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Cataract in adults

Cataract in adults
Literature review current through: Jan 2024.
This topic last updated: Jul 14, 2023.

INTRODUCTION — A cataract is an opacity of the lens of the eye that may cause blurred or distorted vision, glare problems, or, in very advanced cases, blindness. Cataract is a significant cause of blindness worldwide [1].

Cataracts occur frequently with increasing age and may be a normal part of aging. However, poor nutrition, metabolic insults, excessive exposure to sunlight or other sources of radiation, trauma, and certain medications such as cortisone can speed their development. There are no proven medical therapies. Modern microsurgical technique combined with intraocular lens implantation can restore normal vision in the vast majority of patients [2]. Except in certain uncommon situations, delay in treatment does not result in an adverse outcome. The major advances in the surgical treatment of cataract have not been matched by advances in the understanding of cataract formation, approaches to prevention, or in nonsurgical therapy.

This topic will discuss cataract in adults. Cataract in children is reviewed separately. (See "Cataract in children".)

SIGNIFICANCE — Cataracts continue to be an important cause of blindness. Worldwide, cases of blindness due to cataract have increased from 12.3 million in 1990 to 20 million in 2010, with the proportion of blindness due to cataract ranging from 12.7 percent in North America to 42 percent in Southeast Asia [1]. Cataract surgery has increased in most areas of the world, and the proportion of cases of blindness due to cataract has been decreasing, with the greatest decreases in East Asia, tropical Latin America, and western Europe and the smallest decreases in sub-Saharan Africa.

The pattern and rate of blinding disorders differs between nations depending upon whether nutritional and infectious causes of blindness are eradicated and whether there are resources available for treatable disorders such as cataract. In addition, there are differences in how blindness is defined; for example, blindness by international health standards converts to 10/200 by Snellen notation, while the standard for legal blindness in the United States is 20/200.

PATHOGENESIS — The lens of the eye has a unique structure which renders it vulnerable to insults due to aging or other causes. It is composed of specialized cells arranged in a highly ordered and complex manner, which contain a high content of cytoplasmic protein. These proteins, the crystallins, along with the complex structure, impart transparency to the lens. Unlike other epithelia, the lens cannot shed its nonviable cells; these cells are compressed into the center of the lens over time and begin to lose their transparency [3].

The pathogenesis of cataract may relate to the type.

Age-related cataracts – Older age accounts for the vast majority of cataracts. Pathogenesis is related to the degenerative effects of aging on cell structure. Some of the anatomic and ultrastructural correlates of lens opacity are known, although exact pathogenetic mechanisms are not. Epidemiologic and experimental evidence suggests that photo-oxidative insult, perhaps potentiated by toxic or sensitizing substances, plays a role.

Non-age-related cataracts – These cataracts are most often due to trauma, uveitis, scleritis (particularly necrotizing scleritis), radiation of an intraocular tumor, metabolic impact of systemic disease such as myotonic dystrophy, use of topical corticosteroids or certain phenothiazines, and topical anticholinesterases (toxic cataract).

RISK FACTORS — Several risk factors for cataract have been identified [4-9]:

Older age.

Smoking.

Alcohol consumption.

Sunlight exposure.

Malnutrition.

Genetic factors.

Physical inactivity.

Metabolic syndrome.

Diabetes mellitus.

HIV/AIDS.

Systemic corticosteroid use and possibly prolonged administration of high doses of inhaled corticosteroids. Intranasal steroids do not appear to pose a risk [10]. (See "Major adverse effects of systemic glucocorticoids" and "Major side effects of inhaled glucocorticoids".)

Statin use, although data conflict about this association. (See "Statins: Actions, side effects, and administration", section on 'Other possible associations'.)

Most of these risk factors are environmental stressors that lead to the formation of toxins or the impairment of antioxidants. A dose-response relationship has been demonstrated with ultraviolet B exposure in sunlight [11] and smoking [12]. Some damage to the lens caused by smoking may be reversible upon quitting, although the reduction in cataract risk associated with smoking cessation is primarily due to limiting further dose-related damage to the lens [13]. Other environmental stressors may be involved as well. Low-level accumulated lead exposure, at levels commonly experienced by adults in the United States, appears to be associated with an increased risk of cataract [14].

The size of the risk associated with duration of exposure to diabetes has not been quantified [4].

Patients with HIV/AIDS who do not have ocular opportunistic infections undergo cataract surgery at a younger age than the general population; whether this is related to accelerated aging, drug effect, or occult inflammation remains unclear [7,8].

CLINICAL PRESENTATION — The development of cataract is a painless, progressive process that is highly variable among individuals. Patients usually present with bilateral symptoms and complain of difficulty with night driving (especially due to glare of oncoming headlights) or reading road signs or fine print. Most cases occur in patients over age 60. Younger individuals with cataracts are likely to have risk factors such as diabetes mellitus or systemic steroid use. Patients of all ages are subject to cataract due to significant eye trauma. The clinical presentation of age-related and non-age-related cataracts is the same.

In many patients, there is an increase in nearsightedness before there is opacity of the lens that degrades vision. This increase in nearsightedness, called a "myopic shift," is caused by an increase in the refractive power of a lens that is gradually becoming cataractous and can continue as opacity develops. Patients will report more difficulty with distance vision and some may note that their near vision is better. It is not unusual to require updates of spectacle prescription at more frequent intervals prior to development of frank opacity.

DIAGNOSTIC EVALUATION — A lens opacity can be confirmed by a nondilated fundus examination with the direct ophthalmoscope; there may be darkening of the red reflex, opacities within the red reflex, or obscuration of ocular fundus detail. In the absence of other visual symptoms, a red eye, or other abnormality noted on fundus examination, these patients should be referred on a nonurgent basis for comprehensive ophthalmic examination.

During the comprehensive examination, the type and extent of lens opacity is noted, and a dilated fundus examination is performed to rule out other pathology that could account for diminished vision or prevent full restoration of vision after cataract surgery.

DIAGNOSIS — The diagnosis of cataract is based on characteristic findings of opacity on comprehensive ophthalmic examination. A diagnosis of visually significant cataract is made if no other pathology is detected and the degree of lens opacity correlates with the patient's complaints and best-corrected visual acuity.

Cataracts typically have one of three components: nuclear sclerosis (picture 1), cortical spoking (picture 2), and posterior subcapsular haze (picture 3). Each affects a different anatomical part of the lens (figure 1) and has different symptoms and progression. Most patients have a combination of components. (See 'Classification' below.)

Cataracts are also described by their maturity. An immature cataract still allows a view of the retina and transmits a red reflex (picture 4). Once the red reflex is lost, it is called mature (picture 5). A mature cataract degrades vision to the 20/400 level or worse. A hypermature cataract is one in which the cortex of the lens has liquefied and the lens nucleus is mobile within the capsule (picture 6). A moderate to advanced cataract can interfere with the diagnosis and therapy of diseases involving the retina and optic nerve. (See "Slit lamp examination".)

Associated diagnoses — A small fraction of mature and hypermature cataracts can give rise to secondary glaucoma which may be evident on initial presentation. These types of glaucoma sometimes cause a red, painful eye, in contrast to many other glaucomas, which are usually asymptomatic. (See "Open-angle glaucoma: Epidemiology, clinical presentation, and diagnosis" and "Angle-closure glaucoma".)

Three rare types of intractable glaucoma may occur:

Phacolytic glaucoma, in which lysed lens proteins cause a pressure rise

Phacoanaphylactic glaucoma, in which the autoimmune reaction to these proteins causes a pressure rise

Phacomorphic glaucoma, in which the swollen lens causes a form of angle closure glaucoma

Classification — Cataracts are classified as having nuclear, cortical, or posterior subcapsular components, evident on examination. However, these distinctions are mostly important for research classification rather than clinical management. Most patients have a combination of components.

Nuclear cataract – Nuclear cataract dulls colors and white significantly; this is rarely a patient complaint until after the first cataract is removed, at which time the effect on color is noted by comparison with the brightness of colors in the operated eye.

Nuclear cataract progresses very slowly. Distance vision typically is affected much more than near vision. It is not unusual to find individuals in their 80s with nuclear cataract degrading acuity to the 20/70 to 20/100 level, with near vision preserved at the 20/25 level. Such an individual may not be particularly aware of or bothered by the decreased vision from cataract if they do not drive.

Cortical cataract – Although it is a prominent finding on examination with a biomicroscope (a low-power binocular microscope used with a slit lamp), cortical cataract does not degrade vision very much. Cortical cataracts may appear suddenly after trauma or other insult but tend to progress slowly.

Posterior subcapsular cataract – Posterior subcapsular cataract tends to cause disabling glare in bright sunlight and from headlights, even if visual acuity is degraded only slightly. Typically, distance and near vision are affected equally.

Posterior subcapsular cataract tends to progress more quickly than nuclear cataract (over a period of months rather than years); the explanation for this pattern of progression is not known.

Systemic and topical steroid use is associated with formation of this type of cataract, as is diabetes. (See "Major adverse effects of systemic glucocorticoids".)

INDICATIONS FOR SURGERY AND TIMING — Surgery is indicated if symptoms from the cataract interfere with the patient's ability to meet his or her needs of daily living; there are no criteria based upon the level of visual acuity. The indication for surgical intervention is the same for age-related as well as other types of acquired cataract. Some forms of acquired cataract, such as that related to trauma or uveitis, require modification of standard surgical technique, but in most cases special surgical considerations are not necessary.

Age alone is not a contraindication to cataract surgery. Cataract surgery and the resultant improvement in vision may have important benefits for older adults. Data from a Medicare database, comparing hip fracture rates in patients with cataract who did or did not undergo cataract surgery, found a 16 percent decrease in the adjusted odds ratio [OR] for hip fracture within one year in patients who had surgery and a 23 percent decrease for patients with severe cataract [15]. Additionally, a longitudinal study of over 550,000 adults observed a 9 percent relative reduction in serious traffic accidents in the year following a first cataract surgery [16].

The indication and timing of surgery depends to some degree on the presence or absence of coexisting eye disease:

Patients without coexisting eye disease – The choice of whether and when to pursue surgery should be determined by the informed patient rather than the surgeon, except in cases in which cataract limits monitoring for retinal or optic nerve disease, or in the rare instance in which it is inducing glaucoma [17].

For some patients, the myopic shift caused by the cataract may be correctable with a change in spectacle correction. Surgery should be deferred as long as diminished acuity can be corrected with spectacles to meet a patient's needs. In rare cases, the patient may not tolerate the full correction of refractive error because the result is imbalanced with respect to the fellow eye, and cataract surgery is chosen without first dispensing full correction.

Patients with coexisting eye disease – The ophthalmologist must assess what proportion or aspect of diminished vision is accounted for by cataract in the presence of coexistent pathology such as age-related macular degeneration (AMD), glaucoma, or diabetic retinopathy. Even if it seems that cataract accounts only partially for loss of vision, surgery may be indicated if the other disease process is under control and the patient understands that the prognosis for complete recovery of visual acuity is guarded. Many patients with impaired vision from cataract and AMD or diabetic retinopathy have significant improvement in visual function after cataract extraction, even when coexistent retinal disease precludes recovery of 20/20 vision [18].

Adjunctive tests that can be done preoperatively, such as the potential acuity meter (PAM), may provide useful information in advising whether cataract surgery is likely to yield improvement in vision in patients with coexistent pathology. Retrospective data suggest that cataract surgery for patients with wet AMD can improve vision, but that close monitoring is warranted postoperatively because of a trend toward increased macular thickening or intraretinal cysts [19].

SURGICAL PLANNING — Once the decision for surgery has been made, a number of factors should be considered:

Timing of surgery on second eye — Same-day surgery on the second eye (also referred to as immediate sequential bilateral cataract surgery) is a good, or potentially superior option compared to delayed sequential bilateral cataract surgery, although it remains relatively uncommon in the United States. Historically, immediate sequential bilateral cataract surgery has not been routinely performed because of concerns related to the possibility of bilateral infection, inferior optimization of postoperative refractive error, and lack of potential for modification of regimens based on any complications in the first eye. However, there is potential for cost savings with same-day second eye surgery, and observational, as well as trial data show equivalent or improved outcomes [20-24].

Examples include:

A 2022 systematic review of 14 studies concluded there are probably no clinically important differences in outcomes between same-day versus delayed surgery on the second eye, although costs are likely to be lower for same-day procedures [24].

A 2022 retrospective cohort study of patients in the American Academy of Ophthalmology Intelligent Research in Sight (IRIS) Registry database found that risk of postoperative endophthalmitis was not significantly different between patients who underwent immediate sequential bilateral cataract surgery versus delayed sequential bilateral cataract surgery or unilateral cataract surgery from 2013 through 2018 [25].

A 2023 noninferiority trial among 865 patients in 10 Dutch hospitals found that patients randomized to receive same-day second eye surgery had equivalent outcomes to those in the conventional treatment group, at lower costs [26]. There were no cases of endophthalmitis in either group.

Limiting risk of intraoperative floppy iris syndrome — Alpha-1 antagonists, particularly tamsulosin, and certain second-generation antipsychotic medications (paliperidone and risperidone) have been associated with intraoperative floppy iris syndrome (IFIS), a surgical condition characterized by a triad of findings: a flaccid iris billowing through the surgical incision, iris prolapse, and intraoperative pupillary constriction. This condition may affect 2 to 3 percent of all cataract operations [27]. IFIS both complicates the surgical procedure and increases risk for postoperative complications (retinal detachment and endophthalmitis) related to posterior capsular rupture and lens fragments within the vitreous.

It is important to make sure the surgeon is aware that the patient was or is taking one of these agents, as there are preoperative and intraoperative regimens (eg, cycloplegia, mydriatics, nonsteroidal antiinflammatory drugs [NSAIDs], low-flow fluids, iris retractors, and pupillary ring expanders) that can reduce the risk of IFIS [27]. Most surgeons do not insist that these agents be discontinued, as discontinuing the medication prior to cataract surgery has not been shown to prevent or decrease the severity of IFIS [28]. For example, IFIS has been reported years after the discontinuation of alpha-1 antagonists.

Alpha-1 antagonistsTamsulosin, with strong affinity for the alpha-1a receptor, has particularly been associated with IFIS, along with other alpha-1 antagonists (eg, terazosin, doxazosin, tamsulosin, alfuzosin) [27,29-33].

Antipsychotic medications – Cases of IFIS have been reported during cataract surgery with the second-generation antipsychotic medications paliperidone and risperidone [34,35].

Preoperative planning — No routine testing (laboratory, imaging, electrocardiogram [ECG]) is needed in patients undergoing cataract extraction [36]. A systematic review of randomized trials (21,531 cataract surgeries) comparing routine preoperative testing with either no testing or selective testing found that routine preoperative medical testing increased surgical costs but did not reduce the risk of intraoperative or postoperative medical adverse events [37]. Certain patients may require targeted preoperative testing, for example, patients with recent cardiac interventions or those with increased risk of metabolic disturbance or out-of-range coagulation indices.

Management of comorbid conditions

Hypertension — Preoperative blood pressure control is important to avoid complications such as suprachoroidal hemorrhage. Patients should be given their antihypertensive medications with a sip of water on the morning of surgery. It is important to avoid intraoperative spikes in blood pressure that may be dangerous to the eye or to the patient’s overall health. A general rule of thumb is that elective surgery should not be performed if preoperative systolic pressures are over 180 or if diastolic pressures are over 110. (See "Anesthesia for patients with hypertension".)

Diabetes — Patients with diabetes should preferably undergo surgery in the early morning so insulin or oral hypoglycemic drugs can be held until after surgery; this reduces the risk of hypoglycemia before or during surgery. If patients with type 1 diabetes are scheduled later in the morning or afternoon, one-third to one-half of the morning insulin dose can be given. Marked derangement of glycemic control is uncommon in patients with diabetes who undergo cataract surgery since the procedure is brief.

Coronary heart disease — Patients with coronary heart disease should continue all antianginal medications, except possibly aspirin. (See 'Aspirin and other antiplatelet agents' below.)

Upper respiratory infection — Elective cataract surgery should be postponed in patients with an acute upper respiratory infection, since cough may pose some ophthalmic risk during the procedure.

Valvular disease — Endocarditis prophylaxis is not necessary in patients undergoing cataract surgery.

Management of antithrombotic agents

General considerations — Cataract surgery is considered a low-risk procedure for bleeding [38]. In general, patients can be continued on their antiplatelet or anticoagulant therapies [39]. However, the decision to continue or discontinue these medications should be made after discussion with the ophthalmologist who is performing the surgery. Individual considerations (eg, reason for anticoagulation, whether the patient has monocular or binocular vision, history of prior hemorrhage in the fellow eye) should factor into this decision. Individuals with higher bleeding risks (eg, monocular patients, patients with previous bleeding complications, or in cases where a larger incision or retro-bulbar block is planned or topical anesthesia is not possible) may have oral anticoagulants stopped prior to surgery. If discontinuation of anticoagulants is not possible in a high-risk case, topical anesthesia should be considered to reduce the bleeding risks related to use of a needle block.

Aspirin and other antiplatelet agents

ASA – The 2012 anticoagulation guidelines from the American College of Chest Physicians (ACCP) recommend that patients who are receiving aspirin and are undergoing cataract removal continue to receive aspirin around the time of the procedure [40]. The risks associated with either continuing or stopping aspirin appear to be very small [41,42].

Clopidogrel – Limited data are available regarding the risk of bleeding with cataract surgery in patients receiving clopidogrel. Consideration should be given to delaying cataract surgery until the period of dual antiplatelet therapy (aspirin plus clopidogrel) has passed for patients receiving therapy for prevention of stent thrombosis. (See "Long-term antiplatelet therapy after coronary artery stenting in stable patients", section on 'Noncardiac surgery or gastrointestinal endoscopy'.)

Patients with cardiovascular disease who take clopidogrel (or ticlopidine) chronically (eg, other than the prevention of coronary artery stent thrombosis) are at increased risk for acute cardiovascular events when these agents are discontinued. Therefore, these agents are usually continued in patients undergoing cataract removal.

Warfarin — The 2012 anticoagulation guidelines from the ACCP recommend that warfarin be continued for patients undergoing cataract removal [40]. The risks associated with either continuing or stopping warfarin appear to be small [41,43-46].

Other oral anticoagulants — In general, as with warfarin, patients may continue other oral anticoagulants (direct thrombin or factor Xa inhibitors) prior to cataract surgery.

Perioperative management of oral anticoagulants is discussed in detail separately. (See "Perioperative management of patients receiving anticoagulants".)

SURGICAL TREATMENT — The only treatment for cataract is to surgically remove and replace the opacified lens from the eye to restore transparency of the visual axis. Modern surgical technique is extremely safe with few major complications [47], and the intraocular lens allows rehabilitation of one eye so that it is compatible with vision in the fellow eye with the natural lens.

Surgical techniques — Cataract surgery is typically performed on an outpatient basis under local anesthesia supplied topically, by block, or by sub-Tenon's infusion. Monitored intravenous sedation is also commonly used. [48,49]. General anesthesia is necessary only for patients who cannot reliably cooperate under local anesthesia (eg, cognitive impairment or other communication barrier) or possibly those who had a complication of local anesthesia in the fellow eye. The intraocular components of cataract surgery can be performed in 10 to 20 minutes by experienced surgeons, but typically patients spend 30 to 60 minutes in the operating room for positioning, draping, preliminary, and final steps.

The two techniques most commonly used for cataract extraction are:

Phacoemulsification – Also called small incision surgery, this has become the most common form of cataract removal technique in high-resource countries. The lens is removed using a handpiece with a 1 to 3 mm tip inserted through a small incision. This tip, also called a phaco probe, contains a needle that vibrates with ultrasonic energy to fragment the hard central part of the lens, and an irrigation and aspiration sleeve. The softer cortex is then aspirated and the lens capsule is left behind as in extracapsular cataract extraction. A foldable plastic or silicone lens may be passed through this smaller incision, or the incision can be extended if needed to accommodate a larger, rigid plastic lens. Phacoemulsification may not be feasible in advanced cataracts in which the lens nucleus may be very hard.

The small incision may be self-sealing, requiring one or even no sutures. Phacoemulsification has the advantage of more rapid visual recovery due to the small incision size and decreased likelihood of suture-induced astigmatism.

Standard extracapsular cataract extraction – This typically involves removal of the lens nucleus in one piece through a large incision. The lens cortex is aspirated from the eye and the lens capsule is left behind to support an intraocular lens. A rigid plastic lens is inserted through the same incision and placed on or in the capsule, behind the iris. A modification of this technique which offers some of the advantages of a smaller incision (although not as small as the phacoemulsification incision) is described below.

Phacoemulsification is commonly performed, although it is technology-dependent and relatively costly and not available in all countries. A systematic review comparing phacoemulsification with extracapsular cataract extraction (ECCE) for age-related cataract found lower complication rates with phacoemulsification but concluded that the lower costs for ECCE support its use when high-volume surgery is important, since differences in visual outcomes for the two procedures are small [50].

A patient and surgeon may choose phacoemulsification under topical anesthesia for its apparent short-term advantages. However, traditional ECCE is a reasonable option in certain instances of advanced cataract or if ECCE is the preferred technique of the ophthalmologist whom the patient has chosen for surgery.

Two other surgical techniques are sometimes used if standard approaches are not available:

Intracapsular cataract extraction (ICCE), an approach to cataract surgery in which the cataract and its surrounding capsule are both removed. Frequently, no lens implant is placed in the eye.

Manual small incision cataract surgery (MSICS) or sutureless small-incision extracapsular cataract surgery (SICS) has many of the advantages of phacoemulsification without the costs. In MSICS, no phacoemulsification equipment is used; instead, the lens is manually, mechanically divided into smaller pieces before removal from the eye through a small incision through which a foldable lens can be implanted. Fewer sutures are used than for ECCE; sometimes none are required. A systematic review of three randomized trials in Nepal and India comparing short-term outcomes of MSICS and ECCE found better visual acuity with MSICS, though overall good functional visual acuity was achieved in less than half of subjects with either method and complications were greater with MSICS in one trial [51]. A systematic review of eight trials comparing MSICS and phacoemulsification in India, Nepal, and South Africa found similar results for best corrected visual acuity for the two techniques at six to eight weeks, but there were quality concerns with the trials and longer-term outcomes are needed [52]. Comparative trials have not been performed in moderate- and high-resource settings, so these findings may not be generalizable to these settings.

Preventing endophthalmitis — The application of povidone-iodine to the ocular surface as part of the surgical preparation of the operative field has been shown to lower the incidence of postoperative endophthalmitis in intraocular surgery [53], is inexpensive, and is a generally adopted practice in cataract surgery.

Prophylactic use of topical antibiotics (eye drops) before and after cataract surgery is common, despite little evidence to support the practice. By contrast, the use of periprocedural intracameral antibiotics appears to be effective in reducing the low risk of postoperative endophthalmitis, with or without the addition of topical antibiotics [54,55].

However, we recommend not using prophylactic intracameral vancomycin, alone or in a compounded drug combining multiple active ingredients, during cataract surgery because of the risk of hemorrhagic occlusive retinal vasculitis (HORV) [56].

Choice of intraocular lens — Most patients in resource-rich countries will have synthetic intraocular lenses (IOLs) implanted during these procedures, except in some forms of uveitis, in some cases of high myopia, and in the event of unusual intraoperative complications. IOLs can also be implanted secondarily in a subsequent operation. The alternatives to lens implantation are aphakic (cataract) spectacles (picture 7) or contact lenses. However, results with either of these alternatives are unsatisfactory for most patients.

There are four types of IOLs: monofocal, multifocal, accommodative, and toric. In general, monofocal and multifocal lenses are equally effective at improving distance visual acuity. Multifocal IOLs result in better uncorrected near vision when compared with monofocal IOLs, but multifocal IOL users report more bothersome visual side effects such as glare or haloes [57]. Toric IOLs can reduce or eliminate the need for astigmatism correction in spectacles or contact lenses. Multifocal, accommodative, and toric IOLs are more expensive than monofocal lenses and are typically offered as “premium” lenses; the additional expense is typically born by the patient because these lenses, which reduce dependence on glasses, are not covered by insurance.

A 2014 systematic review of four trials in the United Kingdom, Italy, and Germany comparing accommodative IOL with monofocal IOL found moderate-quality evidence of small gains in near vision after six months with accommodative IOL [58].

Overall, more data are needed to determine the relative benefits of monofocal, multifocal, accommodative, and toric lenses. Preoperative education and counseling are warranted to assure that patient expectations are realistic when “premium” lenses are offered at higher cost to patients. Studies are needed to correlate patient-reported outcomes with patient expectations [59].

Postoperative care and follow-up — There may be some mild pain within the first 24 hours, typically relieved by acetaminophen. Patients can resume normal activity such as reading, walking, eating, and watching television the evening of surgery.

The eye may be patched, depending upon whether anesthesia was local or topical. All systemic medications can be resumed immediately, including anticoagulant/antithrombotic agents, assuming there were no concerns of bleeding during surgery. The eye is typically examined on the first postoperative day, although some surgeons are eliminating this step for uncomplicated cases and having staff contact patients by telephone instead. Many surgeons allow resumption of driving at the level immediately prior to surgery at this time, as long as continued patching is not required.

Patients are then typically seen one week and one month after surgery to monitor for complications and proper healing. Corticosteroid or nonsteroidal antiinflammatory drug (NSAID; eg, ketorolac, nepafenac, bromfenac) drops are often prescribed postoperatively to reduce pain, inflammation, and the likelihood of macular edema, an inflammatory complication that may limit recovery of vision. Regimens typically start at two to four times daily and usually taper down after the first week, depending on the drug. The available evidence suggests that NSAIDs may be more effective than steroids in suppressing cystoid macular edema. [60-62].

Sutures are removed at 6 to 12 weeks if there is astigmatism related to the presence of tight sutures. However, suturing of wounds is less common in this era of small-incision phacoemulsification.

Recommendations on physical activity restriction vary widely among surgeons depending upon their confidence in the technique used. Patients with large incisions typically are advised not to undertake heavy lifting or strenuous activity including sexual activity for several weeks to several months. Surgeons who perform phacoemulsification tend to restrict heavy lifting or strenuous activity for a period of only days to weeks. Most patients are able to return to work by one week unless driving or heavy lifting is required. There is no contraindication to air travel. There are no evidence-based data for these recommendations.

The final spectacle prescription is determined at any point between one and three months after surgery depending upon the need for suture removal. Patients usually require spectacles for night driving and/or reading after cataract surgery. Some patients may note improved vision as soon as the day after surgery and others may not appreciate the full impact until updated spectacles are prescribed one to three months after surgery.

Outcomes — Outcomes depends for the most part on the presence or absence of ocular comorbidity. For example, improvement in vision may be limited by underlying age-related, diabetic, or traumatic maculopathy; glaucoma; or uveitis or unrecognized amblyopia. Intraoperative challenges and complications may limit optimal outcome.

A 1994 review from the Cataract Outcome Team found that 95.5 percent of eyes without preexisting ocular comorbidity had postoperative visual acuity of 20/40 or better (the acuity necessary to obtain an unrestricted driver's license); if all eyes were included in the pool, 89.7 percent had 20/40 acuity or better following cataract surgery [63]. A 2013 report from Europe found that a corrected distance visual acuity (CDVA) of 0.5 (20/40) or better and of 1.0 (20/20) or better was achieved in 94.3 percent and 61.3 percent of cases, respectively, consistent with the 1994 United States data [64]. Improvement in visual acuity has been reported to be less robust in a population of patients with diabetes, particularly in the setting of diabetic retinopathy [65].

A 2014 systematic review and meta-analysis of studies evaluating cataract surgery in patients with uveitis found that 20/40 visual acuity was achieved in 68 percent of patients following phacoemulsification and 72 percent following ECCE, with worse visual outcomes in patients with active uveitis at the time of surgery [66].

A Swedish study of patients with self-assessed poor outcomes found that the majority had improvement in corrected distance vision after surgery. In this report, younger patients (52 to 68 years) had a better self-assessed outcome than older adult patients, with surgical complication and poor near vision correlating with poor self-assessed outcome [67].

Complications — Because of the frequency with which cataract surgery is performed, even infrequent complications affect large numbers of people. As with most surgical procedures, adverse events are lower among surgeons who perform more procedures [68]. Cataract surgery is a low-risk procedure [69], but the surgery is typically performed on older adults, and multiple medical morbidities increase the risk of any procedure. In a systematic review of 21,531 total cataract surgeries, 707 adverse medical events related to the surgery were reported, resulting in three deaths and 61 hospitalizations [37].

Reported complications of the procedure include the following:

Immediate complications — These complications may limit vision at the end of the one- to three-month recovery period:

Endophthalmitis (bacterial or fungal infection within the eye), a complication that can result in markedly reduced vision and typically leaves some impairment (0.04 to 0.1 percent) [70,71]. Increased risk has been reported with certain demographic characteristics, combined ophthalmic surgeries, anterior vitrectomy, and comorbid conditions. (See "Bacterial endophthalmitis", section on 'Acute endophthalmitis after cataract surgery'.)

Corneal edema, which may reduce vision and cause pain (0.3 percent) [63].

Intraocular lens malposition/dislocation (1.1 percent) [63].

Clinically apparent cystoid macular edema (retinal thickening and edema involving the macula, 1.4 percent) [63].

Toxic anterior segment syndrome (TASS) is inflammation of the anterior segment of the eye, occurring typically within 24 hours of surgery and related to noninfectious contaminants of equipment, solutions, or other supplies used during the procedure [72]. Clusters of cases have been traced to faulty preparation of sterilization equipment.

HORV is a rare and devastating condition that can occur as soon as one day or as much as 21 days after intraocular use of vancomycin. For this reason, vancomycin is generally not recommended as prophylaxis against endophthalmitis in cataract surgery [56,73].

Delayed complications

Retinal detachment, which typically requires intervention in the form of laser, cryotherapy, or surgery (0.7 percent). It can result in marked loss of vision and moderate impairment, although sometimes it can be treated with no loss of vision [63]. (See "Retinal detachment".)

A population-based study suggested that the risk of retinal detachment is increased for up to 20 years after cataract surgery [74]. In one longitudinal study of 9400 patients, the cumulative rate of retinal detachment was 2.3 percent at eight years [75].

Highly myopic eyes appear to be at particularly high risk for retinal detachment after cataract surgery [75,76]. Patients with a history of retinopathy of prematurity (ROP) who develop cataracts at a relatively early age are also at high risk for postoperative retinal detachment; retinal tear or detachment occurred in 23 percent of 66 eyes with ROP in one retrospective series [77].

Risk of macular degeneration – Concerns have been raised that patients undergoing cataract surgery may be at increased risk for AMD. Proposed mechanisms include an increased post-procedure susceptibility to light damage, inflammatory changes secondary to surgery, or induction of angiogenesis. However, this association may be due to overlapping risk factors for the two conditions, or the fact that AMD may be discovered after cataract surgery and thus may represent prior disease not recognized due to lens opacity [78,79]. A 2017 systematic review concluded that it is not possible to draw reliable conclusions from the available data as to whether cataract surgery is beneficial or harmful in people with AMD after 12 months [80]. A subsequent cohort study of 1767 eyes did not find an association between cataract surgery and the development of late AMD with up to 10 years of follow-up [81].

Posterior capsule opacification (19.7 percent) can be successfully treated with yttrium-aluminum-garnet (YAG) laser capsulotomy and therefore is not considered a complication by many surgeons. The procedure, which is done as an outpatient in the doctor’s office, surgery center, or laser center, is painless and yields improvement in vision almost immediately. YAG capsulotomy does increase the risk of retinal detachment, however, and cannot be considered entirely benign. A meta-analysis found that biomaterials and edge design of the intraocular lens may influence posterior capsule opacification; incidence was lower for acrylic or silicone lenses and for those with sharp optic edges [82].

FINDINGS AFTER CATARACT SURGERY — An eye that has had cataract surgery with lens implantation is described as pseudophakic. Penlight and fundus examination findings are unchanged, except that sometimes the pupil takes on an irregular shape due to surgical manipulation. The pupil will appear black as opposed to grayish or opalescent after removal of the native lens. Some good observers notice a strange reflection of light in the pupil of younger pseudophakic patients who have larger pupils. This is an optical reflection off of the intraocular lens that is not present with the native lens. The fundus examination will be improved due to removal of media opacity.

PREVENTION — There is no proven therapy to either prevent cataract formation or slow progression of lens opacity once it develops. However, observational studies suggest that some interventions such as a healthy diet rich in fruits and vegetables and smoking cessation may be helpful [83-86]. The evidence supporting vitamin supplementation is mixed, and there is no clear recommendation to support vitamin use in cataract prevention [87-89].

Although postmenopausal estrogen use (longer than 10 years) may reduce the risk of nuclear cataracts, this is not a recommended strategy to prevent cataracts. (See "Menopausal hormone therapy: Benefits and risks".)

Several interventions have been suggested for prevention but have not been proven. Since sunlight exposure is a risk factor, sunglasses may offer protection, particularly for persons exposed to high reflected light (eg, water, snow, high desert ground), but there is no evidence that any particular type of sunglasses are more effective in cataract prevention or progression. Similarly, wearing a brimmed hat may offer protection against cataracts. Increased dietary glycemic load is not associated with risk for cataract [90], and no studies have been performed to evaluate whether blood glucose control in patients with diabetes correlates with cataract risk.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Preoperative medical evaluation and risk assessment".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Cataracts (The Basics)" and "Patient education: Capsulotomy after cataract surgery (The Basics)" and "Patient education: Age-related vision loss (The Basics)" and "Patient education: Anesthesia for elective eye surgery (The Basics)")

SUMMARY AND RECOMMENDATIONS

Significance – A cataract is an opacity of the lens of the eye that may cause blurred or distorted vision, glare problems, or, in very advanced cases, blindness. Cataracts are a major cause of blindness globally worldwide. (See 'Significance' above.)

Pathogenesis – Risk factors for cataract include older age, smoking, poor lifestyle habits, alcohol consumption, sunlight exposure, lower educational status, diabetes mellitus, and systemic and possibly high-dose inhaled corticosteroids. (See 'Pathogenesis' above.)

Clinical presentation – Cataract formation is usually bilateral and presents with problems with night driving, reading road signs, or difficulty with fine print. There is often an increase in myopia. (See 'Clinical presentation' above.)

Diagnosis – Cataract should be suspected in any patient who complains of painless progressive decline in vision. Most cases of cataract occur in patients over age 60 or in younger individuals who have risk factors. Diagnosis is by comprehensive eye examination; a dilated fundus examination should be performed to rule out other pathology that could account for diminished vision. (See 'Diagnosis' above.)

Surgery

Indications – Surgery is indicated when symptoms from the cataract interfere with the patient's ability to meet their needs of daily living. Surgery is typically on an outpatient basis under local anesthesia with monitored sedation. (See 'Indications for surgery and timing' above.)

Management of comorbid conditions – Cataract surgery is a low-risk procedure. Extensive preoperative evaluation is not indicated, but blood pressure should be controlled in hypertensive patients; endocarditis prophylaxis is not necessary. As the risk of bleeding is low, aspirin or anticoagulants may be continued for most patients. The decision to continue or discontinue these medications should be made after discussion with the ophthalmologist who is performing the surgery. (See 'Management of comorbid conditions' above.)

Intraoperative floppy iris syndrome (IFIS) – IFIS is seen in patients treated with alpha-1 antagonists and some antipsychotics; it is important that the surgeon be aware when patients have been taking these agents since special surgical protocols can be used to reduce risk for IFIS. (See 'Limiting risk of intraoperative floppy iris syndrome' above.)

Surgical techniques

-Small incision surgery, involving phacoemulsification of the lens and implantation of a synthetic intraocular lens, is the most commonly performed technique for cataract surgery in many countries. (See 'Surgical techniques' above.)

-Extracapsular cataract extraction (ECCE), including the variant manual small incision cataract surgery (MSICS), may be performed at the surgeon's preference or based on resources available. Intracapsular cataract extraction (ICCE) is rarely undertaken, as it does not allow for capsule-supported intraocular lens (IOL) placement and requires aphakic spectacle or contact lens correction or an anterior chamber or sutured IOL, each of which involves compromise compared with the long-term safety and full-time correction of a capsule-supported IOL. (See 'Surgical techniques' above.)

Postoperative care and follow-up – Patients are typically seen on the first postoperative day and then one week and one month post-surgery. Most surgeons advise restricted physical activity for days to weeks, though there is scant evidence basis for this. The final prescription for glasses is determined at one to three months. (See 'Postoperative care and follow-up' above.)

Complications – Infrequent complications include endophthalmitis, lens malposition/dislocation, cystoid macular edema, and retinal detachment. (See 'Complications' above.)

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Topic 6904 Version 75.0

References

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