What are the typical exam findings and management for cataracts?

Cataracts Exam Findings and Management

The diagnosis of cataracts requires a comprehensive ophthalmic evaluation including slit-lamp biomicroscopy after pupillary dilation to identify lens opacities, along with assessment of visual function through visual acuity testing, glare testing, and contrast sensitivity evaluation when indicated. 1

Clinical Presentation and Symptoms

• Painless, progressive blurring of vision is the most common symptom of cataracts 2
• Visual glare, especially in bright lighting conditions or while driving at night 1
• Monocular diplopia or ghosting of images due to irregular refraction through the lens 3
• Myopic shift ("second sight") as nuclear sclerosis progresses 3
• Changes in color perception, typically with colors appearing more yellow or brown 3
• Reduced contrast sensitivity affecting daily activities 1

Examination Findings

Visual Function Assessment

• Decreased visual acuity at distance and/or near that may not improve with refraction 1
• Impaired contrast sensitivity testing, especially in real-world conditions 1
• Significant reduction in visual acuity with glare testing (indicates functional disability greater than Snellen acuity alone suggests) 1
• Potential acuity testing may help determine visual potential in cases with coexisting retinal pathology 1

Slit-Lamp Biomicroscopy

• Nuclear cataracts: yellowing or brunescence of the central lens nucleus 3, 4
• Cortical cataracts: wedge-shaped or spoke-like opacities in the lens cortex 3, 4
• Posterior subcapsular cataracts: granular opacities at the posterior lens capsule 3, 4
• Mixed cataracts: combination of different types of opacities 4

Additional Examination Elements

• Pupillary assessment to rule out other causes of visual impairment 1
• Intraocular pressure measurement 1
• Dilated fundus examination to evaluate for coexisting retinal or optic nerve pathology 1
• Assessment of ocular alignment and motility 1

Supplemental Testing When Indicated

• Corneal topography/tomography to assess for corneal irregularities that may affect surgical planning 1
• Optical coherence tomography of the macula to rule out concurrent retinal pathology 1
• Specular microscopy in patients with suspected endothelial compromise 1
• Biometry for intraocular lens calculations prior to surgery 1
• Wavefront analysis may help quantify visual aberrations caused by cataracts 1

Classification and Grading

• The Lens Opacity Classification System III (LOCS III) is the gold standard for research purposes, comparing lens opacities to standard photographs 4
• Advanced imaging technologies including Scheimpflug imaging and OCT provide objective assessment of lens structure 4
• Classification based on anatomical distribution (nuclear, cortical, posterior subcapsular) helps guide management and surgical planning 3, 4

Management

Non-Surgical Management

• Optimization of spectacle correction for early cataracts 1
• Management of contributing factors (e.g., controlling diabetes, discontinuing medications that accelerate cataract formation when possible) 1, 2
• Consideration of glare-reducing lenses for driving and outdoor activities 1

Surgical Management

• Surgery is indicated when visual impairment from cataracts affects activities of daily living despite optimal correction 1, 2
• Phacoemulsification with intraocular lens implantation is the standard surgical approach 2
• Special considerations for patients on alpha-1 antagonists (e.g., tamsulosin) due to risk of intraoperative floppy iris syndrome 1, 2
• Intraoperative antibiotics (moxifloxacin or cefuroxime) reduce the risk of endophthalmitis 2
• Advanced technology intraocular lenses may reduce dependence on glasses but have additional costs not covered by insurance 2

Important Considerations and Pitfalls

• Visual acuity alone may underestimate the functional impact of cataracts; glare testing and contrast sensitivity provide additional information 1
• Always rule out other causes of vision loss before attributing symptoms solely to cataracts 1, 3
• Consider secondary causes of cataracts (medications, trauma, systemic diseases) before concluding age-related etiology 3
• Patients may not need to discontinue anticoagulants for modern cataract surgery 2
• Preoperative general medical testing (bloodwork, ECG) is typically not required for cataract surgery under topical anesthesia 2