What is the prevalence and treatment of cataracts in the elderly?

Cataracts in the Elderly: Prevalence and Management

Cataracts are extremely common in the elderly, affecting approximately two-thirds of adults over age 80, and cataract surgery is the definitive treatment when visual impairment affects daily activities. 1

Prevalence

Cataracts represent a major public health burden in the aging population:

• Approximately 67% of individuals over 80 years old develop cataracts, making age the strongest predictor of cataract development 1
• The prevalence increases dramatically with age: among those 65-75 years, rates range from 21.6% to 39.1% depending on demographic factors 2
• In the United States alone, over 3.5 million cataract operations are performed annually, and this number is projected to reach 50 million affected individuals by 2050 as the population ages 1
• Age-related cataracts are the leading cause of blindness worldwide and one of the most common causes of visual impairment in the United States 3

Clinical Presentation and Types

Three main morphologic types exist, with nuclear cataracts being most prevalent:

• Nuclear opacity is the most common type (38.9% prevalence), followed by cortical opacity (21.9%) and posterior subcapsular opacity (9.2%) 4
• Patients typically present with painless, progressive blurring of vision and visual glare 1
• Functional consequences include loss of driving privileges, inability to read or watch television, inability to participate in social activities, and a 30% increased risk of falls 3, 1

Risk Factors Beyond Age

While age is the primary driver, multiple modifiable and non-modifiable factors increase risk:

• Female gender is associated with higher prevalence (64.0% vs 56.1% in men) 4
• Modifiable risk factors include diabetes (especially uncontrolled), smoking, obesity, poor nutrition, significant UV exposure, alcohol use, and corticosteroid use 3, 1
• Non-modifiable factors include family history, genetic predisposition, ocular trauma, radiation therapy, and certain conditions like retinitis pigmentosa, Down syndrome, and congenital rubella 1
• Higher systolic blood pressure is associated with increased risk, particularly for cortical and posterior subcapsular cataracts 4

Definitive Treatment: Surgical Intervention

Surgery is the only definitive treatment for cataracts—there is no medical therapy available. 3, 5

Surgical Technique and Outcomes

• Phacoemulsification with posterior chamber intraocular lens (IOL) implantation is the standard surgical approach in the United States 3
• Surgery is indicated when visual impairment impedes activities of daily living 1
• Cataract surgery reduces fall rates by more than 30% and dementia risk by 20-30%, in addition to reversing progressive vision loss 1

Perioperative Management Considerations

Most cataract operations are performed with topical anesthesia, eliminating the need for routine preoperative testing:

• No preoperative bloodwork or electrocardiogram is required for routine cataract surgery 1
• Anticoagulants do not need to be discontinued for the procedure 1
• Alpha-1 adrenergic antagonists (such as tamsulosin) increase surgical complication risk, and some ophthalmologists temporarily discontinue these medications preoperatively 1
• Intraocular antibiotics (moxifloxacin or cefuroxime) delivered intraoperatively have reduced sight-threatening endophthalmitis rates from 0.07% to 0.02% 1

Refractive Options

• Standard IOLs correct distance vision, with glasses prescribed for residual refractive errors 3
• Advanced technology IOLs (such as multifocal designs) can reduce eyeglass dependence but involve additional out-of-pocket costs not covered by medical insurance 1

Common Pitfall

The most critical pitfall is delaying surgical referral until cataracts are "ripe"—this outdated concept leads to unnecessary visual disability, increased fall risk, and cognitive decline. Surgery should be considered as soon as visual impairment affects the patient's quality of life or daily activities, not when cataracts reach arbitrary severity thresholds 1.