• Philippine Academy of Ophthalmology. Clinical practice guideline for the management of cataract among adults. Philippines: Philippine Academy of Ophthalmology; 2001. 27 p. [73 references]



• Philippine Academy of Ophthalmology. Clinical practice guidelines for the management of cataract among adults. Updated recommendation #14. Philipp J Ophthalmol 2005 Apr-Jun;30(2):95-6. [9 references]

This is the current release of the guideline.

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the group shall tackle this task by evaluating the document in sections, prioritizing recommendations that are deemed outdated in reference to changes in the evidence, available resources, and values placed on outcomes.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

1. Good evidence (at least 1 properly conducted randomized controlled trial) to support the recommendation that the alternative be specifically considered
2. 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.
3. Poor evidence (descriptive studies, experts' opinion) regarding inclusion or exclusion of the alternative, but recommendations may be made on other grounds.
4. Fair evidence (at least 1 properly conducted randomized controlled trial) to support the recommendation that the alternative be specifically excluded from consideration.
5. 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.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

• Philippine Academy of Ophthalmology. Clinical practice guideline for the management of cataract among adults. Philippines: Philippine Academy of Ophthalmology; 2001. 27 p. [73 references]



• Philippine Academy of Ophthalmology. Clinical practice guidelines for the management of cataract among adults. Updated recommendation #14. Philipp J Ophthalmol 2005 Apr-Jun;30(2):95-6. [9 references]

Not applicable: The guideline was not adapted from another source.

2001 (addendum released 2005)

Family Medicine Research Group, UP-PGH - Academic Institution
Philippine Academy of Ophthalmology - Medical Specialty Society

The development of this clinical practice guideline was a joint project of the Philippine Academy of Ophthalmology, and the Family Medicine Research Group of UP-PGH, Manila.

The Philippine Health Insurance Corporation and the Christoffel-Blindenmission provided financial assistance. However, the Philippine Health Insurance Corporation and the Christoffel-Blindenmission did not exert any influence in the formulation of this guideline.

Ad Hoc Committee on Clinical Practice Guidelines 2001, chaired by Jacqueline Hernandez-King, MD

Ophthalmologists: Romulo N. Aguilar, MD; Manuel B. Agulto, MD; Benjamin Gerardo G. Cabrera, MD; Noel G. Chua, MD; Jacinto U. Dy-Liacco, MD; Teodoro K. Gonzales, MD; Rustan A. Hautea, MD; Jacqueline Hernandez-King, MD; Shelley Ann M. Mangahas, MD; Carlos G. Naval, MD; Cosme I.N. Naval, MD; Reynaldo E. Santos, MD; Antonio S. Say, MD; Kim Te-Milana, MD

Family Physicians: Gemma Arellano, MD; Maria Elinore M. Alba, MD; Leilani S. Apostol-Nicodemus, MD; Noel L. Espallardo, MD; Shiela Marie S. Lavina, MD; Andrelita Bonielyn C. Lelina, MD; Zorayda O. Leopando, MD

The authors declare that they have no competing financial interests.

This is the current release of the guideline.

This summary was completed by ECRI on February 26, 2002. The information was verified by the guideline developer as of April 11, 2002. This summary was updated on May 3, 2005 following the withdrawal of Bextra (valdecoxib) from the market and the release of heightened warnings for Celebrex (celecoxib) and other nonselective nonsteroidal anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI on June 16, 2005, following the U.S. Food and Drug Administration advisory on COX-2 selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs). This NGC summary was updated to include the addendum on October 24, 2005. The updated information was verified by the guideline developer on November 28, 2005.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording, or otherwise without prior written permission from the developers/owners of the guidelines.