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Cataract in Adults:  Management of Functional Impairment 
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Clinical Practice Guideline.
**Panel Chair:  Denis M. O'Day, M.D., F.A.C.S.,Vanderbilt University School of Medicine.Guideline Release Date:  February 25, 1993.**

*A guideline was developed by an 18-member multidisciplinarypanel of private-sector experts to promote appropriate management of adults with cataract-relatedfunctional impairment.  After an extensive literature review, the panel concluded that surgery isnot justified merely because a cataract exists.  Its appropriateness depends on the degree offunctional impairment, including the patient's assessment of vision and lifestyle needs*.

**Cataract Guideline Contents (Spring 1995)**
- Introduction
- Findings
- Dissemination
- Implications
- Bibliography 
Introduction
When people with cataracts (clouding of the eye lens, a normalpart of aging) try to perform everyday activities, they can experience serious difficulties.  As aresult, more than 1.3 million cataract extractions are performed each year on Medicarebeneficiaries. 

Cataract in adults was designated as a clinical practice guideline topic because of itsprevalence in elderly Americans, and expenditures for cataract surgery are a significant part ofthe Medicare budget.  The goal of the guideline—*Cataract in Adults:  Management ofFunctional Impairment*—is to encourage appropriate treatment for restoring ormaintaining functional independence.

To ensure a broad approach to care, the AHCPR-supported guideline covered:
- Ethical issues in the caregiver-patient relationship.
- Natural history and major risk factors of cataract.
- Referral pathways and access to care.
- Treatment settings and health care providers, and their impact on outcomes.
- Value and suitability of preoperative tests.
- Various aspects of treatment, including surgical and nonsurgical management.
- Care, rehabilitation, and YAG laser treatment for clouding of the capsule behind the lensafter cataract surgery.

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Findings
Using data bases of the National Library of Medicine as a foundation for literature sources, the guideline panel analyzed nearly 8,000 relevant English-language scientific articles publishedbetween January 1975 and April 1991.  Based on this extensive literature review, expert opinion,and panel consensus, the panel reached the following conclusions and recommendations:
- Cataract surgery is not justified merely because a cataract exists.  The appropriateness ofremoving it depends on how much it interferes with the patient's ability to functionindependently, including his or her assessment of vision and lifestyle needs.
- Management decisions should be based mainly on a complete patient history and eyeexam.
- Special tests before surgery rarely help decide whether to recommend cataract removal. These tests include contrast sensitivity testing, glare testing, and potential vision testing. 
- Depending on the degree of functional impairment, patients, together with their eye careprofessionals, should explore options such as the use of stronger eyeglasses or magnifying lensesbefore choosing cataract surgery.  That decision should be made by the patient, after discussionwith the eye surgeon.
- When cataract surgery is needed, it should be performed where the patient can receivequality care, as close as possible to home or another social support system.  This may mean that, if it is in the patient's interest, the operation may be performed by a surgeon otherthan the one who diagnosed the cataract.  It is best for the surgery to be performed in the samecommunity as the care given before and after surgery.
- In no case should cataract surgery be performed on both eyes at the same time. 
- The period after cataract surgery is extremely important to the outcome.  The eye surgeon is responsible for the patient's care during followup until the patient's vision has improved andstabilized.
- YAG laser surgery appears to be effective for correcting the clouding of the capsule behindthe lens that frequently occurs after cataract surgery.  However, the wide variations in rates andtiming of YAG laser surgery after cataract removal suggests that it may not be usedappropriately.  YAG laser surgery should be performed only because of functional impairment,not as a preventive measure.

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Dissemination
The guideline was released at a Washington, DC, press conference in February 1993.  It receivedimmediate nationwide coverage on more than 100 television stations, including the CBS, NBC,and CNN networks.  A video news release produced by the American Association of RetiredPersons with AHCPR assistance was used by 46 television stations and seen by an estimatedaudience of 16.8 million persons.

Extensive radio coverage included National Public Radio, the Associated Press, and CNNand CBS networks.  An audio news release by North American Network was aired in 19 Statesto more than 324,000 listeners.

Supported by a grant from AHCPR, American Medical Television produced a continuingmedical education program on the cataract guideline.  The National Society to Prevent Blindnessproduced eight radio public service announcements that aired in March 1993 for CataractAwareness Month.

Major daily newspapers that carried reports of the guideline included the *New YorkTimes*, *Wall Street Journal*, *Washington Post*, *Chicago Tribune*, *Miami Herald*, and *Boston Globe*,  with front page stories in the *Los Angeles Times*, *PhiladelphiaInquirer*, and both the national and international editions of *USA Today*,  *U.S. News andWorld Report*, *Consumer Reports on Health*, *Arizona Senior World*, *New York Newsday*, and *Mature American* also reported on the guideline. 

Health care professionals were informed of the guideline through journals such as*Ophthalmology*, *Archives of Ophthalmology*, *American Family Physician*, and*American Journal of Nursing*.  Four journals reprinted versions of the guideline, and*Ophthalmology* reprinted the entire 350-page *Guideline Report*.

AHCPR conducted a special mailing of the guideline to more than 50 Indian Health Serviceophthalmologists and eye clinics.  AHCPR also filled hundreds of bulk requests nationwide fromhospitals, medical and nursing schools, Veterans Affairs Medical Centers, health maintenanceorganizations, State medical societies and agencies, health insurance companies, and medicalpeer review and consumer education and advocacy organizations.

To date, AHCPR has distributed more than 253,000 copies of the *Clinical PracticeGuideline* and the *Quick Reference Guide for Clinicians*.  More than 289,000 copies of the*ConsumerVersion* of the guideline in English have been sent, as have 9,000 copies in Spanish.
Dissemination Summary: Cataract GuidelinePresentations: 2Publications and Professional Articles: 11Health Industry Articles: 27Professional Mentions: 92Consumer Print: 499Consumer Broadcast: 217Total: 848
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Implications
The Island Peer Review Organization (IPRO), which conducts quality assessments for the HealthCare Financing Administration, is using the guideline in reviewing Medicare hospitaldischarges in New York State.  IPRO ophthalmologists use the guideline as a resource to assessthe appropriateness of cataract procedures performed.  IPRO, which oversees more than 1million discharges annually, is one of the largest independent peer review organizations in theUnited States.

The guideline stresses that, in all but a few cases, the deciding factor for performing cataractor YAG laser surgery should be whether the patient feels that he or she is impaired functionally. This patient-centered approach may lead to a lower volume of surgery.

The guideline emphasizes the operating eye doctor's responsibility and ethical obligation to thepatient for care before, during, and after surgery.

Special eye tests before surgery such as glare testing may be used less routinely because ofthepanel's finding that such tests have not proven useful in most cases.

The cataract guideline has been endorsed by the Alliance for Aging Research, AmericanAcademy of Ophthalmology, American College of Surgeons, National Society to PreventBlindness, Association of University Professors of Ophthalmology, American NursesAssociation, and American Society of Ophthalmic Registered Nurses.

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Bibliography
*Cataract in Adults:  Management of Functional Impairment (Clinical Practice Guideline)*. Publication No. AHCPR  93-0542.  Rockville, MD:  Agency for Health Care Policy andResearch,Public Health Service, U.S. Department of Health and Human Services, February 1993.

*Cataract in Adults:  Management of Functional Impairment (Quick Reference Guide forClinicians)*.  Publication No. AHCPR 93-0543.  Rockville, MD:  Agency for HealthCarePolicy and Research, Public Health Service, U.S. Department of Health and Human Services,February 1993.

*Cataract in Adults:  Management of Functional Impairment (A Patient's Guide)*. Publication No. AHCPR 93-0544.  Rockville, MD:  Agency for Health Care Policy andResearch,Public Health Service, U.S. Department of Health and Human Services, February 1993.

*Las Cataratas en los Adultos* (Spanish Version of *A Patient's Guide*). Publication No.AHCPR 94-0545.  Rockville, MD:  Agency for Health Care Policy and Research, PublicHealthService, U.S. Department of Health and Human Services, May 1994.

Cataract Management Guideline Panel. (1993).  Clinical guidelines:  Cataract surgery and itsalternatives. *American Journal of Nursing* 93(7), 59-61.

Cataract Management Guideline Panel. (1993).  Management of functional impairment dueto cataract in adults. *Ophthalmology* 100(8, suppl.), 1S-350S.

O'Day, D.M. (1993).  A new guideline for patients with cataract [editorial].  Archives of*Ophthalmology* 111(3), 317-318.

O'Day, D.M. (1993).  Clinical practice guidelines, quick reference guide for clinicians. Management of cataract in adults. *American Family Physician* 47(6),1421-1430.

O'Day, D.M., & the Cataract Management Guideline Panel of the Agency for Health CarePolicy and Research. (1993).  Management of cataract in adults:  Quick reference guide forclinicians. *Archives of Ophthalmology* 111(4), 453-459.

O'Day, D.M., Steinberg, E.P., & Dickersin, K. (1993).  Systematic literature review forclinical practice guideline development. *Transactions of the American OphthalmologicalSociety* 91, 421-436.

U.S. Department of Health and Human Services, AHCPR. (1993).  Cataract in adults: Management of functional impairment. A patient's guide. *Journal of Ophthalmic Nursing andTechnology* 12(4), 159-162.

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