Note from the National Guideline Clearinghouse (NGC) and the Philippine Academy of Ophthalmology (PAO): To ensure the validity of their guidelines, the PAO Evidence-Based Ophthalmology (EBO) group has initiated the review of the cataract clinical practice guideline released in 2001. However, since the process of updating the entire set of guidelines can be very costly and time consuming, the group shall tackle this task by evaluating the document in sections, prioritizing recommendations that are deemed outdated in reference to changes in the evidence, available resources, and values placed on outcomes. In this update, they have prioritized the review of Recommendation #14 for the Management of Cataract among Adults that states that both phacoemulsification and extra capsular cataract extraction (ECCE) are acceptable techniques among patients undergoing cataract surgery. The EBO concluded that the recommendation should be retained, and relevant new information for clinicians has been included in the original guideline document.
The recommendation grades (A-E) are defined at the end of the "Major Recommendations" field.
Definition
Recommendation 1
In medical practice, cataract is defined as any opacity of the lens that may or may not be associated with visual problems and manifest as an obstruction of the red orange reflex on funduscopy. (Grade C Recommendation)
Recommendation 2
In medical practice the objective of management of cataract is (a) correction of visual impairment, (b) maintenance of quality of life, and (c) prevention of progression. (Grade C Recommendation)
Classification
Recommendation 3
In family practice cataract should be classified according to types based on visual impairment using the Snellen's far and near visual testing. The classification types are the following (Grade C Recommendation):
- Type I - is characterized by patients with visual acuity better than 20/40 in the affected eye/eyes
- Type II - is characterized by patients having visual acuity of 20/40 or worse in the affected eye/eyes
Physical Examination
Recommendation 4
In family practice, funduscopy (Grade C Recommendation), visual acuity testing and pinhole (Grade B Recommendation) should be done for all patients suspected to have cataracts.
Recommendation 5
For patients suspected of having cataracts, slit lamp examination, dilated funduscopy and tonometry should routinely be done in ophthalmologic practice. (Grade C Recommendation)
Diagnostic Procedures
Recommendation 6
For patients with suspected cataract whose visual acuity is 20/40 or better but referred to ophthalmology for further evaluation contrast glare sensitivity may be done to detect potential problems in nighttime vision. (Grade C Recommendation)
Differential Diagnosis
Recommendation 7
Among patients suspected of having cataracts, the following causes of visual impairment should be ruled out: (a) error of refraction, (b) corneal opacities, (c) glaucoma, (d) retinopathy, and (e) age-related macular degeneration. (Grade B Recommendation)
Prognostic Factors
Recommendation 8
Among patients with cataracts, the following socio-demographic characteristics need to be elicited because it leads to poorer outcomes: (a) age, (b) sex, (c) social strata, (d) education, and (e) race. (Grade B Recommendation)
Recommendation 9
The following clinical entities such as: (a) diabetes, (b) hematologic disorders, (c) rheumatoid disorders, (d) alcohol abuse, (e) ocular trauma and concomitant ocular symptoms, (f) myopia/high error of refraction (EOR), and (g) steroid use should also be elicited because they also lead to poor outcomes. (Grade B Recommendation)
Surgical Approach to Management
Recommendation 10
Among patients with cataracts, any one of the following may be an indication for surgery: (a) patient's preference and needs, (b) functional disability as measured by Snellen's visual acuity test and modified visual field-14 (VF-14), (c) cataracts with concomitant ocular problems. (Grade C Recommendation)
Recommendation 11
Prior to cataract surgery, the patient must be informed about the benefits, possible side effects and complications, and costs of available alternative surgical and anesthesia procedures. (Grade C Recommendation)
Recommendation 12
Pre-operatively, keratometry, biometry, lacrimal apparatus irrigation (LAI) should routinely be done.
Recommendation 13
Among healthy adult patients scheduled for cataract surgery under local anesthesia, no routine preoperative medical testing is necessary. (Grade A Recommendation)
For patients who are symptomatic and are at high risk of developing cardiopulmonary complications, pre-operative work-up may be done. (Grade C Recommendation)
Recommendation 14 (2005 Update)
Among patients undergoing cataract surgery, small incision surgery (either by phacoemulsification or manual phacofragmentation) and extracapsular cataract extraction (ECCE) are acceptable techniques. (Grade A Recommendation)
Recommendation 15
Among patients who will undergo cataract extraction, implantation of an intraocular lens is recommended. (Grade A Recommendation)
Recommendation 16
While local anesthesia is recommended in majority of patients undergoing cataract surgery, general anesthesia may be used when indicated. (Grade A Recommendation)
Recommendation 17
Among patients who will undergo cataract extraction, surgery on an out-patient basis is recommended. (Grade B Recommendation)
Recommendation 18
Indications for second eye surgery in those with bilateral cataracts are the same as for the first eye. Timing of second eye surgery is best discussed by the surgeon and the patient; however, simultaneous cataract extraction is not recommended. (Grade C Recommendation)
Recommendation 19
Post-operatively, topical antibiotics, steroids, or nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended. (Grade A Recommendation)
Recommendation 20
Post-surgery, close follow-up with refractive evaluation of the patient is recommended until best corrected vision achieved. (Grade C Recommendation)
Non-Surgical Options
Recommendation 21
Non-surgical management is recommended in the following conditions; (1) patient's refusal of surgery, (2) no visual disability, (3) best correction results in satisfactory visual function, and (4) surgery is unlikely to improve visual function. (Grade C Recommendation)
Recommendation 22
Refraction that affords the best visual function together with patient education is the only non-surgical option for cataract patients. (Grade C Recommendation)
Health Education
Recommendation 23
Patient education should include the following; (1) advice on modifiable risk factors, (2) advice on eventual need for surgery for non-surgical patients, (3) advice on all available surgical procedures and outcomes, and (4) advice that to date no medications have been proven to retard the progression of age-related cataracts. (Grade C Recommendation)
Referral
Recommendation 24
Patients with Type II cataracts and those with Type I suspected of having other ocular blinding conditions should be referred to an ophthalmologist. (Grade C Recommendation)
Definitions:
Grades of Recommendations
- Good evidence (at least 1 properly conducted randomized controlled trial) to support the recommendation that the alternative be specifically considered
- Fair evidence (evidence from well designed controlled trials without randomization, from well designed cohort or case control studies, comparisons between times and places) the recommendation that the alternative be specifically considered.
- Poor evidence (descriptive studies, experts' opinion) regarding inclusion or exclusion of the alternative, but recommendations may be made on other grounds.
- Fair evidence (at least 1 properly conducted randomized controlled trial) to support the recommendation that the alternative be specifically excluded from consideration.
- Good evidence (evidence from well designed controlled trials without randomization, from well designed cohort or case control studies, comparisons between times and places) the recommendation that the alternative be specifically excluded from consideration.