Cataract Extraction

Indications for Procedure 

Cataract surgery is one of the most common ophthalmic procedures performed today. Patients who are eligible for this procedure often present with symptoms associated with the accumulation of proteins on their eye's natural lens. The primary symptom reported by these patients is often described as a cloudy or hazy visual field. Cataract extraction is indicated when these visual changes affect a patient’s ability to perform everyday activities, thereby impacting his or her quality of life. 

Patient Assessment 

Assessment of symptoms

• Note if the patient’s symptoms are unilateral or bilateral and if symptoms are more severe in one eye than in the other.

Confirmation and marking of the surgical site  

• Implement safeguards to reduce the risk of wrong-sided surgery. 
  • Confirm that the surgical site or sites are correct and marked per protocol.  
  • Ensure that the site marking is close enough to the eye that it will remain visible after draping. 

Review of past medical history

• Diabetes  
  • Diabetic patients should have their blood sugar levels carefully managed before surgery and throughout their perioperative course to promote wound healing after the procedure. Consider giving diabetic patients early case-start times for optimal management of their blood sugar levels. 
• Bleeding disorders and anticoagulant use  
  • For patients with bleeding disorders and other patients who take anticoagulants, care may need to be coordinated with the physician who regularly manages these medications. Typically, patients should stop taking anticoagulants 24 to 48 hours before surgery.  
  • Unless contraindicated, using sequential compression devices (i.e., SCDs) during and after the procedure can help mitigate the risk of blood clots. 
    

Patient Positioning 

• Supine positioning: Patients undergoing cataract surgery typically lie in the supine position on specialized ophthalmology stretchers. After the patient arrives in the OR, his or her head can be positioned on the stretcher’s headrest to limit movement during the procedure. 
• Head Placement: Proper alignment of the head is essential both for patient comfort and accessibility to the surgical site. If an ophthalmology stretcher is not available, a regular OR bed can be used with a foam headrest as a stabilization device.
  
• Upper extremity positioning: If a patient is moving his or her upper extremities too much during the procedure, it may be necessary to secure the patient's arms at his or her sides to prevent inadvertent movements that could disrupt the surgical process.
  
• Additional considerations: Patients are typically awake during cataract surgery; therefore, it is important to consider their comfort throughout the procedure. Patients with a history of back pain or prior spinal surgery may have difficulty lying flat for an extended period. For these and other patients who prefer it, placing a pillow under their knees can help alleviate pressure on their backs and enhance their comfort.
  

Surgical Prep 

To prep the surgical site, an eye irrigation solution may be used in the operative eye or eyes and flushed with sterile saline. Surrounding structures, including the eyelids and eyelashes, can be prepped with 5% povidone-iodine solution.  

Supplies and Equipment 

• Phacoemulsification (i,e. phaco) machine 
  • Uses ultrasonic technology to break up the cataract  
  • Has irrigation and aspiration capabilities to vacuum up the cataract 
  • Increases visibility of the surgical site and surrounding anatomy  
  • Maintains stable intraocular pressure 
  • Includes a foot pedal attachment 
  • Has the ability to save settings unique to each surgeon’s preferences 
• Eye microscope  
  • Many eye microscopes have procedure-specific settings: adjust to the cataract setting. 
• Eye chair for the surgeon 
• Ophthalmology stretcher or regular OR bed 
• Bipolar cautery device (used if phacoemulsification machine is unavailable) 
• Lower body warming device 
• SCD - Sequential compression devices 
• 10-0 nylon suture 
• Dressing: eye shield or eye pad, depending on the surgeon’s preference and whether the patient has had an anesthetic nerve block or not. 
• Intraocular lens (i.e, IOL) 
  • The OR circulator should verify that the team has the correct lens implant and check the expiration date on the IOL box before the patient enters the OR and again before passing the lens to the scrub person.  

 Procedure 

• Exposure of the surgical site: The surgeon will insert an eye retractor to keep the eye open and use a microscope to see the eye more clearly. He or she will then use a keratome to incise the cornea to reach the level of the cataract.  
  
• Removal of the lens: Next, the surgeon will insert a cystotome to puncture the capsule of the lens and remove it by peeling it off. He or she can then perform any necessary additional dissection while irrigating the eye with balanced salt solution.  
  
• Use of the phacoemulsification machine: After removing the lens, the surgeon will use the phaco handpiece to sculpt the cataract with ultrasound vibration: typically, he or she divides the cataract into four quadrants for easier removal. The surgeon then vacuums any additional cortical materials using the handpiece. 
• Inflation of the anterior chamber: After extracting the cataract, the surgeon uses viscoelastic material to inflate the anterior chamber so that it can accommodate a new intraocular lens.  
• Insertion of the new lens: The IOL is typically folded by the scrub person. The surgeon will then insert the folded lens into the injector.  
• Irrigation and aspiration of excess fluid: After placing the new lens, the surgeon will use the phaco machine to irrigate the surgical site and aspirate any remaining viscoelastic material. He or she can control leaking from the wound by hydrating the edges of the eye or using a 10-0 nylon suture. 
• Closure and Dressing: A member of the OR team will apply topical antibiotics in the form of eye drops or ophthalmic ointment on the affected eye and protect it with either an eye shield or eye pad. 
  

Complications 

• Infection 
• Bleeding 
• Swelling 
• IOL dislocation 
• Retinal detachment 
• Glaucoma  
• Secondary cataract formation 
• Vision loss 
  

Postoperative Considerations 

• An eye shield or eye pad should remain on the patient’s surgical eye for protection. 
• Patient education will be needed for patients to continue their eye drops at home after they are discharged. 
• Itching, mild discomfort, and sensitivity at the surgical site are common postoperative symptoms.  
  

Editor's notes: This content is adapted from AORN eGuidelines+. If your facility subscribes to eGuidelines+, you can access the full content. This article is intended to serve as a guide to prepping and may not represent every available antiseptic solution. Always prep in accordance with the manufacturer’s instructions for use for the antiseptic solution being used. AORN does not endorse any commercial company’s products or services, including particular skin preparation products. Inclusion of a solution in this article does not constitute an endorsement by AORN of the quality or value of such solution or process, or of the claims made by its manufacturer. 

AORN Resources

If your facility subscribes to eGuidelines+, you can access:

• Positioning At a Glance | AORN eGuidelines+

• Skin Prep at a Glance | AORN eGuidelines+ 

• Instruments at a Glance | AORN eGuidelines+

• Procedures at a Glance | AORN eGuidelines+

• Room Setup at a Glance | AORN eGuidelines+

• Patient Skin Antisepsis Guideline | AORN eGuidelines+ 

• Positioning the Patient Guideline | AORN eGuidelines+