Cataract

Document monocular visual acuity and perform slit-lamp examination in undilated and dilated pupils to characterize lens opacity and assess whether it plausibly accounts for reduced acuity, glare, halos, photophobia, or reduced contrast function. Cataract diagnosis is clinical; management should be driven by cataract stage, symptoms, age, and the expected contribution of lens extraction to functional vision. PubMedPubMedCataract - StatPearls - NCBI Bookshelf

Do not use visual acuity alone as the surgical indication. A patient with disabling glare, night-driving limitation, or contrast loss may have clinically meaningful cataract despite relatively preserved chart acuity, whereas limited postoperative potential should be anticipated when another ocular disorder is the dominant source of impairment. In patients undergoing surgery, corrected distance visual acuity of 20/20 or better after surgery has been associated with more accurate refractive outcome. Wolters Kluwer+1Wolters KluwerEffect of corrected distance visual acuity on intraocular lens ...PubMedCataract - StatPearls - NCBI Bookshelf

Before committing to surgery, identify ocular conditions that alter prognosis or procedure selection. In particular, evaluate suspected Fuchs endothelial corneal dystrophy with targeted history, slit-lamp examination, corneal tomography, specular microscopy, and pachymetry; glare and contrast loss overlap with cataract symptoms and are insufficient discriminators by themselves. PubMedPubMedFuchs Dystrophy and Cataract: Diagnosis, Evaluation and Treatment

Use the preoperative visit to establish the desired refractive target, tolerance for spectacles, and need for astigmatism correction, then reconcile those goals with corneal status and the expected quality of vision. Presbyopia-correcting and toric intraocular lens strategies are available, but selection should be individualized because coexisting corneal disease can reduce the predictability or quality of a premium-lens outcome. Nature+2NatureClinical outcomes of presbyopia-correcting intraocular ...NatureVisual outcomes and patient satisfaction after implantations ...PubMedFuchs Dystrophy and Cataract: Diagnosis, Evaluation and Treatment

For Fuchs endothelial corneal dystrophy, the pivotal decision is whether cataract surgery alone is likely to meet the visual goal without precipitating or leaving clinically significant endothelial failure. DMEK, replacing diseased endothelium and Descemet membrane with donor tissue, is the established therapeutic option for clinically significant Fuchs disease; cataract extraction and DMEK may be performed alone, in combination, or sequentially after assessment of corneal and lenticular contributions. PubMedPubMedFuchs Dystrophy and Cataract: Diagnosis, Evaluation and Treatment

Consider femtosecond laser-assisted cataract surgery as a technical option rather than a presumed universal outcome advantage. Compared with conventional phacoemulsification, femtosecond assistance can create more precise capsulotomies and reduce ultrasound energy; its astigmatic keratotomy application has evidence for low-to-moderate astigmatism below 1.5 diopters. Wolters KluwerWolters KluwerClinical outcomes of femtosecond laser–assisted cataract... : Indian Journal of Ophthalmology

Obtain a focused history and examination directed at conditions that can impair cooperation, anesthesia safety, perioperative hemodynamic control, or postoperative recovery. Assess the patient’s ability to cooperate during surgery and postoperative care; test and record blood pressure and blood glucose, and tailor further medical or laboratory evaluation to symptoms, medical conditions, and the planned anesthetic approach. WHOWHOSummary of recommendations for quality of care in cataract ...

Defer elective surgery for active infection and treat or stabilize uncontrolled systemic conditions, including high blood glucose, coronary heart disease, and severe hypertension, before proceeding. Medication review close to surgery should focus on agents that materially affect operative safety or healing. WHOWHOSummary of recommendations for quality of care in cataract ...

Avoid reflexive preoperative laboratory panels, electrocardiography, or universal medical consultation in asymptomatic patients undergoing routine cataract surgery. In a cohort of 968 patients, outpatient preoperative evaluation was associated with less perioperative hypertension after adjustment but did not reduce posterior capsule rupture or emergency visits or hospitalization within 7 days; no major perioperative cardiovascular events occurred. Nature+1NatureThe impact of preoperative evaluation on perioperative events in patients undergoing cataract surgery: a cohort study | EyePubMedThe impact of preoperative evaluation on perioperative events in patients undergoing cataract surgery: a cohort study - PubMed A broader editorial assessment likewise concludes that routine medical testing has not improved patient medical outcomes in cataract surgery. aaojournalaaojournalPreoperative Medical Evaluation for Cataract Surgery: Finally an Opportunity for Common Medical Sense to Prevail - Ophthalmology

Use povidone-iodine 5% for conjunctival-sac instillation and periorbital preparation. In a prospective study of 50 phacoemulsification patients receiving no topical antibiotic, eyelid-margin bacterial isolation declined from 96% before antisepsis to 56% afterward, with a statistically significant reduction. ScienceDirectScienceDirectPreoperative Antisepsis With Povidone-Iodine 5% in Cataract Surgery - ScienceDirect

Routine preoperative topical antibiotic prophylaxis has no clear demonstrated benefit in cataract surgery and may promote bacterial resistance; complete eradication of ocular-surface bacteria is not achieved with this approach. Wolters KluwerWolters KluwerStandard preoperative topical antibiotics do not... : Journal of Cataract & Refractive Surgery The cited European guidance recommends intracameral cefuroxime 1 mg at the close of surgery, and multiple studies summarized in the same report found a significant reduction in postoperative endophthalmitis with this practice. Wolters KluwerWolters KluwerStandard preoperative topical antibiotics do not... : Journal of Cataract & Refractive Surgery

Counsel patients that posterior capsule rupture and vitreous loss are important intraoperative complications with implications for visual outcome and downstream retinal risk. Procedure planning should account for factors that make capsulotomy, nuclear fragmentation, endothelial preservation, or intraocular lens positioning more challenging; femtosecond assistance may reduce cumulative dissipated energy but does not eliminate complication risk. Wiley+1WileyComplications of cataract surgery - Chan - 2010 - Clinical and Experimental Optometry - Wiley Online LibraryWolters KluwerClinical outcomes of femtosecond laser–assisted cataract... : Indian Journal of Ophthalmology

At postoperative visits, measure visual acuity and perform slit-lamp evaluation to assess visual recovery and identify postoperative abnormalities. A follow-up visit at 4 to 6 weeks is recommended in practice guidelines to evaluate visual acuity and address the need for refraction. WHO+1WHOSummary of recommendations for quality of care in cataract ...PubMedCataract - StatPearls - NCBI Bookshelf

Modify the follow-up plan when the intraoperative course, ocular comorbidity, or postoperative examination indicates increased risk. In Fuchs endothelial corneal dystrophy, monitor corneal status after cataract surgery because the preoperative corneal reserve and the relative contribution of endothelial disease determine whether subsequent endothelial keratoplasty is needed. PubMedPubMedFuchs Dystrophy and Cataract: Diagnosis, Evaluation and Treatment

Treat unexpected visual deterioration as a diagnostic trigger rather than routine recovery. The postoperative differential includes intraocular pressure elevation, cystoid macular edema, retinal detachment, posterior capsular opacification, and infectious endophthalmitis; examination should be directed by timing, symptoms, and anterior- and posterior-segment findings. Wiley+1WileyComplications of cataract surgery - Chan - 2010 - Clinical and Experimental Optometry - Wiley Online LibraryWolters KluwerJournal of Cataract & Refractive Surgery