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General Principles in Older Adults
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A cataract is a clouding of the lens and is a leading cause of vision impairment in the United States and globally. Cataracts progress gradually, and may require removal. By age 80 years, more than half of all people in the United States either have a cataract or have had cataract surgery. Risk factors for cataracts include advanced age, diabetes, cumulative exposure to ultraviolet B radiation, smoking, current or previous long-term use of corticosteroids, previous eye surgery, or a history of eye injury.
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Decreasing UV exposure by wearing sunglasses and hats, encouraging smoking cessation and good glycemic control may delay the onset and progression of cataracts. Currently, there is no evidence that medication or nutritional supplementation prevents, delays the progression of, or cures cataracts.
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Typical symptoms of cataracts include a gradual onset of blurred vision and increased sensitivity to glare (especially when driving at dusk or night). A common sign of a sight-limiting cataract is an insensitivity to subtle color differences such as those caused by food stains on clothing in an otherwise neatly dressed patient. Observing a white haze in the pupil during pupil testing suggests a moderate or worse cataract. With the pupil dilated, the red eye reflex may exhibit focal or diffuse areas of darkness when viewed with the direct ophthalmoscope or a slit lamp.
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Differential Diagnosis
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Patients with significant cataracts often present with a history of painless, gradual and progressive deterioration of vision and a normal appearing external eye. Other possibilities include uncorrected refractive error, diseases of the macula or optic nerve, or diabetic eye disease. If vision loss is rapid, consider vitreal or retinal hemorrhage, or other vascular disorders. Associated eye pain and/or conjunctival hyperemia should raise concern for uveitis or angle-closure glaucoma.
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Complications due to cataracts are very rare and include lens-induced glaucoma or uveitis. In the case of glaucoma, the lens pushes the iris forward into the anterior chamber angle, and blocks aqueous drainage. In lens-induced uveitis, disruption of the lens capsule causes an immune-related intraocular inflammation, which can also induce glaucoma by blocking aqueous outflow. In both situations, surgical removal of the lens is curative.
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Management & Treatment
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Cataracts usually develop slowly, and in the early stages an updated spectacle correction often will improve vision. Environmental modifications, such as avoiding high glare situations (eg, night driving) the use of antiglare sunglasses and providing adequate ambient light, can help patients cope. The only treatment for cataracts is removal. Surgery is usually indicated when visual acuity is approximately 20/40 or when a patient’s daily activities are compromised by reduced vision, despite best correction. The decision for surgery should take into account other pathologies, such as macular degeneration or diabetic retinopathy, which may limit postsurgical vision.
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Pre- and Postoperative Care
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Most older adults can tolerate cataract surgery. Patients should be medically stable and ideally be able to lie supine for 30 minutes. Postoperative care typically requires the administration of antibiotic and antiinflammatory eye drops, as well as follow-up office visits. For patients with comorbidities such as chronic obstructive pulmonary disease, poorly controlled blood pressure, coronary artery disease, or diabetes, the ophthalmologist will typically request a medical evaluation by the patient’s primary care physician. Although preoperative laboratory testing for any medical problems indicated by the history and physical examination is appropriate, studies show that routine medical testing before cataract surgery does not improve outcomes.
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Cataract surgery is usually an outpatient procedure. In patients deemed to have a reasonably healthy cornea, the incision is made through the cornea, which results in minimal or no blood loss and usually requires only topical anesthesia and minimal systemic medications. Because of this, anticoagulant or antiplatelet therapy may be continued, based on the preferences of the eye surgeon and primary care physician.
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Serious postoperative complications from cataract surgery are rare (<1.5%). Symptoms of pain or a decrease in vision in the days following surgery suggest intraocular infection (endophthalmitis), and an increase in floaters or flashes of light could signal retinal detachment. Both of these conditions require immediate ophthalmologic consultation. While less vision-threatening, 2 more common complications, cystoid macular edema and the development of opacities on the posterior capsule of the lens, also require consultation because they can reduce visual acuity. Cystoid macular edema occurs at a rate of <3% in the weeks following cataract removal and is typically treated with topical antiinflammatory medications. Posterior capsular opacities (sometimes called secondary cataracts) can develop months to years following lens removal surgery and occur at a rate of 18% to 50%. If the opacity becomes visually significant, a laser is used to ablate the area of membrane that blocks vision.
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Age-related cataracts typically progress slowly over time. Through regular evaluations, an optometrist or ophthalmologist can monitor their progress and recommend when the risks of cataract surgery are justified by its potential benefits in terms of ensuring the patient’s visual capacities continue to meet the demands of daily living.
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Owsley
C, McGwin
G
Jr, Scilley
K
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S Epidemiology of cataract: accomplishments over 25 years and future directions.
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