Cataract - Treatment of Adults

Effective Date: September 1, 2005
Revised Date : April 1, 2007

Recommendations and Topics

Scope

1. Non-Surgical Management

2. Surgical Management

3. Contraindications for Surgery

4. Second Eye Surgery

Benefits, Risks and Costs

References

Sponsors

 

Scope

This guideline provides recommendations for the management of cataracts in adults (age 19 and older). The goal is to:

  1. improve visual function
  2. improve independence and quality of life
  3. resolve medical disease induced by cataracts
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RECOMMENDATION 1: Non-Surgical Management

During early cataract development, visual improvement may be achieved through a number of means including:

  • changes in spectacle lens prescription
  • use of strong bifocals
  • magnification or other visual aids
  • appropriate illumination

Pupillary dilatation has a limited role in the management of posterior subcapsular cataracts.

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RECOMMENDATION 2: Surgical Management

The presence of a cataract does not itself indicate a need for surgery. Cataract surgery may be indicated when the cataract reduces visual function to a level that interferes with everyday activities of the patient and the patient desires surgical intervention to improve vision.

Glare testing and potential acuity testing can be useful in certain cases in the decision to recommend or not recommend cataract surgery.

The following specific indications for cataract surgery are suggested:

a) Visual disability and Snellen Acuity of 20/50 or worse

The visual impairment produced by the cataract is responsible for the patient's disability in carrying out needed or desired activities (driving, reading, occupational needs) and the best correctable visual acuity in the affected eye is 20/50 or worse.

b) Visual disability and Snellen Acuity of 20/40 or better

The visual impairment produced by the cataract is responsible for the patient's disability in carrying out needed or desired activities (driving, reading, occupational needs), as documented by any of the following reasons:

  • visual disability increases due to glare or dim illumination
  • patient complains of monocular diplopia or polyopia
  • visual disparity exists between the two eyes

and the best correctable visual acuity in the affected eye is 20/40 or better.

c) Other indications for cataract removal

  • Lens-induced disease: phacomorphic glaucoma, phacolytic glaucoma, and other lens-induced disease may require cataract surgery and the need for extraction may be urgent.
  • Concomitant ocular disease that requires clear media: cataract extraction may be required to adequately diagnose other ocular conditions such as diabetic retinopathy.

d) Visual ability in patients legally blind in one eye

The indications for surgery in patients with cataract in one eye who are legally blind in the other eye are the same as for other patients, except that the risk of total blindness must be considered and emphasized.

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RECOMMENDATION 3: Contraindications for Surgery

Surgery should not be performed solely to improve vision if:

  1. the patient does not desire surgery
  2. glasses or other visual aids provide functional vision satisfactory to the patient
  3. the patient's quality of life is not compromised
  4. the patient is medically unfit
  5. the patient has concomitant disease where functional improvement is unlikely
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RECOMMENDATION 4: Second Eye Surgery

Although the risks of loss of an eye or blindness in cataract surgery are very small, only in very exceptional circumstances where there are documented medical reasons should surgery be done on both eyes at the same time.

In individuals who are pseudophakic in one eye and require cataract surgery at a later date, an interval of at least one week should occur to assess the benefit of the first surgery before the second eye is done (endophthalmitis may not be evident until 7 days after surgery).

Evidence

The Cataract Guideline Working Group of the Guidelines and Protocols Advisory Committee (GPAC) reviewed the guideline Treatment of Cataract in Adults, developed in 1996 by the British Columbia Council on Clinical Practice Guidelines. The Working Group was made up of practising physicians including cataract experts, an endocrinologist/internist, general practitioners, and a Ministry of Health medical consultant.

The Council's 1996 guideline was adapted from the work of the College of Physicians and Surgeons of B.C., which was based on the Agency for Health Care Policy and Research (AHCPR) guideline of 1993. The AHCPR stated that there was a lack of literature demonstrating precise indications for surgery and recommended adoption of the American Academy of Ophthalmology's (AAO) 1989 and 1991 Preferred Practice Patterns (PPP), which, the AHCPR stated, lacked scientific evidence to support their validity, but were developed by an exhaustive consensus method. The 1989 and 1991 PPPs are superseded by the AAO's 1996 PPP Cataract in the Adult Eye. This GPAC Working Group revised guideline remains consistent with AAO recommendations.

The Cataract Guideline Working Group reviewed material published since the release of the 1996 B.C. guideline, as well as the original literature. The Working Group found that while some new material has added to the general knowledge base and to the body of evidence regarding indications for and outcomes of cataract surgery, there are still relatively few published papers concerning evidence for the procedure and its outcomes. There are studies underway that could, in future, contribute to a stronger evidence base.

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Benefits, Risks and Costs

Cataracts are one of the more common problems associated with ageing and occur as well, for specific medical reasons, in younger individuals.

Benefits:

The primary benefit of both surgical and non-surgical treatment of cataracts is the functional rehabilitation of affected individuals leading to an improvement in vision and greater autonomy and independence.

A review of the literature shows that if no co-morbid ocular conditions exist, cataract surgery results in an improvement in visual acuity in >95 per cent of patients and, if there is co-morbidity, an improvement in visual acuity in >80 per cent of patients. If the patient has other vision problems, such as macular degeneration, the improvement in visual acuity can be less than 80 per cent.

Risks:

Risks include anaesthetic and surgical complications (serious complications include endophthalmitis, retinal detachment and hemorrhage), decreased vision and blindness (less than 1:1000), and general complications associated with surgery in the elderly, especially those with other or multisystem illness. Complications are rare, the most common post-operative complication being posterior capsular opacity which may occur in up to 40 per cent of patients using polymethylmethacrylate lenses. These can be treated by Nd:YAG laser surgery.

Costs:

The cost of cataract treatment to the health system is significant. In 2003/04, 40,000 cataract surgeries were performed at a cost of $17 million in surgical fees alone. Other significant costs include fees for anaesthesia, consultations and office visits, and office expenses for equipment and staff.

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References

  1. Apple DJ, Solomon KD, Tetz MR, Assia EI, Holland EY, Legler UF, et al. Posterior capsule opacification. Surv Ophthalmol 1992;37:73-116.
  2. Cataract Guideline Management Panel. Cataract in adults: management of functional impairment. Clinical practice guideline, number 4. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1993 Feb. AHCPR Pub. No. 93-0542.
  3. Cataract in the adult eye. Preferred practice pattern. San Francisco: American Academy of Ophthalmology; 1996 Sep.
  4. Detry-Morel M. [Combined interventions: cataract and glaucoma review of the literature]. [Article in French] Bull Soc Belge Ophtalmol 1998;268:45-60.
  5. Guideline for surgical & non-surgical management of cataract in the otherwise healthy adult eye. Edmonton (AB): Alberta Clinical Practice Guidelines Program; 1999 Jun.
  6. Guideline for the management of cataracts in adults. Vancouver (BC): College of Physicians and Surgeons of British Columbia; 1996 Feb.
  7. Hove MT, Siegel K, Groll D, Hopman W, MacKenzie T. The measurement of quality of life in patient with unilateral visual impairment [abstract]. Abstr Book Assoc Health Serv Res 1998;187.
  8. Lee PP. Understanding the American Academy of Ophthalmology's preferred practice pattern for cataract. Int Ophthalmol Clin 1998;38:87-92.
  9. Nishi O. Posterior capsule opacification. Part 1: experimental investigations. J Cataract Refract Surg 1999;25:106-17.
  10. Powe NR, Schein OD, Gieser SC, Tielsch JM, Luthra R, Javitt J, et al. Synthesis of the literature on visual acuity and complications following cataract extraction with intraocular lens implantation. Cataract Patient Outcome Research Team [published erratum appears in Arch Ophthalmol 1994 Jul;112:889]. Arch Ophthalmol 1994;112:239-52.
  11. Hove M, Siegel K, Groll D, Hopman W. Evaluating the quality of life in patients undergoing surgery to restore bilateral sight [abstract]. Annu Meet Int Soc Technol Assess Health Care 1998;14:83.
  12. Treatment of cataract in adults. Victoria (BC): British Columbia Medical Association and Medical Services Commission; 1996 Oct.
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Sponsors

This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association and adopted by the Medical Services Commission.

Funding for this guideline was provided in full or part through the Primary Health Care Transition Fund.

Revised Date: April 1, 2007

This guideline is based on scientific evidence current as of the effective date.

 

The principles of the Guidelines and Protocols Advisory Committee are to:

  • encourage appropriate
    responses to common
    medical situations
  • recommend actions
    that are sufficient
    and efficient, neither
    excessive nor deficient
  • permit exceptions
    when justified by
    clinical circumstances.

Contact Information
Guidelines and Protocols
Advisory Committee
PO Box 9642
STN PROV GOVT
Victoria BC V8W 9P1
E-mail: 
hlth.guidelines@gov.bc.ca
Web site:
www.BCGuidelines.ca

 

Disclaimer The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems.  We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.