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Cataract in Adults: Management of Functional Impairment

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Clinical Practice Guideline.

Panel Chair: Denis M. O'Day, M.D., F.A.C.S., Vanderbilt University School of Medicine.
Guideline Release Date: February 25, 1993.

A guideline was developed by an 18-member multidisciplinary panel of private-sector experts to promote appropriate management of adults with cataract-related functional impairment. After an extensive literature review, the panel concluded that surgery is not justified merely because a cataract exists. Its appropriateness depends on the degree of functional impairment, including the patient's assessment of vision and lifestyle needs.

Cataract Guideline Contents (Spring 1995)


When people with cataracts (clouding of the eye lens, a normal part of aging) try to perform everyday activities, they can experience serious difficulties. As a result, more than 1.3 million cataract extractions are performed each year on Medicare beneficiaries.

Cataract in adults was designated as a clinical practice guideline topic because of its prevalence in elderly Americans, and expenditures for cataract surgery are a significant part of the Medicare budget. The goal of the guideline—Cataract in Adults: Management of Functional Impairment—is to encourage appropriate treatment for restoring or maintaining functional independence.

To ensure a broad approach to care, the AHCPR-supported guideline covered:

  • Ethical issues in the caregiver-patient relationship.
  • Natural history and major risk factors of cataract.
  • Referral pathways and access to care.
  • Treatment settings and health care providers, and their impact on outcomes.
  • Value and suitability of preoperative tests.
  • Various aspects of treatment, including surgical and nonsurgical management.
  • Care, rehabilitation, and YAG laser treatment for clouding of the capsule behind the lens after cataract surgery.

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Using data bases of the National Library of Medicine as a foundation for literature sources, the guideline panel analyzed nearly 8,000 relevant English-language scientific articles published between January 1975 and April 1991. Based on this extensive literature review, expert opinion, and panel consensus, the panel reached the following conclusions and recommendations:

  • Cataract surgery is not justified merely because a cataract exists. The appropriateness of removing it depends on how much it interferes with the patient's ability to function independently, including his or her assessment of vision and lifestyle needs.
  • Management decisions should be based mainly on a complete patient history and eye exam.
  • Special tests before surgery rarely help decide whether to recommend cataract removal. These tests include contrast sensitivity testing, glare testing, and potential vision testing.
  • Depending on the degree of functional impairment, patients, together with their eye care professionals, should explore options such as the use of stronger eyeglasses or magnifying lenses before choosing cataract surgery. That decision should be made by the patient, after discussion with the eye surgeon.
  • When cataract surgery is needed, it should be performed where the patient can receive quality care, as close as possible to home or another social support system. This may mean that, if it is in the patient's interest, the operation may be performed by a surgeon other than the one who diagnosed the cataract. It is best for the surgery to be performed in the same community as the care given before and after surgery.
  • In no case should cataract surgery be performed on both eyes at the same time.
  • The period after cataract surgery is extremely important to the outcome. The eye surgeon is responsible for the patient's care during followup until the patient's vision has improved and stabilized.
  • YAG laser surgery appears to be effective for correcting the clouding of the capsule behind the lens that frequently occurs after cataract surgery. However, the wide variations in rates and timing of YAG laser surgery after cataract removal suggests that it may not be used appropriately. YAG laser surgery should be performed only because of functional impairment, not as a preventive measure.

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The guideline was released at a Washington, DC, press conference in February 1993. It received immediate nationwide coverage on more than 100 television stations, including the CBS, NBC, and CNN networks. A video news release produced by the American Association of Retired Persons with AHCPR assistance was used by 46 television stations and seen by an estimated audience of 16.8 million persons.

Extensive radio coverage included National Public Radio, the Associated Press, and CNN and CBS networks. An audio news release by North American Network was aired in 19 States to more than 324,000 listeners.

Supported by a grant from AHCPR, American Medical Television produced a continuing medical education program on the cataract guideline. The National Society to Prevent Blindness produced eight radio public service announcements that aired in March 1993 for Cataract Awareness Month.

Major daily newspapers that carried reports of the guideline included the New York Times, Wall Street Journal, Washington Post, Chicago Tribune, Miami Herald, and Boston Globe, with front page stories in the Los Angeles Times, Philadelphia Inquirer, and both the national and international editions of USA Today, U.S. News and World Report, Consumer Reports on Health, Arizona Senior World, New York Newsday, and Mature American also reported on the guideline.

Health care professionals were informed of the guideline through journals such as Ophthalmology, Archives of Ophthalmology, American Family Physician, and American Journal of Nursing. Four journals reprinted versions of the guideline, and Ophthalmology reprinted the entire 350-page Guideline Report.

AHCPR conducted a special mailing of the guideline to more than 50 Indian Health Service ophthalmologists and eye clinics. AHCPR also filled hundreds of bulk requests nationwide from hospitals, medical and nursing schools, Veterans Affairs Medical Centers, health maintenance organizations, State medical societies and agencies, health insurance companies, and medical peer review and consumer education and advocacy organizations.

To date, AHCPR has distributed more than 253,000 copies of the Clinical Practice Guideline and the Quick Reference Guide for Clinicians. More than 289,000 copies of the Consumer Version of the guideline in English have been sent, as have 9,000 copies in Spanish.

Dissemination Summary: Cataract Guideline

Presentations: 2
Publications and Professional Articles: 11
Health Industry Articles: 27
Professional Mentions: 92
Consumer Print: 499
Consumer Broadcast: 217
Total: 848

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The Island Peer Review Organization (IPRO), which conducts quality assessments for the Health Care Financing Administration, is using the guideline in reviewing Medicare hospital discharges in New York State. IPRO ophthalmologists use the guideline as a resource to assess the appropriateness of cataract procedures performed. IPRO, which oversees more than 1 million discharges annually, is one of the largest independent peer review organizations in the United States.

The guideline stresses that, in all but a few cases, the deciding factor for performing cataract or YAG laser surgery should be whether the patient feels that he or she is impaired functionally. This patient-centered approach may lead to a lower volume of surgery.

The guideline emphasizes the operating eye doctor's responsibility and ethical obligation to the patient for care before, during, and after surgery.

Special eye tests before surgery such as glare testing may be used less routinely because of the panel's finding that such tests have not proven useful in most cases.

The cataract guideline has been endorsed by the Alliance for Aging Research, American Academy of Ophthalmology, American College of Surgeons, National Society to Prevent Blindness, Association of University Professors of Ophthalmology, American Nurses Association, and American Society of Ophthalmic Registered Nurses.

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Cataract in Adults: Management of Functional Impairment (Clinical Practice Guideline). Publication No. AHCPR 93-0542. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, February 1993.

Cataract in Adults: Management of Functional Impairment (Quick Reference Guide for Clinicians). Publication No. AHCPR 93-0543. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, February 1993.

Cataract in Adults: Management of Functional Impairment (A Patient's Guide). Publication No. AHCPR 93-0544. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, February 1993.

Las Cataratas en los Adultos (Spanish Version of A Patient's Guide). Publication No. AHCPR 94-0545. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, May 1994.

Cataract Management Guideline Panel. (1993). Clinical guidelines: Cataract surgery and its alternatives. American Journal of Nursing 93(7), 59-61.

Cataract Management Guideline Panel. (1993). Management of functional impairment due to cataract in adults. Ophthalmology 100(8, suppl.), 1S-350S.

O'Day, D.M. (1993). A new guideline for patients with cataract [editorial]. Archives of Ophthalmology 111(3), 317-318.

O'Day, D.M. (1993). Clinical practice guidelines, quick reference guide for clinicians. Management of cataract in adults. American Family Physician 47(6), 1421-1430.

O'Day, D.M., & the Cataract Management Guideline Panel of the Agency for Health Care Policy and Research. (1993). Management of cataract in adults: Quick reference guide for clinicians. Archives of Ophthalmology 111(4), 453-459.

O'Day, D.M., Steinberg, E.P., & Dickersin, K. (1993). Systematic literature review for clinical practice guideline development. Transactions of the American Ophthalmological Society 91, 421-436.

U.S. Department of Health and Human Services, AHCPR. (1993). Cataract in adults: Management of functional impairment. A patient's guide. Journal of Ophthalmic Nursing and Technology 12(4), 159-162.

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