The complete guide to cataract surgery in Singapore – Everything you need to know and more
Introduction to cataract
Cataract is the leading cause of blindness affecting millions of people globally, with individuals aged 40 and above having an increased risk of being affected by this condition.
Here in Singapore, studies have shown that about 95% of the population above 70 years of age, and 80% of those aged 60 and above, have cataracts. At the other end of the scale; people aged 45 and above, more than 30% have some degree of cataract.
It is not surprising then that you probably have a parent or older relative who has cataracts. What is surprising however, is that the number of cataract cases may be even higher – a study by the SEED (Singapore Epidemiology of Eye Diseases) programme, found that as many as 68.8% of Singaporean adults (across ethnicities and more than 40 years of age) who have visually significant cataract were unaware of their condition.
This lack of awareness is a cause for concern, however if you are reading this 3,600-word guide, you have come to the right place to find out everything you need to know about cataracts and more.
What is cataract?
Cataract is a condition that occurs when the natural lens in our eye becomes cloudy or opaque. The cloudiness is usually caused by the accumulation of protein which leads to a blurred and/or decreased field of vision, while contrast and colour perception may also be affected during the early stages of the condition.
Types of cataracts
The 3 main types of cataracts are:
1 Nuclear cataract
The most common form of cataract associated with old age. The clouding takes place in the nucleus or centre of the lens.
2 Posterior sub-capsular
This is an opaque area that forms at the back of the lens. It occurs in individuals who are on prolonged use of steroids and/or who have diabetes.
3 Cortical cataract
The clouding occurs on the cortex or periphery of the lens, working its way to the centre likes spokes in a wheel.
Causes of cataract
Cataract is largely an age-related condition hence individuals over the age of 40 should pay increased attention to their sight and go for regular eye check-ups as a precautionary measure.
Outside of ageing, cataracts may also form as a result of the following:
- Family history of cataract (congenital)
- Alcohol consumption
- Diabetes that is not under control
- Trauma to the eye
- Inflammation of the eye
- Previous eye surgery including refractive surgery
- High degree of myopia (short-sightedness)
- UV radiation exposure from sunlight
- Ionising radiation such as X-rays and gamma rays
- Prolonged use of steroid medication such as oral steroids, nasal steroid sprays, steroid eyedrops, etc
Symptoms of cataract
The effects of cataracts during the initial stages are hardly noticeable as the changes to vision are minimal. As the condition progresses, you may notice that your vision is being affected to the extent that you find it difficult to complete daily tasks such as reading and driving. If this occurs, visit an eye specialist to get your eyes checked.
The following are the symptoms that you may encounter:
- Cloudy, hazy, misty or blurry vision
- Seeing a ‘film’ over the eye
- Light from the sun, lamps, or car headlights are bright or too glaring
- Difficulty to see in dim light or at night
- Experiencing a brown or yellow tinge to your vision
- Colours that look faded and less clear
- Having double vision
- Seeing haloes or a glare around bright lights
- Frequent prescription changes for your spectacles or contact lenses
Note that cataracts are usually not painful and hardly cause discomfort or redness in the eye. There are cases however, where they may be associated with increased intraocular pressure leading to symptoms of pain and nausea.
Eye check-up for cataracts
Make it a point to go for regular eye check-ups once you turn 40. Besides cataracts, there are other conditions that may affect your vision such as refractive errors, floaters, retinal tears, macular degeneration, and glaucoma, so it is advisable to have a full eye check-up rather than just checking for cataracts.
If you have any of these other conditions along with cataracts, there is a possibility to address them during cataract surgery. For example, glaucoma patients undergoing cataract surgery may undergo surgery for glaucoma simultaneously to improve intraocular pressure within the eye and/or to decrease their need for glaucoma eyedrops.
How does the doctor check for cataracts?
A check-up for cataracts will typically involve a number of tests including checking your eye prescription – this process called Manifest Refraction, involves the manual measurement of your prescriptive power via placing lenses of varying degrees in front of your eyes.
Secondly, a test to determine your eye pressure will be conducted. This measurement will give an indication of whether you are at risk of glaucoma.
The actual test to confirm if there are cataracts in your eye first involves the use of eyedrops to dilate the pupil of your eye. Once dilated, the doctor uses a Slit Lamp to look for signs of cataract as well as for any other conditions in your eye. If cataracts are present, a photograph will be taken for further evaluation and as a record to compare with the effects of surgery.
Once all the tests are completed, there will be a consultation with the doctor who will share the test findings and discuss your condition and options available to you.
When to have cataract surgery?
There is a general belief that you have to wait till the cataract gets ‘ripe’ or ‘mature’ before it can be removed. This stemmed from the time when the eye lens could only be extracted safely when the cataract was at a relatively advanced stage of development. With today’s technology, the lens can now be removed at any stage of development so there is no need to wait until it gets ‘ripe’ as it may increase the risk and complexity of the surgery.
So, when is it a good time to have surgery? The answer is when it affects your daily life; when cataracts are impairing your vision to the level that it interferes and hinders your daily activities.
If your cataract is in its early stages and you can still conduct your daily activities with ease, you may delay having surgery. However, as cataracts tend to affect your eye prescription, have your vision checked yearly and make new pairs of glasses if required.
Your cataract condition will increasingly get worse; it will not improve over time. However, there are some measures that you can take to slow down its progression – read more here.
What is the ideal age to have cataract surgery?
There is no right age to have the surgery, although there is increased risk as one gets older especially if there are other age-related medical conditions to contend with.
There is a trend however, of cataract patients getting younger – not because of the aforementioned age-related risk, but due to these factors:
- Greater awareness due to information found on the Internet on how one should not wait until cataracts are mature to get surgery done.
- Higher confidence in the procedure as a result of improvements in technology.
- Ability to use Medisave and insurance for the procedure.
- Cataract surgery being used as a refractive procedure – although the primary objective is to remove cataracts, given the opportunity, many younger patients will opt for Refractive Cataract Surgery to resolve both their cataract and refractive conditions such as myopia, hyperopia, and astigmatism – continue reading below to find out how.
The earliest known surgical method to remove cataracts dates back a number of centuries. They involve techniques such as ‘couching’ and ‘needling’ which are best left undescribed here as they are squirm-inducing.
Modern cataract surgical methods on the other hand, can be traced back to the middle of the last century; in 1949 with the introduction of intraocular lens (IOL) implantation and in 1967 with phacoemulsification, a method using ultrasonic vibrations to break up cataracts into small particles, which are then removed with a small probe. Today, cataract surgery is the only way to effectively remove cataracts.
Main types of cataract surgery:
Micro-incision phacoemulsification surgery – this employs the use of ultrasound energy to liquify the cataract in the lens of the eye. The emulsified cataract is then removed via a narrow incision of 2 to 3mm. No stitches (sutures) are required as the wounds are self-healing, allowing for faster recovery.
Laser-assisted cataract surgery – adopting the same technology used in LASIK, this procedure involves the use of a femtosecond laser to create the incision and fragment the cataract. Some surgeons deem this process as minimally invasive, has improved wound construction, allows for accurate lens positioning, and can be ideal for complex surgeries. However, aside from certain conditions that may benefit from this, there are no significant benefits over micro-incision phacoemulsification surgery to warrant the increased cost for most patients.
Intraocular Lens (IOL)
Once the cataracts and the natural lens have been removed, an artificial intraocular lens (IOL) will be implanted through a small incision of between 2 and 3mm. The implantation of the IOL is a permanent procedure, hence the lens need not be replaced.
There are broadly 2 types of IOLs; monofocals and multifocals:
- Monofocal – an IOL that provides corrective power in a specific portion of your visual range; it can be for near, mid or distance vision. As only one focus can be selected (with most individuals opting for distance vision), reading glasses are still required for near tasks.
- Multifocal – akin to progressive spectacles, these lenses have different zones in different parts of the lens which enable you to clearly see objects that are near or far. Multifocals can be used to correct presbyopia.
In addition to monofocals and multifocals, there are also toric lenses. These IOLs can address astigmatism where the cornea or lens is of irregular shape. Toric IOLs have different powers in different meridians of the lens, which when properly aligned, are able to provide optimal correction for astigmatism.
Although uncommon, and depending on how the eye heals, a patient may still have residual refractive errors after the implantation of an IOL. In such cases, the error may be corrected by laser vision correction such as LASIK or the patient has to continue to rely on wearing glasses.
Possible risks and side effects
Cataract surgery is considered to be low-risk. Infections for example, have an incidence rate of 1:1,000.
The following are some of the rare complications that may arise from surgery:
- Endophthalmitis – an infection resulting in inflammation of the eye. If left untreated, it may lead to vision loss. Treatment involves administration of antibiotics via intravitreal injection.
- Posterior capsular rupture – where fragments of the cataract may fall into the back of the eye. If this occurs, a follow-up surgery may be required to remove them.
- Posterior capsular opacification – cloudiness that may be noticeable by patients months or years after the surgery. This is not a case of cataracts returning (they do not). It is a cloudy layer of scar tissue forming behind the lens implant. If your vision is affected, YAG laser capsulotomy surgery can be performed to correct the problem.
In any form of surgery, there may be some side effects. The common ones encountered after cataract surgery are dry eye and night vision problems. They are temporary for most patients and may last about 3 months, usually tapering off as the days go by. Note that night vision problems may be more prominent with multifocal IOLs while floaters may become more visible due to the clarity gained after the procedure, regardless of the type of IOL.
After having your surgery, it is important to monitor your condition closely. In the event of any increased redness and/or blurring of vision, swelling, sharp pain or tearing, please contact your doctor as soon as possible.
Cataract surgery on 1 eye is a 30-minute day procedure performed in the hospital.
Surgery for the right and left eye is performed on separate days. Having surgery done on both eyes at the same time is not recommended because of potential complications such as infections affecting both eyes. However, you can have both eyes operated on at the same time – read more here.
To help you relax or to fall asleep, an anaesthetist will administer intravenous sedation. To ensure you are suitable for the sedation during surgery, you will be required to undergo a pre-op ECG and blood test.
To numb your eye and provide you with a level of comfort, anaesthetic eyedrops will be applied. However, you may experience a sensation of coldness and pressure on the eye and around the eyelids.
The whole procedure is relatively painless – however, some patients may experience discomfort due to lower pain thresholds.
In rare cases during surgery, it may be discovered that a multifocal IOL may not be suitable for a patient. In the event of this, a monofocal IOL will be used instead.
The day of the surgery
Fasting is required at least 6 hours before the surgery.
You can expect to stay in the hospital for half a day.
Please do not drive – you can either arrange for someone to bring you home after the surgery or take a cab and return home on your own.
Bring a pair of sunglasses to put them on after the surgery as your eyes may be sensitive to bright lights.
You will be given hospitalisation leave lasting 1 to 4 weeks – most patients are able to resume work the week after the surgery although it takes about a month for the eye to fully recover.
You are required to attend a post-op review on the day after the operation. At this moment, you can expect about 75% of your vision to be restored, although recovery differs for every individual. Post-op reviews are typically scheduled 1 day, 1 week and 1 month after surgery.
In the following days, your vision will fluctuate; on some days it is clearer while on others blurrier – it may take about 3 months before your vision fully stabilises.
- Avoid the following activities during the first 12 hours after surgery: prolonged reading, computer work and watching television.
- You are not to drive or operate heavy machinery during the first 24 hours.
- During the first week, please use the eye shields provided while sleeping to prevent the accidental rubbing of your eyes while you are asleep.
- Avoid travelling during the first week.
- Avoid dusty and smoky areas to prevent particles from entering and irritating your eye. Stay indoors if you can – if unavoidable, wear protective glasses when heading out during the first 2 weeks.
- When washing your hair during the first 2 weeks, avoid water getting into the eyes.
- Do not apply eye makeup during the first 2 weeks.
- Do not also cook during the first 2 weeks.
- No swimming, hot tubs, hot yoga, jacuzzi and sauna for a period of 1 month.
- Avoid contact sports and heavy lifting for 1 month. When exercising, use a headband to prevent sweat from entering the eye.
- Follow all medication instructions strictly:
- Wash your hands thoroughly before applying the prescribed eyedrops – shake the bottle well before use.
- When applying the eyedrops, tilt your head backwards and gently pull down the outer edge of the lower eyelid. Squeeze the bottle gently – one drop is sufficient per application.
- Avoid touching your eye and eyelashes with the bottle tip to prevent contamination of the bottle.
- If the bottle becomes contaminated, please discard and use a new bottle.
- Wait approximately 15 minutes after applying the antibiotic and anti-inflammatory eyedrops, before applying the lubricant eyedrops.
- Use a different set of medication for each eye.
If you are a Singapore citizen and eligible for government medical subsidies, you can expect to pay an average of $1,269 for cataract surgery on one eye in a public hospital (includes the operation, implant, and other fees). Visit the MOH website for more information.
According to the Singapore Doctor’s Directory, the average cost of a cataract surgery at 5 private hospitals is $4,490 per eye. The figure, however, can go up to $10,000 per eye, depending on the complexity of your condition, the seniority of the surgeon operating on you, the assessments conducted, the type of IOL used, and the type of medication prescribed.
Here is a range in the breakdown of costs for cataract surgery performed by a senior eye surgeon at private eye centres:
|Cataract assessment||$80 to $300|
|Cataract surgery (1 eye)||$3,000 to $10,000|
|Post-op medication||$100 to $300|
|Post-op review||$80 to $200|
Most eye centres will be able to give you an estimate of the costs involved. It will depend on your eye condition and lifestyle needs. Note that the cost of operating on 1 eye is usually more than half of that of 2 eyes – this is due to the cost of consumables, booking of operating theatre, etc, regardless whether it is 1 or 2 eyes being operated on.
Medisave and insurance
Cataract surgery is claimable by Medisave and insurance.
You can claim from Medisave up to the maximum amount of $2,450 per eye. You can claim from either your own, spouse’s, or children’s Medisave account.
Most insurance policies also provide coverage for cataract surgery. The amount claimable will depend on the coverage of your policy.
Which surgeon/eye centre to choose?
When it comes to assessing the options available for your cataract surgery, approach only credible and reputable eye doctors and/or eye centres. As cataract surgery in Singapore is a very common procedure, there are many surgeons who can perform it, so check their credentials and read reviews online. In addition, you can get recommendations from your family and friends.
Other things you should find out before making your decision:
- The type of technology and medical equipment used by the clinic
- The quality of service provided by the clinic
- The ability to listen to your needs and give you an unbiased consultation
- Transparency in pricing; without hidden costs and trying to hard-sell/upsell to you
- The percentage of complications arising from surgery
All in all, you should select the eye surgeon/centre you feel the most comfortable with.
Frequently Asked Questions
Cataracts do not always develop rapidly; it may take several years before it gets to the point where it becomes difficult for individuals to go about their daily tasks. The progression is not reversible but there are certain things you can do to help slow down the progression:
- See your eye doctor regularly – early discovery allows for better management of the condition.
- Eat a balanced diet comprising leafy vegetables, whole grains, nuts, citrus fruits and fish that are rich in omega-3 fatty acids.
- Wear headwear (caps with long visors, wide-brimmed hats, etc) or sunglasses with UV protection to protect your eyes from the sun.
- Share with your doctor the prescription medication that you are on (e.g., long-term use of steroids), to ensure that they do not have the side effect of hastening cataract development.
- Ensure that your diabetes is under control.
- Drink in moderation and stop smoking.
No. Once they are removed, cataracts do not come back.
For convenience, some patients might prefer to have surgery done on both eyes at the same time. The procedure – bilateral cataract surgery – offers the advantages of fewer visits to the doctor and a quicker return to daily living.
However, many eye doctors do not recommend this. Firstly, having surgery performed on separate days allows for a proper evaluation of the results on one eye before proceeding to the next. Secondly, although there is a low risk of complications arising, if infection in both eyes occurs, it could mean the patient is ‘out-of-action’ for a period of time.
If you have a multifocal IOL implanted, you usually do not have to return to wearing glasses after cataract surgery. However, if you have a monofocal IOL for long-distance vision implanted, you may still need reading glasses.
If you have one eye operated on first, you can wear a contact lens in the unoperated eye for the time being. It usually takes several weeks to a month for the first eye to stabilise.
Depending on the IOL/s being implanted, you usually do not have to return to wearing contact lenses after cataract surgery.
Yes. Cataract surgery is possible if you have had laser vision correction/refractive surgery such as LASIK and ReLEx SMILE done on your eyes. Due to the change in the shape of the cornea after laser vision correction however, a more detailed assessment of your eyes will be performed to calculate the required lens power of the IOL.
Surgeons generally discourage the use of multifocal IOLs if you have had LASIK done as it is challenging to accurately match the lens to the cornea. Instead, monofocal IOLs are recommended to fix distance vision so reading glasses will still be required.
As a result of on–going developments, there is a wider choice of IOLs for post-LASIK eyes – extended depth-of-focus and low-add diffractive multifocals. Consult with your surgeon to assess your options.
Yes. LASIK can be performed after having had cataract surgery. However, it may not be needed as you can correct myopia, hyperopia, and astigmatism, by implanting an appropriate IOL. This procedure is known as Refractive Cataract Surgery.
As both are age-related conditions, many cataract patients also have presbyopia. By implanting a multifocal IOL, you can correct your presbyopia at the same time.
DR DAVID CHAN
Senior Consultant Eye Surgeon
MB ChB (UK), M Med, FAMS,
MRCS (Edin), FRCS (Edin)
Dr David Chan is the Medical Director and Senior Consultant Eye Surgeon at Atlas Eye Specialist Centre. He specialises in complex cataract surgery, anterior segment surgery and refractive surgery. His treatments include high-risk cataract surgery, lens replacement or exchange, lens capsular bag support, iris repair, laser vision correction (ReLEx SMILE/LASIK), collagen cross-linking, implantable contact lens and refractive lens exchange.