Age-related cataract
At a glance
Lens opacity matters when it impairs visual function or prevents management of other eye disease.
CAVE
- Do not attribute disproportionate visual loss to a mild cataract.
- Check the macula, optic nerve and ocular surface.
Clinical presentation
- Progressive blur, glare, reduced contrast, monocular diplopia or refractive change.
Diagnosis & investigations
- Record the functional complaint, best-corrected acuity/refraction, glare needs and realistic visual potential. Examine the surface, cornea, pupil, zonules, lens and dilated fundus; macular OCT when symptoms, examination or IOL choice require it.
- Before biometry, stabilise dry eye. Record axial length and keratometry quality, prior corneal surgery, pseudoexfoliation/phacodonesis, poor dilation, alpha-blocker exposure, anticoagulants, diabetes and previous uveitis/retinal disease. Do not stop systemic drugs automatically; plan with the responsible clinician.
Differential diagnosis
- Macular disease, corneal irregularity, uncorrected refractive error and optic neuropathy.
Treatment
- Offer surgery when cataract-related limitations justify its risks, not at a fixed acuity threshold. Agree the refractive target and IOL before consent; plan support devices or senior surgery for zonular/pupillary risk.
- Use ocular antisepsis and an evidence-based intracameral antibiotic protocol. ESCRS supports cefuroxime 1 mg in 0.1 mL at the end of surgery when appropriate; correct preparation and allergy assessment are essential. Postoperative anti-inflammatory treatment commonly combines topical steroid and NSAID, with attention to corneal disease and diabetic macular risk.
Follow-up
- Tailor early review to the operation and risk: complications, glaucoma, monocular status or unexpected symptoms favour direct early assessment. Check acuity, IOP, wound integrity, corneal clarity, chamber inflammation and IOL position. Provide a same-day contact route for pain or falling vision. Refraction and final visual outcome are assessed after stabilisation.
| Finding | Action | Timing / detail |
|---|---|---|
| Pain, reduced vision, hypopyon or marked inflammation | Exclude endophthalmitis urgently; assess vitreous, wound and fundus, with B-scan if needed | Same-day surgical/retinal review; onset alone does not reliably distinguish TASS from infection |
| Corneal oedema or unexpectedly poor acuity | Check IOP, wound/Seidel, chamber depth, Descemet membrane and retained lens material | Painful high IOP or shallow chamber needs prompt treatment, not routine discharge |
| Low IOP or suspected wound leak | Examine wound integrity and chamber; inform the operating team | A leak creates an infection risk; management depends on leak size and chamber stability |
| Later central blur/metamorphopsia | Examine macula with OCT for cystoid oedema; assess refraction, ocular surface and posterior capsule | Do not assume posterior capsule opacification explains every reduced postoperative acuity |
Risk factors & context
- Record previous trauma or surgery, steroid exposure, diabetes, pseudoexfoliation and pupil dilation.
- These findings affect surgical planning.
Complications
- Discuss individual risks of capsular rupture, infection, cystoid macular oedema and refractive surprise.
- Later posterior capsule opacification can reduce vision again.
When to refer
- Pain and reduced vision after surgery require urgent exclusion of endophthalmitis or other complications.
References 2
- ESCRS · Recommendations for Cataract Surgery ↗2024 recommendations · online executive summary · 4.1 Patient selection; 4.2 Preoperative assessment; IOL selection; postoperative care
- RCOphth · Managing an outbreak of postoperative endophthalmitis ↗2022 · Recognition and initial management of suspected cases
European guidance. Drug availability and authorisations must be checked locally.