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Although phacoemulsification has become the preferred method of extracapsular extraction for most cataracts in the United States since the 1990s, conventional or standard ECCE is considered less risky for patients with very hard cataracts or weak epithelial tissue in the cornea. The ultrasound vibrations that are used in phacoemulsification tend to stress the cornea.
A conventional extracapsular cataract extraction takes less than an hour to perform. After the area around the eye has been cleansed with antiseptic, sterile drapes are used to cover most of the patient's face. The patient is given either a local anesthetic to numb the tissues around the eye or a topical anesthetic to numb the eye itself. An eyelid holder is used to hold the eye open during the procedure. If the patient is very nervous, the doctor may administer a sedative intravenously.
After the anesthetic has taken effect, the surgeon makes an incision in the cornea at the point where the sclera and cornea meet. Although the typical length of a standard ECCE incision was 10–12 mm in the 1970s, the development of foldable acrylic IOLs has allowed many surgeons to work with incisions that are only 5–6 mm long. This variation is sometimes referred to as small-incision ECCE. After the incision is made, the surgeon makes a circular tear in the front of the lens capsule; this technique is known as capsulorrhexis. The surgeon then carefully opens the lens capsule and removes the hard nucleus of the lens by applying pressure with special instruments. After the nucleus has been expressed, the surgeon uses suction to remove the softer cortex of the lens. A special viscoelastic material is injected into the empty lens capsule to help it keep its shape while the surgeon inserts the IOL. After the intraocular lens has been placed in the correct position, the viscoelastic substance is removed and the incision is closed with two or three stitches.
Preparation
ECCE is almost always elective surgery—emergency removal of a cataract is performed only when the cataract is causing glaucoma or the eye is severely injured or infected. After the surgery has been scheduled, the patient will need to have special testing known as keratometry if an IOL is to be implanted. The testing, which is painless, is done to determine the strength of the IOL needed. The ophthalmologist measures the length of the patient's eyeball with ultrasound and the curvature of the cornea with a device called a keratometer. The measurements obtained by the keratometer are entered into a computer that calculates the correct power for the IOL.
The IOL is a substitute for the lens in the patient's eye, not for corrective lenses. If the patient was wearing eyeglasses or contact lenses before the cataract developed, he or she will continue to need them after the IOL is implanted. The lens prescription should be checked after surgery, however, as it is likely to need adjustment.
Risks
The risks of extracapsular cataract extraction include:
Edema (swelling) of the cornea.
A rise in intraocular pressure (IOP).
Uveitis. Uveitis refers to inflammation of the layer of eye tissue that includes the iris.
Infection. Infection of the external eye may develop into endophthalmitis, or infection of the interior of the eye.
Hyphema. Hyphema refers to the presence of blood inside the anterior chamber of the eye and is most common within the first two to three days after cataract surgery.
Leaking or rupture of the incision.
Retinal detachment or tear.
Malpositioning of the IOL. This complication can be corrected by surgery.
Aftercare
Patients can use their eyes after ECCE, although they should have a friend or relative drive them home after the procedure. The ophthalmologist will place some medications—usually steroids and antibiotics—in the operated eye before the patient leaves the office. Patients can go to work the next day, although the operated eye will take between three weeks and three months to heal completely. At the end of this period, they should have their regular eyeglasses checked to see if their lens prescription should be changed. Patients can carry out their normal activities within one to two days of surgery, with the exception of heavy lifting or extreme bending. Most ophthalmologists recommend that patients wear their eyeglasses during the day and tape an eye shield over the operated eye at night. They should wear sunglasses on bright days and avoid rubbing or bumping the operated eye. In addition, the ophthalmologist will prescribe eye drops for one to two weeks to prevent infection, manage pain, and reduce swelling. It is important for patients to use these eye drops exactly as directed.
Patients recovering from cataract surgery will be scheduled for frequent checkups in the first few weeks following ECCE. In most cases, the ophthalmologist will check the patient's eye the day after surgery and about once a week for the next several weeks.
About 25% of patients who have had a cataract removed by either extracapsular method will eventually develop clouding in the lens capsule that was left in place to hold the new IOL. This clouding, which is known as posterior capsular opacification or PCO, is not a new cataract but may still interfere with vision. It is thought to be caused by the growth of epithelial cells left behind after the lens was removed. PCO is treated by capsulotomy, which is a procedure in which the surgeon uses a laser to cut through the clouded part of the capsule.
