Wait and Observe – Do Not Operate
In an adult with early cortical cataract and 6/6 visual acuity without visual symptoms, cataract surgery should NOT be performed; continued observation is the appropriate management. 1
Primary Contraindication to Surgery
The American Academy of Ophthalmology 2022 guidelines explicitly state that surgery for cataract should NOT be performed when "tolerable refractive correction provides vision that meets the patient's needs and desires" and when "surgery is not expected to improve visual function and no other indication for lens removal exists." 1
Key Decision Points
Visual Function Assessment
- The primary indication for cataract surgery is a decline in visual function such that it no longer meets a patient's visual needs, with reasonable likelihood of surgical improvement 1
- With 6/6 visual acuity and no symptoms, this patient's vision clearly meets their functional needs 1
- The absence of visual symptoms (no glare, no difficulty with daily activities, no reading problems) means there is no functional impairment requiring intervention 2, 3
Natural History of Early Cortical Cataracts
- Early cortical cataracts typically begin after age 45 and progress slowly over time 4, 5
- These opacities initially form in the equatorial deep lens cortex as small opaque shades that may take years to grow into segmental opacities 4
- The segregation mechanism in cortical cataracts effectively delays outgrowth into the pupillary space, meaning early opacities may remain non-visually significant for extended periods 4
Non-Surgical Management Strategy
Monitoring Protocol
- Schedule regular follow-up examinations to monitor cataract progression 1
- Assess for development of visual symptoms at each visit, specifically asking about reading difficulty, driving impairment, and distortional changes 1
- Update refractive correction as needed to account for any refractive shifts during early cataract development 1
Patient Education
- Counsel the patient about UV-B protection with brimmed hats and UV-blocking sunglasses to potentially slow progression 1
- Advise smoking cessation if applicable, as this is associated with lens opacities 1
- Inform the patient about symptoms that would warrant earlier surgical consideration (progressive vision decline, glare disability, functional impairment) 1, 2
When Surgery Would Become Appropriate
Surgery should be reconsidered when ANY of the following develop:
- Decline in visual acuity that no longer meets the patient's daily needs (reading, driving, work activities) 1, 2
- Symptomatic visual dysfunction despite optimal refractive correction 1, 3
- Clinically significant anisometropia in the presence of cataract 1
- Lens opacity interfering with diagnosis or management of posterior segment pathology 1
Common Pitfall to Avoid
Do not operate based solely on the presence of cataract on examination. The decision must be driven by functional visual impairment and patient symptoms, not by the mere existence of lens opacity 1, 3. Operating on asymptomatic patients with good visual acuity exposes them to surgical risks (endophthalmitis, retinal detachment, posterior capsule rupture) without meaningful benefit 6, 7.