17/8/2017 Senile Cataract (Age-Related Cataract) Treatment & Management: Medical Care, Surgical Care, Consultations

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Senile Cataract (Age-Related

Cataract) Treatment & Management
Updated: May 09, 2017
Author: Vicente Victor D Ocampo, Jr, MD; Chief Editor: Andrew A Dahl, MD, FACS more...

TREATMENT

Medical Care
No time-tested, FDA-approved, or clinically proven medical treatment exists to delay, prevent, or
reverse the development of senile cataracts.

Aldose reductase inhibitors, which are believed to inhibit the conversion of glucose to sorbitol, have
shown promising results in preventing sugar cataracts in animals. Other anticataract medications
being investigated include sorbitol-lowering agents, aspirin, glutathione-raising agents, and
antioxidant vitamins C and E.

Surgical Care
The definitive management for senile cataract is lens extraction. Over the years, various surgical
techniques have evolved from the ancient method of couching to the present-day technique of
modern phacoemulsification. Phacoemulsification offers the advantage of a smaller incision size at
the time of cataract surgery. [23] Historically parallel to the development of phacoemulsification is
the evolution of advanced IOL design, which offers a wide selection of target implantation
locations, materials, chromophores, premium features, and manner of implantation. Depending on
the integrity of the posterior lens capsule, the 2 main types of lens surgery are the intracapsular
cataract extraction (ICCE) and the extracapsular cataract extraction (ECCE). Below is a general
description of the 3 commonly used surgical procedures in cataract extraction, namely ICCE,
standard ECCE, and phacoemulsification. Referencing literature dedicated specifically to cataract
surgeries for a more in-depth discussion of the topic, particularly with regard to technique and
procedure, is also recommended.

Results from a large database study by Lundstrm et al indicate that poor visual outcome following
surgery is most strongly determined by the following factors [24, 25] :

Short-term postoperative complications

Ocular comorbidity
Surgical complications
Complex surgery

Data (some self-reported) for the study were drawn from the European Registry of Quality
Outcomes for Cataract and Refractive Surgery, which contained information on 368,256 cataract
extractions. According to the investigators, although cataract surgery yielded excellent visual
outcomes for more than 60% of patients in the study, vision was unchanged in 5.7% of them, while
1.7% of patients experienced a decrease in corrected distance visual acuity (CDVA). [24, 25]

Intracapsular cataract extraction

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Prior to the onset of more modern microsurgical instruments and better IOLs, ICCE was the
preferred method for cataract removal. It involves extraction of the entire lens, including the
posterior capsule and mechanical or enzymatic lysis of the zonular support structures. In
performing this technique, there is no need to worry about subsequent development and
management of capsular opacity. The technique can be performed with less sophisticated
equipment and in areas where operating microscopes and irrigating systems are not available.

However, a number of disadvantages and postoperative complications accompany ICCE. The

larger limbal incision, often 160-180, is associated with the following risks: delayed healing,
delayed visual rehabilitation, significant against-the-rule astigmatism, iris incarceration,
postoperative wound leaks, and vitreous incarceration. Corneal edema is a common intraoperative
and immediate postoperative complication.

Furthermore, endothelial cell loss is greater in ICCE than in ECCE. The same is true about the
incidence of postoperative cystoid macular edema (CME) and retinal detachment. The broken
integrity of the vitreous face can lead to postoperative complications, even after a seemingly
uneventful operation. Finally, because the posterior capsule is not intact, the IOL to be implanted
must be placed in the anterior chamber, sutured to the iris, or surgically fixated in the posterior
chamber. Both techniques are more difficult to perform than simply placing an IOL in the capsular
bag and are associated with postoperative complications, the most notorious of which is
pseudophakic bullous keratopathy (PBK).

Although the myriad postoperative complications has led to the decline in popularity and use of
ICCE, it still can be used when zonular integrity is too severely impaired to allow successful lens
removal and IOL implantation with an ECCE, particularly carefully selected posttraumatic and
hypermature cataracts. Furthermore, ICCE can be performed in remote areas where more
sophisticated equipment is not available.

ICCE is contraindicated in children and young adults with cataracts and any case with traumatic
capsular rupture where intact removal of the lens capsule unit may prove difficult or incomplete.
Relative contraindications include high myopia, Marfan syndrome, morgagnian cataracts, and
vitreous presenting in the anterior chamber. Many of these patients may benefit from a pars plana
lensectomy by a vitreoretinal surgeon prior to judicious selection of the appropriate IOL type.

Extracapsular cataract extraction

In contrast to ICCE, ECCE involves the removal of the lens nucleus through an opening in the
anterior capsule with retention of posterior capsular integrity. ECCE possesses a number of
advantages over ICCE, most of which are related to an intact posterior capsule, as follows:

A smaller incision is required in ECCE, and, as such, less trauma to the corneal endothelium
is expected. Only the diameter of the nucleus must be accommodated by the opening rather
than the diameter of the entire lens capsule unit.
Short- and long-term complications of vitreous adherence to the cornea, iris, and incision are
minimized or eliminated.
A better anatomical placement of the IOL is achieved with an intact posterior capsule.
An intact posterior capsule also (1) reduces the iris and vitreous mobility that occurs with
saccadic movements (eg, endophthalmodonesis); (2) provides a barrier restricting the
exchange of some molecules between the aqueous and the vitreous; (3) reduces the
incidence of CME, retinal detachment, and corneal edema; and (4) reduces movement of the
IOL upon eye movements and eye rubbing (pseudophakodonesis).
Conversely, an intact capsule prevents bacteria and other microorganisms inadvertently
introduced into the anterior chamber during surgery from gaining access to the posterior
vitreous cavity and causing endophthalmitis.
Secondary IOL implantation, filtration surgery, corneal transplantation, and wound repairs are
performed more easily with a higher degree of safety with an intact posterior capsule.

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The main requirements for a successful ECCE and endocapsular IOL implantation are zonular
integrity and an intact posterior capsule. As such, when zonular support is insufficient or appears
suspect to allow a safe removal of the cataract via ECCE, ICCE or pars plana lensectomy should
be considered.

Phacoemulsification
Standard ECCE and phacoemulsification are similar in that extraction of the lens nucleus is
performed through an opening in the anterior capsule or anterior capsulotomy. Both techniques
also require mechanisms to irrigate and aspirate fluid and cortical material during surgery. Finally,
both procedures place the IOL in the posterior capsular bag, which is far more anatomically correct
than the anteriorly placed IOL.

Needless to say, significant differences exist between the 2 techniques. Removal of the lens
nucleus in ECCE can be performed manually in standard ECCE or with an ultrasonically driven
needle to fragment the nucleus of the cataract and then to aspirate the lens substrate through a
needle port in a process termed phacoemulsification.

The more modern of the 2 techniques, phacoemulsification offers the advantage of using smaller
incisions, minimizing complications arising from improper wound closure, and affording more rapid
wound healing and faster visual rehabilitation. Furthermore, it uses a relatively closed system
during both phacoemulsification and aspiration with better control of intraocular pressure during
surgery, providing safeguards against positive vitreous pressure and choroidal hemorrhage. A
closed system also minimizes fluid turbulence within the anterior chamber, reducing endothelial
and trabecular meshwork trauma. However, more sophisticated and expensive machines,
disposables, and instruments are required to perform phacoemulsification.

Ultimately, the choice of which of the 2 procedures to use in cataract extraction depends on the
patient, the type of cataract, the availability of the proper instruments, and the degree to which the
surgeon is comfortable and proficient in performing standard ECCE or phacoemulsification. The
vast majority of modern cataract surgeons perform and prefer phacoemulsification.

The surgeon should also consider whether to use topical or regional anesthesia during the
procedure. A study by Zhao et al examined the clinical outcomes of topical anesthesia and regional
anesthesia including retrobulbar anesthesia and peribulbar anesthesia in phacoemulsification. The
authors found that regional anesthesia provides better perioperative pain control, but that surgical
outcomes were the same for both. [26]

Other Considerations

Although single-eye cataract surgery improves vision, including the second eye may yield greater
rewards, according to a prospective, population-based study by Lee et al. The investigators studied
1739 participants aged 65-84 years at enrollment, 90 of whom following enrollment had unilateral
cataract surgery, and 29 of whom had bilateral surgery. In the 1620 patients who did not undergo
surgery, bilateral baseline best-corrected visual acuity logarithm of the minimum angle of resolution
(BCVA of logMAR) was no greater than 0.3 (at least 20/40). [27, 28]

BCVA of logMAR improved by 0.04 in the unilateral group and 0.13 in the bilateral group, while
reading speed increased by 12 words per minute in the unilateral group and 31 words per minute
in the bilateral group. Moreover, the Activities of Daily Vision Scale scores (measuring vision at a
distance, close-up, glare, and day and night driving) showed a 5-point relative improvement in the
bilateral group, while the unilateral group actually showed a 5-point relative decrease.

Bell et al reviewed exposure to alpha-adrenergic blockers frequently prescribed to treat benign

prostatic hypertrophy (BPH) and their association with serious postoperative adverse effects
following cataract surgery. [29] The study included more than 96,000 older men who had cataract
surgery over a 5-year period (3.7% had recent exposure to tamsulosin and 7.7% had recent
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exposure to other alpha blockers). Exposure to tamsulosin within 14 days of cataract surgery was
significantly associated with serious postoperative ophthalmic adverse events (7.5% vs 2.7%;
adjusted odds ratio [OR], 2.33; 95% confidence interval [CI], 1.22-4.43), specifically intraoperative
floppy iris syndrome and its complications (ie, retinal detachment, lost lens or fragments, uveitis,
endophthalmitis). No significant associations were noted with exposure to other alpha blocker
medications (7.5% vs 8%; adjusted OR, 0.91; 95% CI, 0.54-1.54) or to previous exposure to
tamsulosin or other alpha blockers.

A study by Baker et al found that 23-gauge pars plana vitrectomy is a possible surgical
management approach in select cases of retained lens fragments. While 12 patients were
successfully treated by this initial intervention, 8 required sclerotomy enlargement to a 20-gauge
access. [30]

An association between cataract surgery and late age-related macular degeneration, independent
of additional risk factors, has been shown in some studies. [31] Most surgeons do not believe that
cataract extraction accelerates the onset of age-related macular degeneration. UV protection with
sunglasses and hats is always recommended following cataract extraction.

Multifocal IOLs after cataract extraction are more effective at improving near vision than monofocal
IOLS are, but whether this improvement outweighs the potential adverse effects of multifocal
lenses varies between patients. [32] Careful patient selection to recommend a multifocal IOL only to
patients with a pristine macula and ocular surface can be very rewarding for both the clinician and
patient.

In 2008, the US Food and Drug Administration (FDA) approved the Alcon line of acrylic toric IOLs.
In 2013, the FDA approved Abbott's Tecnis Toric 1-piece IOL to treat preexisting astigmatism in
patients with cataract. [33] Toric IOLs are used to manage corneal astigmatism in patients who have
undergone cataract surgery and whose natural lenses have been removed. Unlike other devices
on the market, this 1-piece IOL can correct loss of focus of 1 diopter or greater. Clinical data show
that the device offers exceptional rotational stability while improving visual results and improving
distance and night vision.

In early 2014, the FDA approved a synthetic polyethylene glycol hydrogel sealant (ReSure Sealant,
Ocular Therapeutix, Inc) for use in cataract surgery with IOL placement. [34] The sealant is
indicated for prevention of postoperative fluid egress from incisions with a demonstrated wound
leak after cataract surgery. Approval was based on a prospective, randomized, controlled
multicenter study of 471 patients in which the sealant was more effective than a single suture in
preventing incision leakage in the 7 days after surgery.

An increased risk for intraoperative floppy iris syndrome (IFIS) was observed during cataract
surgery in patients with benign prostatic hypertrophy (BPH) who were taking a nonselective
alpha1-antagonist. Alfuzosin and tamsulosin, 2 drugs commonly used to treat BPH, are both linked
to permanent changes in the iris and associated with an increased risk of IFIS. A prospective,
masked, cross-sectional multicenter study by Chang et al determined that patients taking systemic
alfuzosin for BPH were less likely to experience moderate or severe IFIS during cataract surgery
than patients taking tamsulosin. [35, 36]

Of the 226 eyes studied, 70 were in patients receiving systemic tamsulosin, 43 in patients receiving
systemic alfuzosin, and 113 in patients with no history of systemic alpha1-antagonist therapy. [36]
The incidence of IFIS was 34.3% in the tamsulosin group, 16.3% in the alfuzosin group, and 4.4%
in the control group. Severe IFIS was statistically more likely with tamsulosin than with alfuzosin (P
= 0.036). Thus, patients with symptomatic BPH and cataracts requiring a uroselective alpha1-
antagonist may consider trying alfuzosin first.

Consultations

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Prior to surgery, a thorough preoperative evaluation must be conducted, which would also include
a thorough explanation of the procedure to be performed and its accompanying risks.

Not all senile cataracts require removal at the time of diagnosis. If vision, performance of daily
tasks, and quality of life are not impaired significantly or if the patient is not prepared medically,
psychologically, and financially for surgery, periodic consultations are encouraged to assess
progression of the cataract. The procedure is, by definition, almost always elective. Very rarely,
lens-induced glaucoma or uveitis warrants urgent or emergent cataract surgery.

Postoperatively, regular follow-up visits are necessary to monitor visual rehabilitation, as well as to
detect and address any immediate and late complications arising from the surgery.

Diet
In relation to the surgery, no established dietary restrictions exist that would affect the course of the
operation when a small corneal incision technique is planned. Larger scleral incisions, MIGS,
simultaneous pars plana vitrectomy, or a planned retrobulbar anesthetic may dictate limitation of
any dietary supplement (eg, fish oil) that may prolong bleeding times 2 weeks prior to surgery.

Activity
After surgery, the patient is dissuaded from performing activities that would increase the intraocular
pressure, especially after undergoing ICCE or standard ECCE. These activities include lifting
heavy loads, chronic vigorous coughing, and straining. Similarly, trauma and exposure to toxic
fumes or particular matter should specifically be avoided.

Medication

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