Indications for cataract surgery

Cataract surgery is usually recommended when you have trouble seeing well enough to carry out your normal daily activities. As part of your assessment, your clinician may test how clearly you can read an eye chart (visual acuity). They will also take into account other visual problems, including any difficulty you have seeing in bright or dim light.

You will be asked about how your eye problems affect your daily activities. What this means may differ from person to person. Daily activities include working, driving and reading, as well as your ability to live independently and safely with your visual problems (for example, whether you are at risk of falls). The clinician may ask you to complete a questionnaire.

The likely benefits and possible harms of surgery might depend on whether you have any other health conditions, including other eye problems. Your clinician will consider these factors when discussing the possibility of cataract surgery with you, and will let you know if you have a condition that means that surgery is not recommended or there is a higher risk of complications.

Sometimes cataract surgery is recommended for medical reasons rather than for improving vision. This includes surgery for people who need regular check-ups of the retina (back of the eye) but the retina cannot be seen because of the cataract.

Note: This statement applies to people having cataract surgery primarily to improve vision.
It does not apply to other indications for cataract surgery including angle closure and phacolytic glaucoma, or to allow monitoring of retinal conditions.

The clinical decision about whether to offer cataract surgery takes into account the patient’s level of visual impairment, the impact of visual deficits on their daily life, and the potential benefits and harms associated with surgery.

Visual acuity of 6/12 or worse may provide a useful objective measure of visual impairment, but may significantly underestimate function – for example, in conditions of high or low light. Glare or contrast sensitivity may be disabling without an impact on visual acuity. Some patients will have higher visual acuity needs, such as for occupational activities. Vision-related activity limitations include activities of daily living, which are specific to the individual’s social circumstances and occupation. Validated tools for assessing vision related activity limitations, and the impact of visual problems on activities and social functioning are described in Box 2, see Cataract Clinical Care Standard full document. Some of these tools correlate well with positive patient reported outcomes after cataract surgery.^50-52,54,57

Use of standardised criteria and tools allows consistency of assessment, and assists when prioritising patients within a health service or system.^27,31 These criteria do not replace the need for an individualised clinical assessment or clinical judgements about the severity of impairment and the appropriate treatment options.

Most patients have an improvement in visual function after surgery. Patients most likely to report a poor outcome after surgery include those with good self-assessed preoperative visual function.^7,57,58 Consider conditions that increase the risk of complications or a poor outcome from cataract surgery (such as diabetes, diabetic retinopathy or uveitis) or limit the extent of visual gain (such as age-related macular degeneration).⁷

If the patient chooses not to have surgery or is not considered suitable for surgery at this time, offer details of other healthcare providers who can help, such as an occupational therapist or optometrist.

Ensure that protocols support the use of suitability criteria for cataract surgery, and that cataract surgery is offered to patients who meet agreed criteria. Protocols should allow other compelling indications for surgery to be considered, based on clinical judgement, and should cater for patients who choose non-surgical options.

Consider implementing common clinical criteria or tools into protocols to enable standardised assessment, documentation and prioritisation. Box 2 provides examples of tools that could be considered, see Cataract Clinical Care Standard full document. Implement tools and protocols within a quality improvement framework, monitoring their use and impact to ensure that desired outcomes are being achieved. Such outcomes may include whether criteria are being consistently applied, equity of access, timeliness of access and patient-reported outcomes.