Good Hope, Heartlands, and Solihull Eye Clinics

Cataract Surgery Risk

David Kinshuck



Cataract operation decision making tool to use it Oct 2004, D Kinshuck

When to use it

  • This aid is in development.
  • It may be helpful to use this for some consultations, particularly in patients where it is difficult to make a decision.
  • The tool may be more useful to the doctor...remind him how to explain the decision making process to the patient (this will only be necessary in the minority of consultations).
  • Decision making tools may be useful (see), but naturally this depends on how they are used.
  • Naturally very experienced surgeons have lower risks, especially in 'high risk' patients. Similarly, less experienced surgeons have higher risks.
  • This tool is really designed to give patients an idea as to how decisions are made, it cannot be very accurate.
  • It may be particularly helpful if a patient is hoping for a better result than the surgeon expects.
  • A patient happy with their level of vision is less likely to want surgery. If a patient is coping well and happy despite their cataracts, then surgery is not usually needed.
  • Eg: An 80y patient with heart disease who drives, with glare at night and wants to drive at night but who still has good reading vision, with 6/9 surgery, may want surgery. But if that patient has risk factors, as below, such as being on anticoagulants, he may be best without surgery for the time being.
  • Many patients believe they will not need to wear spectacles after cataract surgery, and hence ask for surgery even if their cataract is in its early stages: if patients want good sight then spectacles are usually needed. High expectations can lead to unhappy patients.
  • Take into account the best achievable visual acuity. For example, if the patient's sight is very poor, due to cataract AND a condition such as macular disease, then operate only if the risks are low.

How to use it

  • Point to the appropriate point on the visual acuity, and then the risk axis
  • If the target circle is on red, surgery may be best, if on green, no surgery at this stage may be best.
  • Use the tool with the patient watching on your desktop PC monitor. Alternatively, print this page and use the static image at the bottom, marking the lines with a pen with the patient present.

cataract surgery risk diagram

Interpreting risk, some ideas

with some ideas from Muhtaseb's & Mahmood study.

Low risk related

  • good general health
  • no eye risk factors/pathology
  • aware of small risk of problems
  • may need spectacles after surgery (needs to be aware of this)
  • must be able to lie comfortably for time of surgery
  • Blood pressure less than 140 systolic

Reasonably low risk

  • reasonable general health
  • mild eye problems, such as controlled glaucoma
  • controlled diabetes & no retinopathy
  • professionals see

Intermediate risk

  • one point in Muhtaseb's study
  • Previous vitrectomy
  • Corneal scarring
  • Small pupil (<3mm)
  • Shallow anterior chamber (<2.5mm)
  • age >88years
  • high ametropia: >6d myopia or hypermetropia
  • posterior capsule plaque
  • poor eye position (e.g. enophthalmos, narrow palpebral fissure)
  • tremor
  • communication difficulties
  • breathing difficulties
  • using flomax any time in the last 2 years If the pupil dilates fully pre-operatively, the risk is lower. If the pupil does not dilate, expect iris prolapse during surgery (flomax=tamulosin).

...and Good Hope adds

  • mild fuchs dystrophy
  • other risks
  • emphysema
  • background diabetic retinopathy (may develop maculopathy)
  • previous trabeculectomy and controlled pressure and dilated pupil (slightly greater risk if pupil small/experienced surgeon)
  • difficult lying still for 10-40 minutes
  • anticoagulants
  • Blood pressure higher than 140 systolic...increases risk of cystoid macular oedema etc
  • obesity...shallow AC

High risk

  • AJO 19  Dense/total/white/brunescent cataract/no fundus  view, pseudoexfoliation, Phacodonesis
  • incomplete pupil dilation (59.5% vs 8.8%) Mahmood
  • Dense/total/white or brunescent cataract..use procedures such as vision blue
  • Pseudoexfoliation (5.6% vs 1.4%) Mahmood
  • phacodonesis
  • severe dry eyes
  • a combination of the above risk factors
  • previous vitrectomy (7.8% vs 2.2%) Mahmood
  • related to surgical experience, topical (14.3% vs 3.1%) and sub-Tenon's (51.4% vs 37.2%) anaesthesia Mahmood
  • requirement for vision blue (trypan blue ophthalmic solution) (13.7% vs 2.4%). Mahmood
  • posterior polar cataract Eye 2012

Intermediate risk

  • Oral alpha-receptor antagonist  AJO 19 

Less severe risk

  • AJO 19 
  • Age > 88 years
  • Corneal scarring
  • High ametropia (>6 diopter myopia/hyperopia)
  • Posterior capsule plaque
  • Posterior polar cataract
  • Shallow AC (<2.5 mm)
  • Small pupil (<3 mm)
  • Miscellaneous risks assessed by surgeon (eg, poor position/cooperation


Miscellaneous risks assessed by surgeon (eg, poor position/cooperation) 1


..and Good Hope adds

  • severe breathing difficulties or very poor health
  • posterior polar cataract..may need vitrectomy
  • severe fuchs dystrophy
  • poor general health
  • uncontrolled glaucoma
  • diabetic maculopathy/retinopathy
    (if active, this gets worse after surgery)
  • emphysema on oxygen therapy at home
  • advanced glaucoma with very little visual field remaining.
  • active blepharitis
  • severe atopic conjuncitivitis as below
  • extreme obesity

Shallow AC/hypermetropia

  • expect problems if AC <2mm and lens thickness >5mm
  • high risk axial length (AL) <20mm...
  • use AC maintainer 20-22 mm
  • vitrectomy first for highest risk <20mm, especially if lens thickness/axial length ratio >20%, and AC maintainer for cataract surgery: large PI with vitrector probe at end
  • use Hoffer Q formula



at time of listing

  • treat blepharitis with lid hygiene
  • severe cases need systemic oxytetracycline/doxycyline if tolerated
  • use chloramphenicol (or alternative drops) to clear blepharitis
  • active blepharitis..AVOID SURGERY if possible
  • check repsonse 2 weeks before surgery

week pre-operatively

  • start intensive chloramphenicol drops 3-7 days prior to surgery (or alternative drops)
  • check for active blepharitis


  • use polvidone iodine to clean eye, and leave it to clean for several minutes before local anaesthetic
  • repeat before sstarting surgery

post-operatively, if lid not completely clean

  • check patient frist day and 2-3 days later
  • warn patient to attend as an emergency if the eye becomes achy, painful, with decreasing vision

Severe dry eyes/conjunctival disease

  • Avoid 'Maxitrol' drops after cataract surgery if you have dry eyes or conjunctival disease. It can cause very severe corneal problems (Midland Ophth Meeting, 2005).
  • Preservative free drops for severe cases
  • Maxidex AND chloramphenical (with preservatives, in combination, as separate drops) are well tolerated in mildly dry eyes.
  • Use a schirmers tears test prior to cataract surgery if the patient's history suggests dry eyes. Also, if the patient has significant rheumatoid arthritis.
  • Use lacrimal plugs...normally we insert these AFTER the operation, perhaps at the first post-op visit.

Inflamatory uveitis & Fuchs Heterochromic Cyclitis (FHC)

  • Usually increase steroids 4-8 weeks before surgery
  • pre-operatively boost steroids with a pulse
  • FHC patients certainly benefit from pulsed methylprednisolone just before surgery, and have much higher risk of problems
  • Non-steroidal anti-inflammatory NSAID drops help to prevent post-op macular oedema. They are not yet given routinely because of the expense. Even starting 2 days pre-operatively can be helpful.NSAID after cataract surgery are just as effective (but more expensive).
  • Steroids or NSAID should be given 2 weeks pre-operatively in uveitis patients... uveitis experts often have local guidelines.

Severe eczema

  • cataracts are a common complication
  • atopes...develop anterior cortical cataracts... surgery is difficult needs vision blue; rhexis turns out; cortex leaks out; young patients especially atopes have double risk; zonules weak; fibrosed lids-shallow fornix..cicatricial changes increase risks further;
  • postop...capsule phimosis; hole in post cap...more likely to detach retina
  • sodium Hyaluronate drops (vismed); hyalocomod; help lubricate after surgery

Prophylaxis: Infection in cataract surgery.

Pre-operative antibiotic drops have been proven to reduce endophthalmitis risk. Chloramphenicol starting 3 days before is ideal. Olfoxacin is not as effective.

5% polvidone iodine to clean the eye is more important & essential (unless allergic). This should be done twice...first before the anaesthetic (and not wiped off), then again by the surgeon before the operation.


Flomax (tamulosin) & doxazosin

This drug may cause a floppy iris etc. Effects are reduced with intracameral phenylephrine.  See paper, not summarised in detail here. First 1% lignocaine intracameral (?without preservative) to prevent pain, then  0.25 mls of 2.5% minims phenylephrine hydrochloride, mixed with 1.0 ml balanced salt.

  • Doxazosin
  • excellent article page 10
  • alfuzocin, Teraazocin, Prazocin, Labetolol, Carvedilol, some antipsychotics,Donezepil, Finesride, Mianserin, impiramine, warfarin ec



For printing out and using off line:cataract surgery risk diagram