What is the recommended treatment for cataracts?

Recommended Treatment for Cataracts

Surgery is the only effective treatment for cataracts—there are no proven pharmacological treatments to eliminate existing cataracts or retard their progression. 1

Primary Treatment: Surgical Intervention

Cataract surgery is indicated when visual function declines to the point that it no longer meets the patient's needs and surgery provides a reasonable likelihood of improvement. 1 This patient-centered approach prioritizes functional impairment over arbitrary visual acuity thresholds. 2

Surgical Technique

• Phacoemulsification with foldable intraocular lens (IOL) implantation is the gold standard surgical approach, performed as sutureless, small-incision surgery on an outpatient basis. 1
• This technique produces superior uncorrected distance visual acuity and lower complication rates (including iris prolapse and posterior capsule rupture) compared to manual extracapsular cataract extraction or manual small-incision techniques. 1
• The procedure limits astigmatic changes and enables specialty IOL implantation for optimal refractive outcomes. 1

Additional Surgical Indications Beyond Visual Symptoms

Surgery is also indicated when: 1

• Clinically significant anisometropia exists in the presence of cataract
• Lens opacity interferes with diagnosis or management of posterior segment pathology
• The lens causes inflammation and secondary glaucoma (phacolytic, lens particle, or phacoantigenic)
• The lens induces primary angle closure or other lens-related glaucoma

Contraindications to Surgery

Do not perform cataract surgery when: 1

• Tolerable refractive correction (glasses or contact lenses) provides vision meeting the patient's needs
• Surgery is not expected to improve visual function and no other indication for lens removal exists
• The patient cannot safely undergo surgery due to coexisting medical or ocular conditions
• Appropriate postoperative care cannot be arranged
• Informed consent cannot be obtained for nonemergent surgery

Nonsurgical Management (Temporizing Only)

Before surgery becomes necessary, limited nonsurgical options exist: 1

• Updating glasses or contact lens prescriptions can temporarily account for refractive shifts in early cataract stages
• Low-vision devices can maximize remaining vision or defer surgery in high-risk patients
• Pupil dilation may provide better vision around small central cataracts, though this worsens glare disability

Important Caveat on Pharmacological Treatments

There is insufficient evidence to support any pharmacological treatments for cataract, including N-acetylcarnosine drops per a 2017 Cochrane Systematic Review. 1 While animal studies with lanosterol showed promise in rabbits and dogs, 3 no human treatments have proven effective for reversing or preventing cataract progression. 3, 4

Outcomes and Benefits

Cataract surgery substantially improves vision-dependent functioning, with up to 90% of patients reporting improvement in functional status and satisfaction. 2 Additional benefits include: 2, 5

• Reduced fall risk (>30% reduction)
• Decreased dementia risk (20-30% reduction)
• Improved health-related quality of life
• Reduced glare symptoms
• Potential for reduced dependence on eyeglasses with advanced technology IOLs

Preoperative Considerations

The operating ophthalmologist should: 1

• Perform comprehensive preoperative examination documenting symptoms, findings, and surgical indications
• Obtain informed consent after discussing risks, benefits, expected outcomes, and refractive options
• Counsel regarding postoperative refractive options (bilateral emmetropia, myopia, or monovision)
• Discuss elective refractive options including astigmatism management and specialty IOLs (toric, multifocal, extended depth of focus)
• Assess ability to cooperate and position for surgery
• Ensure commitment to postoperative visits and address transportation/medication barriers

Common Pitfall: Unnecessary Preoperative Testing

Most patients do not require preoperative medical evaluation, bloodwork, or electrocardiogram, as three randomized trials failed to show this reduces complications. 1, 5 Patients do not need to discontinue anticoagulants for cataract surgery performed under topical anesthesia. 5

Exception: Patients taking systemic α1-adrenergic antagonists (e.g., tamsulosin) have increased surgical complication risk, and some ophthalmologists temporarily discontinue these medications preoperatively. 5