Treatment Guideline Chart
Cataract is the presence of opacity in the crystalline lens of the eye. It causes painless, progressive blurring of vision.
It is the leading cause of blindness worldwide and the most prevalent ocular disease.
The initiating events that lead to loss of transparency of both the cortical and nuclear lens tissue is the oxidation of the membrane lipids, structural or enzymatic proteins or DNA by peroxidases or free radicals induced by UV light.

Cataract Diagnosis

Ocular Evaluation

  • Ocular examination involves assessment of any other diseases that might contribute to the symptoms or limit the potential for good vision following cataract surgery
  • Determine visual acuity under low and high illumination
    • Gives objective evaluation of the impact of cataract
    • Excellent method for testing distance refractive error in healthy eyes
  • Check refraction to rule out refractive shift as a cause for the decreased vision
  • Perform dilated examination of the lens, macula, peripheral retina, optic nerve and vitreous
  • Examine the ocular surface to see if there is a presence of dry eye as it is increasingly being recognized as a complication of post-cataract surgery
  • Measure intraocular pressure (IOP)
  • Assess ocular motility and binocularity

Biomicroscopy with Pupillary Dilation

  • Used to evaluate the 3 clinical zones of the lens, and the classification and quantification of the cataract

Dilated Fundoscopy

  • Obstruction of the red-orange reflex is noted
  • Used to evaluate the presence of ocular conditions that may complicate cataract (eg glaucoma and retinal problems)

External Examination of Lids, Lashes and Lacrimal Apparatus

  • Used to rule out any external ocular infections (eg blepharitis) and blocked nasolacrimal duct

Supplemental Tests

  • Used to identify the cause and the level of severity of the patient’s visual symptoms, and functional disability as well as the extent to which comorbidities may be contributing to these symptoms

Glare Testing

  • Determines the degree of visual impairments by swinging a light source in the patient’s visual field
  • Presence of severe visual disability in brightly lit conditions (eg ambient daylight) is typical of cataracts
  • To see if the patient’s symptoms of functional disability is far worse than suggested by visual acuity measurements

Contrast Sensitivity

  • Measures visual function by testing the ability of the eyes to detect subtle variations in shading by using figures that vary in contrast, luminance and spatial frequency
  • Uses linear sine-wave gratings

Wavefront Aberrometry

  • Measures the optical quality in terms of spatial distortion

B-scan Ultrasonography

  • Used when a dense cataract precludes adequate visualization of the posterior segment or to confirm the presence of posterior staphyloma
  • Establishes that the retina is attached; may be used to identify any intraocular masses

Electrophysiologic Testing

  • Electrical response to visual stimuli presented is measured and potential retinal function in nonverbal patients is indicated


Assessment and Grading of Cataracts

  • Done through the use of direct ophthalmoscopy with retroillumination, lens opacification classification system II (LOCS-II) slit-lamp grading system
  • Most commonly done in cataract research, in studies to define causation, and in clinical trials of anticataract drugs
  • Surgical removal of the cataract remains the only effective treatment available to restore or maintain vision
  • Visual acuity, visual impairment and potential for functional benefits should be the primary considerations

Indications for Cataract Surgery

  • Visual function does not meet the patient’s needs and for which cataract surgery can provide reasonable likelihood in obtaining improved vision is the primary indication for surgery
  • Presence of clinically significant anisometropia
  • Opacity of the lens affects the optimal diagnosis or management of posterior segment conditions
  • Lens causes inflammation or secondary glaucoma
  • Lens induces angle closure or angle-closure glaucoma

Contraindications for Cataract Surgery

  • Refractive correction is tolerable and provides the patient’s vision needs and desires
  • Surgery is not expected to provide improvement in visual function and no other indications for lens removal exist
  • Patient has coexisting ocular or medical conditions that may cause the patient not to safely undergo the surgery
  • Appropriate post-op care cannot be arranged
  • Patient or patient’s surrogate decision maker is unable to give informed consent for nonemergent surgery

Types of Cataract

Cortical Cataract

  • Liquefaction of the lens fibers is due to electrolyte imbalance that leads to over hydration of the lens
  • Glare is the usual complaint and vision is not much degraded
  • Slit lamp: Shows white spoke-like opacities in the outer layers of the lens with formation of vacuoles, clefts, wedges or lamellar separations
  • May be central or peripheral and best visualized using retinoscopy or retroillumination

Nuclear Cataract

  • Caused by deamidation of the lens proteins by oxidation, proteolysis and glycation
  • Progression is slow and affects distance vision more than near vision
  • Slit lamp: Reveals an opaque nucleus, manifested as a yellow-brown hazy structure at the center of the lens that interferes with visual function
  • Lens becomes brown and opaque in advanced cases
  • May give rise to myopia or reduction in hyperopia

Posterior Subcapsular Cataract (PSC)

  • Is associated with trauma and systemic and topical steroid use
  • Usual symptoms are glare and poor vision with bright lighting
  • Progress quickly and near vision is more affected
  • Slit lamp: Reveals “frost like” haze just anterior to the posterior lens capsule which is the back surface of the lens
  • Commonly affects young patients

Immature Cataract

  • The retina is still visible and transmits a red reflex
  • Vision is only mildly decreased

Mature Cataract

  • There is absence of red reflex
  • Parts of the cortex becomes white and opaque usually in a heterogenous pattern
  • Vision is at 20/400 level or usually worse

Hypermature Cataract

  • Nucleus of the lens is mobile within the capsule and the cortex of the lens is liquefied
  • Increased risk of phacolytic glaucoma
  • Increased difficulty of surgery
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