Follow-up
Further Inpatient Care
- Most cataract surgeries are performed on an outpatient basis, especially with the onset of phacoemulsification performed under topical anesthesia. Often, patients are discharged from the clinic as soon as they have recovered from the emotional stress of the procedure. Patients are sent home on topical steroids and antibiotics either separately or in combination. An eye shield is placed on the newly operated eye and removed a few hours later.
Further Outpatient Care
- On the first postoperative day, visual acuity should be consistent with the refractive state of the eye, the clarity of the cornea and media, and the visual potential of the retina and optic nerve. Mild edema of the eyelid may be evident, as well as some conjunctival injection. The cornea is normally clear with minimal edema and striae. The anterior chamber should be deep with mild cellular reaction. It is important to check whether the posterior capsule is intact and whether the IOL is positioned properly. The red reflex must be strong and clear and the intraocular pressures should be within normal limits. Transient intraocular pressure elevations may be observed and attributed to retained viscoelastic.
- Significant improvement of these initial findings is to be expected in subsequent postoperative evaluation as the ocular inflammation subsides typically within 2 weeks. Topical steroids and antibiotics are tapered accordingly. Refraction is believed to be stable at the sixth to eighth postoperative week, at which time corrective lenses can be prescribed. Significant postoperative astigmatism can be addressed by suture removal by the sixth week as guided by keratometry or corneal topography.
Inpatient & Outpatient Medications
- During the postoperative period, the patient is prescribed topical 1% prednisolone acetate, which is applied every hour for the first day, then tapered depending on the inflammatory state of the eye. Studies have shown that topical ketorolac tromethamine provides adequate postoperative control of intraocular inflammation without the risk of increased intraocular pressure, which may be associated with steroid use. A broad-spectrum topical antibiotic also is given 4-6 times a day for 1-2 weeks.
Deterrence/Prevention
- Age is believed to be the most significant risk factor for senile cataract and, as such, it is almost inevitable to develop some degree of lens opacity as one becomes older. No study has established firmly whether avoidance of some of the risk factors for senile cataract (eg, UV exposure, hypercholesterolemia, diabetes mellitus) will lessen the chance of developing a senile cataract.
Complications
- The following are the major intraoperative complications encountered during cataract surgery:
- Shallow or flat anterior chamber
- Capsular rupture
- Corneal edema
- Suprachoroidal hemorrhage or effusion
- Expulsive choroidal hemorrhage
- Retained lens material
- Vitreous disruption and incarceration into wound
- Iridodialysis
- Retinal light toxicity
- The following are the major immediate postoperative complications encountered during cataract surgery often seen within a few days or weeks after the operation:
- Flat or shallow anterior chamber due to wound leak
- Choroidal detachment
- Pupillary block
- Ciliary block
- Suprachoroidal hemorrhage
- Stromal and epithelial edema
- Hypotony
- Brown-McLean syndrome (peripheral corneal edema with a clear central cornea most frequently seen following ICCE)
- Vitreocorneal adherence and persistent corneal edema
- Delayed choroidal hemorrhage
- Hyphema
- Elevated intraocular pressure (often due to retained viscoelastic)
- Cystoid macular edema - Studies have shown that diclofenac was more effective than topical steroids in preventing CME.12
- Retinal detachment - Significant risk factors include axial length greater than 25 mm, age younger than 65 years, and intraoperative complications.13
- Acute endophthalmitis
- Uveitis-glaucoma-hyphema (UGH) syndrome
- The following are the major late postoperative complications seen weeks or months after cataract surgery:
- Suture-induced astigmatism
- Pupillary capture
- Decentration and dislocation of the IOL
- Corneal edema and pseudophakic bullous keratopathy
- Chronic uveitis
- Chronic endophthalmitis
- Wrong power of IOL used
- At any stage of the postoperative recovery of the eye, a risk of noninfectious endophthalmitis and infectious endophthalmitis exists. Noninfectious endophthalmitis is believed to be a multifactorial process or an interindividual variable response to a common factor as a hypersensitivity reaction. Treatment may range from the use of topical, transseptal, or oral steroids to the explantation of the intraocular lens.
- Although of low incidence, infectious endophthalmitis may lead to severe vision loss and blindness.14 Staphylococcus epidermidis is the most common isolated organism, and rupture of the posterior capsule is one of the most common risk factors.14 Of late, a significant increase in the incidence of gram-positive bacteria in bacterial isolates from postoperative eyes suspected of having endophthalmitis has been observed. Furthermore, a significant increase in resistance to ciprofloxacin has occurred. Seemingly, the spectrum of bacteria causing postcataract endophthalmitis is changing partly because of an increased resistance to mainstay antibiotics in the treatment of endophthalmitis.
Prognosis
- In the absence of any other accompanying ocular disease prior to surgery, which would affect significantly the visual outcome, such as macular degeneration or optic nerve atrophy, a successful uncomplicated standard ECCE or phacoemulsification carries a very promising visual prognosis of gaining at least 2 lines in the Snellen distance vision chart. The main cause of visual morbidity postoperatively is CME. A major risk factor affecting visual prognosis is the presence of diabetes mellitus and diabetic retinopathy.
Patient Education
- To date, no established guidelines are available for the prevention of senile cataracts. Education programs are geared toward early detection and surgical intervention when vision is impaired functionally. With the advent of phacoemulsification, patients are advised against delaying lens extraction to the point when the cataract is hard and mature and the likelihood of postoperative complications increases.
- For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education article Cataracts.
Miscellaneous
Medicolegal Pitfalls
- Tasked with the pivotal role of restoring vision to a functionally impaired patient, the cataract surgeon must now also confront issues that may ultimately jeopardize the medical practice, for example, malpractice litigation, administrative sanctions in the form of expulsion from participation in third-party reimbursement plans, revocation or cancellation of hospital privileges, and, ultimately, limitation or loss of the license to practice. In addition, cut-throat competition coupled with profound changes in the eye care delivery system makes it necessary for the surgeon to be aware of the legal intricacies affecting increased productivity and income creation.
- The onset of office setting phacoemulsification under topical anesthesia performed in less than 30 minutes ironically has turned the art of cataract surgery into an industry. Remaining productive, creative, and fairly paid is both a concern and a challenge to the modern-day cataract surgeon. As such, the surgeon must be well informed of what is and what is not legal, to thrive and remain in business. Rabin grouped the current legal concerns of the ophthalmologist into 3 categories: (1) conventional malpractice liability, (2) surveillance for regulatory compliance, and (3) practice productivity and income creation.15
More on Cataract, Senile |
| Overview: Cataract, Senile |
| Differential Diagnoses & Workup: Cataract, Senile |
| Treatment & Medication: Cataract, Senile |
 Follow-up: Cataract, Senile |
| References |
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References
Meddings DR, Marion SA, Barer ML, Evans RG, Green B, Hertzman C, et al. Mortality rates after cataract extraction. Epidemiology. May 1999;10(3):288-93. [Medline].
Hirsch RP, Schwartz B. Increased mortality among elderly patients undergoing cataract extraction. Arch Ophthalmol. Jul 1983;101(7):1034-7. [Medline].
Sperduto RD, Hiller R. The prevalence of nuclear, cortical, and posterior subcapsular lens opacities in a general population sample. Ophthalmology. Jul 1984;91(7):815-8. [Medline].
Nishikiori T, Yamamoto K. Epidemiology of cataracts. Dev Ophthalmol. 1987;15:24-7. [Medline].
Martinez GS, Campbell AJ, Reinken J, Allan BC. Prevalence of ocular disease in a population study of subjects 65 years old and older. Am J Ophthalmol. Aug 1982;94(2):181-9. [Medline].
West SK, Valmadrid CT. Epidemiology of risk factors for age-related cataract. Surv Ophthalmol. Jan-Feb 1995;39(4):323-34. [Medline].
Miglior S, Marighi PE, Musicco M, Balestreri C, Nicolosi A, Orzalesi N. Risk factors for cortical, nuclear, posterior subcapsular and mixed cataract: a case-control study. Ophthalmic Epidemiol. Jun 1994;1(2):93-105. [Medline].
Johns KJ, Feder RS, Rosenfeld SI, et al. Lens and cataract. In: American Academy of Ophthalmology Basic and Clinical Science Course. Vol. 11. 1999-2000.
Al-Ghadyan AA, Cotlier E. Rise in lens temperature on exposure to sunlight or high ambient temperature. Br J Ophthalmol. Jun 1986;70(6):421-6. [Medline].
Costello MJ, Oliver TN, Cobo LM. Cellular architecture in age-related human nuclear cataracts. Invest Ophthalmol Vis Sci. Oct 1992;33(11):3209-27. [Medline].
Bell CM, Hatch WV, Fischer HD, Cernat G, Paterson M, Gruneir A, et al. Association between tamsulosin and serious ophthalmic adverse events in older men following cataract surgery. JAMA. May 20 2009;301(19):1991-6. [Full Text].
Asano S, Miyake K, Ota I, Sugita G, Kimura W, Sakka Y, et al. Reducing angiographic cystoid macular edema and blood-aqueous barrier disruption after small-incision phacoemulsification and foldable intraocular lens implantation: multicenter prospective randomized comparison of topical diclofenac 0.1% and betamethasone 0.1%. J Cataract Refract Surg. Jan 2008;34(1):57-63. [Medline].
Szijarto Z, Schvoller M, Poto L, Kuhn F, Kovacs B. Pseudophakic retinal detachment after phacoemulsification. Ann Ophthalmol (Skokie). Jun 2007;39(2):134-9. [Medline].
Cao X, Liu A, Zhang J, Li Y, Jie Y, Liu W, et al. Clinical analysis of endophthalmitis after phacoemulsification. Can J Ophthalmol. Dec 2007;42(6):844-8. [Medline].
Rabin SM. Medicolegal concerns of cataract surgeons. In: Management and Care of the Cataract Patient. 1992:331-8.
Belkin M, Jacobs DR, Jackson SM, Zwick H. Senile cataracts and myopia. Ann Ophthalmol. Jan 1982;14(1):49-50. [Medline].
Bellows JG, Bellows RT. Crosslinkage theory of senile cataracts. Ann Ophthalmol. Feb 1976;8(2):129-35. [Medline].
Bilge AH, Aykan U, Akin T, Unsal U. Review of sterile, postoperative, anterior segment inflammation following cataract extraction and intraocular lens implantation. Eur J Ophthalmol. Mar-Apr 2005;15(2):224-7. [Medline].
Bunce GE, Kinoshita J, Horwitz J. Nutritional factors in cataract. Annu Rev Nutr. 1990;10:233-54. [Medline].
Burgess CA, Sowers M. Systemic hypertension and senile cataracts: an epidemiologic study. Optom Vis Sci. Apr 1992;69(4):320-4. [Medline].
Charakidas A, Kalogeraki A, Tsilimbaris M, Koukoulomatis P, Brouzas D, Delides G. Lens epithelial apoptosis and cell proliferation in human age-related cortical cataract. Eur J Ophthalmol. Mar-Apr 2005;15(2):213-20. [Medline].
Chatterjee A, Milton RC, Thyle S. Prevalence and aetiology of cataract in Punjab. Br J Ophthalmol. Jan 1982;66(1):35-42. [Medline].
Chylack LT Jr. Mechanisms of senile cataract formation. Ophthalmology. Jun 1984;91(6):596-602. [Medline].
Eckerskorn U, Hockwin O, Muller-Breitenkamp R, Chen TT, Knowles W, Dobbs RE. Evaluation of cataract-related risk factors using detailed classification systems and multivariate statistical methods. Dev Ophthalmol. 1987;15:82-91. [Medline].
Emery JM, Wilhelmus KA, Rosenberg S. Complications of phacoemulsification. Ophthalmology. Feb 1978;85(2):141-50. [Medline].
Fujiwara H, Takigawa Y, Suzuki T, Nakata K. Superoxide dismutase activity in cataractous lenses. Jpn J Ophthalmol. 1992;36(3):273-80. [Medline].
Ghafour IM, Allan D, Foulds WS. Common causes of blindness and visual handicap in the west of Scotland. Br J Ophthalmol. Apr 1983;67(4):209-13. [Medline].
Gibson JM, Rosenthal AR, Lavery J. A study of the prevalence of eye disease in the elderly in an English community. Trans Ophthalmol Soc U K. 1985;104 (Pt 2):196-203. [Medline].
Gibson JM, Shaw DE, Rosenthal AR. Senile cataract and senile macular degeneration: an investigation into possible risk factors. Trans Ophthalmol Soc U K. 1986;105 (Pt 4):463-8. [Medline].
Hirneiss C, Neubauer AS, Kampik A, Schönfeld CL. Comparison of prednisolone 1%, rimexolone 1% and ketorolac tromethamine 0.5% after cataract extraction: a prospective, randomized, double-masked study. Graefes Arch Clin Exp Ophthalmol. Aug 2005;243(8):768-73. [Medline].
Hollows F, Moran D. Cataract--the ultraviolet risk factor. Lancet. Dec 5 1981;2(8258):1249-50. [Medline].
Hu TS, Lao YX. An epidemiologic survey of senile cataract in China. Dev Ophthalmol. 1987;15:42-51. [Medline].
Imbach P, Odavic R, Bleher EA, Bucher U, Deubelbeiss KA, Wagner HP. [Autologous bone marrow reimplantation in children with advanced tumor. First experiences of feasibility]. Schweiz Med Wochenschr. Feb 24 1979;109(8):283-7. [Medline].
Jacques PF, Chylack LT Jr, McGandy RB, Hartz SC. Antioxidant status in persons with and without senile cataract. Arch Ophthalmol. Mar 1988;106(3):337-40. [Medline].
Javitt JC, Taylor HR. Cataract and latitude. Doc Ophthalmol. 1994-1995;88(3-4):307-25. [Medline].
Kador PF. Overview of the current attempts toward the medical treatment of cataract. Ophthalmology. Apr 1983;90(4):352-64. [Medline].
Kahn HA, Leibowitz HM, Ganley JP, Kini MM, Colton T, Nickerson RS, et al. The Framingham Eye Study. I. Outline and major prevalence findings. Am J Epidemiol. Jul 1977;106(1):17-32. [Medline].
Kamei A. Characterization of water-insoluble proteins in normal and cataractous human lens. Jpn J Ophthalmol. 1990;34(2):216-24. [Medline].
Kamei A. Glutathione levels of the human crystalline lens in aging and its antioxidant effect against the oxidation of lens proteins. Biol Pharm Bull. Sep 1993;16(9):870-5. [Medline].
Katoh N, Sasaki K, Shibata T, Obazawa H, Fujiwara T, Kogure F, et al. Case-control study of senile cataract in Japan: a preliminary report. Jpn J Ophthalmol. 1993;37(4):467-77. [Medline].
Ke Y, Jiang J, Chen P, Weng Y, Yang Y. Phacoemulsification and posterior chamber intraocular lens implantation. Zhonghua Yan Ke Za Zhi. Mar 1996;32(2):85-91. [Medline].
Kini MM, Leibowitz HM, Colton T, Nickerson RJ, Ganley J, Dawber TR. Prevalence of senile cataract, diabetic retinopathy, senile macular degeneration, and open-angle glaucoma in the Framingham eye study. Am J Ophthalmol. Jan 1978;85(1):28-34. [Medline].
Knekt P, Heliövaara M, Rissanen A, Aromaa A, Aaran RK. Serum antioxidant vitamins and risk of cataract. BMJ. Dec 5 1992;305(6866):1392-4. [Medline].
Lee SM, Lin SY, Li MJ, Liang RC. Possible mechanism of exacerbating cataract formation in cataractous human lens capsules induced by systemic hypertension or glaucoma. Ophthalmic Res. 1997;29(2):83-90. [Medline].
Lu M, Taylor A, Chylack LT Jr, Rogers G, Hankinson SE, Willett WC, et al. Dietary fat intake and early age-related lens opacities. Am J Clin Nutr. Apr 2005;81(4):773-9. [Medline].
Lydahl E. Infrared radiation and cataract. Acta Ophthalmol Suppl. 1984;166:1-63. [Medline].
Moffat BA, Landman KA, Truscott RJ, Sweeney MH, Pope JM. Age-related changes in the kinetics of water transport in normal human lenses. Exp Eye Res. Dec 1999;69(6):663-9. [Medline].
Mozaffarieh M, Heinzl H, Sacu S, Wedrich A. Clinical outcomes of phacoemulsification cataract surgery in diabetes patients: visual function (VF-14), visual acuity and patient satisfaction. Acta Ophthalmol Scand. Apr 2005;83(2):176-83. [Medline].
Packer M, Fishkind WJ, Fine IH, Seibel BS, Hoffman RS. The physics of phaco: a review. J Cataract Refract Surg. Feb 2005;31(2):424-31. [Medline].
Papamatheakis DG, Demers P, Vachon A, Jaimes LB, Lapointe Y, Harasymowycz PJ. Thrombocytopenia and the risks of intraocular surgery. Ophthalmic Surg Lasers Imaging. Mar-Apr 2005;36(2):103-7. [Medline].
Recchia FM, Busbee BG, Pearlman RB, Carvalho-Recchia CA, Ho AC. Changing trends in the microbiologic aspects of postcataract endophthalmitis. Arch Ophthalmol. Mar 2005;123(3):341-6. [Medline].
Robertson JM, Donner AP, Trevithick JR. A possible role for vitamins C and E in cataract prevention. Am J Clin Nutr. Jan 1991;53(1 Suppl):346S-351S. [Medline].
Sack R, Cohen J. Comparative diets of a idiopathic senile cataract and normal population: dietary risk factors in cataractogenesis. Metab Pediatr Syst Ophthalmol. 1987;10(1):9-13. [Medline].
Shaikh MR, Janjua MZ. Morphological and morphometrical study of human lens in senile cataract. J Pak Med Assoc. May 1997;47(5):141-4. [Medline].
Sharma YR, Vajpayee RB, Honavar SG. Sunlight and cortical cataract. Arch Environ Health. Sep-Oct 1994;49(5):414-7. [Medline].
Sommer A. Cataracts as an epidemiologic problem. Am J Ophthalmol. Mar 1977;83(3):334-9. [Medline].
Sommer A, Tielsch JM, Katz J, Quigley HA, Gottsch JD, Javitt JC, et al. Racial differences in the cause-specific prevalence of blindness in east Baltimore. N Engl J Med. Nov 14 1991;325(20):1412-7. [Medline].
Steinkuller PG. Cataract: the leading cause of blindness and vision loss in Africa. Soc Sci Med. 1983;17(22):1693-702. [Medline].
Street DA, Javitt JC. National five-year mortality after inpatient cataract extraction. Am J Ophthalmol. Mar 15 1992;113(3):263-8. [Medline].
Tseng SH, Tang MJ. Na,K-ATPase in lens epithelia from patients with senile cataracts. J Formos Med Assoc. Sep 1999;98(9):627-32. [Medline].
Tseng SH, Yen JS, Chien HL. Lens epithelium in senile cataract. J Formos Med Assoc. Feb 1994;93(2):93-8. [Medline].
Worgul BV, Merriam GR Jr, Medvedovsky C. Cortical cataract development--an expression of primary damage to the lens epithelium. Lens Eye Toxic Res. 1989;6(4):559-71. [Medline].
Wu TT, Amini L, Leffler CT, Schwartz SG. Cataracts and cataract surgery in mentally retarded adults. Eye Contact Lens. Mar 2005;31(2):50-3. [Medline].
Further Reading
Keywords
senile cataract, age-related cataract, vision loss, visual deficit, blindness
