CURRENT Practice Guidelines in Primary Care 2025–2026

Chapter 4: Ears, Eyes, Nose, and Throat Disorders

CATARACTS

Management

Adults

Recommendations from

►AAO 2021

–Refer patients with symptomatic cataracts for surgery.
–Do not recommend specific dietary intake or nutritional supplements for the prevention or treatment of cataract.
–Obtain initial history of symptoms, ocular history, systemic history, assessment of visual functional status, and medications currently used (Fig. 4–1).
–Refer for removal of cataracts when visual function no longer meets the patient’s needs and cataract surgery provides a reasonable likelihood of quality-of-life improvement.
–Avoid surgery in the following circumstances:
- Vision with corrective lenses provides acceptable quality of life, surgery is not expected to improve visual function, and no other indication for lens removal exists.
- The patient cannot safely undergo surgery because of coexisting medical or ocular conditions.
- Appropriate postoperative care cannot be arranged.
- Patient or patient’s surrogate decision-maker is unable to give informed consent for nonemergent surgery.

Practice Pearls

Cataracts will cause the red reflex to appear shadowed or absent on physical exam. Postoperative symptoms may include vision impairment, sensitivity to glare, and difficulty with night vision.
Routine preoperative medical testing does not measurably increase the safety of the surgery. Avoid requiring preoperative clearance for cataract surgeries.

Fig. 4–1

Cataract in Adults: Evaluation and Management Algorithm.

$“The flowchart begins with the text that reads Patient complaining of vision impairment (Begin evaluation only when patients complain of a vision problem or impairment). It leads to a Comprehensive eye and vision examination, Cataract identified as the cause (Essential elements of the comprehensive eye and vision exam: Patient history: consider cataract if the acute or gradual onset of vision loss; vision problems under special conditions (eg, low contrast, glare); difficulties performing various visual tasks. Ask about refractive history, previous ocular disease, amblyopia, eye surgery, trauma, general health history, medications, and allergies. It is critical to describe the actual impact of the cataract on the person’s function and quality of life. There are several instruments available for assessing functional impairment related to cataracts, including VF-14, Activities of Daily Vision Scale, and Visual Activities Questionnaire. The ocular examination includes Snellen acuity and refraction; measurement of intraocular pressure; assessment of pupillary function; external exam; slit-lamp exam; and dilated exam of the fundus. Supplemental testing: may be necessary to assess and document the extent of the functional disability and to determine whether other diseases may limit preoperative or postoperative vision. Most elderly patients presenting with visual problems do not have a cataract that causes functional impairment. Refractive error, macular degeneration, and glaucoma are common alternative etiologies for visual impairment). If no, treat as appropriate. If yes, it leads to patient counseling and decision (Once cataracts have been identified as the cause of visual disability, patients should be counseled concerning the nature of the problem, its natural history, and the existence of both surgical and nonsurgical approaches to management. The principal factor that should guide decision-making with regard to surgery is the extent to which the cataract impairs the ability to function in daily life. The findings of the physical examination should corroborate that the cataract is the major contributing cause of the functional impairment and that there is a reasonable expectation that managing the cataract will positively impact the patient’s functional activity. Preoperative visual acuity is a poor predictor of postoperative functional improvement: the decision to recommend cataract surgery should not be made solely on the basis of visual acuity). It leads to a Degree of functional impairment sufficient to warrant surgery (Patients who report mild-to-moderate limitation in activities due to a visual problem, those whose corrected acuities are near 20 over 40, and those who do not yet wish to undergo surgery may be offered nonsurgical measures for improving visual function. Treatment with nutritional supplements is not recommended. Smoking cessation retards cataract progression. Indications for surgery: cataract-impaired vision no longer meets the patient’s needs; evidence of lens-induced disease (for example, phacomorphic glaucoma, phacolytic glaucoma); necessary to visualize the fundus in an eye that has the potential for sight (eg, diabetic patient at risk for diabetic retinopathy). If yes, it leads to Ophthalmic or medical contraindications to surgery (Contraindications to surgery: the patient does not desire surgery; glasses or vision aids provide satisfactory functional vision; surgery will not improve visual function; the patient’s quality of life is not compromised; the patient is unable to undergo surgery because of coexisting medical or ocular conditions; a legal consent cannot be obtained; or the patient is unable to obtain adequate postoperative care. Routine preoperative medical testing (12-lead ECG, CBC, measurement of serum electrolytes, BUN, creatinine, and glucose), while commonly performed in patients scheduled to undergo cataract surgery, does not appear to measurably increase the safety of the surgery). If no, it leads to Nonsurgical measures and follow-up at 4 through 12 months intervals. If no to ophthalmic or medical contraindications to surgery, it leads to Patient counseling and decision (patients with significant functional and visual impairment due to cataracts who have no contraindications to surgery should be counseled regarding the expected risks and benefits of and alternatives to surgery). It prefers surgery that leads to Surgery, postoperative care, and follow-up. If yes to ophthalmic or medical contraindications to surgery, it leads to Nonsurgical measures and follow-up at 4 through 12 months intervals. Patient counseling and decision prefer nonsurgical measures and follow-up at 4 through 12-month intervals that lead to Strong bifocals or magnifying glasses, pupillary dilation, patient education, and determining whether functional disability develops.”$

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Sources: American Academy of Ophthalmology Preferred Practice Pattern: Cataract in the Adult Eye. 2006. http://www.aao.org; American Optometric Association Consensus Panel on Care of the Adult Patient with Cataract. Optometric Clinical Practice Guideline: Care of the Adult Patient with Cataract. 2004. http://www.aoa.org.

Sources

–American Academy of Ophthalmology Preferred Practice Pattern: Cataract/Anterior Segment Summary Benchmark. 2021. http://www.aao.org
–American Optometric Association Consensus Panel on Care of the Adult Patient with Cataract. Optometric Clinical Practice Guideline: Care of the Adult Patient with Cataract. 2004. http://www.aoa.org
–Am Fam Physician. 2016;94(3):219–226.

CERUMEN IMPACTION

Management

Children and Adults

Recommendations from

►AAO-HNS 2017

–Treat cerumen impaction when it is symptomatic or prevents a necessary examination.
–Treat with an appropriate intervention:
- Cerumenolytic agents (water or saline, Cerumenex, Addax, Debrox, or dilute solutions of acetic acid, hydrogen peroxide, or sodium bicarbonate).
- Irrigation.
- Manual removal.
–Prevent recurrent impaction by using alcohol or hydrogen peroxide drops, routine irrigation with bulb syringe or irrigation kits, topical cerumen-softening agents, or physical removal by clinician.
–Avoid ear candling, olive oil, and probing ear canal with objects such as cotton swabs.

Practice Pearls

Removal of cerumen is not necessary if the patient is asymptomatic and adequate clinical exam is possible.

- Irrigation is contraindicated if TM rupture, tympanostomy tubes are present, or significant anatomic abnormalities exist. While irrigating, pull gentle traction on the ...

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Chapter 4: Ears, Eyes, Nose, and Throat Disorders

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CATARACTS

Management

Recommendations from

Fig. 4–1

Sources

CERUMEN IMPACTION

Management

Recommendations from

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