Does laser eye surgery cause cataracts?
There is no good evidence that LASIK, PRK or SMILE causes cataracts. The laser reshapes the cornea, the clear window at the front of the eye, while a cataract forms in the natural lens that sits behind the iris and is not treated. People who have had LASIK do tend to have cataract surgery earlier than average; this has been studied specifically for LASIK, and the same reasoning is likely to apply to PRK. The most likely reasons are the short-sightedness that led them to laser surgery in the first place, and a tendency to notice and act on small changes in vision sooner. Implant lenses placed close to the natural lens to correct short sight, such as the implantable collamer lens (ICL), are different: because they sit right in front of it, they can cause a cataract.
Where does laser eye surgery act, and where does a cataract form?
The eye has two focusing parts. The cornea at the front does most of the focusing, and the natural lens behind the coloured iris fine-tunes it. Laser vision correction works on the cornea. LASIK reshapes tissue under a thin corneal flap, PRK reshapes the surface, and SMILE removes a small disc of tissue from within the cornea. None of these operations opens the eye or touches the lens.
A cataract is a clouding of that natural lens. It is not a film on the surface of the eye, and it is not caused by the cornea "wearing out". This is why laser eye surgery neither causes nor prevents an age-related cataract: the two happen in different parts of the eye, separated by a space filled with clear fluid. The cataracts guide explains the symptoms and how a cataract is diagnosed.
How does the natural lens age?
The lens is unusual among the body's tissues. It keeps adding new layers of cells throughout life, a little like the rings of a tree, so the oldest cells are packed into the centre (the nucleus) and newer ones form the outer layer (the cortex). The whole lens sits inside a thin, clear bag called the capsule.
The proteins that keep the lens clear, called crystallins, are made early in life and are never replaced. For decades they stay tightly and evenly arranged, which lets light pass straight through. Over time they accumulate small chemical changes. They oxidise, bind to one another, clump together and slowly turn yellow. Research suggests that from middle age a natural barrier forms inside the lens that slows the movement of its main protective antioxidant, glutathione, from the outer layers into the centre. With less protection, oxidation in the centre can build up. Once enough proteins have clumped, light is scattered instead of focused, and the lens becomes cloudy.
This is a normal part of ageing rather than a sign that something has gone wrong. From around 40, most lenses start to show some of these changes, but they usually take many years to affect vision.
What kinds of cataract form, and how do they affect vision?
Where the clouding starts depends on which part of the lens is affected, and each pattern has a slightly different feel. The types of cataracts guide illustrates many more patterns; three are relevant here.
A nuclear cataract affects the old central cells. It usually develops slowly, making vision gradually blurred and colours duller or more yellow. It can also make the eye more short-sighted, which matters for people who have had laser surgery, as the section below on the laser "wearing off" explains.
A cortical cataract starts as spoke-like wedges in the outer layer, working inwards from the edge. The spokes scatter light, so glare from headlights and bright sunlight is common.
A posterior subcapsular cataract forms as a small hazy plaque on the back surface of the lens, right in the line of sight. Cells that should stay at the edge of the lens migrate to the back and form an irregular layer. Because it sits so centrally, even a small one can cause marked glare, difficulty reading in bright light and haloes around lights at night, and it can progress over months rather than years. It is the type linked with steroid medicines, diabetes and short-sightedness.
| Type | Where it starts | Often linked with | Typical effect on vision |
|---|---|---|---|
| Nuclear | The centre of the lens | Age, short-sightedness, smoking | Slow blur, dull or yellowed colours, more short-sighted |
| Cortical | Spokes in the outer layer | Age, sunlight, diabetes | Glare from headlights and sun |
| Posterior subcapsular | The back surface, centrally | Steroid medicines, diabetes, short-sightedness | Glare, trouble reading in bright light, haloes |
Why do people who had laser eye surgery need cataract surgery earlier?
This is the pattern many people notice, and it is real. In three studies from the United States, Japan and Mexico, people who had previously had LASIK had cataract surgery about 7 to 10 years earlier than groups matched for eye length and cataract severity. One of the studies also compared its LASIK patients with a much larger, unmatched group of everyone having cataract surgery at the same centre and found a gap of about 15 years; because that group was not matched, it is a weaker comparison and likely overstates the true difference. In the Mexican study, the average age at cataract surgery was 60 after LASIK and 67 without it.
These studies measured when people had cataract surgery, not when their cataract began, and they were small and looked back through records. They cannot show that the laser caused anything. Several explanations are likely to contribute.
- Short-sightedness itself. Most laser eye surgery has been done to correct short sight, and short-sighted eyes are more likely to develop the types of cataract that bring people to surgery. The next section explains the evidence.
- Noticing sooner. People who chose laser surgery usually valued clear vision without glasses. A small cataract that blurs the view, or brings back a need for glasses, may prompt an earlier visit and an earlier decision to operate.
- A less forgiving optical system. The Japanese study found more subtle optical irregularities in corneas treated by laser. Together with an early cataract, these can reduce the crispness of vision more than either would alone.
All three studies compared people with eyes of similar length and still found earlier surgery after LASIK, so short-sightedness is probably not the whole explanation. Which of these reasons matters most is not known.
Why does being short-sighted raise the risk of cataract?
Short-sighted eyes are usually longer than average, and there is good evidence that they develop certain cataracts earlier. The Blue Mountains Eye Study, which followed thousands of people over 49 living west of Sydney, found that high short-sightedness roughly tripled the odds of developing a new nuclear cataract over five years. Moderate to high short-sightedness was linked with about four times the odds of a new posterior subcapsular cataract, and short-sighted people had about twice the odds of having cataract surgery. The same pattern continued at ten years.
An international review of population studies confirmed the link with nuclear and posterior subcapsular cataract, although not every long-term study reached statistical significance. A more recent genetic study also points towards short-sightedness itself raising the risk, rather than the link being coincidence. Why this happens is not fully understood. The practical point is that someone who needed laser surgery for strong short sight carried that risk before the laser and still carries it afterwards. The cataract surgery with myopia article explains how long, short-sighted eyes are assessed when cataract surgery is needed.
Has my laser eye surgery worn off, or is it a cataract?
It is often the cataract. As the centre of the lens hardens and becomes denser, it bends light more strongly, and the eye drifts towards short-sightedness. Population research has measured this shift in people developing nuclear cataract. After laser surgery this can feel like the original prescription creeping back, when the cornea itself has not changed much at all.
Other changes can also blur vision years after laser surgery, including dry eye and some genuine change in the cornea. An examination can tell these apart. If a cataract is the cause, a stronger pair of glasses may help for a while, but the underlying blur and glare continue to progress.
Is there any evidence the laser affects the lens?
Very little, and none of it shows that the laser causes cataracts in people. In the 1990s, some laboratory studies in rabbits found chemical signs of oxidation in the lens after a high dose of PRK laser, while another rabbit study found no such change after treatment. A single published case described a young short-sighted man who developed a cataract after repeated LASIK treatments; its authors noted that the idea of laser surgery speeding up cataract had not been proven. We found no study showing that SMILE or modern femtosecond LASIK affects the clarity of the lens.
Absence of evidence does not prove there is no effect at all, but after decades of laser eye surgery worldwide, the laser is not a recognised cause of cataract.
Could the eye drops after laser surgery cause a cataract?
Steroid anti-inflammatory drops are routinely used after laser eye surgery. Steroid medicines are a recognised cause of posterior subcapsular cataract, and the risk rises with the dose and the length of treatment, particularly over many months. Steroid tablets, long-term drops, and injections or implants in the eye all count.
After LASIK and SMILE the course is usually short. After PRK it can last longer, sometimes a few months, to control healing and haze; a review of the evidence suggests long courses are unnecessary for most people with low to moderate short sight. We found no study showing that the usual course after laser surgery causes cataract. If you needed steroid drops for many months, or have used steroids for another condition, mention it to your eye doctor. Do not stop prescribed steroids without advice.
What else speeds up cataract formation?
Age remains by far the biggest factor. Others include diabetes, smoking, many years of sun exposure, steroid medicines, a previous eye injury or eye operation, heavy alcohol use and a family history of cataract. The what causes cataracts guide explains each of these in detail.
Wearing sunglasses that meet the Australian standard, with a broad-brimmed hat outdoors, and not smoking are sensible ways to protect your eyes. No eye drop or supplement has been shown to prevent or dissolve a cataract.
Do implant lenses for short-sightedness cause cataract?
They can. A phakic implant, such as the implantable collamer lens (ICL), corrects short sight by placing a thin lens inside the eye, just behind the iris and in front of the natural lens, which is left in place. Because it sits so close, the natural lens can develop an anterior subcapsular cataract, a hazy patch on its front surface. This is most likely when there is too little clearance between the implant and the natural lens.
The risk has fallen as designs have improved. In the United States trial of earlier models, lens opacities fell from about 13 in 100 eyes with one design to about 3 in 100 with its successor. A ten-year Japanese series of a design without that opening found about 1 in 10 eyes developed an anterior subcapsular cataract, and about 1 in 30 needed surgery for it. Newer designs with a tiny central opening, which allow fluid to flow freely around the natural lens, have reported much lower rates, although with shorter follow-up. Very high short-sightedness, a shallow space at the front of the eye and being older when the implant is inserted increase the risk.
When a cataract does develop, the implant can be removed and the cataract operation performed at the same time, and in one long-term series vision returned to the level it had been before the cataract. The video below shows this combined operation.
Phakic lens removal and cataract surgery by Dr Simon Chen
This short video shows real eye surgery.
Watch on YouTube →Can I get a cataract after lens replacement surgery?
No. Refractive lens exchange removes the natural lens and replaces it with an artificial one, the same operation as cataract surgery performed before a cataract has formed. With the natural lens gone, a cataract cannot develop in it later.
What can happen, sometimes months or years later, is clouding of the thin capsule behind the new lens, called posterior capsule opacification. It is often described as a "secondary cataract", but it is not the lens clouding again. It is usually cleared with a quick YAG laser treatment, described in the cataract surgery guide. The recovery after refractive lens exchange article covers what the first weeks involve.
What does this mean if I need cataract surgery after laser eye surgery?
Cataract surgery after LASIK, PRK or SMILE is common and is carried out in the usual way. The main difference is in planning. Because the laser changed the shape of the cornea, standard calculations of the replacement lens power are less reliable, and your surgeon will use methods designed for eyes that have had laser treatment. Even so, glasses may still be needed for some tasks afterwards.
Records from your original laser surgery help, especially your glasses prescription before treatment and the treatment details. If you can obtain them from your laser clinic, keep a copy with your health records. The article on cataract surgery after LASIK, PRK or SMILE explains the planning, which records are worth finding and which lens options remain available.
Other questions about laser eye surgery and cataracts
Is SMILE different from LASIK or PRK for cataract risk?
There is no evidence that any of the three affects cataract risk differently. All three act on the cornea only. Planning a later cataract operation needs to take each of them into account.
Can I still have laser eye surgery if my lens is starting to age?
It depends on how far the lens has changed and on your age. If a cataract is already affecting vision, correcting the cornea will not clear the blur, and the prescription may keep changing as the cataract progresses. In that situation lens-based surgery is often discussed instead. The refractive lens exchange page explains who it may suit.
Will cataract surgery undo my laser eye surgery?
No. Cataract surgery replaces the lens and does not remove the corneal reshaping. The new lens power is chosen with the reshaped cornea in mind.
Can I slow a cataract down after laser eye surgery?
The same measures apply as for anyone: protect your eyes from the sun, do not smoke, and keep diabetes well managed. These may help to slow cataract development, but none reverses it, and no drop or tablet has been shown to prevent it.
I had laser surgery for long-sightedness. Does any of this apply?
The main points do. The laser acts only on the cornea, and cataracts form in the lens for the same reasons. Long-sighted eyes are not affected by the short-sightedness link described above, although long-term data suggest long-sightedness may also be associated with nuclear cataract. Lens power planning after laser for long-sightedness also needs special calculations.
Where can I read more?
When do changes in vision need urgent attention?
A cataract develops gradually and is not an emergency. Contact your ophthalmologist urgently, or attend an emergency department, if you have a sudden loss or change in vision, a sudden shower of new floaters, new flashes of light, or a shadow or curtain across part of your vision. These can be signs of a retinal tear or detachment, which can be painless, and short-sighted eyes are at higher risk. A painful, red eye with reduced vision, particularly soon after any eye operation, also needs same-day assessment. The guide to flashes, floaters or a curtain explains why these symptoms need prompt review.
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