FFinalistSouthampton · 2027
Ophthalmology
AKT · Ophthalmology/Lens

Cataract

Opacification of the crystalline lens (age-related; also diabetes, steroids, trauma, congenital)

Overview

Opacification of the crystalline lens causing gradual, painless visual loss with glare and reduced contrast. Mostly age-related; secondary causes include diabetes, corticosteroids, uveitis, trauma and congenital infection. Definitive treatment is day-case phacoemulsification with intraocular lens implant; NICE: do not ration surgery by visual acuity.

Recognise

  • Gradual painless blurring of vision, GLARE/dazzle (especially night driving, oncoming headlights), faded colours
  • Reduced red reflex; the opacity is visible against the red reflex; second sight (myopic shift) in nuclear sclerosis
  • Risk factors: age, diabetes, corticosteroids (posterior subcapsular), smoking, UV, trauma, prior intraocular surgery

Red flags

  • A child with a white pupil/absent red reflex (congenital cataract or retinoblastoma) → urgent referral
  • Sudden visual loss is NOT cataract — look for another cause

Differentials & how to tell them apart

Age-related macular degenerationcentral (not global) distortion/scotoma; cataract blurs more uniformly with glare
Open-angle glaucomaperipheral field loss with disc cupping, not lens opacity
Refractive errorcorrectable with glasses; clear lens
Diabetic retinopathyretinal changes on fundoscopy; cataract is anterior
Cataract — opacified crystalline lens

Cataract — opacified crystalline lens

Rakesh Ahuja, MD / CC BY-SA 3.0 — Wikimedia Commons

Investigations

Visual acuity and slit-lamp/dilated examination by optometry; biometry before surgery. Diagnosis is clinical.

Management

Phacoemulsification + intraocular lens (day-case) when vision affects quality of life

  1. 1Refer to optometry to confirm and exclude other causes. Decide on surgery by discussing how vision/quality of life is affected — NICE: do NOT restrict surgery on the basis of visual acuity.Gate: A WHITE pupil/absent red reflex in a child is not adult cataract — urgent referral to exclude retinoblastoma/congenital cataract
  2. 2Day-case phacoemulsification with intraocular lens implant. Counsel re posterior capsule opacification (treated later with YAG laser capsulotomy) and the small endophthalmitis risk.
None medical — there is no drug treatment — definitive management is surgical
Post-op topical antibiotic + steroid — standard after phacoemulsification

Key points

Gradual painless blur + glare + reduced red reflex in an older patient = cataract; surgery is offered by impact on life, not an acuity threshold. In a child, a white pupil is an emergency.

Monitor & prognosis

Post-op review; watch for PCO (late blurring → YAG).

Excellent visual recovery with surgery.

Source: NICE CKS Cataracts; NICE NG77