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## Complete Summary

#### GUIDELINE TITLE

Care of the adult patient with cataract.

#### BIBLIOGRAPHIC SOURCE(S)

American Optometric Association. Care of the adult patient with
cataract. 2nd ed. St. Louis (MO): American Optometric Association; 1996.
84 p. (Optometric clinical practice guideline; no. 16). \[151
references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

According to the guideline developer, this guideline has been reviewed
on a biannual basis and is considered to be current as of 2004. This
review process involves updated literature searches of electronic
databases and expert panel review of new evidence that has emerged since
the original publication date.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Cataract

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management

#### CLINICAL SPECIALTY

Optometry

#### INTENDED USERS

Health Plans\
Optometrists

#### GUIDELINE OBJECTIVE(S)

-   To identify patients at risk of developing cataracts

-   To accurately diagnose cataracts

-   To improve the quality of care rendered to patients with cataracts

-   To effectively manage patients with cataracts

-   To identify and manage postoperative complications

-   To inform and educate patients and other health care practitioners
    about the visual complications and functional disability from
    cataracts and the availability of treatment

#### TARGET POPULATION

Adults with cataracts

#### INTERVENTIONS AND PRACTICES CONSIDERED

*Diagnosis*

1.  Patient history and physical examination

2.  Ocular examination

3.  Supplemental testing

*Treatment*

1.  Nonsurgical treatment

2.  Cataract surgery (extracapsular cataract extraction by
    phacoemulsification or nuclear expression)

#### MAJOR OUTCOMES CONSIDERED

-   Visual acuity

-   Activities of daily living

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches using the National
Library of Medicine\'s Medline database and the VisionNet database.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus (Committee)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not applicable

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The Reference Guide for Clinicians was reviewed by the American
Optometric Association (AOA) Clinical Guidelines Coordinating Committee
and approved by the AOA Board of Trustees.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Every patient with cataract should be informed of the presence of the
condition. The optometrist should discuss with the patient the natural
course of the cataract and the treatment options, as well as the
importance of routine examinations. Cataract patients whose vision loss
is correctable with spectacles should be informed that the lens
opacities might progress and require other spectacle lens changes or
surgery. Patients who cannot otherwise achieve adequate vision for their
activities of daily living should be informed that only surgery can help
rehabilitate their vision (i.e., that further spectacle changes would be
of limited value). A candidate for cataract surgery must be informed of
all of the risks and benefits of surgery. The patient should be provided
complete information on the pros and cons of the various surgical
techniques, the skills of the surgeons in the area, and the expected
outcome and schedule for postoperative care. The patient who has had
cataract surgery should receive proper and timely postoperative care and
proper monitoring of both overall ocular health and vision status.

A.  **Diagnosis of Cataract**

> Many patients with undiagnosed cataract first present for examination
> when they experience symptoms of reduced vision that affects their
> daily activities. Such patients should undergo a comprehensive eye and
> vision examination with particular attention given to inspection of
> the lens of the eye. The essential elements of this evaluation
> include:

1.  **Patient History**

2.  **Ocular Examination**

> Elements of the ocular examination may include, but are not limited
> to, the following:

-   Measurement of visual acuity under both low and high illumination

-   Biomicroscopy with pupillary dilation, with special attention to the
    three clinical zones of the lens and the classification and
    quantification of the cataract

-   Stereoscopic fundus examination with pupillary dilation

-   Assessment of ocular motility and binocularity

-   Visual fields screening by confrontation, and if a defect is noted,
    further investigation by formal perimetry

-   Evaluation of pupillary responses to rule out afferent pupillary
    defects

-   Refraction to rule out refractive shift as a cause for the decreased
    vision

-   Measurement of intraocular pressure (IOP).

3.  **Supplemental Testing**

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B.  **Management of Cataract**

> Care of the patient with cataract may require referral for
> consultation with or treatment by another optometrist or an
> ophthalmologist experienced in the treatment of cataract, for services
> outside the optometrist\'s scope of practice. The optometrist may
> participate in the co-management of the patient, including both
> preoperative and postoperative care. The extent to which an
> optometrist can provide postoperative treatment for patients who have
> undergone cataract surgery may vary, depending on the state\'s scope
> of practice laws and regulations and the individual optometrist\'s
> certification.

1.  **Basis for Treatment**

> The treatment decision for the patient with cataract depends on the
> extent of his or her visual disability.

2.  **Available Treatment Options**

    a.  **Nonsurgical Treatment**

    b.  **Indications for Surgery**

> Surgery is indicated when cataract formation has reduced visual acuity
> to the level that it interferes with the patient\'s lifestyle and
> everyday activities, and when satisfactory functional vision cannot be
> obtained with spectacles, contact lenses, or other optical aids. The
> vision needs of the patient, as they relate to his or her lifestyle,
> occupation, and hobbies, should be considered.

1.  **Patient Education**

> Surgical candidates should be informed of the risks involved with
> cataract surgery.
>
> Patients should be advised of the advantages and disadvantages of the
> available cataract extraction techniques and intraocular lenses and
> the postoperative care available to them. The qualifications of the
> surgeon(s) and the setting for delivery of care should be discussed.
> Patient counseling may include a discussion of the following aspects
> of the surgery:

-   Anesthesia

-   Location and type of incision

-   Intraocular lens options

-   Medications

-   Disposition

-   Continuing postoperative care

1.  **Follow-up**

> The frequency and composition of evaluation and management visits for
> an uncomplicated clinical course following cataract surgery are
> summarized in the table, below. Refer to the guideline document for
> discussion of postoperative care of surgical complications.

**Frequency and Composition of Evaluation and Management Visits for an
Uncomplicated Clinical Course Following Cataract Surgery**

  ----------------- ------------- -------------- ------------ ---------------- --------------- ------------- ---------------------
                                                                                                             

  **Postoperative   **History**   **Visual       **External   **Refraction**   **Tonometry**   **Dilated     **Management Plan**
  Visits**                        Acuity Unaided and Slip                                      Fundus        
                                  and With       Lamp Exam**                                   Exam^4^**     
                                  Pinhole^1^**                                                               

                                                                                                             

  #1\               Yes           Yes            Yes                           Yes             If indicated  Administer topical
  One day                                                                                      by symptoms   antibiotic/steroid;
                                                                                               of very poor  counsel patient
                                                                                               vision or     
                                                                                               retinal       
                                                                                               disease       

  #2\               Yes           Yes            Yes                           Yes             If indicated  Continue and/or taper
  7 to 14 days\                                                                                by signs or   medications; counsel
  Usually 1 week                                                                               symptoms of   patient
                                                                                               retinal       
                                                                                               disease       

  #3\               Yes           Yes            Yes          Yes              Yes             Yes^5^        Continue and/or taper
  3 to 4 weeks                                                                                               medications; counsel
                                                                                                             patient; prescribe
                                                                                                             refractive correction

  #4^2^\            Yes           Yes            Yes^3^       Yes              Yes             Yes^5^        Discontinue
  6 to 8 weeks                                                                                               medications if exam
                                                                                                             is normal; counsel
                                                                                                             patient; prescribe/
                                                                                                             modify refractive
                                                                                                             correction

  #5\               Yes           Aided visual                If vision is     Yes             If indicated  Reschedule for yearly
  Subsequent                      acuity with                 reduced                          based on      evaluation or as
  visits\                         pinhole                                                      findings and  needed
  3 to 6 months                                                                                symptoms^5^   

                                                                                                             
  ----------------- ------------- -------------- ------------ ---------------- --------------- ------------- ---------------------

^1^ Pinhole VA: assess if visual acuity worse than 20/30 unaided.\
^2^ Optional visit: some clinicians elect to schedule three
postoperative visits, others four prior to determining a final spectacle
prescription.\
^3^ Consider need to cut sutures if high astigmatism is present.\
^4^ Dilated fundus exam: provided at least once during the postoperative
period.\
^5^Check clarity of posterior capsule.

#### CLINICAL ALGORITHM(S)

An algorithm is provided for Optometric Management of the Adult Patient
with Cataract.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Cataract is a common problem in an aging population. Reduced vision due
to cataract can greatly affect the patient\'s ability to perform
day-to-day activities. Proper care through both nonsurgical and surgical
intervention can lead to improved productivity, reduction of personal
suffering, and substantial cost savings for the affected individuals,
their families, and the health care system as a whole.

**Subgroups Most Likely to Benefit**:

*Risk factors for the development of cataract include*:

-   *Age*

-   *Diabetes mellitus*. Persons with diabetes mellitus are at higher
    risk for cataracts, and persons with diabetes who have cataracts
    have a higher morbidity than those without cataracts.

-   *Drugs*. Certain medications have been found to be associated with
    cataractogenesis and vision loss. There is an association between
    corticosteroids and posterior subcapsular cataracts. Drugs such as
    phenothiazine or other thiazines and chlorpromazine have been
    associated with the induction of cataract formation.
    Antihypertensive agents have not shown a high association with onset
    of cataract.

-   *Ultraviolet radiation*. Studies have shown that there is an
    increased chance of cataract formation with unprotected exposure to
    ultraviolet (UV) radiation. These studies find that patients living
    in environments with high UV-B radiation levels have a higher
    incidence of cataract. Also, if not protected, persons with higher
    occupational exposure to UV light are at greater risk for cataract
    than those with lower occupational exposure rates.

-   *Smoking*. An association between smoking and increased nuclear
    opacities has been reported.

-   *Alcohol*. Several studies have shown increased cataract formation
    in patients with higher alcohol consumption compared with patients
    who have lower or no alcohol consumption.

-   *Nutrition*. Although the results are inconclusive, studies have
    suggested an association between cataract formation and low levels
    of antioxidants (e.g., vitamin C, vitamin E, carotenoids). Further
    study may show that antioxidants have a significant effect on
    decreasing the incidence of cataract.

#### POTENTIAL HARMS

The risks associated with cataract surgery include serious complications
(e.g., endophthalmitis) which may result in vision worse than that prior
to surgery or in total vision loss. Other complications (e.g., cystoid
macular edema or CME) may require additional medications or prolonged
follow-up, but do not necessarily result in long-term vision loss.

Early emergent complications that may arise following cataract surgery
include ocular hypertension, malignant glaucoma, would leak with shallow
or flat anterior chamber, endophthalmitis, iris prolapse or vitreous in
the wound, intraocular lens dislocation, retinal break and detachment.
Early less-emergent complications include ptosis, diplopia, wound leak
with well-formed anterior chamber, acute corneal edema, hyphema,
anterior uveitis, intraocular lens decentration/pupillary capture,
choroidal detachment, and anterior ischemic optic neuropathy.
Intermediate to late complications include ptosis, diplopia, ocular
hypertension or glaucoma, epithelial downgrowth, chronic corneal
edema/corneal decompensation, late hyphema, chronic anterior uveitis,
posterior capsular opacity, pseudophakic cystoid macular edema.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

Clinicians should not rely on this Clinical Guideline alone for patient
care and management. Please refer to the references and other sources
listed in the original guideline for a more detailed analysis and
discussion of research and patient care information.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

American Optometric Association. Care of the adult patient with
cataract. 2nd ed. St. Louis (MO): American Optometric Association; 1996.
84 p. (Optometric clinical practice guideline; no. 16). \[151
references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1995 (revised 1999; reviewed 2004)

#### GUIDELINE DEVELOPER(S)

American Optometric Association - Professional Association

#### SOURCE(S) OF FUNDING

Funding was provided by the Vision Service Plan (Rancho Cordova,
California) and its subsidiary Altair Eyewear (Rancho Cordova,
California)

#### GUIDELINE COMMITTEE

American Optometric Association Consensus Panel on Care of the Adult
Patient with Cataract

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Members*: Cynthia A. Murrill, O.D., M.P.H.; David L. Stanfield, O.D.

*Principal Authors*: Michael D. VanBrocklin, O.D.; Ian L. Bailey, O.D.;
Brian P. DenBeste, O.D.; Ralph C. DiIorio, M.D.; Howell M. Findley,
O.D.; Robert B. Pinkert, O.D.

*AOA Clinical Guidelines Coordinating Committee Members*: John F. Amos,
O.D., M.S. (Chair); Barry Barresi, O.D., Ph.D.; Kerry L. Beebe, O.D.;
Jerry Cavallerano, O.D., Ph.D.; John Lahr, O.D.; David Mills, O.D.

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

According to the guideline developer, this guideline has been reviewed
on a biannual basis and is considered to be current as of 2004. This
review process involves updated literature searches of electronic
databases and expert panel review of new evidence that has emerged since
the original publication date.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American Optometric Association Web
site](http://www.aoa.org/documents/CPG-8.pdf).

Print copies: Available from the American Optometric Association, 243 N.
Lindbergh, Blvd., St. Louis, MO 63141-7811

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

The following is available:

-   Answers to your questions about cataracts. St. Louis, MO: American
    Optometric Association. (Patient information pamphet).

Print copies: Available from the American Optometric Association, 243 N.
Lindbergh Blvd., St. Louis, MO 63141-7881; Web site,
[www.aoanet.org](http://www.aoanet.org/).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This summary was completed by ECRI on December 2, 1999. The information
was verified by the guideline developer as of January 31, 2000.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions as follows:

Copyright to the original guideline is owned by the American Optometric
Association (AOA). NGC users are free to download a single copy for
personal use. Reproduction without permission of the AOA is prohibited.
Permissions requests should be directed to Jeffrey L. Weaver, O.D.,
Director, Clinical Care Group, American Optometric Association, 243 N.
Lindbergh Blvd., St. Louis, MO 63141; (314) 991-4100, ext. 244; fax
(314) 991-4101; e-mail, <JLWeaver@AOA.org>.

### DISCLAIMER

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Date Modified: 11/3/2008