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Dr Chelvin Sng's guide to cataract surgery in Singapore (2022)

Cataracts. This prevalent eye condition is the leading cause of blindness worldwide and is also known to be one of the top global causes of visual impairment. Today, cataracts affect more than 95 million people globally, and remains the top cause of blindness in developing nations.

Individuals with visually significant cataracts tend to experience symptoms including blurred vision, loss of contrast and colour, halos and glare. These symptoms can heavily impact patients’ day-to-day lives, and this is made even more apparent via studies that have linked increased mortality in older persons with cataracts.

Thankfully, vision loss from cataracts can be effectively restored with modern surgical options today. Cataract surgery is considered to be one of the most cost-effective interventions available in modern health care and is known to consistently improve patients’ quality of life.

Many patients get used to the visual impairment associated with cataracts, hence may not notice any functional decline. Educating the Singaporean public regarding the prevalence, risk factors and treatment options for cataracts will increase the awareness of eye health. 

Ready? Here we go:

An introduction to cataracts

Patient suffering from Cataract

Cataract is the leading cause of blindness affecting millions of people globally, with individuals aged 401 and above at an increased risk of developing this condition.

Here in Singapore, studies have shown that about 95% of the population above 70 years of age, and 80% of those aged 60 and above, have cataracts. For Singaporeans aged 45 and above, 30% had cataracts.

Statistic of people suffering from cataract

It wouldn’t be surprising to have a parent or older relative who has cataracts. What is surprising, however, is that the number of cataract cases may actually be even higher – a study by the Singapore Epidemiology of Eye Diseases programme found that nearly 70%2 of Singaporean adults who are over the age of 40 and have visually significant cataracts were obliviously unaware of their condition.

This lack of awareness means that many patients are unnecessarily suffering from poor eyesight when a quick and safe procedure can restore their vision. If you are reading this cataract guide, you have come to the right place to find out everything you need to know about this easily-treatable condition.

What is a cataract?

A cataract develops when the natural lens in our eyes becomes cloudy or opaque. This cloudiness is usually caused by aggregated protein, which results in blurring of vision. Even an early cataract can affect one’s colour perception and contrast sensitivity.

Normal eyes VS eyes with Cataract

A cataract is not just a concern for those in their old age; they can also appear as a result of eye injuries, or following eye surgery for other conditions. They can also be present from birth. In some developing nations, where healthcare and medical services may be less readily available, cataracts are a leading cause of blindness.

Certain conditions are associated with early cataracts. These include high myopia, diabetes, prolonged steroid use, eye trauma, and smoking.

The three main types of cataracts

The three main types of cataracts
Nuclear cataractPosterior sub-capsularCortical cataract
This cataract is most commonly associated with old age. The cloudiness occurs in the centre of the lens.The cloudiness occurs in the cortex or peripheral part of the lens, progressing towards the centre like spokes on a wheel.An opaque area forms at the back of the lens. This usually occurs in long-term steroid users.

Cataracts: The facts and figures in Singapore

Doctor checking on the patient's eyes

Despite being easily treatable, cataract continues to be the leading cause of visual impairment amongst elderly adults in Singapore3 and other developed countries - Additionally, as our population continues to age, the number of people experiencing vision loss as a result of cataract will only increase4

In Singapore, 78.6% of the elderly are affected by cataracts. And it appears that the number of people affected by cataracts only increases with age - The condition affects 63.6% of people between the ages of 60 to 64, and a whopping 94.6% of individuals aged 75 and above.

What are the risk factors of cataracts?

A cataract is largely an age-related condition, which is why individuals over the age of 40 should pay increased attention to their vision and go for routine eye check-ups. Apart from ageing, cataracts are also associated with:

  • Eye trauma or inflammation
  • Previous eye surgery (eg. refractive surgery)
  • High degree of myopia
  • UV radiation exposure
  • Ionising radiation exposure (eg. x-rays and gamma rays)
  • Prolonged use of steroid medication (eg. oral steroids, nasal sprays, eyedrops etc.)
  • Obesity5
  • Smoking6
  • Alcohol consumption
  • Uncontrolled diabetes7
  • Congenital cataract
What are the risk factors of cataracts?

What are some of the common symptoms of cataracts?

What are some of the common symptoms of cataracts?

Usually, cataract patients do not experience itching, tearing or any headaches. Rather, common cataract symptoms include:

  • Blurred or dim vision
  • Difficulty seeing in low light conditions
  • Sensitivity to light (lights might look glaring)
  • Seeing a halo around bright lights
  • Colours looking faded or muted
  • Your vision looking washed-out

If you have cataracts, things might start to look dim or blurred, almost like you’re looking through a fog. As the cataract worsens, one’s vision will slowly become cloudier, eventually making it hard to even make out details or colours. If left untreated for too long, cataracts can sometimes result in glaucoma or even blindness, hence it is essential that you visit a trusted eye doctor if you experience these symptoms.

If you’re still unsure about how cataracts affect your vision, try this online simulator to see the world from the eyes of a person with cataracts.

What is a cataract check-up like?

Dr Chelvin Sng examining patient's eyes

A screening or check-up for cataracts will typically involve various tests, including:

  • Checking your vision
  • Manifest Refraction, which involves the manual measurement of your prescriptive power by placing lenses of varying degrees in front of your eyes
  • An eye pressure test, which will give an indication of whether you are at risk of glaucoma.

The actual test to confirm if there are cataracts in your eye involves instilling eye drops to dilate the pupil of your eye. Once your pupils are dilated, your eye doctor will use a Slit Lamp to look for signs of cataracts and other conditions. A photograph will be taken to document the appearance of your cataract.

After your tests, you will have a consultation with your doctor, who will explain the examination findings, answer your questions, and openly discuss your condition and the treatment options available.

What are the different treatment options available for cataracts?

The only known effective way to treat cataracts is to surgically remove them. Thankfully, modern cataract surgery is a highly effective way of restoring vision to individuals who have become visually impaired due to cataracts.

What are the procedures for cataract surgery like?

The oldest surgical methods for removing cataracts date back to archaic techniques such as ‘couching8’ and ‘needling’, which are honestly best left un-googled as they look brutal. Thankfully, cataract surgery today is much less terrifying and way more effective, with excellent outcomes:

Micro-incision phacoemulsification surgery

This employs the use of ultrasound energy to liquify cataracts in the eye. 

The emulsified cataract is then removed via a 2-3mm incision.

No stitches are required. The wounds are self-healing and allow for a speedier recovery.

Laser-assisted cataract surgery

This adopts the same technology used in LASIK.

The procedure involves the use of a femtosecond laser to create incisions and fragment cataracts.

However, studies have shown that, for routine cataracts, the outcomes of laser-assisted cataract surgery are not superior to cataract surgery without laser-assistance. Hence, the higher cost of laser-assisted cataract surgery is not justifiable for the vast majority of patients.

Intraocular Lens (IOL)

An intraocular lens implant is an artificial replacement for the lens of your eye, and a crucial part of the surgery process. 

Once cataracts and the natural lens have been removed, an artificial intraocular lens (IOL) is implanted through a small 2-3mm incision.

The implantation of the IOL is a permanent procedure, so the lens need not be replaced. 

An IOL is made of clear acrylic and comprises several different types9.

Lens typeProsCons
Monofocal IOLThis common IOL provides good vision at a specific distance.
Toric monofocal IOLs also correct for astigmatism. 
Monovision: Provides good distance vision in one eye, and good close-up vision in the other This will allow most patients to be spectacle-independent.   
You might be able to see distant things perfectly well but will likely need glasses to see close up or read.

For patients who choose monovision, you may not get used to using one eye for distance vision and one eye for near vision. This may also compromise your depth perception.
Multifocal IOLsProvides good vision, both near and far, without glasses. This is suitable for patients who: Want to reduce spectacle use Have minimal astigmatism Mostly drive in the day
These lenses should be used in both eyes for the most optimal results.
After surgery, some people may notice: Difficulty reading small print in dim light Dimmer vision Seeing halos around lights and experience glare at night Most patients get used to these symptoms and are not bothered by them. However, monofocal IOLs still provide better quality of vision if one does not mind wearing spectacles for near vision.
Extended Depth of Focus IOLsProvides good distance and intermediate vision without the need for glasses.
This type of lens is suitable for those who: Want to rely on their glasses less for distant and intermediate distance vision (eg. using the computer) Do not mind wearing glasses for near vision Drive at night and in the day
Near vision is limited for patients with Extended Depth of Focus IOLs. After surgery, some people may: Require glasses for reading small print up close Seeing halos around lights and experience glare at night, though at a lesser extent compared with Multifocal IOLs

Your choice of lenses depends on the health of your eye, your lifestyle, and your preferences. Discuss your IOL options with your doctor in detail before making your choice.

Can I operate on both eyes on the same day?

Due to very rare potential complications such as bilateral-eye infections, doctors usually recommend a separate surgery date for each eye. This is certainly the safer option, though for very rare circumstances, eg. a patient who requires general anaesthesia for cataract surgery for whom the risks of anaesthesia is high, rarely bilateral cataract surgery on the same day may be considered.

What should one expect cataract surgery to be like?

While it depends on the complexity of your condition, most cataract surgeries take 10-20 minutes. This is a day surgery procedure, so you can go home on the same day.

Before surgery, most adult patients are given local anaesthetic and/or sedatives. Children undergoing cataract surgery, on the other hand, usually require general anaesthetic.

Here’s what you need to know about preparing for cataract surgery:

What happens during cataract surgery?

To help you relax or to fall asleep, an anaesthetist will sedate you intravenously. Your doctor will assess whether you are suitable for sedation during surgery.

Your surgeon will use anaesthetic eye drops to numb your eye so you will not feel any pain during the surgery, though you might experience a sensation of pressure on your eye.

How soon can I resume normal activities post-surgery?

After the procedure, a plastic shield will be placed over the operated eye to protect it for a day or two. Most patients can usually go home on the same day.

You will be given medical leave that may last up to 4 weeks.

Although it can take a month for the eye to fully recover, most patients are able to return to work the week after their surgery. If your work involves being in a dusty or smoky environment, it is recommended to stay away from work for a longer time. 

Post-operative reviews are typically scheduled at 1 day, 1 week, and 1 month after surgery.

What are some of the possible side effects or risks of treatment?

Cataract surgery is a low-risk procedure with a very high success rate. However, all surgeries have potential complications. Infections after cataract surgery occur in 1 out of every 1,000 cases, and can result in blindness. The following are some other rare complications that may arise from surgery:

  • A detached retina: This is a medical emergency that occurs if a crucial layer of nerve cells separates from the back of your eye. Another surgery is required to address the detached retina.
  • Posterior capsular rupture: This occurs when the capsule around the cataract breaks during surgery and fragments of the cataract can fall into the back of a patient’s eye. Follow-up surgery might be required. 
  • High eye pressure: The eye pressure can be raised after cataract surgery, and this is usually transient.
  • Residual refractive errors after cataract surgery: Spectacles may be required if this happens. LASIK can also correct such refractive errors.
  • Dislocation or malposition of the implant.
  • Damage of the cornea, which is the transparent structure in the front of the eye. 
  • Posterior capsular opacification (after-cataract):While cataracts do not return, cloudiness may be noticeable by patients months or years after the surgery. This cloudy layer is scar tissue forming behind the lens implant. YAG laser capsulotomy surgery can be performed to correct the problem, especially if your vision is impacted.

Apart from the risks listed above, the more common side effects encountered after cataract surgery are dry eye and night vision problems. And while these side effects are usually temporary, they may last up to 6 months. 

After going through surgery, it is important to closely monitor your condition. If you experience any increased redness, eyelid swelling, eye pain, eye discharge or blurring of vision, please make an appointment with your doctor immediately.

Is there any way to avoid developing cataracts?

Cataracts usually do not develop rapidly. In fact, it might take up to several years before a cataract gets to the point where it starts to affect a person’s daily life. The progression might be slow, but it is not reversible without surgery.

How to prevent cataracts?

  • Wear sunglasses and wide-brimmed hats to protect your eyes when under the sun.
  • See your eye doctor regularly: Early detection helps you to optimize your vision despite early cataracts.  
  • Eat well: A balanced diet comprising leafy vegetables, whole grains, nuts, citrus fruits, and fish that are rich in omega-3 fatty acids will go a long way in preventing cataracts. 
  • Keep your diabetes under control
  • Drink alcohol in moderation and stop smoking

Who should get tested for cataracts?

You should make it a point to go for regular eye check-ups once you hit the age of 40. Besides cataracts, there are other conditions that may affect your vision, such as retinal tears, macular degeneration, floaters, glaucoma, refractive errors, and more. With our eyes being potentially susceptible to a wide range of eye diseases, it is advisable to have regular full eye check-ups10 instead of just checking for the presence of cataracts. 

If you have any eye conditions in addition to cataracts, you may be eligible for cataract-plus procedures which offer additional benefit to cataract surgery alone. For example, glaucoma patients undergoing cataract surgery may choose to simultaneously undergo glaucoma surgery that’ll improve their eye pressure and lower their need for glaucoma medication.

Such procedures may be more common than you think, as about 10% of Singaporeans aged 70 and above have glaucoma, according to CNA Lifestyle.

When should one have cataract surgery?

Many people think that in order to successfully remove a cataract, you have to wait till the cataract gets ‘ripe’ or ‘mature’ before going for surgery. This belief is bogus today - it stemmed from the time when cataract surgery had significant risks hence was only advised for advanced cataracts. 

The vast improvements in cataract surgery and the high safety profile of the procedure means that surgery can be offered for cataracts at any stage of development. There is really no need to wait until your cataract ‘ripens’ and becomes advanced as it may increase the risks and complexities of the surgery.

If your cataracts are impairing your vision and interfering with your daily life, it’s time to see a trusted doctor. If your cataract is in its early stages and does not interfere with your daily activities, you may choose to delay having surgery. 

Moreover, as cataracts tend to affect your spectacles prescription, you’ll need to have your vision checked yearly and get a new pair of spectacles if need be.

Which surgeon or eye clinic should you choose?

When it comes to assessing the myriad of options available for potential cataract surgery, saving money and going cheap should not be prioritised above the credibility and reputation of your eye doctor or clinic.

You would do well to check and read through reviews online. Don’t forget to ask trusted friends and family for recommendations.

Also, your eye doctor should be able to listen to your needs, answer your questions, allay your fears, and eventually give you an unbiased consultation. Importantly, you should find a doctor who makes you feel comfortable and reassured.

Conclusion

Individuals with visual impairment are known to have lower self-esteem compared to their sighted peers11. Further research states that for individuals with cataracts or other causes of visual impairment, healthy self-esteem is impacted by quality social support, independence in conducting their daily activities, patients’ perceived independence, and more12.

Simply put, losing your vision is a slippery slope that you do not want to go down. Do not tarry, and keep your eye on the ball.

References

  1. Liu, Y. C., Wilkins, M., Kim, T., Malyugin, B., & Mehta, J. S. (2017). Cataracts. Lancet (London, England), 390(10094), 600–612. https://doi.org/10.1016/S0140-6736(17)30544-5
  2. Chua, J., Lim, B., Fenwick, E. K., Gan, A. T., Tan, A. G., Lamoureux, E., Mitchell, P., Wang, J. J., Wong, T. Y., & Cheng, C. Y. (2017). Prevalence, Risk Factors, and Impact of Undiagnosed Visually Significant Cataract: The Singapore Epidemiology of Eye Diseases Study. PloS one, 12(1), e0170804. https://doi.org/10.1371/journal.pone.0170804
  3. Sabanayagam, C., Fenwick, E., Ong, P. G., Tey, M. L., Tapp, R., Cheng, C. Y., Cheung, G. C., Aung, T., Wong, T. Y., & Lamoureux, E. (2016). Visual Impairment in Old and Very Old Community-dwelling Asian Adults. Ophthalmology, 123(11), 2436–2438. https://doi.org/10.1016/j.ophtha.2016.06.036
  4. Wong T. Y. (2001). Cataract extraction rates among Chinese, Malays, and Indians in Singapore: a population-based analysis. Archives of ophthalmology (Chicago, Ill. : 1960), 119(5), 727–732. https://doi.org/10.1001/archopht.119.5.727
  5. Pan, C. W., & Lin, Y. (2014). Overweight, obesity, and age-related cataract: a meta-analysis. Optometry and vision science : official publication of the American Academy of Optometry, 91(5), 478–483. https://doi.org/10.1097/OPX.0000000000000243
  6. Ye, J., He, J., Wang, C., Wu, H., Shi, X., Zhang, H., Xie, J., & Lee, S. Y. (2012). Smoking and risk of age-related cataract: a meta-analysis. Investigative ophthalmology & visual science, 53(7), 3885–3895. https://doi.org/10.1167/iovs.12-9820
  7. Tan, A. G., Kifley, A., Tham, Y. C., Shi, Y., Chee, M. L., Sabanayagam, C., Tan, N., Wong, K. H., Mitchell, P., Cumming, R. G., Wong, T. Y., Wang, J. J., & Cheng, C. Y. (2018). Six-Year Incidence of and Risk Factors for Cataract Surgery in a Multi-ethnic Asian Population: The Singapore Epidemiology of Eye Diseases Study. Ophthalmology, 125(12), 1844–1853. https://doi.org/10.1016/j.ophtha.2018.07.026
  8. Ademola-Popoola, D. S., & Owoeye, J. F. (2004). Traditional couching for cataract treatment: a cause of visual impairment. West African journal of medicine, 23(3), 208–210. https://doi.org/10.4314/wajm.v23i3.28122
  9. https://www.singhealth.com.sg/patient-care/patient-education/cataracts
  10. Chua, J., Lim, B., Fenwick, E. K., Gan, A. T., Tan, A. G., Lamoureux, E., Mitchell, P., Wang, J. J., Wong, T. Y., & Cheng, C. Y. (2017). Prevalence, Risk Factors, and Impact of Undiagnosed Visually Significant Cataract: The Singapore Epidemiology of Eye Diseases Study. PloS one, 12(1), e0170804. https://doi.org/10.1371/journal.pone.0170804
  11. Papadopoulos, K., Montgomery, A. J., & Chronopoulou, E. (2013). The impact of visual impairments in self-esteem and locus of control. Research in developmental disabilities, 34(12), 4565–4570. https://doi.org/10.1016/j.ridd.2013.09.036
  12. Papadopoulos K. (2014). The impact of individual characteristics in self-esteem and locus of control of young adults with visual impairments. Research in developmental disabilities, 35(3), 671–675. https://doi.org/10.1016/j.ridd.2013.12.009 

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    Dr Chelvin Sng of Chelvin Sng eye center

    Dr Chelvin Sng

    Adjunct Associate Professor
    Senior Consultant Ophthalmologist
    ✓ 4 Gold Medals (Specialist Accreditation Examination)
    ✓ "Top 50 Rising Stars” (2017), “Top 100 Female Ophthalmologists” (2021)
    and "Top 100 Ophthalmologists" (2022)
    ⋆ Global Ophthalmologist Power List (voted by peers worldwide)
    ✓ Cambridge University Graduate with Triple First Class Honours and Distinctions

    Address

    38 Irrawaddy Road Mt Elizabeth Novena Specialist Centre, #06-25, Singapore 329563

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