Cataract in The Adult Eye PPP

Cataract in the
Adult Eye Preferred

Practice Pattern®
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Cataract in the Adult Eye PPP—Journal Adult EyeDraft
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Secretary for Quality of Care

Timothy W. Olsen, MD
Academy Staff
Andre Ambrus, MLIS
Meghan Daly
Flora C. Lum, MD
Medical Editor: Susan Garratt
Approved by: Board of Trustees

October 13, 2021
Copyright © 2021 American Academy of Ophthalmology®

All rights reserved
AMERICAN ACADEMY OF OPHTHALMOLOGY and PREFERRED PRACTICE PATTERN are

registered trademarks of the American Academy of Ophthalmology. All other trademarks are the property of
their respective owners.
Preferred Practice Pattern® guidelines are developed by the Academy’s H. Dunbar Hoskins Jr., MD Center
for Quality Eye Care without any external financial support. Authors and reviewers of the guidelines are
volunteers and do not receive any financial compensation for their contributions to the documents. The
guidelines are externally reviewed by experts and stakeholders before publication.
American Academy of Ophthalmology®

P. O. Box 7424
San Francisco, CA 94120-7424
415.561.8500
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CATARACT AND ANTERIOR SEGMENT

PREFERRED PRACTICE PATTERN®
DEVELOPMENT PROCESS AND PARTICIPANTS
The Cataract and Anterior Segment Preferred Practice Pattern® Panel members wrote the Cataract in
the Adult Eye Preferred Practice Pattern® guidelines (PPP). The PPP Panel members discussed and reviewed
successive drafts of the document, meeting in person twice and conducting other review by e-mail
discussion, to develop a consensus over the final version of the document.
Cataract and Anterior Segment Preferred Practice Pattern Panel 2020–2021

Kevin M. Miller, MD, Co-Chair
Thomas A. Oetting, MD, Co-Chair
James P. Tweeten, MD
Kristin Carter, MD
Bryan S. Lee, MD, JD
Shawn Lin, MD, MBA
Afshan A. Nanji, MD
Neal H. Shorstein, MD
David C. Musch, PhD, MPH, Methodologist
We thank our partners, the Cochrane Eyes and Vision US Satellite (CEV@US), for identifying reliable
systematic reviews that we cite and discuss in support of the PPP recommendations.
The Preferred Practice Patterns Committee members reviewed and discussed the document during a
meeting in June 2021. The document was edited in response to the discussion and comments.
Preferred Practice Patterns Committee 2021

Roy S. Chuck, MD, PhD, Chair
Steven P. Dunn, MD
Christina J. Flaxel, MD
Steven J. Gedde, MD
Deborah S. Jacobs, MD
Francis S. Mah, MD
Kevin M. Miller, MD
Thomas A. Oetting, MD
David K. Wallace, MD, MPH
David C. Musch, PhD, MPH, Methodologist
The Cataract in the Adult Eye Preferred Practice Pattern was then sent for review to additional internal and
external groups and individuals in June 2021. All those who returned comments were required to provide
disclosure of relevant relationships with industry to have their comments considered (indicated with an
asterisk below). Members of the Cataract and Anterior Segment Preferred Practice Pattern Panel reviewed
and discussed these comments and determined revisions to the document.
Academy Reviewers Association of University Professors in Ophthalmology*

Board of Trustees and Committee of Secretaries* American Uveitis Society*
Council* Consumer Reports Health Choices
General Counsel* Canadian Ophthalmological Society*
Ophthalmic Technology Assessment Committee Cornea & European Society of Cataract & Refractive Surgery
Anterior Segment Disorders Panel* International Council of Ophthalmology
Basic and Clinical Science Course Section 11 International Society of Refractive Surgery*
Subcommittee National Eye Institute*
Practicing Ophthalmologists Advisory Committee for National Medical Association, Section on Ophthalmology
Education Outpatient Ophthalmic Surgery Society
Women in Ophthalmology*
Invited Reviewers Zaina Al-Mohtaseb, MD
American College of Surgeons* David F. Chang, MD
American College of Physicians Bonnie An Henderson, MD*
American Glaucoma Society* Terry Kim, MD
American Ophthalmological Society Samuel Masket, MD*
Association for Research in Vision and Ophthalmology* Randall J. Olson, MD*
American Society of Cataract and Refractive Surgery
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FINANCIAL DISCLOSURES
In compliance with the Council of Medical Specialty Societies’ Code for Interactions with Companies
(available at https://cmss.org/code-signers-pdf/), relevant relationships with industry are listed. The Academy
has Relationship with Industry Procedures to comply with the Code (available at www.aao.org/about-
preferred-practice-patterns). A majority (78%) of the members of the Cataract and Anterior Segment
Preferred Practice Pattern Panel 2020–2021 had no related financial relationship to disclose.
Cataract and Anterior Segment Preferred Practice Pattern Panel 2020–2021

Kevin M. Miller, MD: Alcon Laboratories, Johnson & Johnson Vision, LENSAR, Oculus, Inc.—Consultant
Thomas A. Oetting, MD: No financial relationships to disclose
James P. Tweeten, MD: No financial relationships to disclose
Kristin Carter, MD: No financial relationships to disclose
Bryan S. Lee, MD, JD: New World Medical, Inc.—Consultant
Shawn Lin, MD, MBA: No financial relationships to disclose
Afshan A. Nanji, MD: No financial relationships to disclose
Neal H. Shorstein, MD: No financial relationships to disclose
David C. Musch, PhD, MPH: No financial relationships to disclose
Preferred Practice Patterns Committee 2021

Roy S. Chuck, MD, PhD: No financial relationships to disclose
Steven P. Dunn, MD: No financial relationships to disclose
Christina J. Flaxel, MD: No financial relationships to disclose
Steven J. Gedde, MD: No financial relationships to disclose
Francis S. Mah, MD: Abbott Medical Optics, Inc., Alcon Laboratories, Avedro, Inc., Bausch + Lomb,
EyePoint, Novartis, Alcon Pharmaceuticals, Ocular Science, Ocular Therapeutix, Omeros Corporation,
PolyActiva, Sun Pharmaceuticals—Consultant; Abbott Medical Optics, Inc., Bausch + Lomb, Novartis,
Alcon Pharmaceuticals, Sun Pharmaceuticals—Lecture Fees; Ocular Science—Equity Owner
Kevin M. Miller, MD: Alcon Laboratories, Johnson & Johnson Vision, LENSAR, Oculus, Inc.—Consultant
Thomas A. Oetting, MD: No financial relationships to disclose
David K. Wallace, MD, MPH: No financial relationships to disclose
David C. Musch, PhD, MPH: No financial relationships to disclose
Secretary for Quality of Care

Timothy W. Olsen, MD: No financial relationships to disclose
Academy Staff
Andre Ambrus, MLIS: No financial relationships to disclose
Meghan Daly: No financial relationships to disclose
Flora C. Lum, MD: No financial relationships to disclose
Susan Garratt: No financial relationships to disclose
The disclosures of relevant relationships to industry of other reviewers of the document from January to
October 2021 are available online at www.aao.org/ppp.
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Cataract in the Adult Eye PPP
TABLE OF CONTENTS
OBJECTIVES OF PREFERRED PRACTICE PATTERN GUIDELINES................................................P6
METHODS AND KEY TO RATINGS ...........................................................................................................P7
HIGHLIGHTED FINDINGS AND RECOMMENDATIONS FOR CARE................................................P8
INTRODUCTION ............................................................................................................................................P9
Disease Definition...............................................................................................................................................P9
Patient Population ...............................................................................................................................................P9
Clinical Objectives ..............................................................................................................................................P9
BACKGROUND ...............................................................................................................................................P9
Prevalence...........................................................................................................................................................P9
Risk Factors ........................................................................................................................................................P10
Natural History ...................................................................................................................................................P11
Visual Function and Quality of Life ...................................................................................................................P11
CARE PROCESS..............................................................................................................................................P13
Patient Outcome Criteria.....................................................................................................................................P13
Diagnosis ............................................................................................................................................................P13
Evaluation of Visual Impairment .................................................................................................................P13
Ophthalmic Evaluation ................................................................................................................................P14
Supplemental Ophthalmic Testing ...............................................................................................................P14
Management........................................................................................................................................................P16
Prevention ....................................................................................................................................................P16
Nonsurgical Management ............................................................................................................................P17
Surgical Management ..................................................................................................................................P17
Indications for Surgery........................................................................................................................P17
Contraindications to Surgery...............................................................................................................P17
Preoperative Evaluation and Counseling ............................................................................................P18
Biometry and Intraocular Lens Power Calculation .............................................................................P19
Anesthesia ...........................................................................................................................................P21
Infection Prophylaxis ..........................................................................................................................P22
Toxic Syndromes ................................................................................................................................P25
Cataract Surgery Checklist..................................................................................................................P26
Surgical Techniques ............................................................................................................................P26
Intraocular Lens Materials, Design, and Implantation ........................................................................P28
Alternatives to Capsular Bag Fixation ................................................................................................P31
Intraocular Lens Optical Considerations .............................................................................................P31
Outcomes ............................................................................................................................................P32
Complications of Cataract Surgery .....................................................................................................P33
Complications of Intraocular Lenses...................................................................................................P39
Ocular Comorbidities ..........................................................................................................................P41
Systemic Comorbidities ......................................................................................................................P46
Combined Surgery and Special Circumstances ...................................................................................P47
Second-Eye Surgery............................................................................................................................P53
Immediate Sequential (Same-Day) Bilateral Cataract Surgery ...........................................................P54
Discharge from Surgical Facility ........................................................................................................P55
Postoperative Management .................................................................................................................P55
Postoperative Follow-up .....................................................................................................................P56
Posterior Capsular Opacification.........................................................................................................P57
Provider and Setting............................................................................................................................................P58
Counseling and Referral .....................................................................................................................................P59
Socioeconomic Considerations ...........................................................................................................................P59
Utilization of Cataract Surgery in the United States ....................................................................................P59
Cost and Cost-Effectiveness of Cataract Surgery in the United States ........................................................P60
Merit-based Incentive Payment System .......................................................................................................P61
APPENDIX 1. QUALITY OF OPHTHALMIC CARE CORE CRITERIA ..............................................P62
APPENDIX 2. INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND
RELATED HEALTH PROBLEMS (ICD) CODES ..............................................................................P64
APPENDIX 3. NUTRITION AND CATARACTS ........................................................................................P65
APPENDIX 4. WRONG-SITE WRONG-IOL SURGERY CHECKLIST .................................................P65
APPENDIX 5. LITERATURE SEARCHES FOR THIS PPP ......................................................................P68
LIST OF ABBREVIATIONS ..........................................................................................................................P73
RELATED ACADEMY MATERIALS ..........................................................................................................P74
REFERENCES..................................................................................................................................................P76
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OBJECTIVES OF PREFERRED PRACTICE

PATTERN® GUIDELINES
As a service to its members and the public, the American Academy of Ophthalmology has developed a series
of Preferred Practice Pattern® guidelines that identify characteristics and components of quality eye care.
Appendix 1 describes the core criteria of quality eye care.
The Preferred Practice Pattern® guidelines are based on the best available scientific data as interpreted by
panels of knowledgeable health professionals. In some instances, such as when results of carefully conducted
clinical trials are available, the data are particularly persuasive and provide clear guidance. In other instances,
the panels have to rely on their collective judgment and evaluation of available evidence.
These documents provide guidance for the pattern of practice, not for the care of a particular individual.
While they should generally meet the needs of most patients, they cannot possibly best meet the needs of all
patients. Adherence to these PPPs will not ensure a successful outcome in every situation. These practice
patterns should not be deemed inclusive of all proper methods of care or exclusive of other methods of care
reasonably directed at obtaining the best results. It may be necessary to approach different patients’ needs in
different ways. The physician must make the ultimate judgment about the propriety of the care of a particular
patient in light of all of the circumstances presented by that patient. The American Academy of Ophthalmology
is available to assist members in resolving ethical dilemmas that arise in the course of ophthalmic practice.
Preferred Practice Pattern® guidelines are not medical standards to be adhered to in all individual
situations. The Academy specifically disclaims any and all liability for injury or other damages of any kind,
from negligence or otherwise, for any and all claims that may arise out of the use of any recommendations or
other information contained herein.
References to certain drugs, instruments, and other products are made for illustrative purposes only and are not
intended to constitute an endorsement of such. Such material may include information on applications that are
not considered community standard, that reflect indications not included in approved U.S. Food and Drug
Administration (FDA) labeling, or that are approved for use only in restricted research settings. The FDA has
stated that it is the responsibility of the physician to determine the FDA status of each drug or device he or she
wishes to use, and to use them with appropriate patient consent in compliance with applicable law.
Innovation in medicine is essential to ensure the future health of the American public, and the Academy
encourages the development of new diagnostic and therapeutic methods that will improve eye care. It is
essential to recognize that true medical excellence is achieved only when the patients’ needs are the foremost
consideration.
All Preferred Practice Pattern® guidelines are reviewed by their parent panel annually or earlier if
developments warrant and updated accordingly. To ensure that all PPPs are current, each is valid for 5 years
from the “approved by” date unless superseded by a revision. Preferred Practice Pattern guidelines are funded
by the Academy without commercial support. Authors and reviewers of PPPs are volunteers and do not receive
any financial compensation for their contributions to the documents. The PPPs are externally reviewed by
experts and stakeholders, including consumer representatives, before publication. The PPPs are developed in
compliance with the Council of Medical Specialty Societies’ Code for Interactions with Companies. The
Academy has Relationship with Industry Procedures (available at www.aao.org/about-preferred-practice-
patterns) to comply with the Code.
Appendix 2 contains the International Statistical Classification of Diseases and Related Health Problems
(ICD) codes for the disease entities that this PPP covers. The intended users of the Cataract in the Adult Eye
PPP are ophthalmologists.
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METHODS AND KEY TO RATINGS

Preferred Practice Pattern guidelines should be clinically relevant and specific enough to provide useful
information to practitioners. Where evidence exists to support a recommendation for care, the
recommendation should be given an explicit rating that shows the strength of evidence. To accomplish these
aims, methods from the Scottish Intercollegiate Guideline Network1 (SIGN) and the Grading of
Recommendations Assessment, Development and Evaluation2 (GRADE) group are used. GRADE is a
systematic approach to grading the strength of the total body of evidence that is available to support
recommendations on a specific clinical management issue. Organizations that have adopted GRADE include
SIGN, the World Health Organization, the Agency for Healthcare Research and Policy, and the American
College of Physicians.3
 All studies used to form a recommendation for care are graded for strength of evidence individually, and
that grade is listed with the study citation.
 To rate individual studies, a scale based on SIGN1 is used. The definitions and levels of evidence to rate
individual studies are as follows:
I++ High-quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs
with a very low risk of bias
I+ Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
I- Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
II++ High-quality systematic reviews of case-control or cohort studies
High-quality case-control or cohort studies with a very low risk of confounding or bias and a
high probability that the relationship is causal
II+ Well-conducted case-control or cohort studies with a low risk of confounding or bias and a
moderate probability that the relationship is causal
II- Case-control or cohort studies with a high risk of confounding or bias and a significant risk that
the relationship is not causal
III Nonanalytic studies (e.g., case reports, case series)
 Recommendations for care are formed based on the body of the evidence. The body of evidence quality
ratings are defined by GRADE2 as follows:
Good quality Further research is very unlikely to change our confidence in the estimate of
effect
Moderate quality Further research is likely to have an important impact on our confidence in the
estimate of effect and may change the estimate
Insufficient quality Further research is very likely to have an important impact on our confidence in
the estimate of effect and is likely to change the estimate
Any estimate of effect is very uncertain
 Key recommendations for care are defined by GRADE 2 as follows:

Strong Used when the desirable effects of an intervention clearly outweigh the
recommendation undesirable effects or clearly do not
Discretionary Used when the trade-offs are less certain—either because of low-quality
recommendation evidence or because evidence suggests that desirable and undesirable effects are
closely balanced
 The Highlighted Findings and Recommendations for Care section lists points determined by the PPP
Panel to be of particular importance to vision and quality of life outcomes.
 All recommendations for care in this PPP were rated using the system described above. Ratings are embedded
throughout the PPP main text in italics.
 Literature searches to update the PPP were undertaken in March 2020 and January 2021 in the PubMed
database. Complete details of the literature searches are available in Appendix 5.
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HIGHLIGHTED FINDINGS AND

RECOMMENDATIONS FOR CARE
Symptomatic cataract is a surgical disorder. Dietary intake and nutritional supplements have demonstrated
minimal effect on the prevention or treatment of cataract.
Most cataract surgery in the United States is performed by small-incision phacoemulsification with foldable
intraocular lens (IOL) implantation on an outpatient basis.
Refractive cataract surgery, including astigmatism management, intraoperative refractive guidance, and
specialty IOL implantation, has the potential to reduce a patient’s dependence on eyeglasses or contact lenses
for distance, intermediate, and near vision.
Femtosecond laser-assisted cataract surgery (FLACS) increases the circularity and centration of the
capsulorrhexis and the precision of the corneal incisions. It may also reduce the amount of ultrasonic energy
required to remove a cataract. However, the technology is not yet cost-effective, and the overall risk profile
and refractive outcomes have not been shown to be superior to that of standard phacoemulsification.
Topical nonsteroidal anti-inflammatory drugs (NSAIDs) reduce the incidence of early postoperative cystoid
macular edema (CME), but a long-term benefit has not been demonstrated.
There is substantial evidence that intracameral antibiotic administration reduces the risk of postoperative
bacterial endophthalmitis. Increasing evidence also suggests that topically applied antibiotics do not add to
the benefit of intracameral injection.
Minimally invasive glaucoma surgery can enhance the intraocular pressure-lowering effects of cataract
surgery in some patients with mild to moderate glaucoma.
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INTRODUCTION
DISEASE DEFINITION
A cataract is a degradation of the optical quality of the crystalline lens that affects vision. Most
cataract development is related to aging, and it can occur in one or both eyes.
PATIENT POPULATION
Adults (18 years old and older) with cataracts.
CLINICAL OBJECTIVES
 Identify the presence and characteristics of a cataract.
 Assess the impact of cataract on a patient’s visual status and function as well as the effect on
quality of life.
 Educate the patient about the natural history of cataract and its impact on vision and functional
activity. Explain the benefits and risks of surgery and other treatment alternatives to enable the
patient to make an informed decision about treatment options.
 Explain advantages and disadvantages of intraocular lens (IOL) options, including astigmatic,
multifocal, extended depth of focus, accommodating, postoperatively power adjustable, and
monovision IOL alternatives, to reduce the patient’s need for spectacles or contact lenses after
surgery.
 Identify any ocular comorbidities, high-risk ocular features, or systemic issues that could impact
the performance and outcomes of surgery.
 Establish criteria for a successful treatment outcome with the patient, including working
distance(s) and potential limitations in visual outcome(s).
 Discuss potential postoperative refractive options, including bilateral emmetropia, bilateral
myopia, and monovision, as well as the management of any anisometropia between surgical
procedures.
 Perform cataract surgery when surgery will result in enhanced patient function and when the
informed patient elects this option. Timing of surgery should be based on what is mutually
agreeable between the patient and surgeon.
 Perform surgery when indicated for improved visualization and management of coexisting ocular
disease, such as glaucoma, macular degeneration, or diabetic retinopathy.
 Provide appropriate postoperative care, visual rehabilitation, and treatment of any complications,
such as elevated intraocular pressure (IOP) or corneal edema.
 Improve patient safety by reducing the risk of traffic accidents, falls, and fractures.
BACKGROUND
PREVALENCE
Cataract is the leading cause of blindness worldwide.4 The risk of cataract increases with each decade
of life starting around age 40.5 Cataract is the leading cause of visual impairment among Americans of
all studied ethnic and racial backgrounds.6, 7 In the United States, the number of people with cataract
is forecasted to double from 24.4 million to about 50 million by the year 2050.5
There are several different types of cataracts that can be categorized according to which part of the
lens becomes opaque. Each type has its own anatomical location, pathology, and risk factors for
development. The different types can exist separately or in various combinations. Several systems are
available to classify and grade lens opacities,8-12 but variations in grading systems make it difficult to
compare prevalence rates between studies.13
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The three most common types of cataracts are nuclear, cortical, and posterior subcapsular. Less
common are anterior subcapsular, anterior polar, and posterior polar cataracts. Nuclear cataract
consists of a central opacification or discoloration of the lens that interferes with visual function.
There are different types of nuclear cataract: brunescent, opalescent, or both.14 Nuclear cataract tends
to progress slowly and affect distance vision more than near vision.
Cortical cataract can be central or peripheral. It can take the appearance of opaque spokes or oil
droplets. Patients with cortical cataract commonly complain of glare. When the entire cortex becomes
white and opaque, the cataract is referred to as a mature cortical cataract.
Posterior subcapsular cataract (PSC), located just inside the posterior lens capsule, can cause
substantial visual impairment if it involves the axial region of the lens. Patients with PSC often have
glare symptoms and poor vision in bright light. Their near vision is typically more affected than
distance due to miosis with near accommodation. In young patients, PSC is more common than
nuclear and cortical cataract.
Three population-based studies found that cataract surgery was most frequently performed when PSC
was a component of the cataract.15-17 In a study of an older population undergoing cataract surgery
(mean age 79 years), the nuclear type was most frequently encountered.18
RISK FACTORS
Non-modifiable risk factors for cataract formation include increasing age,19-25 female gender,6, 18, 20, 26,
27
and family history.18, 28-34 Numerous risk factors have been linked with cataract development, the
most common of which are listed in Table 1.
Most studies on risk factors are observational and strongly suggest an association with cataract
formation, but they fail to prove causation.30, 35
TABLE 1 FACTORS ASSOCIATED WITH INCREASED RISK OF CATARACT DEVELOPMENT*

Cataract Type Associated Risk Factors
Cortical Diabetes 19, 20, 31, 32, 36-40
Family history20, 41-45

Hypertension19, 39, 46, 47
Ionizing radiation (low and high dose)48
Myopia (>1 D)32, 49, 50
Obesity33, 34, 39
Systemic corticosteroid use51
Trauma52
Ultraviolet-B light exposure21, 32, 41, 53, 54
Nuclear Diabetes32, 39
Family history41, 44, 55, 56
Hypertension57, 58
Myopia19, 20, 32, 59-62
Obesity63
Prior PPV29, 64, 65
Smoking19, 32, 49, 66-72
Tobacco (smokeless)73
Ultraviolet-B light exposure54, 74
Posterior subcapsular Diabetes19, 20, 31, 36, 39
Hypertension19, 57, 75, 76
Corticosteroids (inhaled orally)77
Ionizing radiation (low and high dose)48, 78, 79
Myopia19, 32, 59, 60, 62, 75
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TABLE 1 FACTORS ASSOCIATED WITH INCREASED RISK OF CATARACT DEVELOPMENT* (CONTINUED)

Cataract Type Associated Risk Factors
Posterior subcapsular (continued) Obesity 33, 63
Ocular trauma52
Prior PPV29
Retinitis pigmentosa80-82
Smoking71, 72
Systemic corticosteroid use83
Topical corticosteroid use84
Trauma52
Mixed Diabetes38, 39
Hypertension19
Inactivity85, 86
Inhaled corticosteroid use87-90
Intravitreal corticosteroids91, 92
Ionizing radiation (low and high dose)78, 79, 93-96
Lower education20, 31, 97, 98
Ocular inflammatory disease99
Prior PPV29
Smoking72, 100, 101
Tobacco use (smoking and smokeless)73
Trauma102
Ultraviolet-B light exposure21
*All associations determined by observational study.

D = diopter; PPV = pars plana vitrectomy.
NATURAL HISTORY
Cataract typically progresses over time, although the type, severity, and rate of progression vary
considerably among patients. With age, the lens increases in thickness and weight. Once visual acuity
and function decline, the disease progresses with no chance of reversal. Three large studies
demonstrate that PSCs progress more quickly than nuclear and cortical cataracts.23, 103-105
VISUAL FUNCTION AND QUALITY OF LIFE

The multiple components of visual function include near, intermediate, and distance visual acuity;
peripheral vision; visual search; binocular vision; depth perception; contrast sensitivity; color
perception; dark adaptation; and visual processing speed.106 Visual function can also be measured in
terms of patient-reported disability caused by visual impairment.107-111 Many activities of daily living
require adequate function of more than one of these visual components.
The treatment outcomes that are the most crucial and relevant to the patient are improved visual
function and quality of life. Well-designed studies consistently show that cataract surgery has a
substantial positive impact on vision-dependent functioning. Up to 90% of patients undergoing first-
eye cataract surgery note improvement in functional status and satisfaction with vision.112-116 Several
studies report an association between improved visual function and an improved health-related quality
of life.109, 117-120 Visual function plays an important role in physical performance and well-being,121-123
particularly with regard to mobility.117, 124 Loss of vision in the elderly is associated with a decline in
physical and mental function as well as a loss of independence in the activities of daily living.125
Examples include daytime and nighttime driving as well as community and home activities. A 10-year
evaluation of patients in the Blue Mountains Eye Study found that those who underwent cataract
surgery experienced a significant improvement in mental health domain scores on the SF-36
questionnaire.126 Cataract surgery may also help alleviate insomnia.127, 128 The very elderly (80+ to
85+ years, depending on the study) also benefit from cataract surgery, with benefits outweighing the
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ocular and systemic risks. They are just as likely to have improved visual acuity compared with
younger patients, comorbidities excluded.129-131 However, they are at slightly higher risk of
developing endophthalmitis.132
Visual impairment, such as poor depth perception and low contrast sensitivity, is an important risk
factor for falls133, 134 and hip fractures.135, 136 In a randomized controlled trial, first-eye cataract surgery
reduced the rate of falls and fracture by 34% over a 12-month period.117, 137 Visual loss from cataract
and the increased risk of falls are both contributory factors for nursing home placement.138 Additional
studies show a reduction in mortality after cataract surgery,139-142 and evidence exists that waiting
more than 4 months to perform cataract surgery after it is clearly indicated can result in vision-related
complications such as falls and accidents.143, 144 Similar improvement following second-eye surgery
has also been confirmed.124, 145 Second-eye cataract surgery also increases the sense of independence,
reduces social isolation, and improves mood and the ability to interact socially.146
A decrease in visual acuity and contrast sensitivity is associated with trouble driving.106, 147-150 Drivers
with visually significant cataract are 2.5 times more likely to have an at-fault motor vehicle crash over
a 5-year period compared with drivers without cataract.151 In a cohort of 277 patients with cataract,
those who underwent surgery had half the rate of crash involvement compared with those who did not
have surgery in a 4- to 6-year follow-up period.152, 153 Patients who undergo cataract surgery are less
likely to be in serious car crashes as the driver.154 One large study that assessed patients’ visual
function preoperatively and postoperatively found the largest improvements in “driving during the
day,” “self-care activities,” and “driving during the night.” 155 Additionally, cataract surgery is shown
to increase cognitive abilities in the very elderly. The majority of very elderly patients live at least 1
year following surgery, and many live much longer.156
In summary, numerous studies show that physical function, mental health, emotional well-being,
safety, and overall quality of life can be enhanced when visual function is restored by cataract
extraction.157, 158
Improved visual function from cataract surgery can be characterized by the following:
 Improved distance-corrected visual acuity113-116
 Increased ability to read or do near work156, 159
 Reduced glare160
 Improved ability to function in dim light160
 Improved depth perception and binocular vision by elimination of anisometropia and achievement
of good functional acuity in both eyes106, 135
 Improved color vision161
 Improved peripheral vision146
Improved physical function as a beneficial outcome of cataract surgery can be characterized by the
following:
 Increased ability to perform activities of daily living116, 155, 159
 Increased ability to continue or resume an occupation157, 158
 Increased mobility (walking, driving)106, 147-153, 155, 159
 Decreased falls117, 133-137, 143, 144
 Improved sleep127, 128
Improved mental health and emotional well-being as another beneficial outcome of cataract surgery
includes the following:
 Improved self-esteem and independence146
 Improved injury avoidance145
 Improved cognition125, 156
 Better social engagement and mood118, 146, 159
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CARE PROCESS
PATIENT OUTCOME CRITERIA

Outcome criteria can vary for each patient, depending on the patient’s needs, lifestyle, and medical
condition. In general, outcome criteria include the following:
 Reduction of visual symptoms
 Improvement in visual function
 Achievement of desired refractive outcome, including desired working distance(s)
 Improvement in physical function, mental health, and quality of life
DIAGNOSIS
The purpose of the comprehensive evaluation of a patient whose chief complaint might be related to
cataract development is to identify the presence of a cataract, confirm that a cataract is a significant
factor contributing to the visual impairment and symptoms described by the patient, and identify other
ocular or systemic conditions that might be contributing to visual impairment.
Evaluation of Visual Impairment

The impact of cataract on visual function can be subjectively assessed by self-reported
functional status or difficulty with vision.
Patients may adapt to their visual impairment over time, however, and may fail to notice
functional decline that accompanies the insidious progression of typical cataract. Visual function
may be assessed using tests that measure contrast sensitivity, glare disability, or visual acuity at
near and distance. It is also possible to objectively measure the higher-order aberrations from
cataract that may compromise visual acuity and quality.162, 163
There is no single test or measure that adequately describes the effect of a cataract on a patient’s
visual status or functional ability.164 Similarly, no single test can properly define a threshold for
performing cataract surgery. The Snellen visual acuity chart is an excellent tool for testing
distance visual acuity in healthy eyes, and it is widely used clinically. Poor preoperative visual
acuity correlates with greater postoperative functional improvement in many patients with
cataract.164, 165 Testing only at distance with high-contrast letters that are viewed in low-ambient
lighting conditions underestimates the functional problems that are experienced by patients in
common, real-life situations. Other important indicators of vision impairment may include
daytime or nighttime glare, halos and starbursts at night (especially while driving), reduced
reading speed,120, 166 and impaired optical quality causing monocular diplopia or ghosting.107
Cataract development makes it difficult for patients to perform basic activities of daily living
such as eating and dressing, shopping, personal finances, medication management, and
driving.167 Because preoperative distance visual acuity alone may be an unreliable predictor of
postoperative functional improvement, the decision to recommend cataract surgery should not be
made solely on the basis of Snellen visual acuity.113, 168
Studies have indicated that measures of functional visual impairment provide valid and reliable
information that is not reflected in the measurement of visual acuity alone.108, 169-171
Several patient-reported outcome measures (PROMs) have been developed.172 Two main
categories of validated questionnaires for measuring function exist; those that measure general
health status (e.g., Short Form-36 , 173 Quality of Well-Being Scale170) and vision-specific
measures. Questionnaires that measure general health status provide findings that are less
strongly correlated with improvement following cataract surgery than vision-specific
measures.170, 174 Examples of vision-specific instruments developed or used for cataract
evaluation include the Visual Activities Questionnaire,175 the Activities of Daily Vision Scale
(ADVS),169 the Visual Function-14 (VF-14)107 and modified versions (e.g., VF-8R),176 the
National Eye Institute-Visual Function Questionnaire (NEI-VFQ),177, 178 and the Catquest-
9SF.110, 179
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These questionnaires have been used as research tools to provide a standardized approach to
assess visual function, and they can be compared across various time periods and populations.
When compared with visual acuity measurement, the ability of questionnaires to better correlate
with potential visual improvement, when used preoperatively, or to gauge improvement after
surgery, is controversial.180, 181
Ophthalmic Evaluation
A comprehensive ophthalmic evaluation, or history and physical examination, includes those
components of the comprehensive adult medical eye evaluation182 specifically relevant to the
diagnosis and treatment of a cataract as listed below.
 Patient history, including an 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, use of systemic alpha-1
antagonists, diabetes)
 Visual acuity with correction (the power of the present correction recorded) at distance and,
when appropriate, at near
 Refraction and measurement of corrected distance visual acuity (CDVA) in both eyes
 Glare testing when indicated
 Assessment of pupil size and function
 Visual field assessment
 Examination of ocular alignment and motility
 External examination (eyelids, lashes, lacrimal apparatus, orbit)
 Measurement of IOP
 Slit-lamp biomicroscopy of the cornea, anterior chamber, iris, lens, vitreous, macula,
peripheral retina, and optic nerve through a dilated pupil
 Indirect ophthalmoscopy
Supplemental Ophthalmic Testing

Supplemental preoperative ophthalmic tests are not specific for a cataract but may help to
identify both the cause and level of severity of an individual’s visual symptoms as well as the
extent to which comorbidities may be contributing to these symptoms. For most patients, an
ophthalmologist can determine whether a cataract is responsible for an individual patient’s visual
loss by comparing slit-lamp biomicroscopy findings with the patient’s specific symptoms.
Occasionally, a patient presents with visual symptoms that are disproportionate to the degree of
cataract formation. Visual acuity testing alone does not quantify certain visual symptoms, such
as disability due to glare and reduced contrast sensitivity.183-187
Optical Testing
Glare testing determines the degree of visual impairment in the presence of light scatter.
Cataracts may produce a severe visual disability in brightly lit scenarios, such as sunny
daytime lighting or oncoming automobile headlamps at night. The visual acuity of some
patients with cataract may be normal or near normal when tested in a darkened examination
room, but when retested in the presence a source of glare, it (or contrast sensitivity) may
drop significantly.188 However, significant reduction in visual acuity with glare testing is by
no means specific for cataract since the etiology may be secondary to other conditions,
such as ocular surface disease. Accordingly, correlation with slit-lamp biomicroscopy
findings is required to establish cataract as the etiology. Stray light (or light scatter) can be
measured and may be used for the evaluation of glare and indication for cataract surgery. 189
Contrast sensitivity testing measures the patient’s ability to detect subtle variations in
shading by using figures that vary in contrast, luminance, and spatial frequency and is a
more comprehensive and time-consuming measure of visual function than Snellen testing.
For the patient who complains of visual loss and has lens changes, contrast sensitivity
testing may demonstrate a loss of visual function that is not appreciated by Snellen testing
alone.184, 185, 190, 191 Contrast sensitivity (along with Snellen visual acuity) may decline for a
number of reasons, and therefore, this test is not a specific indicator of cataract. In spite of
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substantial progress over the past years, there remains no standard or universally preferred
method for contrast sensitivity testing.
Ocular wavefront imaging has demonstrated that even relatively mild cataracts may cause
visual aberrations. For example, the naturally occurring negative spherical aberration of the
crystalline lens, which offsets the stable and naturally occurring positive spherical
aberration of the cornea, typically changes to positive spherical aberration later in life as
cataract develops, leading to a decrease in contrast sensitivity.192, 193 This may explain the
symptoms reported by some older individuals who have a mild lens opacity and reasonably
good CDVA.
Corneal Testing
Measuring corneal aberrometry might be useful during IOL selection and help identify
appropriate candidates for advanced technology IOLs.194, 195
Assessment of tear function is also important. Reduced tear meniscus and tear breakup time
(less than 10 seconds), debris in the tear film, a low basal tear secretion score on Schirmer
testing, filaments, or punctate erosions are all indicators of tear dysfunction that may
compromise preoperative keratometry and the postoperative result.196
Specular microscopy and corneal pachymetry can be used to evaluate patients with known
preoperative corneal endothelial disease to determine whether the cornea is likely to remain
clear following cataract surgery. These tests are usually unnecessary in healthy eyes.
However, they may be useful in eyes where corneal endothelial function is suspected to be
abnormal as a result of endothelial dystrophies, previous ocular surgery, or trauma. Several
studies suggest that specular microscopy has relatively low accuracy in predicting corneal
clarity following cataract surgery.197, 198
Although not routinely necessary, assessment of the corneal contour using topography or
tomography may be useful to determine whether irregularities in corneal power and shape
are contributing to visual impairment. Additionally, a corneal contour evaluation is helpful
in the assessment and management of regular and irregular astigmatism, especially when
considering advanced technology IOLs or corneal relaxing incisions in conjunction with
cataract surgery. Additionally, tomography devices can evaluate posterior corneal
astigmatism to aid in toric IOL selection or astigmatism management. 199-202 Manual
keratometry is a simple tool for assessing the degree of surface irregularity, which can
contribute to visual disability.
Gonioscopy, anterior segment optical coherence tomography (OCT) and ultrasound
biomicroscopy can be useful for evaluating complex anterior pathology such as narrow
angle configuration, posterior polar cataract, or subluxated lenses.203
Macula Testing
Optical coherence tomography is very useful before cataract surgery to evaluate foveal
architecture and identify the presence of concomitant retinal disease,204-206 even when the
foveal center and immediately surrounding areas appear normal on direct examination.
Preoperative evaluation with macular OCT may be considered when visual acuity or
impairment are disproportionate to the degree of cataract to identify retinal disease that
may either be treatable or may impact postoperative visual prognosis. Macular OCT can
detect an epiretinal membrane, which will increase the risk of cystoid macular edema
(CME) and unexplained vision loss postoperatively. Fluorescein angiography is sometimes
performed when abnormalities of the circulation of the posterior pole are suspected.
When a patient corrected for near can read small print through a pinhole on a brightly
illuminated card, this indicates that the macula has some function.207-209
B-scan ultrasonography is appropriate when a dense cataract or other media opacity
precludes adequate visualization of the posterior segment or to detect the presence of an
intraocular mass, retinal detachment (RD), or posterior staphyloma.
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Electrophysiologic testing (e.g., electroretinography and visual evoked potential) measures

the electrical response to presented visual stimuli and indicates potential retinal function,
which may be helpful in nonverbal patients.
Optic Nerve and Central Nervous System Testing

Rarely, a formal visual field test will reveal that optic nerve or central nervous system
disease is responsible for central visual loss rather than, or in addition to, cataract. If
concomitant glaucoma is present, optic disc photography, retinal nerve fiber layer imaging,
or retinal ganglion cell analysis may be indicated. If an optic neuropathy or post-chiasmal
disorder is suspected, preoperative assessment by a neuro-ophthalmologist should be
considered.
MANAGEMENT
Prevention
Preventive measures that impart even a modest decrease in the risk of cataract could have a large
public health impact, given that 24.4 million people over the age of 40 years in the United States
are affected by cataract.5
The role of diet and antioxidant supplements has been studied with mixed conclusions. A 2012
Cochrane Systematic Review of nine randomized controlled trials found no evidence to support
high doses of vitamin E, vitamin C, or beta-carotene in preventing development or progression
of cataract.210 (I+, Good, Strong) A more recent systematic review about the role of nutrient
supplementation on lens pathology found that vitamin C, beta-carotene, and lutein and
zeaxanthin had a protective effect against cataract, but this analysis included observational
data.211 There is currently no level 1 evidence to suggest that high-dose antioxidant
supplementation slows cataract progression. There is moderate evidence that a
multivitamin/mineral supplement may decrease the risk of cataract.20, 212-214
Several observational studies also demonstrate the potential benefit of a healthy diet in
preventing cataract.215-220 There is currently insufficient evidence to support a specific diet, but a
well-balanced diet rich with fruits and vegetables is a reasonable recommendation based on
observational studies.216 Appendix 3 summarizes studies of nutrition and cataract.
Long-term increased physical activity and exercise may decrease the risk of cataract. 86, 221, 222
Additionally, long periods of inactivity and prolonged sitting may be associated with cataract
progression.85, 86
The effect of medications on the formation of cataract is difficult to study since the effect of the
medication is hard to distinguish from the effect of the disease being treated. Long-term users of
inhaled or oral corticosteroids are at higher risk of cataract formation.51, 77, 83, 87, 88, 223 The use of
intranasal corticosteroids, however, is not associated with a significant risk of incident cataract
based on two recent systematic reviews.84, 224 The association between statin use and cataract has
been studied extensively with conflicting results.225-231 Phenothiazines have been associated with
anterior subcapsular opacities.232, 233 Multiple studies show no benefit of aspirin on cataract
development or the need for cataract surgery.234-238 There is a long list of drugs that may be
associated with cataract in prevalence studies, but longitudinal studies are needed to confirm a
causative relationship.51, 239, 240 Patients on medications who are at high risk for cataract
formation should be counseled and monitored.
The presence of diabetes mellitus,19, 20, 37-39 hypertension,39, 57, 75, 241, 242 obesity,33, 34, 39, 243 and
metabolic syndrome (diabetes, hypertension, obesity, and dyslipidemia)46, 242, 244, 245 is associated
with an increased risk of cataract or cataract surgery in numerous observational studies.
Prevention and treatment of these conditions may reduce the risk of cataract.
Smoking is a risk factor for various types of cataracts, with a dose-response effect seen for
nuclear sclerosis. 19, 20, 49, 66-68, 71, 72, 100, 246, 247 Cessation of smoking reduces the risk of cataract
development or progression and cataract surgery, and patients should be counseled to quit
smoking. 67, 68, 100, 101, 248, 249 32, 101, 250
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A cumulative lifetime exposure to ultraviolet-B radiation has been associated with lens
opacities.21, 53, 54, 74, 251, 252 Therefore, brimmed hats and ultraviolet-B blocking sunglasses are
reasonable precautions to recommend to patients.32, 48
Ionizing radiation is a proven cause of cataracts.48 A recent study of U.S. radiologic
technologists suggested an elevated risk of cataract even at relatively low exposures.96
Therefore, the use of radiation protective shields and lead glasses is advisable.
Several studies demonstrate an increased risk of cataract with blunt and penetrating trauma.52, 102,
Therefore, safety glasses are recommended for high-risk recreational or work activities.
253, 254
Nonsurgical Management
The management of visually significant cataract is primarily surgical. However, there are
nonsurgical means for managing the symptoms of cataract before surgery is necessary.
Changes to glasses and contact lens prescriptions can often be made to account for refractive
shifts in the early stages of cataract development. Low-vision devices can maximize remaining
vision pending cataract surgery or allow surgery to be deferred in patients at high risk of
complications.
Currently, no pharmacological treatments are known to eliminate existing cataract or retard its
progression. Ophthalmologists should advise patients that, at this time, there is insufficient
evidence to support the use of pharmacological treatments for cataract, based on a 2017
Cochrane Systematic Review of N-acetylcarnosine drops.255 (I+, Good, Strong)
Patients who are long-term users of topical ophthalmic, periocular, oral, and inhaled
corticosteroids should be informed of the increased risk of cataract development51, 83, 87, 88, 90, 256-
258
and may wish to discuss alternative treatments with their primary care physician. In limited
circumstances, and often as a temporizing measure, the pupil can be dilated to provide better
vision around a small central cataract. However, this strategy may worsen glare disability.
Surgical Management
The predominant method of cataract surgery in much of the world is sutureless, small-incision
phacoemulsification with foldable IOL implantation performed on an outpatient basis.259 Sutures
or sealants are used for incision closure if needed. In randomized clinical trials,
phacoemulsification produces better uncorrected distance visual acuity (UDVA) and a lower rate
of surgical complications, such as iris prolapse and posterior capsule rupture, than manual
extracapsular cataract extraction (ECCE) with incision closure by sutures or manual small-
incision cataract extraction (MSICS).260, 261 Phacoemulsification limits the astigmatic changes
that occur with larger incisions and enables both astigmatism management and the implantation
of specialty IOLs.262 In economically disadvantaged countries, MSICS remains popular because
of its cost-effectiveness, and sutureless ECCE with IOL implantation performed very well
compared with phacoemulsification in one randomized clinical trial.263
Indications for Surgery

The primary indication for cataract surgery is a decline in visual function such that it no
longer meets a patient’s visual needs and for which surgery provides a reasonable
likelihood of improvement. Other indications for cataract removal include the following:
 There is clinically significant anisometropia in the presence of a cataract.
 A lens opacity interferes with optimal diagnosis or management of posterior segment
pathology.
 A lens causes inflammation and related secondary glaucoma (phacolytic, lens particle,
phacoantigenic).
 The lens induces primary angle closure or other forms of lens-related glaucoma.
Contraindications to Surgery
Surgery for a cataract should not be performed under the following circumstances:
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 Tolerable refractive correction provides vision that meets the patient’s needs and
desires.
 Surgery is not expected to improve visual function and no other indication for lens
removal exists.
 The patient cannot safely undergo surgery because of coexisting medical or ocular
conditions.
 Appropriate postoperative care cannot be arranged.
 The patient or patient’s surrogate decision maker is unable to give informed consent for
nonemergent surgery.
Preoperative Evaluation and Counseling

The ophthalmologist who will perform cataract surgery should do the following:264, 265
 Examine the patient preoperatively (see Ophthalmic Evaluation section).
 Ensure that the documented evaluation accurately reflects the symptoms, findings, and
indications for treatment.
 Obtain informed consent from the patient or the patient’s surrogate decision maker after
discussing the risks, benefits, and expected outcomes of surgery, including the patient’s
expected surgical experience and the anticipated refractive outcome.266
 Review the results of the presurgical evaluation with the patient or the patient’s
surrogate decision maker.
 Counsel the patient about postoperative refractive options, such as bilateral emmetropia,
bilateral myopia, or monovision, that will work best given the ophthalmic history and
patient’s desires.
 Counsel the patient about elective refractive options, such as astigmatism management,
intraoperative refractive guidance, specialty IOLs (toric, extended depth of focus,
multifocal, accommodating, and postoperative power adjustable), and postoperative
refractive enhancement.
 Consider the effect of ocular comorbidities in the cataract care process.
 Formulate a plan, including preoperative medical management, selection of appropriate
anesthesia, surgical approach, concurrent procedures, and IOL design and power.
 Assess relevant aspects of the patient’s mental and physical status, such as the ability to
cooperate and position for surgery.
 Formulate a postoperative care plan and inform the patient or the patient’s surrogate
decision maker of these arrangements (setting of care, care provider).
 Determine the effect of any concurrent upper-eyelid blepharoptosis. Blepharoptosis can
induce corneal astigmatism or make astigmatism more difficult to measure.
Additionally, cataract surgery can worsen blepharoptosis.267
 Answer the patient’s questions about the surgery and care, including associated costs.
 Assess barriers to communication, including language or hearing impairment.
 Ensure that the patient and the patient’s caregiver, if applicable, are committed and able
to attend the postoperative visits and address transportation, medication administration,
and other potential challenges.
Ideally, the operating ophthalmologist should perform the preoperative assessment because
this allows the surgeon to formulate a plan and establish a relationship with the patient
before surgery. Although the ophthalmologist is responsible for the examination and
review of the data, certain aspects of data collection may be conducted by other trained
team members under the ophthalmologist’s supervision and with his or her review. 264, 265
Patients undergoing cataract surgery frequently have a preoperative medical evaluation,
including a history and physical examination that takes into consideration the risk factors
for undergoing the planned anesthesia. However, three randomized clinical trials have
failed to show that this evaluation reduces systemic or ocular complications 268 and no trials
have shown it to be efficacious. For patients with certain severe systemic diseases (e.g.,
chronic obstructive pulmonary disease, poorly controlled arterial blood pressure, recent
myocardial infarction, unstable angina, poorly controlled congestive heart failure, or poorly
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controlled diabetes), a preoperative medical evaluation by the patient's primary care

physician or a dedicated preoperative service may be considered.269
Routine preoperative laboratory testing in association with the history and physical
examination is not indicated. A very large, prospective, randomized clinical trial
demonstrated that routine medical testing did not reduce perioperative morbidity and
mortality.270 Despite this finding, routine medical testing is still performed on many
Medicare recipients.271 Directed testing may be recommended as appropriate for a
particular surgical candidate with medical problems.268, 270, 272
Biometry and Intraocular Lens Power Calculation

Optical biometry refers to highly accurate and non-invasive methods for measuring
anatomical characteristics of the eye by optical methods. Optical biometry devices for
measuring axial length initially used partial coherence interferometry as a replacement for
ultrasound. If a signal-to-noise ratio is adequately high, interferometry is significantly more
accurate and consistent than contact (applanation) A-scan biometry.273-275 In applanation A-
scan, an ultrasound probe compresses the cornea, causing both a variable and artificial
shortening of axial length. The accuracy and overall consistency of applanation ultrasound
techniques are highly dependent on the skill and experience of the operator.274, 276, 277 When
the immersion A-scan ultrasound technique is used, the probe does not come in direct
contact with the cornea, making the measurements more consistent and accurate.
Optical biometry was once considered comparable to immersion A-scan biometry, but it
has since been shown to produce better refractive outcomes. The patient’s postoperative
spherical equivalent is also more likely to be closer to the target refraction.278-280 Optical
biometry has also been shown to give user-independent results.281 Other advantages over
A-scan ultrasonography include ease and speed of automated operation and the ability to
measure to the fovea when proper fixation is achieved. Optical biometry can also obtain
additional measurements required for newer and potentially more accurate IOL formulas. A
newer form of optical biometry, swept-source OCT, allows for measurement through an
even greater percentage of cataracts and other media opacities than partial coherence
interferometry.282-286
A shortcoming of optical biometry is that it currently assigns a global refractive index to
the entire eye rather than adjusting to the specific optical elements (e.g., cornea, aqueous
humor, lens, and vitreous humor) through which light passes. In a highly myopic eye
measured using an optical biometer, the axial length of the vitreous gel relative to the other
structures results in an overestimation of the true axial length, causing an underestimation
of IOL power using standard formulas. To compensate for this effect, approaches such as
the Wang-Koch adjustment can be applied to the axial length for eyes longer than 25
mm.287 However, the Wang-Koch adjustment is not to be used with newer-generation
formulas such as the Barrett Universal II or Hill-RBF formulas, or with any of the
specialized formulas used to calculate IOL power in eyes with a history of keratorefractive
surgery.
Because optical biometry measures the “refractive” axial length rather than the anatomical
axial length, this method is more accurate than standard forms of ultrasound A-scan
biometry when the fovea is located on the sloping wall of a posterior staphyloma.288
Additionally, it is easier to use optical biometry than ultrasound when a patient has silicone
oil in the posterior segment.289, 290 Despite recent advances in optical biometry that allow
the measurement of axial length through increasingly dense cataracts,282-286, 291 A-scan
biometry may be necessary to measure axial length in certain dense cataracts or when a
patient is unable to fixate properly.292, 293 The measurement and comparison of axial length
for both eyes is advisable, even if surgery is not planned for the fellow eye.
Formulas for calculating IOL power rely on keratometry to determine the net refractive
contribution of the cornea. These measurements can be obtained by manual or automated
keratometers, biometers, topographers, Scheimpflug tomographers, and anterior segment
OCT devices (see Table 2). Following keratorefractive surgery, the determination of true
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central corneal power is particularly challenging (see Cataract Surgery Following

Refractive Surgery in the Combined Surgery and Special Circumstances section).
TABLE 2 INTRAOCULAR LENS POWER CALCULATION

FORMULAS
Formula Variables in Addition to Keratometry Notes
and Axial Length
Barrett Universal II  Anterior chamber depth  Uses a theoretical ray-tracing formula with
 Lens thickness data-driven enhancement
 White-to-white  Model eye correlates axial length and
keratometry to anterior chamber depth
 Includes location of the principal plane of
refraction of the IOL
Haigis  Anterior chamber depth  Uses double regression analysis to optimize

three variables
Hill-RBF  Anterior chamber depth  Uses artificial intelligence for pattern

 Lens thickness recognition and data interpolation
 White-to-white
Hoffer Q294-296  None  Optimizes equation constant (personalized

anterior chamber depth)
Holladay 1  None  Optimizes surgeon factor to derive anterior

chamber depth
Holladay 2  Anterior chamber depth  Adds additional variables to Holladay 1

 Lens thickness  Updated with nonlinear regression model
 Age
 White-to-white
 Preoperative refraction
Kane297, 298  Anterior chamber depth  Based on theoretical optics incorporating

 Biological sex regression and artificial intelligence
 Lens thickness components
 Central corneal thickness
Olsen299  Anterior chamber depth  Uses ray tracing and thick lens calculations to
 Lens thickness derive the C constant
SRK/T300  None  Combines theoretical optics with regression

analysis
 T2 formula uses regression analysis to update
SRK/T
IOL = intraocular lens
Although IOL manufacturers supply lens constants to be used with calculation formulas,
these numbers are generally considered to be only a recommendation and may not
correspond to the biometry method actually used. Optimization of lens constants for a
specific IOL based on an individual surgeon’s actual refractive outcomes may be helpful,
as may online databases pooling information from multiple surgeons.301
The surgeon should consider the patient’s desires and needs when selecting an appropriate
postoperative refractive target. Patients with high myopia may require unique lens
constants for plus and minus power IOLs that are quite different from those recommended
by the manufacturer because of IOL geometry.302, 303 For patients with extreme hyperopia
who require an IOL beyond the available power range, piggybacking two posterior
chamber IOLs is possible, including as a staged procedure.304-308 When this is indicated, it
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is highly preferable to place one IOL in the capsular bag and one in the sulcus to reduce the
risk of interlenticular membrane formation.309, 310
Corneal relaxing incisions can correct small amounts of preoperative corneal astigmatism,
but for larger amounts, toric IOLs should be considered.311-313 A 2016 systematic review
and meta-analysis found that toric IOLs provided lower amounts of residual astigmatism
than nontoric IOLs, even when corneal relaxing incisions were used.312 (I+, Good, Strong)
Toric lenses available in the United States are designed for implantation within the capsular
bag. Toric calculators require preoperative measurement of the corneal cylinder and a
knowledge of surgically induced astigmatism. Adding the contribution of the posterior
cornea has been shown to improve outcome accuracy, whether by nomogram or by
measuring the posterior cornea directly.314-317 The power of the toric component should be
adjusted for the effective lens position of the IOL.
Most modern IOLs contain aspheric optical surfaces. These lenses improve mesopic and
scotopic contrast sensitivity and visual quality by reducing or eliminating spherical
aberration.318-322 However, they are less tolerant of tilt and decentration and might not be
the best choice in patients with zonulopathy.323 Some surgeons choose the asphericity of an
IOL to match the asphericity of the cornea to maximize visual quality under mesopic and
scotopic conditions.324, 325
Intraocular lens power can be confirmed or refined intraoperatively in the aphakic and
pseudophakic states using intraoperative aberrometry. Aberrometry can assist with toric
IOL axis alignment as well.326 Intraoperative aberrometry can be useful in eyes with a
history of keratorefractive surgery such as photorefractive keratectomy (PRK) and laser-
assisted in situ keratomileusis (LASIK), although it is not as useful after radial
keratotomy.327, 328 It is not clear that intraoperative aberrometry always improves
outcomes.329-332
Anesthesia
Cataract surgery may be performed using a variety of anesthesia techniques that include
local (regional) anesthesia (e.g., retrobulbar, peribulbar, sub-Tenons injection,
intracameral, and topical) and occasionally general anesthesia. The planned mode of
anesthesia should be discussed with the patient so that she or he knows what to expect in
terms of pain, discomfort, consciousness level, visual experiences, and complications. The
outcomes of cataract surgery measured in terms of visual acuity, visual function,
complications, adverse medical events, and patient satisfaction have not been shown to
vary significantly between the anesthesia techniques.333-340 Intravenous (IV) sedation is
commonly used to complement the local anesthesia to optimize a patient's surgical
experience and cooperation.
Anesthesia techniques with needles or blunt cannulas may be associated with
complications that are not encountered with topical/intracameral techniques. Complications
include strabismus, globe perforation, retrobulbar hemorrhage, intravascular or
subarachnoid injection, and macular infarction.333, 337-341 Eyes with posterior staphylomas or
scleral buckles are at increased risk for globe perforation by peribulbar or retrobulbar
injections.342
A Cochrane Systematic Review of randomized clinical trials (RCTs) comparing peribulbar
with retrobulbar blocks found no difference in efficacy (in terms of akinesia, anesthesia, or
need for supplemental injections) or safety.336 (I+, Good, Strong) Conjunctival chemosis
was more likely with peribulbar blocks, whereas lid hematoma was more likely with
retrobulbar blocks.
A 2015 Cochrane Systematic Review of RCTs comparing topical with sub-Tenon’s
anesthesia found greater intraoperative but less postoperative pain at 24 hours with topical
anesthesia.343 While statistically significant, the magnitude of differences in pain was not
clinically relevant. There was insufficient evidence to draw conclusions about the incidence
of surgical complications between the two techniques. (I+, Moderate, Discretionary)
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Patients undergoing cataract surgery with topical or peribulbar anesthesia occasionally

experience visual sensations such as seeing lights, colors, the movement of instruments,
and the surgeon’s hand or fingers. Because 3% to 18% of patients find these visual
sensations disturbing, preoperative counseling about these phenomena may make their
occurrence less frightening.344, 345
Intravenous access is recommended to treat potential adverse events when
sedation/analgesic agents are administered.346 A systematic review and meta-analysis found
IV sedation was significantly associated with a decrease in pain when compared with non-
intravenous methods.347 (I+, Good, Strong) However, given the trend toward topical
anesthesia and the reduction or elimination of IV analgesia/sedation, IV access may be
unnecessary. Topical anesthetic drops may be supplemented with preservative-free
intracameral lidocaine for increased pain control.348 Monitoring during administration of
anesthesia and surgery generally includes using a cardiac monitor, pulse oximeter, and
measurement of blood pressure and respiration. These should be performed by personnel
(other than the operating ophthalmologist) qualified to monitor and manage the patient’s
systemic status. One study of patients receiving peribulbar anesthesia found that being
under age 60 and/or having hypertension, pulmonary disease, renal disease, or a prior or
current diagnosis of cancer was associated with the need for intervention by anesthesia
personnel, while an abnormal preoperative electrocardiogram or presence of diabetes was
not predictive of the need for intervention.349 Several studies reported on using registered
nurses350, 351 or respiratory therapists trained as sedation nurses to administer anesthesia.352
Office-based cataract surgery is currently being studied, and large studies of patient
outcomes are being performed at several Kaiser Permanente locations. Kaiser is a managed
health care provider in the United States. There is insufficient evidence to make a definite
recommendation currently.353
A review of cataract surgery studies involving local anesthesia found weak evidence for
improved pain relief, anxiety control, and patient satisfaction with IV or intramuscular
sedation or analgesia and insufficient evidence to recommend one technique over the
other.333 The evidence was also insufficient to determine if any analgesic or sedation
regimen was better than any other. The Study of Medical Testing for Cataract Surgery found
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) used.334 Also, excessive use of IV sedatives during cataract surgery was
associated with an increased risk of an adverse intraoperative medical events, and this risk
was even greater when both IV opiates and sedatives were used. 335, 354, 355 Evidence is mixed
on the value of oral anxiolytic medication to reduce the patient’s anxiety levels when given
before cataract surgery.354-359 Some studies demonstrated the noninferiority of oral sedation
compared with IV sedation, though high-quality meta-analysis and systemic reviews are
lacking.357, 359 Patients undergoing sequential cataract surgery typically perceive more pain
and discomfort during the second surgery. This suggests that preoperative expectations
should be reviewed with patients undergoing second-eye surgery.360 These measures may
translate into improved patient comfort and cooperation intraoperatively. 361, 362
Given the lack of evidence for a single optimal anesthesia strategy for cataract surgery, the
type of anesthesia management should be determined by the surgeon according to careful
consideration of the patient's needs, preference of the patient,363 the medical judgment of
the anesthesia team, and the surgeon.
Infection Prophylaxis
Preventing postoperative infection is a key aspect of cataract surgery because of the
potentially severe consequences of endophthalmitis. Controlled trials of antibiotics have
been difficult to perform because of the low incidence of endophthalmitis following
cataract surgery in the United States.364 A sufficiently controlled trial for FDA approval
would require tens of thousands of subjects and an estimated initial research and
development expense of over $350 million.365 These and other factors have led to a paucity
of level I evidence for endophthalmitis prophylaxis, leaving a number of large retrospective
cohort studies to fill this gap.
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A study found endophthalmitis rates as high as 0.327% in the 1970s decreasing to 0.087%
in the 1990s when ECCE became predominant.366 The infection rate subsequently increased
and by 2003 reached 0.265% (1 infection in every 377 cases), whereas the incidence of
infection after other anterior segment procedures was reportedly on the decline.366-369 It has
been proposed that the period of rising rates of infection corresponded to the increased
adoption of clear corneal incisions in cataract surgery, where improperly constructed
corneal incisions were prone to postoperative instability, leakage, and a potential influx of
microbes compared with sclerocorneal incisions.370-377 On the other hand, four large case
series found no greater likelihood of infection with corneal versus other types of incisions
during this period.378-381 Nevertheless, careful watertight incision construction and closure
(with sutures or sealants, if necessary) is obligatory, irrespective of surgical style, because
the incidence of infection increases with wound leak.382 The endophthalmitis rate after
cataract surgery in the United States between 2013 and 2017 was estimated to be 0.04%.364
Other factors associated with increased rates of endophthalmitis include intraoperative
posterior capsule rupture, vitreous loss, prolonged surgical time, immunodeficiency, active
blepharitis, lacrimal duct obstruction, inferior incision location, incomplete removal of the
lens cortex, male gender, older age, previous intraocular injections, lower surgical volume,
and less experienced surgeons.379, 382-394
Role of antiseptic
Although rare clusters of infections may be induced by contaminated surgical products,395-
400
topical drops,401, 402 or contaminated operating room environments,403, 404 the patient’s
periocular flora is the primary source of microbes responsible for most cases of sporadic
postoperative infection.405
Nonrandomized controlled trials and a prospective trial with the unoperated eye as the
control provide evidence that instilling topical 5% povidone iodine in the conjunctival cul
de sac preoperatively reduces the bacterial load and the incidence of postoperative
infection.406-408 A one-time application of lower concentrations of povidone-iodine was less
effective in some studies at reducing conjunctival bacterial colony counts.409-411 Other
studies have shown that dilute concentrations of povidone-iodine between 0.05% and 1%
have better bactericidal activity, through greater availability of diatomic free iodine, and
reduce cornea toxicity and patient discomfort.412-415 The presence of lidocaine gel prior to
povidone-iodine instillation appears to diminish its antimicrobial efficacy. 416
Chlorhexidine is not recommended because it is toxic to the ocular surface and can cause
irreversible keratitis.417
Topical antibiotics
There is growing evidence that preoperative topical antibiotic administration is unnecessary
and may increase the potential for resistance.418-420 Although instilling antibiotics before
surgery decreases the bacterial load of the ocular surface,421 topical povidone-iodine alone
was as effective as povidone-iodine combined with preoperative topical antibiotics in a
randomized clinical study.420
A retrospective study of 315,246 cataract surgeries demonstrated that intracameral
antibiotic injection was more effective at preventing postoperative endophthalmitis than
topical antibiotic administration alone.393 No difference in effectiveness was apparent
between topical gatifloxacin, ofloxacin, or polymyxin/trimethoprim; however, topical
aminoglycoside use was associated with double the rate of postoperative endophthalmitis,
the same rate as the group with no antibiotic prophylaxis (5% of the study population).
However, the small benefit of topical postoperative antibiotics was outweighed by the
greater effectiveness of intracameral antibiotic injection.
Intracameral Injection in combination with postoperative topical drops

There is substantial evidence to support the injection of antibiotics intracamerally to reduce
the risk of endophthalmitis. The intracameral route delivers a much higher concentration of
drug to the surgical site, resulting in higher bactericidal activity compared with topical
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administration.422, 423 Following initial studies in Sweden,423 a seminal large, prospective,

randomized and partially masked trial was conducted by the European Society of Cataract
and Refractive Surgeons (ESCRS).424 The incidence of endophthalmitis after
phacoemulsification was compared between four groups receiving the following: injection
of intracameral cefuroxime 1 mg/0.1 mL, pulsed dosing of perioperative levofloxacin eye
drops, both injection and pulsed drops, and neither injection nor drops. All groups were
treated with topical postoperative levofloxacin for 6 days, starting one day after surgery.
Based on intent-to-treat analysis of 16,211 patients, investigators found that the absence of
intracameral cefuroxime injection was associated with a 4.92-fold increase (95%
confidence interval [CI], 1.87–12.9) in the risk of postoperative endophthalmitis.424
Numerous other retrospective studies and two prospective studies have since reported a
reduction in endophthalmitis after cataract surgery when intracameral cefazolin,
cefuroxime, or moxifloxacin were added to postoperative topical antibiotic drops .393, 425-446
In one of these, the low baseline endophthalmitis rate of 0.07% fell further to 0.02% (one
infection in 5,000 cases) when intracameral moxifloxacin was added.443 A systematic
review and meta-analysis of over 900,000 eyes documented the effectiveness of
intracameral cefuroxime, moxifloxacin, and vancomycin in reducing endophthalmitis.
Secondary analyses showed no difference in efficacy between intracameral plus topical
antibiotics versus intracameral alone (P > 0.3). The safety analysis showed minimal
toxicity for moxifloxacin. Dosing errors led to most cases of toxicity when cefuroxime was
used. Although rare, vancomycin was associated with toxic retinal events.447
Moxifloxacin is currently the most common intracameral prophylactic agent in use in the
United States, whereas cefuroxime is preferred in European countries.448 There is no
evidence to date to suggest the superiority of either agent.393, 442 The standard dose of
cefuroxime is 1 mg in a 0.1 mL injection.424 However, there is no current universally
agreed upon dose for moxifloxacin,449 so it is important to ensure that an adequate
concentration of drug is achieved in the eye at the conclusion of surgery for sufficient
bactericidal activity.450
Several studies support the safety of intracameral moxifloxacin injection for
endophthalmitis prophylaxis;441, 446, 451 however, there is some evidence that higher
concentrations may have a deleterious effect on the corneal endothelium.452-454 Intracameral
cefuroxime is available as a government-approved product in Europe, and moxifloxacin is
commercially available in India. Because there is no FDA-approved product in the United
States for endophthalmitis prophylaxis, moxifloxacin must be compounded for
intracameral injection. Outsourcing facilities produce intracameral antibiotics in bulk and
must meet stringent criteria under section 503B of the Federal Food, Drug, and Cosmetic
Act.455 Antibiotics may also be compounded on a patient-by-patient basis by 503A
pharmacies, which do not have the same rigorous standards as 503B pharmacies. Onsite
compounding of cefuroxime has been associated with dilution errors that have the potential
for severe toxicity.456-461 The routine injection of vancomycin for endophthalmitis
prophylaxis is strongly discouraged based on its association with the rare condition
hemorrhagic occlusive retinal vasculitis (HORV) after uncomplicated cataract surgery.462,
463
Suspected cases of HORV can be registered on a joint American Society of Retina
Specialists and American Society of Cataract and Refractive Surgery (ASCRS) survey
(https://www.surveymonkey.com/r/HORV).
Intracameral injection alone

There is growing interest in drop-free chemoprophylaxis regimens, which would eliminate
the need for the instillation of eyedrops following cataract surgery.464, 465 Retrospective
studies comparing antibiotic injection alone with combination injection and topicals have
demonstrated a low frequency of endophthalmitis in the injection-only group and no
difference in infection risk compared with the combination group.466-468 In an observational
study, the infection rate was higher in the combination treatment group than in the
injection-only group, although this was not statistically significant (OR 1.63 ([CI]) 0.48–
5.47).393 Finally, two meta-analyses conclude there is a lack of a clear benefit to prescribing
topical antibiotics when injecting an intracameral antibiotic.447, 469 (I+, Good, Strong) It
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should be stressed that even with the added benefit of intracameral antibiotic injection, a
proper povidone-iodine prep and attention to surgical technique are important to prevent
postoperative infection.470
Alternative prophylaxis strategies have been used. One is mixing antibiotics into the
irrigation bottle, although this generally results in an inadequate drug concentration and
duration of action.406, 471 Another is subconjunctival antibiotic injection, which has been
shown to be inferior to the intracameral route of injection430, 433 because a much lower
concentration of the drug reaches the anterior chamber.472, 473 Transzonular and pars plana
intravitreal injection have been proposed as alternative routes of antibiotic delivery;474
however, large randomized studies establishing the safety and effectiveness of these
approaches are lacking.456, 475-477
Toxic Syndromes
Substances introduced into the eye during cataract surgery may result in immediate or
subsequent damage for reasons other than infection. Tissue injury may result from direct
toxicity or exuberant inflammation and involve the anterior or posterior segment.
Toxic anterior segment syndrome

Toxic anterior segment syndrome (TASS) is a sterile postoperative inflammatory reaction
that typically presents within 12 to 48 hours following surgery and can mimic infectious
endophthalmitis.478 Common clinical findings are diffuse limbus-to-limbus corneal edema,
severe anterior chamber cell and flare, fibrin, and hypopyon. Sequelae may include an
atonic pupil, secondary glaucoma, and corneal decompensation. 479 The inflammation
associated with TASS usually responds to anti-inflammatory medications, but permanent
intraocular damage can occur. If there is a suspicion of an infectious etiology, cultures of
the aqueous humor and vitreous should be obtained to test for infectious etiologies, and
antibiotic treatment should be initiated.480
The incidence of TASS is unknown and may vary because of its sporadic occurrence, often
in clusters. A retrospective study of 26,408 consecutive cataract surgeries from a single
institution in southern India during a 1-year period reported 60 cases of TASS, for an
incidence of 0.22%. There were two identified clusters, but more than half of the cases
were sporadic and unexplained. The visual outcomes were excellent, based on 6-month
follow-up reported on 40% of cases.481 In a series of 11,935 consecutive cataract surgeries
performed at one U.S. center between 2010 and 2013, there were no reported cases of
TASS. Subsequently, 10 cases of TASS in 3,003 cataract surgeries occurred in the
following year.482 Reservoirs of tabletop autoclaves were found to be contaminated and to
contain microbial biofilms, which likely led to the cluster.
All the following have been associated with development of TASS:
 Biofilm residues formed from dried ophthalmic viscosurgical devices (OVDs) and
ultrasound baths, particularly in cannulated instruments483-485
 Detergents and enzymatic cleaners483, 484, 486
 Drug preservatives, including benzalkonium chloride479, 487
 Incompatible additives such as xanthan gum in some commercially available topical
moxifloxacin eyedrop preparations intended only for topical application488
 Residue on IOLs during the manufacturing process489-491
 Non-ophthalmic agents such as sterile water, methylene blue,492 indocyanine green,493
and gentamicin479, 487
 Contaminated manufactured ophthalmic agents such as a balanced salt solution,
OVD,478 Trypan blue,492 and silicone oil494
Preventive strategies for TASS include thoroughly cleaning and sterilizing ophthalmic
instruments,478, 495 minimizing enzymatic detergents478, 495 or thoroughly rinsing if used,496
periodically cleaning tabletop autoclaves,482 frequently cleaning ultrasound baths,479, 487 and
avoiding agents not specifically formulated for intraocular administration.478 Replacing
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reusable instruments with single-use, disposable products is another strategy to avoid

residue, but there is increasing concern for environmental waste and emissions with this
practice.495, 497 Additional resources for the prevention of TASS and a registry to report
suspected cases can be found on the ASCRS TASS task force website
(https://tassregistry.org/).
Toxic posterior segment syndrome

Injected pharmaceuticals may cause toxic posterior segment syndrome (TPSS), which is
temporary or permanent damage to the retina and adjacent structures resulting from a
compounding error or incompatible additives. Macular edema, ischemia, and infarction
have been associated with injection of excessive cefuroxime in a dose-dependent fashion457,
459-461
as well as with the standard dose.458 498 Permanent, severe vision loss in seven
patients was attributed to intravitreal injection of a triamcinolone-moxifloxacin compound
containing an unapproved binding agent produced by a single pharmacy.456 These cases
highlight the importance of obtaining injectable drugs from verified, reputable sources.
Hemorrhagic occlusive retinal vasculitis is a type of delayed TPSS. Suspected cases of
TPSS can be registered on the ASCRS website to aid with ongoing surveillance and
research (https://tpssregistry.org/).
Cataract Surgery Checklist

Protocols to minimize the incidence of preventable surgical errors with respect to the
surgical site (e.g., wrong eye) and surgical procedure (e.g., wrong IOL) describe the
recommended steps to be taken before and on the day of surgery. The roles and
responsibilities for different members of the health care team are delineated. 499-504 In 2008,
the World Health Organization created a surgical safety checklist. The checklist was
intended to be universally applicable, with adaptations to fit specific disciplines. It is
administered at three critical junctures: before the introduction of anesthesia, before the
incision, and before the patient leaves the operating room. It was adapted for eye surgeries
by The Royal College of Ophthalmologists and the American Academy of Ophthalmology.
The Wrong-Site Wrong-IOL Surgery Checklist (see Appendix 4) is an example of how to
document that appropriate steps were taken to prevent wrong-site and wrong-surgery
events. Adherence to presurgical protocols or checklists has resulted in fewer surgical
errors and should be implemented.500, 503, 505-509
Surgical Techniques
Beyond the skill set needed to perform the steps of the operation, cataract surgery also
requires the cognitive skills, judgment, and experience necessary to recognize and respond
to unexpected events, problems, and complications that may arise intraoperatively. Only an
ophthalmologist has the medical and microsurgical training as part of a comprehensive
residency experience needed to perform cataract surgery.
In countries with adequate infrastructure to support advanced ophthalmic technology,
phacoemulsification is the preferred method to remove a cataract.
The ideal technical elements of a successful cataract procedure include the following:
 A secure, watertight incision that minimizes surgically induced astigmatism or reduces
pre-existing corneal astigmatism510-513
 Thorough removal of all nuclear, epinuclear, and cortical material514
 Negligible or no trauma to the corneal endothelium, iris, and other ocular tissues 515, 516
 Preservation of the integrity of the lens capsule
 Capsular bag fixation of an appropriate posterior chamber IOL
Intraocular steps that are commonly used during phacoemulsification include the
following:
 Construction of an appropriately sized incision that is tight enough to achieve a stable
anterior chamber517
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 Use of an OVD to protect the corneal endothelium, manipulate tissues, and maintain
adequate working space during surgery518, 519
 Creation of a capsulorrhexis,520 which can be made manually, or by a femtosecond laser
or radiofrequency device. The capsulorrhexis aids in hydrodissection; prevents posterior
capsule tears that originate from radial anterior capsule tears; and facilitates the
implantation, fixation, and centration of the IOL within the capsular bag. A
capsulorrhexis that completely overlaps the IOL edge limits the development of
posterior capsular opacification (PCO) for some IOL designs and blocks the anterior
migration of vitreous gel following a laser posterior capsulotomy.521
 Hydrodissection, which reduces zonular stress during phacoemulsification by
mobilizing the nucleus and epinucleus, and facilitates thorough cortical aspiration.522
Hydrodissection also helps to retard PCO.523, 524
 Nuclear disassembly and emulsification using techniques such as divide and conquer,525
chopping or pre-chopping,526 and femtosecond laser-assisted cataract surgery (FLACS)
fragmentation to allow nuclear removal through a capsulorrhexis and small incision527-
529
 Thorough removal of remaining epinucleus and cortex514 (polishing the anterior and
posterior aspects of the capsule when appropriate)
 Implantation of a foldable IOL within the capsular bag
 Removal of OVD to minimize postoperative IOP elevation530
 Establishment of a watertight incision by various means (raising the IOP, stromal
hydration, sealant, or suture)374, 386, 510, 531-533
Incision location, size, and design may depend on several factors, including the patient's
orbital anatomy, the type of IOL to be implanted, the role of the incision in astigmatism
management, and surgeon preference and experience. For example, varying the incision
characteristics and centering it on the steep corneal meridian may reduce pre-existing
astigmatism.534-537
When feasible, small-incision surgery is generally preferred for several reasons.538 Smaller
incisions are more amenable to self-sealing wound construction, are inherently safer in the
event of sudden patient movement or a suprachoroidal hemorrhage during surgery, and
lead to fewer physical restrictions postoperatively. They are also associated with less initial
postoperative inflammation and less unwanted astigmatic change.538-549
When required, manual ECCE or MSICS may be preferred for certain cataract surgeries,
such as those with mature nuclei, weak zonular fibers, or a higher risk of corneal
decompensation.550-554 Chang reported no significant difference in outcome between
phacoemulsification and MSICS in a prospective comparison between two experienced
surgeons.263
Femtosecond lasers can be used to construct corneal incisions,555, 556 create astigmatic
relaxing incisions,557-559 perform an anterior capsulotomy, and fragment or soften the
nucleus.527, 528
A 2020 meta-analysis of 73 studies was published in the Journal of Cataract & Refractive
Surgery comparing 12,769 eyes that underwent FLACS procedures with 12,274
conventional cataract procedures. It showed significantly improved uncorrected and
corrected visual acuity at 1 to 3 months, along with significantly decreased cumulative
dissipated energy, improved capsulorrhexis circularity, decreased central corneal thickness
at 1 day and at 1 to 3 months, and decreased endothelial cell loss at both 3 to 6 weeks and
at 3 months. However, anterior capsular ruptures were found to be more common with
FLACS. No differences in visual acuity were found at 1 week and after 6 months, and there
was no difference in posterior capsule rupture rates and endothelial cell loss after 6 months.
See the Outcomes section for a full discussion.
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Intraocular Lens Materials, Design, and Implantation

Intraocular lens implantation is the method of choice for correcting aphakia, unless there
are specific contraindications.560 Posterior chamber IOL implantation inside the capsular
bag is the optimal method for most cases.561
Cataract surgeons can choose from a wide variety of posterior chamber IOL styles and
materials to find an appropriate lens to match their patients’ needs. Intraocular lens optic
size, shape, haptic configuration, optic edge design,562-565 optic and haptic materials,566-568
and chromophore content are engineered with a variety of characteristics.569, 570
Foldable IOLs are commonly used because of their ability to fit through small incisions, and
they have largely replaced rigid polymethyl methacrylate (PMMA) posterior chamber IOLs.
Foldable IOLs can be made from silicone, hydrophilic acrylic, and hydrophobic acrylic. All
foldable IOL materials are associated with minimal giant-cell foreign-body reaction.571-573
Surgeons should be familiar with the unique positive and negative features of each IOL type
with regard to material, design, and insertion system.
Silicone IOLs:
 Incidence of PCO is low, especially with capsulorrhexis overlap.574
 Use in patients with silicone oil or expansile gas in the posterior segment may
compromise surgical visibility and should be avoided.575, 576
 Use in eyes at high risk of future retinal surgery, such as those with severe proliferative
diabetic retinopathy, should be avoided.
Hydrophobic acrylic IOLs:
 Sharp-edged IOLs decrease the incidence of PCO, especially in the presence of
capsulorrhexis overlap.574 This finding holds true for IOLs made from other materials as
well.577
 Glistenings, which are fluid-filled vacuoles, may develop in some lenses but rarely affect
vision or require explantation.578-582
 Blue filtering IOLs have not been clearly shown to protect the macula, based on a 2018
Cochrane Systematic Review (I+, Good, Discretionary), nor do they seem to impair
color discrimination.583
Hydrophilic acrylic IOLs:
 Use in patients undergoing keratoplasty or vitrectomy may result in IOL calcification
upon exposure to intraocular air or gas and thus should be avoided.584
 The incidence of PCO is higher with hydrophilic acrylic IOLs than with silicone or
hydrophobic acrylic IOLs.
Foldable IOLs can be inserted with forceps or injection devices; in many cases IOLs come
preloaded in insertion devices.585, 586 Insertion devices facilitate consistently reproducible
insertion through small incisions while preventing any contact of the lens with debris or
microorganisms residing on the patient’s ocular surface. 587 Preloaded insertion reduces the
risk of improper IOL loading at the time of surgery, which may result in IOL optic
scratches, haptic kinking, or other damage, or an IOL flipping upside down.
Intraocular Lens Optical Considerations

Spherical IOLs, in which marginal light rays focus proximally relative to paraxial light
rays, have positive spherical aberration. Positive spherical aberration results in a myopic
shift and increased depth of focus when the pupil dilates.
Some aspheric IOLs are designed to compensate for the spherical aberration of the cornea.
Multiple clinical studies demonstrate a pupil-dependent reduction in ocular spherical
aberration with aspheric IOLs, and some studies also reveal varying degrees of superior
contrast sensitivity with these IOLs relative to spherical IOLs.325, 588-600 However, the
potential advantages of aspheric IOLs remain controversial, particularly with respect to
functional benefit601-603 and depth of focus.162, 604 The potential advantages and
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disadvantages can be affected by pupil size,605 IOL tilt606 and decentration,607 and whether
the spherical aberration of the IOL and the patient’s cornea are custom matched.324, 608-613
Between 15% and 29% of cataract patients have more than 1.5 D of keratometric
astigmatism.614, 615 Toric IOLs, which correct for astigmatism, have been shown to decrease
eyeglass dependence compared with nontoric monofocal IOLs.616-619 In addition, they may
offer better predictability and stability of correction compared with incisional astigmatic
keratotomy, based on a 2019 Cochrane Systematic Review.620-624 (I+, Good, Strong)
For a toric IOL to be effective, the axis and magnitude of corneal or keratometric
astigmatism must be accurately measured, and the IOL must be accurately and permanently
aligned.625 The lenticular contribution to refractive astigmatism is eliminated with cataract
surgery; thus, preoperative manifest refractive astigmatism is irrelevant in astigmatism
planning. Toric IOL axis misalignment may reduce the desired refractive effect or may even
worsen the overall astigmatism.626 Because toric IOLs do not correct irregular astigmatism,
they should be used cautiously in patients who might require a rigid contact lens
postoperatively.627 Modified keratometers and aberrometers, collectively known as
intraoperative refractive guidance devices, are available to help with IOL power refinement
and toric IOL alignment intraoperatively.328, 628-631 An effort should be made to determine the
true corneal refractive power, which incorporates both the anterior and posterior corneal
power, either by direct assessment or by algorithmic adjustment.620, 632-638
Use of presbyopia-correcting IOLs or monovision may improve quality of life by reducing
eyeglass or contact lens dependence after cataract surgery.639 For each of these options,
patient selection is critical. Certain patient-related factors may be associated with suboptimal
postoperative performance and reduced patient satisfaction. Surgeons must understand an
individual patient’s lifestyle and expectations so that the most appropriate IOL can be
selected. Patients should be informed of the potential compromise in quality of vision
associated with the various choices.640-644
Monovision involves correction of one eye for distance vision and the fellow eye for
intermediate or near vision. The success of monovision depends on interocular blur
suppression where the blurred image from one eye does not interfere with the image from
the eye in focus.645 In one study, when the dominant eye was corrected for distance visual
acuity, the overall monovision acceptance rate following cataract and IOL surgery was
90% in patients with cataract who desired independence of correction with eyeglasses. 646 In
another study that analyzed modified monovision (-0.75 D anisometropia) versus
conventional monovision (-1.75 D or more anisometropia), the authors found that binocular
vision in relation to contrast sensitivity and stereopsis was better preserved with modified
monovision but near vision was compromised.647 In a small nonrandomized study
comparing patients who had bilateral multifocal IOLs versus bilateral monofocal IOLs
implanted to achieve monovision, there was no statistical difference in bilateral uncorrected
distance and near vision or in the satisfaction scores.648 Patients with a history of successful
adaptation to monovision with eyeglasses or contacts lenses are particularly well suited for
this modality.649, 650 Such patients may benefit from distance-corrected eyeglasses for
driving at night. In general, patients with latent strabismus, macular disease, or optic nerve
disease are poor candidates for monovision, unless they have previously done well with
optical correction.651-655
Presbyopia-correcting IOLs can be classified as multifocal or accommodative. Multifocal
lenses have near and distance elements in the optic of the lens, and accommodative lenses
change position, shape, or refractive index. When the focal points of the defocus curve of a
multifocal IOL are relatively close together, producing a minimal drop in visual acuity
between peaks, the lenses are said to have extended depth of focus (EDOF). 656 There is
usually a measurable drop in unaided visual acuity between the peaks of the defocus curve
foci of a standard bifocal multifocal IOL.
Extended depth of focus lenses can be implanted for bilateral distance focus or in a
monovision arrangement. They are often favored over full-add bifocal or trifocal IOLs for
eyes with subtle macular pathology or a history of keratorefractive surgery. 657-660 Extended
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depth of focus IOLs come in diffractive and nondiffractive designs, and each has
advantages and disadvantages with respect to glare, halos, near focus, and contrast loss.
Multifocal IOLs achieve their effect by dividing incoming light into two or more focal
points and can be classified as refractive, diffractive, or a combination.661, 662 They come in
bifocal, trifocal, and quadrifocal varieties.663 Some lenses are pupil-size dependent.664
Optical effects of multifocal IOLs may include reduced contrast sensitivity, halos around
point light sources, multiple images, and glare.665 A 2019 systematic review and meta-
analysis found that patients have better near and intermediate vision with multifocal IOLs
and have greater spectacle independence but are more likely to have glare, halos, and
reduced contrast sensitivity than patient with monofocal IOLs.666 (I+, Good, Strong)
Whether the improvement in near unaided acuity outweighs the optical side effects of
multifocal IOLs varies among patients, with important factors being the motivation to
achieve eyeglass independence, residual refractive error, posterior capsular wrinkles and
opacities, and adaptation over time.666, 667 Patient selection and counseling are particularly
important with these IOLs. There may be a symptomatic reduction in the quality of
distance vision, particularly if other ocular pathology is present, such as macular disease,
advanced glaucoma, or latent strabismus. Therefore, the candidacy of patients with
amblyopia or abnormalities of the cornea, optic disc, or macula for a multifocal IOL must
be carefully considered.644
Toric multifocal IOLs correct astigmatism and concurrently provide a range of vision.
When compared with spherical multifocal IOLs combined with peripheral corneal relaxing
incisions, they were found to be more predictable and to have good rotational stability.618,
668
Bifocal IOLs with low adds for near vision are available to help minimize issues of halo
and glare.669, 670
In an attempt to mimic human accommodation, accommodative presbyopia-correcting
IOLs, with or without a toric component, are designed to change their position or shape in
the eye with accommodative effort.671 These IOLs have demonstrated varied
accommodative potential without the loss of contrast sensitivity inherent in multifocal
IOLs.672-675 A modified monovision technique with the nondominant eye corrected
for -0.50 D or -0.75 D is used by some surgeons to improve uncorrected near vision.
Postoperative in situ power adjustment is a recent advance in IOL power refinement.676, 677
After refractive stability is achieved, the power of certain IOLs can be adjusted to reduce or
eliminate refractive errors. In one such technology, unpolymerized photosensitive silicone
macromers can be made to move down their concentration gradient after treating a special
silicone IOL with ultraviolet light. After the desired spherocylindrical adjustment is
achieved, remaining photosensitive macromers are consumed with an ultraviolet lock-in
treatment.
In another technology that is not commercially available, the chemistry of an acrylic IOL is
changed by a femtosecond laser with high spatial sensitivity to effect a change in
hydrophilicity. The resulting change in local chemistry induces a change in water content
and a corresponding alteration in the material’s focal refractive index. The technology,
known as refractive index shaping, can be applied across an IOL to produce changes in
sphere, cylinder, and the number of focal points. 678-680 Theoretically, it might be possible to
apply wavefront error compensation as well. This technology has the potential for multiple
treatments over time. Other technologies being investigated include multicomponent IOLs,
mechanically adjustable IOLs, magnetically adjustable IOLs, and liquid crystal IOLs. 677
Capsular Bag Fixation

The capsular bag is the best location to fixate an IOL. However, noncapsular bag fixation
may be necessary if there are zonular abnormalities or anterior or posterior capsular tears.
The surgeon should have backup IOLs available to handle these occurrences. Options
include anterior chamber IOLs or posterior chamber IOLs that can be positioned with or
without active fixation within the ciliary sulcus.681-685 Optic capture or reverse optic capture
through a capsulorrhexis opening, if possible, may help center an IOL.686 Suturing posterior
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chamber IOL haptics to the iris or sclera may be necessary in the absence of capsular
support.681-685 Certain unique IOL designs, such as plate haptic IOLs, require capsular-bag
fixation. In the event of posterior capsule rupture, the surgeon should reconsider capsular
IOL implantation without proper posterior capsular support and use an alternative IOL
style. No single method of noncapsular-bag fixation has been found to be superior. All
appear to be equivalent with respect to visual acuity and safety profile. Each type of
fixation has its own specific risks.687
Alternatives to Capsular Bag Fixation

Active and passive alternative techniques of IOL fixation can be used when capsular bag or
zonular support is insufficient. Appropriately designed IOLs can be passively secured in
the ciliary sulcus or anterior chamber. Suitable IOLs can be actively fixated to the iris or
sclera as an alternative.
Sulcus fixation
Optimal characteristics of a sulcus posterior chamber IOL include sufficient overall optic
diameter and haptic length, posterior haptic angulation, and the absence of sharp anterior
optic or haptic edges.685 Anticipating a more anterior location of the optic, the sulcus IOL
power for the average eye should be decreased by 0.5 diopters (D) to 1.0 D relative to that
calculated for capsular bag fixation (but decreased less with capsulorrhexis capture of the
optic).688, 689 Optic capture through a centered capsulorrhexis reduces reliance on adequate
haptic length to provide optic centration and stability. 690, 691 Because noncapsular fixation
increases the potential for optic tilt and decentration, the surgeon should reconsider
whether multifocal IOLs or IOLs with higher degrees of negative spherical aberration
should be implanted.607, 692 Also, single-piece acrylic IOLs currently available in the United
States are contraindicated in the ciliary sulcus because of associated risks such as IOL
decentration and iris chafing, which can cause transillumination defects, pigment
dispersion, elevated IOP, recurrent hyphema, and inflammation.685
Suture fixation of one or both haptics of a posterior chamber IOL to the iris or sclera is an
option in the absence of sufficient capsular support. 681-685 Risks include improper anatomic
placement and suture breakage or knot unraveling.693-697
Iris suture fixation

Suturing a posterior chamber IOL to the posterior aspect of the iris is an option for IOL
fixation in the setting of a ruptured posterior capsule or inadequate sulcus support, or for a
secondary implantation in an aphakic eye, or for correcting IOL dislocation. Surgical time
is usually shorter than for scleral fixation, but postoperative inflammation may be higher. 698
Possible complications include recurrent IOL dislocation, dyscoria, postoperative IOP
elevation, CME, epiretinal membrane development, and postoperative inflammation.698, 699
The implantation of iris-claw IOLs is an alternative in countries where they are
commercially available.700-702
Sutured inner scleral, intrascleral, or transscleral fixation

The inner scleral approach involves ab externo or ab interno fixation of the haptics of a
posterior chamber IOL to the sclera using nonabsorbable sutures. The most common
complications include recurrent IOL dislocation, tilt, intraocular hemorrhage, and RD.
There is also a risk of suture knot exposure, erosion or breakage, and glaucoma.698, 703
Intrascleral fixation appears to be an effective and safe technique in the absence of capsular
support, and studies have found good positioning of the IOL and insignificant tilt over a
relatively short period of time.704, 705 Haptics may be placed in scleral pockets with or
without fibrin glue. However, long-term studies to evaluate glue use are lacking. Possible
complications include haptic deformation and breakage, IOL decentration and dislocation,
intraocular hemorrhage, glaucoma, CME, optic capture, and RD.703
Transscleral fixation refers to the Yamane technique and its variants.706-708 The haptics of
the IOL are externalized through the sclera and conjunctiva, and the haptic ends are
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cauterized to create a flange. The flanged haptic ends are then tucked subconjunctivally
into their respective scleral tunnels. Complications include ocular hypertension, IOL tilt,
optic capture, vitreous hemorrhage, CME, haptic erosion through the conjunctiva, and
endophthalmitis.703, 709
Anterior chamber fixation

Effective use of an anterior chamber IOL depends on appropriate IOL design, sizing, and
placement. Iris deformity, pupil distortion, corneal endothelial failure, and ocular
discomfort may result from an IOL that is too long, whereas rotation and movement of an
IOL that is too short may induce chronic inflammation, CME, and corneal endothelial
damage.685 White-to-white corneal diameter measurement in the horizontal meridian has
been found to be the most accurate way to estimate proper anterior chamber IOL length if
anterior chamber OCT is unavailable. An anterior chamber IOL should be oriented with its
haptics away from the incision to prevent early haptic prolapse.710 A peripheral iridectomy
should be fashioned to prevent pupillary block.711 A 2018 network meta-analysis712
supports the efficacy of all three methods of IOL fixation—iris, transscleral and intrascleral
—in the absence of adequate capsular support. (I+, Good, Strong)
Outcomes
Multiple large studies of cataract surgery, including a review of the Cochrane Library, have
repeatedly demonstrated favorable outcomes from cataract surgery.713 (I+, Good, Strong)
While there are many earlier outcome studies,714 a 2013 European Registry of Quality
Outcomes for Cataract and Refractive Surgery examined 368,256 surgeries from surgeon
dataset entries, national registries, and electronic medical record systems. It reported 94.3%
with 20/40 or better CDVA and 61.3% with 20/20 or better CDVA.112 Only 1.7% had worse
CDVA postoperatively, with the greatest risk factors being a postoperative complication,
ocular comorbidity, or surgical complication.
A study that accessed 2013 and 2014 Intelligent Research in Sight (IRIS®) registry data
reported 81.7% of 33,437 eyes having CDVA of 20/40 or better by postoperative month
1.715 A large multicenter study in the United Kingdom showed that over 95% of eyes with
no ocular comorbidity had a CDVA of 20/40 or better.716
The Cataract Patient Outcomes Research Team (PORT) study identified independent
predictors for greater improvement after surgery that included younger age (under 65), less
comorbidity, a higher cataract symptom score, and a worse VF-14 (visual function)
score.168 In several studies, preoperative Snellen visual acuity was found to be unrelated to
the likelihood of improvement in symptoms or self-reported visual function after cataract
surgery.168, 171, 717 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.717 However, even patients with diabetes and age-related macular
degeneration (AMD) show substantial improvements after cataract surgery, albeit at a
lower magnitude than patients without these conditions.718-722 There is no evidence that
AMD accelerates following cataract surgery.723 Although these studies have shown greater
benefits in younger patients, the improvement in quality of life for those 75 and older is
still functionally and statistically significant.
Another study used a validated visual function questionnaire and a variety of psychophysical
methods to assess visual improvement in patients with symptomatic cataracts but with
preoperative Snellen acuity better than or equal to 20/50. 724 Even in eyes with 20/20 or better
preoperative Snellen acuity, cataract surgery improved patients’ self-reported visual
impairment.171 Neither the preoperative best corrected high-contrast Snellen distance acuity
nor change in Snellen acuity predicted the observed improvement in visual function as
reflected in the preoperative and postoperative questionnaire scores. The strongest
preoperative indicators for improved visual function were glare disability tested at low and
medium spatial frequencies and the visual function questionnaire score. This suggests that in
patients with symptomatic nonadvanced cataract, Snellen visual acuity in isolation does not
accurately predict who will benefit from surgery.725
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Cataract surgery improves driving safety. There is an increased risk of motor vehicle
accidents in patients with cataract and a significant reduction after cataract surgery. 726
Multiple papers on FLACS show results similar to standard ultrasonic
phacoemulsification.527, 727, 728 They also confirm the generally excellent results of modern
cataract surgery. The ESCRS FLACS study compared 2814 consecutive cases from high-
volume FLACS surgeons with 4987 control patients matched by age, preoperative CDVA,
ocular comorbidities, and surgical comorbidities from the 2014 European Registry of Quality
Outcomes for Cataract and Refractive Surgery. The control group had better postoperative
CDVA (logMAR 0.03 vs. 0.05, P < 0.05) and a statistically significantly higher likelihood of
being 20/20 or better (76.1% vs. 70.8%) or 20/25 or better (90.4% vs. 87.8%) and a lower
likelihood of worse CDVA than preoperatively (0.4% vs. 1.0%).728 The mean refractive error
was 0.40 D versus 0.43 D for FLACS, P < 0.05, with 74.3% of control eyes being within 0.5
D and 94.1% being within 1 D of target.
The French Ministry of Health-sponsored femtosecond laser-assisted versus
phacoemulsification cataract surgery (FEMCAT) prospective, multisite, randomized
controlled trial enrolled 909 patients for bilateral FLACS or manual phacoemulsification. A
sham docking procedure was performed on manual eyes. The FEMCAT trial defined success
as no intraoperative or postoperative complications within 3 months; a UDVA of 20/20 or
better at postoperative month 3, an absolute refractive error of 0.75 D or less, and surgically
induced astigmatism of 0.5 D or less.727 The success rate was 41.1% for FLACS and 43.6%
for manual surgery (odds ratio 0.85, 95% CI 0.64–1.12, P = 0.250). Another randomized
controlled trial of 400 eyes found no significant difference between femtosecond and manual
cataract surgery. The laser group had a lower posterior capsule rupture rate, but the rate of
3% in the manual group was higher than in the other studies.729
Complications of Cataract Surgery

Although numerous complications can occur intraoperatively or postoperatively, those
resulting in permanent loss of vision are rare. Major complications that are sight-
threatening include infectious endophthalmitis, TASS, TPSS, suprachoroidal hemorrhage,
CME, RD, persistent corneal edema, IOL dislocation, secondary glaucoma, diplopia, and
blindness.
The Cataract PORT study reviewed the incidence of cataract complications from studies
published prior to 1992 and with an overall phacoemulsification/manual ECCE case mix of
2:1.730 Six subsequent studies of adverse perioperative outcomes from cataract surgery are
summarized in Table 3. In one of these studies, Greenberg et al731 reviewed the incidence
of complications from cataract surgeries performed at the U.S. Veterans Health
Administration system from 2005 to 2007. The most common ocular complications were
posterior capsular tear, anterior vitrectomy, or both during surgery (3.5%), and PCO after
surgery (4.2%). Of note, many surgeries in this setting are performed by residents in
training.
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Cataract in the Adult Eye PPP—Journal in the Adult Eye PPP
Draft
TABLE 3 COMPLICATION RATES FROM SELECTED STUDIES OF CATARACT SURGERY

Cataract Schein et NEON, Zaidi et al, Jaycock et Greenberg Clark et Pershing Mahr et
PORT, al, 2000732 2007733 al, 2009716 et al, al, et al, al,
1994730 1994113 2011731 2011734 2019364 2020735
Number of cases * 717 2603 1000 55,567 45,082 65,060 8,542,838 2,267,182
Percent 65 65 92 100 99.7 95 100

phacoemulsification (approx)†
Intraoperative (%)
Posterior 3.1 1.95 1.6 1.5 1.92‡ 3.5§ NA NA NA
capsular or
zonular rupture
Vitreous loss/ 0.8 1.39 1.1 1.1 NA NA NA NA NA
anterior
vitrectomy or
aspiration
Iris/ciliary body 0.7 0.84 0 1.2 0.55 0.1 NA NA NA
injury
Loss of nuclear NA 0.28 <1 0.1 0.18 0.2 0.16 NA NA
material into
vitreous
Suprachoroidal NA 0.14 0 0 0.07 0 NA NA NA
hemorrhage
Retrobulbar NA 0 0 0.1 NA 0 NA NA NA
hemorrhage
Postoperative (%) (n =
16,731)║
CME 3.5 3.21 NA 1.2 1.62 3.3 NA NA NA
Iris abnormalities 1.3 2.51 NA NA 0.16 NA NA NA NA

Corneal edema NA 1.95 <1 0.7 5.18 NA 0.03 NA NA
Wound leak or NA 0.84 <1 1.1 0.14 NA 0.06 NA NA
rupture
IOL dislocation, 1.1 0.28 <1 NA 0.22 0.9 0.19 NA NA
removal, or
exchange
Endophthalmitis 0.13 0.14 <1 0.1 NA 0.2 0.17 0.04 NA
Retinal tear, 0.7 0.14 <1 0.2 NA 0.9 0.37 NA NA
break, or
detachment
Visually NA NA <1 NA NA NA NA NA NA
significant CME
Persistent iritis NA NA 1.1 1.1 NA NA NA NA NA
Retained lens NA 0.18
fragment
requiring return
to OR for
removal
CME = cystoid macular edema; IOL = intraocular lens; NA = not available; NEON = National Eyecare Outcomes Network; OR =
operating room; PORT = Cataract Patient Outcomes Research Team.
* Number of cases varies depending on the studies included for each complication.
† The study used Current Procedural Terminology codes to identify cases that do not specify whether cataract surgeries are performed
by phacoemulsification or manual extracapsular cataract extraction. A survey736 of Veterans Health Administration facilities found that
phacoemulsification was performed in approximately 95% of extracapsular cataract surgeries.
‡ This is a composite figure that includes posterior capsule rupture without vitreous loss, posterior capsule rupture with vitreous loss,
and zonule rupture with vitreous loss.
§ This is a composite figure that includes diagnostic codes for posterior capsule tear and procedural codes for anterior vitrectomy.
║Postoperative information was not available for all study patients.
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Stein et al737 stratified Medicare beneficiaries who underwent cataract surgery into three
cohorts: those who had their first cataract surgery in 1994 –1995 (n = 57,780), 1999–2000
(n = 73,064), or 2005–2006 (n = 90,750). The overall rate of severe complications in the 1-
year postoperative interval was 0.5%. Severe complications were defined as
endophthalmitis (0.16%), suprachoroidal hemorrhage (0.06%), and RD (0.26%). The
occurrence of a severe complication declined over time from 0.6% in the earliest cohort to
0.4% in the most recent group.
A study performed in the United Kingdom reported a 9% complication rate in the overall
rate of complications after phacoemulsification.733 Of the complications reported, 2% were
considered major, including vitreous loss (1%), lens drop (0.1%), iris trauma (1%), RD
(0.2%), and endophthalmitis (0.1%). Less severe complications included wound leak (1%),
prolonged corneal edema (0.7%), uveitis (1%), and persistent elevated IOP (0.3%). A 2015
study showed similar results.738
Specific complications following cataract surgery are discussed below.
Incision complications
An incision that is not watertight can lead to several complications, including postoperative
wound leak, hypotony, and endophthalmitis.382 An incision that is too large will cause
leakage of fluid from the wound and destabilize the anterior chamber during surgery. An
incision that is too tight dramatically increases friction, which increases the heat from the
ultrasonic phacoemulsification needle and increases the risk of wound burn. Wound burn
(ultrasound stromal thermal damage) occurs at 60º C or higher. 739 A survey identified 419
cases of wound burn, which yielded an incidence of 0.043%.740 In a multivariable analysis,
factors associated with this problem in order of decreasing significance were lower surgical
volume, surgical technique, and type of OVD used.740 The risk of wound burn varies
among different OVDs.741 Clearing viscoelastic to create a working space before beginning
phacoemulsification of a cataract can help prevent burns. Thermal injury can result in
incisions that are difficult to close. Burn-induced astigmatism may affect refractive
outcomes, particularly with new-technology IOLs.
An incision that is not self-sealing at the end of the surgery will require sutures or adhesive
for proper closure. The risk of perioperative wound leak (e.g., risk increased with eye
rubbing, poor scleral rigidity) is another consideration for the use of sutures or eye
protection postoperatively. Sutures can induce postoperative astigmatism, the magnitude of
which is dependent on their location and tension.537, 742 The induced astigmatism is usually
reversed upon suture removal. 743, 744
Iris complications
Iris injury induced by cataract surgery can be classified according to location. Iris sphincter
damage at the pupillary margin may cause mydriasis and an irregular pupil. Mid-peripheral
defects are located peripheral to the sphincter but do not extend to the iris root.
Iridodialysis involves disinsertion of the iris from the internal wall of the eye.745 Damage to
the iris can result from iris prolapse due to conditions such as intraoperative floppy iris
syndrome (IFIS)746, 747 or a poorly constructed incision. Causes of surgical iris trauma due
to a shallow chamber may include iris aspiration or agitation from the phacoemulsification
tip, sphincterotomies, and excessive stretching or manipulation from expansion devices
(iris hooks and rings) and instruments. The sequelae of such trauma may include
iridodialysis; hyphema; transillumination defects; traumatic mydriasis; and an irregular,
atonic, or misshapen pupil.745 Sphincter necrosis may occur perioperatively as a result of
endophthalmitis, TASS, or excessively increased IOP that may result in a chronically
dilated or irregular pupil.
Corneal complications
Improper instrument entry into the anterior chamber can lead to Descemet membrane tears
or detachment.748, 749 Femtosecond laser-assisted cataract surgery is also known to
produce small Descemet membrane detachments.750 A small tear may require no attention,
since such tears often spontaneously resolve. Larger tears can be repaired by repositioning
and tamponading the flap of Descemet membrane with a gas bubble or sutures. The corneal
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endothelium is susceptible to damage from any mechanical injury and from prolonged
ultrasonic power. It can also be damaged by intraocular solutions that have a
nonphysiologic osmolarity or pH, or by chemical insult from toxic contaminants or
improperly formulated intraocular solutions and medications. 479, 483 Prolonged elevated IOP
can lead to further endothelial decompensation and corneal edema. The surgeon should
avoid working close to the cornea and orient irrigation ports away from the corneal
endothelium. Replenishing dispersive OVD during prolonged phacoemulsification or in the
presence of several smaller shards of brunescent cataract can also help protect the corneal
endothelium. Fuchs endothelial dystrophy and other corneal pathologies may predispose to
prolonged corneal edema after surgery and, if severe with no improvement over time, may
require corneal endothelial transplantation.
Patients with a history of Herpes simplex virus stromal keratitis should receive
perioperative antiviral prophylaxis to avoid postoperative recurrence.
Inflammation
Prolonged inflammation
There are several potential etiologies for prolonged postsurgical inflammation. Prolonged
inflammation, or iritis, is defined as inflammation that does not resolve within a few weeks
of cataract surgery. This is in contrast to rebound inflammation, which is inflammation that
resolves in the usual time frame but then recurs. Persistent iritis has been associated with
herpetic eye disease, retained lens fragments,751 previous history of uveitis,752 and a
subacute infection with Propionibacterium acnes.753 Gonioscopy may be necessary to see
small lens fragments in the inferior angle. Ultrasound biomicroscopy, long-wavelength
OCT, or endoscopy may be needed to identify lens fragments trapped in the ciliary sulcus.
Other infectious agents, such as fungi, can cause indolent infection and inflammation.
Malposition or misplacement of IOLs of specific design may also lead to persistent
intraocular inflammation, such as a malpositioned anterior chamber IOL or a one-piece
acrylic IOL placed in the ciliary sulcus. The surgeon should ensure proper orientation of
IOLs to prevent corneal complications. Insufficient postoperative anti-inflammatory
medication may also be a contributory cause.754 Diabetic patients and patients who required
a pupil expansion device at the time of surgery are at increased risk of persistent
postoperative inflammation.755, 756 These patients are also at increased risk for developing
CME, up to 29.5% in one study. However, long-term outcomes are still equivalent to
patients without prolonged inflammation.755, 756
Rebound inflammation
Discontinuation of corticosteroid eye drops after cataract surgery may be followed by a
recurrence of inflammation, resulting in increased cell and flare or CME. Reinstituting anti-
inflammatory eye drops will decrease the inflammation and may require a slower taper to
prevent reappearance.
Endophthalmitis
According to peer-reviewed literature, the incidence of postoperative endophthalmitis
ranges from 0.04% to 0.2% in the United States,113, 364, 367, 379, 715, 731 and from 0.02% to
1.16% elsewhere according to other English-language peer-reviewed literature.387, 443, 730, 732,
734, 737, 757-763
Staphylococcus epidermidis is the most common pathogen.757, 759 Risk factors
for endophthalmitis after cataract surgery include posterior capsular rupture (up to 10-fold
increase),379, 382, 387, 388, 763 older age,387 relative immunodeficiency,379 resident-performed
cataract surgery,388 wound leak on the first postoperative day,382 inferior incision
location,379 longer surgery,764 topical anesthesia,764 and the use of topical lidocaine gel
before povidone iodine application.379 The absence of intracameral cefuroxime
administration in the European endophthalmitis study was associated with a statistically
higher rate of postoperative endophthalmitis.424
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The type and size of incision (clear corneal vs. sclera) has been implicated as a possible
factor in the development of endophthalmitis.372 However, several articles found no
conclusive evidence for an association between clear corneal incision and
endophthalmitis.379, 765, 766
As mentioned earlier in the Infection Prophylaxis section, two pharmacologic interventions
have been shown to reduce the rate of postoperative endophthalmitis conclusively in clinical
trials. They include treating the eyelids and conjunctival cul de sac with povidone iodine
immediately before surgery and injecting cefuroxime into the anterior chamber at the
conclusion of surgery.406, 407, 424, 432, 767-770 Moxifloxacin injection is currently popular in the
United States even though it lacks randomized, prospective clinical trial evidence.
For a detailed discussion of endophthalmitis prophylaxis, please refer to the Infection
Prophylaxis section.
Patients who develop endophthalmitis may present with complaints of decreased vision,
pain, redness, new floaters, and eyelid edema.771, 772 Although, the onset of symptoms was
historically considered to occur during the first postoperative week, 773-775 newer studies
report delayed onset of up to several weeks.379, 776 Patients should be encouraged to call
their surgeon if they experience pain or worsening vision. Common findings include
conjunctival injection, corneal edema, anterior chamber inflammation, fibrin, hypopyon,
and vitritis.771, 772 Endophthalmitis must be differentiated from TASS and TPSS, which
have slightly different time courses and require completely different treatments.
If endophthalmitis is suspected, referral to a retina specialist is appropriate. If a retina
specialist is unavailable within 24 hours, the anterior or posterior segment should be tapped
by any experienced ophthalmologist, including the cataract surgeon, for evaluation of
possible pathogens, followed by intravitreal injection of antibiotics.773 The Endophthalmitis
Vitrectomy Study (EVS) recommended an intravitreal tap plus injection of antibiotics in
patients who present with vision of hand motion or better. Conversely, patients who present
with vision of light perception or worse are more successfully treated by means of pars
plana vitrectomy and antibiotics.773
Posterior capsular tear or zonular rupture

Reported rates of posterior capsular tear or zonular rupture average around 2% in low-risk
cases and up to 9% in patients with a history of pars plana vitrectomy.716, 732, 777-779 Additional
risk factors for posterior capsular tear with or without vitreous loss include older age, male
gender, glaucoma, diabetic retinopathy, brunescent or white cataract, posterior polar cataract,
inability to visualize the posterior segment preoperatively, pseudoexfoliation (exfoliation
syndrome), small pupils, axial length greater than 26 mm, use of systemic alpha-1a antagonist
medication (e.g., tamsulosin), previous trauma, inability of the patient to lie flat, history of
intravitreal injections, patient movement, and resident-performed cataract surgery.780-782
Maintaining a stable anterior chamber and a well-dilated pupil are two factors a surgeon can
control to reduce risk. Early adopters of femtosecond lasers for lens fragmentation experienced
a higher rate of capsular rupture.783 However, recent reports have not confirmed these higher
rates. According to both the FEMCAT and FACTS studies, randomized, controlled trials that
compare FLACS with conventional cataract surgery, there were no differences in the rate of
posterior capsular rupture between the two groups.727, 784 Intraoperative risk factors include
loose zonular fibers, a need for capsular stain, and miosis.781 The factors listed here are some of
the known risks, but posterior capsular and zonular complications may occur without any
obvious predisposing factors.
Dropped lens fragments

The incidence of lens fragments dropping into the posterior segment is 0.1% to 0.28%.716, 730
If there is vitreous displacement, the surgeon should perform a vitrectomy if comfortable or
refer immediately to a retina specialist.785 The use of injected triamcinolone may aid in
visualization of vitreous.786 Because there is an increased risk of inflammation and elevated
IOP, consideration should be given to referring patients with dropped nuclear lens fragments
to a retina surgeon once the cornea has cleared.787
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The most appropriate timing of a secondary pars plana vitrectomy is unclear, but the eye
should be carefully monitored for complications, such as elevated IOP and
inflammation.788-790
Retinal detachment
Overall rates of RD range from 0.26% to 4%.734, 737, 766, 791-796 Risk factors for the
development of RD after cataract surgery include moderate to high axial length, posterior
capsule tear, vitreous loss, younger age, male gender, lattice retinal degeneration, zonular
dehiscence, RD in the fellow eye, and the new onset of a postoperative posterior vitreous
detachment.766, 791-796 In one study, the mean interval between cataract surgery and RD was
39 months,796 but the increased risk of RD in pseudophakic eyes may continue for as long
as 20 years.797 There was no statistically significant difference in the probability of RD
after phacoemulsification compared with ECCE.797
Suprachoroidal hemorrhage
Historically, the incidence of suprachoroidal hemorrhage related to large-incision cataract
surgery was reported to be 0.15% to 0.19% and to be associated with myopia, glaucoma,
diabetes, atherosclerotic vascular diseases, hypertension, and prolonged intraoperative
hypotony.798 Published data on the incidence of suprachoroidal hemorrhage following
phacoemulsification are lacking. The risk is probably lower because the surgical duration is
shorter and the hypotony time is reduced. Suprachoroidal hemorrhage has been reported
during FLACS.799 The majority of published studies support the continuation of
anticoagulant and antiplatelet therapy during cataract surgery.800 Anticoagulation with
warfarin does not significantly increase the frequency of (supra)choroidal hemorrhage.801
Clinical signs and symptoms of an intraoperative (supra)choroidal hemorrhage include
sudden pain, scotoma and loss of red reflex, elevated IOP, shallowing of the anterior
chamber, and iris prolapse.802 Prompt diagnosis of a hemorrhage and immediate incision
closure minimizes the likelihood of sight-threatening complications.
Cystoid macular edema

Clinically significant CME occurs infrequently after routine, uncomplicated
phacoemulsification (1%–3%)716, 731, 733 and often responds well to topical anti-
inflammatory medication; however, recalcitrant cases (0.02% of cases) may be associated
with permanent impairment of visual acuity. Risk factors for CME include previous uveitis,
posterior capsule rupture with vitreous loss, retained lens material, diabetic retinopathy,
venous occlusive disease, epiretinal membranes, prior vitreoretinal surgery,
nanophthalmos, retinitis pigmentosa, radiation retinopathy, male gender, older age, and a
history of pseudophakic CME in the fellow eye.803 Anatomic diagnosis is frequently made
using OCT, a less invasive technique than fluorescein angiography. Snellen visual acuity
may underestimate the impact of CME on visual function.
Because CME is generally associated with postsurgical inflammation, topical anti-
inflammatory medications are used to prevent it and to treat established CME. There is
evidence that nonsteroidal anti-inflammatory drugs (NSAIDs), alone or in combination
with topical corticosteroids, decrease the likelihood of postoperative CME, especially in
diabetics.804, 805 (I+, Good, Strong) Studies show a short term benefit in visual recovery, but
no level I evidence yet of long-term benefit (i.e., 3 months or more).806, 807 The 2018
ESCRS PREMED randomized clinical trial compared bromfenac 0.09% twice a day with
dexamethasone 0.1% four times a day versus a combination of the two. The study found
that patients receiving the combination had a lower incidence of CME after cataract
surgery than patients treated with either medication alone.808
The use of intravitreal anti-angiogenesis agents at the time of cataract surgery for
prophylaxis or treatment of select cases of CME is being investigated.809 In the PREMED 2
study, patients were randomized to receive 40 mg of subconjunctival triamcinolone
acetonide, a 1.25mg injection of bevacizumab, a combination of both, or no treatment. The
study found that subconjunctival triamcinolone decreased macular thickness and volume at
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6 to 12 weeks and that intravitreal bevacizumab had no effect. In another study of patients
with stable diabetic retinopathy without macular edema, injections of ranibizumab reduced
the incidence of postoperative CME in the study group.810
At present, there is no firmly established protocol for preventing postsurgical CME. Aside
from retinitis pigmentosa, there are no known genetic predispositions. The perioperative
prophylactic use of NSAIDs for the prevention of CME has been advocated for high-risk
eyes based on a number of studies.803, 811 Administration of NSAIDs before and
immediately after surgery may hasten the recovery of vision in the first few weeks
following surgery.812 Again, there is no level I evidence that long-term visual outcomes are
improved by the routine use of prophylactic NSAIDs at 3 months or more after cataract
surgery.813 Anti-vascular endothelial growth factors and intravitreal corticosteroids may be
useful, especially in diabetics, when topical medications fail or produce limited results. 812,
814, 815
Elevated Intraocular pressure

Transient elevation of IOP is commonly encountered during the early postoperative period.
Although it rarely causes permanent injury, acute postoperative IOP elevation can cause
nausea and pain and induce microcystic corneal edema. The long-term impact of
postoperative IOP spikes is unknown and could be a subject for future study. Some eyes
may be more susceptible to optic nerve damage or retinal vascular occlusion. The
likelihood of IOP elevation increases if a patient has a history of glaucoma and/or if OVD
is left in the eye, including behind the IOL, at the conclusion of surgery. Therefore,
thorough removal of OVD is recommended.816 Dispersive OVDs are more likely than
cohesive OVDs to be retained because they adhere more to intraocular structures. The
optimal pharmacological regimen for preventing an immediate postoperative IOP spike is
unclear. It appears that topical aqueous suppressants, oral carbonic anhydrase inhibitors,817,
818
and intracameral carbachol are beneficial.819-838 Topical corticosteroid use may elevate
IOP in eyes that are “corticosteroid responders.”839 Difluprednate 0.05% is more likely to
elevate IOP than prednisolone acetate 1%, and steroid-induced pressure elevation is more
likely to occur in patients who are younger, highly myopic, or have glaucoma or
pseudoexfoliation.840-842 Corticosteroid cessation usually results in a reduction of the IOP to
normal levels, and IOP should be monitored in patients treated with corticosteroid
medication postoperatively.839 The desire to control IOP elevation must always be balanced
against the need to control postoperative inflammation.
Complications of Intraocular Lenses
Incorrect intraocular lens power

Incorrect IOL power may necessitate an IOL exchange. A preoperative “Time Out” that
includes the surgical staff in the operating room can help avoid placement of a wrong IOL.
Incorrect IOL labeling, transcription errors, or mistakenly implanting the wrong IOL may
result in an unwanted refractive surprise. Preoperative measurement error may occur with
uncooperative patients, post-refractive surgery eyes, and atypical anatomic variations such
as staphylomas (see Biometry and Intraocular Lens Power Calculation section and sections
that discuss cataract surgery following prior keratorefractive surgery). Finally, surgical
factors that can affect the postoperative position of the IOL (the effective lens position),
and thus the postoperative refractive state, include retained OVD, capsular block, improper
haptic or optic placement, and upside-down placement of the IOL. A three-piece IOL with
angulated haptics that is placed upside down or in the sulcus will result in a myopic shift
from an anteriorly displaced optic. Aqueous misdirection into the vitreous cavity can also
result in anterior displacement of an optic.
When an unacceptable or intolerable refractive error results following IOL implantation,
the risks of surgical intervention must be weighed against the alternatives of eyeglass or
contact lens correction. Surgical alternatives to IOL exchange include keratorefractive
surgery and secondary piggyback IOL implantation.
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Damaged intraocular lens

Rarely, an IOL will be damaged during the insertion process or a laser capsulotomy. When
IOL defects are visually significant, the ophthalmologist must weigh the risks and benefits
of IOL exchange.
Decentration
Intraocular lens decentration or subluxation has been reported with virtually all IOL
materials and models, including both one-piece and three-piece designs.843 This
complication is seen most commonly when the haptics are not placed symmetrically inside
the capsular bag or when an IOL is placed in a bag with a capsular tear and the optic is not
fixated within an intact and centered capsulorrhexis. Major predisposing factors for IOL
subluxation in one study were secondary implantation, posterior capsule rupture, and
mature cataract.844 Posterior chamber IOL decentration can result from damaged haptics,
zonular dialysis, anterior or posterior capsular tears, asymmetric capsulorrhexis,
asymmetric contraction and fibrosis of the capsular bag, and asymmetric placement of the
haptics with one in the ciliary sulcus and the other in the capsular bag. Asymmetric haptic
placement can cause visual complaints, including edge glare, blur from high-order
aberrations, inflammation associated with uveal irritation, secondary glaucoma, and
hyphema (see the Uveitis-glaucoma-hyphema syndrome section).685
Malposition
Toric IOLs may rotate after implantation, usually in the first few hours following surgery.
Single-piece acrylic IOLs are more rotationally stable than early generation silicone plate-
haptic IOLs, although malposition is seen occasionally and may depend on design.845, 846
Improper positioning at the time of surgery, high myopia, anterior capsule polishing,
retained OVD, and shifts in postoperative corneal astigmatism account for most cases of
toric IOL misalignment.847 Reoperation to reorient a toric optic on axis usually remedies
this problem.848
Pseudo-accommodative lenses with flexible hinges are at risk of tilting or of a “Z
syndrome” if the capsular bag is too small at the time of implantation or if it contracts
aggressively following surgery.849-851 Anterior capsule polishing and capsule tension ring
(CTR) implantation may reduce the incidence of this problem.
Luxation
Delayed spontaneous in-the-bag posterior IOL luxation is associated with diffuse zonular
insufficiency, such as with pseudoexfoliation (exfoliation), prior vitreoretinal surgery, or a
history of trauma.852-855 In one study of 86 consecutive cases, the onset of late dislocation
occurred on an average of 8.5 years following uncomplicated cataract surgery and was
most commonly associated with exfoliation syndrome.855 Spontaneous bag-IOL dislocation
can occur with all types of IOL materials, including PMMA, silicone, and hydrophobic
acrylic one-piece and three-piece IOL designs.855 There is no evidence that the implantation
of a CTR reduces the risk of late dislocation of the capsular bag.856-858
Plate haptic silicone IOLs can dislocate posteriorly following laser capsulotomy and,
rarely, they can dislocate spontaneously from capsular contraction.859 The problem usually
occurs many years after surgery and may happen even if large fixation holes are present in
the haptics.860
Lens-related visual disturbances (dysphotopsias)

The term dysphotopsia has been used to describe a variety of unwanted visual phenomena
encountered by pseudophakic patients.861, 862 Positive dysphotopsias may include halos;
ghost images; starbursts; and arcs, rings, or flashes of light that may ultimately interfere
with visual function. Negative dysphotopsia refers to a thin, dark crescent in the temporal
midperipheral field of vision. Initially, dysphotopsias were commonly reported with high-
refractive–index hydrophobic acrylic IOLs with reflective square edges. However, they
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have since been reported with many different IOL materials and designs, including silicone
and hydrophilic acrylic IOLs.563, 863-866 Certain optic design characteristics such as a square
peripheral edge, flat anterior surface, smaller optic diameter, and multifocality are more
likely to result in unwanted optical images.864, 867-869 Complications such as IOL
opacification, cracked or damaged optics, and IOL decentration may also cause
dysphotopsias. Multifocal implants, in particular, are most often explanted because of
“waxy” vision, glare, halos, other dysphotopsias, and blurred vision that cannot be
corrected optically.870
As mentioned, negative dysphotopsia is commonly described as a dark crescent or curved

shadow that can appear, similar to a scotoma or “horse blinder” in the midtemporal field of
vision.869, 871, 872 Negative dysphotopsia symptoms tend to diminish with time. In one study,
the incidence of negative dysphotopsias was 15% on the first postoperative day, whereas 1
year after surgery, only 3% of patients without intervention reported them.872 Implantation
of a piggyback IOL or reverse capture of the existing optic (placing the optic anterior to the
capsulorrhexis) appears to reduce the symptoms of negative dysphotopsia. 873 Although
controversial, scleral or iris suture fixation of the haptics of a lens so that it sits more
anteriorly in the posterior chamber may help.874 Negative dysphotopsia may also be
induced at the interface of the capsulorrhexis and the anterior surface of the IOL. 873, 875
Henderson reported that positioning one optic-haptic junction in the inferior temporal
region resulted in a decrease in complaints of negative dysphotopsia.876 The benefits of this
simple maneuver have been corroborated by other studies. 877-879
Opacification
In one recent study, optic opacification was the most common indication for IOL
exchange.880 However, the prevalence of IOL opacification or calcification may be
decreasing, at least according to a survey of IOL explantation.843
Hydrophilic acrylic or silicone IOLs may make future surgery complicated.881 Hydrophilic
acrylic IOLs may calcify if air or gas tamponade is necessary subsequently, such as in pars
plana vitrectomy, Descemet stripping endothelial keratoplasty (DSEK) or Descemet
membrane endothelial keratoplasty (DMEK).584, 882-885 In eyes at risk for corneal
endothelial decompensation, it is prudent to choose another lens material. Silicone IOLs
may become cloudy from adherent silicone oil in subsequent retinal surgery.886 Rarely,
hydrophobic acrylic IOLs must be explanted because of intolerable glistenings.578
Uveitis-glaucoma-hyphema syndrome
The uveitis-glaucoma-hyphema (UGH) syndrome is often associated with uveal irritation
from IOLs, especially modern single-piece acrylic IOLs.685 Thick square-edge haptics and
a square-edge optic in the sulcus can cause pigment dispersion, iris transillumination
defects, elevated IOP, recurrent inflammation and/or hemorrhage.685 Pseudophacodonesis
was a risk factor for UGH syndrome in a recent review of cases.887 Ultrasound
biomicroscopy and anterior segment OCT may be helpful in identifying lens-iris contact.
Anterior chamber IOLs can also cause UGH syndrome if there is improper sizing, iris tuck
following implantation, or rotation of a haptic through a peripheral iridectomy.887, 888
Ocular comorbidities
Preoperative ocular comorbidities may adversely affect the outcome of cataract surgery.112,
717, 889
Many comorbid conditions are associated with the potential for reduced improvement
in visual function or CDVA,890-892 and the patient should be informed and counseled prior to
surgery. This is particularly true if the patient is electing to receive a multifocal IOL.
Comorbid conditions found in patients with cataracts and the special considerations
associated with these conditions are listed in Table 4.
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TABLE 4 SELECTED PREOPERATIVE OCULAR COMORBIDITIES

Comorbidity Anticipated Complicating Factors
Amblyopia  Reduced visual potential

Age-related macular degeneration723, 893-899  Reduced visual potential
 Unrecognized preoperative exudative disease
Diabetic retinopathy900-907  Reduced visual potential
 Unrecognized retinopathy
 Progression of existing retinopathy
 CME
 Poorly dilating pupil
 Neovascularization of the iris, neovascularization of the angle, and
neovascular glaucoma
Epiretinal membrane803, 908-912  Reduced visual potential
 Visual distortion
 CME
Fuchs corneal endothelial dystrophy913  Reduced visualization during surgery
 Prolonged postoperative corneal edema
 Pseudophakic corneal decompensation
 Reduced visual potential
 Calcification of the lens surface if a hydrophilic acrylic IOL is implanted
and an endothelial keratoplasty is performed subsequently
Glaucoma914-925  Elevated postoperative IOP
 Reduced function of prior filtering surgery
 Reduced contrast sensitivity
Keratoconus926-928  IOL power calculation inaccuracy
 Possible need for a rigid contact lens for optimal visual acuity after
surgery
 Problems associated with implanting a toric IOL if irregular corneal
astigmatism is significant
Ocular surface disease/Dry eye929, 930  Chronic irritation and redness
 Unstable ocular surface
 Variable astigmatism and high-order aberrations
 Fluctuating vision postoperatively
Pseudoexfoliation (exfoliation syndrome)931-940  Intraoperative miosis
 Zonular laxity or instability
 Vitreous loss
 Retained nuclear fragments
 Elevated postoperative IOP
 Accelerated PCO
 Anterior capsulorrhexis contraction
 IOL tilt and decentration
 Late dislocation of IOL or of bag-IOL complex
Retinitis pigmentosa941-943  Reduced visual potential
 Zonular laxity
 Capsulorrhexis phimosis
 Preoperative and postoperative CME
 Late decentration or dislocation of the bag-IOL complex
Retinopathy of prematurity944, 945  Amblyopia
 Intraoperative miosis
 Traction RD
 Loose zonular fibers
Strabismus946-948  Amblyopia
 Postoperative diplopia
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Uveitis756, 949-958  Posterior synechiae

 Weakened zonular fibers
 Protein and cellular deposits on the lens implant
 CME
 Secondary glaucoma
 Prolonged postoperative inflammation
CME = cystoid macular edema; IOL = intraocular lens; IOP = intraocular pressure; PCO = posterior capsule opacification; RD =
retinal detachment.
The presence and extent of AMD may be identified preoperatively using diagnostic
instrumentation such as OCT and fluorescein angiography, which can assist in establishing
realistic expectations. These tests, however, do not assist with the prediction of visual
potential. There is considerable evidence that the risk of pre-existing AMD worsening
following cataract surgery is low compared with its natural history.959-962
The status of coexisting diabetic retinopathy, particularly macular edema, may be evaluated
using OCT, thereby directing a more vigorous approach to preoperative, intraoperative, and
postoperative medical treatment, including the use of intravitreal injections. 810, 901, 963-969
Cataract surgery does not appear to increase the risk of progression of adequately treated
proliferative diabetic retinopathy or macular edema. 903, 970 However, patients inadequately
treated who have pre-existing diabetic macular edema (DME) are at increased risk for
progression of DME following cataract surgery.803, 901
Because of the risk of corneal decompensation in the presence of corneal endotheliopathy,
the surgeon may consider using dispersive OVDs along with optimizing machine
parameters and surgical techniques that reduce cumulative ultrasound time, fluid
movement through the eye, and endothelial trauma.971, 972 When selecting IOL power, the
potential hyperopic shift associated with endothelial replacement surgery should be
considered.973
Pseudoexfoliation (exfoliation syndrome) is commonly associated with a small pupil and
weak zonular fibers, which increase the risk of capsular rupture, retained nuclear
fragments, and pseudophacodonesis.938 An anterior chamber depth of less than 2.5 mm
measured preoperatively may be indicative of zonular weakness and increases the risk of
complications almost fivefold.934 Because of the risk of late bag-IOL dislocation in these
patients, larger capsulorrhexis, capsule polishing, and laser anterior capsule-relaxing
incisions may be considered to prevent or treat anterior capsule contraction. 855, 856, 974
Although there is no evidence that implantation of a CTR reduces the risk of late-in-the-
bag IOL dislocation, CTR implantation may facilitate its repair using the lasso suture
technique.975
The optimal timing of cataract surgery in the presence of uveitis is a function of many
factors.976, 977 Inflammation should be inactive or at its best level of control possible,
generally for 3 or more months prior to elective surgery. 957, 978, 979 Topical and/or
periocular, intraocular, and systemic anti-inflammatory medications should be started prior
to surgery. They are then used more frequently and for a longer duration following surgery.
Intravitreal, periocular, or systemic administration of anti-inflammatory medication may
also be considered.980
In addition to ocular comorbidities, other characteristics of the eye may be associated with
a higher risk for intraoperative and postoperative complications. High-risk ocular
characteristics include a history of previous eye surgery, special types of cataracts, very
large and very small eyes, deeply set eyes, small pupils, anterior or posterior synechiae,
scarred or cloudy corneas, zonular weakness or absence, prior ocular trauma, and the
systemic use of alpha-1a antagonists. Each set of circumstances poses unique challenges
(see Table 5). As with ocular comorbidities, patients with high-risk ocular characteristics
should be informed about the specific impact of their condition on the expected course and
outcome of surgery, along with options that may be considered if complications occur.
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TABLE 5 HIGH-RISK CHARACTERISTICS FOR INTRAOPERATIVE AND POSTOPERATIVE COMPLICATIONS

High-Risk Characteristic Anticipated Complicating Factors
Anterior megalopia  Zonular laxity

 Pigment dispersion (associated with elevated IOP)
 RD
Corneal opacification981  Reduced visibility
 Worsening of corneal clarity
Deeply set eye, narrow lid fissure, or prominent brow982  Reduced visibility
 Poor access to the limbus
 Pooling of irrigation fluid
 Wound deformation and leakage
Dense brunescent nuclear cataract983, 984  Concomitant zonular laxity and intraoperative miosis
 Little cortex to protect the capsule during phacoemulsification
 Increased phacoemulsification time with increased risk of
postoperative corneal edema
 Greater risk of thermal and mechanical injury to the cornea
and iris with phacoemulsification
 Increased risk of posterior capsule rupture and zonular
dehiscence
High hyperopia985-988  Shallow anterior chamber with increased risk of endothelial
(with short axial length) trauma
 Increased risk of iris trauma and prolapse
 Difficulty calculating lens implant power
 Intraoperative suprachoroidal effusion (particularly in
nanophthalmic eyes)
 Aqueous misdirection
High myopia989-994  Anterior chamber depth fluctuation, possibly aggravated by
periodic reverse pupillary block
 Difficulty calculating lens implant power, especially with
posterior staphyloma
 Decreased ocular rigidity, difficulty sealing the wound
 Increased risk of RD
Miotic pupil781, 995  Poor visualization
 Increased risk for capsule tear/vitreous prolapse
 Increased risk for iris damage and prolapse
Posterior polar cataract996-999  Defective posterior capsule
 Increased risk of dropped nucleus
Posterior synechiae  Intraoperative miosis
 Prolonged postoperative inflammation
 Inflammatory deposits on IOLs
 Iris bleeding
Potential need for vitreoretinal surgery584, 1000-1002  Silicone IOLs may compromise subsequent surgical visibility if
posterior segment surgery or silicone oil is needed
 Hydrophilic IOLs may opacify if a gas bubble is injected
Prior intravitreal injections782, 1003-1005  Endophthalmitis
 Posterior capsular rupture
 Retained lens fragments
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TABLE 5 HIGH-RISK CHARACTERISTICS FOR INTRAOPERATIVE AND POSTOPERATIVE COMPLICATIONS (CONTINUED)
High-Risk Characteristic Anticipated Complicating Factors

Prior keratoplasty1006-1008  Poor visualization
 Graft rejection or failure
 Endothelial decompensation
 IOL power calculation inaccuracy
 Hyperopic shift in association with endothelial keratoplasty
Prior keratorefractive surgery1009-1012  IOL power calculation inaccuracy
 Transient hyperopic shift immediately after surgery in eyes
with a history of radial keratotomy
 Dehiscence of refractive keratotomy incision
 Reduced visual potential due to irregular astigmatism
 Corneal aberrations with glare and haloes
Prior PPV1013-1016  Conjunctival scarring
 Intraoperative anterior chamber depth fluctuation, especially
severe deepening
 Intraoperative miosis
 Increased nuclear sclerosis
 Increased frequency of posterior capsule plaques
 Weakened lens capsule and zonular fibers
Prior scleral buckling surgery1017, 1018  Change in axial length affects IOL power calculation
 Conjunctival scarring
 Increased risk of sclera perforation with injection anesthesia
Prior trabeculectomy or tube shunt surgery919, 1019-1022  Increased filtration through the bleb during surgery
 Decreased filtration or bleb failure after surgery
 Postoperative hypotony
 Zonular laxity
Relative anterior microphthalmos1023, 1024  Damage to iris, cornea, and posterior capsule
 IOL power calculation inaccuracy
Shallow anterior chamber1025  Iris injury
 Iris prolapse
 Postoperative corneal edema
Use of systemic sympathetic alpha-1a antagonist  Poor pupillary dilation, intraoperative miosis, iris billowing and
medication for treatment of prostatic hypertrophy1026, 1027 prolapse
and other systemic conditions
White cataract (mature cortical cataract)1028-1031  Difficulty performing the capsulorrhexis (capsule staining and
femtosecond lasers may be helpful)1032-1034
 Lens intumescence
 Radial capsulorrhexis tear with extension to the posterior
capsule
Zonular laxity or dehiscence (e.g., trauma)781, 1035, 1036  Phacodonesis
 Vitreous prolapse around the lens equator
 Capsular rupture with retained lens fragments
 Fluid misdirection syndrome
 Postoperative lens implant decentration
 Increased risk of radial capsulorrhexis tear
 Capsular contraction with late IOL/capsular bag decentration
or dislocation
IOL = intraocular lens; IOP = intraocular pressure; PPV = pars plana vitrectomy; RD = retinal detachment.
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In handling high-risk eyes, several technique modifications and/or adjunctive devices

should be considered.
Ophthalmic viscosurgical devices vary in rheologic properties that may be advantageous
for certain higher risk cases.1037 A specific OVD may be selected based on its
characteristics in cases of corneal endothelial deficiency, shallow anterior chamber,
intumescent cataract, and small pupil.1037
Capsular dyes to stain the anterior capsule may be considered in cases of a white or mature
cataract, or where visibility is compromised.1029, 1034
Capsule tension rings can be useful adjunctive devices when zonular weakness is present,
reducing the likelihood of intraoperative zonular separation and capsular complication, 1038
and they may improve postoperative IOL centration. 1039 In cases of more profound
zonulopathy, other options include capsule retractors, a modified CTR or a capsular tension
segment for scleral suture fixation.1040
When zonular strength is insufficient to hold an IOL stably within the capsular bag or
ciliary sulcus, alternative methods of lens fixation must be considered. They include suture
fixation to the iris or sclera, iris clip fixation, intrascleral or transscleral haptic fixation, or
anterior chamber placement.
Intraoperatively, a variety of methods have been described to expand the small pupil.
Pharmacologic methods include intracameral alpha-1 agonists such as epinephrine or
phenylephrine.1041 Mechanical methods include viscomydriasis, release of posterior
synechiae, pupil stretching, mini sphincterotomies, iris retractors, and pupil expansion
rings.1042, 1043 Patients should be offered surgical repair of symptomatic iris defects caused
by cataract surgery.1044
Intraoperative floppy iris syndrome is a unique small-pupil syndrome associated with iris
billowing and prolapse as well as with progressive intraoperative miosis. 1026, 1045 It is
associated with a higher rate of surgical complications, particularly when it is not
recognized or anticipated.1026, 1045-1048 Intraoperative floppy iris syndrome can be anticipated
when a patient has a history of using oral alpha-1 antagonists (e.g., tamsulosin, terazosin,
doxazosin, silodosin) and the herbal remedy saw palmetto. Pupil stretching and
sphincterotomies are ineffective in these eyes, and pharmacologic approaches,
viscomydriasis, and pupil-expansion devices, either alone or in combination, should be
used to manage IFIS.1026, 1045, 1046
Systemic Comorbidities
Systemic comorbidities that may be of importance intraoperatively include diabetes
mellitus, pulmonary dysfunction, cardiovascular dysfunction (e.g., poorly controlled blood
pressure, heart failure), musculoskeletal disorders causing positional difficulties, tremor,
severe hearing impairment, anxiety disorders, intellectual disability, dementia, and
coagulopathies.1049 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.
Not only is diabetes a risk factor for early cataract development,19, 20, 37-39 but it also leads to
poor intraoperative pupillary dilation, slowed ocular surface healing, and an increased risk
of postoperative macular edema.804, 1050-1054 In a study of 65,370 patients, patients with
diabetes and no diabetic retinopathy achieved 20/20 vision at a rate similar to those without
diabetes. However, patients with diabetic retinopathy were less likely to achieve CDVA of
20/20, but they gained as many lines of vision from phacoemulsification as those without
diabetes.805
A 2009 meta-analysis found that patients taking warfarin while undergoing cataract surgery
had a threefold increase (overall 9%–10% incidence) of nonclinically significant bleeding
events compared with patients not on warfarin.1055 The majority of bleeding events were
self-limited and included hyphema or subconjunctival hemorrhage. There was no evidence
that continuing warfarin had a negative impact on postoperative visual acuity. This analysis
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included studies with patients undergoing ECCE as well as phacoemulsification and who
had topical, sub-Tenon’s, peribulbar, or retrobulbar anesthesia.
Similarly, an analysis of 48,862 surgeries from the U.K. Cataract National Dataset found
that patients on warfarin or clopidogrel had an increased incidence of subconjunctival
hemorrhage (3.7% warfarin, 4.4% clopidogrel, 1.7% nonusers) and complications from
anesthetic blocks via sharp needle injection or sub-Tenon’s cannula (6.2% warfarin, 8%
clopidogrel, 4.3% nonusers).801 However, there was no significant increase in potentially
sight-threatening complications from local anesthetic or operative hemorrhage (hyphema,
choroidal/suprachoroidal hemorrhage). In patients taking aspirin alone, there was no
increase in hemorrhagic or anesthetic complications.
A study of 19,283 surgeries (74% of which included a peribulbar or retrobulbar block)
found that patients who continued aspirin or warfarin did not have an increased risk for
ocular hemorrhagic events (hyphema, vitreous hemorrhage, retrobulbar hemorrhage). No
information was provided on subconjunctival hemorrhage or eyelid ecchymosis.1056
Data on the use of newer anticoagulants with cataract surgery are sparse.
An increasing number of patients are on dual antithrombotic medications. A recent study
screened 141,213 emergencies referred to a university hospital. Three cases of grade IV
retrobulbar hemorrhage were identified; two of these patients were on combined
acetylsalicylic acid and clopidogrel and received retrobulbar injections.1057 In contrast, the
U.K. study of 48,862 cataract surgeries found no increase in anesthetic or hemorrhagic
complications in patients on dual antiplatelet or combined aspirin/warfarin treatment who
received blocks or sub-Tenon’s anesthesia.801
In summary, several studies show a higher incidence of subconjunctival hemorrhage in
patients undergoing cataract surgery while taking antiplatelet or anticoagulant
medication,801, 1055, 1058, 1059 but the available data do not show an increase in sight-
threatening complications801, 1056, 1058, 1059 or decreased postoperative visual acuity.1055
Evidence-based guidelines recommend continuation of anticoagulants and antiplatelet
medications in patients undergoing cataract surgery.1060-1063 Management of these cases
should still be tailored to the individual patient’s situation.1064, 1065
There are no recommendations from either the American Heart Association1066 or the
American Academy of Orthopaedic Surgeons to prescribe systemic antibiotic prophylaxis
for patients with artificial heart valves or joint prostheses who undergo cataract surgery.1067
Combined Surgery and Special Circumstances
Cataract surgery and glaucoma

Cataract surgery with IOL implantation results in a modest reduction of IOP.713, 917, 1068-1070
Studies have found that the degree of IOP reduction is greater with higher preoperative IOP
levels and that the benefit may last for several years.920, 922, 924, 1071, 1072 A more recent
prospective study found that older patients, eyes with shorter axial length, women, and
those with glaucoma or pseudoexfoliation were more likely to benefit from this effect.1073
When a candidate for cataract surgery also has glaucoma, surgical treatment options include
cataract and IOL surgery alone, combined cataract and glaucoma surgery, glaucoma
surgery after cataract surgery, or cataract surgery after glaucoma surgery. Glaucoma
surgical options include trabeculectomy, aqueous shunts, nonpenetrating glaucoma surgery,
minimally invasive glaucoma surgery (MIGS), transscleral cyclophotocoagulation, and
endocyclophotocoagulation.1074 A Veterans Affairs retrospective cohort study showed that
eyes with glaucoma are at increased risk for complications and have more modest visual
outcomes after cataract surgery compared with eyes that do not have glaucoma.1075
Phacoemulsification combined with trabeculectomy provides good IOP control as well as
improved CDVA with the potential benefits of protection against potential postoperative
IOP spikes and long-term IOP control with a single operation.1076-1078 However, there are
some data suggesting that overall bleb survival rates and long-term IOP control may be
diminished in a combined procedure versus a stand-alone trabeculectomy.1033,1040 A 2015
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Cochrane Systematic Review examined combined versus cataract surgery alone in patients
with glaucoma and concluded that there was low-quality evidence that combined cataract
and glaucoma surgery resulted in better IOP control at 1 year compared with cataract
surgery alone. (I-, Insufficient, Discretionary) The authors suggested the need for further
RCTs to further develop evidence-based therapeutic guidelines.1079 In the absence of such
guidelines, the decision to perform combined surgery rests with the surgeon and should be
based on individual patient circumstances.
In the presence of a pre-existing filtering bleb, cataract surgery may diminish the
effectiveness of the bleb.919, 1020
Cataract surgery with minimally invasive glaucoma surgery

A variety of minimally invasive techniques are available that can be performed in
conjunction with or following cataract surgery.1080 These include ab interno
canaloplasty,1081 ab interno trabeculotomy,1082 endocyclophotocoagulation,1083, 1084 and
several generations of ab interno trabecular bypass microstents,1085-1088 any of which can be
performed or implanted at the time of cataract surgery. Compared with traditional filtering
surgery with antimetabolite usage, these adjunctive technologies may reduce the risk of
hypotony and bleb complications, but they may not lower IOP as effectively.1089, 1090 A
multicenter, randomized, single-masked, controlled clinical trial showed that IOP was
clinically lower at 2 years in the trabecular bypass microstent plus cataract surgery group
compared with the cataract surgery alone group, with no differences in safety. 1085 The best
surgical option depends on a number of factors, including the patient’s response to medical
or laser surgical treatment of the glaucoma, the degree of optic nerve damage, changes in
the visual field, severity of the cataract, and the surgeon’s experience. A thorough
discussion of the MIGS devices can be found in the Primary Open-Angle Glaucoma
(POAG) PPP.1091
Cataract surgery and corneal disease
Combined cataract and endothelial transplant surgery

Cataract surgery in patients with coexistent endothelial dystrophy should be approached
with careful patient consent and attention to which patients are most at risk of rapid
progression. The presence of endothelial dystrophy presents a challenge to the cataract
surgeon in predicting how well the compromised cornea will function following cataract
surgery. Often the best strategy is to simply perform cataract surgery with proper consent
regarding the possibility of subsequent corneal failure. This strategy has become more
common as cataract surgery has become gentler and as endothelial keratoplasty has become
more elegant. Using dispersive OVD to coat the endothelium and minimizing ultrasound
energy can delay or even eliminate the need for subsequent keratoplasty in some cases. It is
not clear if FLACS reduces the risk of subsequent endothelial failure because of conflicting
studies.1092, 1093
A history of blurred vision upon awakening in the morning may indicate endothelial pump
impairment. If the lack of tear evaporation while sleeping leads to symptomatic corneal
edema, then the likelihood of decompensation after cataract surgery is higher. Patients with
Fuchs dystrophy who have a history of morning decline in vision or who have epithelial or
stromal edema on slit lamp examination are more likely to progress rapidly after cataract
surgery, and surgeons should consider concurrent endothelial transplant surgery.1094
Endothelial keratoplasty can create a hyperopic shift that can complicate combined surgery,
as described earlier in the Ocular Comorbidities section.
Combined cataract surgery and penetrating keratoplasty

There are several reasons to consider combining cataract extraction with corneal
transplantation, even in the presence of a mild cataract:
 Cataracts may progress more rapidly after corneal transplantation.
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 The use of topical corticosteroids following corneal surgery may hasten PSC
development.
 Cataract surgery after corneal transplantation may damage the corneal graft.
 Surgery is limited to a single procedure.
 Visual rehabilitation is quicker.
Cataract surgery at the time of penetrating keratoplasty (PK) presents surgical challenges.
Intraocular lens power calculation is complicated because the post-penetrating keratoplasty
corneal curvature can only be estimated. Since IOL power calculations are less accurate,
toric and multifocal IOLs should generally be avoided.1095 Some surgeons prefer to perform
PK first, followed by cataract removal later after sutures are out and the corneal graft has
stabilized. If a cataract is removed following suture removal and stabilization of corneal
graft keratometry, a more predictable IOL power and, hence, refractive result may be
possible.1096, 1097
Surgeons should attempt to limit “open-sky” time (the time between corneal trephination
and replacement) in whatever approach is taken because of the increased risk of expulsive
hemorrhage during hypotony. Performing the PK first and following it with later cataract
extraction decreases the open-sky time. These considerations apply to deep anterior
lamellar keratoplasty as well. In combined cases, phacoemulsification should be performed
before PK if visualization is adequate to limit the amount of open-sky time.1098 Capsular
staining dyes may improve the likelihood of achieving an intact capsulorrhexis when
performing cataract extraction through a cloudy cornea.1099
Cataract surgery and vitreoretinal procedures
Cataract surgery following intravitreal injections

A history of intravitreal injection can make cataract surgery more complicated. Intravitreal
injections are an increasingly common for a variety of conditions including macular
degeneration and diabetes.1100, 1101 Intravitreal injection of corticosteroids can increase the
rate of cataract progression.1102 Iatrogenic capsular damage from intravitreal injections can
be difficult to detect preoperatively and may complicate surgery.1103 Several studies
reported a several-fold increase in capsular rupture and retained nuclear material in patients
with a history of intravitreal injections.782, 1005, 1104, 1105 Careful preoperative and
intraoperative evaluation of the capsule can sometimes detect capsular damage from
intravitreal injections. The surgical approach with known damage to the capsule is similar
to other conditions where there is a breach in the posterior capsule (e.g., posterior polar
cataract). The surgeon should counsel the patient about the increased risk of complications
due to the history of intravitreal injections.
Cataract surgery after pars plana vitrectomy

Cataract surgery is often necessary before, during, or following vitreoretinal surgery.
Vitreoretinal procedures may cause pre-existing cataracts to progress, typically manifesting
as increased nuclear sclerosis, and a predilection for the development of posterior capsular
plaques.1106-1111 Management of such cataracts may be more complex, because capsular
defects or weakened zonular fibers may be present.782, 1004, 1105 The anterior chamber depth
may also be unstable during surgery. Iris hooks can be helpful in these situations. Adequate
visual rehabilitation may occur with cataract surgery alone for some retinal pathologies. In
silicone oil-filled eyes, bubbles can migrate to the anterior segment and may have to be
managed intraoperatively.
Cataract surgery before pars plana vitrectomy

Phacoemulsification may be recommended before a planned vitrectomy to improve
visualization of the posterior segment. Secure wound closure is important to permit safe
subsequent vitreoretinal maneuvers.1112-1114 Surgeons should avoid silicone or hydrophilic
optic materials when a patient is having a planned vitrectomy following the cataract
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surgery. Intraoperative visualization of the posterior segment may become impaired when a
silicone optic comes into contact with silicone oil or a gas bubble. 575, 576 Additionally, there
have been reports of IOL calcification with the use of intravitreal air, gas, or silicone oil in
retinal surgery, often with hydrophilic acrylic IOLs, but other IOL materials can also be
similarly affected.1115
Combined cataract surgery and vitrectomy

Combined vitreoretinal and cataract surgery offers the advantage of a single operative
procedure and anesthesia, potentially faster recovery, and cost-effectiveness.1116-1118 A wide
range of vitreoretinal disorders may be dealt with concomitantly, including vitreous
hemorrhage, diabetic retinopathy, epiretinal membrane, macular hole, RD, and posterior
vitreous detachment with symptomatic vitreous floaters.1119-1121 Secure wound closure
following the cataract phase of surgery is important to permit safe subsequent vitreoretinal
maneuvers.1112-1114 Possible disadvantages of simultaneous cataract and vitreoretinal
surgery include scheduling difficulties, prolonged surgical time, cataract-wound dehiscence
caused by globe manipulation during the vitreoretinal portion of surgery, intraoperative
miosis after cataract extraction, IOL decentration or optic capture, and undesirable optical
effects during vitreoretinal surgery if the IOL is implanted prior to the posterior segment
procedure.
Cataract surgery following refractive surgery

Patients who have had corneal refractive surgery present challenges with respect to IOL
power calculation. In addition to difficulty measuring the central corneal power accurately,
many IOL formulas predict the effective lens position based on the corneal curvature.
Keratorefractive steepening or flattening of the cornea therefore introduces a formula
artifact. Postoperative power adjustable IOLs may make accurate preoperative power
prediction less important. Intraocular lens formulas such as the Kane and the Barrett True
K and ASCRS post-refractive surgery IOL power calculator have made IOL selection more
accurate.
Cataract surgery following laser refractive procedures

Cataract surgery following refractive surgery is simpler thanks to advances in IOL
formulas. Although prior laser refractive surgery, including LASIK and PRK, does not
cause anatomic challenges during cataract surgery, IOL power estimation is not as accurate
as in normal eyes.1122
Following myopic laser vision correction, the cornea tends to have more positive spherical
aberration than average and so would benefit from a negative aspheric IOL. Conversely,
after hyperopic laser correction, the cornea generally has a negative asphericity and would
benefit from a positively aspheric IOL.1123
After excimer laser refractive surgery (by either surface or intrastromal photoablation),
corneal-power readings with manual keratometers, automated refractors, and topographers
are often incorrect as a result of the surgical alteration of the anterior corneal curvature and
the changed relationship between anterior and posterior corneal powers. This results in a
tendency for hyperopic refractive errors after cataract surgery in eyes with prior myopic
photoablation.1010, 1124-1127 Similarly, eyes that have had prior hyperopic photoablation are
prone to myopic optical errors after cataract surgery. 1128
A number of calculation methods and correction algorithms, some of which require
knowledge of prior corneal power, refraction, and the change in manifest refraction, have
been developed to help determine IOL power following refractive surgery, but there is
presently no consensus about a best method.1129-1139 Patients should be informed of the
potential inaccuracies of IOL power calculation and that further surgery may be necessary
to achieve the desired target refraction.
Also, as mentioned in the Intraocular Lens Optical Considerations section, intraoperative
aberrometry may aid in IOL selection in laser vision corrected eyes.328
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Cataract surgery following radial keratotomy

Radial keratotomy (RK) can complicate cataract incision placement. Following RK, it is
best to avoid having the new cataract surgical incision cross or intersect pre-existing radial
or arcuate incisions, because this could lead to incision dehiscence, wound leak, delayed
healing, and irregular astigmatism.1140-1143 A short scleral incision may lessen the chance of
involving the original incisions. The refractive outcome may be quite variable for several
weeks or beyond following cataract surgery. Postoperative corneal hydration or edema and
elevated IOP may amplify the effect of the RK incisions, causing transient hyperopia and
changes in astigmatism. The timing of any further refractive surgical intervention should be
delayed until the refraction is stable.1140
The ASCRS post-RK IOL power calculator can improve the accuracy of IOL selection. In
the case of RK, the induced central corneal flattening renders traditional keratometric
readings inaccurate. This is because keratometers estimate the central corneal curvature
based on paracentral measurements, and they fail to detect the full degree of central
flattening.1144, 1145 The clinical history method (which requires knowledge of presurgical
keratometry and refraction) is generally not helpful following RK due to the common
occurrence of progressive central corneal flattening (hyperopic drift) that may continue for
years to decades. There are automated computerized systems (topography and tomography)
that can help to determine true central corneal power.1146, 1147
For the most accurate IOL power calculation for patients who have previously undergone
RK or myopic or hyperopic photoablation, the ASCRS developed an online IOL power
calculator that is regularly updated and available at http://iolcalc.ascrs.org.290, 1148
Cataract surgery and uveitis

There are special issues to consider when patients with uveitis undergo cataract
surgery.1149-1151 Patients with active inflammation, particularly those with anterior or
intermediate uveitis, are at substantial risk for complications. A major potential problem,
especially among patients with pre-existing iris damage or extensive posterior synechiae, is
the development of adhesions between the iris and lens capsule postoperatively. Other
potential problems include membrane formation, IOL deposits, zonular problems, and
CME. Coordination with the physicians treating the patient's uveitis and any systemic auto-
immune disease systemic prior to cataract surgery will provide for appropriate prophylactic
anti-inflammatory therapy and improve postsurgical outcomes.
Preoperative management of uveitis

There are many important factors to consider in the presence of uveitis. Ideally,
inflammation should be inactive or controlled as much as possible before surgery.978 Many
uveitis specialists advocate 3 months or more of quiescence before surgery, as this reduces
the risk of postoperative CME.957, 978, 979 Even if a patient is on chronic anti-inflammatory
therapy, additional topical and/or oral corticosteroids are often recommended before
surgery to pre-empt severe postoperative exacerbations.958 In one study, preoperative
treatment with oral corticosteroids seemed to decrease the risk of postoperative CME.979
The medical regimen should be individualized based on the severity and sequelae of past
episodes of uveitis and the ease with which inflammation has been controlled previously.
Surgical planning should account for the possible need for other procedures, which are
often required because of associated uveitic complications, such as secondary glaucoma.
Surgical procedures may need to be modified to manage pre-existing posterior synechiae,
pupillary membranes, zonular compromise, and fibrotic scarring of the pupillary margin.
Intraocular lens material in uveitis

The safety of IOLs in most eyes with uveitis is now generally accepted. Intraocular lens
material does not seem to have a major influence on the course of postoperative
inflammation. A 2014 Cochrane Systematic Review did not represent with certainty the
advantage of any IOL material. (I-, Moderate, Discretionary) This review did include a
study that showed a superior effect of hydrophobic acrylic lenses over silicone lenses,
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specifically for posterior synechiae outcomes, but this effect was based on a single study
that suffered from potential performance and detection bias.958 A more recent evidence-
based review and meta-analysis indicates that some IOL materials may be associated with
better outcomes than others.957 In this study, eyes receiving acrylic IOLs or heparin-
surface-modified (HSM) polymethylmethacrylate IOLs had better visual outcomes than
eyes receiving non-HSM polymethylmethacrylate or silicone IOLs.1152 The authors
concluded that preoperative control of uveitis, use of an acrylic or HSM IOL, and a
diagnosis of Fuchs heterochromic cyclitis were associated with better outcomes. Lastly, a
study of 171 eyes found a good long-term biocompatibility and safety profile in uveitic
eyes receiving hydrophobic acrylic IOLs.1153
Intraocular lens placement in uveitis

Intraocular lens-related complications may include inflammatory deposits, surface
membrane formation, and inflammatory capsular complications capable of causing IOL
subluxation. Leaving an eye aphakic may be considered in severely damaged uveitic eyes
with extensive pupillary or ciliary membrane formation or signs of intractable
inflammation such as hypotony and severe flare. In most cases, placement of an IOL with
the optic and haptics in the capsular bag is preferred. However, placement of the entire IOL
in the sulcus or prolapse of the optic into the sulcus (haptics in the bag) allows the IOL
optic to block the formation of iridocapsular adhesions in high-risk eyes (e.g., extensive iris
damage or preoperative posterior synechiae). This technique does not seem to increase
postoperative inflammation.954, 1154 Placement of the haptics in the bag and the optic in the
sulcus may prevent posterior synechiae.1154 With capsular bag placement, a large-diameter
capsulorrhexis may also decrease the risk of postoperative synechiae to the anterior
capsule. Anterior chamber IOLs may stimulate more inflammation and may be problematic
if angle anatomy is compromised. Zonulopathy is common in patients with uveitis and may
require supplementary devices such as CTRs for IOL centration. Uveitic zonulopathy can
lead to capsular phimosis and late in-the-bag IOL subluxation.855, 1155 Cleaning off the
anterior subcapsular lens epithelial cells (LECs) may be beneficial in preventing capsular
phimosis in eyes with uveitis.
Pupil management
Although the pupil may dilate poorly in eyes with uveitis, iris manipulation should be
minimized to the extent possible to avoid worsening of inflammation and posterior
synechiae formation. Iris prolapse should be avoided during surgery.
Postoperative management
The postoperative use of short-acting topical mydriatic agents may help to prevent
postoperative synechiae formation; however, fixed dilation with long-acting cycloplegic
agents such as atropine may lead to formation of posterior synechiae in the dilated state.
Adjunctive corticosteroids at the time of surgery (IV, periocular, or intraocular) should be
considered. Patients with uveitis are at risk of postoperative inflammatory exacerbation.
Postoperatively, eyes with uveitis generally require a greater frequency and duration of
topical anti-inflammatory treatment and should be monitored closely for complications
such as severe iridocyclitis, secondary glaucoma, posterior synechiae, secondary
membranes, and CME.1156
Postoperative inflammation and CME generally respond to anti-inflammatory treatments.
As with preoperative prophylactic treatment, postoperative coordination of management of
uveitis patients with a uveitis care provider is recommended.
Cataract in the functionally monocular patient

A functionally monocular patient is one who is primarily dependent on the eye being
considered for cataract surgery. There may be significant ocular comorbidity or other high-
risk characteristics in such eyes.1157, 1158 The indications for surgery in the functionally
monocular patient are the same as for other patients; that is, when the cataract-impaired
vision no longer meets the patient’s needs and the anticipated benefits of surgery exceed
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the risks. Cataract surgery for these patients results in a greater improvement in functional
vision than surgery in binocularly sighted patients.1159 When the long-term visual outcomes
of cataract surgery on the better seeing eye are compared between monocular patients with
limited vision in the poorer-seeing eye and no light perception in the poorer-seeing eye,
those with limited vision in the poorer-seeing eye fare worse over the long term. The
reason is that these eyes are more likely to harbor medical comorbidities such as macular
degeneration and diabetic retinopathy, which tend to progress. 1160 Blind eyes are often
blind because of trauma or surgical mishap; these issues tend not to affect the better-seeing
eye. When cataract surgery is contemplated in a functionally monocular patient, the
ophthalmologist has an obligation to inform the patient that bilateral blindness is one of the
risks of cataract surgery and that it can result from worsening ocular comorbidity following
surgery as well.1161
The ophthalmologist and patient should understand that delaying surgery until a cataract is
advanced may increase surgical risk and slow visual recovery.
Second-Eye Surgery
Clinical studies provide convincing evidence that binocular summation occurs in
individuals who have similar visual acuities in the two eyes and at low illuminance
levels.1162-1167 Patients with a cataract and dissimilar vision in their two eyes (or one eye
status post cataract extraction and the second eye with a cataract) demonstrate binocular
inhibition.1167 A large epidemiological study found that persons who exhibit binocular
inhibition are more likely to have driving difficulties compared with those who do not.1162
However, patients with monovision may successfully sacrifice some binocular summation
to improve their spectacle independence.
Studies comparing the outcomes of first-eye and second-eye cataract surgeries concluded
that patients who had surgery in both eyes had greater improvement in functional status
than those who underwent surgery in one eye only.120, 124, 146, 1168-1173 Patients who had
surgery in both eyes were significantly more satisfied with their visual function than
patients who had surgery in only one eye.1168, 1174, 1175 One study demonstrated that the
cataractous eye interfered with the visual function of the pseudophakic eye and that
complaints of visual disability were eliminated after second-eye surgery.1176 Another study
found that the presence of stereoacuity increased from 32% after first-eye surgery to 90%
after second-eye surgery. Binocular horizontal field of vision improved by 20 degrees or
more in 54% of patients. The number of patients able to meet the driving standard
increased from 52% after first-eye surgery to 86% after second-eye surgery.1177
A population-based cohort study of 2849 drivers 60 years old and older in Australia found
that both first-eye (61%) and second-eye (23%) cataract surgery were statistically
significantly associated in a reduction in crashes compared with the year before first-eye
surgery.1178 Another study showed that drivers 55 and older were significantly less likely to
self-regulate their driving practices after first-eye (70% less likely) and second-eye (90%
less likely) cataract surgery.1179 Patients reported spending statistically significantly more
time on moderate leisurely physical activity after both first-eye and second-eye surgery.1178
A study of patients 55 and older who maintained a falls diary documented a 54% (P =
0.04) decrease in falls from baseline after first-eye cataract surgery and a 73% (P = 0.002)
decrease after second-eye cataract surgery.1180 A study from Vietnam showed similar
results.145 Cataract surgery for both eyes is an appropriate treatment for patients with
bilateral cataract-induced visual impairment.1168, 1170, 1171, 1181
A review of multiple randomized, controlled studies showed that, in the long term, second-
eye cataract surgery is not only clinically effective but has also been found to be cost-
effective.1182 A study in the United Kingdom determined that second-eye surgery was
100% likely to be cost-effective at even relatively low willingness-to-pay thresholds.1183
The indications for second-eye surgery are the same as for the first eye. The outcome of
surgery on the first eye may affect the timing of second-eye surgery. In some patients, a
byproduct of reducing ametropia in the first operated eye may be anisometropia. This may
result in impaired stereoacuity and a reduction in a patient’s ability to perform daily
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activities.146 A contact lens may make the anisometropia tolerable, but if the imbalance
interferes with visual function, second-eye surgery may be appropriate at an earlier stage of
cataract development.1170, 1184
The appropriate interval between the first-eye surgery and the second-eye surgery is
influenced by several factors, including a patient's visual needs and preferences, visual
acuity and function of the second eye, the medical and refractive stability of the first eye,
and the degree of anisometropia. Before performing second-eye surgery, knowing the
refractive error of the first eye can be helpful for refining the IOL power choice for the
second eye.1185-1187
Immediate Sequential (Same-Day) Bilateral Cataract Surgery

In recent years, centers in Canada, Europe, and other parts of the world have reported
excellent safety, efficacy, and economic benefits of immediate sequential bilateral cataract
surgery (ISBCS).1188-1198 The procedure is not commonly performed in the United States448
because of a fear of bilateral vision loss from complications such as endophthalmitis,1199 the
inability to adjust IOL power selection in the second eye based on the postoperative refractive
outcome from the first eye,1200 and the reduction in Medicare fee-for-service reimbursement
for second-eye surgery when performed on the same day.1201, 1202
Benefits of ISBCS include fewer perioperative visits and a reduction in associated economic
costs to the patient and accompanying driver due to time off from work and travel expenses;
increased operating room efficiency; and societal economic savings.1201, 1203-1206 Prospective
comparative trials of ISBCS versus delayed bilateral cataract surgery (DSBCS) document a
more rapid improvement of patients’ self-reported visual function and similar long-term
results.1192, 1194, 1195 One study found a potential annual cost savings to Medicare of $522
million in 2012 dollars. These potential benefits may become increasingly important in the
years ahead, since the projected rate of cataract surgery is expected to grow 72% or more by
the year 2036.1207 An additional potential benefit of ISBCS is a reduction of patient exposure
to infection in the health care setting by reducing perioperative visits.1208 These savings,
however, are unlikely to be realized under current facility reimbursement policy, which
reduces payment for the second eye when done on the same day. The operating room
resources required for bilateral surgery are almost double those for unilateral surgery. Current
payments for ISBCS are below costs for most facilities, making them unlikely to schedule
ISBCS cases.
Cited drawbacks of ISBCS have included the lack of opportunity to adjust the IOL power in
the second eye based on the results in the first eye when there is a refractive surprise.1199, 1200
This adjustment is based on the assumption that both eyes are optically symmetrical and the
type and amount of error in the preoperative measurements or calculations are approximately
equivalent in the two eyes.1187 There is also the potential problem of bilateral dysphotopsia.
However, prospective and retrospective studies show similar results in CDVA, UDVA, and
refractive outcomes for immediate and delayed bilateral surgery.1195, 1196, 1202, 1209 One
prospective study showed that 5% of patients in the delayed group had a change of IOL power
based on the results of the first eye, but refractive results of second eyes were no different
between groups.1197 As biometric technology and predictive formulas continue to improve, the
risk of a refractive surprise and the need for adjusting the second eye appears to be
decreasing.1187, 1210, 1211 Nevertheless, patients at risk for refractive surprise, including a history
of post-refractive corneal surgery and very short or long axial lengths, may not be optimal
candidates for ISBCS.
The most serious potential complication of ISBCS is bilateral blindness due to
endophthalmitis or TASS.1212, 1213 Sporadic cases of bilateral endophthalmitis following
ISBCS have been reported when separation of the two surgical setups was not followed.1193,
1214-1217
In published reviews, however, bilateral complications are rare and the procedure is
considered safe,1189-1191, 1195, 1209, 1218-1223 with no reports of bilateral endophthalmitis or TASS
when recommended guidelines are followed,1224, 1225 including injection of an intracameral
antibiotic.1194, 1195, 1209, 1222 In a retrospective cohort studying using the American Academy of
Ophthalmology IRIS® Registry (Intelligent Research in Sight) database, the rate of
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postoperative endophthalmitis following ISBCS versus DSBCS was not statistically

significantly different.1226 Bilateral HORV has been reported, although not following
ISBCS.462 Patients should be screened for ocular comorbidity and those at risk for bilateral
adverse events, such as corneal or macular edema, should be considered for exclusion.1227, 1228
Immediate sequential bilateral cataract surgery offers a potential benefit for patients who
desire same-day surgery. Individual patient preferences and the best interests for the
individual patient’s visual health and refractive status should be the predominant factors in
determining whether same-day bilateral cataract surgery should be performed.1229 Patient
safety considerations should include surgeon comfort with the procedure, attention to
cleaning and sterilization practices in the surgery center, use of intracameral medications
from different lots, injection of intracameral antibiotic, IOL selection using contemporary
biometric technology and formulas, and evaluation and discussion of the potential impact
of a patient’s ocular comorbidities, if any.1206, 1228
Discharge from Surgical Facility

Typical criteria for discharge after ambulatory surgery are as follows:
 Vital signs are stable.
 The preoperative mental state is restored.
 Nausea and vomiting are controlled.
 Pain is absent or minimal.
 A responsible adult is available to escort the patient home.
 Postsurgical care has been reviewed with the patient and/or a responsible family
member and written postoperative instructions have been provided, including
emergency contact numbers.
 A follow-up appointment has been scheduled.
Operative complications of an ocular or medical nature are possible indications for transfer
and postoperative hospitalization. In the Study of Medical Testing for Cataract Surgery (n
= 19,250 surgeries), there were 61 (0.3%) hospitalizations on the day of cataract surgery. 270
Ocular complications that may require hospitalization include hyphema, uncontrolled
elevated IOP, threatened or actual expulsive suprachoroidal hemorrhage, retrobulbar
hemorrhage, severe pain, or other ocular problems requiring acute management or careful
observation. Medical complications can include cardiac or respiratory instability, a
cerebrovascular episode, diabetes mellitus or hypertension requiring acute management,
uncontrolled nausea or vomiting, acute urinary retention, and acute psychiatric
disorientation requiring management in an acute-care setting with careful monitoring.
Postoperative Management
The operating ophthalmologist has the ultimate responsibility for the preoperative
assessment1230 and postoperative care of the patient, beginning with determining the need
for surgery and ending with completing the postoperative care contingent on medical
stability of the patient.1231, 1232 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 postoperative period is the time in
which most complications occur and within which stable visual function is achieved. The
operating ophthalmologist 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. These do not necessarily
include those aspects of postoperative care permitted by law to be performed by auxiliaries.
If such follow-up care is not possible, the operating ophthalmologist must make
arrangements before surgery to refer the patient to another ophthalmologist for
postoperative care with the prior approval of the patient and the ophthalmologist.1232, 1233
Comanagement is a relationship between an operating ophthalmologist and a nonoperating
practitioner for shared responsibility in the postoperative care. Comanagement occurs when
the patient consents in writing to multiple providers, the services being performed are
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within the providers’ respective scopes of practice, and there is written agreement between
the providers to share patient care. Transfer of care takes place when there is transfer of
responsibility for a patient’s care from one qualified health care provider functioning
within his or her scope of practice to another who also functions within his or her scope of
practice.
The ophthalmologist who performs surgery has an obligation to inform patients about
medication instructions, activity restrictions, postoperative eye protection, required visits,
signs and symptoms of possible complications, and information for accessing emergency
care. The ophthalmologist should also inform patients of their responsibility to follow the
advice and instructions provided during the postoperative phase and to notify the
ophthalmologist promptly if problems occur. Patients should always have access to an
ophthalmologist for appropriate care if serious problems arise.
(See the Comprehensive Guidelines for the Co-Management of Ophthalmic Postoperative
Care for detailed information.1232)
Postoperative medication regimens vary among practitioners; use of topical antibiotics for
infection prophylaxis and of topical corticosteroids and NSAIDs for CME prophylaxis are
discussed earlier in this PPP. Topical corticosteroids and NSAIDs are also used for control
of postoperative inflammation, but there is insufficient high-level evidence to compare
these interventions,807 (I+, Moderate, Discretionary) making it the decision of the
operating surgeon to use one or both of these medication classes. Complications of
postoperative medications include elevated IOP with corticosteroids and allergic reactions
to antibiotics. Significant corneal reactions, including epithelial defects and stromal
ulceration and melting, are rare complications of topical ocular NSAID use.1234-1236
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
promptly and accurately diagnosing and treating the complications of surgery, providing
satisfactory optical correction, educating and supporting the patient, and reviewing
postoperative instructions. Postoperative patients with low-risk surgeries and with no signs
or symptoms of possible complications following cataract surgery should be seen within
the first 48 hours of surgery. Studies have reported that, for the routine patient, omitting an
examination on the day after uncomplicated cataract surgery is associated with a low
frequency of serious ocular complications.1237-1241 Functionally monocular patients and
those at high risk of early postoperative complications should be seen within the first 24
hours of surgery.
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. In patients with low-risk, uncomplicated cataract surgery who are seen within 1
day of surgery and remain asymptomatic, a subsequent visit 1 week later rarely serves to
change management;1242 however, this visit may increase medication compliance. More-
frequent postoperative visits are generally indicated if unusual findings, symptoms, or
complications occur. The patient should have ready access to the ophthalmologist’s office
to ask questions or seek care.
Components of each postoperative examination should include the following:
 Interval history, including use of postoperative medications, new symptoms, and self-
assessment of vision
 Measurement of visual function (e.g., visual acuity, including pinhole testing or
refraction when appropriate)
 Measurement of IOP
 Slit-lamp biomicroscopy
 Counseling/education for the patient or the patient’s caretaker
 Provision of a management plan
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A dilated fundus examination is indicated if there is a reasonable suspicion or higher risk of

posterior segment problems. In the absence of symptoms or surgical complications, no
study has demonstrated that a dilated fundus examination results in earlier detection of RD.
However, dilation is often critical in assessing anterior ocular concerns, such as capsular
contracture and IOL malposition and in evaluating retinal issues, such as CME.
When postoperative visual improvement is less than anticipated, the ophthalmologist may
perform additional diagnostic testing to evaluate the cause. For example, if maculopathy is
suspected, OCT or fluorescein angiography would be appropriate to diagnose cystoid or
diffuse macular edema, epiretinal membranes, or AMD. Likewise, corneal topography
could help diagnose irregular corneal astigmatism. Automated visual fields may help
diagnose a neuro-ophthalmic abnormality. Other testing may be conducted if appropriate.
A final visit should be made to provide an accurate refractive prescription to allow for the
patient’s optimal visual function. Optical correction can usually be prescribed between 1
and 4 weeks after small-incision cataract surgery1243 and between 6 and 12 weeks after
sutured large-incision cataract extraction surgery.
Posterior Capsular Opacification

Posterior capsular opacification often occurs following cataract surgery by any method and
can cause a gradual decrease in visual function.551, 1244, 1245 The most common cause of PCO
is proliferation and metaplasia of LECs that remain in the capsular bag following cataract
surgery.1246, 1247
The onset of PCO from the time of surgery varies, but it generally increases over time.1248-
1250
The frequency of laser posterior capsulotomy has been reported in the range of less
than 5% to 54%.1251-1253
The incidence of PCO is influenced by multiple variables. In some eyes, plaques or

capsular opacities cannot be removed during surgery for a variety of reasons, or capsular
wrinkles develop during the early postoperative period. Studies generally find significantly
lower PCO scores for sharp-edged IOLs compared with rounded-edged models.568, 1254 A
2013 meta-analysis of nine RCTs and several recent longitudinal studies found that
hydrophobic sharp-edged IOLs have lower PCO and Nd:YAG laser capsulotomy rates than
hydrophilic sharp-edged IOLs.1255-1258 Additionally, square-edged acrylic, PMMA, and
silicone IOLs were found to be comparable in terms of reducing the need for Nd:YAG
laser capsulotomy.1259 (I+, Strong, Good) However, one randomized trial indicated that the
protective effect of the sharp-edged hydrophobic lens may only be to delay the
development of PCO compared with round-edged silicone and PMMA IOLs after 12 years
of follow-up.1260 The incidence of PCO is lower in older patients,1261 when the anterior
capsulorrhexis completely overlaps the entire optic,1262-1264 and with phacoemulsification
(vs. ECCE).260 No difference in PCO has been found with more prolonged administration
of topical corticosteroids or topical NSAIDs.1012, 1014, 1015
Polishing the anterior capsule has a variable effect on reducing PCO development.1265-1267 It
probably increases the rate of PCO and accelerates the need for a Nd:YAG laser
capsulotomy in most eyes by limiting the ability of the capsule to form a tight bend around
the posterior edge of the optic, a bed that would otherwise retard LEC migration posterior
to the optic.1268 Benefits of anterior capsule polishing are improved anterior capsule clarity
postoperatively and reduced IOL decentration and capsulorrhexis phimosis.
Posterior laser capsulotomy is an effective surgical procedure to clear the visual pathway to
restore visual function and to improve contrast sensitivity.1269 The indication for performing
laser capsulotomy is PCO consistent with an impairment of vision to a level that does not
meet the patient’s functional needs or critically interferes with visualization of the fundus.
The decision to perform capsulotomy should take into consideration the benefits and risks
of the laser surgery. Posterior capsulotomy may be indicated earlier in patients with
multifocal IOLs because of a greater functional impact of early PCO in low-contrast and
glare conditions. Laser posterior capsulotomy should not be performed prophylactically
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(i.e., when the capsule remains clear). Same-day bilateral laser capsulotomy is occasionally
performed when there are extenuating circumstances such as difficulty traveling. The eye
should be inflammation free and the IOL stable prior to performing laser capsulotomy.1260
An uncommon condition that is treated with laser posterior capsulotomy is capsular bag
distension syndrome, or capsular block syndrome.1270 This complication is characterized by
an accumulation of a milky or clear fluid behind the lens optic associated with anterior
displacement of the lens, which may induce decreased vision and produce a myopic
refractive shift.1271, 1272
Although uncommon, complications of laser capsulotomy include increased IOP,1273 RD,
CME, corneal abrasion, iritis, vitritis, damage to the IOL, persistent floaters, and
dislocation of the IOL.1274 There have been case reports of macular hole formation1275, 1276
and indolent endophthalmitis1277 following laser capsulotomy. Having a posterior
capsulotomy can also complicate IOL exchange. Axial myopia increases the risk of RD
after laser capsulotomy,1278 as does pre-existing vitreoretinal disease, male gender, young
age, vitreous prolapse into the anterior chamber, and spontaneous extension of the
capsulotomy.1279 Two case series reported a 0% to 0.4% incidence of RD 1 to 8 years
following laser capsulotomy. In one of these series, there were no RDs in eyes with an
axial length less than 24.0 mm.1280 A recent study of billing records of a large number of
patients concluded there was a 0.29% risk of tear and 0.87% risk of RD in the first 5
months following capsulotomy.1281 Because retinal breaks or detachments are acute events
that can occur weeks to possibly years after laser capsulotomy, a routine dilated fundus
examination is unlikely to detect retinal pathology that requires treatment in the absence of
symptoms. Educating high-risk patients about the symptoms of retinal tears or detachment
may facilitate early diagnosis. 1282
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.1283, 1284 In the presence of risk factors, such as pre-existing glaucoma, a variety of
agents to lower IOP have demonstrated efficacy at blunting IOP elevation. 1285-1290 In high-
risk patients, the surgeon should monitor the IOP in the early postoperative period.
Treatment with topical corticosteroid, NSAID, ocular hypotensive, or cycloplegic agents is
dependent on the patient’s risk factors and surgeon’s preference.
Anterior capsular fibrosis and contracture (capsular contraction syndrome) is caused by
metaplastic LECs.1291 Shrinkage of the anterior capsular opening occurs more frequently in
conditions such as pseudoexfoliation syndrome, retinitis pigmentosa, diabetes, uveitis, and
eyes with zonular pathology.1265 Anterior capsule contracture also happens more frequently
with silicone than with acrylic optic materials. Anterior capsule polishing may reduce this
postoperative phenomenon.1265, 1266, 1292, 1293 Capsular contracture can lead to decreased
visual acuity, IOL tilt or decentration, and IOL dislocation in extreme cases. Treatment of
anterior capsular contracture with Nd:YAG or femtosecond laser anterior capsulotomy may
be effective.1265, 1266, 1292
PROVIDER AND SETTING

It is the unique role of the ophthalmologist who performs cataract surgery to confirm the presence of
the cataract, determine the need for surgery, and design and carry out a treatment plan, including
postoperative care.264, 265 Diagnosis and management require medical expertise, surgical skills, and
specialized diagnostic and surgical equipment. The ophthalmologist’s training, clinical experience,
and judgment are necessary to evaluate the medical, ocular, and psychosocial factors used to
determine the appropriateness and timing of surgery. Cataract surgery, including use of the
femtosecond laser, should be performed only by an appropriately trained ophthalmologist. 1294
While the performance of certain diagnostic procedures (e.g., measurement of IOP, refraction,
biometry) may be delegated to appropriately trained personnel supervised by the ophthalmologist,
interpretation of these procedures requires the clinical judgment of the ophthalmologist.
Nearly all cataract surgery is performed in an outpatient setting, which may be in a hospital-based
outpatient department or freestanding ambulatory surgery center. In-office surgery is being considered
by Medicare at the time of this PPP. A Cochrane Systematic Review has concluded that there is no
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difference in outcome or increased risk of postoperative complications between outpatient and

inpatient cataract surgery.1295 (I+, Good, Strong)
The surgical facility should comply with local, state, and federal regulations and standards governing
the particular setting of care. Inpatient surgery may be necessary if there is a need for complex
anesthetic or surgical care, multiple procedures, or postoperative care requiring an acute-care setting.
COUNSELING AND REFERRAL

The patient should be informed preoperatively about the possibility of visual impairment continuing
after cataract surgery and the potential for rehabilitation in such cases.1296 More information on vision
rehabilitation, including materials for patients, is available at www.aao.org/smart-sight-low-vision.
Appropriate referral to a specialist should be considered when the postoperative course does not
proceed as expected or does not respond to standard therapy. Examples include persistent
inflammation, nonresolving CME, or uncontrolled glaucoma.
SOCIOECONOMIC CONSIDERATIONS
Utilization of Cataract Surgery in the United States

In 2017, a total of 3.38 million cataract procedures were performed on Medicare beneficiaries
who were not enrolled in Medicare advantage plans (managed care plans for Medicare patients).
This suggests that 5.2 million cataract surgeries were performed in 2017, if Medicare advantage
plans are also considered and if the rate in these plans is the same as for Medicare patients.1297
The projected rate of cataract surgery is expected to grow 72% or more by the year 2036, and
this may be an underestimate.1207
When assessed across populations residing in different states or metropolitan areas, there is wide
and largely unexplained variation in the rate of cataract surgery, from 7.5% to 37.3%.1298 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.1299 A higher concentration of ophthalmologists was
not associated with a higher rate of cataract surgery. The average age of patients undergoing
cataract surgery is widely variable from 60 to 80 years old, with great variation in different areas
of the country.1298
The utilization of cataract surgery in the United States has been found to be appropriate in the
vast majority of studies. A study at 10 academic medical centers found that 2% of cataract
surgeries performed were classified as inappropriate based on available records.1300 An
inappropriate rating meant that the risks of surgery were deemed to exceed the potential benefits
as rated by a physician review panel. The percentage deemed inappropriate in this study is
consistent with earlier estimates of 2.5% by the 1993 U.S. General Accounting Office and a rate
of 1.7% by the U.S. Inspector General.1300 Cataract surgery inappropriateness 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). 1301, 1302 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 recorded information varied, particularly on functional impairment, and increased
attention to documenting specific functional impairments would be 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.1303 Also, second-opinion programs
implemented for cataract surgery have not lowered surgical rates, because the 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.1304 More recent studies have added a patient-reported visual function
questionnaire.1305 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 2 lines postoperatively.
For the group that had surgeries rated as inappropriate, 36% had a visual acuity improvement of
at least 2 lines postoperatively. This finding suggests that the functional benefit of cataract
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surgery can be unpredictable in some individuals and cannot always be accurately predicted
preoperatively.
Cost and Cost-Effectiveness of Cataract Surgery in the United States

In 2010, the national average surgeon reimbursement for cataract surgery/IOL implantation was
$713.86. In 2020, it dropped to $557, a 22% decrease. 1306 The total cost for cataract surgery/IOL
implantation for a Medicare beneficiary in the ambulatory surgery center setting was about
$2335 in 2010. This includes the initial office evaluation as well as refraction, biometry, surgical
facility fee, surgeon and anesthesia professional fees, and medications.
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.
Methods to evaluate whether the cost of a medical intervention is an effective use of available
resources include cost-effectiveness or cost-utility calculations. The quality-adjusted life year
(QALY) is a measure of a disease burden, including both the quality and the quantity of life
lived. It is used in assessing the monetary value of a medical intervention. The QALY is based
on the number of years of life that would be added by the intervention. Each year in perfect
health is assigned the value of 1.0 down to a value of 0.0 for death. If the extra years would not
be lived in full health, for example, if the patient would be blind, lose a limb, or have to use a
wheelchair, then the extra life-years are given a value between 0 and 1 to account for this. The
QALY is used in cost-utility analysis to calculate the ratio of cost to QALY improvement and
compare the value of interventions of different health conditions. Lower cost per QALY
represents a more cost-effective medical intervention.
The 2017 hypothetical cost per QALY gained for cataract surgery in one eye was estimated at
US $1,001 in the United States, depending on the study and including direct costs only,1307
which is 41.8% more cost-effective than in 2012 and 73.1% more cost-effective than in the year
2000.The patient value gained from cataract surgery is in the top 5% of 700 health care
interventions that have been evaluated by cost-utility analysis.1297 The cost per QALY
calculation for cataract surgery compares favorably with other medical treatments. Single-vessel
coronary artery bare-metal stent for coronary artery disease costs $13,972/QALY, beta blocker
treatment of arterial hypertension costs $3,640/QALY, total knee arthroplasty costs
$15,292/QALY, and normoglycemic management of non-insulin dependent diabetes mellitus
costs $25,560/QALY. Cataract surgery is far more cost-effective than these important medical
treatments.
Medical technology is valuable if the benefits of medical advances exceed the costs. One study
analyzed technological advances in treatment of five conditions, including cataracts. 1308 In four
of the conditions—heart attacks, low-birthweight infants, depression, and cataracts—the
estimated benefit of technological changes is much greater than the cost. The medical advances
in cataract surgery from the late 1960s to present have resulted in increased safety and improved
outcomes. Additionally, the cost-effectiveness of new-technology IOLs, such as toric IOLs, was
superior to the lifetime cost of eyeglasses.1309 One estimate of the present benefit value of
cataract surgery is $370,018, which is far greater than the average cost of treatment at $2,526.
This accounts for direct costs of cataract surgery and the costs of impaired vision without
cataract surgery over a 14-year period. 1297
Cataract surgery is the most cost-effective procedure performed in medicine today. 1310-1312
Immediate sequential bilateral cataract surgery may be more cost-effective in some payer
settings than delayed sequential bilateral cataract surgery.1313 The cost-effectiveness of cataract
surgery compares favorably with other fall prevention strategies such as strength and balance
exercise programs and home safety evaluations.1314
The common use of intraoperative and postoperative prescription drops also adds to the patient’s
financial burden. In 2016, the mean cost of postoperative drops was $228 for one cataract
surgery, and $324 for two. Brand name prescriptions accounted for over 57% of the
prescriptions. Generic medications could save patients 70%.1315
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New technology in cataract surgery, including the use of advanced technology IOLs and
femtosecond lasers, represent an increased out-of-pocket expense for cataract patients.
Currently, these technologies are used in a small portion of total cases, but their use is expected
to increase over the coming years. Although some benefits of new technology are clear, others
remain ambiguous. Their use does add to the patient’s economic health care burden. 1316
Merit-based Incentive Payment System

The Merit-Based Incentive Payment System (MIPS) is a replacement and expansion of the
Physician Quality Reporting System program that was initially launched by the Centers for
Medicare and Medicaid Services in July 2007. The purpose is to encourage quality improvement
and cost reduction using clinical performance measures on a variety of clinical conditions.
Physicians are rewarded or penalized via Medicare reimbursement for reporting on quality
measures and practice improvement performance. The latest information on the Physician
Quality Reporting System is available at www.aao.org/medicare/quality-reporting.
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APPENDIX 1. QUALITY OF OPHTHALMIC CARE

CORE CRITERIA
Providing quality care

is the physician's foremost ethical obligation, and is
the basis of public trust in physicians.
AMA Board of Trustees, 1986
Quality ophthalmic care is provided in a manner and with the skill that is consistent with the best interests of
the patient. The discussion that follows characterizes the core elements of such care.
The ophthalmologist is first and foremost a physician. As such, the ophthalmologist demonstrates
compassion and concern for the individual, and utilizes the science and art of medicine to help alleviate
patient fear and suffering. The ophthalmologist strives to develop and maintain clinical skills at the highest
feasible level, consistent with the needs of patients, through training and continuing education. The
ophthalmologist evaluates those skills and medical knowledge in relation to the needs of the patient and
responds accordingly. The ophthalmologist also ensures that needy patients receive necessary care directly or
through referral to appropriate persons and facilities that will provide such care, and he or she supports
activities that promote health and prevent disease and disability.
The ophthalmologist recognizes that disease places patients in a disadvantaged, dependent state. The
ophthalmologist respects the dignity and integrity of his or her patients and does not exploit their
vulnerability.
Quality ophthalmic care has the following optimal attributes, among others.
 The essence of quality care is a meaningful partnership relationship between patient and physician. The
ophthalmologist strives to communicate effectively with his or her patients, listening carefully to their
needs and concerns. In turn, the ophthalmologist educates his or her patients about the nature and
prognosis of their condition and about proper and appropriate therapeutic modalities. This is to ensure
their meaningful participation (appropriate to their unique physical, intellectual and emotional state) in
decisions affecting their management and care, to improve their motivation and compliance with the
agreed plan of treatment, and to help alleviate their fears and concerns.
 The ophthalmologist uses his or her best judgment in choosing and timing appropriate diagnostic and
therapeutic modalities as well as the frequency of evaluation and follow-up, with due regard to the
urgency and nature of the patient's condition and unique needs and desires.
 The ophthalmologist carries out only those procedures for which he or she is adequately trained,
experienced and competent, or, when necessary, is assisted by someone who is, depending on the urgency
of the problem and availability and accessibility of alternative providers.
 Patients are assured access to, and continuity of, needed and appropriate ophthalmic care, which can be
described as follows.
 The ophthalmologist treats patients with due regard to timeliness, appropriateness, and his or her own
ability to provide such care.
 The operating ophthalmologist makes adequate provision for appropriate pre- and postoperative patient
care.
 When the ophthalmologist is unavailable for his or her patient, he or she provides appropriate alternate
ophthalmic care, with adequate mechanisms for informing patients of the existence of such care and
procedures for obtaining it.
 The ophthalmologist refers patients to other ophthalmologists and eye care providers based on the
timeliness and appropriateness of such referral, the patient's needs, the competence and qualifications
of the person to whom the referral is made, and access and availability.
 The ophthalmologist seeks appropriate consultation with due regard to the nature of the ocular or other
medical or surgical problem. Consultants are suggested for their skill, competence, and accessibility.
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They receive as complete and accurate an accounting of the problem as necessary to provide efficient
and effective advice or intervention, and in turn respond in an adequate and timely manner.
 The ophthalmologist maintains complete and accurate medical records.
 On appropriate request, the ophthalmologist provides a full and accurate rendering of the patient's
records in his or her possession.
 The ophthalmologist reviews the results of consultations and laboratory tests in a timely and effective
manner and takes appropriate actions.
 The ophthalmologist and those who assist in providing care identify themselves and their profession.
 For patients whose conditions fail to respond to treatment and for whom further treatment is
unavailable, the ophthalmologist provides proper professional support, counseling, rehabilitative and
social services, and referral as appropriate and accessible.
 Prior to therapeutic or invasive diagnostic procedures, the ophthalmologist becomes appropriately
conversant with the patient's condition by collecting pertinent historical information and performing
relevant preoperative examinations. Additionally, he or she enables the patient to reach a fully informed
decision by providing an accurate and truthful explanation of the diagnosis; the nature, purpose, risks,
benefits, and probability of success of the proposed treatment and of alternative treatment; and the risks
and benefits of no treatment.
 The ophthalmologist adopts new technology (e.g., drugs, devices, surgical techniques) in judicious
fashion, appropriate to the cost and potential benefit relative to existing alternatives and to its
demonstrated safety and efficacy.
 The ophthalmologist enhances the quality of care he or she provides by periodically reviewing and
assessing his or her personal performance in relation to established standards, and by revising or altering
his or her practices and techniques appropriately.
 The ophthalmologist improves ophthalmic care by communicating to colleagues, through appropriate
professional channels, knowledge gained through clinical research and practice. This includes alerting
colleagues of instances of unusual or unexpected rates of complications and problems related to new
drugs, devices or procedures.
 The ophthalmologist provides care in suitably staffed and equipped facilities adequate to deal with
potential ocular and systemic complications requiring immediate attention.
 The ophthalmologist also provides ophthalmic care in a manner that is cost effective without unacceptably
compromising accepted standards of quality.
Reviewed by: Council

Approved by: Board of Trustees
October 12, 1988
2nd Printing: January 1991
3rd Printing: August 2001
4th Printing: July 2005
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APPENDIX 2. INTERNATIONAL STATISTICAL

CLASSIFICATION OF DISEASES AND RELATED
HEALTH PROBLEMS (ICD) CODES
Cataract, which includes entities with the following ICD-10 classifications:
ICD-10 CM
Cortical ARC H25.01–
Anterior subcapsular polar ARC H25.03–
Posterior subcapsular polar ARC H25.04–
Other age-related incipient cataract, right eye (coronary; H25.09–
punctate ARC, water clefts)
Age-related nuclear cataract H25.1–

ARC, morgagnian type, (hypermature cataract) H25.2–
Combined forms of ARC H25.81–
Total or mature cataract H25.89 Other ARC
ARC; exfoliation of lens capsule H25.89 Other ARC
ARC = age-related cataract; ICD = International Classification of Diseases; CM = Clinical Modification used in the United
States; (–) = 1, right eye; 2, left eye; 3, bilateral.
Additional information:
 For bilateral sites, the final character of the codes indicates laterality. If no bilateral code is provided and the condition
is bilateral, separate codes for both the left and right side should be assigned. Unspecified codes should be used only
when there is no other code option available.
 When the diagnosis code specifies laterality, regardless of which digit it is found in (i.e., 4 th digit, 5th digit, or 6th digit):
• Right is always 1
• Left is always 2
• Bilateral is always 3
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APPENDIX 3. NUTRITION AND CATARACTS

Most randomized controlled studies of nutritional supplements have not demonstrated a beneficial effect of
high-dose supplements on cataract development or progression (Table A3-1). Observational studies of
nutrition and cataract with more than 10,000 participants (Table A3-2) have reported either no association1317
or a reduced risk of cataract.211, 217-219, 1318-1321 1317
TABLE A3-1 SUMMARY OF RANDOMIZED CONTROLLED TRIALS OF NUTRITIONAL SUPPLEMENTS AND CATARACTS
Study Date Sample Results
Published Size
Beta Carotene
Alpha-tocopherol, beta-carotene 1998 28,934 No effect of beta-carotene on risk for cataract
study1322 men surgery
Physicians’ Health Study1323 2003 22,071 No effect of treatment on cataract
development
For current smokers at baseline,
supplementation appeared to lessen their
excess risk by about one-quarter
Women’s Health Study1324 2004 36,735 women No effect of treatment on cataract
development
Lutein/Zeaxanthin
Age-Related Eye Disease Study 2 2013 3159 No effect on rate of cataract surgery,
(AREDS2)1325 development of posterior subcapsular or
cortical cataracts, or vision loss
Multivitamin/Mineral
Linxian Cataract1326 1993 2141 36% reduction in development of nuclear
cataracts in a nutritionally deficient population
Nutritional Supplements and Age- 2008 1020 34% reduction in nuclear cataract; twofold
Related Cataract212 increased risk of posterior subcapsular
cataract
Physicians’ Health Study II213 2014 11,497 Long-term multivitamin use moderately
men decreased the risk (9% lower) of nuclear
cataract
Omega-3 Long-Chain Polyunsaturated Fatty Acids (LCPUFAs)
Age-Related Eye Disease Study 2 2013 3159 No effect on cataract progression
(AREDS2)1325, 1327
Riboflavin/Niacin
Linxian Cataract1326 1993 3249 44% reduction in development of nuclear
cataracts in a nutritionally deficient population
Selenium
Selenium and Vitamin E Cancer 2015 11,267 No effect of selenium on development of
Prevention Trial (SELECT) Eye men cataract
Endpoints Study1328
Vitamin C and E
Physicians’ Health Study II1329 2010 11,545 No effect on cataract development of C alone,
men E alone, or C and E
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TABLE A3-1 SUMMARY OF RANDOMIZED CONTROLLED TRIALS OF NUTRITIONAL SUPPLEMENTS AND CATARACTS
(CONTINUED)
Study Date Sample Results
Published Size
Vitamin C, E, and Beta-Carotene
Age-Related Eye Disease Study1330 2001 4629 No effect of treatment on the development or
progression of cataracts
Antioxidants in Prevention of 2006 798 No effect of treatment on progression of
Cataracts Study1331 cataracts
Roche European American Cataract 2002 297 No effect of treatment on the progression of
Trial1332 cataracts in the U.K. group; small positive
treatment effect in U.S. participants
Vitamin E
Alpha-tocopherol, beta-carotene 1998 28,934 No effect of vitamin E on risk for cataract
study1322 surgery
SELECT Eye Endpoints Study1328 2015 11,267 No effect of vitamin E on development of
men cataract
Vitamin E, Cataract and Age-Related 2004 1193 No effect of treatment on the development or
Maculopathy Trial1333 progression of cataracts
Women’s Health Study1334 2008 37,675 women No effect of vitamin E on development of
cataract (600 IU QOD)
Vitamin E and Beta-Carotene
Alpha-tocopherol, beta-carotene 1997 1828 No effect of treatment on the development or
Cancer Prevention Study1335 progression of cataracts
TABLE A3-2 SUMMARY OF OBSERVATIONAL STUDIES OF NUTRITION AND CATARACTS (n>10,000)

Study Date Type of Sample Measure Results
Published Study Size
Dietary Antioxidants
Swedish Mammog- 2014 Prospective 30,607 Dietary intake Antioxidants in diet (primarily fruits
raphy Cohort220 cohort women and vegetables, whole grains,
coffee): 12.8% lower risk for
cataract extraction in highest
quintile of antioxidant intake
compared with those in lowest
quintile
Dietary Intake
European Prospective 2011 Prospective 27,670 Dietary intake Progressive decrease in risk of
Investigation into cohort cataract in high meat eaters to low
Cancer and meat eaters, fish eaters
Nutrition219 (participants who ate fish but not
meat), vegetarians, and vegans
Vegetarianism
Oxford arm of 2011 Prospective 27,670 Dietary intake Vegetarians at lower risk of
European Prospective cohort cataracts than meat eaters
Investigation into
Cancer and Nutrition
(EPIC-Oxford)219
Fat Intake
Nurses’ Health 2005 Prospective 71,083 Dietary intake Reduced risk of cataract extraction
Study218 cohort women with higher intake of long-chain fatty
acids and fish
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TABLE A3-2 SUMMARY OF OBSERVATIONAL STUDIES OF NUTRITION AND CATARACTS (n>10,000) (CONTINUED)
Study Date Type of Sample Measure Results
Published Study Size
Fruit and Vegetable Intake
Women’s Health 2005 Prospective 35,724 Dietary intake Reduced risk of cataracts
Study217 cohort women associated with higher intakes of
fruits and vegetables
Lutein/Zeaxanthin
Health Professionals 1999 Prospective 36,644 Dietary intake Modestly lower risk of cataract
Follow-up Study1336 cohort men extraction in men with higher dietary
intake of lutein/zeaxanthin
Multivitamin Supplement
Nurses’ Health 1992 Prospective 50,828 Supplement No association with multivitamin use
Study1317 cohort women use and cataract extraction
Nurses’ Health 1999 Prospective 73,956 Supplement Little overall benefit for risk of
Study1337 cohort women use cataract extraction in those taking
for ≥10 years
Physicians’ Health 1994 Prospective 17,744 Supplement Reduced risk of cataracts
Study1318 cohort men use
Cohort of Swedish 2013 Prospective 31,120 Supplement Not associated with cataract risk
men1338 cohort men use
Riboflavin/Niacin
Nurses’ Health 1992 Prospective 50,828 Total dietary No association
Study1317 cohort women intake
Vitamin C
Nurses’ Health 1999 Prospective 73,956 Supplement No significant association with risk
Study1337 cohort women use for cataract extraction, used
continuously for ≥10 years
Japan Public Health 2007 Prospective 35,186 Total dietary Reduced incidence of cataract
Center-Based cohort intake diagnosis or extraction with higher
Prospective Study1320 vitamin C intake
Swedish 2010 Prospective 24,593 Supplement 25% increased risk for cataract
Mammography cohort women use extraction for vitamin C supplement
Cohort1339 users
Cohort of Swedish 2013 Prospective 31,120 Supplement 21% increased risk of cataract
Twins U.K. Cohort1231 2016 Prospective 2054 Total dietary Reduced risk of cataracts
cohort white intake associated with vitamin C intake
female over 10 years
twins
Vitamin E
Nurses’ Health 1992 Prospective 50,828 Total dietary No association
Study1317 cohort women intake and
supplement
Cohort of Swedish 2013 Prospective 31,120 Supplement 59% increased risk of cataract
AREDS2 = Age-Related Eye Disease Study 2.
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APPENDIX 4. WRONG-SITE WRONG-IOL SURGERY

CHECKLIST
This checklist may be downloaded from the Patient Safety Statement, Recommendations of American
Academy of Ophthalmology Wrong-site Task Force (revised 2014), available at www.aao.org/patient-safety-
statement/recommendations-of-american-academy-ophthalmology-.
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APPENDIX 5. LITERATURE SEARCHES FOR THIS

PPP
Literature searches of the PubMed and Cochrane databases were conducted in July 2021; the search strategies
were as follows.
Refractive cataract surgery:
("refractive cataract surgery"[tiab]) OR ((("cataract extraction"[mh] OR "cataract surgery"[tiab] OR "cataract
extraction"[tiab] OR Lens implantation, intraocular[mh] OR cataract[tiab]) AND (refractive[tiab] OR “power
calculation” OR toric[tiab] OR multifocal[tiab] OR presbyopic[tiab] OR multifocality[tiab])))
Intraoperative refractive guidance:

((((((("cataract extraction"[mh] OR "cataract surgery"[tiab] OR "cataract extraction"[tiab]))))) AND
(((((((((((((("image guidance") OR (("image guidance system" OR "image guidance systems"))) OR
"intraoperative aberrometry") OR (intraoperative[tiab] AND aberrometry[tiab])) OR "fluoroscopic
guidance"[tiab]) OR (fluoroscopic[tiab] AND guidance[tiab])) OR (("intracameral illumination" OR
"intracameral illuminations"))) OR "intraoperative oct") OR "intraoperative optical coherence tomography")
OR "monitoring, intraoperative"[mh]) OR "tomography, optical coherence/methods"[mh]) OR
"microscopy"[tiab]) OR "monitoring, intraoperative/instrumentation"[mh]) OR "optical
imaging/methods"[mh]))) OR (("intraoperative refractive monitoring") OR (intraoperative[tiab] AND
refractive[tiab] AND guidance[tiab]))
Alternative technologies for nucleus disassembly: (((((nucleus[tiab]) AND (removal[tiab] OR

disassembly[tiab] OR dropped[tiab] OR division[tiab])) AND ("cataract extraction"[mh] OR "cataract
surgery"[tiab] OR “cataract extraction”[tiab] OR cataract[tiab]))) OR ((((("flacs"[tiab] OR "femtosecond laser
assisted surgery"[tiab] OR "miloop" OR "microfilament" OR "small incision cataract surgery"[tiab] OR
sics[tiab])) AND ("cataract extraction"[mh] OR "cataract surgery"[tiab] OR “cataract extraction”[tiab] OR
cataract[tiab]))) AND nucleus[tiab])) OR ((("nucleus disassembly") OR "nucleus removal"))
Alternative to drops for postoperative drug delivery: (((("cataract extraction"[mh] OR "cataract surgery"[tiab]
OR “cataract extraction”[tiab]))) AND (postoperative[tiab] OR postop[tiab])) AND (((“drug delivery”[tiab]
OR drug[tiab] OR drugs[tiab] OR antibiotic[tiab] OR antibiotics[tiab]) AND (intracameral[tiab] OR “sub
tenons”[tiab] OR subtenon[tiab] OR “intracanalicular”[tiab] OR “reservoir devices”[tiab] OR dropless[tiab]
OR nondropless[tiab] OR alternative[tiab] OR dual[tiab] OR drug delivery systems[mh] OR
"glucocorticoids/administration and dosage"[mh] OR "injections, intraocular"[mh] OR "postoperative
complications/prevention and control"[mh] OR "drug delivery systems/methods"[mh] OR “sustained-
release”[tiab] OR drop-free[tiab] OR topical[tiab] OR subconjunctival[tiab] OR “slow-release”[tiab] OR
irrigative[tiab]))
Surgical care delivery settings: ((("cataract extraction"[mh] OR "cataract surgery"[tiab] OR “cataract
extraction”[tiab]))) AND (“office-based”[tiab] OR “office”[tiab] OR “hopd”[tiab] OR “hospital outpatient
department”[tiab] OR “asc”[tiab] OR “ambulatory surgery center”[tiab] OR outpatient[tiab] OR
hospital[tiab] OR ambulatory[tiab] OR “emergency department”[tiab] OR outpatients[mh] OR
ambulatory[mh] OR “ambulatory care facilities”[mh] OR ambulatory care facilities/trends[mh])
Timing of second eye surgery: ((((("cataract extraction"[mh] OR "cataract surgery"[tiab] OR “cataract

extraction”[tiab]))) AND (((((“second eye” AND surg*))) OR "same day"[tiab]) OR "second eye"[tiab]))) OR
((("second eye surgery" AND cataract)) OR (("second eye cataract" OR "second eye cataract extraction" OR
"second eye cataract patients" OR "second eye cataract surgeries" OR "second eye cataract surgery")))
Legal Risks: ((((("cataract extraction"[mh] OR "cataract surgery"[tiab] OR “cataract extraction”[tiab]))) OR
(((((((("retinal detachment"[tiab] OR "capsule tear"[tiab] OR "dropped nucleus"[tiab] OR perforation[tiab]
OR perforated[tiab]))) OR ((wrong[tiab] AND (lens OR "intraocular lens"[tiab]))))) OR (((lens[tiab] OR
iol[tiab])) AND (removal[tiab] OR exchange[tiab])))) AND cataract))) AND (((legal[tiab] OR law[tiab] OR
lawsuit[tiab] OR problem* OR Liability, legal[mh] OR malpractice[mh] OR medical errors[mh] OR cataract
extraction/legislation and jurisprudence[mh] OR diagnostic errors[mh] OR medicolegal[tiab])) OR
(litigation[tiab] OR litigations[tiab] OR malpractice[tiab] OR medicolegal[tiab] OR misdiagnosis[tiab]))
General: "cataract extraction"[mh] OR "cataract surgery"[tiab] OR “cataract extraction”[tiab]
Diagnosis: "cataract"[tiab] AND (diagnosis[majr] OR diagnose[tiab] OR diagnosis[tiab] OR detect[tiab])
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Therapy: "cataract extraction"/therapy[mh]
Lens Implantation: "lens implantation, intraocular"[mh] OR lens implantation[tiab]
Endophthalmitis: (endophthalmitis[mh] OR endophthalmitis[tiab]) AND ("cataract extraction"[mh] OR

"cataract surgery"[tiab] OR “cataract extraction”[tiab] OR cataract[tiab])
Corneal Transplantation/Penetrating Keratoplasty: ("cataract extraction"[mh] OR "cataract surgery"[tiab] OR

“cataract extraction”[tiab] OR cataract[tiab]) AND (Keratoplasty, Penetrating [mh] OR "corneal
transplantation"[mh] OR "Endothelial Keratoplasty" OR DSAEK OR DSEK OR DMEK OR DLEK OR
"posterior lamellar keratoplasty")
Risk Factors: ((("cataract/etiology"[mh] OR "cataract/epidemiology"[mh] OR "cataract/ethnology"[mh])

AND "risk factors"[mh])) OR ((("cataract/prevention and control"[majr]) OR ("cataract/epidemiology"[mh]))
AND "prevalence"[mh]
Rate – Appropriateness: ((((cataract extraction[mh] AND "statistics and numerical data"[MeSH

Subheading])) AND appropriate*[tiab])) OR ((cataract extraction[MeSH Terms] AND appropriateness))
Visual Function and Quality of Life: ((("cataract extraction"[mh] OR "cataract surgery"[tiab] OR “cataract
extraction”[tiab]))) AND (("Quality of Life"[mh] OR “qol”[tiab] OR "Activities of Daily Living"[mh] OR
"Disability Evaluation"[mh] OR "Automobile Driving"[mh] OR depression[mh] OR anxiety[mh] OR "stress,
Psychological"[mh] OR "accidental falls"[mh]))
Evaluation of Visual Impairment: ((("cataract/diagnosis"[MeSH Terms]) AND ("visual acuity"[mh] OR

"contrast sensitivity"[mh] OR "vision tests"[mh] OR Questionnaires[mh]))) OR ((cataract[mh]) AND
((Questionnaires[tiab] OR "sickness impact profile"[mh])))
Supplemental Ophthalmic Testing: ((("cataract"[MeSH Terms]) AND ("ultrasonography"[MeSH Terms] OR

ultrasonography[tiab]))) OR ((((cataract[mh]) OR ("cataract extraction"[mh]))) AND (("potential
vision"[tiab] OR "ocular wavefront"[tiab] OR "corneal topography"[tiab] OR "potential acuity"[tiab] OR
"near card"[tiab] OR glare disab*[tiab] OR glare test*[tiab])OR "scanning laser"[tiab] OR "laser
interferometer"[tiab] OR "fluorescein angiography"[mh] OR "Tomography, Optical Coherence"[MAJR] OR
"corneal pachymetry"[tiab] OR specular microscop*[tiab] OR "evoked potential"[tiab])))
Nonsurgical Management: ((("cataract/chemically induced"[MeSH Terms]) AND ((corticosteroid*[tiab] OR

steroid*[tiab] OR glucocorticoid*[tiab] OR glucosteroid*[tiab])))) OR ((cataract[mh]) AND (smoking[mh]
OR "dietary supplements"[mh] OR vitamins[mh] OR antioxidants[mh]))
Preoperative Medical Evaluation: (("cataract extraction"[mh] OR "cataract surgery"[tiab] OR “cataract

extraction”[tiab] OR cataract[mh])) AND ("diagnostic tests, routine"[mh] OR "preop"[tiab] OR
preoperative[tiab] OR "diagnostic test"[tiab] OR "diagnostic evaluation"[tiab])
Anesthesia: ((("cataract extraction"[mh] OR "cataract surgery"[tiab] OR “cataract extraction”[tiab]))) AND

((Anesthesia[mh] OR aenesth*[tiab] OR anesthet*[tiab]))
TASS (Toxic anterior segment syndrome): ("tass"[tiab]) OR ("toxic anterior segment syndrome" OR "toxic
anterior segment syndrome tass" OR TASS[tiab])
TPSS (Toxic posterior segment syndrome): ((("toxic posterior segment syndrome") OR (toxic[tiab] AND
posterior[tiab] AND segment[tiab] AND syndrome[tiab]))) OR (("cataract extraction"[mh] OR "cataract
surgery"[tiab] OR “cataract extraction”[tiab]) AND TPSS)
HORV (Hemorrhagic Occlusive Retinal Vasculitis): ((((("cataract extraction"[mh] OR "cataract

surgery"[tiab] OR “cataract extraction”[tiab] OR cataract[tiab]))) AND horv)) OR "hemorrhagic occlusive
retinal vasculitis"
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Surgical Techniques: (((("cataract extraction"[mh] OR "cataract surgery"[tiab] OR “cataract

extraction”[tiab])))) AND ((((((("incision"[tiab]) OR "microincision"[tiab]) OR "femtosecond"[tiab]) OR
"minimally invasive surgical procedures"[mh]) OR "phaco"[tiab]) OR "phacoemulsification"[tiab]) OR
"femtosecond laser")
Outcomes: ("cataract extraction"[MeSH Terms]) AND ("visual acuity"[majr] OR "treatment outcome"[majr]

OR "outcome assessment, health care"[majr])
Complications of Surgery & Complications of IOLs: (((((((("cataract extraction"[majr]) AND

(("postoperative complications"[majr]) OR "intraoperative complications"[majr]))) OR "cataract
extraction/adverse effects"[MeSH Major Topic]) OR (("lenses, intraocular/adverse effects"[majr]) AND
(cataract[tiab] OR cataracts[tiab]))) OR (("lenses, intraocular"[MAJR]) AND ("Postoperative
Complications"[MAJR) AND (cataract[tw] OR cataracts[tw]))) OR (("lenses, intraocular"[MAJR]) AND
("Intraoperative Complications"[MAJR) AND (cataract[tw] OR cataracts[tw]))) OR "lens implantation,
intraocular/adverse effects"[MeSH Terms]) OR ("lens capsule, crystalline/injuries"[MeSH Terms] AND
(cataract[tw] OR cataracts[tw]))
Ocular Comorbidities: ((((((((((((((((("uveitis"[mh] OR uveitis[tiab])) OR ("diabetic retinopathy"[mh] OR

"diabetic retinopathy"[tiab])) OR ("macular degeneration"[mh] OR "macular degeneration"[tiab])) OR
("amblyopia"[mh] OR amblyopia[tiab])) OR (glaucoma[mh] OR glaucoma[tiab])) OR ("exfoliation
Syndrome"[mh] OR “exfoliation syndrome”[tiab] OR "retinopathy of prematurity"[mh] OR “retinopathy of
prematurity”[tiab])) OR (fuchs*[tiab] AND dystrophy[tiab])) OR ("cloudy cornea"[tiab] OR "cloudy
corneas"[tiab] OR (cloud*[tiab] AND cornea*[tiab]))) OR ((miotic[tiab] OR miosis[tiab]) AND pupil[tiab]))
OR ((high[tiab] OR highly[tiab]) AND myop*[tiab])) OR ((high[tiab] OR highly[tiab]) AND
hyperopi*[tiab])) OR (scleral[tiab] AND buckling[tiab])) OR "posterior synechiae"[tiab])) AND
((((("cataract extraction"[mh] OR "cataract surgery"[tiab] OR “cataract extraction”[tiab] OR cataract[tiab]))
AND ("comorbidity"[mh] OR complications[tiab])))) OR "cataract/complications"[mh]))) OR ((("cataract
extraction"[mh] OR "cataract surgery"[tiab] OR “cataract extraction”[tiab] OR cataract[tiab])) AND
("comorbidity"[mh] OR comorbidities[tiab]))
Systemic Comorbidities: ((("cataract extraction"[mh] OR "cataract surgery"[tiab] OR "cataract

extraction"[tiab] OR cataract[tiab]))) AND ((((((systemic[tiab]) AND (comorbidity[tiab] OR
comorbidities[tiab]))) OR (("systemic comorbidity"[tiab]) OR "systemic comorbidities"[tiab]))) OR
((hypertension[tiab] OR diabetes[tiab] OR diabetic[tiab] OR myocardial infarct[tiab] OR cardiac[tiab] OR
asthma[tiab] OR thyroid disease[tiab] OR thyroid[tiab] OR hiv[tiab] OR “renal disease”[tiab] OR
angina[tiab] OR cancer[tiab] OR stroke[tiab] OR “chronic disease”[tiab] OR anticoagulants[mh] OR "platelet
aggregation inhibitors"[mh])))
Cataract Surgery & Vitreoretinal Surgery: ((("cataract extraction"[mh] OR "cataract surgery"[tiab] OR

"cataract extraction"[tiab] AND cataract[tiab]))) AND (((("vitrectomy"[tiab] OR "vitreoretinal
surgery"[tiab])) OR (vitreoretinal[tiab] AND (surgery[tiab] OR surgeries[tiab]))) OR "vitrectomy"[mh])
Cataract in the Functionally Monocular Patient: ((("cataract extraction"[mh] OR "cataract surgery"[tiab] OR

“cataract extraction”[tiab]))) AND (Vision, Monocular[mh])
Presbyopia-correcting intraocular lenses: ("presbyopia"[mh]) AND ("lenses, intraocular"[mh] OR

“intraocular lenses”[tiab])
Simultaneous Bilateral Cataract Surgery: ((("cataract extraction"[mh] OR "cataract surgery"[tiab] OR

“cataract extraction”[tiab]))) AND (bilateral[tiab] OR "same-day"[tiab] OR simultaneous[tiab] OR
sequential[tiab]))
Postoperative Management, Postoperative Follow-up: ("cataract extraction"[mh] OR "cataract surgery"[tiab]

OR “cataract extraction”[tiab]) AND ("Postoperative Care"[mh]) AND ("time factors" [mh])
Posterior Capsular Opacification: ("cataract extraction"[mh] OR "cataract surgery"[tiab] OR “cataract

extraction”[tiab]) AND ("posterior capsular opacification"[tiab])
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Cost of Cataract Sx: (((("cataract extraction"[mh] OR "cataract surgery"[tiab] OR “cataract

extraction”[tiab])))) AND (("cost benefit analysis"[mh] OR "cost control"[mh] OR "cost savings"[mh] OR
cost[tiab]))
Nutrition: (((("cataract"[majr]) OR "cataract/epidemiology"[mh]) OR ("cataract/prevention and

control"[mh]))) AND (((("nutrition assessment"[mh]) OR ("diet"[mh]) OR (diet surveys[mh]) OR
("nutritional physiological phenomena"[mh]) OR (fruit[mh]) OR (vegetables[mh]) OR ("vitamins"[mh]) OR
("minerals"[mh]) OR ("antioxidants"[mh]) OR ("dietary supplements"[mh]) OR ("beta carotene"[mh]) OR
("riboflavin"[mh]) OR ("niacin"[mh]) OR ("ascorbic acid"[mh]) OR ("vitamin e"[mh]))))
Cataract Surgery & Uveitis: ("cataract extraction"[mh] OR "cataract surgery"[tiab] OR “cataract

extraction”[tiab]) AND (Uveitis[mh] OR uveitis[tiab])
Cataract Surgery & Immunosuppression: ("cataract extraction"[mh] OR "cataract surgery"[tiab] OR “cataract

extraction”[tiab]) AND "Immunosuppression"[Mesh]
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Adult Eye PPP
LIST OF ABBREVIATIONS
ADVS: Activities of Daily Vision Scale

AMD: age-related macular degeneration
AREDS: Age-Related Eye Disease Study
ASCRS: American Society of Cataract and Refractive Surgery
CDVA: corrected distance visual acuity
CME: cystoid macular edema
CTR: capsule tension ring
D: diopter
DME: diabetic macular edema
DMEK: Descemet membrane endothelial keratoplasty
DSBCS: delayed bilateral cataract surgery
DSEK: Descemet stripping endothelial keratoplasty
ECCE: extracapsular cataract extraction
EDOF: extended depth of focus
ESCRS: European Society of Cataract and Refractive Surgeons
EVS: Endophthalmitis Vitrectomy Study
FEMCAT: femtosecond laser-assisted versus phacoemulsification cataract surgery
FLACS: femtosecond laser-assisted cataract surgery
HORV: hemorrhagic occlusive retinal vasculitis
HSM: heparin-surface-modified
IFIS: intraoperative floppy iris syndrome
IOL: intraocular lens
IOP: intraocular pressure
IRIS: Intelligent Research in Sight
ISBCS: immediate sequential bilateral cataract surgery
IV: intravenous
LASIK: Laser-assisted in situ keratomileusis
LEC: lens epithelial cells
MIGS: minimally invasive glaucoma surgery
MIPS: merit-based incentive payment system
MSICS: manual small-incision cataract extraction
Nd:YAG: neodymium: yttrium-aluminum-garnet
NEI-VFQ: National Eye Institute-Visual Function Questionnaire
NEON: National Eyecare Outcomes Network
NSAID: nonsteroidal anti-inflammatory drug
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OCT: optical coherence tomography

OVD: ophthalmic viscosurgical device
PCO: posterior capsular opacification
PK: penetrating keratoplasty
PMMA: polymethyl methacrylate
PORT: Patient Outcomes Research Team
PPP: Preferred Practice Pattern
PPV: Pars plana vitrectomy
PRK: Photorefractive keratectomy
PROM: Patient-reported outcome measure
PSC: posterior subcapsular cataract
QALY: quality-adjusted life year
RCT: randomized controlled trial
RD: retinal detachment
RK: radial keratotomy
TASS: toxic anterior segment syndrome
TPSS: toxic posterior segment syndrome
UDVA: uncorrected distance visual acuity
UGH: Uveitis, Glaucoma, Hyphema
VF-14: visual function index
VF-8R: visual function index
RELATED ACADEMY MATERIALS
Basic and Clinical Science Course

Clinical Optics (Section 3, 2021-2022)
Lens and Cataract (Section 11, 2021–2022)
Focal Points
Cataract Surgery in the Developing World (2011)
Diagnosis and Management of Cataract after Vitrectomy (2016)
Femtosecond Laser-assisted Cataract Surgery (2015)
Pseudophakic Cystoid Macular Edema (2012)
Patient Education Booklets
Cataract Surgery
Enhanced Lens Options for Cataract Surgery
Patient Education Brochures
Cataract
Cataract (Spanish: Catarata)
Cataract Surgery
Enhanced Lens Option for Cataract Surgery
Posterior Capsulotomy
Multifocal and Accommodative IOLs
Laser Eye Surgery
Patient Education Downloadable Videos
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in the Adult
Cataract and Refractive Surgery Patient Education Video Collection

Performance Improvement CME
Wrong Site/Wrong IOL Surgery Performance Improvement CME – Available at: www.aao.org/pi-
cme/wrong-site-wrong-iol (login required)
Preferred Practice Pattern® Guidelines – Free downloads available at www.aao.org/ppp.
Comprehensive Adult Medical Eye Evaluation (2020)
To order any of these materials, except for the free materials, please contact the Academy’s Customer Service
at 866.561.8558 (U.S. only) or 415.561.8540 or www.aao.org/store.
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Adult Eye Preferred

Secretary for Quality of Care

Medical Editor: Susan Garratt

Approved by: Board of Trustees

Copyright © 2021 American Academy of Ophthalmology®

AMERICAN ACADEMY OF OPHTHALMOLOGY and PREFERRED PRACTICE PATTERN are

American Academy of Ophthalmology®

CATARACT AND ANTERIOR SEGMENT

Cataract and Anterior Segment Preferred Practice Pattern Panel 2020–2021

Preferred Practice Patterns Committee 2021

Academy Reviewers Association of University Professors in Ophthalmology*

Cataract and Anterior Segment Preferred Practice Pattern Panel 2020–2021

Preferred Practice Patterns Committee 2021

Secretary for Quality of Care

OBJECTIVES OF PREFERRED PRACTICE

METHODS AND KEY TO RATINGS

 Key recommendations for care are defined by GRADE 2 as follows:

HIGHLIGHTED FINDINGS AND

TABLE 1 FACTORS ASSOCIATED WITH INCREASED RISK OF CATARACT DEVELOPMENT*

Family history20, 41-45

TABLE 1 FACTORS ASSOCIATED WITH INCREASED RISK OF CATARACT DEVELOPMENT* (CONTINUED)

*All associations determined by observational study.

VISUAL FUNCTION AND QUALITY OF LIFE

PATIENT OUTCOME CRITERIA

Evaluation of Visual Impairment

Supplemental Ophthalmic Testing

Electrophysiologic testing (e.g., electroretinography and visual evoked potential) measures

Optic Nerve and Central Nervous System Testing

Indications for Surgery

Preoperative Evaluation and Counseling

controlled diabetes), a preoperative medical evaluation by the patient's primary care

Biometry and Intraocular Lens Power Calculation

central corneal power is particularly challenging (see Cataract Surgery Following

TABLE 2 INTRAOCULAR LENS POWER CALCULATION

Haigis  Anterior chamber depth  Uses double regression analysis to optimize

Hill-RBF  Anterior chamber depth  Uses artificial intelligence for pattern

Hoffer Q294-296  None  Optimizes equation constant (personalized

Holladay 1  None  Optimizes surgeon factor to derive anterior

Holladay 2  Anterior chamber depth  Adds additional variables to Holladay 1

Kane297, 298  Anterior chamber depth  Based on theoretical optics incorporating

SRK/T300  None  Combines theoretical optics with regression

Patients undergoing cataract surgery with topical or peribulbar anesthesia occasionally

Intracameral Injection in combination with postoperative topical drops

administration.422, 423 Following initial studies in Sweden,423 a seminal large, prospective,

Intracameral injection alone

Toxic anterior segment syndrome

reusable instruments with single-use, disposable products is another strategy to avoid

Toxic posterior segment syndrome

Cataract Surgery Checklist

Intraocular Lens Materials, Design, and Implantation

Intraocular Lens Optical Considerations

Capsular Bag Fixation

Alternatives to Capsular Bag Fixation

Iris suture fixation

Sutured inner scleral, intrascleral, or transscleral fixation

Anterior chamber fixation

Complications of Cataract Surgery

TABLE 3 COMPLICATION RATES FROM SELECTED STUDIES OF CATARACT SURGERY