Ophthal. Physiol. Opt. Vol. 19, Suppl. 1001, pp.
S10S15, 1999
Management of patients with age-related
cataract
David B. Elliott*
Department of Optometry, University of Bradford, Bradford, West Yorkshire BD7 1DP, UK
This article has been approved for the award of one CET credit, subject to achieving
the 60% pass mark in the MCQs.
Introduction
The optometric assessment of
patients with age-related cataract
was reported previously (Elliott,
1998). This article completes the
discussion by considering the man-
agement of such patients. From a
management viewpoint, there are
essentially two types of age-related
cataract patients: those who could
be referred for surgery and those
that are too early for referral. The
former group will be discussed
rst.
When should a patient be
referred for cataract surgery?
In the majority of cases cataract
patients should be referred for sur-
gery when their ability to function
in their desired lifestyle is reduced
due to poor vision (AHCPR,
1993). For some patients, other
clinical factors take precedence
and become the basis for referral.
For example, hypermature catar-
acts must always be referred,
dense unilateral cataracts should
be referred to avoid exotropia
occurring and surgery may be
*MCOptom. Tel.: +44 1274 234642; Fax:
+44 1274 235570; E-mail: d.elliot1@brad-
ford.ac.uk.
# 1999 The College of Optometrists. Published by Elsevier Science Ltd
PII: S0275-5408(98)00065-9
required in a diabetic patient to
allow treatment of retinopathy.
Visual acuity becomes the reason
for referral when patients are
happy with their vision but do not
meet required standards for driv-
ing or work etc.
However, for the majority of
patients, case history should deter-
mine referral. A ow chart of the
decision process is given in
Figure 1. In a recent survey,
Latham and Misson (1997) found
that at present optometrists tend
to refer patients based on visual
acuity. The optometrists surveyed
indicated that they would refer
when a cataract patient has 6/18
or 6/24 visual acuity. Surveyed
ophthalmologists from the same
area indicated they were happy to
see patients with 6/9 or 6/12 visual
acuity. In addition, the ophthal-
mologists thought they received
many inappropriate referrals from
optometrists, mainly because they
were referred too early! This
appears to be inconsistent.
However, ophthalmologists want
to have cataract patients referred
when their ability to function in
their desired lifestyle is reduced
due to poor vision. If these
patients happen to have 6/9 or
6/12 visual acuity, then this is
S10
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quite acceptable. However,
ophthalmologists do not want to
see patients with no visual pro-
blems or who do not want sur-
gery, regardless of how poor their
visual acuity is. Referring these
patients is inappropriate as it is
too early. So, if the patient is 6/18
and happy, then do not refer.
Note that you discussed referral
and the patient wanted to wait,
and send a report to the patient's
GP. There seems little point in
clogging up ophthalmology clinics
with patients not yet ready for cat-
aract surgery.
Referral for second eye surgery
Second eye cataract extractions
increased with the invention of the
intraocular implant by Harold
Ridley at St. Thomas Hospital,
London, in 1949. Ridley had seen
many ocular injuries caused by the
shattering of Spitre canopies
during World War II and discov-
ered that the imbedded plastic ma-
terial did not produce any ocular
reaction (Wilensky, 1975). Because
of the cost of second eye surgery
(30,000,000 a year in the UK), at
least one local health authority
has stopped its provision for the
present time. This is hopefully an

Figure 1. A flow chart indicating the decision making process regarding referral of a patient with uncomplicated
age-related cataract.
interim measure, as much recent
research has indicated the benets
occurring from second eye surgery.
These particularly include
improvements in stereopsis, ani-
sometropia and mobility orien-
tation (Laidlaw and Harrad, 1993;
Whitaker et al., 1996; Desai et al.,
1996; Elliott et al., 1997). Referral
for second eye surgery should be
based on the patient's visual symp-
toms but can be justied using
stereopsis and anisometropia
measurements in addition to the
usual clinical data. Some hospital
eye departments ask for monocu-
lar pseudophakic patients to be
referred back to them if anisome-
tropia is greater than about 5.00
D.
Management of patients with age-related cataract: D. B. Elliott
Referral letters
The ophthalmologist's decision
will be based on the eects of
reduced vision on the patient's
lifestyle and this is the information
they want to read in your referral
letter. For example state that:
``This patient has nuclear cataracts
in both eyes and would like to
have surgery as at present she is
unable to knit or sew. In addition,
her vision in bright sunlight is
very poor, making it dicult for
her see friends or even walk safely
outside.'' Visual acuity infor-
mation should also be given, but
generally this is only the reason
for referral when patients do not
meet required standards for driv-
ing or work, etc.
S11
Patients not referred optometric
Once a patient has been referred
for surgery, optometric manage-
ment of the patient's visual health
ceases until they have been
returned to your care post-opera-
tively. The management of
patients after cataract surgery is
discussed in a later article. How
do you manage those patients with
cataract that is too early for refer-
ral or those patients who do not
wish to be referred?
Refractive prescribing
Any dicult decisions when pre-
scribing spectacles for cataract
patients are generally due to catar-
act-induced refractive change, such
S12 Ophthal. Physiol. Opt. 1999 19: No Suppl. 1001
as increased myopia with nuclear
cataract and increased astigmatism
or signicantly altered astigmatic
axis with cortical cataract (Amos,
1987). Elderly patients tend not to
adapt as well as younger ones to
large refractive changes. Partial
corrective changes are therefore
recommended to aid adaptation.
Consider prescribing the cylinder
axis 1/2 to 2/3 of the way from
the old to the new axis, and like-
wise with altered cylinder power.
With a partial astigmatic power
correction, you could either
change the sphere to give the opti-
mal best mean sphere (sphere + 1/2
cylinder) or, better still, recheck
the best mean sphere with the par-
tial astigmatic correction. It is also
common to consider a partial cor-
rection of nuclear cataract-induced
myopic changes. Adaptation to
large increases in negative power
can be dicult, and as myopic
increases tend to be dierent in
the two eyes, there can be pro-
blems due to anisometropia and
aniseikonia. A partial correction
of the most myopic error is rec-
ommended. Undercorrecting a
myopic error is not as detrimental
to visual acuity (VA) with nuclear
cataract-induced myopia as with
other forms of myopia. In young
myopes, an undercorrection of
1.00 DS would probably lose four
lines of VA. However, with
nuclear cataract an undercorrec-
tion of 1.00 DS may only lose the
patient less than one line of VA,
and this may be preferable to pro-
blems of adaptation and anisome-
tropia. The prescribing of equal
base curves and centre thicknesses
may also help reduce induced ani-
seikonia to a tolerable level
(Amos, 1987). A full correction
could be attempted if the patient
was a contact lenses wearer. In all
these cases it is important to docu-
ment the VA with the partial pre-
scription. For example, you may
need to make sure that the partial
prescription does not reduce the
VA below legal driving limits.
Tints
Glare symptoms can often lead
to the prescribing of tints. Tints
are often prescribed by clinicians
under the assumption that they
provide some improvement in
visual function, especially in the
presence of glare. However, dis-
ability glare, the reduction in
vision caused by a glare source, is
not generally improved with a tint
(Steen et al., 1993). Not only does
a tint reduce the amount of light
from the glare source, it also
reduces the amount of light from
the object the patient is looking
at. The net eect is for the
patient's vision to remain
unchanged. Tints may, of course,
help alleviate discomfort glare
(discomfort caused by a glare
source). The optimum method by
which disability glare may be alle-
viated is to reduce the light reach-
ing the eye from a glare source
without aecting the light from
the object of interest. This eect is
achieved by the use of visors,
broad-brimmed hats and squinting
in bright sunlight, although these
tactics are often considered purely
as methods to combat discomfort
glare. Graduated tints, which
selectively block glare from above,
work along the same principles,
but are usually prescribed on a
cosmetic rather than a functional
basis. Another example of selective
attenuation of glare is in the use
of polarising lters which preferen-
tially absorb light which has been
polarised by surface reection. In
summary, the best advice to a
patient with cataract is generally
to wear a peaked cap or broad-
brimmed hat, rather than wear a
tint.
Given the lack of any signicant
Rayleigh (blue light) scattering in
the eye (Whitaker et al., 1993),
there seems to be little rationale
for prescribing blue absorbing
tints. This is particularly true for
patients with nuclear cataract, as
they already have a built-in blue
absorbing lter. A tint may be
helpful to patients with centrally
placed subcapsular (PSC) opaci-
ties, as it may help vision by
slightly increasing pupil size. In
these situations a neutral grey tint
may be preferred, so as not to
reduce the patient's already
reduced colour vision. Tints
should be prescribed with care to
patients with cortical cataracts, as
any increase in pupil size in these
patients can further reduce vision.
Ultra-violet tints
An ultra-violet (UV) blocking
tint can be useful for cataract
patients for two reasons:
. Nuclear and cortical cataracts
contain signicant amounts of
uorescent pigments which con-
vert invisible UV radiation into
scattered visible light which can
reduce vision. UV-blocking l-
ters can therefore improve
vision in these patients (Zigman,
1992).
. UV radiation may be involved
in the aetiology of cataract (e.g.,
van Rongen and Vrensen,
1994), so that a UV-blocking
tint may help to reduce the pro-
gression of cataract.
Prescribing UV-blocking tints
post-operatively is discussed in a
later article.
Anti-reection coats
Patients with cataract, particu-
larly nuclear cataract, have
reduced light reaching the retina
because of increased backscatter
and light absorption, and can have
poor vision in dim illumination
(Elliott et al., 1997). Anti-reec-
tion coats will increase the amount
of light transmitted through any
spectacles and may help in this

regard. In addition, a small
amount of disability glare could
be reduced by anti-reection coats
(light scattered from the back sur-
face of spectacles can produce a
slight veiling glare) which may
again be of some benet. A draw-
back for all patients with anti-
reection coats is that they need
cleaning more often as any nger-
prints, dust, etc. are noticed more
readily. Patients who are pre-
scribed these coatings should have
the manual dexterity to be able to
clean their spectacles easily (avoid
prescribing them for patients with
arthritic hands for example). Some
patients with cataract are continu-
ally cleaning their lenses, as the
eects on vision of the cataract
are similar to those from a dirty
spectacle lens.
Counselling
`Have I got cataract?'
Should you inform patients if
they have cataract? Given that the
vast majority of people will have
some form of lens opacity when
they get older, is any lens opacity
a cataract? A good approach is to
dene cataract as a lens opacity
that reduces vision, and only
inform those patients who have
symptoms of reduced vision due
to a lens opacity that they have
cataract. Any patient who has a
lens opacity which is not reducing
vision in any way could be told
they have a small lens opacity or
`age change'. This should then be
described (a similar description to
that used for cataract can be used,
see below) and you may wish to
inform the patient that this can
`turn into' a cataract in later
years. Informing a patient with a
small lens opacity that they have
cataract can worry some anxious
or sensitive patients.
There is a possibility of pro-
blems with this approach if a
patient is subsequently told by a
Management of patients with age-related cataract: D. B. Elliott
GP or another optometrist that
they have cataract. It may appear
that you have `missed' it. This
could potentially occur if a patient
has a particularly rapidly progres-
sing cataract. Another scenario
could be a patient with no pro-
blems when they were examined
by you, who subsequently decided
to resume driving or went on a
sunny holiday and encountered
severe diculties. In this regard, it
is important that any lens opaci-
ties are documented, preferably
with a diagram. This is particu-
larly true of posterior subcapsular
cataracts which can progress sud-
denly and even when small can
cause dramatic reductions in
vision under certain conditions
(night driving, bright sunlight).
These types of cataract must be
carefully looked for and an expla-
nation of their eect on vision
given to the patient. It is also im-
portant to briey document any
explanation provided to the
patient (e.g. `notied re lens opa-
city and prognosis').
There are still some patients
who believe that a cataract is a
skin growing over the eye, and an
accurate description can be useful.
A cross-sectional diagram of the
eye and identication of the lens is
a useful start. A cataract (or lens
opacity) can be described as a
slight greying of the lens, similar
to the greying of hair with age,
which scatters light in the eye. The
eect of the light scatter can be
described as similar to looking
through a dirty car windscreen or
dirty spectacles. The very success-
ful nature of modern cataract sur-
gery should also be stated at this
point. In addition, many local
health authorities now produce
excellent pamphlets regarding cat-
aract and cataract surgery and
these can be provided to patients.
S13
Advice on driving
Any patient who has visual
acuity below the required driving
level should obviously be
informed. It is also important to
realise that although a patient has
6/9+ or 6/6 VA in your examin-
ation room, this does not necess-
arily mean they have the required
level of vision for driving. It has
been shown that some patients
with cataract can see 6/6 or 6/9+
in the examination room, but only
6/18 or worse outside in the sun-
light (Neumann et al., 1988).
Similarly, they may be able to see
better than the legal driving limit
on an overcast day, but not on a
sunny day or when night driving.
For this reason, it is important to
measure a patient's vision under
glare conditions, particularly those
with posterior subcapsular catar-
act. You can then give informed
advice to the patient regarding
whether it is safe (and legal) for
them to drive, and they should
consider this information when
deciding whether they wish to be
referred for cataract surgery. Any
advice given regarding driving
should obviously be documented
and it can be useful to inform
their GP.
Prognosis and follow-up
Most cataracts progress rela-
tively slowly and it can take many
years for a cataract to progress to
the level of needing extraction.
Follow-up examinations of
patients with lens opacity (i.e. with
no reduction in vision) are typi-
cally every 2 years unless there are
other considerations. Follow-up
examinations of patients with cat-
aract (i.e. lens opacity causing a
reduction in vision) are typically
every year. Some patients should
be asked to return in 6 months or
less. These include patients with
cataract-induced myopia and/or
astigmatism that is quickly pro-
S14 Ophthal. Physiol. Opt. 1999 19: No Suppl. 1001

gressing and some patients with

PSC or diabetic cataract or other
rapidly progressing cataract.

`Use up my eyes'
There are some elderly people
with reduced vision who believe
that they can make their vision
`last longer' if they save their eyes
and only read/sew/knit, etc. for a
short time each day. They view
their remaining sight as being held
in a bank from which they should Figure 2. A typoscope.
only make small amounts of daily
cating the ecacy of the anti-oxi- contrast of the retinal image) is
withdrawals so they will keep their
dant vitamins to slow the also increased. The ideal situation
vision longer. They should be
progression of early cataract (e.g. for a cataract patient is a good
advised to use their vision as
Christen et al., 1996; Brown et al., anglepoise lamp (and/or advise the
much as they like and that this
1998). In addition, a major multi- patient to sit with their back
will not aect their eyes.
centre (Boston, Bradford, Oxford) towards the window during the
clinical study has shown that an day) and a typoscope (Figure 2).
Removal of risk factors oral antioxidant micronutrient Typoscopes reduce the amount of
supplement slowed the progression light entering the eye from areas
Although it is likely that age-re-
of early age-related cataract over a of the page which are not being
lated cataract is multi-factorial in
3-year period (Chylack et al., read, light which is otherwise scat-
aetiology and there are many pro-
1998). The micronutrients used tered by the cataract. Typoscopes
posed risk factors, few of them
were: vitamin C (750 mg/day), sound grand, but are merely pieces
have been substantiated. However,
vitamin E (600 mg/day) and b-car- of black card with a slot cut in
epidemiological studies have
otene (18 mg/day), and there were them which is wide enough to
suggested that exposure to ultra-
no reported side-eects. These allow patients to read two or three
violet radiation, cigarette smoking,
reports suggest that it may be lines of text. They are, therefore,
and a low vitamin diet can con-
good advice to encourage patients very simple and cheap to make
tribute to cataract (e.g. Cumming
with early cataract to take an anti- and can be given out free of
and Mitchell, 1997; Leske et al.,
oxidant vitamin supplement. charge to cataract patients.
1998). Despite the lack of rm evi-
dence that these factors cause cat-
aract, it can be useful to provide
Improving reading Summary
this information to patients.
Reducing UV exposure and ciga- Generally, older patients require The majority of patients
rette smoking and appropriately more light to read. This is due to referred because of age-related cat-
increasing vitamin intake may help reduced near acuity with age and aract should be referred when
and is highly unlikely to cause a reduction in retinal light levels their ability to function in their
harm. due to age-related pupillary miosis desired lifestyle is reduced due to
and lens absorption. In patients poor vision. Generally the decision
with cataract, the light reaching to refer should not be based on
Vitamins and anti-cataract drugs
the retina is reduced further (the visual acuity, and the referral
There are over 50 anti-cataract light scatter you see using an opti- letter should reect this. Patients
drugs available wordwide and cal section at the slit-lamp is back- who are not referred should not
although none are available in the scatter, which is light that does not just be monitored until referral.
UK, many are available in reach the retina). Unfortunately, There are several simple strategies
Europe. None of these agents have increasing the amount of light for for improving their vision which
been proven to work in properly reading for cataract patients can should be discussed with the
controlled clinical trials. There is, make things worse, as forward patient, such as broad-brimmed
however, some epidemiological light scatter (the light scattered hats or caps, typoscopes, anti-
and animal research evidence indi- onto the retina which reduces the reection coats and UV-blocking

tints. There are also several strat-
egies which may delay the progress
of their cataract, which include
reducing UV exposure and ciga-
rette smoking and taking anti-oxi-
dant vitamin supplements. These
could also be discussed with the
patient.
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