Cataract Surgery: Procedure, Steps, and Types of Intraocular Lenses

The only known effective treatment for developed cataract is cataract surgery. During this procedure, the clouded natural lens is removed and replaced with an artificial intraocular lens. This artificial lens can remain in the eye for life; replacement is only necessary in exceptional cases.

Cataract surgery is performed under local anesthetic eye drops. It is typically carried out as a same-day surgical procedure. During the surgical preparation, anesthetic, pupil-dilating, and antiseptic drops are administered several times. The surgery is painless and usually takes 10 minutes. The total time spent in the operating room does not exceed 30 minutes.

During the surgery, small incisions are made in the cornea. Through these, the clouded inner portion of the natural lens is removed, and an artificial lens is implanted into the preserved transparent capsular bag. The incisions are self-sealing, so no sutures are required. At the end of the surgery, medicated ointment is placed in the eye and a transparent protective dressing is applied. On the day of surgery, you will spend only a few hours at the clinic. The mandatory next-day examination is usually just a quick check-up.

Types of Cataract Surgery

Cataract surgery is traditionally performed using ultrasound. A more modern variant is laser cataract surgery. The technique and instruments of ultrasound procedures are continuously evolving, allowing increasingly better results with shorter recovery times.

Ultrasound Cataract Surgery

The most widespread variant of refractive lens exchange is ultrasound cataract surgery, whose technique and instruments are continuously evolving, allowing increasingly better results with shorter recovery times. The surgery is performed under local anesthetic drops, under a microscope; in the hands of an experienced surgeon, it is a quick and painless procedure during which you may feel only slight pressure at certain moments.

The first step is to make two small incisions in the cornea, through which we can access the clouded natural lens to remove it. However, the lens is not removed entirely: the outer, thinner-than-a-hair, transparent portion called the capsular bag must be almost completely preserved along with its entire intraocular suspension system, so that the artificial lens can be implanted in the ideal position. This is achieved by first creating a medium-sized, circular opening in the anterior capsule of the lens, after which the capsule is separated from the lens and only the inner, clouded lens material is removed.

To remove the lens through the small incisions, it must first be divided into smaller pieces using manual instruments, then further emulsified and aspirated from the eye with an ultrasound device. The removal of the finest tissue fragments is achieved by polishing the capsular bag, at the end of which only a clean, transparent membrane remains. The capsular bag thus prepared becomes suitable for implantation of the artificial lens, which can be delivered to its position through the small incision in a folded state. The artificial lens unfolds by itself within the capsular bag and only needs to be adjusted into its final position.

Thanks to the modern procedure, the specially designed incisions do not require sutures and are self-sealing. At the end of the surgery, anti-inflammatory and antibiotic ointment is placed in the eye and a transparent plastic protective dressing is applied to the eye for the first day.

Femtosecond Laser Cataract Surgery (FLACS)

The newest variant of cataract removal is femtosecond laser cataract surgery, during which the most critical parts of the surgery are performed automatically and atraumatically. The goal of the femtosecond laser procedure is to increase precision and safety, as well as to reduce complications.

As the first step of laser cataract surgery, even before making any incision in the cornea, the femtosecond laser creates a perfectly circular opening in the lens capsule in a matter of moments, without exerting any pulling or tearing force on it. This completely eliminates the risk of one of the most common complications associated with this step of the surgery. The laser then automatically cuts the clouded lens into many smaller pieces in seconds, so the capsular bag is not subjected to unfavorable tension or pulling forces during this process either. As a result, cataract removal becomes much easier and the capsular bag is more likely to remain intact, which is a critical requirement especially when implanting premium lenses. In the case of a damaged capsular bag, only a monofocal spherical lens can be implanted. The remaining steps of the surgery from this point match those described for the traditional procedure.

Traditional or Femtosecond Laser Cataract Surgery?

Femtosecond laser cataract surgery can almost completely eliminate damage to the lens capsule and its suspension system. This is responsible for the majority of complications in traditional surgery. Damage to the lens capsule during surgery can prevent immediate implantation of the artificial lens. In such cases, only a monofocal spherical lens can be implanted at a later time, a few weeks later.

With laser surgery, there is a greater chance of implanting a premium lens following cataract removal. With the laser procedure, the position of the implanted lens within the capsular bag will always be guaranteed to be central, which ultimately ensures a more perfect post-operative visual outcome. The femtosecond laser procedure can further increase the precision of the surgery and reduce the incidence of complications associated with individual steps.

Traditional Cataract Surgery

Femtosecond Laser Cataract Surgery

ℹ️ Read this too: Laser cataract surgery is a brilliant procedure!

What Types of Intraocular Lenses Exist?

Standard Lenses

Monofocal or single-focus spherical lenses provide sharp vision at only one focal distance. With monofocal lenses, we typically aim to improve distance vision; reading glasses will still be required. In standard cases, monofocal lenses only correct spherical refractive error, not astigmatism; if astigmatism is present, glasses will be needed for distance as well. In state-funded institutions, this is the most commonly implanted lens type.

Premium Lenses

To achieve the appropriate post-operative visual experience, perfectly executed surgery is critically important when implanting these lenses. Premium lens implantation should only be performed by an ophthalmologist with extensive experience. The following lens options are available.

Toric Lenses

Astigmatism of the eye can be corrected during cataract surgery with a toric intraocular lens. Toric lenses can be manufactured in any type, so there are monofocal toric, multifocal toric, and extended depth-of-focus toric lenses. If measurements indicate that a toric lens is needed, it is definitely worth choosing, because without it, astigmatic glasses will be required at all distances after surgery.

To achieve the appropriate result, this astigmatic lens must be positioned at a precise, predetermined angle during implantation, and we must ensure that it cannot easily rotate from this position.

Extended Depth-of-Focus Lenses (EDOF)

Uncompromising and nearly complete spectacle independence can be achieved with extended depth-of-focus lenses (EDOF). The range of sharp vision with EDOF lenses is significantly wider than with monofocal lenses, and although not as wide as with multifocal lenses, it provides optically better image quality at the focal distances it covers, without disturbing light phenomena.

Extended depth-of-focus lenses can provide spectacle-free sharp vision from arm’s length all the way to distance. At near distances, they can provide moderate visual acuity even without glasses, which in most life situations generally proves more than sufficient. You will be able to read larger-print text, but for small-print or extended book reading or other precise near work, glasses will be needed.

Multifocal (Trifocal) Lenses

Virtually complete spectacle independence can be achieved with multifocal or trifocal lenses. In reality, multifocal lenses can provide sharp vision at three different distances—distance, intermediate, and near—which is why they are also called trifocal (tri: three, focal: focal distance).

This provides functional spectacle independence, but even these lenses cannot perfectly replicate the vision and continuous diopter change that our natural lens provides. For example, in a small percentage of patients, visual acuity at monitor distance may be slightly weaker. It should also be noted that these lenses involve certain compromises and their implantation is not recommended in the presence of certain ophthalmic conditions.

Due to their optical design (some light is lost at the rings or steps), multifocal lenses provide slightly reduced contrast sensitivity and slightly weaker image quality, the extent of which is usually imperceptible. For this reason, we do not recommend implanting multifocal lenses for very precise, color-accurate work requiring stronger illumination or frequently viewing light sources.

These lenses can cause light-scattering complaints around traditional light sources (halos, glare, starburst), which in certain cases can be particularly bothersome (e.g., when driving at night). Although in most cases these phenomena are barely noticeable, they can become particularly disturbing for certain individuals. Fortunately, after the first month, these complaints significantly decrease or disappear in most of these patients, and only a small percentage find them persistently bothersome.

Multifocal PRO Lenses (NEW!)

The newest generation of implants that can be inserted during cataract surgery are the multifocal PRO (Pure Refractive Optics) lenses, which closely approximate natural vision with one’s own lens. This type fundamentally differs from previously known multifocal lenses in that it does not use concentric rings to provide the full range of sharp vision. While the older types provide refraction through these rings in a “stepped” manner—which can cause nighttime halo phenomena or contrast loss—the multifocal PRO lens employs a continuous, uninterrupted refractive surface.

Multifocal PRO lenses provide virtually continuous, uninterrupted full range of vision (FRoV): the patient sees sharply and evenly, without loss of focus, from distant points through intermediate distances (monitor, dashboard) all the way to near reading distance.

Using Allied Ray Technology (ART), these new-generation multifocal lenses utilize 100% of light energy, thus providing outstanding image quality even in twilight, without the light-scattering phenomena of traditional multifocal lenses. This solution is recommended for patients who lead active lives, drive frequently at night, and wish to achieve the greatest possible spectacle independence and the least compromise after surgery.

ℹ️ Would you like to better understand how the lenses differ? Want to be certain which is the best lens for you? Check these out:
> How to choose a lens for cataract surgery?
> New-generation multifocal PRO lens: unlimited sensational vision.

Which Type of Procedure and Lens Should I Choose for Cataract Surgery?

Regardless of the type of lens and procedure we choose, we must also consider the limitations of the surgery. Lens design, lens manufacturing, and the surgery itself all have margins of error (e.g., increased wound healing, lens displacement) and can have complications. In rare cases, the combined side effects of these can result in significant refractive error after surgery.

Complete spectacle independence after cataract surgery cannot be 100% guaranteed with any procedure or any lens. Nevertheless, in the vast majority of cases, the residual refractive error after the procedure is zero or negligibly small and does not require wearing glasses for the distance that the given lens is optically capable of.

Selecting the intraocular lens requires careful consideration, as replacement is usually no longer possible without damaging the capsular bag; we resort to this only as a last resort.

How Can the Intraocular Lens Be Customized?

The diopter power of the lens to be implanted can be determined through a process called IOL calculation. During IOL calculation, non-contact measurements of the eye are performed, and using computer software, the diopter power of the lens is calculated individually, striving to select the implant that will provide the best possible visual experience.

In the IOL selection process, the use of modern, non-contact IOL calculation devices and programs employing advanced calculation formulas is critically important to achieving the appropriate result. This is especially true for premium lens types, since in these cases the goal is spectacle independence not only at distance but also at closer ranges. Older ultrasound-based IOL calculation is now generally used only in cases of hypermature cataract, and in such cases we recommend only monofocal lens implantation, as this measurement has a higher margin of error.

How Should We Prepare for Cataract Surgery?

Before cataract surgery, we perform a comprehensive ophthalmic examination, which is always done with pupil dilation and includes OCT examination. As a result, vision will be blurrier for a few hours and driving is not recommended. During the detailed examination, we also determine whether any type of lens or only a monofocal lens can be implanted. If other eye disease is suspected or present, additional examinations may be necessary. This is followed by IOL calculation, after which it becomes clear whether a toric lens is needed.

Surgery is contraindicated in the presence of infectious or other acute illness; a general examination is recommended prior to surgery to screen for this. Age alone is not an obstacle.

Before cataract surgery in Hungary, the following examinations are required:

• laboratory and ECG examination (no older than 1–3 months),
• internal medicine assessment and opinion (from general practitioner or treating physician).

The internal medicine opinion should preferably state that there is no internal medicine contraindication to performing cataract surgery under local anesthesia.

What Happens After Cataract Surgery?

What Are the Post-Operative Steps After Cataract Surgery?

After surgery, you will typically need to use antibiotic eye drops for about 1 week and anti-inflammatory eye drops for a few weeks. During the first week, you will usually need to instill drops several times a day, then less frequently afterward. For undisturbed healing, it is important to always follow your treating physician’s instructions.

When Does Vision Clear After Cataract Surgery?

Vision improvement after cataract surgery can be noticeable immediately after the procedure, but meaningful change usually occurs after a few days. The eye ointment applied immediately after surgery and the protective dressing will themselves limit your vision on the first day, but you will still be able to get around and perform everyday tasks.

Driving is contraindicated on the first day; thereafter, when it becomes possible depends on the degree of improvement. The extent of recovery depends on several factors; in younger patients and with milder cataracts, vision may be good as early as the next day, while in older age and with advanced cataracts, recovery may take longer.

Although in the vast majority of cases vision improvement is nearly complete after 1 week, from a medical standpoint we generally declare the operated eye fully healed after 6 weeks.

What Can I Expect After Cataract Surgery?

For a few days after surgery, the eye may be slightly redder; stinging sensation, tearing, and mild light sensitivity may occur. You may wear sunglasses, but their use is not mandatory. The final refractive error stabilizes after 4–6 weeks; if you need glasses, they can be prescribed at that time.

In the days after surgery, if you experience vision deterioration and/or your eye becomes markedly red and/or you have persistent pain and/or marked light sensitivity, contact your treating physician or the ophthalmology emergency service immediately.

ℹ️ Don’t want “surprises” after surgery? In our knowledge base, we have compiled every important detail: we thoroughly explain what to watch out for after cataract surgery, what natural or concerning symptoms may appear in the first days, and what else may occur in the long term that may require action.

Post-Operative Follow-Up Examinations

After cataract surgery, follow-up examinations are usually required at 1 day, 1 week, and 6 weeks. Typically, vision is already good during the first week after surgery and most restrictions are lifted. From a medical standpoint, however, complete healing takes 4–6 weeks; during this time, rubbing the eye or submerging the head in water is still not allowed. Upon completion of healing, a follow-up examination is recommended even in the absence of new complaints. In the 3–5 years following surgery, annual examinations are recommended, then every 2 years until age 65, and then annually again, with pupil dilation.

ℹ️ Having trouble deciding? Read our brief summary and pricing: Types of cataract surgery and available intraocular lenses.