ENTITY
A cataract in the adult eye (ICD-9 #366.1).

DISEASE DEFINITION
A cataract is a degradation of the optical quality of the crystalline lens.

PATIENT POPULATION DEFINITION
Adults (18 years old and older) with cataracts.

ACTIVITY
Management of cataracts that interfere with a patient’s functional status or an ophthalmologist’s ability to manage other ocular conditions.

PURPOSE
The purpose in managing a patient with a cataract is to improve functional vision and the quality of life. Occasionally cataract surgery may be undertaken to aid in the management of other ocular diseases.

GOALS

• Identify the presence and characteristics of a cataract.
• Assess the impact of the cataract on the patient’s visual and functional status and on quality of life.
• Inform the patient about the impact of a cataract on vision, functional activity, and natural history as well as the benefits and risks of surgical and other alternatives so that the patient can make an informed decision about treatment options.
• Establish criteria for a successful treatment outcome with the patient.
  Perform surgery when there is the expectation that it will benefit the patient’s function and when the patient elects this option.
• Perform surgery when indicated for management of coexistent ocular disease.
• Provide necessary postoperative care, rehabilitation, and treatment of any complications.

Patients with diabetes mellitus are at higher risk for cataract formation,^51-53 and behavior modification to reduce the risk of developing type 2 diabetes may be effective.

* potentially modifiable

D = diopters

RATE OF CATARACT SURGERY IN THE UNITED STATES
In 2004, a total of 1.8 million cataract procedures were performed on Medicare beneficiaries who were not enrolled in health maintenance organizations. In 2004, the national average surgeon reimbursement was $684.39 for a national total of $1.2 billion. Other associated costs are facility fees, including intraocular lens (IOL) implant costs, and anesthesia services. Cataract surgery with IOL implantation was the most frequently performed operation and the single largest expenditure for any Part B procedure in the Medicare program, calculated by Part B procedure codes based on allowed charges.⁹¹ For the period January 1, 1995, to December 31, 2002, a longitudinal study estimated that the annual rate of cataract surgery was 5.3%.⁹² When assessed across populations residing in different states or metropolitan areas, there is some variation in the rate of cataract surgery, but it is relatively low compared with geographic variations observed in other surgical procedures. In one study, factors associated with a higher rate of cataract surgery were female gender, living in a more southerly latitude, a higher concentration of optometrists in a specific geographic area, and a higher allowed charge for cataract surgery.⁹³ A higher concentration of ophthalmologists was not associated with a higher rate of cataract surgery. A decreased likelihood of undergoing cataract surgery was reported among African American Medicare beneficiaries when compared with Caucasian Americans.⁹³

The utilization of cataract surgery in the United States has been found to be appropriate for the majority of cases studied. A study at ten academic medical centers found that 2% of cataract surgeries performed were classified as inappropriate based on available records.⁹⁴ An inappropriate rating meant that the risks of surgery were deemed to exceed the potential benefits as rated by a panel. The percentage deemed inappropriate in this study correlates to earlier estimates of 2.5% by the 1993 US General Accounting Office and a rate of 1.7% by the US Inspector General.⁹⁴ Cataract appropriateness ratings are comparable to the rate found for coronary artery bypass graft surgery (2.4% inappropriate) and lower than the rate for carotid endarterectomies (10.6% inappropriate).^95,96 The criteria for appropriateness of cataract surgery were based on indicators of visual acuity and functional impairment, such as difficulty driving, reading, and other activities of daily living. The study did note that the information that was recorded varied, particularly on functional impairment, and increased attention to documenting specific functional impairments is appropriate. A study of Medicare beneficiaries in 13 large areas in the United States found that cataract surgery ranked among procedures with the least variation in use.⁹⁷ Also, second opinion programs implemented for cataract surgery have not succeeded because initial recommendations for surgery were found to be appropriate. The validity of the appropriateness methodology used to evaluate the utilization of cataract surgery was supported by a study of the association between the appropriateness rating and postoperative visual acuity.⁹⁸ For a sample of 768 patients, 89% of those who had surgeries rated as appropriate were found to have a visual acuity improvement of at least two lines postoperatively. For the group that had surgeries rated as inappropriate, 36% had a visual acuity improvement of at least two lines postoperatively.

VISUAL FUNCTION AND QUALITY OF LIFE
The multiple components of visual function include central near, intermediate, and distance visual acuity; peripheral vision; visual search; binocular vision; depth perception; contrast sensitivity; perception of color; adaptation; and visual processing speed.^99,100 Visual function also can be measured in terms of functional disability caused by visual impairment.¹⁰¹ Many activities are affected by more than one of these visual components.

Function and quality of life are the outcomes of treatment that are most critical and applicable to the patient. In well-designed observational studies, cataract surgery consistently has been shown to have a significant impact on vision-dependent function; up to 90% of patients undergoing first-eye cataract surgery note improvement in functional status and satisfaction with vision.^102-105 Several studies have reported an association between improved visual function after cataract surgery and an improved health-related quality of life.^{99,103,106-108} Visual function plays an important role in physical function and well-being,^109-112 particularly in terms of mobility.¹¹³ The loss of visual function in the elderly is associated with a decline in physical and mental functioning as well as in independence in activities of daily living,^114,115 including night-time driving, daytime driving, community activities, and home activities.

Visual impairment is an important risk factor for falls¹¹⁶ and for hip fracture;¹¹⁷ poor depth perception and decreased contrast sensitivity has been found to increase independently the risk of hip fracture.¹¹⁸ In a randomized controlled trial, first-eye cataract surgery was found to reduce the rate of falling and fracture over a 12-month period.¹⁰⁸ Visual impairment, in particular a decrease of visual acuity and contrast sensitivity, has been shown to be associated with difficulties in driving.^119,120 Drivers with visually significant cataracts were 2.5 times more likely to have had an at-fault involvement in a motor vehicle crash over a 5-year period compared with drivers without cataracts.¹²¹ When older adults with cataracts who have undergone surgery are compared with those who did not undergo surgery, motor vehicle crash rates in the 4 to 6 years of follow-up were halved in the surgery group.¹²²

The quality-adjusted life year (QALY) is a generic outcome measure that was developed to compare the cost-utility of different health care interventions.¹²³ A lower dollar cost per QALY indicates a better value (see Appendix 2). Using Swedish registry data, the hypothetical cost per QALY gained (calculated in 2002) for cataract extraction in one eye was estimated at US $4,500.¹²⁴ Studies in the United States found that the cost per QALY gained for cataract extraction in the first eye was $2,023¹²⁵ (calculated in 2002) and in the second eye was US $2,727 (calculated in 2003).¹²⁶ The value of cataract surgery compares favorably with that reported for other ophthalmic (e.g., laser photocoagulation for diabetic macular edema, $3,101¹²⁷; laser photocoagulation for extrafoveal choroidal neovascularization, $23,640¹²⁸) and non-ophthalmic procedures (e.g., single-vessel coronary artery bypass surgery for disease of the left anterior descending artery costs $7,000/QALY¹²⁷) and demonstrate the value of cataract surgery.

In summary, these studies show that physical function, emotional well-being, safety, and overall quality of life can be enhanced when visual function is restored by cataract extraction.

Improved visual function as a result of cataract surgery includes the following:

• Better optically corrected vision.
• Better uncorrected vision with reduced spectacle dependence.
• Increased ability to read or do near work.
• Reduced glare.
• Improved ability to function in dim levels of light.
• Improved depth perception and binocular vision.
• Improved color vision.

• Increased ability to perform activities of daily living.
• Increased opportunity to continue or resume an occupation.
• Increased mobility (walking, driving).

• Improved self-esteem and independence.
• Increased ability to avoid injury.
• Increased social contact and ability to participate in social activities.
• Relief from fear of blindness.

• Reduction of visual symptoms.
• Improvement in visual function.
• Achievement of desired refractive outcome.
• Improvement in quality of life.

• Patient history,^[A:III]including the patient’s assessment of functional status, pertinent medical conditions, medications currently used, and other risk factors that can affect the surgical plan or outcome of surgery (e.g., immunosuppressive conditions, sympathetic alpha-1a antagonists).
• Visual acuity with current correction (the power of the present correction recorded) at distance and when appropriate at near.^[A:III]
• Measurement of best-corrected visual acuity (with refraction when indicated).^[A:III]
• External examination (lids, lashes, lacrimal apparatus, orbit).^[A:III]
• Examination of ocular alignment and motility.^[A:III]
• Assessment of pupillary function.^[A:III]
• Measurement of intraocular pressure (IOP).^[A:III]
• Slit-lamp biomicroscopy of the anterior segment.^[A:III]
• Dilated examination of the lens, macula, peripheral retina, optic nerve, and vitreous.^[A:III]
• Assessment of relevant aspects of the patient’s mental and physical status.^[B:III]

Supplemental Ophthalmic Testing
Supplemental preoperative ophthalmic tests are not specific for a cataract but may help to elucidate better the cause of an individual’s visual symptoms and the extent to which comorbidities are contributing to these symptoms. In a large majority of patients, the ophthalmologist is able to determine that the cataract is responsible for the patient’s visual loss by examining the patient and correlating the findings with the patient’s specific symptoms.

Occasionally, however, a patient presents with visual symptoms that appear to be disproportionate to the degree of cataract formation. Visual acuity testing does not measure certain visual symptoms, such as glare disabilities and reduced contrast sensitivity.^135,139-142 In addition, measurements taken in a darkened examination lane may significantly underestimate the functional problems experienced in environments with varied lighting conditions. Therefore, supplemental testing directed toward these problems can help to better assess and quantify functional visual impairment due to a cataract. Glare testing determines the degree of visual impairment caused by the presence of a light source located in the patient’s visual field. Cataracts may cause severe visual disability in brightly lit situations such as ambient daylight or from oncoming auto headlights at night. Visual acuity in some patients with cataracts is normal or near normal when tested in a dark examination room, but when these patients are retested using a source of glare, visual acuity (or contrast sensitivity) drops precipitously.¹⁴³

Contrast sensitivity testing measures the eye’s ability to detect subtle variations in shading by using figures that vary in contrast, luminance, and spatial frequency. It is a more comprehensive measure of visual function than visual acuity, which determines perception of high-contrast letters or numbers. In the patient who complains of visual loss and has lens changes, contrast sensitivity testing may demonstrate a significant loss of visual function not appreciated in testing of visual acuity.^{139-142,144,145} Decreased contrast sensitivity (as well as decreased visual acuity) may occur for a number of reasons, and this test is, therefore, not a specific indicator of visual loss due to a cataract. In spite of substantial progress over the past few years, there is no standard or universally preferred method for testing contrast sensitivity.

Ocular wavefront testing has demonstrated that even mild degrees of cataracts may be associated with a significant increase in lower and higher order visual aberrations. The crystalline lens can contribute either net positive or negative spherical aberration, depending on the cataract type. This may explain the symptoms reported by some individuals with mild lens opacity and reasonably good visual acuity.
Other supplemental tests attempt to differentiate between a cataract and ocular comorbidities as the cause of visual impairment. Potential acuity tests attempt to predict the visual acuity that will be obtained following cataract surgery. Subjective potential acuity tests require the patient to respond to questions about visual stimuli presented and can be divided into two categories. The Guyton-Minkowski Potential Acuity Meter, laser interferometer, and scanning laser ophthalmoscope¹⁴⁶ project an image onto the retina through relatively clear regions of the lens. Other tests such as the Retinal Acuity Meter (formerly the Illuminated Near Card) and potential acuity pinhole require the patient to read a brightly illuminated near card through a trial frame that combines their near spectacle correction with a pinhole.^147-150 The near-card pinhole methods are simpler and less expensive and appear to be as accurate as the technology-dependent Guyton-Minkowski Potential Acuity Meter and scanning laser ophthalmoscope.^147,148 Objective potential acuity tests (electroretinography, visual evoked potential) electronically measure the response to visual stimuli presented. Potential acuity tests are most accurate with mild to moderate cataracts and normal macular function. Unfortunately, all of these tests perform less reliably in the presence of dense cataracts or macular pathology.^{147,149,151,152}

The biomicroscopic and ophthalmoscopic examination of the macular region do not necessarily predict macular function when the macula is abnormal. Potential acuity testing may contribute helpful adjunct information in these situations.^147,153

Specular microscopy and corneal pachymetry have been used in patients with known preoperative corneal disease to help determine whether the cornea is likely to remain clear following cataract surgery. These tests are generally not needed, but they may be useful in eyes in which the corneal endothelial function is suspected to be abnormal as a result of endothelial corneal dystrophies, previous ocular surgery, or trauma, for example. However, several studies suggest that specular microscopy has low accuracy in predicting whether the cornea will remain clear following cataract surgery.^154,155

Additional specialized preoperative evaluations may provide valuable information in selected cases but are not routinely necessary. Corneal topography and rigid contact lens overrefraction are useful when irregular astigmatism is suspected to be contributing to visual impairment. Additionally, corneal topography is used when high astigmatism is present and corrective surgery is contemplated concurrently with cataract surgery. Fluorescein angiography is occasionally helpful in the presence of mild to moderate cataracts when the ophthalmologist suspects conditions such as diabetic or inflammatory macular edema, or submacular neovascularization. Unlike fluorescein angiography, optical coherence tomography can diagnose subtle macular pathology even in the presence of significant media opacity. B-scan ultrasonography is appropriate when the cataract inhibits adequate fundus visualization. Visual fields, external and fundus photography, and special color vision testing have not been shown to be of value in routinely evaluating patients before cataract surgery.

MANAGEMENT

Nonsurgical Management
Management of a visually significant cataract is primarily surgical. Nonsurgical management includes counseling patients about cataract-related visual symptoms, providing reassurance about the cause of the visual disability, and prescribing new eyeglasses where appropriate. For some patients with a clinically significant cataract, a change in spectacle correction or use of specialized tints may restore acceptable vision for daily activities. In rare cases, the optical advantage of dilating a pupil of a patient with a small central cataract may outweigh the risk of glare problems that are induced by the dilating agent.¹⁵⁶

At the present time, the highest quality evidence does not support a benefit from nutritional supplementation in preventing or delaying progression of cataracts; therefore, treatment with supplements is not recommended (see tables 2A and 2B).^45[A:I] Currently, there are no pharmacological treatments known to eliminate existing cataracts or retard their progression.

Patients may reduce their risk of cataract development or progression by modifying their exposure to risk factors. Patients who are currently smoking should be informed of the increased risk of cataract progression and the benefits of smoking cessation in retarding the progression of cataracts that have been demonstrated in several studies.^{20-22 [A:II]} Studies have found that smokers report that a physician’s advice to quit is an important motivator in attempting to stop smoking.^157-160 Patients who are long-term users of oral or inhaled corticosteroids should be informed of the increased risk of cataract formation^{47-50,59[A:II]} and may wish to discuss alternate medications with their primary care physician. Patients with diabetes mellitus should be informed of their increased risk of cataract formation.^{51-53 [A:II]} Brimmed hats and ultraviolet-B blocking sunglasses are reasonable precautions to recommend to patients.³⁶

Surgical Management

Indications for Surgery

• The primary indication for surgery is visual function that no longer meets the patient’s needs and for which cataract surgery provides a reasonable likelihood of improved vision.^[A:III]
• Other indications for a cataract removal include the following:
  • Clinically significant anisometropia in the presence of a cataract.^[A:III]
  • The lens opacity interferes with optimal diagnosis or management of posterior segment conditions.^[A:III]
  • The lens causes inflammation (phacolysis, phacoanaphylaxis).^[A:III]
  • The lens induces angle closure (phacomorphic or phacotopic).^[A:III]

Contraindications to Surgery
Surgery for a visually impairing cataract should not be performed under the following circumstances:^[A:III]

• Eyeglasses or visual aids provide vision that meets the patient’s needs.
• Surgery will not improve visual function.
• The patient cannot safely undergo surgery because of coexisting medical or ocular conditions.
• Appropriate postoperative care cannot be arranged.

Preoperative Medical Evaluation
The ophthalmologist who is to perform the cataract surgery has the following responsibilities:

• To examine the patient preoperatively (see Ophthalmic Evaluation).^[A:III]
• To ensure that the evaluation accurately documents the symptoms, findings, and indications for treatment.^[A:III]
• To obtain informed consent from the patient or the patient’s surrogate decision maker after discussing the risks, benefits, and expected outcomes of surgery, including anticipated refractive outcome and the surgical experience.^[A:III]
• To review the results of presurgical and diagnostic evaluations with the patient or the patient’s surrogate decision maker.^[A:III]
• To formulate a surgical plan, including selection of an appropriate IOL.^[A:III]
• To formulate postoperative care plans and inform the patient or the patient’s surrogate decision maker of these arrangements (setting of care, individuals who will provide care).^[A:III]
• To afford the patient or the patient’s surrogate decision maker the opportunity to discuss the costs associated with surgery.^[B:III]

The best interest of the patient is served by having the operating ophthalmologist perform the preoperative evaluation, because this will allow the surgeon to formulate the surgical plan and to establish a relationship with the patient prior to surgery. Patients feel more comfortable and reassured knowing and meeting the ophthalmologist performing the surgery. Although the ophthalmologist is responsible for the examination and reviewing the data, certain aspects of data collection may be conducted by another trained individual under the ophthalmologist’s supervision and with his or her review.^161,162

All patients undergoing cataract surgery should have a history and physical examination relevant to the risk factors for undergoing the planned anesthesia and sedation and as directed by a review of systems.^[A:III] For patients with certain severe systemic diseases (e.g., chronic obstructive pulmonary disease, recent myocardial infarction, unstable angina, poorly controlled diabetes, or poorly controlled blood pressure) a preoperative medical evaluation by the patient's physician should be strongly considered.^{163 [A:II]}

Laboratory testing as indicated by the findings in the history and physical examination is appropriate.^{164 [A:I]} The Study of Medical Testing for Cataract Surgery demonstrated that perioperative morbidity and mortality were not decreased by the use of routine medical testing.¹⁶⁴

Biometry and Intraocular Lens Power Calculation
Achieving the targeted postoperative refraction requires measuring axial length accurately, determining corneal power, and using the most appropriate IOL power formula.^[A:III] The axial length can be measured by A-scan ultrasonography using either an applanation (contact) or an immersion (noncontact) technique. Because the applanation probe can compress the cornea, resulting in artificial shortening of the axial length, the accuracy of this method is more dependent on the skill and experience of the operator.^165-167

Partial coherence interferometry is a noncontact method to measure axial length that uses optical rather than ultrasound technology. It is comparable to immersion A-scan biometry in terms of accuracy and consistency^168,169 and more accurate than contact A-scan biometry.^165,170,171 Its advantages include ease and speed of automated operation and the ability to determine and measure to the point of fixation. Because of the latter feature this method is more accurate than ultrasound when the fovea is located on the slope of a staphyloma.¹⁷² Additionally, partial coherence interferometry is more useful than ultrasound when the patient has silicone oil in the posterior segment.¹⁷³ However, because this optical method of biometry is unable to measure accurately through certain cataracts or when patients are unable to fixate properly, A-scan biometry is required to measure the axial length in these eyes.^{174,175 [A:III]} Biometry measurement for both eyes is advisable, even if surgery is not planned for the other eye.

Formulas for calculating IOL power rely on keratometry to determine the net refractive contribution of the cornea. These measurements can be obtained through either manual or automated keratometry, or through corneal topography. Following keratorefractive surgery, determination of central corneal power is particularly difficult (see Cataract Surgery Following Refractive Surgery section). Current keratometers are unable to measure accurately the central corneal power following keratorefractive surgery. The use of standard keratometry measured values without a compensatory adjustment will usually result in an unexpected postoperative refraction for these eyes.

Latest generation lens calculation formulas such as Haigis, Hoffer Q, Holladay, Olsen, and SRK/T should be used in the IOL selection process.^{176-181 [A:III]} Some formulas incorporate additional measurements such as corneal diameter and anterior chamber depth. All of these formulas rely on a numerical constant that should correlate with the chosen IOL’s predicted effective lens position within the eye. This constant varies according to the IOL design and therefore is specific to each individual IOL model. Although the lens manufacturer supplies this value, there are methods available to customize further this numerical constant based on an individual surgeon’s actual refractive outcome data for each particular lens.

The surgeon should consider the patient’s individual desires and needs in selecting an appropriate postoperative refractive target.^[A:III] Depending on the manufacturer, extended ranges of both high plus and high minus IOL powers are available. For the rare patient requiring an IOL power in excess of the available range, piggybacking of two posterior chamber IOLs has been used.¹⁸² Intraocular lens power calculations for piggybacked IOLs may be less accurate because it is difficult to predict the effective lens position. Although refractive results with piggybacking IOLs have been favorable in two small case series,^183,184 consideration must be given and patients counseled about the development of interlenticular (between the IOLs) membrane formation.^{185,186 [A:III]}

Anesthesia
Cataract surgery may be performed using a variety of anesthesia techniques that include general and local (regional) anesthesia (e.g., retrobulbar, peribulbar, periocular, sub-Tenons injection, topical, and intracameral), as well as no anesthesia.¹⁸⁷ The planned mode of anesthesia should be discussed with the patient so that she or he will know what to expect in terms of pain, discomfort, consciousness level, visual experiences, and complications.^[A:III] The outcomes of cataract surgery measured in terms of visual acuity, functional impairment, complications, adverse medical events, and patient satisfaction have not been shown to vary significantly among anesthesia techniques.^188-190

Local (regional) anesthesia is generally used, with or without sedation/analgesia. General anesthesia may be utilized if needed for those patients with medical, psychosocial, or surgical indications. Deep sedation may carry a higher risk of intraoperative respiratory compromise. In a review of 195 studies on cataract surgery using local anesthesia, the investigators concluded that a variety of anesthesia strategies for cataract surgery are safe and effective and that they provide good or excellent intraoperative pain control.^188,191

Anesthesia techniques with needle injection may be associated with complications such as strabismus, globe perforation, retrobulbar hemorrhage, and macular infarction not seen with topical, blunt cannula, and other non-needle injection techniques.^188,191 Many patients who have cataract surgery under regional anesthesia experience a variety of visual sensations such as seeing lights, colors, flashes, movement of instruments, and the surgeon’s hand or fingers. Three percent to 16% of patients were frightened by their intraoperative visual experience.^192-196 Appropriate preoperative counseling about this phenomenon may make it less frightening to the patient.¹⁹⁶

In the 2005 Leaming Survey (16% response rate with 743 responses), 48% of ophthalmologists who performed cataract surgery preferred using topical anesthesia with intracameral lidocaine.^197,198 The questionnaire in this report was sent to US members of the American Society of Cataract and Refractive Surgery (ASCRS), not to all ophthalmologists who perform cataract surgery. Intracameral lidocaine injection has been reported to be safe in various studies but variably effective.^199-202

Intravenous (IV) access is generally recommended to treat potential side effects when anxiolytics are administered.^{203 [A:III]} However, given the trend toward topical anesthesia and reduction or elimination of intravenous analgesia/sedation, IV access may not be routinely necessary. Monitoring during administration of anesthesia and surgery should include electrocardiogram, pulse oximetry, blood pressure, and respirations. These should be performed by personnel (other than the operating ophthalmologist) qualified to monitor and manage the patient’s status.^{204 [A:III]} One study found that a patient's medical history, laboratory values, and electrocardiogram were not predictive of the need for intervention by anesthesia personnel, and intervention was required in 37% of all cataract cases.²⁰⁵ However, this study, in which all patients received a peribulbar block, did not document that any of the interventions by anesthesia personnel affected cataract surgery outcomes. In another study, monitored anesthesia care for 1,957 cataract surgery cases was provided by registered respiratory practitioners who were trained as anesthesia assistants and who used topical anesthesia with or without IV sedation. Anesthesiologist intervention was required in 4% of the cases.²⁰⁴

The review of cataract surgery studies using local anesthesia found weak evidence to support the benefits of IV or intramuscular sedation or analgesia to improve pain relief, anxiety, or patient satisfaction.¹⁸⁸ The evidence was insufficient to determine if any analgesic or sedation regimen was better than any other. The supplemental report from the Study of Medical Testing for Cataract Surgery showed that patients experienced more postoperative drowsiness and nausea when IV agents were used and that nausea and vomiting increased significantly with the number of agents (opioid, sedative, hypnotic, diphenhydramine) used.¹⁸⁹ In another report from the same study, the investigators found that the use of IV sedatives during cataract surgery was associated with increased risk of an adverse intraoperative medical event.¹⁹⁰ In addition, the risk of an adverse intraoperative medical event was increased when IV opiates and sedatives were both used.¹⁹⁰ Some studies have reported that oral anxiolytic medications decrease anxiety levels^206,207 and induce amnesia^206-209 when given to patients before cataract surgery, but another trial found that there was no difference between the treatment and control group in reported anxiety levels.²¹⁰

In summary, given the lack of evidence for an optimal anesthesia strategy during cataract surgery, the type of anesthesia management should be determined by the patient's needs and the preferences of the patient and surgeon.^{188 [A:II]}

Infection Prophylaxis
Owing to the potentially severe consequences of endophthalmitis, prevention remains of great concern. However, controlled studies of endophthalmitis prophylaxis have been difficult to perform due to the low incidence of endophthalmitis, varied practice patterns, inconsistent definitions, and the rapid evolution of surgical techniques.

Until recently the accepted incidence of sporadic endophthalmitis has been between 0.5 and 1 case per thousand of routine cataract procedures. However, since 1994 an increased rate of post-cataract surgery infections has been reported, while the incidence of infection after other anterior segment procedures has been on the decline.^211-213 It has been proposed that the increased infection rates correspond to the increased use of clear corneal incisions for cataract surgery, because improperly constructed clear corneal cataract incisions are more prone to postoperative instability, leakage, and a potential influx of microbes than are sclerocorneal incisions.^214-220 On the other hand, two large case series found no greater likelihood of infection with corneal versus other types of incisions.^221,222 Nevertheless, careful watertight incision construction and closure (with or without sutures) is mandatory, irrespective of surgical style, because the incidence of infection increases with wound leak.^{223 [A:III]} Other factors associated with increased rates of endophthalmitis include intraoperative rupture of the posterior capsule, vitreous loss, prolonged surgery, immunodeficiency, active blepharitis, and lacrimal duct obstruction. ^224-226

Regarding the relationship of the IOL to the likelihood for infection, it appears that optic material may not influence the rate of infection.²¹⁶ However, polypropylene loop supports have been associated with a greater chance for infection, because it appears that bacterial adherence to polypropylene exceeds that for other materials.²²⁷ As a corollary, it has been demonstrated that antibiotics reduce the tendency for microorganisms to adhere to the surface of IOLs.^228,229 Also, there has been concern that there is a greater chance for IOL-related contamination of the anterior chamber when the lens comes in contact with the ocular surface prior to implantation.On the other hand, when the IOL is folded into an inserting tube and is placed within the eye directly through the tube, avoiding the ocular surface, likelihood for intraocular contamination is reduced.²³⁰

While very occasional clusters of infections may be induced by contaminated surgical products^231-234 or contaminated operating room environments,^235,236 it has been established that the patient’s periocular flora is the source of the microbes responsible for most cases of sporadic postoperative infection.²³⁷ Presumably the risk for endophthalmitis can be lessened by reducing the number of microbes on the ocular surface, by reducing the opportunity for microbes to reach the intraocular environment during or after surgery, or by eliminating those organisms that may have reached the eye intra- or postoperatively.

In accord with those concepts, prophylactic strategies that have been employed include using topical antibiotic eye drops before surgery, applying 5% povidone iodine to the conjunctival cul de sac, preparing the periocular skin with 10% povidone iodine, careful sterile draping of the eyelid margins and eyelashes, adding antibiotics to the irrigating solution, instilling intracameral antibiotics at the close of surgery, injecting subconjunctival antibiotics, and applying topical antibiotic eye drops after surgery. A nonrandomized controlled trial has provided evidence that using topical 5% povidone iodine in the conjunctival cul de sac reduced the incidence of postoperative infection.^238,239 Lower concentrations of povidone iodine are less effective in reducing conjunctival bacterial colony counts.²⁴⁰ Systemic antibiotics are rarely used; however, it has been shown that certain fluoroquinolone antibiotics penetrate the blood/ocular barrier adequately to reach levels above the minimum inhibitory concentrations for many organisms inside the eye.^241-243

Although still controversial, there is increasing evidence that supports the use of intraocular antibiotics to reduce the risk of endophthalmitis. A preliminary report from a partially masked, randomized, placebo-controlled multinational clinical study has been released, and complete results are pending.²⁴⁴ The European Society of Cataract and Refractive Surgeons study of the prophylactic effect of intracameral cefuroxime injection at the conclusion of the procedure and/or perioperative levofloxacin eye drops on the incidence of endophthalmitis after phacoemulsification was halted early because of results of a beneficial effect of intracameral cefuroxime. With data from 13,698 patients with complete follow-up records, investigators found that the odds ratio for developing endophthalmitis was 4.59 (95% CI, 1.74-12.08; P=0.002) in the group not receiving intracameral cefuroxime injection. However, the incidence of endophthalmitis in the control group was approximately three times higher than that reported in most other studies from US centers. This raises the question of whether the results can be generalized to a US population. An earlier retrospective study in Sweden reported efficacy of intracameral cefuroxime, a second generation cephalosporin, in reducing post-cataract endophthalmitis.²⁴⁵ Two retrospective studies in Spain have reported that intracameral injection of cefazolin, a first generation cephalosporin, reduced post-cataract endophthalmitis.^246,247

Evidence of the benefit of injecting subconjunctival antibiotics at the close of surgery is inconclusive and is associated with risks that include intraocular toxicity with the potential for macular infarction when aminoglycosides are used.²⁴⁸

In summary, use of a 5% solution of povidone iodine in the conjunctival cul de sac is recommended to prevent infection.^{239,249 [A:II]} Given the absence of clear evidence about the benefit of other prophylactic measures, it is up to the ophthalmologist to decide on the use of any particular strategy in addition to povidone iodine in the perioperative period. Nevertheless, it is incumbent on the surgeon to assure that all incisions are closed in a watertight fashion at the end of the procedure.^{223 [A:III]}

Toxic anterior segment syndrome (TASS) is a noninfectious inflammatory disease with symptoms and signs that mimic infection. A variety of factors that may cause TASS have been described²⁵⁰ and outbreaks may occur in a cluster at a specific surgical center. Investigations of TASS outbreaks and ways to prevent them are underway.²⁵¹ Inadequate or inappropriate cleaning of surgical instruments has been implicated as a factor in TASS outbreaks.²⁵⁰ Recommendations for cleaning and sterilizing intraocular surgical instruments have been prepared by the American Society of Cataract and Refractive Surgery and the American Society of Ophthalmic Registered Nurses.²⁵²

• Capsular bag fixation of an appropriate posterior chamber IOL.
• Minimal or no trauma to the corneal endothelium, iris, and other ocular tissues.
• A secure, watertight incision that minimizes surgically-induced astigmatism or reduces pre-existing corneal astigmatism.

• Construction of an appropriately sized incision that is tight enough to achieve a fluidically stable anterior chamber.
• Use of an ophthalmic viscosurgical device (OVD) to protect the corneal endothelium, manipulate tissues, and maintain adequate working space during surgery.
• Capsulorrhexis.²⁵⁶ This is a continuous curvilinear capsulotomy that facilitates hydrodissection, prevents posterior capsule tears that originate from radial anterior capsule tears, and facilitates the implantation and fixation of the IOL within the capsular bag. A capsulorrhexis that completely overlaps the IOL edge impedes the development of PCO.
• Hydrodissection,²⁵⁷ which reduces zonular stress during phacoemulsification by mobilizing the nucleus and epinucleus. By facilitating thorough cortical aspiration, hydrodissection also helps to retard PCO.²⁵⁸
• Nuclear disassembly and emulsification using techniques such as divide and conquer²⁵⁹ or chopping²⁶⁰ to minimize surgical trauma to intraocular tissues.
• Thorough removal of remaining epinucleus and cortex.
• Implantation and centration of a small-incision IOL within the capsular bag, or as dictated by surgical events, secure fixation of the IOL in the ciliary sulcus (with or without sutures) or anterior chamber.
• Removal of the OVD to minimize postoperative IOP elevation.
• Assurance of a watertight incision using sutures if the incision size and architecture alone do not produce a secure, self-sealing wound.

The surgeon should have access to a variety of lens styles to select an appropriate IOL for an individual patient.^[A:III] Variations in the preoperative state of the eye, the surgical technique, patient expectation, and surgeon experience and preference affect the decision.

Monovision is a condition in which one eye is corrected for distance vision and the fellow eye is corrected for intermediate or near vision. The mechanism involves the concept of interocular blur suppression where the blurred image from one eye does not interfere with the image from the in-focus eye. A review of 19 contact lens monovision studies in which the dominant eye was corrected for distance demonstrated patient satisfaction in 75% of cases.²⁸⁵ Similarly, when the dominant eye was corrected for distance visual acuity, the overall monovision acceptance rate following cataract and IOL surgery was 90%, in a cataract population that desired independence of spectacle correction.²⁸⁶ Patients with a history of monovision success are particularly suited for this modality.

Presbyopia-correcting IOLs can be classified as multifocal or dynamic (the lens changes position or shape within the eye).

Multifocal IOLs achieve their effect by dividing incoming light into two or more focal points and can be classified as refractive or diffractive. A Cochrane systematic review concluded that multifocal IOLs were effective at improving near vision when compared with monofocal IOLs and that unaided distance visual acuity was similar in the two groups.²⁸⁷ Adverse effects of multifocal IOLs include reduced contrast sensitivity, haloes around point sources of light, and glare. Whether the improvement in near unaided acuity outweighs the adverse effects of multifocal IOLs will vary among patients, with motivation to achieve spectacle independence likely to be the definitive factor.

In an attempt to mimic human accommodation, dynamic presbyopia-correcting IOLs are designed to change position in the eye with accommodative effort. Available dynamic IOLs have demonstrated limited accommodative ability with no loss of contrast sensitivity.²⁸⁸

Outcomes
The ASCRS National Cataract Database reported that at 3 months postoperatively 85.5% of all patients had a 20/40 or better best-corrected visual acuity (BCVA), 57.2% of patients had 20/25 or better postoperative BCVA, and 74.6% of patients were within ± 1.0 D of target spherical equivalent. Based on 5,788 responses, the mean visual function index score at 3 months postoperatively was 70.3% compared with 55.0% preoperatively. (The score is based on a scale of 0 to 100, with 0 indicating an inability to perform any of the activities.) The European Cataract Outcome Study for 1999 reported that 89% of patients achieved a postoperative visual acuity of 0.5 or more (20/40 or better), the average induced astigmatism was 0.59 D, and 86% of patients had an induced astigmatism within ± 1.0 D (Results of the European Cataract Outcomes Study, 2000. Unpublished data). This study was conducted in 14 countries with up to 40 participating surgeons during the years 1995 to 1999, and it collected operative and follow-up information on a total of 8,646 patients, including 3,033 patients in 1999.

The American Academy of Ophthalmology National Eyecare Outcomes Network (NEON) database (n=7,626) also found similar rates of success, with an improvement in visual acuity in 92.2% of patients and improvement in VF-14 in over 90% of patients.²⁸⁹ Best-corrected visual acuity of 20/40 was achieved by 89% of all NEON patients and 96% of NEON patients without preoperative ocular comorbid conditions.²⁸⁹ Seventy-eight percent of patients were within ± 1.0 D of target spherical equivalent. Ninety-five percent of patients reported being satisfied with the results of their surgery. Patients who were dissatisfied with the results of their surgery were slightly older and more likely to have ocular comorbidity.

In studies of phacoemulsification cataract surgery performed by ophthalmology residents, the reported range of patients with postoperative BCVA of 20/40 or better was 80% to 91%.^290-295 If eyes with ocular comorbidities are excluded, the reported range of patients with postoperative BCVA of 20/40 or better was 86% to 98%.^293-296

The Cataract Patient Outcomes Research Team (PORT) study identified preoperative characteristics that were independent predictors of improvement after surgery: age, comorbidity, cataract symptom score, and preoperative VF-14 (measure of visual function) score.¹²⁹ These investigators found that patients younger than 65 showed greater improvement than those over 65 and that patients with more severe symptoms and more severe dysfunction showed greater improvement than those with less severe symptoms or dysfunction.¹²⁹ Preoperative Snellen visual acuity was found to be unrelated to the likelihood of improvement in symptoms or self-reported visual function after cataract surgery.^129,297 In another study, a prospectively validated model found that predictors of improvement included younger age, a poorer preoperative visual function as measured by the ADVS, and absence of diabetes.²⁹⁷ Even patients with diabetes and age-related macular degeneration, however, showed significant improvements after cataract surgery, albeit at a lower magnitude than patients without these conditions.^298,299 These studies have shown that benefits are greater in those younger than 75 and that the improvement in quality of life for those 75 years old and older is still functionally and statistically significant.

Complications of Cataract Surgery
No broad-based, peer-reviewed, large-scale investigations on complications of cataract surgery have been reported in recent years. A recent small prospective United Kingdom investigation compared outcomes and complication rates of ECCE with small-incision surgery by phacoemulsification. Outcomes regarding uncorrected visual acuity, surgically induced astigmatism, PCO, and surgical complications favored phacoemulsification significantly.²⁵³

Complications that may result in a permanent loss of vision are rare. Major complications that are potentially sight-threatening include infectious endophthalmitis, intraoperative suprachoroidal hemorrhage, cystoid macular edema (CME), retinal detachment, corneal edema, and IOL dislocation. A synthesis of the literature published prior to 1992 found weighted mean complication rates of 0.13% for endophthalmitis, 0.3% for bullous keratopathy, 1.4% clinically detectable CME, 3.5% for angiographically demonstrated CME, 0.7% for retinal detachment, and 1.1% for IOL dislocation (see Table 3).³⁰⁰

A national survey of over 100 hospitals in the United Kingdom from 1997 to 1998 found the following results on 18,454 patients age 50 or older.¹⁰⁴ Seventy-seven percent of these patients had surgery performed by phacoemulsification. Rates for events that occurred during surgery were 4.4% for posterior capsule rupture and vitreous loss, 1.0% for incomplete cortical cleanup, 1.0% for anterior chamber hemorrhage and or collapse, and 0.77% for iris damage. Short-term (within 48 hours) perioperative complications included corneal edema (9.5%), increased IOP (7.9%), uveitis (5.6%), wound leak (1.2%), hyphema (1.1%), and retained lens material (1.1%).

Clinically significant CME occurs infrequently after routine uncomplicated small-incision cataract surgery and often responds well to medical therapy; however, recalcitrant cases may be associated with permanent loss of central visual acuity. Risk factors that increase the tendency for CME include presurgical uveitis, intraoperative capsule rupture with vitreous loss, retained lens fragments, diabetic retinopathy, macular pucker, prior vitreoretinal surgery, nanophthalmos, retinitis pigmentosa, and CME in the fellow eye after surgery. Cystoid macular edema is generally associated with post-surgical ocular inflammation; as a result topical anti-inflammatory agents are used in an attempt to reduce the inflammatory response to cataract surgery and to treat established CME. There is evidence that nonsteroidal anti-inflammatory drugs (NSAIDs) alone or in combination with corticosteroids are more effective than topical corticosteroids alone in preventing and treating CME.^323-333 At present, there is no firmly established specific protocol for preventing CME. Additional information on adverse perioperative outcomes is summarized in Table 4.

A malpositioned posterior chamber IOL can cause visual complaints, such as edge glare or intraocular inflammation associated with iris chafing,³⁴⁰ pigment dispersion, and pupillary capture of the optic. This complication is least likely with capsular bag implantation of the IOL. Posterior chamber IOL decentration can result from a damaged haptic, asymmetric capsular contraction and fibrosis, a torn posterior capsule or zonular dialysis, an insufficiently long IOL implanted in the ciliary sulcus, and placement of one haptic in the ciliary sulcus and the other inside the capsular bag.

Delayed posterior dislocation of the IOL may result from insufficient capsular or zonular support. Plate haptic silicone IOLs can dislocate posteriorly following neodymium: yttrium-aluminum-garnet laser (Nd:YAG) capsulotomy and, rarely, spontaneously from capsular contraction. Posterior dislocation of the entire IOL and capsular bag complex can be caused by trauma or can occur spontaneously in eyes with weak zonules, such as those with pseudoexfoliation.^341,342

Certain design characteristics of the posterior chamber IOL optic such as a square peripheral edge, a flat anterior surface, and multifocality are more likely to result in problematic images.^343-346 These symptoms generally become more tolerable with time and reassurance but may rarely be so bothersome as to require surgical explantation of the IOL.

Intraocular lenses may cause unwanted symptomatic optical images such as with IOL opacification, cracked or damaged optics, and lens decentration.

Malpositioned anterior chamber IOLs may result from improper sizing, from iris tuck following implantation, or from rotation of a haptic through a peripheral iridectomy. Excessive anterior chamber IOL mobility can lead to corneal endothelial decompensation.

A rare late complication of IOL implantation is uveitis-glaucoma-hyphema syndrome.

Ocular Comorbidities
Preoperative ocular comorbidities often have a significant effect on the outcome of cataract surgery.^102,297,347 Most comorbid conditions are associated with the potential for reduced improvement in visual function or BCVA,³⁴⁸ and the patient should be adequately informed and counseled during the care process.^[A:III] Comorbid conditions found in patients with cataracts and the special considerations associated with these conditions are listed in Table 5.

Systemic Comorbidities
Systemic comorbidities that may be of importance intraoperatively are diabetes mellitus, pulmonary dysfunction, poorly controlled blood pressure, musculoskeletal disorders causing positional difficulties, tremor, severe hearing impairment, anxiety disorders, mental retardation, dementia, and coagulopathies. For patients with complex medical conditions, it may be beneficial to coordinate care with the patient's primary care physician. Depending on the planned anesthesia and sedation, appropriate measures should be taken to stabilize and monitor the condition.^[A:III]

There is no strong evidence favoring continuation or discontinuation of anticoagulants during cataract surgery for anticoagulated patients.^419,420 In a study of 19,283 eyes, the incidence of adverse medical and ophthalmic events was low and statistically indistinguishable in patients who either continued or discontinued anticoagulant or antiplatelet medication use before cataract surgery.⁴²¹ Several uncontrolled case series reported minimal or no complications in patients who were maintained on their anticoagulants prior to cataract surgery.^422-430 There is no strong evidence favoring continuation or discontinuation of antiplatelet agents; small case series do not show adverse effects from continuation of these agents when phacoemulsification is performed.^422,431-433

The risk of discontinuing anticoagulant or antiplatelet medications depends on the condition for which they were prescribed. Generally, patients can be left on anticoagulant or antiplatelet medications if routine cataract surgery is anticipated. Alternatives to retrobulbar injections should be considered for these patients.^{420 [B:III]}

Recommendations from the American Heart Association for prevention of bacterial endocarditis do not include cataract surgery as a procedure for which systemic antibiotic prophylaxis is necessary.⁴³⁴ The American Academy of Orthopaedic Surgeons currently does not have guidelines for antibiotic prophylaxis for patients with joint prostheses who are undergoing cataract surgery.⁴³⁵

Cataract surgery with IOL implantation alone sometimes results in a modest reduction of IOP.^{360,362,364,436} Generally, a glaucoma procedure combined with cataract surgery is not as effective as glaucoma surgery alone in lowering IOP.^437,438 Separating the cataract and glaucoma incisions results in lower IOP than a one-site combined procedure, but the differences in outcomes are small.^437,438 Phacoemulsification combined with trabeculectomy provides good IOP control as well as improved BCVA compared with preoperative vision.^439-441 Endoscopic cyclophotocoagulation combined with cataract surgery is an alternative procedure for patients who require both cataract and glaucoma surgery, although it may be less effective than trabeculectomy.⁴⁴² Potential benefits of a combined procedure (cataract extraction with IOL implantation and trabeculectomy) are protection against the IOP rise that may complicate cataract surgery alone, more rapid visual recovery, and long-term glaucoma control with a single operation. Despite these presumed advantages, the evidence does not support combined cataract-glaucoma surgery over two-stage surgery.⁴³⁷ Additionally, combined procedures are technically more complex.

There are several reasons to consider cataract surgery at the time of penetrating keratoplasty, even in the presence of a mild cataract. These benefits include the following:

• Cataracts may progress more rapidly after penetrating keratoplasty.
• The use of topical corticosteroids following surgery may hasten PSC cataract development.
• Cataract surgery subsequent to penetrating keratoplasty may damage the corneal graft.
• Surgery is limited to a single procedure.
• Visual rehabilitation is more rapid.

The use of capsule staining dyes may improve the likelihood of achieving an intact capsulorrhexis when performing a combined penetrating keratoplasty and cataract extraction.⁴⁵²

If the indication for considering corneal transplantation is the presence of a central opacity rather than endothelial dysfunction and adequate clear cornea is present in the midperiphery, then the surgeon has the option of performing cataract surgery followed by a sphincterotomy, establishing a clear visual axis.⁴⁵⁸ The use of a capsule staining dye can facilitate the ability to perform cataract surgery safely in the presence of a mild corneal opacity, possibly avoiding the need for corneal transplantation when the principal indication is the need for a clearer cornea to perform cataract surgery safely.⁴⁵⁹

Combined vitreoretinal surgery and phacoemulsification with IOL implantation has been successfully employed.^460,461 Advantages of combined surgery are the single operative procedure and anesthesia as well as reduced postoperative recovery time.

Possible disadvantages of simultaneous cataract and vitreoretinal surgery include prolonged surgical time, cataract wound dehiscence caused by globe manipulation during subsequent vitreoretinal surgery, intraoperative miosis after cataract extraction, IOL decentration or optic capture, and undesirable optical effects during vitreoretinal surgery if the IOL is implanted before the posterior segment procedure. Silicone IOLs are best avoided in these cases because condensation of gas or silicone oil on the posterior surface of the lens can interfere with the intraoperative view of the posterior segment.^462,463

• Vital signs are stable.
• Preoperative mental state is restored.
• Nausea and vomiting are controlled.
• Pain is absent or minimal.
• An escort is available if necessary.
• Postsurgical care has been reviewed with the patient or escort and written postoperative instructions have been provided.
• Follow-up appointment has been scheduled.

• Medical conditions are present that require prolonged postoperative observation by nurses or other skilled personnel.
• Patient is mentally debilitated or diagnosed as mentally ill.
• Patient cannot exercise self-care (or responsible care is unavailable) during the immediate postoperative period.
• Patient is functionally monocular and has had cataract surgery in the eye on which they are primarily dependent.

Postoperative Management
The ophthalmologist who performs the cataract surgery has a unique perspective and thorough understanding of the patient’s intraoperative course, postoperative condition, and response to surgery. The operating ophthalmologist is responsible for the care of the patient during the postoperative interval, the time in which most complications occur and within which stable visual function is achieved, and has an ethical obligation to the patient that continues until postoperative rehabilitation is complete. The operating ophthalmologist should also provide those aspects of postoperative eye care that are within the unique competence of the ophthalmologist (which do not include those aspects of postoperative care permitted by law to be performed by auxiliaries, and, for non-ophthalmological physicians, may also exclude additional functions). If such follow-up care is not possible, the operating ophthalmologist must make arrangements before surgery to refer the patient to a properly licensed, qualified health care professional for postoperative care with the prior approval of the patient and the health care professional.^{162,514 [A:III]} In rare special circumstances, such as emergencies or if no ophthalmologist is available, the operating ophthalmologist may make different arrangements for the provision of those aspects of postoperative eye care within the unique competence of the ophthalmologist, as long as the patient’s rights and welfare are the primary considerations.

The ophthalmologist who performs surgery has an obligation to inform patients about appropriate signs and symptoms of possible complications, eye protection, activities, medications, required visits, and details for access to emergency care.^[A:III] The ophthalmologist should also inform patients of their responsibility to follow advice and instructions provided during the postoperative phase and to notify the ophthalmologist promptly if problems occur.^[A:III] Patients should always have access to an ophthalmologist for appropriate care if serious problems arise.^[A:III]

Most ophthalmologists provide all postoperative care in their offices. Other members of a team of eye care professionals may also participate in the comanagement of postoperative care. The operating ophthalmologist is responsible to the patient for those aspects of postoperative care delegated to other eye care professionals.^{162 [A:III]}

Postoperative regimens of topically applied antibiotics, corticosteroids, and NSAIDs vary among practitioners. There are no controlled investigations that establish optimal regimens for the use of topical agents; therefore, it is the decision of the operating surgeon to use any or all of these products singly or in combination. Complications of postoperative medications include elevated IOP with corticosteroids and allergic reactions to antibiotics. Rarely, significant corneal reactions, including epithelial defects and stromal ulceration and melting, have been reported with topical ocular NSAIDs.^515-517

Postoperative Follow-up
The frequency of postoperative examinations is based on the goal of optimizing the outcome of surgery and swiftly recognizing and managing complications. This requires prompt and accurate diagnosis and treatment of complications of surgery, providing satisfactory optical correction, educating and supporting the patient, and reviewing postoperative instructions. Table 7 provides guidelines for follow-up based on consensus in the absence of evidence for optimal follow-up schedules. Prospective studies from the United Kingdom have reported that omitting an examination on the day after uncomplicated cataract surgery for the routine patient was associated with a low frequency of serious ocular complications.^518,519

Patients should be instructed to contact the ophthalmologist promptly if they experience symptoms such as a significant reduction in vision, increasing pain, progressive redness, or periocular swelling, because these symptoms may indicate the onset of endophthalmitis.^[A:III]

In the absence of complications, the frequency and timing of subsequent postoperative visits depend largely on the size or configuration of the incision; the need to cut or remove sutures; and when refraction, visual function, and the medical condition of the eye are stabilized. More frequent postoperative visits are generally indicated if unusual findings, symptoms, or complications occur, and the patient should have ready access to the ophthalmologist’s office to ask questions or seek care.^[A:III]

Components of each postoperative examination should include:^[A:III]

• Interval history, including use of postoperative medications, new symptoms, and self-assessment of vision.
• Measurement of visual function (e.g., visual acuity, pinhole testing).
• Measurement of IOP.
• Slit-lamp biomicroscopy.
• Counseling/education for the patient or patient’s caretaker.
• Management plan.

The relationship between lens style and PCO has generated interest in preventing PCO by changing IOL material^523-525 and design. Design factors that have been implicated in reducing PCO include the convexity⁵²⁶ and, in particular, the edge profile of the IOL optic.^527-555 Truncated-edge design has been associated with reduced PCO for both silicone and acrylic IOLs in a number of well-controlled studies. Posterior capsular opacification rates are generally found to be higher for PMMA and hydrophilic IOL optics, but no consistent difference is found between silicone and hydrophobic acrylic IOLs when a sharp edge is present on the IOL optic. Some evidence indicates a lower PCO rate when the anterior capsulorrhexis overlies the entire optic,^534,556 but at least one clinical study failed to find a significant difference whether the capsulorrhexis edge was completely over, completely off, or partially over the IOL optic.⁵⁵⁷ However, the presence of a truncated sharp-edge IOL optic does carry an increased likelihood of undesirable optical phenomena after surgery.^344-346

In the absence of risk factors for IOP elevation, routine prophylaxis with ocular hypotensive agents at the time of capsulotomy is not consistently supported by the literature.^573,574 However, reduction of IOP has been demonstrated with topical brimonidine at the time of capsulotomy compared with a small rise of IOP in placebo-treated controls.⁵⁷⁵ In the presence of risk factors, such as pre-existing glaucoma or inflammation, a variety of agents to lower intraocular pressure have demonstrated efficacy at blunting IOP elevation.^575-580 In addition to using these agents in high-risk patients, the surgeon should monitor the IOP at close intervals in the early postoperative period to modify the medication regimen if necessary.^[A:III]

APPENDIX 1. SUMMARY OF MAJOR RECOMMENDATIONS FOR CARE

DIAGNOSIS
Preoperative visual acuity is a poor predictor of postoperative functional improvement; therefore, the decision to recommend cataract surgery should not be made on the basis of visual acuity alone.^{1,2 [A:II]}

The patient should be asked specifically about near and distant vision under varied lighting conditions for activities that the patient views as important.^[A:III]

Ophthalmic Evaluation
The comprehensive evaluation (history and physical examination) includes those components of the comprehensive adult medical eye evaluation³ specifically relevant to the diagnosis and treatment of a cataract as listed below.

• Patient history,^[A:III]including the patient’s assessment of functional status, pertinent medical conditions, medications currently used, and other risk factors that can affect the surgical plan or outcome of surgery (e.g., immunosuppressive conditions, sympathetic alpha-1a antagonists).
• Visual acuity with current correction (the power of the present correction recorded) at distance and when appropriate at near.^[A:III]
• Measurement of best-corrected visual acuity (with refraction when indicated).^[A:III]
• External examination (lids, lashes, lacrimal apparatus, orbit).^[A:III]
• Examination of ocular alignment and motility.^[A:III]
• Assessment of pupillary function.^[A:III]
• Measurement of intraocular pressure (IOP).^[A:III]
• Slit-lamp biomicroscopy of the anterior segment.^[A:III]
• Dilated examination of the lens, macula, peripheral retina, optic nerve, and vitreous.^[A:III]
• Assessment of relevant aspects of the patient’s mental and physical status.^[B:III]

MANAGEMENT

Nonsurgical Management
At the present time, the highest quality evidence does not support a benefit from nutritional supplementation in preventing or delaying progression of cataracts; therefore, treatment with supplements is not recommended.^{4 [A:I]}

Patients who are currently smoking should be informed of the increased risk of cataract progression and the benefits of smoking cessation in retarding the progression of cataracts that have been demonstrated in several studies.^{5-7 [A:II]} Studies have found that smokers report that a physician’s advice to quit is an important motivator in attempting to stop smoking.^8-11 Patients who are long-term users of oral or inhaled corticosteroids should be informed of the increased risk of cataract formation^{12-16 [A:II]} and may wish to discuss alternate medications with their primary care physician. Patients with diabetes mellitus should be informed of their increased risk of cataract formation.^{17-19 [A:II]} Brimmed hats and ultraviolet-B blocking sunglasses are reasonable precautions to recommend to patients.²⁰

Surgical Management

Indications for Surgery

• The primary indication for surgery is visual function that no longer meets the patient’s needs and for which cataract surgery provides a reasonable likelihood of improved vision.^[A:III]
• Other indications for a cataract removal include the following:
  • Clinically significant anisometropia in the presence of a cataract.^[A:III]
  • The lens opacity interferes with optimal diagnosis or management of posterior segment conditions.^[A:III]
  • The lens causes inflammation (phacolysis, phacoanaphylaxis).^[A:III]
  • The lens induces angle closure (phacomorphic or phacotopic).^[A:III]

• To examine the patient preoperatively (see Ophthalmic Evaluation in the main text).^[A:III]
• To ensure that the evaluation accurately documents the symptoms, findings, and indications for treatment.^[A:III]
• To obtain informed consent from the patient or the patient’s surrogate decision maker after discussing the risks, benefits, and expected outcomes of surgery, including anticipated refractive outcome and the surgical experience.^[A:III]
• To review the results of presurgical and diagnostic evaluations with the patient or the patient’s surrogate decision maker.^[A:III]
• To formulate a surgical plan, including selection of an appropriate IOL.^[A:III]
• To formulate postoperative care plans and inform the patient or the patient’s surrogate decision maker of these arrangements (setting of care, individuals who will provide care).^[A:III]
• To afford the patient or the patient’s surrogate decision maker the opportunity to discuss the costs associated with surgery.^[B:III]

All patients undergoing cataract surgery should have a history and physical examination relevant to the risk factors for undergoing the planned anesthesia and sedation and as directed by a review of systems.^[A:III] For patients with certain severe systemic diseases (e.g., chronic obstructive pulmonary disease, recent myocardial infarction, unstable angina, poorly controlled diabetes, or poorly controlled blood pressure) a preoperative medical evaluation by the patient's physician should be strongly considered.^{21 [A:II]} Laboratory testing as indicated by the findings in the history and physical examination is appropriate.^{22 [A:I]}

Achieving the targeted postoperative refraction requires measuring axial length accurately, determining corneal power, and using the most appropriate IOL power formula.^[A:III]

Given the lack of evidence for an optimal anesthesia strategy during cataract surgery, the type of anesthesia management should be determined by the patient's needs and the preferences of the patient and surgeon.^{23 [A:II]}

Use of a 5% solution of povidone iodine in the conjunctival cul de sac is recommended to prevent infection.^{24,25 [A:II]}

Further management recommendations are in the main body of the text.

Postoperative Follow-up
The frequency of postoperative examinations is based on the goal of optimizing the outcome of surgery and swiftly recognizing and managing complications. Table 7 provides guidelines for follow-up based on consensus in the absence of evidence for optimal follow-up schedules.

• Interval history, including use of postoperative medications, new symptoms, and self-assessment of vision.
• Measurement of visual function (e.g., visual acuity, pinhole testing).
• Measurement of IOP.
• Slit-lamp biomicroscopy.
• Counseling/education for the patient or patient’s caretaker.
• Management plan.

REFERENCES

1. Schein OD, Steinberg EP, Javitt JC, et al. Variation in cataract surgery practice and clinical outcomes. Ophthalmology 1994;101:1142-52.
2. Schein OD, Steinberg EP, CassardSD, et al. Predictors of outcome in patients who underwent cataract surgery. Ophthalmology 1995;102:817-23.
3. AmericanAcademy of Ophthalmology. Comprehensive Adult Medical Eye Evaluation, Preferred Practice Pattern. San Francisco: AmericanAcademy of Ophthalmology, 2005. Available at: www.aao.org/ppp.
4. Huang HY, Caballero B, Chang S, et al. Multivitamin/Mineral Supplements and Prevention of Chronic Disease. Evidence Report/Technology Assessment No. 139. (Prepared by The Johns Hopkins University Evidence-based PracticeCenter under Contract No. 290-02-0018). AHRQ Publication No. 06-E012. Rockville, MD: Agency for Healthcare Research and Quality. May 2006.
5. West S, Munoz B, Emmett EA, Taylor HR. Cigarette smoking and risk of nuclear cataracts. Arch Ophthalmol 1989;107:1166-9.
6. Christen WG, Manson JE, Seddon JM, et al. A prospective study of cigarette smoking and risk of cataract in men. JAMA 1992;268:989-93.
7. Christen WG, Glynn RJ, Ajani UA, et al. Smoking cessation and risk of age-related cataract in men. JAMA 2000;284:713-6.
8. National Cancer Institute. Tobacco and the clinician: interventions for medical and dental practice. Monograph #5 (Publ #M492). Bethesda: National Cancer Institute, 1994;1-22.
9. Ockene JK. Smoking intervention: the expanding role of the physician. Am J Public Health 1987;77:782-3.
10. Pederson LL, Baskerville JC, Wanklin JM. Multivariate statistical models for predicting change in smoking behavior following physician advice to quit smoking. Prev Med 1982;11:536-49.
11. Ranney L, Melvin C, Lux L, et al. Tobacco Use: Prevention, Cessation, and Control. Evidence Report/Technology Assessment No. 140. (Prepared by the RTI International -- University of North Carolina Evidence-Based PracticeCenter under Contract No. 290-02-0016). AHRQ Publication No. 06-E015. Rockville, MD: Agency for Healthcare Research and Quality. June 2006.
12. Garbe E, Suissa S, LeLorier J. Association of inhaled corticosteroid use with cataract extraction in elderly patients. JAMA 1998;280:539-43.
13. Jick SS, Vasilakis-Scaramozza C, Maier WC. The risk of cataract among users of inhaled steroids. Epidemiology 2001;12:229-34.
14. Klein BE, Klein R, Lee KE, Danforth LG. Drug use and five-year incidence of age-related cataracts: The Beaver Dam Eye Study. Ophthalmology 2001;108:1670-4.
15. Smeeth L, Boulis M, Hubbard R, Fletcher AE. A population based case-control study of cataract and inhaled corticosteroids. Br J Ophthalmol 2003;87:1247-51.
16. Urban RC, Jr, Cotlier E. Corticosteroid-induced cataracts. Surv Ophthalmol 1986;31:102-10.
17. Hennis A, Wu SY, Nemesure B, Leske MC. Risk factors for incident cortical and posterior subcapsular lens opacities in the Barbados Eye Studies. Arch Ophthalmol 2004;122:525-30.
18. Klein BE, Klein R, Lee KE. Diabetes, cardiovascular disease, selected cardiovascular disease risk factors, and the 5-year incidence of age-related cataract and progression of lens opacities: the Beaver Dam Eye Study. Am J Ophthalmol 1998;126:782-90.
19. Leske MC, Wu SY, Hennis A, et al. Diabetes, hypertension, and central obesity as cataract risk factors in a black population. The Barbados Eye Study. Ophthalmology 1999;106:35-41.
20. McCarty CA, Nanjan MB, Taylor HR. Attributable risk estimates for cataract to prioritize medical and public health action. Invest Ophthalmol Vis Sci 2000;41:3720-5.
21. Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999;100:1043-9.
22. Schein OD, Katz J, Bass EB, et al. The value of routine preoperative medical testing before cataract surgery. Study of Medical Testing for Cataract Surgery. N Engl J Med 2000;342:168-75.
23. Agency for Healthcare Research and Quality. Evidence Report/Technology Assessment: Number 16. Anesthesia management during cataract surgery. Washington, DC: AHRQ Publication No. 00-E015; 2000. Available at: www.ahrq.gov/clinic/epcsums/anestsum.htm.
24. Speaker MG, Menikoff JA. Prophylaxis of endophthalmitis with topical povidone-iodine. Ophthalmology 1991;98:1769-75.
25. Wu PC, Li M, Chang SJ, et al. Risk of endophthalmitis after cataract surgery using different protocols for povidone- iodine preoperative disinfection. J Ocul Pharmacol Ther 2006;22:54-61.
26. AmericanAcademy of Ophthalmology. Vision Rehabilitation for Adults, Preferred Practice Pattern. San Francisco: AmericanAcademy of Ophthalmology, 2001. Available at: www.aao.org/ppp.

APPENDIX 2. VALUE OF CATARACT SURGERY
Methods to evaluate whether the cost of a health care intervention is a good use of available resources include cost-effectiveness or cost-utility calculations. While cost-effectiveness analyses use monetary terms, cost-utility analyses include the value that a patient places on the quality of additional years of life, using a measure called the quality-adjusted life year (QALY). The QALY is a generic outcome measure of the improvement in quality and quantity of life after a health care intervention and so enables comparison of the value of interventions for different health conditions.^123,583 In calculating the QALY, researchers use the economic technique of discounting to reflect the time-value of money because the effect gained from the dollars spent on the treatment remains over the course of the lifetime of the patient.^584,585 The lower the amount calculated for a QALY, the better the value of the intervention. A further refinement incorporates other parameters to describe value-based medicine analyses.⁵⁸⁶

In a study in Sweden and a study in the United States, the hypothetical cost per QALY gained for cataract extraction in one eye was estimated respectively at US $4,500¹²⁴ and US $2,023.¹²⁵ In a US study, the estimated cost per QALY gained for cataract surgery in the second eye was US $2,727 (calculated in 2003).¹²⁶ These values for cataract surgery compare favorably with those reported for other ophthalmic procedures (e.g., laser photocoagulation for diabetic macular edema, $3,101¹²⁷; laser photocoagulation for extrafoveal choroidal neovascularization, $23,640).¹²⁸

For comparisons outside of ophthalmology, the cost-utility in other areas of medicine have been calculated as follows: single-vessel coronary artery bypass surgery for disease of the left anterior descending artery costs $7,000/QALY¹²⁷; treatment of systemic arterial hypertension (diastolic 95-103 mmHg in males aged 40) costs $58,000/QALY; and ambulatory peritoneal dialysis costs $90,000/QALY.

A review of technological innovation looked at the costs and benefits of several treatments for disease conditions, including heart attack, low birthweight infants, depression, breast cancer, and cataracts.⁵⁸⁷ The authors concluded that expansion in treatment for patients operated at much less severe measures of visual acuity than in the past is almost certainly beneficial and that there have been substantial improvements in quality at no cost increase per patient. The present value of cataract surgery was estimated at $95,000, which is much greater than the estimated costs of $2,000 to $3,000. Thus, the benefits of expanded cataract treatment exceed the costs. This compares well with the present value estimated for the other treatments: $20,000 for breast cancer; $6,000 for depression, $240,000 per low birthweight infant, and $70,000 for heart attack.

ADVS: Activities of Daily Vision Scale

AMD: age-related macular degeneration

ASCRS: American Society of Cataract and Refractive Surgery

BCVA: best-corrected visual acuity

CME: cystoid macular edema

D: diopter

ECCE: extracapsular cataract extraction

HEMA: hydroxy ethyl methacrylate

IFIS: intraoperative floppy iris syndrome

IOL: intraocular lens

IOP: intraocular pressure

IV: intravenous

Nd:YAG: neodymium: yttrium-aluminum-garnet laser

NEI-VFQ: National Eye Institute-Visual Function Questionnaire

NEON: National Eyecare Outcomes Network

NSAID: nonsteroidal anti-inflammatory drug

OVD: ophthalmic viscosurgical device

PCO: posterior capsular opacification

PMMA: polymethyl methacrylate

PORT: Patient Outcomes Research Team

PPP: Preferred Practice Pattern

PSC: posterior subcapsular

QALY: quality-adjusted life year

VF-14: Visual Function Index

Basic and Clinical Science Course
Lens and Cataract (Section 11, 2006-2007)

Clinical Skills Videotapes
Challenging Cases in Cataract Surgery (2001)
More Challenging Cases in Cataract Surgery (2001)

Complementary Therapy Assessment
Antioxidant Vitamin and Mineral Supplements and Cataract Prevention and Progression (limited revision 2002)

Eye Fact Sheets
Posterior Capsulotomy (2004)
Posterior Capsulotomy (Spanish: Capsulotomia Posteriór) (2004)

Focal Points
Cataract Surgery Following Refractive Surgery (2001)
The Capsular Ring: Indications and Surgery (2002)
Complex Axial Length Measurements and Unusual IOL Power Calculations (2004)
Multifocal and Accommodating Lens Implementation (2004)
Strategies for Complicated Lens Surgery, Part 1: Advanced Cataract & Pseudoexfoliation Syndrome (2005)
Strategies for Complicated Lens Surgery, Part 2: Other Conditions (2005)

Information Statement
Cataract Surgery in the Second Eye (2004)

LEO Clinical Update Course CD-ROM
Cataract (2004)

Ophthalmic Technology Assessments
Capsule Staining as an Adjunct to Cataract Surgery (2005)
Intracameral Anesthesia (2001)
Intraocular Lens Implantation in the Absence of Ocular Support (2003)

Ophthalmology Monograph
Cataract Surgery and Intraocular Lenses: A 21^st-Century Perspective, 2^nd ed. (Monograph 7, 2001)

Patient Education Booklet
Cataract Surgery (2005)

Patient Education Brochures
Cataract (2004)
Cataract (Spanish: Catarata) (2004)
Cataract Surgery (2005)
Eye Care Facts & Myths (2005)
Seeing Well as You Grow Older (2004)

Patient Education DVD
Understanding Cataract Surgery (2006) (includes English and Spanish)

Patient Safety Bulletin
Minimizing Wrong IOL Placement (2005)

Preferred Practice Pattern
Comprehensive Adult Medical Eye Evaluation (2005)

Summary Recommendations
Summary Recommendations for Cataract Surgery (2006)

To order any of these materials, please call the Academy’s Customer Service number, 866.561.8558 (US only) or 415.561.8540 or visit www.aao.org/store .

• Level A: Most important to the care process
• Level B: Moderately important to the care process
• Level C: Relevant but not critical to the care process

Strength of Evidence Ratings:

• Level I: Randomized controlled trial or meta-analyses
• Level II: Controlled trials, cohort, or case-control studies
• Level III: Descriptive studies or case reports
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Cataract and Anterior Segment Panel Members

Samuel Masket, MD, Chair, American Society for Cataract and Refractive Surgery Representative

David F. Chang, MD

Stephen S. Lane, MD

Richard H. Lee, MD

Kevin M. Miller, MD

Roger F. Steinert, MD

Rohit Varma , MD , MPH, Methodologist