BLOG: Know the 5 contraindications to cataract surgery

ByOliver Kuhn-Wilken, OD

Fact checked byHeather Biele

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“The one who knows when not to act is wise,” the playwright Euripides wrote over 2,400 years ago. Are you wise enough to know the situations in which you should not send a patient with a cataract for surgery?

Most optometrists feel comfortable with the primary indication for cataract surgery: visual function that no longer meets the patient’s needs and for which cataract surgery provides a reasonable likelihood of improved vision. There are, however, five important cases in which a patient with a cataract should not receive cataract surgery:

1. The most common instance is when there is a cataract present but a refractive correction provides vision that meets the patient’s needs and desires. The reason for this contraindication is severalfold. First, cataract surgery, while low risk, is not zero risk, and a small percentage of patients will lose vision, primarily due to infection, retinal detachment or inflammatory sequelae. If your patient is to take the risk of surgery, the benefit must be more than simply reducing their ametropia.
   Second, excellent vision without glasses cannot be guaranteed at any distance. Cataract surgery is not as refractively precise as LASIK: approximately 27% of cataract patients miss their refractive target by more than 0.50 D (Manning S, et al.), and 7% will miss by more than 1.00 D. Worse, these numbers are roughly double for any patient who has received LASIK (Potvin R, et al.).
   With the rise of the refractive lens exchange, the line between refractive and medical benefit is getting fuzzier. When in doubt, it is wise to wait. An experienced surgeon once said, “I never lose sleep over a patient on whom I did not do surgery.”
2. Surgery is not indicated when it would not be expected to improve visual function and there’s no other reason to remove the lens. If your patient has other ocular disease that is bad enough that they would notice no difference with cataract extraction and the view of the retina is sufficient to monitor that eye for the development of other pathologies, then surgery does not make sense (Olson RJ, et al).
3. Surgery is contraindicated if the patient cannot safely undergo the procedure because of coexisting medical or ocular conditions. This includes patients with uncontrolled seizures, dystonia or other neurological conditions that can cause unpredictable movement in the operating room. It also includes uncontrolled ocular conditions in which surgery would endanger the eye, including uncontrolled cases of uveitis, proliferative diabetic retinopathy or neovascular disease.
   This can also present when a patient who was previously cleared for surgery presents to the surgery center with an acute crisis; most commonly this includes malignant hypertension (diastolic > 180 mm Hg or systolic > 120 mm Hg), acute decompensated heart failure or diabetic ketoacidosis.
4. Surgery is contraindicated if appropriate postoperative care cannot be arranged. Many clinics can substitute intraocular injections for the standard post-op drops, so that even patients who cannot put their own antibiotic and steroid drops in their eye can still get surgery. Even with this, however, if a patient does not have a clean and indoor place to live, the risk of endophthalmitis may be too great.
5. Surgery is contraindicated if the patient, or the patient’s power of attorney, is unable to give informed consent for the surgery.

Cataract surgery is a wonderful opportunity for many patients, but for some, the best decision will be to wait until a more appropriate time.

References:

• Manning S, et al. J Cataract Refract Surg. 2016;doi:10.1016/j.jcrs.2016.10.013.
• Olson RJ, et al. Ophthalmology. 2016;doi:10.1016/j.ophtha.2016.09.027.
• Optometric clinical practice guideline care of the adult patient with cataract. https://www.aoa.org/AOA/Documents/Practice%20Management/Clinical%20Guidelines/Consensus-based%20guidelines/Care%20of%20the%20Adult%20Patient%20with%20Catract.pdf. Published 2004. Accessed Sep. 3, 2024.
• Potvin R, et al. J Cataract Refract Surg. 2015;doi:10.1016/j.jcrs.2014.05.040.

For more information:

Oliver Kuhn-Wilken, OD, practices at Pacific Cataract and Laser Institute’s Tualatin Clinic in Oregon. He can be reached at Oliver.Wilken@pcli.com.

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