Indications for Phacoemulsification
The primary indication for phacoemulsification is a decline in visual function that no longer meets a patient's visual needs and for which surgery provides a reasonable likelihood of improvement. 1
Primary Indications
Phacoemulsification is indicated in the following scenarios:
- Visual function decline: When cataract causes functional impairment affecting daily activities
- Clinically significant anisometropia: When there is unequal refractive error between eyes due to cataract
- Interference with posterior segment management: When lens opacity prevents diagnosis or treatment of retinal conditions
- Lens-induced inflammation or glaucoma: Including phacolytic, lens particle, or phacoantigenic glaucoma
- Angle closure glaucoma: When the lens induces primary angle closure or other lens-related glaucoma 1
Functional Impairment Assessment
Insurance criteria typically require documentation of:
- Subjective visual complaints
- Impact on lifestyle and daily activities
- Best correctable visual acuity (typically 20/40 or better)
- Confirmation that cataract is the limiting factor for visual improvement 2
When visual acuity is 20/40 or better, objective glare disability testing (such as brightness acuity testing or contrast sensitivity testing) is necessary to confirm functional impairment in bright light conditions. 2
Contraindications
Phacoemulsification should not be performed when:
- Tolerable refractive correction provides vision that meets the patient's needs
- Surgery is not expected to improve visual function with no other indication for lens removal
- Patient cannot safely undergo surgery due to medical or ocular conditions
- Appropriate postoperative care cannot be arranged
- Patient or surrogate cannot provide informed consent for non-emergent surgery 1
Special Considerations
Dry Eye Disease Management
For patients with visually significant dry eye disease (DED):
- Surgery should be postponed until significant improvement is observed
- More aggressive treatment approach is recommended starting at step 2 of treatment algorithms
- Multiple simultaneous treatments may be needed to restore tear film homeostasis 1
Hard Cataracts
For patients with hard cataracts, consider that:
- Phacoemulsification carries a significantly higher risk of severe endothelial cell loss compared to manual extracapsular cataract extraction (ECCE) in these cases 3
- ECCE may be preferred for very hard cataracts to minimize endothelial damage while achieving similar visual outcomes 3
Comorbid Glaucoma
- Phacoemulsification can be combined with minimally invasive glaucoma surgery to enhance intraocular pressure-lowering effects in patients with mild to moderate glaucoma 1
- CO2 laser-assisted sclerectomy surgery (CLASS) combined with phacoemulsification has shown effectiveness for patients with primary open-angle glaucoma and visually significant cataracts 4
Outcomes and Benefits
Phacoemulsification offers several advantages:
- Improved visual function and quality of life in patients with senile cataracts 5, 6
- Better uncorrected distance visual acuity compared to manual small-incision cataract surgery 7
- Lower rate of surgical complications such as iris prolapse and posterior capsule rupture 1
- Limits astigmatic changes that occur with larger incisions 1
- Enables astigmatism management and implantation of specialty IOLs 1
Risk Factors for Suboptimal Outcomes
Factors associated with excessive endothelial cell loss (≥15% by 1 year) include:
- Hard cataracts (odds ratio: 2.1)
- Advanced age (odds ratio: 1.04 per year)
- Capsule or vitreous loss during surgery (odds ratio: 2.38) 3
In patients with these risk factors, enhanced clinical intervention and evaluation is required to reduce the risk of poor postoperative vision. 5