weeks.
 Alarming symptoms: In case of any pain, injury, decrease in vision or flashes of light in
the operated eye, contact your surgeon immediately.

Operation procedures
The surgical procedure in phacoemulsification for removal of cataract involves a number of
steps. Each step must be carefully and skillfully performed in order to achieve the desired result.
The steps may be described as follows:

1. Anaesthesia,
2. Exposure of the eyeball using a lid speculum,
3. Entry into the eye through a minimal incision (corneal or scleral)
4. Viscoelastic injection to stabilize the anterior chamber and to help maintain the eye
pressurization
5. Capsulorhexis
 6. Hydrodissection pie
7. Hydro-delineation
8. Ultrasonic destruction or emulsification of the cataract after nuclear cracking or chopping
(if needed), cortical aspiration of the remanescent lens, capsular polishing (if needed)
9. Implantation of the artificial IOL
10. Entration of IOL (usually foldable)
11. Viscoelastic removal
12. Wound sealing / hydration (if needed).

The pupil is dilated using drops (if the IOL is to be placed behind the iris) to help better visualise
the cataract. Pupil constricting drops are reserved for secondary implantation of the IOL in front
of the iris (if the cataract has already been removed without primary IOL implantation).
Anesthesia may be placed topically (eyedrops) or via injection next to (peribulbar) or behind
(retrobulbar) the eye. Oral or intravenous sedation may also be used to reduce anxiety. General
anesthesia is rarely necessary, but may be employed for children and adults with particular
medical or psychiatric issues. The operation may occur on a stretcher or a reclining examination
chair. The eyelids and surrounding skin will be swabbed with disinfectant. The face is covered
with a cloth or sheet, with an opening for the operative eye. The eyelid is held open with a
speculum to minimize blinking during surgery. Pain is usually minimal in properly anesthetised
eyes, though a pressure sensation and discomfort from the bright operating microscope light is
common. The ocular surface is kept moist using sterile saline eyedrops or methylcellulose
viscoelatic. The discission into the lens of the eye is performed at or near where the cornea and
sclera meet (limbus = corneoscleral junction). Advantages of the smaller incision include use of
few or no stitches and shortened recovery time.[3][11]. A capsulotomy (rarely known as cystotomy)
is a procedure to open a portion of the lens capsule, using an instrument called a cystotome[12]. An
anterior capsulotomy refers to the opening of the front portion of the lens capsule, whereas a
posterior capsulotomy refers to the opening of the back portion of the lens capsule. In
phacoemulsification, the surgeon performs an anterior continuous curvilinear capsulorhexis, to
create a round and smooth opening through which the lens nucleus can be emulsified and the
intraocular lens implant inserted.

Following cataract removal (via ECCE or phacoemulsification, as described above), an

intraocular lens is usually inserted. After the IOL is inserted, the surgeon checks that the incision
does not leak fluid. This is a very important step, since wound leakage increases the risk of
unwanted microrganisms to gain access into the eye and predispose to endophathalmitis. An
antibiotic/steroid combination eye drop is put and an eye shield may be applied on the operated
eye, sometimes supplemented with an eye patch.

Antibiotics may be administered pre-operatively, intra-operatively, and/or post-operatively.

Frequently a topical corticosteroid is used in combination with topical antibiotics
postoperatively.

Most cataract operations are performed under a local anaesthetic, allowing the patient to go
home the same day. The use of an eye patch may be indicated, usually for about some hours,
after which the patient is instructed to start using the eyedrops to control the inflammation and
the antibiotics that prevent infection.
Occasionally, a peripheral iridectomy may be performed to minimize the risk of pupillary block
glaucoma. An opening through the iris can be fashioned manually (surgical iridectomy) or with a
laser (called YAG-laser iridotomy). The laser peripheral iridotomy may be performed either
prior to or following cataract surgery.

The iridectomy hole is larger when done manually than when performed with a laser. When the
manual surgical procedure is performed, some negative side effects may occur, such as that the
opening of the iris can be seen by others (aesthetics), and the light can fall into the eye through
the new hole, creating some visual disturbances . In the case of visual disturbances, the eye and
brain often learn to compensate and ignore the disturbances over a couple of months. Sometimes
the peripheral iris opening can heal, which means that the hole ceases to exist. This is the reason
why the surgeon sometimes makes two holes, so that at least one hole is kept open.

After the surgery, the patient is instructed to use anti-inflammatory and antibiotic eye drops for
up to two weeks (depending on the inflammation status of the eye and some other variables). The
eye surgeon will judge, based on each patient's idiosyncrasies, the time length to use the eye
drops. The eye will be mostly recovered within a week, and complete recovery should be
expected in about a month. The patient should not participate in contact/extreme sports until
cleared to do so by the eye surgeon.

After the Procedure

You will probably return home after surgery and then have a follow-up exam with your doctor
the next day. Your doctor may ask you to wear a patch over your operated eye until your exam
the next day. After this, you may want to wear dark sunglasses outside.

Your doctor may prescribe antibiotic and anti-inflammatory eye drops to use for 1 or more
weeks to help with healing.

Make sure your hands are clean before touching your eye. Try not to get soap and water in your
eye when you are bathing or showering for the first few days.

If your doctor closed your incision with sutures, you may need to schedule a visit to have them
removed.

Take it easy. Light activities are best as you recover. Check with your doctor before doing any
strenuous activity, resuming sexual activity, or driving.

Expect complete healing in about 10 weeks. If you need new glasses or contact lenses, have them
fitted after you have healed completely. It is important to have a follow-up visit with your doctor.

Outlook (Prognosis)

The outcome of cataract surgery is usually excellent. The operation has low risk, the pain is
minimal, and recovery time is short. Sight improves for most people.