Cataracts in Adults

Background

• Cataracts are the opacification of the intraocular lens (IOL), resulting in vision changes.
• Cataracts are the most common cause of reversible blindness worldwide.
• They are typically due to aging but may be caused or accelerated by other factors such as diabetes mellitus, tobacco smoking, eye trauma, use of corticosteroids, or some psychotropic medications.
• Age-related cataracts are classified by the part of the lens that is primarily affected and include the following types (can present alone or in combination):
  • nuclear cataract (nuclear sclerosis cataract)
  • cortical cataract
  • posterior subcapsular cataract
• Posterior polar cataract is associated with a preexisting weakness of the posterior capsule or an abnormal adhesion of the posterior capsule to the polar opacity. It can increase risk of posterior capsule rupture during cataract surgery.

Evaluation

• Cataracts may present as lens opacities detected during a routine eye exam in asymptomatic patients.
• Patients may report a gradual painless loss of distance vision and/or near vision in 1 or both eyes.
  • Changes are typically bilateral but often asymmetrical.
  • Functional impairment may include difficulty reading, problems with glare, and trouble with night driving.
• To diagnose cataracts and assess cataracts that produce symptoms or interfere with vision, perform a comprehensive eye exam including:
  • best corrected visual acuity
  • pupil assessment
  • extraocular motility
  • measurement of intraocular pressure
  • slit-lamp examination of the anterior segment
  • dilation of pupil for assessment of lens, vitreous, optic nerve, macula, and peripheral retina
  • brightness acuity testing (glare testing)
• Exclude other causes of reduced vision, including refractive error, glaucoma, and age-related macular degeneration.

Management

• The management of symptomatic cataract is primarily surgical.
• Cataract surgery is indicated when visual function no longer meets the patient's needs and surgery is likely to improve vision (Strong recommendation).
  • Cataract surgery can be performed using local (preferred) or general anesthesia.
  • Small-incision phacoemulsification is the procedure of choice and the most commonly used method in the United States.
  • An IOL is implanted following cataract removal to correct refractive errors.
• Major postoperative complications with the potential to result in vision loss are rare.
  • There is an increased risk of intraoperative floppy iris syndrome in patients taking tamsulosin.
  • Topical nonsteroidal anti-inflammatory drugs prior to cataract surgery may improve outcomes and reduce risk for cystoid macular edema.
  • Prophylaxis against postoperative endophthalmitis is recommended (Strong recommendation).
    • Use a 5% solution of povidone iodine in the conjunctival cul de sac to help prevent infection and risk of postoperative endophthalmitis (Strong recommendation).
    • Use an intracameral moxifloxacin injection to reduce risk for endophthalmitis (Strong recommendation).