Guideline:Care of the adult patient with cataract. Measure Summary

Cataract

Adults with cataracts

Diagnosis

1. Patient history and physical examination
2. Ocular examination
3. Supplemental testing

Treatment

1. Nonsurgical treatment
2. Cataract surgery (extracapsular cataract extraction by phacoemulsification or nuclear expression)

The guideline developer performed literature searches using the National Library of Medicine's Medline database and the VisionNet database.

2009 Review Process

The principal author of the guideline and primary American Optometric Association staff performed searches of PubMed and Cochrane Collaboration using relevant keywords. The Clinical Guidelines Coordinating Committee reviews staff literature searches conducted for each guideline. The committee then determines which guidelines should be reviewed by the consensus panel, revised by the principal author and panel, or completely rewritten.

Not stated

Not stated

Not applicable

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

The Reference Guide for Clinicians was reviewed by the American Optometric Association (AOA) Clinical Guidelines Coordinating Committee and approved by the AOA Board of Trustees.

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.

1. 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:

1. Patient History
2. 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).

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.

1. Basis for Treatment

The treatment decision for the patient with cataract depends on the extent of his or her visual disability.

2. Available Treatment Options
   1. Nonsurgical Treatment
   2. 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.

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

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

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.

An algorithm is provided for Optometric Management of the Adult Patient with Cataract.

The type of supporting evidence is not specifically stated for each recommendation.

Cataract is a common problem in an aging population. Reduced vision due to cataract can greatly affect the patient's ability to perform day-to-day activities. Proper care through both nonsurgical and surgical intervention can lead to improved productivity, reduction of personal suffering, and substantial cost savings for the affected individuals, their families, and the health care system as a whole.

Subgroups Most Likely to Benefit:

Risk factors for the development of cataract include:

• Age
• Diabetes mellitus. Persons with diabetes mellitus are at higher risk for cataracts, and persons with diabetes who have cataracts have a higher morbidity than those without cataracts.
• Drugs. Certain medications have been found to be associated with cataractogenesis and vision loss. There is an association between corticosteroids and posterior subcapsular cataracts. Drugs such as phenothiazine or other thiazines and chlorpromazine have been associated with the induction of cataract formation. Antihypertensive agents have not shown a high association with onset of cataract.
• Ultraviolet radiation. Studies have shown that there is an increased chance of cataract formation with unprotected exposure to ultraviolet (UV) radiation. These studies find that patients living in environments with high UV-B radiation levels have a higher incidence of cataract. Also, if not protected, persons with higher occupational exposure to UV light are at greater risk for cataract than those with lower occupational exposure rates.
• Smoking. An association between smoking and increased nuclear opacities has been reported.
• Alcohol. Several studies have shown increased cataract formation in patients with higher alcohol consumption compared with patients who have lower or no alcohol consumption.
• Nutrition. Although the results are inconclusive, studies have suggested an association between cataract formation and low levels of antioxidants (e.g., vitamin C, vitamin E, carotenoids). Further study may show that antioxidants have a significant effect on decreasing the incidence of cataract.

The risks associated with cataract surgery include serious complications (e.g., endophthalmitis) which may result in vision worse than that prior to surgery or in total vision loss. Other complications (e.g., cystoid macular edema or CME) may require additional medications or prolonged follow-up, but do not necessarily result in long-term vision loss.

Early emergent complications that may arise following cataract surgery include ocular hypertension, malignant glaucoma, would leak with shallow or flat anterior chamber, endophthalmitis, iris prolapse or vitreous in the wound, intraocular lens dislocation, retinal break and detachment. Early less-emergent complications include ptosis, diplopia, wound leak with well-formed anterior chamber, acute corneal edema, hyphema, anterior uveitis, intraocular lens decentration/pupillary capture, choroidal detachment, and anterior ischemic optic neuropathy. Intermediate to late complications include ptosis, diplopia, ocular hypertension or glaucoma, epithelial downgrowth, chronic corneal edema/corneal decompensation, late hyphema, chronic anterior uveitis, posterior capsular opacity, pseudophakic cystoid macular edema.

Clinicians should not rely on this Clinical Guideline alone for patient care and management. Please refer to the references and other sources listed in the original guideline for a more detailed analysis and discussion of research and patient care information.

An implementation strategy was not provided.

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

Funding was provided by the Vision Service Plan (Rancho Cordova, California) and its subsidiary Altair Eyewear (Rancho Cordova, California)

American Optometric Association Consensus Panel on Care of the Adult Patient with Cataract

Members: Cynthia A. Murrill, O.D., M.P.H.; David L. Stanfield, O.D.

Principal Authors: Michael D. VanBrocklin, O.D.; Ian L. Bailey, O.D.; Brian P. DenBeste, O.D.; Ralph C. DiIorio, M.D.; Howell M. Findley, O.D.; Robert B. Pinkert, O.D.

AOA Clinical Guidelines Coordinating Committee Members: John F. Amos, O.D., M.S. (Chair); Barry Barresi, O.D., Ph.D.; Kerry L. Beebe, O.D.; Jerry Cavallerano, O.D., Ph.D.; John Lahr, O.D.; David Mills, O.D.

Not stated

This is the current release of the guideline.

According to the guideline developer, this guideline was last reviewed for currency in 2009.

Electronic copies: Available in Portable Document Format (PDF) from the American Optometric Association Web site .

Print copies: Available from the American Optometric Association, 243 N. Lindbergh, Blvd., St. Louis, MO 63141-7811

None available

The following is available:

• Answers to your questions about cataracts. St. Louis, MO: American Optometric Association. (Patient information pamphet).

Print copies: Available from the American Optometric Association, 243 N. Lindbergh Blvd., St. Louis, MO 63141-7881; Web site, www.aoanet.org .

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

This summary was completed by ECRI on December 2, 1999. The information was verified by the guideline developer as of January 31, 2000. The information was reaffirmed by the guideline developer in 2009 and updated by ECRI Institute on February 26, 2010.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions as follows:

Copyright to the original guideline is owned by the American Optometric Association (AOA). NGC users are free to download a single copy for personal use. Reproduction without permission of the AOA is prohibited. Permissions requests should be directed to Jeffrey L. Weaver, O.D., Director, Clinical Care Group, American Optometric Association, 243 N. Lindbergh Blvd., St. Louis, MO 63141; (314) 991-4100, ext. 244; fax (314) 991-4101; e-mail, JLWeaver@AOA.org.