Ratings of importance to the care process (A-C) and ratings of strength of evidence (I-III) are defined at the end of the "Major Recommendations" field.
Diagnosis
Preoperative visual acuity is a poor predictor of postoperative functional improvement; therefore, the decision to recommend cataract surgery should not be made on the basis of visual acuity alone (Schein et al., 1994; Schein et al., 1995) [A:II].
The patient should be asked specifically about near and distant vision under varied lighting conditions for activities that the patient views as important [A:III].
Ophthalmic Evaluation
The comprehensive evaluation (history and physical examination) includes those components of the comprehensive adult medical eye evaluation (Preferred Practice Patterns Committee, 2005) specifically relevant to the diagnosis and treatment of a cataract as listed below:
- Patient history [A:III], including the patient's assessment of functional status, pertinent medical conditions, medications currently used, and other risk factors that can affect the surgical plan or outcome of surgery (e.g., immunosuppressive conditions, sympathetic alpha-1a antagonists).
- Visual acuity with current correction (the power of the present correction recorded) at distance and when appropriate at near. [A:III]
- Measurement of best-corrected visual acuity (with refraction when indicated). [A:III]
- External examination (lids, lashes, lacrimal apparatus, orbit). [A:III]
- Examination of ocular alignment and motility. [A:III]
- Assessment of pupillary function. [A:III]
- Measurement of intraocular pressure (IOP). [A:III]
- Slit-lamp biomicroscopy of the anterior segment. [A:III]
- Dilated examination of the lens, macula, peripheral retina, optic nerve, and vitreous. [A:III]
- Assessment of relevant aspects of the patient's mental and physical status. [B:III]
Management
Nonsurgical Management
At the present time, the highest quality evidence does not support a benefit from nutritional supplementation in preventing or delaying progression of cataracts; therefore, treatment with supplements is not recommended. (Huang et al., 2006) [A:I]
Patients who are currently smoking should be informed of the increased risk of cataract progression and the benefits of smoking cessation in retarding the progression of cataracts that have been demonstrated in several studies. (West et al., 1989; Christen et al., 1992; Christen et al., 2000) [A:II] Studies have found that smokers report that a physician's advice to quit is an important motivator in attempting to stop smoking. (National Cancer Institute [NCI], 1994; Ockene, 1987; Pederson, Baskerville & Wanklin, 1982; Ranney et al., 2006). Patients who are long-term users of oral or inhaled corticosteroids should be informed of the increased risk of cataract formation (Garbe, Suissa & Lelorier, 1998; Jick, Vasilakis-Scaramozza & Maier 2001; Klein et al., 2001; Smeeth et al., 2003; Urban & Cotlier, 1986) [A:II] and may wish to discuss alternate medications with their primary care physician. Patients with diabetes mellitus should be informed of their increased risk of cataract formation. (Hennis et al., 2004; Klein, Klein & Lee, 1998; Leske et al., 1999) [A:II]. Brimmed hats and ultraviolet-B blocking sunglasses are reasonable precautions to recommend to patients. (McCarty, Nanjan & Taylor, 2000).
Surgical Management
Indications for Surgery
- The primary indication for surgery is visual function that no longer meets the patient's needs and for which cataract surgery provides a reasonable likelihood of improved vision. [A:III]
- Other indications for a cataract removal include the following:
- Clinically significant anisometropia in the presence of a cataract. [A:III]
- The lens opacity interferes with optimal diagnosis or management of posterior segment conditions. [A:III]
- The lens causes inflammation (phacolysis, phacoanaphylaxis). [A:III]
- The lens induces angle closure (phacomorphic or phacotopic). [A:III]
The ophthalmologist who is to perform the cataract surgery has the following responsibilities:
- To examine the patient preoperatively (see "Ophthalmic Evaluation" above). [A:III]
- To ensure that the evaluation accurately documents the symptoms, findings, and indications for treatment. [A:III]
- To obtain informed consent from the patient or the patient's surrogate decision maker after discussing the risks, benefits, and expected outcomes of surgery, including anticipated refractive outcome and the surgical experience. [A:III]
- To review the results of presurgical and diagnostic evaluations with the patient or the patient's surrogate decision maker. [A:III]
- To formulate a surgical plan, including selection of an appropriate intraocular lens (IOL). [A:III]
- To formulate postoperative care plans and inform the patient or the patient's surrogate decision maker of these arrangements (setting of care, individuals who will provide care). [A:III]
- To afford the patient or the patient's surrogate decision maker the opportunity to discuss the costs associated with surgery. [B:III]
All patients undergoing cataract surgery should have a history and physical examination relevant to the risk factors for undergoing the planned anesthesia and sedation and as directed by a review of systems. [A:III] For patients with certain severe systemic diseases (e.g., chronic obstructive pulmonary disease, recent myocardial infarction, unstable angina, poorly controlled diabetes, or poorly controlled blood pressure) a preoperative medical evaluation by the patient's physician should be strongly considered. (Lee et al., 1999). [A:II] Laboratory testing as indicated by the findings in the history and physical examination is appropriate. (Schein, et al., 2000) [A:I].
Given the lack of evidence for an optimal anesthesia strategy during cataract surgery, the type of anesthesia management should be determined by the patient's needs and the preferences of the patient and surgeon. (Agency for Healthcare Research and Quality [AHRQ], 2000) [A:II].
Use of a 5% solution of povidone iodine in the conjunctival cul de sac is recommended to prevent infection. (Speaker & Menikoff, 1991; Wu et al., 2006) [A:II].
Further management recommendations can be found in the main body of the original guideline document.
Postoperative Follow-up
The frequency of postoperative examinations is based on the goal of optimizing the outcome of surgery and swiftly recognizing and managing complications. The table below provides guidelines for follow-up based on consensus in the absence of evidence for optimal follow-up schedules.
Table. Postoperative Follow-up Schedule [A:III]
| Patient Characteristics |
First Visit |
Subsequent Visits |
| Without high risks or signs or symptoms of possible complications following small-incision cataract surgery |
Within 48 hours of surgery |
Frequency and timing dependent upon refraction, visual function, and medical condition of the eye |
| High risk; functionally monocular; glaucoma or glaucoma suspect patients; intraoperative complications |
Within 24 hours of surgery |
More frequent follow-up usually necessary |
Patients should be instructed to contact the ophthalmologist promptly if they experience symptoms such as a significant reduction in vision, increasing pain, progressive redness, or periocular swelling, because these symptoms may indicate the onset of endophthalmitis [A:III].
In the absence of complications, the frequency and timing of subsequent postoperative visits depend largely on the size or configuration of the incision; the need to cut or remove sutures; and when refraction, visual function, and the medical condition of the eye are stabilized. More frequent postoperative visits are generally indicated if unusual findings, symptoms, or complications occur, and the patient should have ready access to the ophthalmologist's office to ask questions or seek care [A:III].
Components of each postoperative examination should include: [A:III]
- Interval history, including use of postoperative medications, new symptoms, and self-assessment of vision
- Measurement of visual function (e.g., visual acuity, pinhole testing)
- Measurement of intraocular pressure (IOP)
- Slit-lamp biomicroscopy
- Counseling/education for the patient or patient's caretaker
- Management plan
A final refractive visit should be made to provide an accurate prescription for spectacles to allow for the patient's optimal visual function [A:III].
Provider and Setting
It is the unique role of the ophthalmologist who performs cataract surgery to confirm the presence of the cataract and to formulate and carry out a treatment plan [A:III]. The surgical facility should comply with standards governing the particular setting of care (e.g., the Accreditation Association for Ambulatory Health Care, Inc., Joint Commission for Accreditation of Healthcare Organizations, American Hospital Association) [A:III].
Counseling/Referral
Patients with functionally limiting postoperative visual impairment should be referred for vision rehabilitation (American Academy of Ophthalmology [AAO], 2001) and social services [A:III].
Definitions:
Ratings of Importance to Care Process
Level A, defined as most important
Level B, defined as moderately important
Level C, defined as relevant, but not critical
Ratings of Strength of Evidence
- Level I includes evidence obtained from at least one properly conducted, well-designed randomized controlled trial. It could include meta-analysis of randomized controlled trials.
- Level II includes evidence obtained from the following:
- Well-designed controlled trials without randomization
- Well-designed cohort or case-control analytic studies, preferably from more than one center
- Multiple-time series with or without the intervention
- Level III includes evidence obtained from one of the following:
- Descriptive studies
- Case reports
- Reports of expert committees/organization (e.g., Preferred Practice Pattern panel consensus with peer review)
