12.1 Anterior Segment Procedures

12.1.1 Cataract Surgery

Y (Why Have the Procedure)

“You have a cataract. This occurs when lens of the eye (that focuses light onto the back of the eye) becomes cloudy (it is normally clear like glass). Cataracts can cause blurred vision as well as glare.”

Aim: “Remove the cataract and replace it with a clear artificial lens to improve vision”.

NB: Cataract surgery is increasingly being undertaken as a refractive surgical procedure and community expectations of refractive outcomes are high. Expected refractive outcomes form an important part of the consent process for all cataract operations. The consent process is different depending on the patient’s current level of vision and desired refractive outcome. Patients requesting spectacle independence must be assessed fully from a refractive surgery perspective. Candidates must be clear with their patients pre-operatively about the expected refractive outcome and criteria for surgical “success”.

M (Mechanism, What is the Procedure)

“A cataract operation involves making a small incision in the front of the eye, taking out the lens with an ultrasound probe and inserting an artificial plastic lens that stays in for life. (Use a model or diagram).

  • “We operate on one eye at a time. The operation takes about 30 minutes, during which time you have to lie very still under a surgical drape (blanket). The operation is usually performed under a LA (small injection around your eye)- your anaesthetist will explain this further”
  • Pre-operation: Fasting, optimise diabetes
  • Post-operation: Usually day surgery, patch, drops, follow up

C (Complications)

“Although cataract surgery has excellent success rates, complications may occur that can leave you with vision worse than you have at present”:

More Common

Refractive Surprise

Many patients still require glasses after cataract surgery, particularly for reading. More common after previous refractive surgery. Clearly establish pre-operatively what refractive outcome is desired and guaranteed, and steps that can be undertaken if this is not achieved


e.g. Pseudophakic cystoid macula oedema. May need drops or another procedure


“Membrane growing on the back of the lens”. Treated with laser in clinic

Less Common

Difficulty Removing Lens

May need another operation

Infection in the Eye

1:1000 risk of endophthalmitis. Permanent loss of vision or eye is rare but possible


Very rare but can result in permanent loss of vision

Retinal Detachment

Especially if young, high myopes

Sympathetic Ophthalmia

Extremely rare but essential to mention

Anaesthetic Risks

Globe perforation

Stress compliance, close follow-up, need for urgent review if develops a sore red eye or reduced vision.

A (Alternatives)

  1. Observation – cataract will get inevitably get worse but the timing of this is uncertain
  2. If the refraction has changed, updated spectacles can improve vision but will not usually improve vision beyond what can be achieved with a pinhole
  3. There are no medical therapies for cataracts

Confirm that the patient understands. Any questions?

12.1.2 Corneal Graft

Y (Why Have the Procedure)

“Your cornea (the front “window” of the eye) has become cloudy (draw a diagram). A corneal graft is the only way to restore its clarity and improve your sight.”

Aims depending on indication:

  1. Restore vision loss caused by damaged cornea
  2. Reduce pain
  3. Preserve integrity of your eye
  4. Help control infection

M (Mechanism, What is the Procedure)

“A corneal graft is an operation where the damaged cornea is removed and replaced with a donor cornea. The donor cornea comes from someone who has died and has donated his or her eye (so the timing of the operation may depend on availability).”

Options for Fuchs’ Endothelial Dystrophy, Pseudophakic Bullous Keratopathy:

Penetrating Keratoplasty

  1. Well established with long -term data
  2. Quicker

Endothelial Keratoplasty
e.g. Descemet’s Stripping Endothelial Keratoplasty (DSEK)


  1. Less risk of traumatic rupture
  2. “No” suture problems (sutures can break, become infected, be a tract for vessels that stimulate rejection)
  3. Less risk of supra-choroidal haemorrhage
  4. Less astigmatism
  5. Faster rehabilitation
  6. Less surface related problems


  1. May not be suitable if corneal scarring, phakic, anterior chamber IOL, filtering tube
  2. Technically difficult (especially if anterior chamber shallow)
  3. Risk of graft dislocation
  4. Greater loss of endothelial cells during procedure
  5. Induces ~0.5-1.0D hyperopia
Options for Keratoconus:

Penetrating Keratoplasty

  1. Well established with long-term data
  2. Quicker
  3. Slightly better VA (no interface haze)

Deep Anterior Lamellar Keratoplasty (DALK)

  1. Less risk of traumatic rupture (for young patients)
  2. Less risk of intraoperative supra-choroidal haemorrhage
  3. No endothelial rejection (for patients living far away, atopic, eye-rubbers)
  4. Less astigmatism
  5. Less late endothelial failure
  • “We operate on one eye at a time, the operation takes about one hour, during which time you have to lie still under a surgical drape (blanket). The operation is usually performed under a GA - your anaesthetist will explain this further.”
  • Pre-operation: Fasting
  • Post-operation: Often admitted to hospital, patch, drops

C (Complications)

“Although corneal grafts have excellent success rates, complications may occur that can leave you with vision worse than you have at present”:

More Common

Suture Related

Break, infection


May need admission, medications, another operation


Astigmatism is common
May need glasses / contact lenses / another operation
Takes time for good vision


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Vitreoretinal Surgery Online
This open-source textbook provides step-by-step instructions for the full spectrum of vitreoretinal surgical procedures. An international collaboration from over 90 authors worldwide, this text is rich in high quality videos and illustrations.


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