Complex Cataract Management: Practical Insights for Optometrists in Shared Care

From an optometric perspective, early recognition of potential complexity flags improves referral quality and expectation management, which is often the single biggest driver of satisfaction in complex eyes. It is frustrating for patients to be referred to an ophthalmologist who needs to refer to a colleague, when the patient could have seen the most appropriate surgeon the first time, so optometrists should feel comfortable checking with their ophthalmologist colleagues whether an individual case is suitable for them, and ask for a recommendation if not.

The most obvious cause of a complex cataract is, of course, the cataract itself. While in some countries very advanced cataracts are commonly encountered, in metropolitan Australia, they are thankfully relatively rare. Patients with long-standing cataracts may present with dense nuclear sclerosis, brunescent lenses, or a very poor red reflex. These cases can increase phaco energy requirements, reduce intraoperative visibility, and increase early corneal oedema. They also make it harder to assess macular and optic nerve status preoperatively, which creates an expectation gap.

Special Mention: Previous radial keratotomy deserves special mention. This treatment for myopia has often created an irregular cornea with progressive hyperopic shift and diurnal fluctuation in vision. IOL choices, in these cases, are determined by the level of irregularity but personally, I am in favour of using a small aperture IOL to reduce impact of aberrations and minimise fluctuations in vision. Surgery can be challenging to avoid hydrating these incisions or splitting the cornea, but in general these eyes can often be well rehabilitated.

Preoperatively: I love when an optometrist has been proactive in managing dry eye prior to consultation as it allows more accurate biometry to be taken and a more efficient process without me needing to initiate treatment and return for repeat biometry. As accurate biometry is the most important determinant of a great outcome, good dry eye management is incredibly important. Severe dry eye would put me off using a diffractive IOL technology and, when a dry eye patient opts for a more advanced IOL technology, we have a very in-depth discussion about the need for ongoing dry eye maintenance for this lens to work. They must be aware that IOL exchange, if dissatisfied, is a potential outcome.

Postoperatively: Dry eye patients can be difficult to manage. Most surgeons will give a period of post-op anti-inflammatory drops that make everything feel better but once these stop, dry eye signs and symptoms will often unveil themselves. Beginning lubricating drops early helps, as does discussion about realistic timeframes for recovery. I prefer to not have patients do hot lid massages in the first week postoperatively, but am happy for preservative free lubricants to be used immediately post-op.

Preoperatively: Decision making about IOL choice in these patients is a controversial topic. Mildly or moderately compromised eyes could usually benefit from presbyopia correcting options, but this is a gamble about disease progression. If posterior health deteriorates, there is some thinking that a multifocal IOL would further degrade vision quality as compared to a monofocal IOL. There is biological plausibility in this thinking, even if evidence is lacking. Surgeons must take into account patient age, disease status, likely progressive nature, and discuss how the future may look. There really is no substitute for chair time and having a conversation with each individual patient.

These patients may do very well, but it is worth preparing them for the possibility that visual quality remains influenced by the underlying retinal issue. These cataracts often come on very rapidly, are very dense, and may be in relatively young patients. Given their probable history of retinal detachment, another episode of rapidly deteriorating vision can be scary for them. It usually helps to explain that cataract surgery is generally a much more minor, and simpler experience than they may have had with their primary surgery, and recovery is usually much more rapid.

High myopes often do well with cataract surgery, but they carry additional considerations – increased risk of peripheral retinal pathology, higher risk of postoperative retinal detachment compared with emmetropes, and sometimes a more complex refractive target discussion. Some high myopes also have myopic maculopathy that limits visual potential. High hyperopes have their own potential issues – increased risk of intraoperative complications including aqueous misdirection, and higher risk of refractive error postoperatively due to a combination of manufacturing tolerances for high power IOLs, and difficult to predict final IOL position within the eye.

Despite careful planning, some complex cases result in outcomes below a patient’s hoped-for target. The most common drivers are pre-existing comorbidity, refractive unpredictability, and issues around quality of vision. The best response is not defensiveness, it is clarity and a plan. Patients often settle when they understand why the outcome looks the way it does and what can still be improved, whether that is surface optimisation, refractive correction, or time for adaptation. Optometrists play a key role in ongoing visual rehabilitation: updating spectacles at the right time, managing the ocular surface, monitoring comorbidity, and reinforcing functional gains.

I am often asked for second opinions about complex cataract surgeries, either preoperatively or postoperatively, and anecdotally, most dissatisfaction, or anxiety stems from a lack of communication and cohesiveness between eye care professionals and the patient. It is important that everyone feels on the same team, and has the same expectations. Most problems can at least be helped by a consultation, giving a patient plenty of time to explain their concerns, and making sure that they fully understand their situation and why their eyes are not routine.