- Symptomatic cataract is a surgical disease. Dietary intake and nutritional supplements have demonstrated minimal to no effect in the prevention or treatment of cataract. (III, G, S)
- The standard of care in cataract surgery in the United States is a small-incision phacoemulsification with foldable intraocular lens (IOL) implantation. It is a standard of care that has withstood the test of time.
- Refractive cataract surgery has the potential to reduce a patient’s dependence on eyeglasses and contact lenses for distance, intermediate, and near vision.
- Intraocular lens technologies and surgical approaches to implanting lenses continue to improve.
- Femtosecond laser-assisted cataract surgery (FLACS) increases the circularity and centration of the capsulorrhexis and reduces the amount of ultrasonic energy required to remove a cataract. However, the technology may not yet be cost-effective, and the overall risk profile has not yet been shown to be superior to that of standard phacoemulsification.
- The use of topical nonsteroidal anti-inflammatory drugs (NSAIDs) is controversial, with evidence suggesting that NSAIDs only be used for the prevention of cystoid macular edema (CME) in patients with diabetic retinopathy or other high-risk ocular comorbidities.
- Increasing evidence demonstrates that intracameral antibiotics
reduce the risk of postoperative bacterial endophthalmitis.
- Surgeons should recognize and prepare to manage high-risk characteristics that may complicate cataract surgery. New risks may become apparent as new technologies come to market. One example is capsular damage with rapid development of a complicated cataract associated with intravitreal injections.
- Toxic anterior segment syndrome (TASS) may be confused with infectious endophthalmitis. However, TASS has an earlier onset, is associated with limbus-to-limbus corneal edema, and responds to corticosteroids.
Table 1. Recommendation Grading
|I++||High-quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with a very low risk of bias|
|I+||Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias|
|I-||Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias|
|II++||High-quality systematic reviews of case-control or cohort studies High-quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal|
|II+||Well-conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal|
|II-||Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal|
|III||Nonanalytic studies (e.g., case reports, case series)|
|G - Good quality||Further research is very unlikely to change our confidence in the estimate of effect|
|M - Moderate quality||Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate|
|In - Insufficient quality||Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate Any estimate of effect is very uncertain|
|S - Strong recommendation||Used when the desirable effects of an intervention clearly outweigh the undesirable effects or clearly do not|
|D - Discretionary recommendation||Used when the trade-offs are less certain—either because of low-quality evidence or because evidence suggests that desirable and undesirable effects are closely balanced|
- To rate individual studies, a scale based on Scottish Intercollegiate Guideline Network (SIGN) is used.
- The body of evidence quality ratings is defined by Grading of Recommendations Assessment, Development and Evaluation (GRADE). GRADE is a systematic approach to grading the strength of the total body of evidence that is available to support recommendations on a specific clinical management issue.
- Key recommendations for care are defined by the Grading of Recommendations Assessment, Development and Evaluation Working Group (GRADE) (Guyatt GH et al. BMJ 2008; 336:924–926).
- Each type of cataract has its own anatomical location, pathology, and risk factors for development. Several systems are available to classify and grade lens opacities, but variations in grading systems make comparing prevalence rates between studies difficult.
Table 2. Types of Cataracts
Central opacification or discoloration
Accompanied by brunescence, opalescence, or both
Affect distance vision more than near vision
May induce myopia or a reduction in hyperopia
Central or peripheral
Spoke-like or nummular appearance
Patients commonly complain of glare
Sometimes best visualized by retroillumination or retinoscopy
|Posterior subcapsular cataracts (PSCs)|
Can cause substantial visual impairment if they involve the axial region of the lens
More frequent in younger patients than either nuclear or cortical cataracts
Patients often have glare and poor vision in bright light, and near vision is typically more affected than distance due to miosis with near accommodation
Table 3. Ophthalmic Examination
- Patient history, including an assessment of functional status, pertinent medical conditions, medications currently used, and other risk factors that can affect the surgical plan or outcome of surgery (e.g., immunosuppressive conditions, use of systemic alpha-1 antagonists, diabetes)
- Visual acuity with current correction (the power of the present correction recorded) at distance and, when appropriate, at near
- Measurement of best-corrected distance visual acuity
- Assessment of the degree of anisometropia after refraction
- Glare testing when indicated
- Assessment of pupillary function
- Examination of ocular alignment and motility
- External examination (eyelids, lashes, lacrimal apparatus, orbit)
- Measurement of intraocular pressure (IOP)
- Slit-lamp biomicroscopy of the anterior segment, examination of the lens, vitreous, macula, peripheral retina, and optic nerve through a dilated pupil
- Assessment of relevant aspects of the patient’s mental and physical status (i.e., cooperation and ability to lie flat)
- Assessment of any barriers to communication (language or hearing impairment)
- Contrast sensitivity
- Ocular wavefront
- Subjective potential acuity; includes potential acuity meter, laser interferometer, scanning laser ophthalmoscope
- Specular microscopy and corneal pachymetry
- Corneal contour using topography or tomography
- Optical coherence tomography (OCT)
- B-scan ultrasonography
- Assessment of tear function (II , G, S)