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{{Short description|Removal of opacified lens from the eye}}
{{cs1 config|name-list-style=vanc}}
{{Good article}}
{{EngvarB|date=February 2023}}
{{Infobox interventions |
 | Name        = Cataract surgery
| synonyms      =
 | Image       = Cataract surgery.jpg
 | Caption     = Cataract surgery, using a temporal approach phacoemulsification probe (in right hand) and "chopper" (in left hand)
 |alt= close-up photo showing the hands of a surgeon holding phaco instruments inserted into the patient's eye. The eyelids are held apart by a speculum.
| pronounce     =
| specialty     = [[Ophthalmology]]
| uses          = Removal of opacified lens from eye to restore vision.
| complications = 
| approach      =
| types         = [[Phacoemulsification]], [[manual small incision cataract surgery]], [[extracapsular cataract extraction]], [[intracapsular cataract extraction]]
<!-- | recovery time = four to six weeks -->
| other options =
| outcomes      = Restoration of useful vision or significant improvement in most cases
| frequency     = Hundreds to thousands per million population per year.
 | ICD10       =
 | ICD9        = {{ICD9proc|13.19}}
 | MeshID      = D002387
 | MedlinePlus = 002957
 | OPS301      =
 | OtherCodes  =
}}
'''Cataract surgery''', also called '''lens replacement surgery''', is the removal of the natural [[lens (anatomy)|lens]] of the [[human eye|eye]] that has developed a [[cataract]], an opaque or cloudy area.<ref name="NEI cataracts" /> The eye's natural lens is usually replaced with an artificial [[intraocular lens]] (IOL) implant.<ref name="Statpearls" />

Over time, metabolic changes of the crystalline lens fibres lead to the development of a cataract, causing impairment or loss of vision. Some infants are born with [[congenital cataract]]s, and environmental factors may lead to cataract formation. Early symptoms may include strong [[Glare (vision)|glare]] from lights and small light sources at night and reduced [[visual acuity]] at low light levels.<ref name="aop" /><ref name="NIH2009" />

During cataract surgery, the cloudy natural lens is removed from the posterior chamber, either by [[emulsification]] in place or by cutting it out.<ref name="Statpearls" /> An IOL is usually implanted in its place (PCIOL), or less frequently in front of the chamber, to restore useful focus. Cataract surgery is generally performed by an [[ophthalmology|ophthalmologist]] in an [[ambulatory care|out-patient]] setting at a surgical centre or hospital. [[Local anaesthesia]] is normally used; the procedure is usually quick and causes little or no pain and minor discomfort. Recovery sufficient for most daily activities usually takes place in days, and full recovery takes about a month.<ref name="Mayo" />

Well over 90% of operations are successful in restoring useful vision, and there is a low complication rate. Day care, high-volume, minimally invasive, small-incision [[phacoemulsification]] with quick post-operative recovery has become the [[standard of care]] in cataract surgery in the [[developed world]].<ref name="Statpearls" /> [[Manual small incision cataract surgery]] (MSICS), which is considerably more economical in time, capital equipment, and consumables, and provides comparable results, is popular in the [[developing world]].<ref name="Haldipurkar et al 2009" /> Both procedures have a low risk of serious complications,<ref name="Cionni et al 2006" /><ref name="Statpearls MSICS" /> and are the definitive treatment for vision impairment due to lens opacification.<ref name="Moshirfar et al 2023" />

==Uses==
{{See also|Cataract}}
[[File:Cataract in human eye.png|thumb|alt=A visibly opacified central part of the lens of an eye with widely dilated iris|Magnified view of a cataract seen on examination with a [[slit lamp]]]]

Cataract surgery is the most common application of lens removal surgery, and is usually associated with lens replacement. It is used to remove the natural lens of the eye when it has developed a cataract, a cloudy area in the lens that causes [[visual impairment]].<ref name=NIH2009/><ref name="Pandey 2009" /> Cataracts usually develop slowly and can affect one or both eyes.<ref name=NIH2009/> Early symptoms may include faded colours, [[Blurred vision|blurred]] or [[double vision]], halos around lights, sensitivity to [[Glare (vision)|glare]] from bright lights, and [[Nyctalopia|night blindness]]. Blindness is the end result.<ref name="NIH2009" /> The procedure is normally elective, but lens removal may be part of trauma surgery in cases where the eye is severely injured. The lens is usually replaced by an intraocular implant when this is reasonably practicable, as removal of the lens also removes the ability of the eye to focus at any distance.<ref name="Statpearls" />

<!-- Cause, mechanisms and diagnosis -->
Cataracts most commonly occur due to aging, but may also be caused by [[Trauma (medicine)|trauma]] or [[radiation exposure]], be [[congenital cataract|present since birth]], or may develop as a complication of eye surgery intended to solve other health problems.<ref name=NIH2009/><ref name=WHOPri/> Cataracts form when clumps of [[protein]]s or yellow-brown pigment accumulate in the lens, which reduces transmission of light to the [[retina]] at the back of the eye.<ref name=NIH2009/> Cataracts can be diagnosed via an [[eye examination]].<ref name=NIH2009/>

<!-- Treatment -->
Early symptoms of cataract may be improved by wearing appropriate [[glasses]]; if this does not help, cataract surgery is the only effective treatment.<ref name=NIH2009/> Surgery with implants generally results in better vision and an improved [[quality of life]]: however, the procedure is not readily available in many countries.<ref name=NIH2009/><ref name="WHOPri" /><ref name="Lamoureux et al 2011" /><ref name=Rao2011/>

==Techniques==
[[File:Flickr - Official U.S. Navy Imagery - Cmdr. Brice Nicholson performs cataract surgery..jpg|thumb|Cataract surgery using a surgical microscope |alt=A surgical team is gathered around the patient in an operating theatre. the surgeon and two learners are observing the procedure through a surgical microscope suspended above the patient's eye.]]
[[File:CataractOperated.jpg|thumb|Cataract surgery recently performed, foldable IOL inserted. A small incision and very slight [[hemorrhage]] are visible to the right of the still dilated pupil. |alt=Photo of a left eye with widely dilated pupil. a small red spot on the lower distal side is all that can be seen of the incision.]]
[[File:Nucleus of hypermature cataract with cut section.jpg|thumb|Nucleus of a mature cataract removed by extracapsular cataract extraction (ECCE) |alt=Front and side views of a highly opacified extracted cataract. It is uniformly yellow in colour.]]

Two main classes of cataract surgical procedures are currently in common use throughout the world: [[phacoemulsification]], and extracapsular cataract extraction. Intracapsular cataract extraction has been superseded where the facilities for surgery under a microscope are available except for cases where the lens capsule cannot be retained, and couching is no longer used in mainstream medicine.

In phacoemulsification (phaco), the natural lens is fragmented by an ultrasonic probe and removed by suction. A more recent and less common variation of this, [[Mode locking|femtosecond]] laser-assisted phacoemulsification surgery, uses a laser to make the corneal incision, execute the [[capsulotomy]], which provides access to the lens, and initiate lens fragmentation, which reduces energy requirements for phacoemulsification.<ref name="Cionni et al 2006" /> The small incision size used in phacoemulsification generally allows for [[Surgical suture|sutureless]] incision closure.<ref name="Cionni et al 2006" />

In {{visible anchor|extracapsular cataract extraction}} (ECCE), and its variation [[manual small incision cataract surgery]] (MSICS), the lens is removed from its capsule and manually extracted from the eye, either whole or after being split into a small number of substantial pieces.<ref name="Moshirfar et al 2023" /> The basic version of ECCE uses a larger incision of {{cvt|10|–|12|mm}} and usually requires stitches. This requirement led to the variation known as MSICS, which does not usually need stitches as the incision should be self sealing under internal pressure due to its geometry.<ref name="Statpearls" />

Comparative trials of MSICS against phaco in dense cataracts have found no significant difference in outcomes, although MSICS had shorter operating times and significantly lower costs.<ref name="Haldipurkar et al 2009" /> MSICS has been prioritized as the method of choice in developing countries, because it provides high-quality outcomes with less surgically-induced [[astigmatism]] than standard ECCE, no suture-related problems, quick rehabilitation, and fewer post-operative visits. MSICS is generally easy and fast to learn for the surgeon, cost-effective and applicable to almost all types of cataract.<ref name="Statpearls MSICS" /> ECCE using a large incision has largely become a contingency procedure to deal with complications during surgery and for managing cataracts expected to be difficult extractions.<ref name="Agarwal 2019" />

In most surgeries, an IOL is inserted. Foldable lenses are generally used for the {{cvt|2|–|3|mm|inch|2}} phaco incision, while non-foldable lenses can be placed through the larger extracapsular incision.

{{visible anchor|Intracapsular cataract extraction}} (ICCE) is the removal of the lens and the surrounding lens capsule in one piece. The procedure has a relatively high rate of complications in comparison to techniques in which the capsule is retained in place, due to the large incision required, pressure placed on the [[vitreous body]] when removing the encapsulated lens, and the removal of the barrier between the chambers of the eye, allowing easier migration of vitreous into the anterior chamber. It has therefore been largely superseded and is rarely performed in countries where [[operating microscope]]s and high-technology equipment are readily available.<ref name="Statpearls" /> After lens removal by ICCE, an intraocular lens implant can be placed in either the anterior chamber or sutured into the ciliary [[sulcus (morphology)|sulcus]].<ref group=Note name="ciliary sulcus" /><ref name="Cionni et al 2006" /> [[Cryoextraction (medicine)|Cryoextraction]] is a technique used in ICCE to extract the lens using a [[Cryosurgery|cryoprobe]], the refrigerated tip of which adheres to the tissue of the lens at the contact point by freezing with a cryogenic substance such as [[liquid nitrogen]], facilitating its removal.<ref name="Cryoextraction" /> Cryoextraction may still be used for the removal of [[Subluxation#Lens of the eye|subluxated]] (partially dislocated) lenses.<ref name="Kim and Ha 2013" />

[[Couching (ophthalmology)|Couching]] is the earliest documented form of cataract surgery. It involves dislodging the lens of the eye, removing the cataract from the optical axis, but leaving it inside the eye. The lens is not replaced and the eye cannot focus at any distance.<ref name="Haripriya et al 2017" />

Phacoemulsification is the most commonly performed cataract procedure in the developed world,<ref name="Boughton 2009" /> but the high capital and maintenance costs of a phacoemulsification machine and of the associated disposable equipment, have made ECCE and MSICS the most commonly performed procedures in developing countries.<ref name="Statpearls" /> Cataract surgery is commonly done as an out-patient or day-care procedure, which is less expensive than hospitalisation and an overnight stay, and day surgery has similar medical outcomes.<ref name="Lawrence et al 2015" />

==Pre-operative evaluation==
An [[eye examination]] or pre-operative evaluation is done to confirm the presence of a cataract and to determine the patient's suitability for surgery:<ref name="Statpearls" />

* The degree of reduction of vision due largely to the cataract is evaluated. While the existence of other sight-threatening diseases, such as [[age-related macular degeneration]] or [[glaucoma]], does not preclude cataract surgery, less improvement may be expected in their presence.<ref name="Statpearls" />
* In cases of uncontrolled glaucoma, a combined cataract-glaucoma procedure (phaco-[[trabeculectomy]]) can be planned and performed.<ref name="Liaska 2014" />
* The [[pupil]] is checked for dilation using [[Eye drop|eyedrops]]; if they do not provide a satisfactory result, injected intracameral [[mydriatic]]s have been shown to be safe and effective for surgery and fast acting.<ref name="Lundberg and Behnding 2003" /> If pharmacologic pupil dilation is insufficient, procedures for mechanical pupil dilatation may be needed during the surgery.<ref name="Akman 2004" /><ref name="Srinivasan 2018" /><ref name="Kumari et al 2022" />
* People with [[retinal detachment]] may be scheduled for a combined [[Vitreoretinal surgery|vitreo-retinal procedure]], along with IOL implantation.<ref name="Rishi et al 2009" />
* People taking [[tamsulosin]] (Flomax), a common drug for [[enlarged prostate]], are prone to developing a [[complication (medicine)|surgical complication]] known as [[intraoperative floppy iris syndrome]] (IFIS), which requires appropriate management to avoid [[#posterior capsule rupture|posterior capsule rupture]].<ref group=Note name="posterior capsule rupture" /><ref name="Charters 2006" />
* A Cochrane Review of three [[Randomized controlled trial|randomized clinical trials]], including over 21,500 cataract surgeries, examined whether routine pre-operative medical testing resulted in a reduction of adverse events during surgery. Results showed performing pre-operative medical testing did not result in a reduction of risk of intra-operative or post-operative medical adverse events, compared to surgeries with no or limited pre-operative testing.<ref name="Keay et al 2019" />
* Infants with congenital cataracts are more likely to have post-operative [[inflammation]] problems,<ref name="Yorston 2001" /> and their eyes grow rapidly and unpredictably, making it challenging to select and fit a posterior chamber IOL in infants younger than seven months that will give satisfactory results later in childhood. A second surgery may be required later.<ref name="Lambert et al 2019" />

===Contraindications===
[[Contraindication]]s to cataract surgery include cataracts that do not cause visual impairment and medical conditions that predict a high risk of unsatisfactory surgical outcomes.<ref name="Statpearls" /> such as:
*Poor general health or a serious medical condition.<ref name="Pacific vision" />
*Surgery will not provide better visual function.<ref name="Gogate and Wood 2008" />
*Advanced [[macular degeneration]]<ref name="Pacific vision" />
*[[Detached retina]].<ref name="Pacific vision" />
*Advanced [[diabetes]] that has affected the retina.<ref name="Pacific vision" />
*An infection of the eyes or nearby that could cause endophthalmitis, so should be treated before cataract surgery.<ref name="Gogate and Wood 2008" />
*The person does not want surgery.<ref name="Gogate and Wood 2008" />
*Functional vision can be provided by glasses or other visual aids which is sufficient for the person's requirements.<ref name="Gogate and Wood 2008" />
*Corneal diseases such as [[glaucoma]] may be a [[relative contraindication]].<ref name="Pacific vision" />

=== Selection of intraocular lenses ===
{{main|Intraocular lens}}
[[File:Hinterkammerlinse 01 (fcm).jpg|thumb|18.5 [[Dioptre|diopter]] foldable intraocular lens|alt=A one-piece intraocular lens resting on a fingertip for scale. The lens is about a quarter of the finger's width in diameter and has flexible haptic loops on opposite sides, which roughly double the length.]]
[[File:IOL-Injector.jpg|thumb|Injector for foldable intraocular lenses. The incision size for this type is 2.8{{nbsp}}mm. |alt=A small plastic disposable syringe with a lens insertion nozzle attached. The nozzle tapers to a small tip through which the foldable lens is expressed into the posterior capsule, and can fit into a 2.8mm wide incision.]]
[[File:Augenoperation-implantierbare-kontaktlinse-02.png|thumb|The IOL injector is inserted in the incision and aimed at the capsule.|alt=The tip of the nozzle can be seen penetrating the incision above a widely dilated pupil]]
[[File:Augenoperation-implantierbare-kontaktlinse-04.png|thumb|The rolled up lens is ejected from the nozzle into the capsule.|alt=The lens can be seen protruding from the nozzle tip through the pupil as it is ejected]]
[[File:Augenoperation-implantierbare-kontaktlinse-08.png|thumb|The lens unfolds in place.|alt=The lens is mostly unfolded, behind the iris]]
[[File:Ocular Implant.png|thumb|Section diagram of the eye, showing intraocular lens implanted in the posterior lens capsule behind the iris|alt=<!--No alt text needed-->]]

After the removal of a cataract, an intraocular lens is usually implanted to replace the damaged natural lens. A foldable IOL may be implanted through a {{cvt|1.8|to|2.8|mm}} incision, whereas a rigid [[poly(methyl methacrylate)]] (PMMA) lens requires a larger cut. Foldable IOLs are made of [[silicone]], [[hydrophobic]], or [[hydrophilic]] [[acrylyl group|acrylic]] material of appropriate [[refractive power]] and are inserted with a special tool.<ref name="Statpearls IOL" /> The IOL is inserted through the incision, usually into the [[capsular bag]] from which the cataract was removed (in-the-bag implantation). Sometimes, a [[Ciliary sulcus|sulcus]] implantation—in front of the capsular bag, but behind the [[Iris (anatomy)|iris]]—may be required because of posterior capsular tears or [[zonular dialysis]] (inadequate support for the capsular bag). This requires an IOL with different refractive power because of the placement further forward on the [[optical axis]].<ref name="Mehta and Aref 2019" />

The appropriate refractive power of the IOL is selected, much like a spectacle or contact lens prescription, to provide the desired refractive outcome. Pre-operative measurements, including corneal curvature, axial length, and [[white-to-white measurement]]s<ref group=Note name="white-to-white" /> are used to estimate the required power of the IOL. These methods include several formulae and free online calculators which use similar input data.<ref name="Goldsberry 2012" /> A history of [[LASIK surgery]], which alters corneal curvature, requires different calculations to take this into account.<ref name="Goldsberry 2012" />

Monofocal IOLs provide accurately focused vision at one distance only; far, intermediate, or near. People who are fitted with these lenses may need to wear glasses or contact lenses while reading or using a computer. These lenses usually have uniform spherical curvature.<ref name="Singh et al 2022" />

Other designs of [[multifocal intraocular lens]] that focus light from distant and near objects, working with similar effect to [[Bifocals|bifocal]] or [[Trifocal lenses|trifocal]] eyeglasses, are also available. Pre-operative patient selection and good counselling is necessary to avoid unrealistic expectations and post-operative patient dissatisfaction, and possibly a requirement to replace the lens.<ref name="Grayson 2011" /> Acceptability of these lenses has improved, and studies have shown good results in patients selected for expected compatibility.<ref name="Salerno et al 2017" />

Cataract surgery may be performed to correct vision problems on both eyes. If both eyes are suitable, people are usually advised to consider [[monovision]]. This procedure involves inserting an IOL providing near vision into one eye, while using one that provides distance vision for the other eye. Although most people can adjust to having monofocal IOLs with differing [[focal length]], some cannot compensate and may experience blurred vision at both near and far distances. An IOL optimised for distance vision may be combined with an IOL that optimises intermediate vision, instead of near vision, as a variation of monovision.<ref name="Statpearls IOL" />

One model of lens designed to [[Accommodation (vertebrate eye)|change focus]] using the natural reflexes of the eye has two hinged struts on opposite edges, which displace the lens along the optical axis when an inward transverse force is applied to the [[Hapticity|haptic loops]] at the outer ends of the struts—the components transferring the movement of the contact points to the device—while recoiling when the same force is reduced. The lens is implanted in the eye's [[Capsule of lens|lens capsule]], where the contractions of the [[ciliary body]], which would focus the eye with the natural lens, are used to focus the implant, instead.<ref name="Statpearls" /><ref name="MacRae" />

IOLs used in correcting [[astigmatism]] have different curvature on two orthogonal axes, as on the surface of a [[torus]]: for this reason, they are called toric lenses. [[Intraoperative aberrometry]]<ref group=Note name="intraoperative aberrometry" /> can be used to assist the surgeon in toric lens placement and minimize astigmatic errors.<ref name="Ramappa et al 2022" /><ref name="Roach 2013" />

The first [[Aspheric lens|aspheric]] IOLs were developed in 2004; they have a flatter periphery than the middle of the lens, improving contrast sensitivity. The effectiveness of aspheric IOLs depends on a range of conditions and they may not always provide significant benefit.<ref name="Roach 2010" />

Some IOLs are able to absorb [[ultraviolet]] and [[Biological effects of high-energy visible light|high-energy blue light]], thus mimicking the functions of the natural crystalline lens of the eye, which usually filters potentially harmful frequencies. A 2018 [[Cochrane review]] found there is unlikely to be a significant difference in distance vision between blue-filtering and plain lenses, and was unable to identify a difference in contrast sensitivity or colour discrimination.<ref name="Downie et al 2018" /><ref name="Hayashi and Hayashi 2006" />

The [[Intraocular lens#Adjustable Lens|light-adjustable IOL]] was approved by the U.S. [[Food and Drug Administration]] (FDA) in 2017.<ref name="UCSF" /> This type of IOL is implanted in the eye and then treated with ultraviolet light to alter the curvature of the lens before fixing it at the final strength.<ref name="Jain et al" />

In some cases, it may be necessary or desirable to insert an additional lens over the already implanted one, also in the posterior capsule. This type of IOL placement is called "piggyback" IOLs and is usually considered when the visual outcome of the first implant is not optimal.<ref name="Piggyback" /> In such cases, implanting another IOL over the existing one is considered safer than replacing the initial lens. This approach may also be used in people who need high degrees of vision correction.<ref name="Statpearls phakic" />

Cost is an important aspect of these lenses. Although [[Medicare (United States)|Medicare]] covers the cost of monofocal IOLs in the United States, people will have to pay the price difference if they choose more expensive lenses.<ref name="Vicchrilli et al 2018" />

==Operation procedures==

===Preparation===
Preparation may begin three-to-seven days before surgery, with the pre-operative application of NSAIDs and antibiotic eyedrops.<ref name="Statpearls MSICS" /> If the IOL is to be placed behind the iris, the pupil is [[Mydriasis|dilated]] by using drops to help better visualise the cataract. [[Miosis|Pupil-constricting]] drops are reserved for secondary implantation of the IOL in front of the iris, when the cataract has already been removed without primary IOL implantation.<ref name="Minakaran et al 2020" />

The operation may occur on a stretcher or a reclining examination chair. The eyelids and surrounding skin are swabbed with a disinfectant, such as 10% [[povidone-iodine]], and topical povidone-iodine is applied to the eye. The face is covered with a cloth or sheet with an opening for the operative eye. The eyelid is held open with a [[speculum (medical)|speculum]] to minimize blinking during surgery.<ref name="Statpearls phaco" /> Pain is usually minimal in properly anaesthetised eyes, though a pressure sensation and discomfort from the bright operating microscope light is common.<ref name="Cionni et al 2006" />

===Anaesthesia===
Most cataract operations are performed under [[local anaesthetic]], allowing the patient to return home the same day. Lens and cataract procedures are commonly performed in an out-patient setting; in the United States, 99.9% of lens and cataract procedures were done in an out-patient setting by 2012.<ref name="Wier et al 2015" />

[[Topical anaesthetic|Topical]], [[Sub-Tenon injection|sub-tenon]], [[Periocular injection|peribulbar]], or [[retrobulbar block|retrobulbar]] local anaesthesia is generally used, usually causing little or no discomfort.<ref name="Mayo 2" /><ref name="Minakaran et al 2020" /> Injections may be used to block regional nerves and prevent eye movement.<ref name="Cionni et al 2006" /> Topical anaesthetics are most commonly used, placed on the [[Globe (human eye)|globe]] of the eye as eyedrops (before surgery), or in the globe (during surgery).<ref name="Minakaran et al 2020" /> Oral or [[intravenous sedation]] to reduce anxiety may be combined with the local anaesthetic. [[General anaesthesia]] and retrobulbar blocks were historically used for intracapsular cataract surgery, and may be used for children and adults whose medical or psychiatric issues significantly affect their ability to remain still during the procedure.<ref name="Cionni et al 2006" /><ref name="Minakaran et al 2020" />

===Phacoemulsification===
{{main|Phacoemulsification}}

[[Phacoemulsification]] uses a machine with an [[ultrasonic]] handpiece with a [[titanium]] or [[surgical stainless steel]] tip, which vibrates at an ultrasonic frequency—commonly 40[[Hertz|&nbsp;kHz]]—to emulsify the lens tissue, which is aspirated by a coaxial annular suction tube. A second instrument, which is sometimes called a "cracker" or "chopper", may be used from a small side incision to break the hard cataract nucleus into smaller pieces, making emulsification and removal of the soft part of the lens around the nucleus easier. After phacoemulsification of the lens nucleus and cortical material is completed, an irrigation–aspiration (I-A) system is used to remove the remaining peripheral lens material. The procedure is done under a surgical microscope.<ref name="Cionni et al 2006" />

[[Mode locking|Femtosecond]] laser-assisted phacoemulsification surgery is a more recent development which may have fewer adverse effects on the [[cornea]] and [[macula]] than manual phacoemulsification. The laser is used to make the corneal incision and the [[capsulotomy]], which provides access to the lens, and initiate lens fragmentation, which reduces energy requirements for phacoemulsification. It provides high-precision, effective lens fragmentation at lower power levels and consequent good optical quality. However, as of 2022, the technique has not been shown to have significant visual, refractive, or safety benefits over manual phacoemulsification, and it has a higher cost.<ref name="Statpearls" /><ref name="Alio et al 2014" /><ref name="Popovic et al 2016" />

Entry into the eye is made through a minimal tunnel incision near the edge of the cornea.<ref name="Cionni et al 2006" /> The incision for cataract surgery has evolved along with the techniques for cataract removal and IOL placement. In phacoemulsification, the width depends on the requirements for IOL insertion. With foldable IOLs, it is often possible to use incisions smaller than {{cvt|3.5|mm|inch}}. The shape, position, and size of the incision affect the capacity for self sealing, the tendency to induce astigmatism, and the surgeon's ability to maneuvre instruments through the opening.<ref name="Devgan 2017" /> A more-posterior incision simplifies wound closure and decreases induced astigmatism, but it is more likely to damage [[blood vessel]]s nearby.<ref name="Cionni et al 2006" /> One or two smaller side-port incisions at 60-to-90 [[Degree (angle)|degrees]] from the main incision may be needed to access the anterior chamber with additional instruments.<ref name="Statpearls phaco" />

[[Ophthalmic viscosurgical device]]s (OVDs), a class of clear, [[gel]]-like materials, are injected into the anterior chamber at the start of the procedure, to support, stabilize, and protect the eyeball, to help maintain eye shape and volume, and to distend the lens capsule during IOL implantation.<ref name="Scholtz 2007" /> Their consistency allows surgical instruments to move through them, although they do not flow and retain their shape under low [[shear stress]]. The OVD will also constrain lens fragments from drifting around in the chamber. OVDs are available in several formulations, which may be combined or used individually as best suits the procedure.<ref name="Cionni et al 2006" />

The lens is inside a capsule supported by the ciliary body, between the aqueous and vitreous, behind the opening in the iris. [[Capsulorhexis]] is the process of tearing a circular opening in the front membrane of the lens capsule to access the lens within. In phacoemulsification, an anterior [[continuous curvilinear capsulorhexis]] is usually used to create a round, smooth-edged opening through which the surgeon can emulsify the lens nucleus, and then implant the intraocular lens.<ref name="Mohammadpour et al 2012" />

The cataract's outer (cortical) layer is then separated from the capsule by a gentle, continuous flow or pulsed dose of liquid from a [[cannula]], which is injected under the anterior capsular flap, along the edge of the capsulorhexis opening, in a step called [[hydrodissection]].<ref name="Yanoff and Duker" /><ref name="Faust 1984" /><ref name="Tas 2018" /> In [[hydrodelineation]], fluid is injected into the body of the lens through the cortex against the nucleus of the cataract, which separates the hardened nucleus from the softer cortex shell by flowing along the interface between them. As a result, the smaller hard nucleus can be more-easily emulsified. The posterior cortex serves as a buffer at this stage, protecting the posterior capsule membrane. The smaller size of the separated nucleus allows it to be broken up using shallower and less-peripheral grooving by the phaco tip, and produces smaller fragments after cracking or chopping. The posterior cortex also maintains the shape of the capsule through this stage, which reduces the risk of posterior capsule rupture.<ref name="Hydrodelineation" />

After nuclear cracking or chopping (if needed), the cataract is [[Phacoemulsification#Ultrasound|reduced to small fragments using ultrasound]] which are simultaneously aspirated. The remaining lens cortex (outer layer of lens) material from the capsular bag is carefully aspirated, and if necessary, the remaining epithelial cells from the capsule are removed by [[capsular polishing]].<ref name="Han et al 2019" /><ref name="Biswas and Batra 2020" /> The folded intraocular replacement lens is implanted, usually into the remaining posterior capsule, and checked to see that it has unfolded and seated correctly. A toric IOL must also be aligned in the correct axis to counteract astigmatism.<ref name="Statpearls" />

===Manual small incision cataract surgery (MSICS)===
{{main|Manual small incision cataract surgery}}
Many of the steps followed during MSICS are similar, if not identical, to those for phacoemulsification; the main differences are related to the alternative method of incision and cataract extraction from the capsule and eye.

[[Manual small incision cataract surgery]] (MSICS) is an evolution of extracapsular cataract extraction (ECCE); the lens is removed from the eye through a self-sealing tunnel wound through the sclera. A well-constructed scleral tunnel is held closed by internal pressure, is [[watertight]], and does not require suturing. The wound is relatively smaller than the one in ECCE, but is still markedly larger than a phaco wound.

The small incision into the anterior chamber of the eye is made at or near the [[corneal limbus]], where the [[cornea]] and [[sclera]] meet, either [[Superior (anatomy)|superior]] or [[Temporal (anatomy)|temporal]].<ref name="Statpearls MSICS" /> Advantages of the smaller incision include use of few-to-no stitches and shortened recovery time.<ref name="Statpearls" /> The MSICS incision is small in comparison with the earlier ECCE incision, but considerably larger than the one used in phacoemulsification. The precise geometry of the incision is important, as it affects the self-sealing of the wound and the amount of astigmatism induced by distortion of the cornea during healing. A sclerocorneal or scleral tunnel incision is commonly used, since it reduces the risk of induced astigmatism if suitably formed.<ref name="Haldipurkar et al 2009" /><ref name="Statpearls phaco" /> A sclerocorneal tunnel, a three-phase incision, starts with a shallow incision perpendicular to the sclera, followed by an incision through the sclera and cornea approximately parallel to the outer surface, and then a beveled incision into the anterior chamber. This structure provides the self-sealing characteristic, because internal pressure presses together the faces of the incision.<ref name="Statpearls MSICS" /> [[Bridle suture]]s<ref group=Note name="bridle suture" /> may be used to help stabilize the eyeball during sclerocorneal tunnel incision, and during extraction of the nucleus and epinucleus through the tunnel.<ref name="Statpearls MSICS" />
The depth of the anterior chamber and position of the posterior capsule may be maintained during surgery by OVDs or an anterior chamber maintainer, which is an auxiliary cannula providing a sufficient flow of [[buffered saline solution]] (BSS) to maintain stability of the shape of the chamber and internal pressure.<ref name="Singh et al 2017" /><ref name="Devgan" /> An anterior [[capsulotomy]], is then done to open the front surface of the lens capsule for access to the lens.<ref name="medrounds" /> The [[continuous curvilinear capsulorhexis]] technique is often used, or [[can-opener capsulotomy]] or [[envelope capsulotomy]].<ref name="Singh et al 2017" /> 
The lens may be divided into two or more pieces of similar size using a constricting loop, blades or other devices. The cataract lens or fragments are then removed from the capsule and anterior chamber using hydroexpression,<ref group=Note name=hydroexpression /> viscoexpression,<ref group=Note name=viscoexpression /> or more direct mechanical methods.<ref name="Singh et al 2017" /><ref name="Varshney and Jhala 2022" /> Following cataract removal, an IOL is usually inserted into the posterior capsule.<ref name="Cionni et al 2006" /> When the posterior membrane of the capsule is damaged, the IOL may be inserted into the ciliary sulcus,<ref name="Mehta and Aref 2019" /> or a [[glued intraocular lens]] technique may be applied.<ref name="Mohan et al 2017" />

===Extracapsular cataract extraction===
{{visible anchor|Extracapsular cataract extraction}} (ECCE), also known as manual extracapsular cataract extraction, is the removal of almost the entire natural lens in one piece, while most of the elastic lens capsule (posterior capsule) is left intact to allow implantation of an intraocular lens.<ref name="Statpearls" /> The lens is manually removed through a {{cvt|10|–|12|mm}} incision in the cornea or [[sclera]]. Although it requires a larger incision and the use of stitches, this method may be preferable for very hard cataracts, which would require a relatively large ultrasonic energy input, which causes more heating, as well as in other situations in which phacoemulsification is problematic.<ref name="Agarwal 2019" />

===Converting to ECCE to manage a contingency===
The most commonly used procedures are phacoemulsification and manual small incision cataract surgery (MSICS). In either of these procedures, it can sometimes be necessary to convert to ECCE to deal with a problem better managed through a larger incision.<ref name="Agarwal 2019" /> This may occur in the event of posterior capsule rupture, [[zonular dehiscence]],<ref group=Note name="zonular dehiscence" /> a dropped nucleus<ref group=Note name="dropped nucleus" /> with a nuclear fragment more than half the size of the cataract,<ref name="Agarwal 2019" /> problematic capsulorhexis with a hard cataract,<ref name="Agarwal 2019" /> or a very dense cataract where the heat developed by phacoemulsification is likely to cause permanent damage to the cornea.<ref name="Agarwal 2019" /> Similarly, a change from MSICS to ECCE is appropriate whenever the nucleus is too large for the MSICS incision,<ref name="Agarwal 2019" /> as well as in cases where the nucleus is found to be deformed during MSICS on a nanophthalmic eye.<ref group=Note name="nanophthalmic" /><ref name="Agarwal 2019" />

===Closing the wound===
After the IOL is inserted, OVDs that were injected to stabilize the anterior chamber, protecting the cornea from damage and distending the cataract's capsule during IOL implantation, are removed from the eye to prevent post-operative viscoelastic glaucoma, a severe intra-ocular pressure increase. This is done via suction from the irrigation-aspiration instrument and replacement by buffered saline solution (BSS). Cohesive OVDs tend to adhere to themselves, a characteristic that makes their removal easier.<ref name="Scholtz 2007" /> Removal of OVDs from behind the implant reduces the risk and magnitude of post-operative pressure spikes or capsular distention.<ref name="Cionni et al 2006" /> In the final step, the wound is sealed by increasing the pressure inside the globe with BSS, which presses the internal tissue against the external tissue of the incision, holding it closed. The surgeon will check whether the incision leaks fluid, because wound leakage increases the risk of penetration into the eye by microorganisms, thus predisposing it to [[endophthalmitis]]. If this does not achieve a satisfactory seal, a suture may be added. The wound is then hydrated, an antibiotic/steroid combination eyedrop is put in, and an eye-shield may be applied, sometimes supplemented with an eyepatch.<ref name="Cionni et al 2006" />

==Post-operative care==
The use of an eye patch may be indicated, usually for some hours after surgery and for a few days while sleeping. A topical [[corticosteroid]] or [[nonsteroidal anti-inflammatory drug]] (NSAID) is used to control inflammation, in combination with topical [[antibiotic]]s to prevent infection in the post-operative phase. These are generally self-administered as eyedrops for a few weeks.<ref name="Cionni et al 2006" />

==Complications==
===During surgery===
{{visible anchor|Posterior capsular rupture}}, a tear in the posterior membrane of the natural [[lens capsule]], is the most common complication during cataract surgery, with its rate ranging from 0.5% to 5.2%.<ref name="Statpearls" /> In most cases the situation can be salvaged, though it may be necessary to modify the original plans for the placement, refractive strength, and type of IOL.<ref name="McKinney 2020" /> Fragments of the nucleus can find their way through the tear into the vitreous chamber, and recovery of the fragments is not always desirable and is rarely successful. The rest of the fragments should generally be stabilised first, and vitreous should be prevented from entering the anterior chamber, and removed if it does. Removal of the fragments may be best referred to a vitreoretinal specialist.<ref name="Cionni et al 2006" /> Surgical management of a rupture may involve the [[Intraocular lens scaffold]] procedure,<ref name="Vajpayee et al 2001" /> anterior [[vitrectomy]], and occasionally, alternative planning for implanting the IOL, either in the ciliary sulcus (the space between the iris and the ciliary body), in the anterior chamber in front of the iris, or less commonly, sutured to the sclera.<ref name="McKinney 2020" /> Posterior capsule rupture can cause corneal oedema, [[cystoid macular oedema]], and retention of lens fragments; it is also associated with a six-times increase in the risk of endophthalmitis and as much as a nineteen-times increase in the risk of retinal detachment.<ref name="Statpearls" /><ref name="Wang et al 2006" /> Risk factors for posterior capsule rupture include advanced age, female sex, small capsulorhexis, small pupil opening during surgery, high myopia, [[pseudoexfoliation]], dense cataract nucleus, [[posterior polar cataract]], history of preoperative trauma, previous treatment for retinal disease, poor patient cooperation, and surgical inexperience.<ref name="Zare et al 2009" /><ref name="McKinney 2020" />

[[Suprachoroidal hemorrhage]] is a rare complication of intraocular surgery, which occurs when damaged [[ciliary arteries]] bleed into the space between the [[choroid]] and the [[sclera]].<ref name="Eyewiki SCH" /> It is a potentially vision-threatening pathology and must be treated immediately to preserve visual functions. Risk factors for suprachoroidal hemorrhage include anterior chamber intraocular lens (ACIOL), [[axial myopia]], advanced age, [[atherosclerosis]], glaucoma, [[systolic hypertension]], [[tachycardia]], [[uveitis]] and previous ocular surgery.<ref name="Cionni et al 2006" />

[[Intraoperative floppy iris syndrome]] has an incidence ranging from around 0.5% to 2.0%.<ref name="Statpearls" /> Iris or ciliary body injury has an incidence of about 0.6–1.2%.<ref name="Statpearls" /> Other complications include failure to aspirate all lens fragments, leaving some in the anterior chamber,<ref name="Wang et al 2006" /> and incisional burns, caused by overheating of the phacoemulsification tip when ultrasonic power continues while the irrigation or aspiration lines are blocked—the flow through these lines is used to keep the tip cool. Burns to the incision may make closure difficult and can cause corneal astigmatism.<ref name="Cionni et al 2006" />

===After surgery===
[[File:Posterior capsular opacification on retroillumination.jpg|thumb|[[Slit lamp]] photo of IOL showing Posterior capsular opacification (PCO) visible a few months after implantation of intraocular lens in eye, seen on retroillumination]]

Complications after cataract surgery are relatively uncommon. [[Posterior vitreous detachment]] (PVD) does not directly threaten vision, but may increase the risk of future vitreoretinal conditions. It may be more problematic in younger eyes because many people older than 60 have already gone through PVD. PVD may be accompanied by peripheral light flashes and increasing numbers of [[floater]]s.<ref name="Hilford et al 2009" />

Some people develop [[posterior capsular opacification]] (PCO), also called an "after-cataract". After cataract surgery, posterior capsular cells usually undergo [[hyperplasia]] and cellular migration as part of a physiological change, showing up as a thickening, opacification, and clouding of the posterior lens capsule, which is left behind after the cataract is removed, for placement of the IOL. This may compromise [[visual acuity]], and can usually be safely and painlessly corrected by using a Nd:YAG laser to clear the central portion of the opacified posterior pole of the capsule ([[posterior capsulotomy]]).<ref name="YAG laser capsulotomy" /> This creates a clear central visual axis, which improves visual acuity.<ref name="capsulotomy" /> In very thick opacified posterior capsules, a manual surgical capsulectomy might be needed. In the event of IOL replacement, a posterior capsulotomy could allow vitreous to migrate into the [[Anterior chamber of eyeball|anterior chamber]] through the opening previously occluded by the IOL, and this would have to be removed. Posterior capsule opacification reaches an incidence of about 28.4% by five years, and is influenced by many factors, including age, IOL lens material, lens design, quantity of residual lens cortex, history of ocular inflammation, and size of capsulorhexis.<ref name="Statpearls" /><ref name="Liu et al 2017" />

[[Retinal detachment]] normally occurs at a prevalence of 1 in 1,000 (0.1%); however, people who have had cataract surgery are at an increased risk (0.5–0.6%) of developing [[rhegmatogenous retinal detachment]] (RRD)—the most common form of the condition.<ref name="Steel 2014" /> Cataract surgery increases the rate of [[vitreous humour liquefaction]], which leads to increased rates of RRD.<ref name="Feltgen and Walter 2014" /> When a retinal tear occurs, vitreous liquid enters the space between the retina and [[retinal pigment epithelium]] (RPE), and presents as flashes of light ([[photopsia]]), dark floaters, and loss of peripheral vision.<ref name="Steel 2014" /> [[Toxic anterior segment syndrome]] (TASS), a non-infectious inflammatory condition, may also occur following cataract surgery: it is usually treated with topical corticosteroids in high dosage and frequency.<ref name="CDC" />

[[Endophthalmitis]] is a serious infection of intraocular tissues, usually following intraocular surgery complications or penetrating trauma, and one of the most severe. It rarely occurs as a complication of cataract surgery, due to the use of prophylactic antibiotics, but there is some concern that the clear cornea incision might predispose to the increase of endophthalmitis, although no conclusive study has corroborated this suspicion.<ref name="Lecturio" /> An [[intracameral injection]] of antibiotics may be used as a preventive measure. A meta-analysis showed the incidence of endophthalmitis after phacoemulsification to be 0.092%. The risk gets higher in association with factors such as diabetes, advanced age, larger incision procedures,<ref name="Statpearls IOL" /> and vitreous communication with the anterior chamber caused by posterior capsule rupture. The risk of vitreous infection is at least six times higher than for the [[Aqueous humour|aqueous]].<ref name="Bennett 2020" /> Endophthalmitis typically presents within two weeks after the procedure, with manifestations such as decreased visual acuity, [[Red eye (medicine)|red-eye]] and pain. [[Hypopyon]] occurs about 80% of the time. About 80% of infections are caused by [[coagulase-negative staphylococci]] and ''[[Staphylococcus aureus]]''. Management includes vitreous humour tap and injection of broad-spectrum antibiotics. Outcomes can be severe even with treatment, and may range from permanently decreased visual acuity to the complete loss of light perception, depending on the [[Etiology (medicine)|microbiological etiology]].<ref name="Statpearls" />

[[Glaucoma]] may occur and may be very difficult to control. It is usually associated with inflammation, especially when fragments of the nucleus enter the vitreous cavity. Some experts recommend early intervention by [[posterior pars plana vitrectomy]] when this condition occurs. In most cases, raised post-operative intraocular pressure is transient and benign, usually returning to baseline within 24 hours without intervention. Glaucoma patients may experience further visual field loss or a loss of [[Fixation (visual)|fixation]], and are more likely to experience intraocular pressure spikes.<ref name="Gokhale and Patterson 2007" /> On the other hand, secondary glaucoma is an important complication of surgery for congenital cataracts: patients can develop this condition even several years after undergoing cataract surgery, so they need lifelong [[Medical surveillance|surveillance]].<ref name="Swamy et al 2007" />

Mechanical pupillary block manifests when the anterior chamber gets shallower as a result of the obstruction of the aqueous humour flow through the pupil by the vitreous face or IOL.<ref name="Masket et al 2017" /> This is caused by contact between the edge of the pupil and an adjacent structure, which blocks the flow of aqueous through the pupil itself. The iris then bulges forward and closes the angle between the iris and cornea, blocking drainage through the [[trabecular meshwork]] and causing an increase in intraocular pressure. Mechanical pupillary block has mainly been identified as a complication of anterior chamber intraocular lens implantation, but has been known to occur occasionally after posterior IOL implantation.<ref name="Gaton et al 2003" />

Occasionally, a [[peripheral iridectomy]] may be made to minimize the risk of [[pupillary block glaucoma]].<ref name="Cionni et al 2006" /> Surgical [[iridectomy]] can be done manually or with a [[Nd:YAG laser]]. [[Laser peripheral iridotomy]] may be done either before or following cataract surgery.<ref name="Ou 2021" />

Swelling of the [[macula]], the central part of the retina, results in [[macular oedema]] and can occur a few days or weeks after surgery. Most such cases can be successfully treated. Preventative use of [[nonsteroidal anti-inflammatory drug]]s has been reported to reduce the risk of macular oedema to some extent.<ref name="Lim et al 2016" />

[[Uveitis–glaucoma–hyphema syndrome]] is a complication caused by the mechanical irritation of a mis-positioned IOL over the iris, ciliary body or iridocorneal angle.<ref name="RJO" />

Other possible complications include [[elevated intraocular pressure]];<ref name="Masket et al 2017" /> swelling or oedema of the cornea, which is sometimes associated with transient or permanent cloudy vision ([[pseudophakic bullous keratopathy]]); displacement or dislocation of the IOL implant; unplanned high refractive error—either myopic or [[hypermetropic]]—due to errors in the ultrasonic biometry (measurement of the eye length and calculation of the required [[Intraocular lens power calculation|intraocular lens power]]); [[cyanopsia]], which often occurs for a few days, weeks or months after removal of a cataract; and [[floaters]], which commonly appear after surgery.<ref name="Hayashi and Hayashi 2006" />

It may be necessary to exchange,<ref group=Note name=exchange/> remove<ref group=Note name=remove/> or reposition<ref group=Note name=reposition/> an IOL after surgery, for any of the following reasons:<ref name="Masket et al 2017" />
* Capsular block syndrome, the hyper-distention of the lens capsular bag, due to the IOL blocking fluid from draining through the anterior capsulotomy. This may cause a myopic refractive error;<ref name="Masket et al 2017" />
* Chronic anterior uveitis, which is a persistent inflammation of the anterior segment;<ref name="Masket et al 2017" />
* Chronic loss of endothelial cells faster than the rate due to normal aging;<ref name="Masket et al 2017" />
* Iris pigment epithelium loss;<ref name="Masket et al 2017" />
* Physical pain;<ref name="Masket et al 2017" />
* Progressive elongation of the pupil in direction of the IOL's long axis;<ref name="Masket et al 2017" />
* Progressive closing of the anterior chamber angle, due to propagation of anterior [[Synechia (eye)|synechiae]] without apparent anterior uveitis;<ref name="Masket et al 2017" />
* Incorrect IOL refractive power;<ref name="Masket et al 2017" />
* Incorrect positioning of the IOL (including decentring, tilt, or rotation), which partially prevents its correct function;<ref name="Masket et al 2017" />
* Damage or deformation of the IOL;<ref name="Masket et al 2017" />
* Unexpected optical results due to defects of the IOL;<ref name="Masket et al 2017" />
* Undesirable optical phenomena reported by the patient due to any other cause.<ref name="Masket et al 2017" />

===Risk===
Cataract surgery and IOL implantation have the safest and highest success rates of any eye care-related procedures. As with any type of surgery, however, some level of risk remains.<ref name="Cionni et al 2006" />

Most complications of cataract surgery do not result in long-term visual impairment, but some severe complications can lead to irreversible blindness.<ref name="Stein et al 2011" /> A survey of adverse results affecting Medicare patients recorded between 2004 and 2006 showed an average rate of 0.5% for one or more severe post-operative complications, with the rate decreasing by about 20% over the study period. The most important risk factors identified were [[diabetic retinopathy]] and a combination of cataract surgery with another intraocular procedure on the same day. In the study, 97% of the surgeries were not combined with other intraocular procedures; the remaining 3% were combined with [[Retinal implant|retinal]], [[Corneal transplantation|corneal]] or [[glaucoma surgery]] on the same day.<ref name="Stein et al 2011" />

==Recovery and rehabilitation==
[[File:إمراة في انتظار نجاح عملية العيون 01.jpg|thumb|A shield or patch may be needed for a few days, mainly to protect from physical impact and contamination. |alt=Woman walking in a street, wearing an adhesive patch over her right eye]]

Following cataract surgery, side-effects such as grittiness, watering, blurred vision, double vision, and a red or bloodshot eye may occur, although they usually clear after a few days. Full recovery from the operation can take four-to-six weeks.<ref name="NHS" /> Patients are usually advised to avoid getting water in the eye during the first week after surgery, and to avoid swimming for two-to-three weeks as a conservative approach, to minimise risk of [[bacterial infection]].<ref name="Cionni et al 2006" /> Most people can return to normal activities the day after phacoemulsification surgery.<ref name="Southcaleye" /> Depending on the procedure, they should avoid driving for at least 24 hours after the surgery, largely due to effects from the anaesthesia, possible swelling affecting focus, and pupil dilation causing excessive glare. At the first post-operative check, the surgeon will usually assess whether the patient's vision is suitable for driving.<ref name="Southcaleye" />

With small-incision self-sealing wounds used with phacoemulsification, some of the post-operative restrictions common with intracapsular and extracapsular procedures are not relevant. Restrictions against lifting and bending were intended to reduce the risk of the wound opening, because straining increases intraocular pressure. With a self-sealing tunnel incision, however, higher pressure closes the wound more tightly. Routine use of a shield is not usually required, because inadvertent finger pressure on the eye should not open a correctly structured incision, which should only open to point pressure.<ref name="Cionni et al 2006" /> After surgery, patients need to prevent contamination by avoiding rubbing their eyes, as well as not using eye makeup, face cream or lotions. Any kind of contact with excessive dust, wind, [[pollen]] or dirt should also be avoided. Moreover, people are advised to wear sunglasses on bright days, since the eyes become more sensitive to bright light for a prolonged period after surgery.<ref name="Texas 2020" />

Topical anti-inflammatory drugs and antibiotics are commonly used in the form of eyedrops to reduce the risk of inflammation and infection. A shield or eye-patch may be prescribed to protect the eye while sleeping. The eye will be checked to ensure the IOL remains in place, and once it has fully stabilized (after about six weeks), vision tests will be used to check whether prescription lenses are needed.<ref name="Statpearls" /><ref name="NHS" /> In cases where the focal length of the IOL is optimised for distance vision, [[reading glasses]] are generally needed for near focus.<ref name="Sridhar and Tripathy" />

In some cases, people are dissatisfied with the optical correction provided by the initial implants, making removal and replacement necessary; this can occur with more complex IOL designs, as the patient's expectations might not match with the compromises inherent in these designs, or they might not be able to accommodate the difference in distance and near-focusing of monovision lenses.<ref name="Grayson 2011" /> The patient should not participate in contact or extreme sports, or similar activities, until cleared to do so by the eye surgeon.<ref name="Porter" />

==Outcomes==
{{see also|Visual acuity}}

After full recovery, [[visual acuity]] depends on the underlying condition of the eye, the choice of IOL, and any long-term complications associated with the surgery. More than 90% of operations are successful in restoring useful vision, with a low complication rate.<ref name="Wong 2001" /> The [[World Health Organization]] (WHO) recommends at least 80% of eyes should have a presenting visual acuity of 6/6 to 6/18 (20/20 to 20/60) after surgery, which is considered a good enough visual outcome; the percentage is expected to reach at least 90% with best correction. Acuity of between 6/18 and 6/60 (20/60 to 20/200) is regarded as borderline, whereas a value worse than 6/60 (20/200) is considered poor. Borderline or poor visual outcomes are usually influenced by pre-surgery conditions such as glaucoma, [[Macular degeneration|macular disease]], and [[diabetic retinopathy]].<ref name="Hashmi et al 2013" />

Refractive results using power calculation formulae based on pre-operative [[biometrics]] leave people within 0.5 dioptres of target (correlates to [[visual acuity]] of 6/7.5 (20/25) when targeted for distance) in 55% of cases and within one dioptre (correlates to 6/12 (20/40) when targeted for distance) in 85% of cases. Developments in intra-operative [[Wavefront|wavefront technology]] have demonstrated power calculations that provide improved outcomes, yielding 80% of patients within 0.5 dioptres (6/7.5 (20/25) or better).<ref name="Roach 2013" />

A ten-year prospective survey on refractive outcomes from a UK [[National Health Service]] (NHS) cataract surgery service from 2006 to 2016 showed a [[mean absolute error]] between the targeted and outcome refraction of 0.50 dioptres, with a [[standard deviation]] of 0.67 dioptres. 88.76% were within one diopter of target refraction and 62.36% within 0.50 dioptres.<ref name="Brogan et al 2019" />

According to a 2009 study conducted in Sweden, factors that affected predicted refraction error included sex, pre-operative visual acuity and glaucoma, together with other eye conditions. Second-eye surgery, macular degeneration, age and diabetes did not affect the predicted outcome. Prediction error decreased with time, which is likely due to the use of improved equipment and techniques, including more-accurate [[biometry]].<ref name="Kugelberg and Lundstrom 2009" /> A 2013 American survey involving nearly two million bilateral cataract surgery patients found immediate sequential bilateral cataract surgery was statistically associated with worse visual outcomes than for delayed sequential bilateral cataract surgery; however, the difference was small and might not be clinically relevant.<ref name="Owen et al 2021" />

There is a tendency for post-operative refraction to vary slightly over several years. A small overall myopic shift has been recorded in 33.6% and a small hypermetropic shift in 45.2% of eyes with the remaining 21.2% in the study having no reported change. Most of the change occurred during the first year after surgery.<ref name="Lee and Ong 2023" />

Phacoemulsification via a coaxial incision<ref group=Note name="coaxial" /> may be associated with less astigmatism than the average for bimanual incisions,<ref group=Note name="bimanual" /> but the difference was found to be small and the evidence statistically uncertain.<ref name="Jin et al 2017" /><ref name="Rose 2006" />

==History==
[[File:Cataract surgery dictionnaire universel.jpg|thumb|A cataract surgery. ''Dictionnaire Universel de Médecine'' (1746–1748)|alt=Engraved illustration of 18th century European surgeon performing a procedure on a seated patient, while an assistant steadies the patient's head from behind. A detail shows the instrument inserted through an incision in the sclera just beyond the edge of the cornea.]]
{{main |History of cataract surgery}}
Cataract surgery has a long history in Europe, Asia, and Africa, with [[Chrysippus|Chrysippus of Soli]], a [[Stoicism|stoic]] [[Ancient Greece|Greek]] [[Philosophy|philosopher]] providing the earliest account.<ref>{{Cite journal |last1=Grzybowski |first1=Juliusz |last2=Grzybowski |first2=Andrzej |date=2020-06-22 |title=Chrysippus and the First Known Description of Cataract Surgery |journal=Medicines |volume=7 |issue=6 |pages=34 |doi=10.3390/medicines7060034 |doi-access=free |issn=2305-6320 |pmc=7344708 |pmid=32580363}}</ref> [[Couching (ophthalmology)|Couching]] was the original form of cataract surgery, and was used from antiquity. It is still occasionally found in traditional medicine in parts of Africa and Asia. In 1753, [[Samuel Sharp (surgeon)|Samuel Sharp]] performed the first-recorded surgical removal of the entire lens and lens capsule, equivalent to intracapsular cataract extraction. The lens was removed from the eye through a limbal incision.<ref name="Davis 2016" />

In 1884, [[Karl Koller (ophthalmologist)|Karl Koller]] became the first surgeon to apply a [[cocaine]] solution to the cornea as a local anaesthetic.<ref name="Goerig et al 2012" /><ref name="Altman et al 1985" /> By the beginning of the 20th century, the standard surgical procedure was intracapsular cataract extraction (ICCE).<ref name="Cionni et al 2006" /> In 1949, [[Harold Ridley (ophthalmologist)|Harold Ridley]] introduced the concept of implantation of the [[intraocular lens]] (IOL) which made visual rehabilitation after cataract surgery a more efficient, effective, and comfortable process.<ref name="Davis 2016" />

Intracapsular cryoextraction was the favoured form of cataract extraction from the late 1960s to the early 1980s using a [[Liquid nitrogen|liquid-nitrogen-cooled]] probe tip to freeze the encapsulated lens to the probe.<ref name="Haripriya et al 2017" /><ref name="Cryoextraction" /><ref name="Meadow" /> In 1967, Charles Kelman introduced [[phacoemulsification]], which uses ultrasonic energy to emulsify the nucleus of the crystalline lens and remove cataracts by aspiration without a large incision. This method of surgery reduced the need for an extended hospital stay and made out-patient surgery the standard.<ref name="Pardey et al 2004" /> [[Ophthalmic viscosurgical device]]s (OVDs), which were introduced in 1972, facilitate the procedure and improve overall safety, particularly of phacoemulsification, by maintaining the shape of the eye at reduced pressure, and protecting the internal tissues of the eye without interfering with the operation.<ref name="Davis 2016" />

In the early 1980s, [[Danièle Aron-Rosa]] and colleagues introduced the [[Nd:YAG laser|neodymium-doped yttrium aluminum garnet laser]] (Nd:YAG laser) for posterior capsulotomy.<ref name="Cionni et al 2006" /> In 1985, [[Thomas Mazzocco]] developed and implanted the first foldable IOL, and [[Graham Barrett (ophthalmologist)|Graham Barrett]] and associates pioneered the use of silicone, acrylic, and hydrogel foldable lenses.<ref name="Cionni et al 2006" /> In 1987, [[M. Blumenthal]] and [[J. Moisseiev]] described the use of a reduced incision size for ECCE. They used a {{cvt|6.5|to|7|mm}} straight scleral tunnel incision {{cvt|2|mm}} behind the limbus with two side ports, and an [[anterior chamber maintainer]].<ref name="Singh et al 2017" /> In 1989, [[M. McFarland]] introduced a self-sealing incision architecture, and in 1990, [[S.L.Pallin]] described a chevron-shaped incision that minimized the risk of induced astigmatism.<ref name="Singh et al 2017" />

In 1983 [[G.T. Keener Jr.]] introduced a constricting wire loop, [[L.L. Fry]] reported the phaco-sandwich technique, and [[Peter Kansas]] suggested the phacosection method for reducing the incision required. The sclerocorneal pocket tunnel incision introduced by Kratz allowed manual small incision cataract surgery without phacoemulsification. The introduction of the anterior chamber maintainer (ACM) by Blumenthal in 1987 facilitated a high-pressure and -flow system, for a stable intraocular environment during surgery.<ref name="Malik and Goel 2009" />

[[Vision 2020: The Right to Sight]], a global initiative of the [[International Agency for the Prevention of Blindness]] (IAPB), was intended to reduce or eliminate the main causes of avoidable blindness worldwide by 2020. Programs instituted under Vision 2020 facilitated the planning, development, and implementation of sustainable national eye-care programs, including technical support and advocacy.<ref name="Vision 2020" /> The IAPB and WHO launched the program on 18 February 1999.<ref name="IAPB" /><ref name="Abdulhussein 2022" />

The Vision 2020 initiative succeeded in bringing avoidable blindness to the global health agenda. The causes have not been eliminated, but there have been significant changes to their distribution, which have been attributed to global demographic shifts. Remaining challenges to management of avoidable blindness include population size, [[Gender disparities in health|gender disparities]] in access to eye-care, and the availability of a professional workforce.<ref name="Abdulhussein 2022" />

Recent developments as of 2022 include continuing research into the possibility of lens regeneration and pharmacological approaches to slowing the development of cataracts. Lens implants that help compensate for age-related macular degeneration by magnification have been developed, but require relatively large incisions. Improved management of inflammatory response, use of ray-tracing models, artificial intelligence and a range of new formulae for refraction prediction.<ref name="Gryzbowski 2020" />

==Accessibility==
{{main|Global access to cataract surgery}}
Access to cataract surgery is very variable by country and region. Even in developed countries availability may vary significantly between rural and more densely populated areas.

The global health situation of cataracts is improving but this progress has not reduced the need for cataract surgery, which is still inadequate in large parts of the world. Older people, women, and lower socioeconomic status are associated with higher untreated cataract numbers.<ref name="Fang et al 2022" />

Cataracts have the most uneven global distribution of non-communicable eye diseases, with the burden of cataracts more concentrated in countries with lower socioeconomic status. Blindness is also correlated with a lack of ophthalmologists, and density of ophthalmologists correlates with a higher national income. High-income countries had an average of 76.2
ophthalmologists, and low income countries an average of 3.7 ophthalmologists per million inhabitants. The countries with highest socioeconomic levels tend to have the best cataract surgery outcomes. Low income countries also tend to lack adequate training facilities for surgeons.<ref name="Fang et al 2022" />

===Europe===
About 4.5 million cataract surgeries were done in the EU Member States in 2016. The rate of surgeries generally varied between 12000 and 4000 per million inhabitants. The highest rate was in Portugal, at 14000 per million and the lowest were Ireland and Slovakia at 2000 per million. The figures are not altogether comparable, as in some countries only surgeries at hospitals are included in the counts. The proportion of out-patient surgeries increased in almost all EU states between 2011 and 2016.<ref name="eurostat 2019" />

===Asia===
The estimated distribution of ophthalmologists in Asia ranges from more than 114 per million of population in [[Japan]], to none in [[Micronesia]].
[[South Asia]] has the highest global age-standardized prevalence of moderate-to-severe visual impairment (17.5%) and mild visual impairment (12.2%). Cataract has traditionally been a major cause of blindness in less-developed countries in the region, and in spite of improvements to the volume and quality of cataract surgeries, the rate of surgery remains low for some of these nations.<ref name="Yusufu et al" />

Cataracts are common in [[China]]; as of 2022, their estimated overall prevalence in Chinese people over 50 years old was 27.45%. The overall cataract-surgery coverage rate was 9.19%. The prevalence of cataract and cataract surgical coverage also significantly varies by region.<ref name="Du et al 2022" />

[[India]]'s cataract-surgical rate rose from just over 700 operations per million people per year in 1981, to 6,000 per million per year in 2011, thus getting closer to the estimated requirement of 8,000–8,700 operations per million per year needed to eliminate cataract blindness in the country. The rate's rise was partly linked to factors such as increased efficiency due to improved surgical techniques, application of day-case surgery, improvements in operating theatre design, and efficient teamwork with sufficient staff.<ref name="Murthy et al 2014" />

===Africa===
[[File:Cataract Surgery in Bedele, Ethiopia.jpg|thumb|Cataract surgery in Bedele, Ethiopia|alt=Surgeon using surgical microscope to operate while theatre staff attend.]]

Cataracts are the main cause of blindness in Africa, and affect approximately half of the estimated seven million blind people on the continent, a number that is expected to increase with population growth by about 600,000 people per year. As of 2005, the estimated cataract-surgery rate was about 500 operations per million people per year. Progress on gathering information on [[epidemiology]], distribution and impact of cataracts within the African continent has been made, but significant problems and barriers limiting further access to reliable data remain.<ref name="Wong 2005" />

These barriers relate to awareness, acceptance, and cost; some studies also reported community and family dynamics as discouraging factors. Most of the studies held locally reported that cataract-surgical rate was lower in females. The higher cataract-surgery coverage found in some settings in [[South Africa]], [[Libya]], and [[Kenya]] suggest many barriers to surgery can be overcome.<ref name="Aboobaker and Courtright 2016" />

According to the [[International Agency for the Prevention of Blindness]], some [[Sub-Saharan Africa|sub-Saharan]] African countries have about one ophthalmologist per million people, while the [[National Center for Biotechnology Information]] stated the percentage of adults above the age of 50 in western sub-Saharan Africa who have developed cataract-induced blindness is about 6%—the highest rate in the world.<ref name="Embrace relief" />

A mathematical model using survey data from sub-Saharan Africa showed the incidence of cataracts varies significantly across the continent, with the required rate of surgery to maintain a visual acuity level of 6/18 (20/60) ranging from about 1,200 to about 4,500 surgeries per year per million people, depending on the area. Such variations may relate to genetic or cultural differences, as well as [[life expectancy]].<ref name="Lewallen et al 2020" />

=== Latin America ===
[[File:SP faz multirão de catarata para operar 6 mil. (25839494537).jpg|thumb|Cataract operation in São Paulo, Brazil|alt=Surgeon operating using microscope while theatre staff attend]]

A four-year longitudinal study of 19 Latin American countries published in 2010 showed most of the countries had increased their surgery rates over that period, with increases of up to 186%, but still failed to provide adequate surgical coverage. The study also showed a significant correlation between [[Per capita income|gross national income per capita]] and cataract-surgery rate in the countries involved.<ref name="Lansingh et al 2010" />

In a study published in 2014, the [[Weighted Mean|weighted-mean]] regional surgery rate was found to have increased by 70% from 2005 to 2012, rising from 1,562 to 2,672 cataract surgeries per million inhabitants. The weighted mean number of ophthalmologists per million inhabitants in the region was approximately 62. Cataract-surgery coverage widely varied across Latin America, ranging from 15% in [[El Salvador]], to 77% in [[Uruguay]]. Barriers cited included cost of surgery and lack of awareness about available surgical treatment. The number of available ophthalmologists appeared to be adequate, but the number of those who practised eye surgery was unknown.<ref name="Batlle et al 2014" />

A 2009 study showed that the prevalence of cataract blindness in people 50 years and older ranged from 0.5% in [[Buenos Aires]], to 2.3% in parts of [[Guatemala]]. Poor vision due to cataracts ranged from 0.9% in Buenos Aires, to 10.7% in parts of [[Peru]]. Cataract-surgical coverage ranged from good in parts of [[Brazil]] to poor in [[Paraguay]], Peru, and Guatemala. Visual outcome after cataract surgery was close to conformity with WHO guidelines in Buenos Aires, where more than 80% of post-surgery eyes had visual acuity of 6/18 (20/60) or better, but ranged between 60% and 79% in most of the other regions, and was less than 60% in Guatemala and Peru.<ref name="Limburg et al 2009" />

==Social, economic and environmental relevance==
It has been estimated there were 43.3 million blind people in 2020, and 295 million with moderate and severe visual impairment (MSVI), 55% of whom were female. The age-standardised global prevalence in blindness decreased by 28.5% between 1990 and 2020, but the age-standardised prevalence of MSVI increased by 2.5%. Cataract remained the global leading cause of blindness in 2020.<ref name="Abdulhussein 2022" />

Cataract impairs vision and lowers quality of life. Improvements in vision help with daily activities, including work productivity and education. Cataract surgery reduces risk of falling and of dementia. It can prevent disability and is very cost effective, so it has large socioeconomic benefits, but the demand is great and the cost remains a large financial burden to public health systems.<ref name="Fang et al 2022" />

The cost of cataract surgery depends on the type of procedure, whether it is provided privately or by a government hospital, whether it is provided by out-patient (day care) or in-patient surgery, and on the economic status of people in the region. Because of the high cost of the equipment, phacoemulsification is generally more expensive than ECCE and MSICS.<ref name="Haldipurkar et al 2009" />

A 2021 study found that perioperative procedures before and after surgery differ considerably between various surgeons and institutions, which suggests the possibility for large amounts of unnecessary expenditure worldwide. Standardised best practice perioperative procedures can improve patient safety and have the potential to reduce unnecessary costs and unnecessary diagnostic procedures.<ref name="Rossi et al 2021" />

The restoration of functional vision or improvement in vision possible in most cases has a large social and economic impact; patients may be able to return to paid work or continue their previous jobs, and may not become dependent on support from their family or the wider society. Studies show a sustained improvement to quality of life, financial situation, physical well-being, and mental health. Cataract surgery is one of the most cost-effective health interventions, since its economic benefits considerably exceed the cost of treatment.<ref name="Fred Hollows 2017" /><ref name="Finger et al 2012" />

The 1998 [[World Health Report]] estimated 19.34 million people were bilaterally blind due to age-related cataracts, and that cataracts were responsible for 43% of all cases of blindness. This number and proportion were expected to increase due to population growth, and increased life expectancy approximately doubling the number of people older than 60 years. The global increase in blindness from cataract is estimated to be at least five million per year; a figure of 1,000 new cases per million population per year is used for planning purposes. The average outcomes of cataract surgery are improving, and consequently, surgery is being indicated at an earlier stage in cataract progression, increasing the number of operable cases. To reduce the backlog of patients, it is necessary to operate on more people per year than the new cases alone.<ref name="Foster 2022" />

As of 1998, the rate of surgeries in economically developed countries was about 4,000 to 6,000 per million population per year, which was sufficient to meet demand. India raised the cataract surgery rate (CSR) to over 3,000, but this was not considered to be sufficient to reduce the backlog. Middle-income countries of Latin America and Asia have CSRs of between 500 and 2,000 per million per year, whereas China, most of Africa, and poor countries of Asia had rates of less than 500. In India and South East Asia, the rate required to keep up with the increase is at least 3,000 per million population per year; in Africa and other parts of the world with smaller percentages of older people, a rate of 2,000 may be sufficient in the short term.<ref name="Foster 2022" />

In addition to the direct costs, associated surgical complications may require further intervention. In high income countries the environmental costs also tend to be higher. A phacoemulsification surgery in a UK hospital was estimated to cost more than 20 times the greenhouse gas emission of an equivalent surgery in an Indian hospital. Some of the unnecessary costs may be due to regulatory requirements that are based on perceived safety rather than actual safety.<ref name="Fang et al 2022" /><ref name="Buchan et al 2022" />

==Special populations==

===Congenital cataracts===
{{main|Congenital cataract}}
[[File:Cataracts due to Congenital Rubella Syndrome (CRS) PHIL 4284 lores.jpg|thumb|Bilateral cataracts in an infant due to [[congenital rubella syndrome]]|alt=Close up showing the eyes of an infant with opaque lenses.]]

In general, there is greater urgency to remove dense cataracts from very young children because of the risk of [[amblyopia]]. For optimal visual development in newborns and young infants, a visually significant unilateral congenital cataract should be detected and removed before the child is six weeks old, while visually significant bilateral congenital cataracts should be removed before 10 weeks.<ref name="aop" /> Congenital cataracts that are too small to affect vision will not be removed or treated, but may be monitored by an ophthalmologist throughout the patient's life. Commonly, a patient with small congenital cataracts that do not damage vision will be affected later in life, though this will take decades to occur.<ref name="NEI" />

{{As of|2015}}, the standard of care for pediatric cataract surgery for children older than two years is primary posterior intraocular lens (IOL) implantation. Primary IOL implantation before the age of seven months is considered to have no advantages over aphakia.<ref name="Struck 2015" /> According to a 2015 study, primary IOL implantation in the seven-months-to-two-years age groups should be considered in children who require cataract surgery.<ref name="Struck 2015" /> Research into the possibility of regeneration of infant lenses from lens [[epithelial cell]]s showed interesting results in a small trial study reported in 2016.<ref name="Science 2016" /><ref name="Lin et al 2016" />

===Higher risk for operations on separate occasions===
Most patients have bilateral cataracts; although surgery in one eye can restore functional vision, second-eye surgery has many advantages, so most patients undergo surgery in each eye on separate days. Operating on both eyes on the same day as separate procedures is known as immediately sequential bilateral cataract surgery; this can decrease the number of hospital visits, thus reducing risk of contagion in an [[epidemic]]. Immediately sequential bilateral cataract surgery also has significant cost savings, and faster visual rehabilitation and [[neuroadaptation]].<ref group=Note name="neuroadaptation" /> Another indication is significant cataracts in both eyes of patients for whom two rounds of anaesthesia and surgery would be unsuitable. The risk of simultaneous bilateral complications is low.<ref name="Alio and Nowrouzi 2022" /><ref name="Obuchowska and Mariak 2006" />

==Other animals==
Cataract surgery in small animals such as dogs and cats is a routine ophthalmic procedure with a success rate of around 90%, and is usually better for eyes with relatively recent cataract development. The presence of other ocular problems may reduce the success rate. Procedures are similar to those for humans. General anesthesia is likely to be used,<ref name="RVC" /> but [[sub-Tenon injection]] and a low-dose [[neuromuscular blockade]] protocol have also been used for canine cataract surgery.<ref name="Bayley et al" />

== See also ==
* {{Portal inline|Medicine}}
* {{Commons category-inline}}
* {{annotated link|Africa Cataract Project}}
* {{annotated link|Eye surgery}}
* {{annotated link|Himalayan Cataract Project}}
* {{annotated link|IOLVIP}}
* {{annotated link|Ophthalmology}}
* [[Phakic intraocular lens]] implantation in series with the natural lens to correct vision in cases of high refractive errors.<ref name="Barsam and Allan 2014" />
* Refractive lens exchange, or [[clear lens extraction]] – Effectively use of the same procedures as for cataract surgery to replace a natural lens with high refractive error when other methods are not effective.

==Notes==
{{notelist}}
{{reflist|group=Note|refs=

<ref name="bimanual" >Bimanual phacoemulsification uses one probe to emulsify and aspirate, and a second that is only used for irrigation.</ref>

<ref name="bridle suture" >Bridle suture:  A suture passing through the ''superior rectus'' muscle of the eye, used to rotate the eyeball downwards in eye surgery.</ref>

<ref name="ciliary sulcus" >Ciliary sulcus:  The space between the anterior surface of the ciliary body and the posterior surface of the base of the iris, just in front of the position of the natural lens.</ref>

<ref name="coaxial" >Coaxial phacoemulsification uses a single probe to irrrigate, emulsify and aspirate, which is operated through a single incision.</ref>

<ref name="dropped nucleus" >Dropped nucleus: A cataract nucleus which has fallen through into the vitreous chamber.</ref>

<ref name=exchange >Exchange: The IOL is replaced with another of the same model.</ref>

<ref name=hydroexpression >Hydroexpression: Method of removing the lens from the capsule and anterior chamber by carrying it out in a flow of saline solution.</ref>

<ref name="intraoperative aberrometry" >Intraoperative aberrometry: A tool to take aphakic and pseudophakic refractive measurements during surgery to help optimise IOL power selection and placement.</ref>

<ref name=nanophthalmic >Nanophthalmic: Exceptionally small eyes.</ref>

<ref name="neuroadaptation">Neuroadaptation: Changes in the brain which accommodate the presence of a new substance or condition, such as the admission of more blue light after removal of a yellow tinted cataract, or the inability to adjust the focus of an IOL by the ciliary muscles.</ref><!-- <ref>Neuroadaptation. (n.d.). In Alleydog.com's online glossary. Retrieved from: https://www.alleydog.com/glossary/definition-cit.php?term=Neuroadaptation, on 12 May 2023</ref> -->

<ref name="posterior capsule rupture" >Posterior capsule rupture: Unintended tearing of the posterior membrane of the lens capsule, which can allow migration of the vitreous into the anterior chamber.</ref>

<ref name=remove >Remove: The IOL is removed and replaced with a different model lens or no replacement lens is implanted.</ref>

<ref name=reposition >Reposition: The IOL is surgically moved to another location or rotated.</ref>

<ref name=viscoexpression >Viscoexpression: Method of removing the lens from the capsule and anterior chamber by carrying it out in a flow of viscoelastic material.</ref>

<ref name=white-to-white >White
-to-white (WTW) measurement of an eye is the horizontal diameter of the cornea, measured across the corneal limbus.</ref>

<ref name="zonular dehiscence" >Zonular dehiscence: Breaking of the fibrous strands (zonules) connecting the crystalline lens to the ciliary body.</ref>

}}

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<ref name="Brogan et al 2019" >{{cite journal |last1=Brogan |first1=K. |last2=Diaper |first2=C.J. |last3=Rotchford |first3=A.P. |title=Cataract surgery refractive outcomes: representative standards in a National Health Service setting |journal=British Journal of Ophthalmology |date=2019 |volume=103 |issue=4 |pages=539–543 |doi=10.1136/bjophthalmol-2018-312209 |pmid=29907629 |s2cid=49219217}}</ref>

<ref name="Boughton 2009" >{{cite news |url=https://www.aao.org/eyenet/article/phaco-ecce |title=Phaco and ECCE |first=Barbara |last=Boughton |work=EyeNet Magazine |publisher=American Academy of Ophthalmology |date=April 2009 |access-date=5 December 2023 |archive-date=5 December 2023 |archive-url=https://web.archive.org/web/20231205073410/https://www.aao.org/eyenet/article/phaco-ecce |url-status=live }}</ref>

<ref name="Buchan et al 2022" >{{cite journal |journal=The Lancet. Planetary Health |volume=6 |issue=6 |pages=e524–e534 |date=June 2022 |title=Addressing the environmental sustainability of eye health-care delivery: a scoping review |first1=John C. |last1=Buchan |first2=Cassandra L. |last2=Thiel |first3=Annalien |last3=Steyn |first4=John |last4=Somner |first5=Rengaraj |last5=Venkatesh |first6=Matthew J. |last6=Burton |first7=Jacqeline |last7=Ramke |doi=10.1016/S2542-5196(22)00074-2 |doi-access=free |pmid=35709809 }}</ref>

<ref name="capsulotomy" >{{cite journal |first1=Eyyup |last1=Karahan |first2=Duygu |last2=Er |first3=Suleyman |last3=Kaynak |title=An Overview of Nd:YAG Laser Capsulotomy |journal=Medical Hypothesis, Discovery & Innovation in Ophthalmology |volume=3 |issue=2 |date=Summer 2014 |pages=45–50 |pmc=4346677
|pmid=25738159 }}</ref>

<ref name="CDC" >{{cite web |url=https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5625a2.htm |title=Toxic Anterior Segment Syndrome After Cataract Surgery |publisher=[[Centers for Disease Control and Prevention]] |date=29 June 2007 |accessdate=18 April 2013 |archive-date=13 March 2013 |archive-url=https://web.archive.org/web/20130313212538/http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5625a2.htm |url-status=live }}</ref>

<ref name="Charters 2006" >{{cite news |last=Charters |first=Linda |url=http://www.ophthalmologytimes.com/ophthalmologytimes/article/articleDetail.jsp?id=339794 |title=Anticipation is key to managing intra-operative floppy iris syndrome |work=Ophthalmology Times |date=15 June 2006 |access-date=2 April 2007 |archive-date=22 October 2006 |archive-url=https://web.archive.org/web/20061022061529/http://www.ophthalmologytimes.com/ophthalmologytimes/article/articleDetail.jsp?id=339794 |url-status=dead }}</ref>

<ref name="Cionni et al 2006" >{{cite book |url=http://www.oculist.net/downaton502/prof/ebook/duanes/pages/v6/v6c006.html |title=Duane's Ophthalmology |date=2006 |publisher=Lippincott Williams & Wilkins |volume=6 |chapter=6: Cataract surgery |first1=Robert J. |last1=Cionni |first2=Michael E. |last2=Snyder |first3=Robert H. |last3=Osher |editor1-first=William |editor1-last=Tasman |via=www.oculist.net |access-date=16 February 2023 |archive-date=20 February 2023 |archive-url=https://web.archive.org/web/20230220154102/http://www.oculist.net/downaton502/prof/ebook/duanes/pages/v6/v6c006.html |url-status=live }}</ref>

<ref name="Cryoextraction" >{{cite journal |last1=Toczolowski |first1=J. |title=Thirty years of cryoophthalmology |journal=Ann. Ophthalmol. |date=July 1993 |volume=25 |issue=7 |pages=254–6 |pmid=8363292}}</ref>

<ref name="Davis 2016" >{{cite journal |last=Davis |first=G. |title=The Evolution of Cataract Surgery |journal=Mo. Med. |date=January–February 2016 |volume=113 |issue=1 |pages=58–62 |pmid=27039493 |pmc=6139750 |publisher=Missouri State Medical Association }}</ref>

<ref name="Devgan" >{{cite web |url=https://cataractcoach.com/2019/01/27/use-of-an-ac-maintainer-in-cataract-surgery/ |website=cataractcoach.com |title=Use of an AC maintainer in Cataract Surgery |first=Uday |last=Devgan |date=27 January 2019 |access-date=1 March 2023 |archive-date=1 March 2023 |archive-url=https://web.archive.org/web/20230301163234/https://cataractcoach.com/2019/01/27/use-of-an-ac-maintainer-in-cataract-surgery/ |url-status=live }}</ref>

<ref name="Devgan 2017" >{{cite web |url=https://www.healio.com/news/ophthalmology/20170811/three-rules-for-corneal-phaco-incisions |title=Three rules for corneal phaco incisions |last=Devgan |first=Uday |date=15 August 2017 |website=www.healio.com |access-date=12 December 2023 |archive-date=12 December 2023 |archive-url=https://web.archive.org/web/20231212122606/https://www.healio.com/news/ophthalmology/20170811/three-rules-for-corneal-phaco-incisions |url-status=live }}</ref>

<ref name="Downie et al 2018" >{{cite journal |last1=Downie |first1=L.E. |last2=Busija |first2=L. |last3=Keller |first3=P.R. |title=Blue-light filtering intraocular lenses (IOLs) for protecting macular health |journal=The Cochrane Database of Systematic Reviews |volume=2018 |pages=CD011977 |date=May 2018 |issue=5 |pmid=29786830 |pmc=6494477 |doi=10.1002/14651858.CD011977.pub2 |collaboration=Cochrane Eyes and Vision Group }}</ref>

<ref name="Du et al 2022" >{{cite journal |last1=Du |first1=Y.F. |last2=Liu |first2=H.R. |last3=Zhang |first3=Y. |last4=Bai |first4=W.L. |last5=Li |first5=R.Y. |last6=Sun |first6=R.Z. |last7=Wang |first7=N.L. |title=Prevalence of cataract and cataract surgery in urban and rural Chinese populations over 50 years old: a systematic review and Meta-analysis |journal=Int J Ophthalmol |date=18 January 2022 |volume=15 |issue=1 |pages=141–149 |doi=10.18240/ijo.2022.01.21 |pmid=35047369 |pmc=8720354 }}</ref>

<ref name="Embrace relief" >{{cite report |url=https://www.embracerelief.org/wp-content/uploads/2019/06/The-Epidemic-of-Cataracts-in-sub-Saharan-Africa-.pdf |title=The Epidemic of Cataracts in sub-Saharan Africa |website=www.embracerelief.org |access-date=24 February 2023 |archive-date=14 March 2023 |archive-url=https://web.archive.org/web/20230314084122/https://www.embracerelief.org/wp-content/uploads/2019/06/The-Epidemic-of-Cataracts-in-sub-Saharan-Africa-.pdf |url-status=live }}</ref>

<ref name="eurostat 2019" >{{cite web |url=https://ec.europa.eu/eurostat/web/products-eurostat-news/-/DDN-20190108-1 |title=Cataract surgery: how countries compare |date=8 January 2019 |website=ec.europa.eu |access-date=17 December 2023 |archive-date=17 December 2023 |archive-url=https://web.archive.org/web/20231217174933/https://ec.europa.eu/eurostat/web/products-eurostat-news/-/DDN-20190108-1 |url-status=live }}</ref>

<!-- <ref name="Eyewiki Iridotomy" >{{cite web |url=https://eyewiki.aao.org/Laser_Peripheral_Iridotomy |title=Laser Peripheral Iridotomy |first1=Ana IM |last1=Miguel |first2=Sara HM |last2=Marques |first3=Mário |last3=Cruz |first4=Ahmad A. |last4=Aref |first5=André Borges |last5=Silva |first6=Jonathan C. |last6=Tsui |editor-first=Ahmad A. |editor-last=Aref |date=25 December 2022 |work=Eyewiki |publisher=American Academy of Ophthalmology |access-date=23 February 2023 |archive-date=23 February 2023 |archive-url=https://web.archive.org/web/20230223202731/https://eyewiki.aao.org/Laser_Peripheral_Iridotomy |url-status=live }}</ref> -->

<ref name="Eyewiki SCH" >{{cite web |url=https://eyewiki.aao.org/Suprachoroidal_Hemorrhage |title=Suprachoroidal Hemorrhage |first1=Vivek |last1=Chaturvedi |first2=Ryan |last2=Sabherwal |first3=Leo A. |last3=Kim |first4=Andrew |last4=Pittner |first5=Neelakshi |last5=Bhagat |first6=Jennifer I |last6=Lim |first7=Lekha |last7=Mukkamala |first8=Nimesh |last8=Patel |editor-first=Nimesh |editor-last=Patel |date=23 June 2022 |work=Eyewiki |publisher=American Academy of Ophthalmology |access-date=22 February 2023 |archive-date=13 December 2022 |archive-url=https://web.archive.org/web/20221213175740/https://eyewiki.aao.org/Suprachoroidal_Hemorrhage |url-status=live }}</ref>

<ref name="Fang et al 2022" >{{cite journal |last1=Fang |first1=Rui |last2=Yu |first2=Yang-Fan |last3=Li |first3=En-Jie |first4=Ning-Xin |last4=Lv |first5=Zhao-Chuan |last5=Liu |first6=Hong-Gang |last6=Zhou |first7=Xu-Dong |last7=Song |title=Global, regional, national burden and gender disparity of cataract: findings from the global burden of disease study 2019 |journal=BMC Public Health |volume=22 |number=2068 |date=2022 |page=2068 |doi=10.1186/s12889-022-14491-0 |pmid=36369026 |pmc=9652134 |doi-access=free }}</ref>

<ref name="Faust 1984" >{{cite journal |last=Faust |first=KJ. |title=Hydrodissection of soft nuclei. |journal=J Am Intraocul Implant Soc. |date=Winter 1984 |volume=10 |issue=1 |pages=75–7 |doi=10.1016/s0146-2776(84)80088-9 |pmid=6706823 }}</ref>

<ref name="Feltgen and Walter 2014" >{{cite journal |last1= Feltgen |first1=N. |last2=Walter |first2=P. |title=Rhegmatogenous retinal detachment--an ophthalmologic emergency |journal=Deutsches Ärzteblatt International |volume=111 |issue=1–2 |pages=12–21; quiz 22 |date=January 2014 |pmid=24565273 |pmc=3948016 |doi=10.3238/arztebl.2014.0012 }}</ref>

<ref name="Finger et al 2012" >{{cite journal |last1=Finger |first1=R.P. |last2=Kupitz |first2=D.G. |last3=Fenwick |first3=E. |last4=Balasubramaniam |first4=B. |last5=Ramani |first5=R.V. |last6=Holz |first6=F.G. |last7=Gilbert |first7=C.E. |title=The impact of successful cataract surgery on quality of life, household income and social status in South India |journal=PLOS ONE |date=August 2012 |volume=7 |issue=8 |pages=e44268 |doi=10.1371/journal.pone.0044268 |pmid=22952945 |pmc=3432104 |bibcode=2012PLoSO...744268F |doi-access=free }}</ref>

<ref name="Foster 2022" >{{cite journal |title=Vision 2020: the cataract challenge. |journal=Community Eye Health |editor1-first=Allen |editor1-last=Foster |date=2000 |volume=13 |issue=34 |pages=17–19 |pmid=17491949 |pmc=1705965 }}</ref>

<ref name="Fred Hollows 2017" >{{cite web |url=https://www.hollows.org/au/research/social-and-economic-impacts-of-restoring-sight |title=Social and Economic Impacts of Restoring Sight |website=www.hollows.org |publisher=The Fred Hollows Foundation |date=7 April 2017 |access-date=25 March 2023 |archive-date=25 March 2023 |archive-url=https://web.archive.org/web/20230325023751/https://www.hollows.org/au/research/social-and-economic-impacts-of-restoring-sight |url-status=live }}</ref>

<ref name="Gaton et al 2003" >{{cite journal |last1=Gaton |first1=D.D. |last2=Mimouni |first2=K. |last3=Lusky |first3=M. |last4=Ehrlich |first4=R. |last5=Weinberger |first5=D. |title=Pupillary block following posterior chamber intraocular lens implantation in adults |journal=Br J Ophthalmol |date=September 2003 |volume=87 |issue=9 |pages=1109–11 |doi=10.1136/bjo.87.9.1109 |pmid=12928277 |pmc=1771845 }}</ref>

<ref name="Goerig et al 2012" >{{cite journal |last1=Goerig |first1=M. |last2=Bacon |first2=D |last3=van Zundert |first3=A. |title=Carl Koller, cocaine, and local anesthesia: some less known and forgotten facts |journal= Regional Anesthesia and Pain Medicine|date=May–June 2012 |volume=37 |issue=3 |pages=318–24 |doi=10.1097/AAP.0b013e31825051f3 |pmid=22531385 |s2cid=205432874 }}</ref>

<ref name="Gogate and Wood 2008" >{{cite journal |last1=Gogate |first1=P. |last2=Wood |first2=M. |title=Recognising 'high-risk' eyes before cataract surgery |journal=Community Eye Health |date=March 2008 |volume=21 |issue=65 |pages=12–14 |pmid=18504470 |pmc=2377383 }}</ref><!-- ref has a lot of detail on conditions with a high risk of complicarions and hints on surgical management -->

<ref name="Goldsberry 2012" >{{cite web |url=https://crstodayeurope.com/articles/2012-may/achieving-better-outcomes-using-free-online-post-lasik-iol-calculators/ |title=Achieving Better Outcomes Using Free Online Post-LASIK IOL Calculators |first=Dennis H. |last=Goldsberry |date=May 2012 |publisher=CRSTEurope |website=crstodayeurope.com |access-date=11 February 2023 |archive-date=11 February 2023 |archive-url=https://web.archive.org/web/20230211042040/https://crstodayeurope.com/articles/2012-may/achieving-better-outcomes-using-free-online-post-lasik-iol-calculators/ |url-status=live }}</ref>

<!-- <ref name=Gim2011 >{{cite journal |last1=Gimbel |first1=H.V. |last2=Dardzhikova |first2=A.A. |title=Consequences of waiting for cataract surgery |journal=Current Opinion in Ophthalmology |volume=22 |issue=1 |pages=28–30 |date=January 2011 |pmid=21076306 |doi=10.1097/icu.0b013e328341425d |s2cid=205670956 }}</ref> -->

<ref name="Gokhale and Patterson 2007" >{{cite magazine |url=https://glaucomatoday.com/articles/2007-may-june/0507_07.html |date=May–June 2007 |title=Elevated IOP After Cataract Surgery |first1=Parag A. |last1=Gokhale |first2=Emory |last2=Patterson |magazine=Glaucoma today |publisher=Bryn Mawr Communications, LLC. |access-date=2023-02-25 |archive-date=2023-02-25 |archive-url=https://web.archive.org/web/20230225121539/https://glaucomatoday.com/articles/2007-may-june/0507_07.html |url-status=live }}</ref>

<ref name="Grayson 2011" >{{cite web |url=https://www.reviewofophthalmology.com/article/the-ins-and-outs-of-lens-explantation |first=Douglas |last=Grayson |date=4 October 2011 |title=The Ins and Outs of Lens Explantation |website=Review of Ophthalmology |access-date=14 February 2023 |archive-date=14 February 2023 |archive-url=https://web.archive.org/web/20230214141238/https://www.reviewofophthalmology.com/article/the-ins-and-outs-of-lens-explantation |url-status=live }}</ref>

<ref name="Gryzbowski 2020" >{{cite journal |last=Grzybowski |first=A. |title=Recent developments in cataract surgery |journal=Ann Transl Med |date=November 2020 |volume=8 |issue=22 |pages=1540 |doi=10.21037/atm-2020-rcs-16 |doi-access=free |pmid=33313285 |pmc=7729366 }}</ref>

<ref name="Haldipurkar et al 2009" >{{Cite journal |last1=Haldipurkar |first1=S.S. |last2=Shikari |first2=Hasanain T. |last3=Gokhale |first3=Vishwanath |date=2009 |title=Wound construction in manual small incision cataract surgery |journal=Indian Journal of Ophthalmology |volume=57 |issue=1 |pages=9–13 |doi=10.4103/0301-4738.44491 |issn=0301-4738 |pmc=2661512 |pmid=19075401 |doi-access=free }}</ref>

<ref name="Han et al 2019" >{{cite journal |last1=Han |first1=M.Y. |last2=Yu |first2=A.H. |last3=Yuan |first3=J. |last4=Cai |first4=X.J. |last5=Ren |first5=J.B. |title=Effect of anterior capsule polish on visual function: A meta-analysis. |journal=PLOS ONE |date=January 2019 |volume=8 |issue=14 |pages=1:e0210205 |doi=10.1371/journal.pone.0210205 |pmid=30620750 |pmc=6324835 |doi-access=free |bibcode=2019PLoSO..1410205H }}</ref>

<ref name="Haripriya et al 2017" >{{cite journal |last1=Haripriya |first1=A. |last2=Sonawane |first2=H. |last3=Thulasiraj |first3=R.D. |title=Changing techniques in cataract surgery: how have patients benefited? |journal=Community Eye Health |date=2017 |volume=30 |issue=100 |pages=80–81 |pmid=29483751 |pmc=5820631 }}</ref>

<ref name="Hashmi et al 2013" >{{cite journal |url=https://applications.emro.who.int/imemrf/J_Coll_Physicians_Surg_Pak/J_Coll_Physicians_Surg_Pak_2013_23_6_448_449.pdf |title=Visual Outcome of Cataract Surgery |first1=Farzeen Khalid |last1=Hashmi |first2=Qazi Assad |last2=Khan |first3=Tanveer Anjum |last3=Chaudhry |first4=Khabir |last4=Ahmad |journal=Journal of the College of Physicians and Surgeons Pakistan |date=2013 |volume=23 |issue=6 |pages=448–449 |pmid=23763813 }}</ref>

<ref name="Hayashi and Hayashi 2006" >{{cite journal |last1=Hayashi |first1=K. |last2=Hayashi |first2=H. |date=2006 |title=Visual function in patients with yellow tinted intraocular lenses compared with vision in patients with non-tinted intraocular lenses |journal=British Journal of Ophthalmology |volume=90 |issue=8 |pages=1019–1023|doi=10.1136/bjo.2006.090712 |pmid=16597662 |pmc=1857188 }}</ref>

<ref name="Hilford et al 2009" >{{cite journal|last1=Hilford |first1=D. |last2=Hilford |first2=M. |last3=Mathew |first3=A. |last4=Polkinghorne |first4=P.J.|year=2009 |title=Posterior vitreous detachment following cataract surgery |journal=Eye |volume=23 |issue=6 |pages=1388–1392 |doi=10.1038/eye.2008.273 |pmid=18776863 |doi-access=free }}</ref>

<ref name="Hydrodelineation" >{{cite web |url=https://eyewiki.aao.org/Hydro_Manoeuvres_in_Cataract_Surgery#cite_note-faust1-1 |title=Hydro Manoeuvres in Cataract Surgery |first1=Alpa S. |last1=Patel |first2=Derek W. |last2=DelMonte |first3=Hridya |last3=Mohan |first4=Joseph |last4=Christenbury |editor1-first=Joseph |editor1-last=Christenbury |date=24 September 2022 |website=Eyewiki |publisher=American Academy of Ophthalmology |access-date=20 February 2023 |archive-date=20 February 2023 |archive-url=https://web.archive.org/web/20230220084202/https://eyewiki.aao.org/Hydro_Manoeuvres_in_Cataract_Surgery#cite_note-faust1-1 |url-status=live }}</ref>

<ref name="IAPB" >{{cite web |url=https://www.iapb.org/about/history/vision-2020/ |title=VISION 2020 |website=www.iapb.org |access-date=5 March 2023 |publisher=International Agency for the Prevention of Blindness |archive-date=7 March 2023 |archive-url=https://web.archive.org/web/20230307005105/https://www.iapb.org/about/history/vision-2020/ |url-status=live }}</ref>

<!-- <ref name="IJO">{{cite journal |last1=Sharma |first1=Bhavana |last2=Abell |first2=Robin G |last3=Arora |first3=Tarun |last4=Antony |first4=Tom |last5=Vajpayee |first5=Rasik B |title=Techniques of anterior capsulotomy in cataract surgery |journal=Indian Journal of Ophthalmology |pages=450–460 |doi=10.4103/ijo.IJO_1728_18 |date=2019|volume=67 |issue=4 |pmid=30900573 |pmc=6446625 |doi-access=free }}</ref> -->

<ref name="Jain et al" >{{cite web |url=https://eyewiki.aao.org/Light_Adjustable_Intraocular_lenses |first1=Sneha |last1=Jain |first2=Alpa S. |last2=Patel |first3=Koushik |last3=Tripathy |first4=Derek W. |last4=DelMonte |first5=Brandon |last5=Baartman |title=Light Adjustable Intraocular lenses |work=EyeWiki |editor1-first=Derek W. |editor1-last=DelMonte |publisher=American Academy of Ophthalmology |date=3 October 2022 |access-date=16 February 2023 |archive-date=16 February 2023 |archive-url=https://web.archive.org/web/20230216154001/https://eyewiki.aao.org/Light_Adjustable_Intraocular_lenses |url-status=live }}</ref>

<ref name="Jin et al 2017" >{{cite journal |last1=Jin |first1=Chongfei |last2=Chen |first2=Xinyi |last3=Law |first3=Andrew |first4=Yunhee |last4=Kang |first5=Xue |last5=Wang |first6=Wen |last6=Xu |first7=Ke |last7=Yao
|title=Different-sized incisions for phacoemulsification in age-related cataract |journal=Cochrane Database of Systematic Reviews |publisher=Cochrane Database Syst Rev |volume=9 |issue=9:CD010510 |date=20 September 2017 |pages=CD010510 |doi=10.1002/14651858.CD010510.pub2 |pmid=28931202 |pmc=5665700 }}</ref>

<ref name="Keay et al 2019">{{cite journal |last1=Keay |first1=L. |last2=Lindsley |first2=K. |last3=Tielsch |first3=J. |last4=Katz |first4=J. |last5=Schein |first5=O. |title=Routine preoperative medical testing for cataract surgery |journal=The Cochrane Database of Systematic Reviews |volume=1 |pages=CD007293 |date=January 2019 |issue=1 |pmid=30616299 |pmc=6353242 | doi=10.1002/14651858.CD007293.pub4 }}</ref>

<ref name="Kim and Ha 2013" >{{cite journal |last1=Kim |first1=Y.J. |last2=Ha |first2=S.J. |title=Intracapsular Lens Extraction for the Treatment of Pupillary Block Glaucoma Associated with Anterior Subluxation of the Crystalline Lens. |journal=Case Rep Ophthalmol |date=2013 |volume=4 |issue=3 |pages=257–264 |doi=10.1159/000356530 |pmid=24348413 |pmc=3861857 }}</ref>

<ref name="Kugelberg and Lundstrom 2009" >{{cite web |work=Cataract Surgery |date=May 2009 |title=Refractive Outcome After Cataract Surgery |first1=Maria |last1=Kugelberg |first2=Mats |last2=Lundström |url=https://crstodayeurope.com/articles/2009-may/0509_04-php/ |publisher=CRST Global: Europe Edition |access-date=2023-03-03 |archive-date=2023-04-17 |archive-url=https://web.archive.org/web/20230417053609/https://crstodayeurope.com/articles/2009-may/0509_04-php/ |url-status=live }}</ref>

<ref name="Kumari et al 2022" >{{cite journal |last1=Kumari |first1=K. |last2=Kaur |first2=S. |last3=Sukhija |first3=J. |title=Commentary: Intracameral mydriatics in cataract surgery |journal=Indian J. Ophthalmol. |date=November 2022 |volume=70 |issue=11 |pages=3853 |doi=10.4103/ijo.IJO_2236_22 |pmid=36308111 |pmc=9907261 |doi-access=free }}</ref>

<ref name="Lambert et al 2019" >{{cite journal |last1=Lambert |first1=S.R. |last2=Aakalu |first2=V.K. |last3=Hutchinson |first3=A.K. |last4=Pineles |first4=S.L. |last5=Galvin |first5=J.A. |last6=Heidary |first6=G. |last7=Binenbaum |first7=G. |last8=VanderVeen |first8=D.K. |title=Intraocular Lens Implantation during Early Childhood: A Report by the American Academy of Ophthalmology |journal=Ophthalmology |date=October 2019 |volume=126 |issue=10 |pages=1454–1461 |doi=10.1016/j.ophtha.2019.05.009 |pmid=31230794 |s2cid=195327519 |url=https://pubmed.ncbi.nlm.nih.gov/31230794/ |access-date=2023-02-27 |archive-date=2023-02-27 |archive-url=https://web.archive.org/web/20230227065742/https://pubmed.ncbi.nlm.nih.gov/31230794/ |url-status=live }}</ref>

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<ref name="Roach 2013" >{{cite news |url=https://www.aao.org/eyenet/article/intraoperative-wavefront-aberrometry-wave-of-futur |title=Intraoperative Wavefront Aberrometry: Wave of the Future? |first=Linda |last=Roach |work=EyeNet Magazine |publisher=American Academy of Ophthalmology |date=September 2013 |access-date=26 February 2023 |archive-date=26 February 2023 |archive-url=https://web.archive.org/web/20230226133408/https://www.aao.org/eyenet/article/intraoperative-wavefront-aberrometry-wave-of-futur |url-status=live }}</ref>

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<ref name="RVC" >{{cite web |url=https://www.rvc.ac.uk/small-animal-vet/teaching-and-research/fact-files/cataract-surgery |title=Cataract surgery |website=www.rvc.ac.uk |publisher=Royal Veterinary College |location=London, UK |access-date=11 December 2023 |archive-date=9 February 2023 |archive-url=https://web.archive.org/web/20230209231307/https://www.rvc.ac.uk/small-animal-vet/teaching-and-research/fact-files/cataract-surgery |url-status=live }}</ref>

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<!-- <ref name="Salmon 2020">{{Cite book |last=Salmon |first=John F. |url=https://www.worldcat.org/oclc/1131846767 |title=Kanski's Clinical Ophthalmology: A Systematic Approach |year=2020 |isbn=978-0-7020-7713-5 |edition=9th |publisher=Elsevier |location=Edinburgh |page=331 |oclc=1131846767 |access-date=2023-02-20 |archive-date=2020-06-16 |archive-url=https://web.archive.org/web/20200616125737/https://www.worldcat.org/oclc/1131846767 |url-status=live }}</ref> -->

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}}

== Further reading ==
{{refbegin}}
* {{cite journal | vauthors = Frampton G, Harris P, Cooper K, Lotery A, Shepherd J | title = The clinical effectiveness and cost-effectiveness of second-eye cataract surgery: a systematic review and economic evaluation | journal = Health Technology Assessment | volume = 18 | issue = 68 | pages = 1–205, v–vi | date = November 2014 | pmid = 25405576 | pmc = 4781176 | doi = 10.3310/hta18680 | publisher = NIHR Journals Library | id = 18.68 }}
* {{cite book |vauthors=Prajna NV, Ravilla TD, Srinivasan S |chapter=Ch: 11. Cataract Surgery |chapter-url=https://www.ncbi.nlm.nih.gov/books/NBK333487/ |title=Essential Surgery |series=Disease Control Priorities |edition=3rd |volume=1 |veditors=Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN |publisher=The International Bank for Reconstruction and Development / The World Bank |year=2015 |doi=10.1596/978-1-4648-0346-8 |pmid=26740991 |hdl=10986/21568 |isbn=978-1-4648-0346-8 |url=https://www.ncbi.nlm.nih.gov/books/NBK333500/ |access-date=2017-08-16 |archive-date=2022-01-19 |archive-url=https://web.archive.org/web/20220119134346/https://www.ncbi.nlm.nih.gov/books/NBK333500/ |url-status=live }}
* {{cite web |url=http://www.oculist.net/downaton502/prof/ebook/duanes/index.html |title=Duane's Ophthalmology |date=2006 |publisher=Lippincott Williams & Wilkins |editor1-first=William |editor1-last=Tasman |via=www.oculist.net |access-date=2023-02-19 |archive-date=2022-11-27 |archive-url=https://web.archive.org/web/20221127024437/http://www.oculist.net/downaton502/prof/ebook/duanes/index.html |url-status=live }}
{{refend}}

== External links ==
<!-- * [https://www.nytimes.com/slideshow/2007/08/01/health/100079Cataractsurgeryseries_index.html Cataract Surgery]&nbsp;– slideshow by ''[[The New York Times]]''
 paywalled-->
* [https://www.youtube.com/watch?v=7IQs4M48NmY YouTube video of phacoemulification technique]

{{Eye surgery|state=collapsed}}

{{DEFAULTSORT:Cataract Surgery}}
[[Category:Refractive surgeries]]
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