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GPAC: Guidelines and Protocols Advisory Committee Cataract - Treatment of Adults Effective Date: September 1, 2005 Summary | Flow Sheet | Patient Guide | Full Guideline in PDF Recommendations and TopicsScopeThis guideline provides recommendations for the management of cataracts in adults (age 19 and older). The goal is to:
 RECOMMENDATION 1: Non-Surgical ManagementDuring early cataract development, visual improvement may be achieved through a number of means including:
Pupillary dilatation has a limited role in the management of posterior subcapsular cataracts. RECOMMENDATION 2: Surgical ManagementThe presence of a cataract does not itself indicate a need for surgery. Cataract surgery may be indicated when the cataract reduces visual function to a level that interferes with everyday activities of the patient and the patient desires surgical intervention to improve vision. Glare testing and potential acuity testing can be useful in certain cases in the decision to recommend or not recommend cataract surgery. The following specific indications for cataract surgery are suggested: a) Visual disability and Snellen Acuity of 20/50 or worse The visual impairment produced by the cataract is responsible for the patient's disability in carrying out needed or desired activities (driving, reading, occupational needs) and the best correctable visual acuity in the affected eye is 20/50 or worse. b) Visual disability and Snellen Acuity of 20/40 or better The visual impairment produced by the cataract is responsible for the patient's disability in carrying out needed or desired activities (driving, reading, occupational needs), as documented by any of the following reasons:
and the best correctable visual acuity in the affected eye is 20/40 or better. c) Other indications for cataract removal
d) Visual ability in patients legally blind in one eye The indications for surgery in patients with cataract in one eye who are legally blind in the other eye are the same as for other patients, except that the risk of total blindness must be considered and emphasized. RECOMMENDATION 3: Contraindications for SurgerySurgery should not be performed solely to improve vision if:
RECOMMENDATION 4: Second Eye SurgeryAlthough the risks of loss of an eye or blindness in cataract surgery are very small, only in very exceptional circumstances where there are documented medical reasons should surgery be done on both eyes at the same time. In individuals who are pseudophakic in one eye and require cataract surgery at a later date, an interval of at least one week should occur to assess the benefit of the first surgery before the second eye is done (endophthalmitis may not be evident until 7 days after surgery). Evidence The Cataract Guideline Working Group of the Guidelines and Protocols Advisory Committee (GPAC) reviewed the guideline Treatment of Cataract in Adults, developed in 1996 by the British Columbia Council on Clinical Practice Guidelines. The Working Group was made up of practising physicians including cataract experts, an endocrinologist/internist, general practitioners, and a Ministry of Health medical consultant. The Council's 1996 guideline was adapted from the work of the College of Physicians and Surgeons of B.C., which was based on the Agency for Health Care Policy and Research (AHCPR) guideline of 1993. The AHCPR stated that there was a lack of literature demonstrating precise indications for surgery and recommended adoption of the American Academy of Ophthalmology's (AAO) 1989 and 1991 Preferred Practice Patterns (PPP), which, the AHCPR stated, lacked scientific evidence to support their validity, but were developed by an exhaustive consensus method. The 1989 and 1991 PPPs are superseded by the AAO's 1996 PPP Cataract in the Adult Eye. This GPAC Working Group revised guideline remains consistent with AAO recommendations. The Cataract Guideline Working Group reviewed material published since the release of the 1996 B.C. guideline, as well as the original literature. The Working Group found that while some new material has added to the general knowledge base and to the body of evidence regarding indications for and outcomes of cataract surgery, there are still relatively few published papers concerning evidence for the procedure and its outcomes. There are studies underway that could, in future, contribute to a stronger evidence base. Benefits, Risks and CostsCataracts are one of the more common problems associated with ageing and occur as well, for specific medical reasons, in younger individuals. Benefits: The primary benefit of both surgical and non-surgical treatment of cataracts is the functional rehabilitation of affected individuals leading to an improvement in vision and greater autonomy and independence. A review of the literature shows that if no co-morbid ocular conditions exist, cataract surgery results in an improvement in visual acuity in >95 per cent of patients and, if there is co-morbidity, an improvement in visual acuity in >80 per cent of patients. If the patient has other vision problems, such as macular degeneration, the improvement in visual acuity can be less than 80 per cent. Risks: Risks include anaesthetic and surgical complications (serious complications include endophthalmitis, retinal detachment and hemorrhage), decreased vision and blindness (less than 1:1000), and general complications associated with surgery in the elderly, especially those with other or multisystem illness. Complications are rare, the most common post-operative complication being posterior capsular opacity which may occur in up to 40 per cent of patients using polymethylmethacrylate lenses. These can be treated by Nd:YAG laser surgery. Costs: The cost of cataract treatment to the health system is significant. In 2003/04, 40,000 cataract surgeries were performed at a cost of $17 million in surgical fees alone. Other significant costs include fees for anaesthesia, consultations and office visits, and office expenses for equipment and staff. References
SponsorsThis guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association and adopted by the Medical Services Commission. Funding for this guideline was provided in full or part through the Primary Health Care Transition Fund. Revised Date: April 1, 2007This guideline is based on scientific evidence current as of the effective date. The principles of the Guidelines and Protocols Advisory Committee are:
DisclaimerThe Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems. PDF Format Some documents on this Web site are in PDF format and require a PDF reader. If you do not have Adobe Acrobat Reader Version 7.0 or the most recent version of another PDF reader, you can download Adobe Acrobat Reader by clicking on the 'Get Acrobat Reader' icon.
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