What is the appropriate management for an adult with a visually significant cataract, including pre‑operative evaluation, cataract extraction with intra‑ocular lens (IOL) implantation, postoperative medication regimen, and alternatives if surgery is contraindicated?

Management of Visually Significant Cataract in Adults

The primary management of visually significant cataract is surgical removal via phacoemulsification with intraocular lens (IOL) implantation, as this is the only effective treatment to restore vision and improve quality of life. 1

Indications for Surgery

Surgery is indicated when visual decline no longer meets the patient's functional needs and surgery offers reasonable likelihood of improvement. 1, 2

Additional indications include: 1

• Clinically significant anisometropia in the presence of cataract
• Lens opacity interfering with diagnosis or management of posterior segment disease
• Lens-induced inflammation causing secondary glaucoma (phacolytic, lens particle, or phacoantigenic)
• Lens-induced angle closure or other forms of lens-related glaucoma

Contraindications to Surgery

Surgery should not be performed when: 1

• Tolerable refractive correction provides vision meeting the patient's needs
• Surgery is not expected to improve visual function and no other indication exists
• Patient cannot safely undergo surgery due to coexisting medical or ocular conditions
• Appropriate postoperative care cannot be arranged
• Patient or surrogate cannot provide informed consent for nonemergent surgery

Preoperative Evaluation

The operating ophthalmologist must perform a comprehensive preoperative assessment including: 1

Clinical Assessment:

• Complete ophthalmic examination documenting symptoms, findings, and surgical indications
• Assessment of mental and physical status, including ability to cooperate and position for surgery
• Evaluation of ocular comorbidities and their impact on surgical planning
• Assessment of concurrent blepharoptosis, which can induce corneal astigmatism or worsen postoperatively 1

Patient Counseling:

• Obtain informed consent after discussing risks, benefits, expected outcomes, and surgical experience 1
• Counsel on postoperative refractive options (bilateral emmetropia, bilateral myopia, or monovision) 1
• Discuss elective refractive options including astigmatism management, specialty IOLs (toric, extended depth of focus, multifocal, accommodating, power adjustable), and postoperative enhancement 1
• Address barriers to communication including language or hearing impairment 1
• Ensure patient and caregiver commitment to attend postoperative visits and address transportation, medication administration, and other challenges 1

Surgical Planning:

• Formulate comprehensive plan including preoperative medical management, anesthesia selection, surgical approach, concurrent procedures, and IOL design and power 1

Surgical Technique

Phacoemulsification with foldable IOL implantation is the preferred surgical method, performed as outpatient sutureless small-incision surgery. 1, 2, 3

Advantages of phacoemulsification over manual extracapsular extraction: 1

• Better uncorrected distance visual acuity
• Lower surgical complication rates (reduced iris prolapse and posterior capsule rupture)
• Minimal astigmatic changes due to smaller incisions
• Enables astigmatism management and specialty IOL implantation

Anesthesia considerations: 3

• Most operations performed with topical anesthesia
• No preoperative general medical testing required (bloodwork or electrocardiogram unnecessary)
• Anticoagulants do not need discontinuation for cataract surgery

Medication considerations: 3

• Systemic α1-adrenergic antagonists (tamsulosin for benign prostatic hyperplasia) increase surgical complication risk; some ophthalmologists temporarily discontinue preoperatively
• Intraoperative intraocular antibiotics (moxifloxacin or cefuroxime) reduce postoperative endophthalmitis rates from 0.07% to 0.02%

Postoperative Management

Standard postoperative care includes 3-4 follow-up visits in uncomplicated cases. 4

Common postoperative issues:

• Posterior capsule opacification (PCO) is the most common side effect but generally harmless, treatable with neodymium:yttrium-aluminum-garnet (Nd:YAG) capsulotomy 4, 5
• Endophthalmitis is the most feared complication requiring immediate treatment 4

Nonsurgical Management (When Surgery Deferred)

When surgery is not yet indicated or must be deferred: 1

• Update glasses or contact lens prescriptions to account for refractive shifts in early cataract stages
• Low-vision devices can maximize remaining vision pending surgery or allow deferral in high-risk patients
• Pupil dilation may provide better vision around small central cataracts as temporizing measure, though this may worsen glare disability

No pharmacological treatments exist to eliminate cataracts or retard progression; insufficient evidence supports N-acetylcarnosine drops per 2017 Cochrane Review. 1, 6

Special Considerations

For patients with glaucoma and cataract: 1, 6

• Cataract surgery alone may be adequate if IOP controlled on 1-2 medications, with additional benefit of modest IOP reduction (average 16.5% decrease)
• Combined cataract-glaucoma surgery is less effective at lowering IOP than glaucoma surgery alone but may be appropriate in select cases
• Mitomycin C use (not 5-fluorouracil) results in lower IOP in combined procedures

For patients with low vision from other conditions: 7

• Cataract surgery offers subjective and objective benefits even in patients with coexisting retinal disease like age-related macular degeneration
• 85% of low-vision patients noted improvement in visual function and would consent to surgery again
• Patients may be more receptive to low-vision services and devices postoperatively when visual rehabilitation prognosis improves

Outcomes and Benefits

Cataract surgery provides substantial benefits: 2, 3

• Up to 90% of patients undergoing first-eye surgery report improvement in functional status and vision satisfaction
• Reduces fall risk by >30% and dementia risk by 20-30%
• Improves health-related quality of life and patient safety
• Can reduce dependence on eyeglasses with advanced technology IOLs (though these incur additional costs not covered by insurance)