Extracapsular cataract extraction


Extracapsular cataract extraction (ECCE) is a category of eye surgery in which the lens of the eye is removed while the elastic capsule that covers the lens is left partially intact to allow implantation of an intraocular lens (IOL). This approach is contrasted with intracapsular cataract extraction (ICCE), an older procedure in which the surgeon removed the complete lens within its capsule and left the eye aphakic (without a lens). The patient's vision was corrected after intracapsular extraction by extremely thick eyeglasses or by contact lenses.

There are two major types of ECCE: manual expression, in which the lens is removed through an incision made in the cornea or the sclera of the eye; and phacoemulsification, in which the lens is broken into fragments inside the capsule by ultrasound energy and removed by aspiration.


Historical background

The purpose of ECCE is to restore clear vision by removing a clouded or discolored lens and replacing it with an IOL. Cataract operations are among the oldest recorded surgical procedures; there are references to cataract surgery in the Code of Hammurabi in 1750 B . C . and in the treatises written around 600 B . C . by Susruta, a famous surgeon from India. In the ancient world, lenses damaged by cataracts were dislocated rather than removed in the strict sense; the surgeon used a lance to push the clouded lens backward into the vitreous body of the eye. This operation, known as couching, was standard practice until the mid-eighteenth century. Couching is still performed by some traditional healers in Africa and parts of Asia.

The first extracapsular extraction of a cataract was performed by a French surgeon named Jacques Daviel in 1753. Daviel removed the lens through a fairly long incision in the cornea of the eye. In 1865, the German ophthalmologist Albrecht von Graefe refined the operation by removing the lens through a much smaller linear incision in the sclera of the eye. After von Graefe, however, intracapsular extraction gradually became the favored method of cataract removal even though it left the patient without a lens inside the eye. The two inventions that made extracapsular extraction preferable again were the operating microscope and the intraocular lens. The first eye surgery performed with an operating microscope was done in Portland, Oregon, in 1948; in the same year, a British ophthalmologist named Harold Ridley implanted the first IOL in the eye of a cataract patient. Between 1948 and the 1980s, manual expression was the standard form of ECCE. Although phacoemulsification was first introduced in 1967, it was not widely accepted at first because it requires special techniques that take time for the surgeon to learn as well as expensive specialized equipment. As of 2003, phacoemulsification is now performed more often in the United States and Europe than "standard" ECCE. The manual expression technique, however, is still widely used in developing countries with large numbers of patients with eye disorders and limited hospital budgets.

The lens and cataract formation

To understand cataract surgery, it is helpful to have a basic description of the structure of the lens in the human eye. The lens, which is sometimes called the crystalline lens because it is transparent, is located immediately behind the iris. In humans, the lens is about 9 mm long and 4 mm wide. It consists of protein fibers and water, with the fibers arranged in a pattern that allows light to pass through the lens. There are three layers of cells in the lens: a central nucleus, which becomes denser and harder as a person ages; a cortex surrounding the nucleus, which contains cells that are metabolically active and continue to grow and divide; and a layer of cells between the cortex and the lens capsule known as the subcapsular epithelium.

Although a few people are born with cataracts or develop them in childhood, most cataracts are the result of the aging process. As people grow older, the protein fibers in the lens become denser, start to clump together, and form cloudy or opaque areas in the lens. Cataracts vary considerably in their speed of progression; they may develop in a few months or over a period of many years. Some people have cataracts that stop growing at an early stage of development and do not interfere with their vision. Although most people develop cataracts in both eyes, they do not usually progress at the same rate, so that the person has much better vision in one eye than in the other.

Ophthalmologists classify cataracts according to their location in the lens. It is possible for a person to have more than one type of cataract.


Cataract extraction is one of the most frequently performed surgical procedures in industrialized countries. It is estimated that 300,000–400,000 cases of visually disabling cataracts occur each year in the United States alone, and that between 1 and 1.5 million cataract extractions are performed annually in the United States. This frequency reflects the importance of cataracts as a

In extracapsular cataract extraction, an incision is made in the eye just beneath the iris, or colored part (A). The diseased lens is pulled out (B). A prosthetic intraocular lens is placed through the incision (D), and is opened to replace the old lens (E). (Illustration by GGS Inc.)
In extracapsular cataract extraction, an incision is made in the eye just beneath the iris, or colored part (A). The diseased lens is pulled out (B). A prosthetic intraocular lens is placed through the incision (D), and is opened to replace the old lens (E). (
Illustration by GGS Inc.

major public health problem. The World Health Organization (WHO) estimated in 1997 that cataracts are responsible for 50% of cases of blindness around the world, or 19 million people. By 2020, that figure is expected to rise to 50 million. More recent publications estimate that 1.2% of the general population of Africa is blind, with cataracts responsible for 36% of these cases of blindness.

About one person in every 50 in the general American population will eventually have to have a cataract removed. It is difficult, however, to compare the rates of cataract formation among various subgroups because present published studies use a number of different grading systems for defining and detecting cataracts. In addition, the elderly are often under-represented in general population studies even though age is the greatest single risk factor for cataract development. Three recent research projects carried out in the United States, Australia, and England, respectively, reported that 50% of people over the age of 60 have some degree of cataract formation, with the figure rising to 100% for those over 80. As of 2003, little conclusive information is available regarding the incidence of cataracts in different racial and ethnic groups in the United States.

A variety of risk factors in addition to age have been associated with cataracts, but their precise significance is debated among researchers:


Conventional extracapsular cataract extraction

Although phacoemulsification has become the preferred method of extracapsular extraction for most cataracts in the United States since the 1990s, conventional or standard ECCE is considered less risky for patients with very hard cataracts or weak epithelial tissue in the cornea. The ultrasound vibrations that are used in phacoemulsification tend to stress the cornea.

A conventional extracapsular cataract extraction takes less than an hour to perform. After the area around the eye has been cleansed with antiseptic, sterile drapes are used to cover most of the patient's face. The patient is given either a local anesthetic to numb the tissues around the eye or a topical anesthetic to numb the eye itself. An eyelid holder is used to hold the eye open during the procedure. If the patient is very nervous, the doctor may administer a sedative intravenously.

After the anesthetic has taken effect, the surgeon makes an incision in the cornea at the point where the sclera and cornea meet. Although the typical length of a standard ECCE incision was 10–12 mm in the 1970s, the development of foldable acrylic IOLs has allowed many surgeons to work with incisions that are only 5–6 mm long. This variation is sometimes referred to as small-incision ECCE. After the incision is made, the surgeon makes a circular tear in the front of the lens capsule; this technique is known as capsulorrhexis. The surgeon then carefully opens the lens capsule and removes the hard nucleus of the lens by applying pressure with special instruments. After the nucleus has been expressed, the surgeon uses suction to remove the softer cortex of the lens. A special viscoelastic material is injected into the empty lens capsule to help it keep its shape while the surgeon inserts the IOL. After the intraocular lens has been placed in the correct position, the viscoelastic substance is removed and the incision is closed with two or three stitches.


In phacoemulsification, the surgeon uses an ultra-sound probe inserted through the incision to break up the nucleus of the lens into smaller pieces. The newer technique offers the advantages of a smaller incision than standard ECCE, fewer or no stitches to close the incision, and a shorter recovery time for the patient. Its disadvantages are the need for specialized equipment and a steep learning curve for the surgeon. One study found that surgeons needed to perform about 150 cataract extractions using phacoemulsification before their complication rates fell to a baseline level.



The diagnosis of cataract is usually made when the patient begins to notice changes in his or her vision and consults an eye specialist. In contrast to certain types of glaucoma, there is no pain associated with the development of cataracts. The specific changes in the patient's vision depend on the type and location of the cataract. Nuclear cataracts typically produce symptoms known as myopic shift (in nearsighted patients) and second sight (in farsighted patients). What these terms mean is that the nearsighted person becomes more nearsighted while the farsighted person's near vision improves to the point that there is less need for reading glasses. Cortical and posterior subcapsular cataracts typically reduce visual acuity; in addition, the patient may also complain of increased glare in bright daylight or glare from the headlights of oncoming cars at night.

Because visual disturbances may indicate glaucoma as well as cataracts, particularly in older adults, the examiner will first check the intraocular pressure (IOP) and the anterior chamber of the patient's eye. The examiner will also look closely at the patient's medical history and general present physical condition for indications of diabetes or other systemic disorders that affect cataract development. The next step in the diagnostic examination is a test of the patient's visual acuity for both near and far distances, commonly known as the Snellen test. If the patient has mentioned glare, the Snellen test will be conducted in a brightly lit room.

The examiner will then check the patient's eyes with a slit lamp in order to evaluate the location and size of the cataract. After the patient's eyes have been dilated with eye drops, the slit lamp can also be used to check the other structures of the eye for any indications of metabolic disorders or previous eye injury. Lastly, the examiner will use an ophthalmoscope to evaluate the condition of the optic nerve and retina at the back of the eye. The ophthalmoscope can also be used to detect the presence of very small cataracts.

Imaging studies of the eye (ultrasound, MRI, or CT scan) may be ordered if the doctor cannot see the back of the eye because of the size and density of the cataract.


ECCE is almost always elective surgery—emergency removal of a cataract is performed only when the cataract is causing glaucoma or the eye is severely injured or infected. After the surgery has been scheduled, the patient will need to have special testing known as keratometry if an IOL is to be implanted. The testing, which is painless, is done to determine the strength of the IOL needed. The ophthalmologist measures the length of the patient's eyeball with ultrasound and the curvature of the cornea with a device called a keratometer. The measurements obtained by the keratometer are entered into a computer that calculates the correct power for the IOL.

The IOL is a substitute for the lens in the patient's eye, not for corrective lenses. If the patient was wearing eyeglasses or contact lenses before the cataract developed, he or she will continue to need them after the IOL is implanted. The lens prescription should be checked after surgery, however, as it is likely to need adjustment.


Patients can use their eyes after ECCE, although they should have a friend or relative drive them home after the procedure. The ophthalmologist will place some medications—usually steroids and antibiotics—in the operated eye before the patient leaves the office. Patients can go to work the next day, although the operated eye will take between three weeks and three months to heal completely. At the end of this period, they should have their regular eyeglasses checked to see if their lens prescription should be changed. Patients can carry out their normal activities within one to two days of surgery, with the exception of heavy lifting or extreme bending. Most ophthalmologists recommend that patients wear their eyeglasses during the day and tape an eye shield over the operated eye at night. They should wear sunglasses on bright days and avoid rubbing or bumping the operated eye. In addition, the ophthalmologist will prescribe eye drops for one to two weeks to prevent infection, manage pain, and reduce swelling. It is important for patients to use these eye drops exactly as directed.

Patients recovering from cataract surgery will be scheduled for frequent checkups in the first few weeks following ECCE. In most cases, the ophthalmologist will check the patient's eye the day after surgery and about once a week for the next several weeks.

About 25% of patients who have had a cataract removed by either extracapsular method will eventually develop clouding in the lens capsule that was left in place to hold the new IOL. This clouding, which is known as posterior capsular opacification or PCO, is not a new cataract but may still interfere with vision. It is thought to be caused by the growth of epithelial cells left behind after the lens was removed. PCO is treated by capsulotomy, which is a procedure in which the surgeon uses a laser to cut through the clouded part of the capsule.


The risks of extracapsular cataract extraction include:

Normal results

Extracapsular cataract extraction is one of the safest and most successful procedures in contemporary eye surgery; about 95% of patients report that their vision is substantially improved after the operation. In the words of a British ophthalmologist, "The only obstacle lying between cataract sufferers and surgical cure is resource allocation."

Morbidity and mortality rates

Mortality as a direct result of cataract surgery is very rare. On the other hand, several studies have indicated that patients over the age of 50 who undergo cataract extraction have higher rates of mortality in the year following surgery than other patients in the same age group who have other types of elective surgery . Some researchers have interpreted these data to imply that cataracts related to the aging process reflect some kind of systemic weakness rather than a disorder limited to the eye.

About 23% of patients who have undergone cataract extraction have a postoperative complication. The majority of these, however, are not vision-threatening. The most common complication is swelling of the cornea (9.5%), followed by raised IOP (7.9%); uveitis (5.6%); leaking from the incision (1.2%); hyphema (1.1%); external eye infection (0.06%); endophthalmitis (0.03%); retinal detachment (0.03%); retinal tear (0.02%), and CME (0.017%). Of these complications, only endophthalmitis and retinal detachment or tear are considered potentially vision-threatening.

Standard ECCE and phacoemulsification have very similar success rates and complication rates when performed by surgeons of comparable skill and length of experience.


Medical treatment

As of 2003 there are no medications that can prevent or cure cataracts. Many ophthalmologists, however, recommend a well-balanced diet as beneficial to the eyes as well as the rest of the body, on the grounds that some studies suggest that poor nutritional status is a risk factor for cataract. While vitamin supplements do not prevent cataracts, there is some evidence that an adequate intake of vitamins A, C, and E helps to slow the rate of cataract progression. Elderly people who may be at risk of inadequate vitamin intake due to loss of appetite and other reasons may benefit from supplemental doses of these vitamins.

Watchful waiting

Not all cataracts need to be removed. A patient whose cataracts are not interfering with his or her normal activities and are progressing slowly may choose to postpone surgery indefinitely. It is important, however, to have periodic checkups to make sure that the cataract is not growing in size or density. In the recent past, surgeons often advised patients to put off surgical treatment until the cataract had "ripened," which meant that the patient had to wait until the cataract had caused significant vision loss and was interfering with reading, driving, and most daily activities. At present, ophthalmologists prefer to remove cataracts before they get to this stage because they are harder and consequently more difficult to remove. In addition, a rapidly growing cataract that is not treated surgically may lead to swelling of the lens, secondary glaucoma, and eventual blindness. In most cases, however, it is up to the patient to decide when the cataract is troublesome enough to schedule surgery.

Surgical alternatives

The major surgical alternative to ECCE is intracapsular cataract extraction, or ICCE. It is rarely performed at present in Europe and North America, but is still done in countries where operating microscopes and high-technology equipment are not always available. In ICCE, the surgeon makes an incision about 150 degrees of arc, or about half the circumference of the cornea, in order to extract the lens and its capsule in one piece. The surgeon then inserts a cryoprobe, which is an instrument for applying extreme cold to eye tissue. The cryoprobe is placed on the lens capsule, where it freezes into place. It is then used to slowly pull the capsule and lens together through the long incision around the cornea. Because of the length of the incision needed to perform ICCE and the pressure placed on the vitreous body, the procedure has a relatively high rate of complications. In addition, the recovery period is much longer than for standard ECCE or phacoemulsification.

See also Cryotherapy for cataracts ; Phacoemulsification for cataracts .



"Cataract." Section 8, Chapter 97 in The Merck Manual of Diagnosis and Therapy , edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.


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Kalpadakis, P., et al. "A Comparison of Endophthalmitis After Phacoemulsification or Extracapsular Cataract Extraction in a Socio-Economically Deprived Environment: A Retrospective Analysis of 2,446 Patients." European Journal of Ophthalmology 12 (September-October 2002): 395-400.

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Pesudovs, Konrad, and David B. Elliott. "The Evolution of Cataract Surgery." Optometry Today (October 19, 2001): 30-32.

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American Academy of Ophthalmology. P. O. Box 7424, San Francisco, CA 94120-7424. (415) 561-8500. http://www.aao.org .

American Optometric Association. 243 North Lindbergh Blvd., St. Louis, MO 63141. (314) 991-4100.

American Society of Cataract and Refractive Surgery (ASCRS). 4000 Legato Road, #850, Fairfax, VA 22033. (888) 949-6753. http://www.ascrs.org .

Canadian Ophthalmological Society (COS). 610-1525 Carling Avenue, Ottawa ON K1Z 8R9. http://www.eyesite.ca .

National Eye Institute. 2020 Vision Place, Bethesda, MD 20892-3655. (301) 496-5248. http://www.nei.nih.gov .

Prevent Blindness America. 500 East Remington Road, Schaumburg, IL 60173. (800) 331-2020. http://www.preventblindness.org .

Wills Eye Hospital. 840 Walnut Street, Philadelphia, PA 19107. (215) 928-3000. http://www.willseye.org .


D'Ocampo, Vicente Victor, and C. Stephen Foster. "Cataract, Senile." eMedicine July 18, 2002 [May 25, 2003]. http://www.emedicine.com/oph/topic49.htm .

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Thomas, Ravi, and Thomas Kuriakose. "Surgical Techniques for a Good Outcome in Cataract Surgery: Personal Perspectives." Journal of Community Eye Health 13 (2000) [May 24, 2003]. http://www.jceh.co.uk/journal/35_4.asp .

Rebecca Frey, Ph.D.


Cataract surgery is performed by ophthalmologists, who are physicians who have completed four to five years of specialized training following medical school in the medical and surgical treatment of eye disorders. Ophthalmology is one of 24 specialties recognized by the American Board of Medical Specialties.

If cataract surgery is being considered, it is a good idea to find out how many extracapsular extractions the surgeon performs each year. The greatest single factor in the success rate of ECCE procedures is not whether the surgeon performs a standard extraction or phacoemulsification, but the volume of operations that he or she performs. Surgeons who perform between 200 and 400 extracapsular extractions per year have higher rates of successful outcomes than those who perform fewer than 200.

Extracapsular cataract extractions are done as outpatient procedures, either in the ophthalmologist's office or in an ambulatory surgery center.


User Contributions:

Judith E. Watson
I am 58 years old and have been diagnose with PSC. These have developed in both eyes since my last eye exam less than four years ago. My eye Dr. could see them easily without dialating my eyes, thus they have progressed fast. I had been having problems with my eye sight, plus my already very light sensitive eyes had become more so and night driving is very difficult for me. Is there anyway in telling how quickly I will have to have corrective surgery for this condition? My eye Dr. says that most Ophthamologists will not operate until the eyes of the patient cannot be corrected with prescription glasses to 20/20 vision, which at this time, my vision can be corrected to that with new glasses. Is it true that most patients after having the surgery no longer have to wear glasses....except perhaps for reading? I have astigmatism and have had to wear glasses since I was around 9 or 10 years of age. Will this surgery help my astigmatism, too?
Thank you for any further info you can send to me and answers to my questions.
Judith Watson
Well Dear howard :the ultra sound technique is commonly known as Phaco emulsification and with an implantaion of posterior intra ocular lens implantation is the best avalable substitute for human crystalline lens.go for it but after due consultation by ur eye doc or you can ask me detail of the procedure.

Dear Judith: well ur eye doc is right.if ur vision is improving with specs then no need of surgery at the moment.yup it is true for most of the ppl with a healthy retina that they wont be needing glasses for far vision but they may have to wear glasses for near for a condition known as Presbyopia.cataract surgery with Phaco wont help much to correct your astigmatism.

my email is mas1469@gmail.com
need another surgery after cotaract operation please give remedial measures
Ivie Grace Pastelero
My father had cataract and he is about to undergo operation. unfortunately he was not operated due to the effect of the stoke.he cant speak well and i think he his brain was also affected.sometimes he dont know what he is doing. is there another remedy for cataract or some medicines to apply aside from the operation? can you suggest what kind of medicine it is and how long it will take for him to apply that medicine.?thank you so much.and i am looking forward for your answer.God bless. Ivie
the information in the article was quite good and informative
What are the types and names of tools they are using in ecce operation. And in phaco what equiptment they are used to operate
I have a scarred cornea from a herpes cold sore infection in my left eye. I also have myasthenia gravis and am presently on 40mg every other day of prednisone. I am legally blind in that eye. Are there any surgeries, procedures, drops etc...that can be given to improve the vision in my left eye. I understand that prednisone brings a risk of infection. I undergo monthy IVIGG infusions which has helped me to reduce my prednisone doses. Is there any hope?
I having some problem with my eye. Presently I am using 6 power lance I need do laser any problems then can I avoid my contact class also if i did after that any problem
Very useful site. I have cataracts which hopefully I will have removed in June 2010. I take Warfarin 5 mg daily for DVT and I am diabetic. Could this be against me having surgery.
hi. my mom has pseudoexfoliation of the ye and a very hard catarct at this point. she is 86 years old. she had glaucoma in both eyes but had operations and used medications etc so she no longer has to use medication and can see fine and has low pressure etc...excpet for this cataract on the one eye.it is floating and sometimes she can see nothing on the eye chart and sometimes she can see down to the fourth line or so. her eye doc suggests having the lens replacement so she can see the health of the eye since now she cannot see thru the cataract. also , of course, my mother's eye sight will improve and her depth perception should improve. i am concerned about the possible complications due to the pseudoexfoliation. can you tell me what the best thing for her to do is? can the lens fall back into the eye and how difficult is that to deal with? what are other possible complications due to the exfolation if any? thans so much ..my email is arouesty@aol.com robin
My Optician says that my cataracts are not bad enough to have the operation on the NHS. I have bought some new distance glasses but they don't make any difference at all, I cannot see any better. I have astigmatism and some scarring of the eyes due to previous eye surgery many years ago. I am trying to find out the cost of cataract removal of both eyes, possible correction for astigmatism andf scarring. I think I shall probably need toic lens fitted. I cannot afford to just pay for a consultation and then have to go elsewhere for the operations because of cost. I would prefer to have ops in this Country but may have to look abroad because of cost. How can I find out where abroad is good and cheap for what I need.

I am supposed to have cataract surgery. At my pre -op exam it was discovered that I have a clotting issue. It was determined that I have Factor X! deficiency. Is it necessary to have a plasma transfusion before having the surgery? My level indicates a severe deficiency. However, my history does not indicate any abnormal bleeding.
Mary Higinbotham
I am a 54yr old female who has mild athritis and pulmonary fibrosis (mild). I have elevated eye pressure and am taking Lantanoprost 0.005% 1 drop in each eye nightly. I got a new eye prescription in April and my eyes changed again a new prescription in August also. Now in October my eyes changed again and my right eye (the one with a cataract) is very different from the left eye. Would you say I have a fast growing cataract? Will my elevated eye pressure be a problem for my surgery? I also take QVAR for my lungs and Plaquenil 200mg 1 pill daily for my arthritis. Thanks for your information.
Myriam Villaverde
I had cataract surgery in both eyes two months ago. Two days ago, I started seeing like a spyder going back and front in my right eye,I went too the emergency Dr.. ysterday, because mu Dr. was in surgery,I was told that it was some gel from my eye after surgery. But that my wasnt ruptured. i most see my Dr. in a month. But the spyder is bothering more than the caatarct on my vision while drivingI also saw some white lights flashing but thanks God they are gone.
What is the name of the "viscous fluid" that is placed into the lens capsule while preparing the IOL to implant? If it is suctioned out after the IOL is placed in the capsule, what would happen if it was not removed, but left in place without the placement of the IOL? Are there any research studies in progress now to try to determine alternatives for IOL placement & where are they being conducted?
I have have had two sugeries to my right eye in the last 3months fistly to remove a Posterior subcapsular cataract and secondly to reposition the new lens which had moved. Whilst i am delighted with my general vision I cannot see to read anything except very large print even with new glasses. Is this like to improve with more time? I am dependant upon my left eye for reading and computer work but I have a cateract developing which is likey to require surgery in the nect 6 months, I wonder therefore if I am likely to experience similar results following the sugery?
My grand mother had a Phaco surgery, but she had black cataract and the surgeon said he had to revert to ECCE because the cataract didn't break/dissolve. The surgery was fine under sedation as my grand mother was very uncooperative.
Now, 1 month after, she still complains of headaches and profuse tearing and pains in the eye. The IOL implant wasn't done because the surgeon said it didn't sit, but kept sinking as the zonules were not holding it, even though her iris was responding normally.
She also has been diagnosed with optic neuro-pathy.
What is the matter, why is she still experiencing all these discomforts? And should I be worried about the constant tearing that makes her look like she's crying??
ghirmay embaye
I have done ECCE before one month still I am suffering from floating subtances and some times cotton like coming to my vision specially when I see down word and seeing up what is the cause?

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