01Purpose and principlesWhat the treatment does and how it fits into care.
Cataract surgery replaces an opaque natural lens with an intraocular lens. The principal indication is a cataract that meaningfully affects activities the person wants or needs to perform, where surgery offers a worthwhile prospect of improvement. A person who reads a well-lit acuity chart adequately may still be unable to recognise faces in dim surroundings or drive safely in glare. Conversely, someone with substantial lens opacity may feel well supported and prefer to defer an elective operation. Clinical judgement and the person's goals belong in the same discussion.
Consent is a conversation about a particular eye and a particular life. Establish which symptoms are likely to improve, which arise from another disease and which uncertainties cannot be resolved before the lens is removed. Discuss the option of continuing with updated spectacles, lighting adaptations and review, as well as the consequences of waiting. In some eyes the lens also obstructs necessary retinal examination or treatment, or contributes to an angle or pressure problem; these additional indications require an ophthalmic plan.
The common operation uses phacoemulsification through a small incision followed by an implant, usually under local anaesthesia as a day case. Removal of the natural lens changes its focusing behaviour permanently. An implant can provide clear focus at a chosen distance, but does not reliably reproduce youthful accommodation. A successful surgical outcome therefore includes both a clearer optical pathway and a refractive result the person understood beforehand.
Key points
- Base referral on the person's functional difficulty, preferences and potential benefit rather than an acuity threshold.
- Explain the likely refractive outcome and continuing need for spectacles before choosing an implant.
- Establish retinal and optic nerve comorbidity because removing the cataract cannot reverse those conditions.
- Use optical biometry where possible, with ultrasound when optical measurements are unavailable or unreliable.
- Discuss individual complication risks, alternatives and the practical support needed during recovery.
- Confirm patient, eye, intended refraction and implant against the original measurements before operating.
02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.
Ask for concrete examples: food preparation, reading labels, recognising steps, working with screens, hobbies and night driving. Record whether one or both eyes contribute. Explore difficulty with glare and contrast as well as blur. NICE advises against restricting surgical access solely by visual acuity.
Examine for macular disease, glaucoma, corneal disease and previous amblyopia. Explain that these may limit the best possible result even if the operation proceeds normally. When the fundus is obscured, describe the uncertainty openly rather than promising a particular chart line.
Identify a dense cataract, small pupil, pseudoexfoliation or weak zonules, previous trauma, uveitis, high myopia and prior intraocular or corneal refractive surgery. Ask about current and previous alpha-blocker exposure, which can affect intraoperative iris behaviour. An only functioning eye increases the consequences of a complication, not automatically the probability.
Discuss positioning, tremor, severe cough, claustrophobia, hearing difficulties and communication needs before the operating day. Establish how postoperative drops will be administered and whether someone can help with transport and daily tasks. Capacity is decision-specific; provide support and accessible information before assuming an inability to decide.
03Assessment before treatmentTests and checks that guide safe selection.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Refraction and visual assessmentFirst step - Why
- Connect lens opacity with the person's actual visual limitation.
- Interpretation and limitations
- Record vision in each eye with appropriate correction, together with the symptom history. Improvement with updated spectacles can inform alternatives, but does not exclude a disabling glare problem. Compare the likely postoperative result with the person's priorities.
- 02
Axial length and keratometry - Why
- Measure ocular dimensions used to select implant power.
- Interpretation and limitations
- Optical biometry is preferred; use ultrasound if optical acquisition is impossible or inaccurate. Keratometry measures corneal curvature. Unexpected asymmetry or implausible measurements must be reconciled before an implant is selected, rather than accepted because a machine produced a number.
- 03
Corneal topography when indicated - Why
- Clarify irregular curvature and previous corneal surgical effects.
- Interpretation and limitations
- Consider topography for irregular, unusually flat or steep corneas, significant astigmatism or previous refractive surgery. Standard assumptions about the relationship between anterior and posterior corneal curvature may be wrong after laser correction, increasing refractive uncertainty.
- 04
Ocular comorbidity and anaesthetic assessment - Why
- Identify factors altering prognosis or procedural preparation.
- Interpretation and limitations
- Dilated examination and targeted macular imaging help define visual potential. Check the medication and allergy history and assess relevant systemic problems. Preoperative investigations should answer a clinical or anaesthetic question; a routine battery of unrelated tests does not improve lens measurements.
04Treatment approachPreparation, options, escalation and aftercare.
01ReferralChoose whether surgery fits the problemFirst stepA confirmed cataract is interfering with activities important to the person.+
- 1Describe the visual difficulties and examine for competing causes before attributing every symptom to the lens.
- 2Discuss surgery, reasonable visual aids and observation, including the person's preferences and the potential effect of delay.
- 3Refer with functional information, ocular history, relevant medicines and support needs; avoid an arbitrary acuity eligibility rule.
- 4Explain that an increasingly dense cataract can make later surgery more complicated in susceptible eyes.
02ConsentMake the proposed operation understandableSurgery offers potential benefit and the person is considering proceeding.+
- 1Explain lens removal, the implant, the proposed anaesthesia and likely recovery using language the person can repeat back.
- 2Agree a refractive goal, discuss spectacle dependence and explain any temporary imbalance between the eyes after first-eye surgery.
- 3Discuss capsule rupture, retained lens material, infection, bleeding, pressure problems, macular swelling, retinal detachment and the possibility of further surgery or permanent visual loss, relating risks to this eye.
- 4Record questions, preferences and any uncertainty about retinal visual potential; allow time for a voluntary decision before final confirmation.
03Operation and dischargeDeliver a safe surgical and recovery planThe patient has agreed to surgery and the planned eye is ready.+
- 1Check identity, laterality, original biometry and the selected implant with the theatre team before anaesthesia and implantation.
- 2Confirm the perioperative plan for existing medicines and allergies; patients should not independently stop anticoagulants or other long-term treatment.
- 3Provide the prescribed drops with clear instructions on which eye, frequency, duration and any taper, plus help with administration where needed.
- 4Give a named urgent contact route and explain the symptoms of infection, pressure rise and retinal detachment before discharge.
05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.
Intracameral cefuroxime for operative prophylaxis
Aprokam: inject 1 mg in 0.1 mL into the anterior chamber once, at the end of cataract surgery, after product-specific reconstitution.This is a specialist intracameral preparation, not a systemic injection dose. Confirm cephalosporin hypersensitivity and assess other beta-lactam allergy carefully. Follow the licensed aseptic dilution instructions; excessive concentration or volume can cause severe ocular toxicity. Use each vial for one patient only.
06Complications, monitoring and follow-upAdverse effects, response and longer-term review.
- After discharge, assess the direction of change as well as the absolute vision: increasing pain or deteriorating sight warrants urgent review even when some early blur was expected.
- Review drop use, ocular inflammation, pressure and wound or implant concerns according to the operation and local pathway; complicated surgery may need closer follow-up.
- Arrange refraction when the eye has sufficiently stabilised and explain how the operated and fellow eyes will work together before purchasing new spectacles.
- Continue monitoring of glaucoma, diabetic retinopathy or macular disease; a successful cataract operation does not discharge these separate conditions.
- Confirm recovery advice about eye protection, avoiding rubbing, driving and return to work, relating it to vision, activities and the surgeon's instructions.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
Material risk is individual
A small chance of reduced fine vision may carry particular importance for a professional driver, musician or someone with one useful eye. Ask what outcome the person most fears and what level of spectacle dependence they would accept. A standard complication list does not replace that discussion.
Lens options and current guidance
Explain monofocal focus and the trade-offs of other optical designs without promising spectacle independence. Current NICE NG77 retains a recommendation not to offer multifocal implants for cataract surgery, while its lens design and material recommendations are under reconsideration. NICE supports retaining monovision in people already using anisometropia or monovision who want it.
Both eyes need a plan
Operating one eye can temporarily produce different refractive errors or image sizes between the eyes. Some people cope with altered spectacles or a contact lens; others need earlier second-eye planning. The second operation should still address the second eye's symptoms, risks and preferences.
Timing is not a universal waiting rule
Neither waiting until a cataract is mature nor operating every visible opacity is appropriate. Balance current disability against visual potential and individual operative risk. If observation is chosen, agree how the person will seek reassessment when function changes instead of leaving an indefinite unreviewed decision.
08Common pitfallsFrequent interpretation and management errors.
- 01
Treating a good high-contrast chart score as proof that cataract cannot cause significant disability.
- 02
Promising that removal of an opaque lens will restore vision limited by macular or optic nerve disease.
- 03
Discussing complication rates without explaining the patient's own concerns and refractive goals.
- 04
Assuming an implant removes the need for all future spectacles or eye examinations.
- 05
Providing postoperative drops without checking whether the person can identify the bottle and instil them.