How should cataract be evaluated and managed in adults over 60 (including those with diabetes, long‑term steroid use, trauma or hereditary risk), covering indications for surgery, pre‑operative assessment (axial length, corneal curvature, ocular comorbidities, systemic conditions), phacoemulsification with intra‑ocular lens implantation, post‑operative regimen (topical moxifloxacin, prednisolone acetate or bromfenac, protective shield, activity restrictions, follow‑up schedule), and non‑surgical alternatives when surgery is contraindicated?

Cataract Evaluation and Management in Adults Over 60

Surgical Indications

Cataract surgery should be performed when the lens opacity impairs visual function to the point that it no longer meets the patient's daily visual needs and surgery offers a reasonable likelihood of improvement, with timing based on mutual agreement between patient and surgeon rather than arbitrary visual acuity thresholds. 1

Primary Indications for Surgery:

• Functional visual decline affecting activities of daily living (reading, driving, work tasks) despite optimal refractive correction 1, 2
• Lens opacity preventing adequate visualization of posterior segment disease (diabetic retinopathy, macular degeneration, glaucoma) requiring management 1
• Symptomatic visual dysfunction including progressive blurring, glare disability, or visual distortions that impede quality of life 3, 4
• Lens-induced complications such as intraocular inflammation or secondary glaucoma 5

When Surgery Should NOT Be Performed:

• Vision with refractive correction already satisfies the patient's functional needs 2
• Patient is asymptomatic with good visual acuity (e.g., 6/6 vision with early cortical cataract) 2
• No other ocular indication for lens removal exists 2

Important caveat: Surgery reduces falls by >30% and dementia risk by 20-30% in older adults, making it beneficial even when visual symptoms are mild if functional impairment exists 3

---

Pre-Operative Assessment

Biometry and Optical Measurements:

• Axial length measurement for IOL power calculation 1
• Corneal curvature (keratometry) assessment 1
• Discussion of IOL options: astigmatic, multifocal, extended depth of focus, accommodating, postoperatively power-adjustable, and monovision alternatives to reduce spectacle dependence 1
• Establish refractive goals: bilateral emmetropia, bilateral myopia, monovision, and management of anisometropia between procedures 1

Ocular Comorbidity Screening:

• Diabetic retinopathy assessment in all diabetic patients requires dilated comprehensive examination by an ophthalmologist experienced in diabetic retinopathy 6
• Glaucoma evaluation to consider combined minimally invasive glaucoma surgery if mild-to-moderate disease present 1
• Macular pathology screening (age-related macular degeneration, epiretinal membrane) 1
• Corneal endothelial assessment for risk of postoperative edema 1

Systemic Condition Management:

Diabetes:

• Optimize glycemic control preoperatively, though no evidence-based HbA1c threshold contraindicates surgery 6
• Target perioperative blood glucose 100-180 mg/dL to minimize infection risk 6
• Proceed immediately if mature cataract prevents diabetic retinopathy assessment or severely impairs safety 6
• Continue intensive diabetes treatment perioperatively without interruption 6

Long-term Corticosteroid Use:

• Recognize significantly elevated risk of posterior subcapsular cataract formation 7
• Regular ophthalmologic monitoring for early detection 7
• No specific preoperative steroid adjustment required for surgery itself

Trauma History:

• Assess for zonular weakness, capsular compromise, or lens subluxation 7
• Plan for potential capsular tension ring or alternative fixation techniques

Hereditary Risk:

• Positive family history correlates with certain cataract types but does not alter surgical approach 7

Medication Review:

• Systemic α1-adrenergic antagonists (tamsulosin): Some ophthalmologists temporarily discontinue preoperatively due to increased risk of intraoperative floppy iris syndrome 3
• Anticoagulants: Do NOT discontinue for cataract surgery performed under topical anesthesia 3
• No preoperative general medical testing (bloodwork, ECG) required for topical anesthesia cases 3

---

Surgical Procedure

Standard technique is sutureless, small-incision phacoemulsification with foldable IOL implantation performed on an outpatient basis under topical anesthesia. 2, 3

Intraoperative Antibiotic Administration:

• Intracameral antibiotic injection (moxifloxacin or cefuroxime) reduces postoperative endophthalmitis risk from 0.07% to 0.02% 1, 3
• Topical antibiotics do NOT add benefit beyond intracameral injection 1

Combined Procedures:

• Minimally invasive glaucoma surgery enhances IOP-lowering effects in patients with mild-to-moderate glaucoma 1

---

Post-Operative Regimen

Topical Anti-Inflammatory Therapy:

Prednisolone acetate 1% is most effective for controlling anterior chamber cells and flare, while NSAIDs (bromfenac, ketorolac, nepafenac) better control ocular pain and hyperemia in early postoperative periods. 8, 9

Recommended regimen:

• Prednisolone acetate 1%: 4 times daily for 2-4 weeks 8, 9
• Bromfenac 0.09%: 2-3 times daily for 1 month to reduce cystoid macular edema risk, though long-term benefit not demonstrated 1, 8, 9
• Combination therapy (prednisolone + bromfenac) results in optimal clinical outcomes with reduced central foveal thickening 9

Critical point: Topical NSAIDs reduce early postoperative cystoid macular edema incidence but long-term benefit has not been demonstrated 1

Protective Measures and Activity Restrictions:

• Protective eye shield during sleep for first week 1
• Avoid eye rubbing, heavy lifting (>10 lbs), and strenuous activity for 1-2 weeks 1
• No swimming or hot tubs for 2 weeks to reduce infection risk 1

Follow-Up Schedule:

• Day 1 postoperative: Assess visual acuity, IOP, anterior chamber reaction, corneal clarity 1
• Week 1: Monitor for elevated IOP, corneal edema, inflammation 1
• Weeks 2-4: Assess visual rehabilitation, refractive outcome, complications 1
• Diabetic patients: Continue annual diabetic retinopathy screening indefinitely, as underlying disease remains and may progress 6

Complication Monitoring:

• Elevated intraocular pressure 1
• Corneal edema 1
• Cystoid macular edema (particularly in diabetic patients) 1, 6
• Endophthalmitis (0.02% with intracameral antibiotics) 3
• Posterior capsular opacification requiring YAG laser capsulotomy 6
• Retinal detachment 3

---

Non-Surgical Management When Surgery Contraindicated or Declined

Observation and Monitoring:

• Regular follow-up examinations to monitor cataract progression 2
• Update refractive correction as needed to accommodate refractive shifts during cataract development 2
• Specifically inquire about new reading difficulty, driving impairment, or visual distortions at each visit 2

Prevention of Progression:

• UV-B protection: Brimmed hats and UV-blocking sunglasses to slow progression 7, 2
• Smoking cessation: Reduces risk of cataract development and progression 7, 2
• Optimize systemic disease control: Diabetes, hypertension, obesity management may reduce risk 7
• Radiation protection: Lead glasses and shields for occupational exposure 7

When Non-Surgical Management Fails:

• Reconsider surgery when progressive vision loss, glare disability, or functional impairment emerges despite optimal refractive correction 2
• Waiting >4 months after surgery is clearly indicated can result in vision-related complications such as falls and accidents 2

Critical warning: Once visual acuity declines from cataract, the disease progresses with no chance of spontaneous reversal; 60% of eyes with full-thickness cataracts lose ≥2 lines of vision over 5 years, and 70-80% reach 20/200 or worse visual acuity after 3-5 years without surgery 7