Every patient with cataract should be informed of the presence of the
condition. The optometrist should discuss with the patient the natural course of
the cataract and the treatment options, as well as the importance of routine
examinations. Cataract patients whose vision loss is correctable with spectacles
should be informed that the lens opacities might progress and require other
spectacle lens changes or surgery. Patients who cannot otherwise achieve
adequate vision for their activities of daily living should be informed that
only surgery can help rehabilitate their vision (i.e., that further spectacle
changes would be of limited value). A candidate for cataract surgery must be
informed of all of the risks and benefits of surgery. The patient should be
provided complete information on the pros and cons of the various surgical
techniques, the skills of the surgeons in the area, and the expected outcome and
schedule for postoperative care. The patient who has had cataract surgery should
receive proper and timely postoperative care and proper monitoring of both
overall ocular health and vision status.
- Diagnosis of Cataract
Many patients with undiagnosed cataract first
present for examination when they experience symptoms of reduced vision that
affects their daily activities. Such patients should undergo a comprehensive
eye and vision examination with particular attention given to inspection of
the lens of the eye. The essential elements of this evaluation include:
- Patient History
- Ocular Examination
Elements of the ocular examination may include, but are not limited to, the
following:
- Measurement of visual acuity under both low and high illumination
- Biomicroscopy with pupillary dilation, with special attention to the
three clinical zones of the lens and the classification and
quantification of the cataract
- Stereoscopic fundus examination with pupillary dilation
- Assessment of ocular motility and binocularity
- Visual fields screening by confrontation, and if a defect is noted,
further investigation by formal perimetry
- Evaluation of pupillary responses to rule out afferent pupillary
defects
- Refraction to rule out refractive shift as a cause for the decreased
vision
- Measurement of intraocular pressure (IOP).
- Supplemental Testing
- Management of Cataract
Care of the patient with cataract may require referral for consultation with
or treatment by another optometrist or an ophthalmologist experienced in the
treatment of cataract, for services outside the optometrist's scope of practice.
The optometrist may participate in the co-management of the patient, including
both preoperative and postoperative care. The extent to which an optometrist can
provide postoperative treatment for patients who have undergone cataract surgery
may vary, depending on the state's scope of practice laws and regulations and
the individual optometrist's certification.
- Basis for Treatment
The treatment decision for the patient with cataract depends on the
extent of his or her visual disability.
- Available Treatment Options
- Nonsurgical Treatment
- Indications for Surgery
Surgery is indicated when cataract formation has reduced visual acuity to the
level that it interferes with the patient's lifestyle and everyday activities,
and when satisfactory functional vision cannot be obtained with spectacles,
contact lenses, or other optical aids. The vision needs of the patient, as they
relate to his or her lifestyle, occupation, and hobbies, should be
considered.
Patient Education
Surgical candidates should be informed of the risks
involved with cataract surgery.
Patients should be advised of the advantages and disadvantages of the available cataract extraction techniques and intraocular lenses and the postoperative care available to them. The qualifications of the surgeon(s) and the setting for delivery of care should be discussed. Patient
counseling may include a discussion of the following aspects of the
surgery:
- Anesthesia
- Location and type of incision
- Intraocular lens options
- Medications
- Disposition
- Continuing postoperative care
Follow-up
The frequency and composition of evaluation and management visits for an uncomplicated clinical course following cataract surgery are summarized in the table, below. Refer to the guideline document for discussion of postoperative care of surgical complications.
Frequency and Composition of
Evaluation and Management Visits for an Uncomplicated Clinical Course Following
Cataract Surgery
|
| Postoperative Visits |
History |
Visual Acuity Unaided and With Pinhole1 |
External and Slip Lamp Exam |
Refraction |
Tonometry |
Dilated Fundus Exam4 |
Management Plan |
|
#1
One day |
Yes |
Yes |
Yes |
|
Yes |
If indicated by symptoms of very poor vision or retinal
disease |
Administer topical antibiotic/steroid; counsel patient |
#2
7 to 14 days
Usually 1 week |
Yes |
Yes |
Yes |
|
Yes |
If indicated by signs or symptoms of retinal disease |
Continue and/or taper medications; counsel patient |
#3
3 to 4 weeks |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes5 |
Continue and/or taper medications; counsel patient; prescribe
refractive correction |
#42
6 to 8 weeks |
Yes |
Yes |
Yes3 |
Yes |
Yes |
Yes5 |
Discontinue medications if exam is normal; counsel patient;
prescribe/ modify refractive correction |
#5
Subsequent visits
3 to 6 months |
Yes |
Aided visual acuity with pinhole |
|
If vision is reduced |
Yes |
If indicated based on findings and symptoms5 |
Reschedule for yearly evaluation or as needed |
|
1 Pinhole VA: assess if visual acuity worse than
20/30 unaided.
2 Optional visit: some clinicians elect to
schedule three postoperative visits, others four prior to determining a final
spectacle prescription.
3 Consider need to cut sutures if high astigmatism
is present.
4 Dilated fundus exam: provided at least once during the postoperative period.
5Check clarity of posterior capsule.
