Phacoemulsification with IOL Implantation for Cataract Treatment
Phacoemulsification with intraocular lens (IOL) implantation is the preferred surgical technique for cataract removal, offering superior outcomes with lower complication rates compared to other surgical approaches. 1
Medical Necessity Criteria
Cataract surgery is indicated when:
- Best-corrected visual acuity is 20/40 or worse
- Glare testing shows significant functional impairment
- The cataract impacts the patient's lifestyle and daily activities
- Visual function decline no longer meets the patient's needs 2
Surgery is contraindicated when:
- Tolerable refractive correction provides adequate vision
- Surgery is not expected to improve visual function
- Medical or ocular conditions make surgery unsafe 2
Preoperative Evaluation
Detailed assessment of:
- Visual acuity and refraction
- Intraocular pressure
- Ocular comorbidities (glaucoma, diabetic retinopathy, macular degeneration)
- Potential for postoperative complications 1
Special considerations:
- Identify ocular comorbidities that could impact surgical outcomes
- Assess for high-risk features (shallow anterior chamber, small pupil)
- Evaluate systemic health issues that might affect surgery 1
Biometry and IOL power calculation are essential for optimal refractive outcomes 1
Surgical Technique
The ideal phacoemulsification procedure includes:
- Capsular bag fixation of an appropriate posterior chamber IOL
- Minimization of trauma to ocular tissues
- Secure, watertight incision that minimizes surgically induced astigmatism 1
Key technical elements:
- Clear corneal incision
- Continuous curvilinear capsulorhexis
- Hydrodissection and hydrodelineation
- Phacoemulsification of the nucleus
- Irrigation/aspiration of cortical material
- In-the-bag IOL placement 1
IOL Options
- Standard monofocal IOLs: Provide good distance vision, typically require reading glasses
- Toric IOLs: Correct pre-existing astigmatism
- Multifocal/extended depth of focus IOLs: Reduce dependence on glasses for near and intermediate vision
- Accommodating IOLs: Attempt to restore some focusing ability 1
Special Considerations
High axial myopia: Abnormal anterior chamber depth and stability during phacoemulsification
Short hyperopic eyes: Increased risk of iris prolapse and choroidal effusion
High axial length: Increased risk of complications with retrobulbar injections 1
Combined procedures: Phacoemulsification can be safely combined with:
Anesthesia Options
- Topical anesthesia (preservative-free 2% lidocaine drops) is effective and safe for most patients
- Consider alternative anesthesia for anxious patients or those with small pupils 4
Complications and Management
Common complications include:
- Posterior capsule opacification
- Increased intraocular pressure
- Corneal edema
- Cystoid macular edema
- Endophthalmitis (rare but serious) 1
Risk reduction strategies:
- Intracameral antibiotics reduce the risk of postoperative endophthalmitis
- Topical NSAIDs reduce the incidence of early postoperative cystoid macular edema
- Careful wound construction minimizes risk of leakage 1
Special Situations
Angle closure: Lens extraction significantly widens the anterior chamber angle and can lower IOP in eyes with narrow, occludable angles 1
Pars planitis: Phacoemulsification with IOL implantation is safe with good outcomes when inflammation is controlled preoperatively 5
Post-vitrectomy eyes with silicone oil: Combined phacoemulsification, IOL implantation, and silicone oil removal through a single corneal incision is effective 6
Post-refractive surgery: Special considerations for IOL power calculation are needed 7
Postoperative Care
- Topical antibiotics and anti-inflammatory medications
- Regular follow-up to monitor for complications
- Management of residual refractive error
- Treatment of posterior capsule opacification if it develops 1
Phacoemulsification with IOL implantation remains the gold standard for cataract surgery, with high success rates and significant improvements in visual function and quality of life for most patients.