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Extracapsular Cataract Extraction

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.

The lens and cataract formation


To understand cataract surgery, it is helpful to have a basic description of the structure of the lens in the human eye.
The lens, which is sometimes called the crystalline lens because it is transparent, is located immediately behind the
iris. In humans, the lens is about 9 mm long and 4 mm wide. It consists of protein fibers and water, with the fibers
arranged in a pattern that allows light to pass through the lens. There are three layers of cells in the lens: a central
nucleus, which becomes denser and harder as a person ages; a cortex surrounding the nucleus, which contains cells
that are metabolically active and continue to grow and divide; and a layer of cells between the cortex and the lens
capsule known as the subcapsular epithelium.
Although a few people are born with cataracts or develop them in childhood, most cataracts are the result of the aging
process. As people grow older, the protein fibers in the lens become denser, start to clump together, and form cloudy
or opaque areas in the lens. Cataracts vary considerably in their speed of progression; they may develop in a few
months or over a period of many years. Some people have cataracts that stop growing at an early stage of
development and do not interfere with their vision. Although most people develop cataracts in both eyes, they do not
usually progress at the same rate, so that the person has much better vision in one eye than in the other.
Ophthalmologists classify cataracts according to their location in the lens. It is possible for a person to have more
than one type of cataract.

Nuclear cataracts. Nuclear cataracts grow slowly over many years but can become very large and hard,
which complicates their removal. They are sometimes called brunescent cataracts because they are
characterized by deposits of brown pigment that give the lens an amber color. Nuclear cataracts are most
commonly associated with age and with smoking as risk factors.

Cortical cataracts. Cataracts in the cortex of the lens develop more rapidly than nuclear cataracts but remain
softer and are easier to remove. They are thought to be caused by an increase in the water content of the
lens. Risk factors for cortical cataracts include female sex and African or Caribbean heritage.

Posterior subcapsular (PSC) cataracts. This type of cataract, which develops between the back of the lens
and the lens capsule, is the softest and most rapidly growing type. PSC cataracts tend to scatter light at
night and thus interfere with nighttime driving. Risk factors for PSC cataracts include diabetes and a history
of treatment with steroid medications.

Diagnosis/Preparation
Diagnosis
The diagnosis of cataract is usually made when the patient begins to notice changes in his or her vision and consults
an eye specialist. In contrast to certain types of glaucoma, there is no pain associated with the development of
cataracts. The specific changes in the patient's vision depend on the type and location of the cataract. Nuclear
cataracts typically produce symptoms known as myopic shift (in nearsighted patients) and second sight
(in farsighted patients). What these terms mean is that the nearsighted person becomes more nearsighted while the
farsighted person's near vision improves to the point that there is less need for reading glasses. Cortical and posterior
subcapsular cataracts typically reduce visual acuity; in addition, the patient may also complain of increased glare in
bright daylight or glare from the headlights of oncoming cars at night.
Because visual disturbances may indicate
glaucoma as well as cataracts, particularly in
older adults, the examiner will first check the
intraocular pressure (IOP) and the anterior
chamber of the patient's eye. The examiner will
also look closely at the patient's medical history
and general present physical condition for
indications of diabetes or other systemic disorders
that affect cataract development. The next step in
the diagnostic examination is a test of the
patient's visual acuity for both near and far
distances, commonly known as the Snellen test. If
the patient has mentioned glare, the Snellen test
will be conducted in a brightly lit room.

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


The examiner will then check the patient's eyes
lens is placed through the incision (D), and is opened to
with a slit lamp in order to evaluate the location
replace
the old
and size of the cataract. After the patient's eyes have been
dilated
withlens
eye (E)
drops, the slit lamp can also be used to
check the other structures of the eye for any indications of metabolic disorders or previous eye injury. Lastly, the
examiner will use an ophthalmoscope to evaluate the condition of the optic nerve and retina at the back of the eye.
The ophthalmoscope can also be used to detect the presence of very small cataracts.
Imaging studies of the eye (ultrasound, MRI, or CT scan) may be ordered if the doctor cannot see the back of the eye
because of the size and density of the cataract.

Preparation
ECCE is almost always elective surgeryemergency 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.

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 medicationsusually steroids and antibioticsin 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.

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.

Cystoid macular edema (CME). The macula is a small yellowish depression on the retina that may be
affected after cataract surgery by fluid collecting within the tissue layers. The patient typically experiences
blurring or distortion of central vision. CME rarely causes loss of sight but may take between two and 15
months to resolve completely.

Normal results
Extracapsular cataract extraction is one of the safest and most successful procedures in contemporary eye surgery;
about 95% of patients report that their vision is substantially improved after the operation. In the words of a British
ophthalmologist, "The only obstacle lying between cataract sufferers and surgical cure is resource allocation."