What is the care plan for a patient with cataract?

Care Plan for Cataract

The primary care plan for patients with cataracts involves surgical intervention when visual function no longer meets the patient's needs and surgery provides a reasonable likelihood of improvement. 1 Phacoemulsification with foldable intraocular lens (IOL) implantation is the preferred surgical method due to better visual outcomes and lower complication rates. 2

Assessment and Diagnosis

• Identify cataract characteristics (nuclear, cortical, posterior subcapsular) and their impact on visual function 1
• Document symptoms including:
  • Blurred vision
  • Glare sensitivity
  • Poor contrast sensitivity
  • Impact on daily activities (reading, driving)
  • Functional limitations

Management Algorithm

1. Early/Mild Cataract Management

For patients with early cataracts or those not yet ready for surgery:

• Refractive correction adjustments:

  • Update glasses or contact lens prescriptions to compensate for refractive shifts 1
  • Consider low-vision devices to maximize remaining vision 2

• Environmental modifications:

  • Improve lighting conditions
  • In limited circumstances, pupil dilation may temporarily improve vision around small central cataracts (note: may worsen glare) 2

• Risk factor management:

  • Advise smoking cessation (reduces risk of progression) 2
  • Recommend UV-B blocking sunglasses and brimmed hats 2
  • Suggest safety glasses for high-risk activities 2
  • Review medications that may accelerate cataract formation (especially corticosteroids) 2

2. Surgical Intervention

Indications for Surgery 2:

• Visual function no longer meets patient's needs
• Clinically significant anisometropia due to cataract
• Lens opacity interfering with management of posterior segment pathology
• Lens-induced inflammation or glaucoma
• Lens-induced angle closure

Contraindications to Surgery 2:

• Tolerable refractive correction provides adequate vision
• Surgery not expected to improve visual function
• Patient cannot safely undergo surgery due to comorbidities
• Appropriate postoperative care cannot be arranged
• Informed consent cannot be obtained

Preoperative Evaluation 2:

1. Complete ophthalmic examination
2. Document symptoms, findings, and indications
3. Obtain informed consent after discussing risks, benefits, and expected outcomes
4. Review presurgical evaluation results with patient
5. Counsel on postoperative refractive options
6. Discuss elective refractive options (astigmatism management, specialty IOLs)
7. Consider impact of ocular comorbidities
8. Formulate surgical plan (anesthesia, approach, IOL selection)
9. Assess patient's mental and physical status
10. Create postoperative care plan
11. Evaluate for concurrent blepharoptosis
12. Address patient questions about surgery and costs
13. Assess communication barriers
14. Ensure patient commitment to postoperative care

3. Surgical Approach

• Preferred method: Sutureless small-incision phacoemulsification with foldable IOL implantation 2, 1

  • Produces better uncorrected distance visual acuity
  • Lower rate of surgical complications
  • Enables astigmatism management and specialty IOL implantation
  • Performed on outpatient basis

• Alternative methods (for resource-limited settings):

  • Manual small-incision cataract extraction (MSICS)
  • Extracapsular cataract extraction (ECCE) 2

4. Perioperative Medication Management

• Antiplatelet therapy: Can generally be continued during surgery 1
• Systemic α1-adrenergic antagonists (e.g., tamsulosin): May increase surgical complications; some ophthalmologists temporarily discontinue preoperatively 3
• Intraocular antibiotics: Moxifloxacin or cefuroxime delivered intraoperatively reduces endophthalmitis rates from 0.07% to 0.02% 3

5. Postoperative Care

• Appropriate follow-up schedule
• Visual rehabilitation
• Treatment of complications
• Management of dry eye
• Continuation of necessary medications 1

Important Considerations

• No proven pharmacological treatments: Currently, there are no medications proven to eliminate existing cataracts or retard progression 2, 1
• Future developments: Research on potential pharmacological treatments is ongoing, including lanosterol therapy which showed promise in animal studies 4, 5
• Refractive benefits: Beyond vision restoration, cataract surgery can reduce dependence on eyeglasses through advanced technology IOLs (multifocal, toric), though these may involve additional costs not covered by insurance 3
• Impact on quality of life: Cataract surgery is associated with lower rates of falls (>30%) and dementia (20%-30%) 3

Special Populations

• Congenital cataracts: Require early intervention to prevent amblyopia; genetic testing is recommended to identify underlying causes and guide multidisciplinary management 6
• Patients with diabetes: Require careful monitoring as they have increased risk of cataract formation 2

Pitfalls to Avoid

• Delaying referral for surgical evaluation when visual function impacts quality of life
• Overlooking systemic conditions that may increase surgical risk
• Failing to manage patient expectations regarding refractive outcomes
• Neglecting to counsel on risk factor modification (smoking cessation, UV protection)
• Assuming pharmacological treatments can effectively treat or prevent cataracts