Guideline:
Care of the adult patient with cataract
Bibliographic Source(s)
- American Optometric Association. Care of the adult patient with cataract. 2nd ed. St. Louis (MO): American Optometric Association; 1996. 84 p. (Optometric clinical practice guideline; no. 16). [151 references]
Guideline Status
This is the current release of the guideline.
According to the guideline developer this guideline has been reviewed on a biannual basis and is considered to be current as of 2004. This review process involves updated literature searches of electronic databases and expert panel review of new evidence that has emerged since the original publication date.
Guideline Category
Diagnosis
Evaluation
Management
Intended Users
Health Plans
Optometrists
Guideline Objective(s)
- To identify patients at risk of developing cataracts
- To accurately diagnose cataracts
- To improve the quality of care rendered to patients with cataracts
- To effectively manage patients with cataracts
- To identify and manage postoperative complications
- To inform and educate patients and other health care practitioners about the visual complications and functional disability from cataracts and the availability of treatment
Target Population
Adults with cataracts
Interventions and Practices Considered
Diagnosis
- Patient history and physical examination
- Ocular examination
- Supplemental testing
Treatment
- Nonsurgical treatment
- Cataract surgery (extracapsular cataract extraction by phacoemulsification or nuclear expression)
Major Outcomes Considered
- Visual acuity
- Activities of daily living
Methods Used to Collect/Select Evidence
Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
The guideline developer performed literature searches using the National Library of Medicine's Medline database and the VisionNet database.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus (Committee)
Rating Scheme for the Strength of the Evidence
Not stated
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence
Not applicable
Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation
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.
Major Recommendations
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
- Patient History
- Ocular Examination
- 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
- Available Treatment Options
- Nonsurgical Treatment
- Indications for Surgery
The treatment decision for the patient with cataract depends on the extent of his or her visual disability.
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.
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:
Elements of the ocular examination may include but are not limited to the following:
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
| 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.
Clinical Algorithm(s)
An algorithm is provided for Optometric Management of the Adult Patient with Cataract.
Type of Evidence supporting the Recommendations
The type of supporting evidence is not specifically stated for each recommendation.
Potential Benefits
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.
Potential Harms
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.
Qualifying Statements
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.
Description of Implementation Strategy
An implementation strategy was not provided.
Implementation Tools
Clinical Algorithm
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness
Bibliographic Source(s)
- American Optometric Association. Care of the adult patient with cataract. 2nd ed. St. Louis (MO): American Optometric Association; 1996. 84 p. (Optometric clinical practice guideline; no. 16). [151 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
Funding was provided by the Vision Service Plan (Rancho Cordova California) and its subsidiary Altair Eyewear (Rancho Cordova California)
Guideline Committee
American Optometric Association Consensus Panel on Care of the Adult Patient with Cataract
Composition of Group that Authored the Guideline
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.
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
According to the guideline developer this guideline has been reviewed on a biannual basis and is considered to be current as of 2004. This review process involves updated literature searches of electronic databases and expert panel review of new evidence that has emerged since the original publication date.
Guideline Availability
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
Availability of Companion Documents
None available
Patient Resources
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.
NGC STATUS
This summary was completed by ECRI on December 2 1999. The information was verified by the guideline developer as of January 31 2000.
COPYRIGHT STATEMENT
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.
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