Ophthal. Physiol. Opt. Vol. 19, Suppl. 1001, pp. S10S15, 1999 # 1999 The College of Optometrists.

Published by Elsevier Science Ltd All rights reserved. Printed in Great Britain 0275-5408/99 $19.00 + 0.00

PII: S0275-5408(98)00065-9

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 management 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 surgery 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 cataracts 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@bradford.ac.uk.

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 driving or work etc. However, for the majority of patients, case history should determine 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 ophthalmologists 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

quite acceptable. However, ophthalmologists do not want to see patients with no visual problems or who do not want surgery, 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 cataract 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 discovered that the imbedded plastic material 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

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Management of patients with age-related cataract: D. B. Elliott

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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, anisometropia and mobility orientation (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 symptoms but can be justied using stereopsis and anisometropia measurements in addition to the usual clinical data. Some hospital eye departments ask for monocular pseudophakic patients to be referred back to them if anisometropia is greater than about 5.00 D.

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 information should also be given, but generally this is only the reason for referral when patients do not meet required standards for driving or work, etc.

Patients not referred optometric

Once a patient has been referred for surgery, optometric management of the patient's visual health ceases until they have been returned to your care post-operatively. 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 referral or those patients who do not wish to be referred?

Refractive prescribing
Any dicult decisions when prescribing spectacles for cataract patients are generally due to cataract-induced refractive change, such

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Ophthal. Physiol. Opt. 1999 19: No Suppl. 1001 prescription does not reduce the VA below legal driving limits. 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) opacities, 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.

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 likewise with altered cylinder power. With a partial astigmatic power correction, you could either change the sphere to give the optimal best mean sphere (sphere + 1/2 cylinder) or, better still, recheck the best mean sphere with the partial astigmatic correction. It is also common to consider a partial correction 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 problems due to anisometropia and aniseikonia. A partial correction of the most myopic error is recommended. 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 undercorrection of 1.00 DS may only lose the patient less than one line of VA, and this may be preferable to problems of adaptation and anisometropia. The prescribing of equal base curves and centre thicknesses may also help reduce induced aniseikonia 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 document the VA with the partial prescription. For example, you may need to make sure that the partial

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, disability 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 alleviated is to reduce the light reaching 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 preferentially 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 broadbrimmed 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

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 convert invisible UV radiation into scattered visible light which can reduce vision. UV-blocking lters 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 progression of cataract. Prescribing UV-blocking tints post-operatively is discussed in a later article.

Anti-reection coats
Patients with cataract, particularly 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-reection coats will increase the amount of light transmitted through any spectacles and may help in this

Management of patients with age-related cataract: D. B. Elliott regard. In addition, a small amount of disability glare could be reduced by anti-reection coats (light scattered from the back surface of spectacles can produce a slight veiling glare) which may again be of some benet. A drawback for all patients with antireection coats is that they need cleaning more often as any ngerprints, dust, etc. are noticed more readily. Patients who are prescribed 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 continually cleaning their lenses, as the eects on vision of the cataract are similar to those from a dirty spectacle lens. 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 progressing cataract. Another scenario could be a patient with no problems 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 opacities are documented, preferably with a diagram. This is particularly true of posterior subcapsular cataracts which can progress suddenly 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 explanation of their eect on vision given to the patient. It is also important to briey document any explanation provided to the patient (e.g. `notied re lens opacity 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 successful nature of modern cataract surgery should also be stated at this point. In addition, many local health authorities now produce excellent pamphlets regarding cataract and cataract surgery and these can be provided to patients. Advice on driving

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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 problems with this approach if a patient is subsequently told by a

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 examination room, this does not necessarily 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 sunlight (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 cataract. 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 relatively 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 typically every 2 years unless there are other considerations. Follow-up examinations of patients with cataract (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-

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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 only make small amounts of daily withdrawals so they will keep their vision longer. They should be advised to use their vision as much as they like and that this will not aect their eyes. Removal of risk factors Although it is likely that age-related cataract is multi-factorial in aetiology and there are many proposed risk factors, few of them have been substantiated. However, epidemiological studies have suggested that exposure to ultraviolet radiation, cigarette smoking, and a low vitamin diet can contribute to cataract (e.g. Cumming and Mitchell, 1997; Leske et al., 1998). Despite the lack of rm evidence that these factors cause cataract, it can be useful to provide this information to patients. Reducing UV exposure and cigarette smoking and appropriately increasing vitamin intake may help and is highly unlikely to cause harm. Vitamins and anti-cataract drugs There are over 50 anti-cataract drugs available wordwide and although none are available in the UK, many are available in Europe. None of these agents have been proven to work in properly controlled clinical trials. There is, however, some epidemiological and animal research evidence indi-

Figure 2. A typoscope.

cating the ecacy of the anti-oxidant vitamins to slow the progression of early cataract (e.g. Christen et al., 1996; Brown et al., 1998). In addition, a major multicentre (Boston, Bradford, Oxford) clinical study has shown that an oral antioxidant micronutrient supplement slowed the progression of early age-related cataract over a 3-year period (Chylack et al., 1998). The micronutrients used were: vitamin C (750 mg/day), vitamin E (600 mg/day) and b-carotene (18 mg/day), and there were no reported side-eects. These reports suggest that it may be good advice to encourage patients with early cataract to take an antioxidant vitamin supplement. Improving reading Generally, older patients require more light to read. This is due to reduced near acuity with age and a reduction in retinal light levels due to age-related pupillary miosis and lens absorption. In patients with cataract, the light reaching the retina is reduced further (the light scatter you see using an optical section at the slit-lamp is backscatter, which is light that does not reach the retina). Unfortunately, increasing the amount of light for reading for cataract patients can make things worse, as forward light scatter (the light scattered onto the retina which reduces the

contrast of the retinal image) is also increased. The ideal situation for a cataract patient is a good anglepoise lamp (and/or advise the patient to sit with their back towards the window during the day) and a typoscope (Figure 2). Typoscopes reduce the amount of light entering the eye from areas of the page which are not being read, light which is otherwise scattered by the cataract. Typoscopes sound grand, but are merely pieces of black card with a slot cut in them which is wide enough to allow patients to read two or three lines of text. They are, therefore, very simple and cheap to make and can be given out free of charge to cataract patients.

Summary
The majority of patients referred because of age-related cataract should be referred when their ability to function in their desired lifestyle is reduced due to poor vision. Generally the decision to refer should not be based on visual acuity, and the referral letter should reect this. Patients who are not referred should not just be monitored until referral. There are several simple strategies for improving their vision which should be discussed with the patient, such as broad-brimmed hats or caps, typoscopes, antireection coats and UV-blocking

Management of patients with age-related cataract: D. B. Elliott tints. There are also several strategies which may delay the progress of their cataract, which include reducing UV exposure and cigarette smoking and taking anti-oxidant vitamin supplements. These could also be discussed with the patient.
Mitchell, S., Thien, U. and Bron, A. J. (1998). Roche European American antioxidant micronutrient mixture to slow progression of agerelated cataract (ARC). Invest. Ophthalmol. Vis. Sci. Suppl. 39, S304. Cumming, R. G. and Mitchell, P. (1997). Alcohol, smoking, and cataractsThe Blue Mountains Eye Study. Arch. Ophthalmol. 115, 1296 1303. Desai, P., Reidy, A., Minassian, D. C., Vadis, G. and Bolger, J. (1996). Gains from cataract surgery: visual function and quality of life. Br. J. Ophthalmol. 80, 868873. Elliott, D. B., Patla, A. and Bullimore, M. A. (1997). Improvements in clinical and functional vision and perceived visual disability after rst and second eye cataract surgery. Br. J. Ophthalmol. 81, 889895. Elliott, D. B. (1998). Assessment of patients with age-related cataract. Ophthal. Physiol. Opt. Suppl. 18, S51S61. Laidlaw, A. and Harrad, R. (1993). Can second eye cataract extraction be justied? Eye 7, 680686. Latham, K. and Misson, G. (1997). Patterns of cataract referral in the West Midlands. Ophthal. Physiol. Opt. 17, 300306. Leske, M. C., Chylack, L. T., He, Q. M., Wu, S. Y., Schoenfeld, E., Friend, J. and Wolfe, J. (1998). Risk factors for nuclear opalescence in a longitudinal study. Am. J. Epidemiol. 147, 3641.

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References
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Neumann, A. C., McCarthy, G. R. and Steedle, T. O. et al. (1988). The relationship between outdoor and indoor Snellen visual acuity in cataract patients. J. Cataract Refract. Surg. 14, 4045. Steen, R., Whitaker, D., Elliott, D. B. and Wild, J. M. (1993). Eect of lters on disability glare. Ophthal. Physiol. Opt. 13, 371376. van Rongen, E. and Vrensen, G. F. J. M. (1994). The UV scenario for senile cataractfact or ction?report of an expert workshop Doc. Ophthalmol. 88, 195199. Whitaker, A., Laidlaw, D. A. H., Hopper, C. D., Donovan, J., Sparrow, J. M. and Harrad, R. A. (1996). Improvement in stereoacuity after 2nd eye cataractextractionsubjective and objective assessment in a randomized controlled trial. Invest. Ophthalmol. Vis. Sci. 37, 869. Whitaker, D., Steen, R. and Elliott, D. B. (1993). Light scatter in the normal young, elderly and cataractous eye demonstrates little wavelength dependency. Optom. Vis. Sci. 70, 963968. Wilensky, J. T. (1975). Intra-ocular Lenses, Appleton-Century-Crofts, New York. Zigman, S. (1990). Vision enhancement using a short wavelength light-absorbing lter. Optom. Vis. Sci. 67, 100124.