Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

cataract without concomitant eye pathology

1st line – observation

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ACUTE
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cataract without concomitant eye pathology
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without functional vision impairment
1st line – 

observation

No treatment is required in this group of patients. Annual eye examination is recommended to follow the progress of the lenticular opacity, and to detect the presence of functional visual complaint.

1st line – extra-capsular cataract extraction with phacoemulsification ± intra-ocular lens implant

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ACUTE
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cataract without concomitant eye pathology
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with functional vision impairment
1st line – 

extra-capsular cataract extraction with phacoemulsification ± intra-ocular lens implant

In one systematic review of systematic reviews, cataract surgery was consistently associated with improved vision-related quality of life, particularly if carried out immediately after diagnosis.[39]

Before proceeding with treatment, it is necessary to ensure that vision loss is sufficiently severe to result in a functional deficit, and that it is due to the cataract, and not some other ocular or neurological condition.

Clinical assessment should include eye examination, biometry and intra-ocular lens (IOL) selection, consent for one or both eyes, and any preoperative anaesthetic or medical health assessment that has not already been completed remotely (e.g., blood pressure check).[45]

Surgery is generally performed as an outpatient under local anaesthesia or topical anaesthesia alone.[54] [ Cochrane Clinical Answers logo ] ​ Opioids are commonly used to increase pain relief during phacoemulsification and postoperatively. A further option is the use of ketorolac, a non-steroidal anti-inflammatory drug (NSAID), which is available in combination with phenylephrine, the mydriatic agent, as an addition to irrigation solution.[56] In specific complex cataract cases or patients with comorbidities, other anaesthetic methods may be added such as sub-Tenon’s anaesthesia, peribulbar block, or general anaesthesia.[57]

Routine surgery usually requires about 5 to 15 minutes of intraoperative time; longer operating times are required for more complex procedures (e.g., no view, poor dilation, weak zonules) and/or management of perioperative complications.

Phacoemulsification is commonly employed to extract the cataract through a small surgical excision (typically 1.8-2.8 mm). This approach uses a rapidly vibrating (ultrasonic) tip combined in a single hand-piece coaxially (or separated biaxially), with both irrigation inflow and aspiration outflow to maintain the pressures within the eye and to flush out the fragmented cataract.

In most surgeries performed in developed countries, an artificial IOL is implanted following removal of the cataract. In general, the implanted lens is a monofocal optically spherical (simple convex) lens set to correct distance vision.

Toric IOLs have a built-in astigmatic correction and are used in patients with corneal regular astigmatic refractive errors. Another method for correcting corneal astigmatism during cataract surgery is limbal relaxing incisions.

Standard IOLs and toric IOLs correct the patient's vision at one distance only. Multi-focal (pseudo-accommodating) or accommodating IOLs provide improved vision at several focal distances, simultaneously targeting good uncorrected distance vision and improved uncorrected near and intermediate vision. Examples include low-add, extended range of correction (depth of focus), multi-focal toric, and light-adjustable IOLs.[62][63][64]

The success of multi-focal or accommodating IOLs mostly depends on proper patient selection, particularly concerning the patient’s expectations for spectacle independence.[65] [ Cochrane Clinical Answers logo ] ​ Although many patients report good vision with these IOLs when used for their approved indication, each design has drawbacks (e.g., glare, halos, reduced contrast sensitivity, insufficient near vision).[63][64][66][67][68][69]​​​

An alternative to multi-focal IOLs, monovision cataract surgery implants a different monofocal lens in each eye. It generally targets best distance focus in the dominant eye and best close focus in the non-dominant eye. The trade-offs with monovision are the loss of stereo vision and reduced depth perception, which some patients may not tolerate.

Mini-monovision involves a smaller dioptre difference between the eyes compared with traditional monovision. It can achieve spectacle independence without the risk of photic phenomena, and is associated with high patient satisfaction rates.[70][71]​ 

In developing countries, cataract surgery may be performed using a larger incision to remove the cataract in one piece. Low-cost IOLs are increasingly available and their use is becoming routine in developing countries. If no IOL is available aphakic glasses are prescribed postoperatively or a secondary IOL may be placed, sutured, or glued in at a later date.

One Cochrane review that compared manual small incision cataract surgery with extracapsular cataract surgery in India and Nepal concluded that there were insufficient data on cost-effectiveness, and that neither procedure was superior to the other.[72]

Consider – correction of residual refractive error

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ACUTE
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cataract without concomitant eye pathology
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with functional vision impairment
Consider – 

correction of residual refractive error

Additional treatment recommended for SOME patients in selected patient group

If an implant lens is not used or a refractive error remains (e.g., astigmatism that is uncorrected by the implant lens), the patient may need to wear contact lenses or spectacles to achieve good postoperative vision.

Adjunctive procedures to correct residual refractive errors can be performed during or after surgery.[73]

cataract with concomitant eye pathology

1st line – extra-capsular cataract extraction with phacoemulsification ± intrao-cular lens implant

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ACUTE
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cataract with concomitant eye pathology
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previous refractive surgery
1st line – 

extra-capsular cataract extraction with phacoemulsification ± intrao-cular lens implant

Patients who have previously undergone refractive surgery may have high expectations of spectacle-free vision after cataract surgery and should be counselled about the risk of excess residual refractive error. If there is a history of laser-assisted in situ keratomileusis (LASIK), pre-surgical planning includes topography to look for decentred or irregular ablations; if present, multi-focal or extended depth of focus IOLs are usually avoided due to the risk of visual disturbances.

Patients with a history of photorefractive keratectomy or radial keratotomy (RK) are likely to have more epithelial remodelling than patients with previous LASIK. Prior RK surgery is also associated with an increased risk of postoperative irregular astigmatism and hyperopic drift. Any surgical incisions should avoid previous incision sites to prevent epithelial ingrowth. An alternative in those with a history of RK is the scleral tunnel approach.

Consider – correction of residual refractive error

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ACUTE
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cataract with concomitant eye pathology
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previous refractive surgery
Consider – 

correction of residual refractive error

Additional treatment recommended for SOME patients in selected patient group

If an implant lens is not used or refractive error remains (e.g., astigmatism uncorrected by the implant lens), the patient may need to wear contact lenses or spectacles to achieve good postoperative vision.

1st line – peripheral iridotomy

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ACUTE
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cataract with concomitant eye pathology
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angle-closure glaucoma
1st line – 

peripheral iridotomy

Sometimes in an eye with a predisposed shallow anterior chamber, cataracts can worsen narrowing of the filtration angle sufficiently to predispose to acute angle-closure glaucoma. In these cases, an opening is created in the iris (a peripheral iridotomy).

See Angle-closure glaucoma.

Consider – extra-capsular cataract extraction with phacoemulsification ± intra-ocular lens implant

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ACUTE
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cataract with concomitant eye pathology
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angle-closure glaucoma
Consider – 

extra-capsular cataract extraction with phacoemulsification ± intra-ocular lens implant

Additional treatment recommended for SOME patients in selected patient group

Cataract surgery may be performed as an additional procedure in people who continue to have raised intra-ocular pressure and/or residual visual impairment, independent of the degree of lenticular opacity.

One Cochrane review reported moderate-certainty evidence that lens extraction has an advantage over laser peripheral iridotomy for chronic primary angle-closure glaucoma over 3 years of follow-up. It also concluded that there was low-certainty evidence that combining phacoemulsification with either viscogonioplasty or goniosynechialysis does not add any benefit over phacoemulsification alone.[74]

Consider – correction of residual refractive error

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ACUTE
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cataract with concomitant eye pathology
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angle-closure glaucoma
Consider – 

correction of residual refractive error

Additional treatment recommended for SOME patients in selected patient group

If an implant lens is not used or refractive error remains (e.g., astigmatism that is uncorrected by the implant lens), the patient may need to wear either contact lenses or spectacles to achieve good postoperative vision.

The patient can also opt for post-cataract refractive surgery.[73]

1st line – pre-treatment of uveitis

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ACUTE
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cataract with concomitant eye pathology
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uveitis
1st line – 

pre-treatment of uveitis

In cases of long-standing and mature cataract, the cortex can become liquefied, resulting in a morgagnian cataract.[Figure caption and citation for the preceding image starts]: Morgagnian cataract: a late end-stage cataractFrom the personal collection of M. Bowes Hamill, MD [Citation ends].com.bmj.content.model.Caption@3c578fe2

In this setting, lens proteins can leak from the capsular bag and cause chronic inflammation and elevated pressures within the eye.

Before surgery, ocular inflammation must be brought under control (which may involve systemic therapy) and raised intra-ocular pressure reduced.

See Uveitis.

Consider – phacoemulsification ± intra-ocular lens implant

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ACUTE
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cataract with concomitant eye pathology
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uveitis
Consider – 

phacoemulsification ± intra-ocular lens implant

Additional treatment recommended for SOME patients in selected patient group

Treatment is the surgical removal of the cataract ± intra-ocular lens implant regardless of the degree of visual loss.

Consider – correction of residual refractive error

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ACUTE
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cataract with concomitant eye pathology
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uveitis
Consider – 

correction of residual refractive error

Additional treatment recommended for SOME patients in selected patient group

If an implant lens is not used or refractive error remains (e.g., astigmatism that is uncorrected by the implant lens), the patient may need to wear contact lenses or spectacles to achieve good postoperative vision.

The patient can also opt for post-cataract refractive surgery.[73]

1st line – closure of open wounds

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ACUTE
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cataract with concomitant eye pathology
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traumatic rupture
1st line – 

closure of open wounds

Following blunt or penetrating injury to the globe, the lens capsule can be ruptured, resulting in exposure of the lens cortex to aqueous fluid. The normally clear lens cortex then becomes fluffy and opaque, and the fluid may enter the anterior chamber.

Initially, the eye should be assessed for penetrating trauma. Open wounds should be sutured, focusing on anterior segment structures. Prophylactic antibiotics should be considered and tetanus status assessed.

See Eye trauma.

Plus – corticosteroid eye drops

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ACUTE
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cataract with concomitant eye pathology
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traumatic rupture
Plus – 

corticosteroid eye drops

Treatment recommended for ALL patients in selected patient group

Subsequent inflammation is treated with corticosteroid eye drops.

Treatment duration varies according to response.

Primary options

prednisolone ophthalmic: (1%) 1 drop into the affected eye(s) every 2 hours

OR

difluprednate ophthalmic: (0.05%) 1 drop into the affected eye(s) every 6 hours

Plus – post-stabilisation extra-capsular cataract extraction with phacoemulsification ± intra-ocular lens implant

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ACUTE
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cataract with concomitant eye pathology
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traumatic rupture
Plus – 

post-stabilisation extra-capsular cataract extraction with phacoemulsification ± intra-ocular lens implant

Treatment recommended for ALL patients in selected patient group

Elective lens removal ± intra-ocular lens is performed once the inflammation is adequately controlled (days to weeks).

Consider – correction of residual refractive error

Back
ACUTE
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cataract with concomitant eye pathology
|
traumatic rupture
Consider – 

correction of residual refractive error

Additional treatment recommended for SOME patients in selected patient group

If an implant lens is not used or refractive error remains (e.g., astigmatism that is uncorrected by the implant lens), the patient may need to wear contact lenses or spectacles to achieve good postoperative vision.

The patient can also opt for post-cataract refractive surgery.[73]

1st line – assessment of need for surgery

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ACUTE
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cataract with concomitant eye pathology
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diabetic retinopathy
1st line – 

assessment of need for surgery

Patients with mild cataract should be assessed carefully. Those without visual loss and with a clear fundus view may not require cataract removal.

Patients with severe cataract where poor fundus view prevents adequate assessment of diabetic retinopathy should have early cataract surgery followed by assessment and treatment of the retinopathy.

See Diabetic retinopathy. 

Consider – pan-retinal photocoagulation

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ACUTE
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cataract with concomitant eye pathology
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diabetic retinopathy
Consider – 

pan-retinal photocoagulation

Additional treatment recommended for SOME patients in selected patient group

Patients with moderate cataract with severe non-proliferative or proliferative diabetic retinopathy should have laser pan-retinal photocoagulation prior to cataract surgery.

Consider – focal/grid laser or anti-vascular endothelial growth factor

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ACUTE
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cataract with concomitant eye pathology
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diabetic retinopathy
Consider – 

focal/grid laser or anti-vascular endothelial growth factor

Additional treatment recommended for SOME patients in selected patient group

Any diabetic macular oedema in patients with moderate cataract should be managed with focal/grid laser or anti-vascular endothelial growth factor (anti-VEGF) therapy prior to surgery.

Consider – phacoemulsification ± intra-ocular lens implant

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ACUTE
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cataract with concomitant eye pathology
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diabetic retinopathy
Consider – 

phacoemulsification ± intra-ocular lens implant

Additional treatment recommended for SOME patients in selected patient group

Cataract surgery in patients with diabetes can be technically challenging if the pupil does not dilate well and because the endothelium is more susceptible to surgical trauma. Postoperatively there is an increased risk of infection, macular oedema, posterior capsule opacification, and diabetic retinopathy exacerbation.[75]

Patients with severe cataract where poor fundus view prevents adequate assessment of diabetic retinopathy should have early cataract surgery followed by assessment and treatment of the retinopathy. If diabetic macular oedema is present, anti-VEGF can be considered perioperatively.[76] One meta-analysis of six studies (283 eyes) found that intravitreal bevacizumab injection significantly reduced progression of diabetic retinopathy and maculopathy at 6 months after cataract surgery.[77]

There is an increased risk of postoperative macular oedema in patients with diabetic retinopathy undergoing cataract surgery, particularly in those with more severe retinopathy.[78] This risk can be reduced by perioperative NSAIDs and corticosteroids.[79][80]​ 

Consider – correction of residual refractive error

Back
ACUTE
|
cataract with concomitant eye pathology
|
diabetic retinopathy
Consider – 

correction of residual refractive error

Additional treatment recommended for SOME patients in selected patient group

If an implant lens is not used or refractive error remains (e.g., astigmatism that is uncorrected by the implant lens), the patient may need to wear either contact lenses or spectacles to achieve good postoperative vision.

The patient can also opt for post-cataract refractive surgery.[73]

ONGOING

post-surgical opacification of the posterior capsule + significant visual impairment

1st line – Nd:YAG laser therapy

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ONGOING
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post-surgical opacification of the posterior capsule + significant visual impairment
1st line – 

Nd:YAG laser therapy

In most cases, the capsular bag of the crystalline lens is left in situ to support the IOL implant. Some lens epithelial cells that remain on the internal surface of the retained capsular bag will proliferate. This may result in a gradual opacification of the posterior capsule that can reduce the patient's vision. This capsular opacification is termed a secondary cataract.

If the vision reduction is significant, an opening can be made in the posterior capsule with a neodymium-doped yttrium aluminium garnet (Nd:YAG) laser.

This treatment is generally done in the clinic and results in almost immediate restoration of vision. Once a capsular opening has been made, the capsule will not regenerate and a second treatment is rarely necessary.

Consider – correction of residual refractive error

Back
ONGOING
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post-surgical opacification of the posterior capsule + significant visual impairment
Consider – 

correction of residual refractive error

Additional treatment recommended for SOME patients in selected patient group

If an implant lens is not used or refractive error remains (e.g., astigmatism that is uncorrected by the implant lens), the patient may need to wear either contact lenses or spectacles to achieve good postoperative vision.[73]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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