Senile Cataract (Age-Related Cataract) 

Updated: Mar 02, 2021
Author: Vicente Victor Dizon Ocampo, Jr, MD; Chief Editor: Andrew A Dahl, MD, FACS 

Overview

Practice Essentials

Senile cataract is an age-related, vision-impairing disease characterized by gradual progressive clouding and thickening of the lens of the eye. It is the world’s leading cause of treatable blindness.

Signs and symptoms

A patient with senile cataract often presents with a history of gradual progressive visual deterioration and disturbance in night and near vision. Characteristic symptoms of senile cataract include the following:

  • Decreased visual acuity - The most common complaint of patients with senile cataract
  • Glare - Can range from a decrease in contrast sensitivity in brightly lit environments or disabling glare during the day to glare with oncoming headlights at night
  • Myopic shift - The progression of cataracts frequently increases the anteroposterior (AP) axis and therefore the dioptric power of the lens, resulting in a mild to moderate degree of increased myopia or myopic shift
  • Monocular diplopia - - At times, the nuclear changes are concentrated in the inner layers of the lens, resulting in a refractile area in the center of the lens, the so called “lens within a lens” phenomenon, which may lead to monocular diplopia that is not correctable with spectacles, prisms, or contact lenses

Diagnosis

A complete ocular examination must be performed, beginning with visual acuity for near and far distances. When the patient complains of glare, visual acuity should be tested in a brightly lit room. Contrast sensitivity may also be checked, especially if the history points to a possible problem.

Diagnosis can also include the following:

  • Examination of the ocular adnexa and intraocular structures - May provide clues to the patient's cataract etiology, concomitant disease, and eventual visual prognosis
  • Swinging flashlight test - Detects a Marcus Gunn pupil or a relative afferent pupillary defect (RAPD) indicative of optic nerve lesions or severe diffuse retinal involvement
  • Slit lamp examination - Should concentrate on the evaluation of not only lens opacity but also other ocular structures (eg, conjunctiva, cornea, iris, anterior chamber)
  • Examination of nuclear size and brunescence - After dilation, nuclear size and brunescence as indicators of cataract density can be determined prior to phacoemulsification surgery
  • Direct and indirect ophthalmoscopy - To evaluate the integrity of the posterior pole

Ocular imaging studies such as ultrasonography, computed tomography (CT) scanning, or magnetic resonance imaging (MRI) are requested when a significant posterior pole pathology is suspected and an adequate view of the back of the eye is obscured by a dense cataract.

Staging

Clinical staging of senile cataract is traditionally based on the appearance of the lens on slit-lamp examination, as follows:

  • Hypermature cataract: This is a dense white opacity that obscures the red reflex and contains milky fluid within the capsule, a result of degenerated lens cortex. The capsule if often tense or wrinkled. A morgagnian cataract is a type of hypermature cataract in which the nucleus sinks within the fluid cortex.
  • Mature cataract: This is a cataract that is opaque, totally obscuring the red reflex. It is either white or brunescent.
  • Immature cataract: This is a cataract characterized by a variable amount of opacification, present in certain areas of the lens. These may include both high- and low-density areas, with some clear lens fibers.
  • Incipient cataract: This is a cataract that is seen on slit-lamp examination but is of little clinical significance.

Clinical staging of senile cataract can also be based on the visual acuity of the patient, as follows:

  • Hypermature cataract: The patient generally sees worse than count fingers (CF) or hand motion (HM).
  • Mature cataract: The patient cannot read better than 20/200 on the visual acuity chart.
  • Immature cataract: The patient can distinguish letters at lines better than 20/200.
  • Incipient cataract or dysfunctional lens syndrome: The patient reports visual complaints but can still read at 20/20 despite lens opacity confirmed via slit lamp-examination.

Management

Lens extraction is the definitive treatment for senile cataract. It can be accomplished via the following procedures:

  • Intracapsular cataract extraction (ICCE) - Involves extraction of the entire lens, including the posterior capsule and zonules; the many potential intraoperative and postoperative complications associated with this procedure has led to a significant decline in its use
  • Extracapsular cataract extraction (ECCE) - Involves the removal of the lens nucleus through an opening in the anterior capsule and a relatively large limbal incision, with retention of the integrity of the posterior capsule
  • Phacoemulsification - Also involves extraction of the lens nucleus through an opening in the anterior capsule; an ultrasonically driven needle is used to fragment the nucleus of the cataract; the lens substrate is then aspirated through a needle port via a small limbal or scleral incision in a process termed phacoemulsification

Intraocular lens (IOL) implantation is customarily used in combination with each of these techniques, although ECCE and phacoemulsification allow for more advantageous anatomical placement of the IOL than does ICCE.

Background

Senile cataract is a vision-impairing disease characterized by gradual, progressive thickening of the lens. It is the leading cause of blindness in the world today. This is unfortunate, considering that the visual morbidity brought about by age-related cataract is reversible. As such, early detection, close monitoring, and timely surgical intervention must be observed in the management of senile cataracts. Even greater challenges abound in economically disadvantaged and geographically isolated regions where limited healthcare access precludes early intervention. The subsequent section is a general overview of senile cataract and its management.

Pathophysiology

The pathophysiology behind senile cataracts is complex and yet to be fully understood. In all probability, its pathogenesis is multifactorial involving complex interactions between various physiologic processes modulated by environmental, genetic, nutritional, and systemic factors. As the lens ages, its weight and thickness increases while its accommodative power decreases. As the new cortical layers are added in a concentric pattern, the central nucleus is compressed and hardened in a process called nuclear sclerosis.

Multiple mechanisms contribute to the progressive loss of transparency of the lens. The lens epithelium is believed to undergo age-related changes, particularly a decrease in lens epithelial cell density and an aberrant differentiation of lens fiber cells. Although the epithelium of cataractous lenses experiences a low rate of apoptotic death, which is unlikely to cause a significant decrease in cell density, the accumulation of small scale epithelial losses may consequently result in an alteration of lens fiber formation and homeostasis, ultimately leading to loss of lens transparency.

Furthermore, as the lens ages, a reduction in the rate at which water and, perhaps, water-soluble low-molecular weight metabolites can enter the cells of the lens nucleus via the epithelium and cortex occurs with a subsequent decrease in the rate of transport of water, nutrients, and antioxidants.

Consequently, progressive oxidative damage to the lens with aging takes place, leading to senile cataract development. Various studies showing an increase in products of oxidation (eg, oxidized glutathione) and a decrease in antioxidant vitamins and the enzyme superoxide dismutase underscore the important role of oxidative processes in cataractogenesis.

Another mechanism involved is the conversion of soluble low-molecular weight cytoplasmic lens proteins to soluble high molecular weight aggregates, insoluble phases, and insoluble membrane-protein matrices. The resulting protein changes cause abrupt fluctuations in the refractive index of the lens, scatter light rays, and reduce transparency. Other areas being investigated include the role of nutrition in cataract development, particularly the involvement of glucose and trace minerals and vitamins.

Senile cataract can be classified into 3 main types: nuclear cataract, cortical cataract, and posterior subcapsular cataract. Nuclear cataracts result from excessive nuclear sclerosis and yellowing, with consequent formation of a central lenticular opacity. In some instances, the nucleus can become very opaque and brown, termed a brunescent nuclear cataract. Changes in the ionic composition of the lens cortex and the eventual change in hydration of the lens fibers produce a cortical cataract. Formation of granular and plaquelike opacities in the posterior subcapsular cortex often heralds the formation of posterior subcapsular cataracts.

Frequency

United States

In the Framingham Eye Study from 1973-1975, senile cataract was seen in 15.5% of the 2477 patients examined. The overall rates of senile cataract in general, and of its 3 main types (ie, nuclear, cortical, posterior subcapsular), rapidly increased with age; for the oldest age group (≥75 y), nuclear, cortical, and posterior subcapsular cataracts were found in 65.5%, 27.7%, and 19.7% of the study population, respectively. Nuclear opacities were the most commonly seen lens change.

An updated study by the Wilmer Eye Institute in 2004 noted that approximately 20.5 million (17.2%) Americans older than 40 years had a cataract in either eye and 6.1 million (5.1%) were pseudophakic/aphakic.[1] These numbers are expected to rise to 30.1 million cataracts and 9.5 million cases with pseudophakia/aphakia by 2020.

Prevent Blindness America currently estimates that more than 22 million Americans aged 40 years and older have a cataract. An average of 3 million Americans undergo cataract surgery every year, with a 95% success rate of obtaining a best corrected vision of 20/20-20/40.

International

Senile cataract continues to be the main cause of visual impairment and blindness in the world. In recent studies performed in China,[2, 3] Canada,[4] Japan,[5] Denmark,[6] Argentina,[7] and India,[8] cataract was identified as the leading cause of visual impairment and blindness, with statistics ranging from 33.3% (Denmark) to as high as 82.6% (India). Published data estimate that 1.2% of the entire population of Africa is blind, with cataract causing 36% of this blindness. In a survey conducted in 3 districts in the Punjab plains, the overall rates of occurrence of senile cataract was 15.3% among 1269 persons examined who were aged 30 years and older and 4.3% for all ages. This increased markedly to 67% for ages 70 years and older. An analysis of blind registration forms in the west of Scotland showed senile cataract as 1 of the 4 leading causes of blindness.

Mortality/Morbidity

Most morbidity associated with senile cataracts occurs postoperatively and is discussed in further detail later. Failure to treat a developing cataract surgically may lead to devastating consequences, such as lens swelling and intumescence, secondary glaucoma, and, eventually, blindness.

Although the risk of dying as a result of cataract extraction is almost negligible, studies have shown an increased risk of mortality in patients who underwent surgery. In a comparison of 167 patients aged 50 years or older who underwent cataract extraction at the New England Medical Center in a period of 1 year to 824 patients who elected 1 of 6 other surgical procedures, it was found that the former had almost twice the mortality of the latter. Further analysis showed no significant correlation between diabetes and increased mortality. In a similar 5-year mortality analysis, patients with cataracts who were younger than 75 years had significantly higher age-specific rates of mortality than would be expected from US life tables.

These data imply an association between senile cataracts and increased mortality. Meddings et al suggest that senile cataract may be a marker of generalized tissue aging, which may be independent of cumulative ultraviolet exposure.[9] Hirsch and Schwartz who proposed the concept that senile cataracts reflect systemic phenomena rather than only a localized ocular disease share this view.[10]

Race

Although race has been suggested as a possible risk factor for senile cataract, scarce literature exists to prove this theory. However, it has been observed that unoperated cataracts account for a higher percentage of blindness among blacks compared to whites. Instead, various other correlates may explain racial disparities, including medical comorbidities such as diabetes mellitus or lifetime ultraviolet (UV) exposure due to occupation, altitude, or latitude.

Sex

Studies on the prevalence of senile cataract between males and females have yielded contrasting results.

In the Framingham Eye Study from 1973-75, females had a higher prevalence than males in both lens changes (63% vs 54.1%) and senile cataract (17.1% vs 13.2%).

Sperduto and Hiller noted that each of the 3 types of senile lens opacities was found more often in women than in men.[11] In a separate investigation by Nishikori and Yamomoto, the male-to-female ratio was 1:8 with a female predominance in patients older than 65 years who were operated on for senile cataract.[12]

In a hospital-based, case-control study of senile cataract conducted in Japan, it was observed that an increased risk of cataract was found in males who were presently spending 7 hours or more outdoors and in females with 4 or fewer remaining teeth. However, in another analysis by Martinez et al, no sexual difference was noted in the prevalence of senile cataract.[13]

Age

Age is an important risk factor for senile cataract. As a person ages, the chance of developing a senile cataract increases. In the Framingham Eye Study from 1973-1975, the number of total and new cases of senile cataract rose dramatically from 23.0 cases per 100,000 and 3.5 cases per 100,000, respectively, in persons aged 45-64 years to 492.2 cases per 100,000 and 40.8 cases per 100,000 in persons aged 85 years and older.

Prognosis

In the absence of any other accompanying ocular disease prior to surgery that would affect significantly the visual outcome (eg 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 patient education resources, see the Eye and Vision Center and Cataracts.

 

Presentation

History

Careful history taking is essential in determining the progression and functional impairment in vision resulting from the cataract and in identifying other possible causes for the lens opacity. A patient with senile cataract often presents with a history of gradual progressive deterioration and disturbance in vision. Such visual aberrations are varied depending on the type of cataract present in the patient.

Decreased visual acuity

Decreased visual acuity is the most common complaint of patients with senile cataract. The cataract is considered clinically relevant if visual acuity is affected significantly. Furthermore, different types of cataracts produce different effects on visual acuity.

For example, a mild degree of posterior subcapsular cataract can produce a severe reduction in visual acuity with near acuity affected more than distance vision, presumably as a result of accommodative miosis. However, nuclear sclerotic cataracts often are associated with decreased distance acuity and good near vision.

A cortical cataract generally is not clinically relevant until late in its progression when cortical spokes compromise the visual axis. However, instances exist when a solitary cortical spoke occasionally results in significant involvement of the visual axis.

Glare

Increased glare is another common complaint of patients with senile cataracts. This complaint may include an entire spectrum from a decrease in contrast sensitivity in brightly lit environments or disabling glare during the day to debilitating glare with oncoming headlights at night.

Such visual disturbances are prominent particularly with posterior subcapsular cataracts and, to a lesser degree, with cortical cataracts. It is associated less frequently with nuclear sclerosis. Many patients may tolerate moderate levels of glare without much difficulty, and, as such, glare by itself does not require surgical management.

Myopic shift

The progression of cataracts may frequently increase the dioptric power of the lens resulting in a mild-to-moderate degree of myopia or myopic shift. Consequently, presbyopic patients report an increase in their near vision and less need for reading glasses as they experience the so-called second sight. However, such occurrence is temporary, and, as the optical quality of the lens deteriorates, the second sight is eventually lost.

Typically, myopic shift and second sight are not seen in cortical and posterior subcapsular cataracts. Furthermore, asymmetric development of lens-induced myopia may result in significant symptomatic anisometropia that may itself require surgical management.

Monocular diplopia

At times, the nuclear changes are concentrated in the inner layers of the lens, resulting in a refractile area in the center of the lens, which often is seen best within the red reflex by retinoscopy or direct ophthalmoscopy.

Such a phenomenon, which some call “lens within a lens phenomenon,” may lead to monocular diplopia that is not correctable with spectacles, prisms, or contact lenses.

Physical

After a thorough history is taken, careful physical examination must be performed. The entire body habitus is checked for abnormalities that may point out systemic illnesses that affect the eye and cataract development.

A complete ocular examination must be performed beginning with visual acuity for both near and far distances. Whether or not the patient complains of glare, visual acuity should be tested in a brightly lit room or with one of the many commercially available glare-testing devices, such as the brightness acuity tester (BAT). Contrast sensitivity may also be checked, especially if the history points to a possible problem.

Examination of the ocular adnexa and intraocular structures may also provide clues to the patient's disease and eventual visual prognosis.

A very important test is the swinging flashlight test, which is used to detect a Marcus Gunn pupil or relative afferent pupillary defect (RAPD), indicative of optic nerve lesions or severe diffuse retinal involvement. A patient with a RAPD and a cataract is expected to have a very guarded visual prognosis, even after uncomplicated cataract extraction.

A patient with long-standing ptosis since childhood may have occlusion amblyopia, which may account more for the decreased visual acuity rather than the cataract. Similarly, a careful history regarding visual acuity in each eye during childhood, checking for problems in ocular motility in all directions of gaze, as well as anisometropia, is important to rule out any other amblyogenic causes for the patient's visual symptoms.

Slit lamp examination should not only concentrate on evaluating the lens opacity but the other ocular structures as well (eg, conjunctiva, cornea, iris, anterior chamber). Corneal thickness and the presence of corneal opacities, such as corneal guttate, must be checked carefully. Appearance of the lens must be noted meticulously before and after pupillary dilation.

The visual significance of oil droplet nuclear cataracts and small posterior subcapsular cataracts is evaluated best with a normal-sized pupil to determine if the visual axis is obscured. However, exfoliation syndrome is best appreciated with the pupil dilated, revealing exfoliative material on the anterior lens capsule, as well as the pupillary margin, trabecular meshwork, and other intraocular structures.

After dilation, nuclear size and brunescence as indicators of cataract density can be determined prior to phacoemulsification surgery. The lens position and integrity of the zonular fibers also should be checked because lens subluxation may indicate previous eye trauma, antecedent ocular surgery, metabolic disorders, or hypermature cataracts.

The importance of direct and indirect ophthalmoscopy in evaluating the integrity of the posterior pole must be underscored. Optic nerve and retinal problems may account for the visual disturbance experienced by the patient. Furthermore, the prognosis after lens extraction is affected significantly by preoperative detection of pathologies in the posterior pole (eg, macular edema, retinal dystrophy, optic atrophy, severe glaucomatous cupping, age-related macular degeneration) and in the retinal periphery (eg, retinal breaks or extensive vitreoretinal traction).

Causes

Numerous studies have been conducted to identify risk factors for development of senile cataracts. Various culprits have been implicated, including environmental conditions, systemic diseases, UV exposure, diet, and age.[14, 15]

West and Valmadrid stated that age-related cataract is a multifactorial disease with different risk factors associated with each of the different cataract types.[16] In addition, they stated that cortical and posterior subcapsular cataracts were related closely to environmental stresses, such as UV exposure, diabetes, and drug ingestion. However, nuclear cataracts seem to have a correlation with smoking. Alcohol use has been associated with all cataract types.

A similar analysis was completed by Miglior et al.[17] They found that cortical cataracts were associated with the presence of diabetes for more than 5 years and increased serum potassium and sodium levels. A history of surgery under general anesthesia and the use of sedative drugs were associated with reduced risks of senile cortical cataracts. Posterior subcapsular cataracts were associated with steroid use and diabetes, while nuclear cataracts had significant correlations with calcitonin and milk intake. Mixed cataracts were linked with a history of surgery under general anesthesia.

In a population-based, longitudinal study of 3471 Latinos with 4 years of follow-up, Richter et al found that independent risk factors for incident nuclear-only lens opacities included older age, current smoking, and the presence of diabetes. Risk factors for cortical-only lens opacities included older age and having diabetes at baseline. Female gender was a risk factor for posterior subcapsular-only lens opacities. Presence of diabetes at baseline and older age were risk factors for mixed lens opacities.[18]

Systemic diseases and senile cataract

Senile cataracts have been associated with numerous systemic illnesses, to include the following: cholelithiasis, allergy, pneumonia, coronary disease and cardiac insufficiency, hypotension, hypertension, mental retardation, and diabetes.

Systemic hypertension was found to significantly increase the risk for posterior subcapsular cataracts. In a related study by Jahn et al, hypertriglyceridemia, hyperglycemia, and obesity were found to favor the formation of posterior subcapsular cataracts at an early age.[19]

A possible pathway for the role of hypertension and glaucoma in senile cataract formation was proposed with induced changes in the protein conformational structures in the lens capsules, subsequently causing alterations in membrane transport and permeability of ions, and, finally, increasing intraocular pressure resulting in the exacerbation of cataract formation.

UV light and senile cataract

The association of UV light and development of senile cataract has generated much interest. One hypothesis implies that senile cataracts, particularly cortical opacities, may be the result of thermal damage to the lens.

An animal model by Al-Ghadyan and Cotlier documented an increase in the temperature of the posterior chamber and lens of rabbits after exposure to sunlight due to an ambient temperature effect through the cornea and to increased body temperature.[20]

In related studies, people living in areas with greater UV exposure were more likely to develop senile cataracts and to develop them earlier than people residing in places with less UV exposure.

Other risk factors

Significant associations with senile cataract were noted with increasing age, female sex, social class, and myopia. Consistent evidence from the study of West and Valmadrid suggested that the prevalence of all cataract types was lower among those with higher education.[16] Workers exposed to infrared radiation also were found to have a higher incidence of senile cataract development.

Although myopia has been implicated as a risk factor, it was shown that persons with myopia who had worn eyeglasses for at least 20 years underwent cataract extraction at a significantly older age than emmetropes, implying a protective effect of the eyeglasses to solar UV radiation.

The role of nutritional deficiencies in senile cataract has not been proven or established. However, a high intake of the 18-carbon polyunsaturated fatty acids linoleic acid and linolenic acid reportedly may result in an increased risk of developing age-related nuclear opacity.

In the Blue Mountains Eye Study, pseudoexfoliation increased the risk of cataract and subsequent cataract surgery.[21]

 

DDx

Diagnostic Considerations

Aside from being age related and due to trauma, cataract formation in adult patients also may be due to chronic uveitis, long-term steroid use, or posterior pole pathologies (eg, intraocular tumor, long-standing retinal detachment).

Differential Diagnoses

  • Diabetic cataract

  • Infrared-induced cataract (true exfoliation)

  • Postsurgical cataract following vitrectomy, corneal transplantation, or glaucoma procedures

  • Radiation therapy–induced cataract (eg, following ocular, facial, or intracranial tumor irradiation)

  • Traumatic Cataract

  • Uveitis cataract

 

Workup

Laboratory Studies

Diagnosis of senile cataract is made basically after a thorough history and physical examination are performed. Laboratory tests are requested as part of the preoperative screening process to detect coexisting diseases (eg, diabetes mellitus, hypertension, cardiac anomalies). Studies have shown that thrombocytopenia may lead to increased perioperative bleeding and, as such, should be properly detected and managed before surgery, especially if synechiolysis, a retrobulbar block, or an adjunctive procedure such as microincisional glaucoma surgery (MIGS) or pars plana vitrectomy is anticipated. Additional risk factors for accentuated perioperative bleeding should also be assessed, including the use of oral NSAIDs, anticoagulant prescription medications, or omega-3 supplements containing vitamin E (eg, fish oil).

Imaging Studies

Ocular imaging studies (eg, ultrasonography, CT scanning, MRI) can be requested when a posterior pole pathology is suspected and an adequate view of the back of the eye is obscured by an extremely dense or hypermature cataract. This is helpful in planning out the surgical management and in providing a more guarded postoperative prognosis for the visual recovery of the patient.

Other Tests

Additional patient-specific tests can be performed when coexisting ocular diseases are suspected, especially in identifying the etiology of preoperative visual loss. Aside from routine visual acuity testing, testing for brightness acuity and contrast sensitivity and confrontation visual field testing can be performed to assess visual function. Patients with a history of glaucoma, optic nerve disease, or retinal abnormality should undergo an automated visual field test to document the degree of preoperative field loss.

In patients suspected of having a macular problem, the following tests may be performed to evaluate macular function: Maddox rod test, photostress recovery test, blue-light entoptoscopy, Purkinje entoptic phenomenon, and visual-evoked response and electroretinography (VER-ERG). Above all, macular optical coherence tomography (OCT) should prove to be the most informative regarding structure.

In patients with dense cataracts that preclude adequate visualization of the fundus, a Maddox rod test can be used to grossly evaluate macular function with detection of a large scotoma, represented as a loss of the red line, a sign suggestive of a macular pathology.

While the photostress recovery test is a semiquantitative estimate of macular function, both blue-light entoptoscopy and Purkinje entoptic phenomenon are subjective means of evaluating macular integrity. The most objective method of measuring macular function is VER-ERG. A simple color vision test with a large Ishihara chart or muscle light illuminated color-coded glaucoma medication caps can also qualitatively predict intact macular function.

Several measurements should be taken preoperatively, particularly in an anticipated cataract extraction with intraocular lens (IOL) implantation.

Careful refraction must be performed on both eyes in selecting the IOL style, power, optics (spheric or aspheric), and premium features best suited to the individual eye. The power of the IOL on the operated eye must be compatible with the refractive error of the fellow eye to avoid complications (eg, postoperative anisometropia), while also anticipating future surgeries. Ocular dominance is also important since many patients tolerate a small degree of monovision with a small add or additional IOL plus power in the nondominant eye, often called mini-monovision.

An accurate biometry also should be performed to calculate for the IOL power to be used.

Corneal integrity, specifically the endothelial layer, must be assessed very well via pachymetry, slit lamp 40x high-magnification endothelial specular illumination, and specular microscopy to predict postoperative corneal morbidities (eg, corneal edema, corneal decompensation) and to weigh the risks versus the benefits of performing cataract extraction. A preoperative discussion of endothelial transplantation, however brief, is wise in the context of even minimal detected endothelial pathology.

Histologic Findings

Nuclear cataracts are characterized by homogeneity of the lens nucleus with loss of cellular laminations. Cortical cataracts typically manifest with hydropic swelling of the lens fibers with globules of eosinophilic material (morgagnian globules) seen in slit-like spaces between lens fibers. Finally, a posterior subcapsular cataract is associated with posterior migration of the lens epithelial cells in the posterior subcapsular area, with aberrant enlargement of the epithelial cells (Wedl or bladder cells).

Costello et al examined senile cataracts using electron microscopy to highlight differences in the cellular architecture of the various forms of age-related lens changes.[22] Comparisons were made between a typical nuclear cataract with a central opacity and a transparent rim, and a more advanced or mature, completely opaque nuclear cataract. The former was described as having no obvious cell disruption, cellular debris, or changes that could readily account for the central opacity. The fiber cells had intact uniformly stained cytoplasm with well-defined plasma membrane borders and gap junctions. The mature cataract exhibited various types of cell disruption in the perimeter but not in the core of the nucleus in the form of globules, vacuoles, multilamellar membranes, and clusters of highly undulating membranes.

Staging

Clinical staging of senile cataract is traditionally based on the appearance of the lens on slit-lamp examination, as follows:

  • Hypermature cataract: This is a dense white opacity that obscures the red reflex and contains milky fluid within the capsule, a result of degenerated lens cortex. The capsule if often tense or wrinkled. A morgagnian cataract is a type of hypermature cataract in which the nucleus sinks within the fluid cortex.
  • Mature cataract: This is a cataract that is opaque, totally obscuring the red reflex. It is either white or brunescent.
  • Immature cataract: This is a cataract characterized by a variable amount of opacification, present in certain areas of the lens. These may include both high- and low-density areas, with some clear lens fibers.
  • Incipient cataract: This is a cataract that is seen on slit-lamp examination but is of little clinical significance.

Clinical staging of senile cataract can also be based on the visual acuity of the patient, as follows: 

  • Hypermature cataract: The patient generally sees worse than count fingers (CF) or hand motion (HM).
  • Mature cataract: The patient cannot read better than 20/200 on the visual acuity chart. 
  • Immature cataract: The patient can distinguish letters at lines better than 20/200.
  • Incipient cataract or dysfunctional lens syndrome: The patient reports visual complaints but can still read at 20/20 despite lens opacity confirmed via slit lamp-examination.

Numerous methods have been formulated to assess the severity of cataracts. Among them are the Lens Opacities Classification (LOCS), the Oxford Clinical Cataract Classification and Grading System, and the Johns Hopkins system.  The LOCS is the most commonly used system in the clinics. It allows a qualitative staging of cataracts based on a series of images for grading nuclear color (NC), nuclear opalescence (NO), cortical cataract (C), and posterior subcapsular cataract (P). Three versions have been developed (LOCS I, II, III).

 

Treatment

Medical Care

No time-tested, FDA-approved, or clinically proven medical treatment exists to delay, prevent, or reverse the development of senile cataracts.

Aldose reductase inhibitors, which are believed to inhibit the conversion of glucose to sorbitol, have shown promising results in preventing sugar cataracts in animals. Other anticataract medications being investigated include sorbitol-lowering agents, aspirin, glutathione-raising agents, and antioxidant vitamins C and E.

Surgical Care

The definitive management for senile cataract is lens extraction. Over the years, various surgical techniques have evolved from the ancient method of couching to the present-day technique of modern phacoemulsification. Phacoemulsification offers the advantage of a smaller incision size at the time of cataract surgery.[23] Historically parallel to the development of phacoemulsification is the evolution of advanced IOL design, which offers a wide selection of target implantation locations, materials, chromophores, premium features, and manner of implantation. Differentiated by the integrity of the posterior lens capsule, the 2 main types of lens surgery are the intracapsular cataract extraction (ICCE) and the extracapsular cataract extraction (ECCE). Below is a general description of the 3 commonly used surgical procedures in cataract extraction, namely ICCE, standard ECCE, and phacoemulsification. Referencing literature dedicated specifically to cataract surgeries for a more in-depth discussion of the topic, particularly with regard to technique and procedure, is also recommended.

Results from a large database study by Lundström et al indicate that poor visual outcome following surgery is most strongly determined by the following factors[24, 25] :

  • Short-term postoperative complications

  • Ocular comorbidity

  • Surgical complications

  • Complex surgery

Data (some self-reported) for the study were drawn from the European Registry of Quality Outcomes for Cataract and Refractive Surgery, which contained information on 368,256 cataract extractions. According to the investigators, although cataract surgery yielded excellent visual outcomes for more than 60% of patients in the study, vision was unchanged in 5.7% of them, while 1.7% of patients experienced a decrease in corrected distance visual acuity (CDVA).[24, 25]

Intracapsular cataract extraction

Prior to the onset of more modern microsurgical instruments and better IOLs, ICCE was the preferred method for cataract removal. It involves extraction of the entire lens, including the posterior capsule and mechanical or enzymatic lysis of the zonular support structures. In performing this technique, there is no need to worry about subsequent development and management of capsular opacity. The technique can be performed with less sophisticated equipment and in areas where operating microscopes and irrigating systems are not available.

However, a number of disadvantages and postoperative complications accompany ICCE. The larger limbal incision, often 160°-180°, is associated with the following risks: delayed healing, delayed visual rehabilitation, significant against-the-rule astigmatism, iris incarceration, postoperative wound leaks, and vitreous incarceration. Corneal edema is a common postoperative complication.

Furthermore, endothelial cell loss is greater in ICCE than in ECCE. The same is true about the incidence of postoperative cystoid macular edema (CME) and retinal detachment. The broken integrity of the vitreous face can lead to postoperative complications, even after a seemingly uneventful operation. Finally, because the posterior capsule is not intact, the IOL to be implanted must be placed in the anterior chamber, sutured to the iris, or surgically fixated in the posterior chamber. Both techniques are more difficult to perform than simply placing an IOL in the capsular bag and are associated with postoperative complications, the most notorious of which is pseudophakic bullous keratopathy (PBK).

Although the myriad postoperative complications has led to the decline in popularity and use of ICCE, it still can be used when zonular integrity is too severely impaired to allow successful lens removal and IOL implantation with an ECCE, particularly carefully selected posttraumatic and hypermature cataracts. Furthermore, ICCE can be performed in remote areas where more sophisticated equipment is not available.

ICCE is contraindicated in children and young adults with cataracts and any case with traumatic capsular rupture where intact removal of the lens capsule unit may prove difficult or incomplete. Relative contraindications include high myopia, Marfan syndrome, morgagnian cataracts, and vitreous presenting in the anterior chamber. Many of these patients may benefit from a pars plana lensectomy by a vitreoretinal surgeon prior to implantation of the appropriate IOL type.

Extracapsular cataract extraction

In contrast to ICCE, ECCE involves the removal of the lens nucleus through an opening in the anterior capsule with retention of posterior capsular integrity. ECCE possesses a number of advantages over ICCE, most of which are related to an intact posterior capsule, as follows:

  • A smaller incision is required in ECCE, and, as such, less trauma to the corneal endothelium is expected. Only the diameter of the nucleus must be accommodated by the opening rather than the diameter of the entire lens within its capsule.
  • Short- and long-term complications of vitreous adherence to the cornea, iris, and incision are minimized or eliminated.
  • A better anatomical placement of the IOL is achieved with an intact posterior capsule.
  • An intact posterior capsule also (1) reduces the iris and vitreous mobility that occurs with saccadic movements (eg, endophthalmodonesis); (2) provides a barrier restricting the exchange of some molecules between the aqueous and the vitreous; (3) reduces the incidence of CME, retinal detachment, and corneal edema; and (4) reduces movement of the IOL upon eye movements and eye rubbing (pseudophakodonesis).
  • Conversely, an intact capsule prevents bacteria and other microorganisms inadvertently introduced into the anterior chamber during surgery from gaining access to the posterior vitreous cavity and causing endophthalmitis.
  • Secondary IOL implantation, filtration surgery, corneal transplantation, and wound repairs are performed more easily with a higher degree of safety with an intact posterior capsule.

The main requirements for a successful ECCE and endocapsular IOL implantation are zonular integrity and an intact posterior capsule. As such, when zonular support is insufficient or appears suspect to allow a safe removal of the cataract via ECCE, ICCE or pars plana lensectomy should be considered.

Phacoemulsification

Standard ECCE and phacoemulsification are similar in that extraction of the lens nucleus is performed through an opening in the anterior capsule or anterior capsulotomy. Both techniques also require mechanisms to irrigate and aspirate fluid and cortical material during surgery. Finally, both procedures place the IOL within the capsular bag, which is far more anatomically correct than the anteriorly placed IOL.

Needless to say, significant differences exist between the 2 techniques. Removal of the lens nucleus in ECCE can be performed manually in standard ECCE or with an ultrasonically driven needle to fragment the nucleus of the cataract and then to aspirate the lens substrate through a needle port in a process termed phacoemulsification.

The more modern of the 2 techniques, phacoemulsification offers the advantage of using smaller incisions, minimizing complications arising from improper wound closure, and affording more rapid wound healing and faster visual rehabilitation. Furthermore, it uses a relatively closed system during both phacoemulsification and aspiration with better control of intraocular pressure during surgery, providing safeguards against positive vitreous pressure and choroidal hemorrhage. A closed system also minimizes fluid turbulence within the anterior chamber, reducing endothelial and trabecular meshwork trauma. However, more sophisticated and expensive machines, disposables, and instruments are required to perform phacoemulsification.

An advancement in cataract surgery techniques is the Femtosecond Laser Assisted Cataract Surgery (FLACS), which employs femtosecond laser in the various stages of phacoemulsification such as wound construction, anterior capsulotomy, and nuclear fragmentation.  The laser creates cleavage planes through photodisruption, resulting in greater precision and repeatability in the mentioned steps compared with the manual technique.

Ultimately, the choice of which of the 2 procedures to use in cataract extraction depends on the patient, the type of cataract, the availability of the proper instruments, and the degree to which the surgeon is comfortable and proficient in performing standard ECCE or phacoemulsification. The vast majority of modern cataract surgeons perform and prefer phacoemulsification.

The surgeon should also consider whether to use topical or regional anesthesia during the procedure. A study by Zhao et al examined the clinical outcomes of topical anesthesia and regional anesthesia including retrobulbar anesthesia and peribulbar anesthesia in phacoemulsification. The authors found that regional anesthesia provides better perioperative pain control, but that surgical outcomes were the same for both.[26]

Other Considerations

Although single-eye cataract surgery improves vision, including the second eye may yield greater rewards, according to a prospective, population-based study by Lee et al. The investigators studied 1739 participants aged 65-84 years at enrollment, 90 of whom following enrollment had unilateral cataract surgery, and 29 of whom had bilateral surgery. In the 1620 patients who did not undergo surgery, bilateral baseline best-corrected visual acuity logarithm of the minimum angle of resolution (BCVA of logMAR) was no greater than 0.3 (at least 20/40).[27, 28]

BCVA of logMAR improved by 0.04 in the unilateral group and 0.13 in the bilateral group, while reading speed increased by 12 words per minute in the unilateral group and 31 words per minute in the bilateral group. Moreover, the Activities of Daily Vision Scale scores (measuring vision at a distance, close-up, glare, and day and night driving) showed a 5-point relative improvement in the bilateral group, while the unilateral group actually showed a 5-point relative decrease.

An increased risk for intraoperative floppy iris syndrome (IFIS) was observed during cataract surgery in patients with benign prostatic hypertrophy (BPH) who were taking a nonselective alpha1-antagonist. Alfuzosin and tamsulosin, 2 drugs commonly used to treat BPH, are both linked to permanent changes in the iris and associated with an increased risk of IFIS. A prospective, masked, cross-sectional multicenter study by Chang et al determined that patients taking systemic alfuzosin for BPH were less likely to experience moderate or severe IFIS during cataract surgery than patients taking tamsulosin.[29, 30]

Of the 226 eyes studied, 70 were in patients receiving systemic tamsulosin, 43 in patients receiving systemic alfuzosin, and 113 in patients with no history of systemic alpha1-antagonist therapy.[30] The incidence of IFIS was 34.3% in the tamsulosin group, 16.3% in the alfuzosin group, and 4.4% in the control group. Severe IFIS was statistically more likely with tamsulosin than with alfuzosin (P = 0.036). Thus, patients with symptomatic BPH and cataracts requiring a uroselective alpha1-antagonist may consider trying alfuzosin first.

Bell et al reviewed exposure to alpha-adrenergic blockers frequently prescribed to treat benign prostatic hypertrophy (BPH) and their association with serious intra-operative adverse effects during cataract surgery.[31] The study included more than 96,000 older men who had cataract surgery over a 5-year period (3.7% had recent exposure to tamsulosin and 7.7% had recent exposure to other alpha blockers). Exposure to tamsulosin within 14 days of cataract surgery was significantly associated with serious postoperative ophthalmic adverse events (7.5% vs 2.7%; adjusted odds ratio [OR], 2.33; 95% confidence interval [CI], 1.22-4.43), specifically intraoperative floppy iris syndrome and its complications (ie, retinal detachment, lost lens or fragments, uveitis, endophthalmitis).A study by Baker et al found that 23-gauge pars plana vitrectomy is a possible surgical management approach in select cases of retained lens fragments. While 12 patients were successfully treated by this initial intervention, 8 required sclerotomy enlargement to a 20-gauge access.[32]

An association between cataract surgery and late age-related macular degeneration, independent of additional risk factors, has been shown in some studies.[33] Most surgeons do not believe that cataract extraction accelerates the onset of age-related macular degeneration. UV protection with sunglasses and hats is always recommended following cataract extraction.

Multifocal IOLs after cataract extraction are more effective at improving near vision than monofocal IOLS are, but whether this improvement outweighs the potential adverse effects of multifocal lenses varies between patients.[34] Careful patient selection to recommend a multifocal IOL only to patients with a pristine macula and ocular surface can be very rewarding for both the clinician and patient.

In 2008, the US Food and Drug Administration (FDA) approved the Alcon line of acrylic toric IOLs. In 2013, the FDA approved Abbott's Tecnis Toric 1-piece IOL to treat preexisting astigmatism in patients with cataract.[35] Toric IOLs are used to manage corneal astigmatism in patients who have undergone cataract surgery and whose natural lenses have been removed. Unlike other devices on the market, this 1-piece IOL can correct loss of focus of 1 diopter or greater. Clinical data show that the device offers exceptional rotational stability while improving visual results and improving distance and night vision.

In early 2014, the FDA approved a synthetic polyethylene glycol hydrogel sealant (ReSure Sealant, Ocular Therapeutix, Inc) for use in cataract surgery with IOL placement.[36] The sealant is indicated for prevention of postoperative fluid egress from incisions with a demonstrated wound leak after cataract surgery. Approval was based on a prospective, randomized, controlled multicenter study of 471 patients in which the sealant was more effective than a single suture in preventing incision leakage in the 7 days after surgery.

Consultations

Prior to surgery, a thorough preoperative evaluation must be conducted, which would also include a thorough explanation of the procedure to be performed and its accompanying risks.

Not all senile cataracts require removal at the time of diagnosis. If vision, performance of daily tasks, and quality of life are not impaired significantly or if the patient is not prepared medically, psychologically, and financially for surgery, periodic consultations are encouraged to assess progression of the cataract. The procedure is, by definition, almost always elective. Very rarely, lens-induced glaucoma or uveitis warrants urgent or emergent cataract surgery.

Postoperatively, regular follow-up visits are necessary to monitor visual rehabilitation, as well as to detect and address any immediate and late complications arising from the surgery.

Diet

In relation to the surgery, no established dietary restrictions exist that would affect the course of the operation when a small corneal incision technique is planned. Larger scleral incisions, MIGS, simultaneous pars plana vitrectomy, or a planned retrobulbar anesthetic may dictate limitation of any dietary supplement (eg, fish oil) that may prolong bleeding times 2 weeks prior to surgery.

Activity

After surgery, the patient is dissuaded from performing activities that would increase the intraocular pressure, especially after undergoing ICCE or standard ECCE. These activities include lifting heavy loads, chronic vigorous coughing, and straining. Similarly, trauma and exposure to toxic fumes or particular matter should specifically be avoided.

Complications

Major intraoperative complications encountered during cataract surgery include the following:

  • 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

Major immediate postoperative complications encountered during cataract surgery often seen within a few days or weeks after the operation include the following:

  • 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.[37]

  • Retinal detachment - Significant risk factors include axial length greater than 25 mm, age younger than 65 years, and intraoperative complications.[38]

  • Acute endophthalmitis

  • Toxic anterior segment syndrome (TASS), a noninfectious acute inflammatory reaction to particulate, chemical, or toxic matter placed in the anterior chamber during surgery - Most commonly implicated are sterile denatured lens proteins retained by surgical instruments, epinephrine solutions that contain bisulfites, and powder from surgical gloves; many mini-epidemics of TASS reveal no obvious proven cause despite intensive investigation

  • Uveitis-glaucoma-hyphema (UGH) syndrome

Major late postoperative complications seen weeks or months after cataract surgery include the following:

  • Suture-induced astigmatism

  • Pupillary capture, decentration, or iris atrophy

  • Decentration and dislocation of the IOL

  • Corneal edema and pseudophakic bullous keratopathy

  • Chronic uveitis

  • Chronic endophthalmitis

  • Wrong power of IOL used

At any postoperative stage, the risk of uveitis, noninfectious endophthalmitis, and infectious endophthalmitis exists. Noninfectious endophthalmitis is believed to be a multifactorial process or an idiosyncratically variable response to a common factor, similar to a hypersensitivity reaction. Treatment may range from the use of topical, transseptal, or oral steroids to the rare explantation of the intraocular lens.

Although of low incidence, infectious endophthalmitis may lead to severe vision loss and blindness.[39]  Staphylococcus epidermidis is the most commonly isolated organism in acute cases, and rupture of the posterior capsule is one of the most common risk factors.[39]  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 and other fluoroquinolones has occurred. Seemingly, the spectrum of bacteria causing postcataract endophthalmitis is changing, partly perhaps because of an increased resistance to mainstay antibiotics in the prevention of endophthalmitis. Delayed-onset infectious endophthalmitis is most commonly caused by Propionibacterium acnes.

Prevention

Age is believed to be the most significant risk factor for senile cataract and, as such, it is essentially inevitable that some degree of lens opacity develops as one becomes older. No study has established firmly whether avoidance of some of the risk factors for senile cataract (eg, UV exposure, hypercholesterolemia, tobacco use, diabetes mellitus) will lessen the chance of developing a senile cataract.

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 and flare 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 are often attributed to retained viscoelastic material.

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 following ECCE or ICCE can be addressed by suture removal after the sixth postoperative week as guided by keratometry, refraction, or corneal topography.

In a prospective, randomized, double-masked trial involving 59 patients undergoing cataract surgery, use of a tapered-release dexamethasone punctum plug after surgery, compared with the use of a placebo plug (Dextenza, Ocular Therapeutix), resulted in fewer cells in the anterior chamber (ie, less evidence of ocular inflammation), lower use of additional anti-inflammatory medications, and less light sensitivity.[40]

The mean pain score in the dexamethasone group on the first day following surgery was three times below that in the placebo group (0.6 vs 2.0), while the ocular pain score on day 14 was 11 times lower than that in the placebo patients. No long-term, plug-associated intraocular pressure spikes or adverse events were observed.

Further Inpatient Care

Most cataract surgeries are performed on an outpatient basis, especially with the widespread adoption 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, NSAIDs, and antibiotics either separately or in combination. An optional eye shield is placed on the newly operated eye and removed a few hours later.

Inpatient & Outpatient Medications

During the postoperative period, the patient is prescribed a topical steroid such as 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.

 

Medication

Medication Summary

No drug is available that has been proven to prevent the progression of senile cataracts. Medical therapy is used preoperatively and postoperatively to ensure a successful operation and subsequent visual rehabilitation.[41]

Mydriatics

Class Summary

Autonomic drugs used to ensure maximal pupillary dilation preoperatively, which is essential for a successful lens extraction. Short-acting mydriatics often are used. Most commonly used mydriatics are phenylephrine hydrochloride and tropicamide.

Phenylephrine ophthalmic (Altafrin)

Direct-acting adrenergic agent available in 2.5% and 10% concentrations. Acts locally as potent vasoconstrictor and mydriatic by constricting ophthalmic blood vessels and radial muscles of the iris. Favorably used by many ophthalmologists because of rapid onset and moderately prolonged action, as well as the fact that it does not produce compensatory vasodilation. Most ophthalmologists prefer 2.5% to 10% concentration because of fewer risks of severe adverse systemic effects. Onset of action is within 30-60 min lasting for 3-5 h.

Tropicamide (Mydriacyl)

Tropicamide blocks the response of the sphincter muscle of the iris and the muscle of the ciliary body to cholinergic stimulation.

Nonsteroidal anti-inflammatory ophthalmics

Class Summary

Used for pain and inflammation associated with cataract surgery.

Nepafenac ophthalmic (Nevanac, Ilevro)

Nonsteroidal anti-inflammatory prodrug for ophthalmic use. Following administration, converted by ocular tissue hydrolases to amfenac, an NSAID. Inhibits prostaglandin H synthase (cyclooxygenase), an enzyme required for prostaglandin production. Indicated for treatment of pain and inflammation associated with cataract surgery.

Bromfenac ophthalmic (Bromday, Prolensa)

Nonsteroidal anti-inflammatory prodrug for ophthalmic use. Following topical administration, this NSAID achieves high therapeutic intraocular levels. Inhibits prostaglandin H synthase (cyclooxygenase), an enzyme required for prostaglandin production. Indicated for treatment of pain and inflammation associated with cataract surgery. 

Combination Ophthalmics

Class Summary

Combination allows for maintenance of intraoperative mydriasis and reduces postoperative pain.

Ketorolac/phenylephrine ophthalmic (Omidria)

Ketorolac/phenylephrine ophthalmic is a proprietary FDA-approved combination agent that is added to the standard irrigating solution used during cataract surgery and other intraocular lens replacement procedures, including refractive lens exchange. Phenylephrine is an alpha1-agonist that prevents intraoperative miosis and ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that facilitates mydriasis and reduces postoperative pain.

Corticosteroids

Class Summary

Help decrease and control the inflammatory response following cataract surgery especially in the immediate postoperative period. The most commonly used ophthalmic steroid is prednisolone acetate 1%. Dexamethasone 0.1% ophthalmic solution sometimes is used as a generic alternative. 

Prednisolone acetate 1% (Pred Forte, Omnipred, Pred Mild)

Topical anti-inflammatory agent for ophthalmic use. A good glucocorticoid that, on the basis of weight, has 3-5 times anti-inflammatory potency of hydrocortisone. Glucocorticoids act at the nuclear level by down-regulating transcription of inflammatory mediators. Thus, they reduce prostaglandin synthesis, block arachidonic acid activity, and inhibit edema, fibrin deposition, capillary dilation, and phagocytic migration of acute inflammatory response, as well as capillary proliferation, deposition of collagen, and scar formation. Indicated for treatment of steroid-responsive inflammation of palpebral and bulbar conjunctiva, cornea, and anterior segment of the globe.

Dexamethasone ophthalmic (Ozurdex, Maxidex)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

Difluprednate ophthalmic (Durezol)

A potent corticosteroid approved for a wide variety of anterior segment surgical procedures, including cataract surgery, as well as acute noninfectious anterior uveitis. Provides powerful control of postoperative pain and inflammation in the cornea, anterior chamber, and, possibly, the retina.

Loteprednol ophthalmic (Alrex, Lotemax)

An ester rather than a ketone steroid, provides FDA-approved control of pain and inflammation following cataract surgery, as well as anterior uveitis, contact lens–induced giant papillary conjunctivitis, and perennial and seasonal allergic conjunctivitis. Newer ointment and gel drop formulations are approved for cataract surgery pain and inflammation.

Antibiotics

Class Summary

Broad-spectrum antibiotic ophthalmic solutions often are used prophylactically off-label in the immediate postoperative period. A number of topical antibiotics are used depending on the surgeon's preference, but, generally, medications are active against both gram-positive and gram-negative organisms.

Ciprofloxacin ophthalmic (Ciloxan)

Active against a broad spectrum of gram-positive and gram-negative organisms. Bactericidal action results from interference with enzyme DNA gyrase needed for bacterial DNA synthesis. In vitro and clinical studies have shown it to be active against following organisms: gram-positive (ie, Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus viridans) and gram-negative (ie, Haemophilus influenzae, Pseudomonas aeruginosa, Serratia marcescens). Other organisms have been found to be susceptible in vitro but have yet to be firmly established by clinical studies.

Moxifloxacin ophthalmic (Moxeza, Vigamox)

A self-preserved topical fluoroquinolone approved for conjunctivitis. Prescribed frequently for cataract and other intraocular surgical procedures as infection prophylaxis. By virtue of its broad spectrum and preservative-free status, many surgeons also inject 0.1 mL directly into the anterior chamber at the conclusion of cataract surgery to prevent endophthalmitis.

Besifloxacin ophthalmic (Besivance)

A uniquely formulated fluoro-chloro fluoroquinolone that is bihalogenated for increased spectrum and potency. Highly effective against multiply drug-resistant strains of Staphylococcus aureus and Staphylococcus epidermidis. Not available for animal, farm, or systemic human use, presumably reducing resistance profiles. Excellent pharmacokinetics due to highly viscous Insite® vehicle.

Levofloxacin ophthalmic (Quixin)

An increased spectrum L-isomer of ofloxacin provides antibiotic coverage for all types of intraocular surgery.

Gatifloxacin ophthalmic (Zymaxid)

A potent fluoroquinolone approved for bacterial conjunctivitis, like all the other listed fluoroquinolones herein, but used frequently for surgical prophylaxis.

Erythromycin ophthalmic (Ilotycin)

Indicated for infections caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival infections.

Dexamethasone/tobramycin (TobraDex, TobraDex ST)

A commonly prescribed topical combination agent used for conjunctivitis and surgical prophylaxis. Available as a generic.

Tobramycin/loteprednol ophthalmic (Zylet)

A commonly prescribed topical combination agent used for conjunctivitis and surgical prophylaxis. Much less likely to produce IOP elevations than dexamethasone-based combination agents.

 

Questions & Answers

Overview

How is senile cataract (age-related cataract) characterized?

What are the signs and symptoms of senile cataract (age-related cataract)?

How is senile cataract (age-related cataract) diagnosed?

How are senile cataracts (age-related cataracts) staged during a slit-lamp exam?

How are senile cataracts (age-related cataracts) staged are based on the visual acuity?

What is the role of lens extraction in the treatment of senile cataracts (age-related cataracts)?

What is a senile cataract (age-related cataract)?

What is the pathophysiology of senile cataract (age-related cataract)?

What is the prevalence of senile cataract (age-related cataract) in the US?

What is the global prevalence of senile cataract (age-related cataract)?

What is the mortality and morbidity associated with senile cataract (age-related cataract)?

What are the racial predilections of senile cataract (age-related cataract)?

What are the sexual predilections of senile cataract (age-related cataract)?

Which age groups have the highest prevalence of senile cataract (age-related cataract)?

What is the prognosis of senile cataract (age-related cataract)?

What is included in patient education about senile cataract (age-related cataract)?

Presentation

Which clinical history findings are characteristic of senile cataract (age-related cataract)?

How is decreased visual acuity characterized in senile cataract (age-related cataract)?

How is increased glare characterized in senile cataract (age-related cataract)?

What are the signs and symptoms of myopic shift in senile cataract (age-related cataract)?

What causes monocular diplopia in senile cataract (age-related cataract)?

Which is included in the physical exam to evaluate senile cataract (age-related cataract)?

What causes senile cataract (age-related cataract)?

What are roles of systemic diseases in the development of senile cataract (age-related cataract)?

What is the role of UV light in the development of senile cataract (age-related cataract)?

What are the risk factors for senile cataract (age-related cataract)?

DDX

Which conditions should be included in the differential diagnoses of senile cataract (age-related cataract)?

What are the differential diagnoses for Senile Cataract (Age-Related Cataract)?

Workup

What is the role of lab tests in the workup of senile cataract (age-related cataract)?

What is the role of imaging studies in the workup of senile cataract (age-related cataract)?

How is vision loss assessed in the workup of senile cataract (age-related cataract)?

How is macular function assessed in the workup of senile cataract (age-related cataract)?

Which tests are performed in the preoperative workup of senile cataract (age-related cataract)?

Which histologic findings are characteristic of senile cataract (age-related cataract)?

How are senile cataracts (age-related cataracts) staged?

Treatment

What is the role of medications in the treatment of senile cataract (age-related cataract)?

What is the role of surgery in the treatment of senile cataract (age-related cataract)?

What is the efficacy of surgery for senile cataract (age-related cataract)?

What is the role of intracapsular cataract extraction in the treatment of senile cataract (age-related cataract)?

What is the role of extracapsular cataract extraction in the treatment of senile cataract (age-related cataract)?

What is the role of phacoemulsification in the treatment of senile cataract (age-related cataract)?

What is the efficacy of bilateral senile cataract (age-related cataract) surgery?

What are the risk factors for intraoperative floppy iris syndrome (IFIS) during senile cataract (age-related cataract) surgery?

Which adverse effects are associated with alpha-adrenergic blockers in patients with senile cataract (age-related cataract)?

What is the association between senile cataract (age-related cataract) and age-related macular degeneration?

What is the role of multifocal IOLs in the treatment of senile cataract (age-related cataract)?

What is the role of acrylic toric IOLs in the treatment of senile cataract (age-related cataract)?

What is the role of sealant (ReSure Sealant) in the treatment of senile cataract (age-related cataract)?

When is surgery indicated for the treatment of senile cataract (age-related cataract)?

Which dietary modifications are used in the treatment of senile cataract (age-related cataract)?

Which activity modifications are used in the treatment of senile cataract (age-related cataract)?

What are the possible intraoperative complications of senile cataract (age-related cataract) surgery?

What are the possible immediate postoperative complications of senile cataract (age-related cataract) surgery?

What are the possible late postoperative complications of senile cataract (age-related cataract) surgery?

What are the possible complications of senile cataract (age-related cataract) surgery?

How is infectious endophthalmitis due to senile cataract (age-related cataract) surgery treated?

How is senile cataract (age-related cataract) prevented?

What is included in the long-term monitoring of senile cataract (age-related cataract)?

What is included in postoperative care of senile cataract (age-related cataract)?

What is the role of topical steroids in the treatment of senile cataract (age-related cataract)?

Medications

Which medications are used in the treatment of senile cataract (age-related cataract)?

Which medications in the drug class Antibiotics are used in the treatment of Senile Cataract (Age-Related Cataract)?

Which medications in the drug class Corticosteroids are used in the treatment of Senile Cataract (Age-Related Cataract)?

Which medications in the drug class Combination Ophthalmics are used in the treatment of Senile Cataract (Age-Related Cataract)?

Which medications in the drug class Nonsteroidal anti-inflammatory ophthalmics are used in the treatment of Senile Cataract (Age-Related Cataract)?

Which medications in the drug class Mydriatics are used in the treatment of Senile Cataract (Age-Related Cataract)?