Indications for Surgery

Although patients with visually significant cataracts may express the desire for improved vision, the decision to operate is not based solely on a specific level of reduced acuity. Key to the decision is determining whether the patient’s visual function would improve enough to warrant cataract surgery. Some governmental agencies and industries have minimum standards of visual function for their workers for tasks such as driving, flying, and operating complex equipment. A patient whose best-corrected visual acuity (BCVA; also called corrected distance visual acuity) does not meet these visual requisites may need to consider cataract surgery. The ophthalmic surgeon must determine whether cataract surgery is advisable, through discussion with the patient and/or the patient’s surrogate and analysis of the results of subjective and objective testing.

Some third-party payers require that patients have a certain level of vision loss before approving reimbursement for cataract surgery; in such cases, glare testing may be useful for documenting loss of visual function beyond that measured by Snellen acuity. In some cases, patients have lens changes that cause unwanted refractive errors or symptoms but do not meet criteria for third-party reimbursement. After a careful discussion of the risks, benefits, alternatives, and costs, surgery may be offered to patients who would benefit from the procedure.

Medical indications for cataract surgery include phacolytic glaucoma, phacomorphic glaucoma, phacoantigenic uveitis, and dislocation of the lens. An additional indication for surgery is a cataract that is sufficiently opaque so as to obscure the view of the fundus and impair the diagnosis or management of other ocular diseases, such as diabetic retinopathy, macular degeneration, or glaucoma.

Cataract in elderly persons, especially those with significant deafness or early dementia, may lead to isolation. The quality of life of such patients may be greatly improved following cataract surgery, with possible spectacle independence. Cataract extraction has been shown to decrease the frequency of falls and hip fractures and to reduce morbidity and mortality.

Common indications for surgery in a patient with a monocular cataract include loss of stereopsis, diminished peripheral vision, disabling glare, and symptomatic anisometropia. The presence of cataract in 1 eye has a negative effect on driving performance and accident avoidance.

There are many possible treatment strategies for a patient with bilateral, visually significant cataracts. The strategy ultimately chosen, and the time waited before performing surgery on the second eye, is based on a combination of the surgeon’s preference and the patient’s needs, expectations, and visual potential. Surgery is usually performed first in the eye with the more advanced cataract, although the dominant or more ametropic eye may be addressed first in order to facilitate the patient’s adaptation after surgery. In patients with active or severe systemic illness, or in those with other ocular diseases contributing to decreased vision, it may be appropriate to operate only on the eye with better visual potential.

Traditionally, before proceeding with the second surgery, the physician and the patient allow some time to confirm the success and safety of the first operation and to assess the refractive outcome. However, symptomatic anisometropia may occur as a result of the first cataract surgery, and the patient may find this disabling enough to justify prompt surgery on the second eye, even if the cataract in that eye is at a relatively early stage of development. After undergoing second-eye cataract surgery, patients have been shown to experience significant improvements not only in acuity and satisfaction with their vision but also in measures of bilateral visual function, such as stereopsis and contrast sensitivity.

Interest has increased in immediate sequential (same-day) bilateral cataract surgery (ISBCS). Indications for ISBCS might include patients with bilateral cataracts or unilateral cataract with a high refractive error that could result in significant postoperative anisometropia or patients who require general anesthesia where the risks of anesthesia outweigh the risks of surgery. ISBCS may be most useful in regions with limited surgical access or for patients with transportation issues. If same-day surgery is performed, each eye is treated as an entirely separate case by using new gloves, draping, instruments, and tubing. When proper safety techniques are used, ISBCS has a demonstrated record of safety. However, most ophthalmologists still do not use this approach due to reimbursement issues, as well as the potential for bilateral complications. The inability to incorporate information regarding refractive outcome into planning for the second eye is another concern; however, with the use of intraoperative aberrometry and improved refractive formulas, this is becoming less significant.

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Excerpted from BCSC 2020-2021 series: Section 11 - Lens and Cataract. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.