Seminar
Cataracts
Lancet 2017; 390: 60012
Published Online
February 24, 2017
http://dx.doi.org/10.1016/
S0140-6736(17)30544-5
Cornea and Refractive Surgery
Group, Singapore Eye Research
Institute, Singapore
(Y-C Liu MD, J S Mehta MBBS);
Department of Cornea and
External Eye Disease, Singapore
National Eye Centre, Singapore
(Y-C Liu, J S Mehta); Department
of Cornea and External Eye
Disease, Moorfields Eye
Hospital, London, UK
(M Wilkins MBBS); Department
of Cornea and External Disease,
Department of
Ophthalmology, Duke
University, Durham, NC, USA
(Prof T Kim MD); Department of
Cataract and Implant Surgery,
S Fyodorov Eye Microsurgery
State Institution, Moscow,
Russia (Prof B Malyugin MD);
and Department of Clinical
Sciences, DukeNUS Medical
School, Singapore (J S Mehta)
Correspondence to:
Dr Jodhbir S Mehta, Singapore
National Eye Centre,
Singapore 168751, Singapore
jodmehta@gmail.com
600 www.thelancet.com Vol 390 August 5, 2017
Yu-Chi Liu, Mark Wilkins, Terry Kim, Boris Malyugin, Jodhbir S Mehta
An estimated 95 million people worldwide are affected by cataract. Cataract still remains the leading cause of blindness
in middle-income and low-income countries. With the advancement of surgical technology and techniques, cataract
surgery has evolved to small-incisional surgery with rapid visual recovery, good visual outcomes, and minimal
complications in most patients. With the development of advanced technology in intraocular lenses, the combined
treatment of cataract and astigmatism or presbyopia, or both, is possible. Paediatric cataracts have a different
pathogenesis, surgical concerns, and postoperative clinical course from those of age-related cataracts, and the visual
outcome is multifactorial and dependent on postoperative visual rehabilitation. New developments in cataract surgery
will continue to improve the visual, anatomical, and patient-reported outcomes. Future work should focus on
promoting the accessibility and quality of cataract surgery in developing countries.
Introduction to the lens equator to form lens fibres that are gradually
The lens is a transparent biconvex structure, which helps compressed centrally and results in lens nuclear sclerosis
to refract and focus light onto the retina. The lens is and opacity.2 A cortical cataract is often wedge-shaped,
composed of fibres, surrounded by a thin capsule, and is starting at the cortex and extending to the centre of the lens.
supported by zonules on either side. The lens fibres are In posterior subcapsular cataract, a plaque-like opacity
generated from the lens epithelium and migrate from the develops in the axial posterior cortical layer. In most
periphery towards the centre.1 Hence, the nucleus of the patients, more than one type of cataract is found.
lens is made up of older lens fibres, and newly formed lens Congenital cataracts refer to a lens opacity that presents
fibres are located in the outermost layers of the lens, the at birth, whereas infantile cataracts refer to a lens opacity
cortex. A cataract is the loss of lens transparency due to that develops during the first year of life. Paediatric
opacification of the lens. In this Seminar, we discuss the cataracts can be unilateral or bilateral, depending on the
pathophysiology and classification, epidemiology, risk and cause. Approximately a third of paediatric cataracts are
protective factors, symptoms, management, complications, inherited, a third are associated with other ocular anom
outcomes, controversies, and future research questions alies or are part of a multisystem syndrome, and a third
of cataracts. have undetermined causes (panel 1).1
Cataractogenesis can be induced by drugs. Long-term
Pathophysiology and classification use of corticosteroids, administered by any route, is
According to the cause, cataracts can be classified as age- strongly associated with posterior subcapsular cataract
related cataracts, paediatric cataracts, and cataracts formation. Other medications known to induce cataract
secondary to other causes. Age-related cataract is the most include phenothiazines, busulfan, miotics, and, rarely,
common type in adults, with the onset between age 45 years amiodarone.3 The relation between the use of statins and
and 50 years. Opacity of the lens is a direct result of cataract is still controversial.4 Other causes of cataract
oxidative stress.2 On the basis of location of opacification include mechanical trauma, chemical injury, electrical
within the lens, age-related cataracts can be divided into injury, and ionising, infrared, or ultraviolet radiation.1
three types: nuclear, cortical, and posterior subcapsular Changes of the lens also often occur secondary to chronic
cataracts (figure 1). The lens epithelial cells are the most uveitis, Fuchs heterochromic uveitis, and pseudo
metabolically active cells of the lens, undergoing oxidation, exfoliation syndrome.1
insolubilisation, and crosslinking. These cells then migrate
Epidemiology
WHO estimated that there were 95 million people
Search strategy and selection criteria visually impaired due to cataracts in 2014.5 Several large-
We searched the Cochrane Library from Jan 1, 2000, to scale population-based studies have reported that the
Dec 31, 2016, and MEDLINE from Jan 1, 1980, to Dec 31, prevalence of cataract increases with age, from 39% at
2016, with no language restrictions, using the search terms age 5564 years to 926% at age 80 years and older.68
cataract, cataract surgery, and intraocular lens. We Additionally, the presence of cataracts is associated with
largely selected publications in the past 6 years, especially in increased mortality, and this association might be due to
the past 3 years, but did not exclude commonly referenced the link between cataracts and systemic conditions such
and highly cited older publications. We focused on as type 2 diabetes mellitus or smoking.9
meta-analysis and systematic review articles, randomised For the past two decades, the prevalence of cataracts has
controlled trials, large-scale clinical studies, or been declining because rates of cataract surgeryie, the
population-based studies. We also included information from number of surgeries per million population per year
standard ophthalmic textbooks and WHO. have been increasing because of the improved techniques
and active surgical initiatives.10 However, cataracts still
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A Anterior capsule Lens epithelium

Nucleus

Cortex

Nuclear cataract
Cortical cataract Cortex

Posterior capsule Posterior subcapsular cataract

B C D

Figure 1: Characteristics of lens structures and different types of cataracts

(A) A schematic view of lens structures and corresponding types of cataracts. Slit lamp biomicroscopy photos showing (B) nuclear cataract, (C) wedge-shaped cortical
cataract, and (D) subcapsular posterior cataract that has plaque opacity in the axial posterior cortical layer. Most patients have more than one type of cataract.

remain the leading cause of blindness in middle-income
and low-income countries,5 accounting for 50% of
blindness, whereas they are responsible for only 5% of
blindness in developed countries.11 It is imperative to
implement a set of strategies to improve the access of
effective ophthalmic service and screening, and the
quality of treatment delivered in developing countries.
Cataract surgery remains one of the most cost-effective
treatments and the most commonly used procedure in
many countries.12 By 2020, more than 30 million people
annually worldwide are predicted to undergo cataract
surgery.13 The socioeconomic effect of cataract surgery is
substantial. It allows people to increase their economic
productivity by up to 1500% of the cost of the surgery
during the first postoperative year,5 but if left untreated it
can result in an individual being removed from work.1 In
the USA, the annual expenditure on cataract surgery is
US$34 billion,14 whereas in rural China, the cost for a
cataract operation can be twice a patients annual
income.15 Numbers of annual cataract surgeries vary
among countries because of differences in accessibility
for diagnosis and surgery, referral, and health-care
systems (appendix).1620 There is also gender inequality in See Online for appendix
cataract surgical coverage in low-income and middle-
income countries, where men are more likely to have
cataract surgery than are women (Peto odds ratio
[OR] 171, 95% CI 148197).21
Paediatric cataracts are one of the most common
causes of treatable childhood blindness, with an
estimated prevalence ranging from one to six per
10000 livebirths.22 Congenital cataracts account for the
majority of paediatric cases and 520% of childhood

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include the , , and crystallin, lens cytoskeletal protein,

Panel 1: Causes of paediatric cataracts connexin, membrane junction protein, growth and
Idiopathic transcription factor, ferritin light chain, and galactokinase
Hereditary genes.49
Ocular anomalies
Aniridia Symptoms
Anterior segment dysgenesis syndrome Different types of cataracts have different effects on
Persistent fetal vasculature visual symptoms. Patients often complain of blurred
Posterior lenticonus vision, and describe glare and haloes from lights.
Posterior pole tumours Nuclear cataracts typically affect distance vision more
Multisystem syndrome than near vision, whereas posterior subcapsular
Downs syndrome cataracts often reduce near visual acuity more than
Lowe syndrome distance visual acuity. The progressive nuclear sclerotic
Trisomy 1315 syndrome changes cause an increase in the lens refractive index.
Fabry disease This increase means that the cataractous lens can refract
Marfan syndrome light more than before, and hence the eye becomes
Alport syndrome more myopic. If this refractive index is not corrected
Myotonic dystrophy with glasses, then the patient experiences deterioration
Metabolic disorders in distance vision and paradoxically some improvement
Galactosaemia in near vision. Glare is particularly common in patients
Hypoglycaemia with posterior subcapsular cataracts. Patients might
Wilsons disease also complain of monocular diplopia due to localised
Hypoparathyroidism variations in the refractive index of the lens opacity.
Galactokinase deficiency Some patients might only have visual difficulty when
Maternal infection doing daily activities such as reading or drivingie,
Rubella visual disability.
Cytomegalovirus infection
Varicella Management
Syphilis The current standard of management of a visually
Toxoplasmosis significant cataract is surgical removal of the cataractous
Toxic effects lens and its replacement with an intraocular lens.
Corticosteroids Cataract surgery is indicated when the patient has vision
Radiation exposure loss of sufficient severity for them to accept the potential
Trauma risks of surgery. Cataract surgery is rarely indicated to
prevent glaucoma, treat lens-induced inflammation, or
permit adequate retinal visualisation. The outcome of
blindness worldwide, but 2230% of childhood blindness cataract surgery is independent of preoperative visual
in developing countries.2325 acuity.50 Despite the improvements in surgical technology
and techniques in the past decade, good surgical outcomes
Risk factors and protective factors still involve thorough preoperative assessment, precise
Cataractogenesis is a multifactorial process. Although the intraocular lens power determination, and appropriate
development of cataract in most patients is age-related, the intraoperative and postoperative management.
identified risk and protective factors provide information
about prevention of cataract progression (panel 2).1,7,2641 Preoperative assessment
Heritability of nuclear cataracts ranges from 36% to 48%, Most patients are able to have their surgery as a day-case
whereas genetic factors account for 35% of the variation procedure.51 Routine medical investigations before
in progression of nuclear cataracts.42,43 However, in com cataract surgery are not required and have not been
parison with congenital cataracts, knowledge about genetic shown to affect surgical outcomes.52 The surgeon should
susceptibility factors in age-related cataract is relatively be aware of the patients general medical problems and
scarce.44 Genes that might play roles in susceptibility to age- their use of any systemic or topical medications.
related cataracts are listed in panel 2.4448 Anticoagulants and antiplatelet agents do not need to be
Approximately 50% of congenital cataracts have a discontinued because these drugs have not been shown
genetic cause. Autosomal dominant transmission is the to increase sight-threatening haemorrhagic compli
most frequent, but it can also be autosomal recessive or cations.53 1-adrenergic receptor antagonistscommonly
X-linked.49 More than 20 genetic loci have been identified, prescribed for benign prostatic hyperplasiaare
and the majority are related to genetic mutations associated with intraoperative floppy iris syndrome,
affecting lens development. These susceptibility loci which is linked to increased intraoperative compli

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cations.54 Discontinuation of 1-adrenergic receptor
antagonists has little effect on the prevention of this
syndrome.55 If known in advance that a patient has taken
an 1-adrenergic receptor antagonist then it is possible to
modify the surgical technique to try to minimise risks of
complicationseg, progressive intraoperative miosis or
iris prolapse. For paediatric cataracts, bilateral cataracts
are often associated with systemic or metabolic diseases,
hence a detailed family or birth history, and history of the
childs growth and development are warranted.
A detailed ophthalmic examination might include
visual acuity testing, refraction, intraocular pressure, slit
lamp examination, and fundus assessment to rule out
other ocular comorbidities that could affect the
postoperative prognosis. Other tests that might be used
include B-scan ultrasonography, if direct visualisation of
the retina is not possible because of dense cataract, and
contrast sensitivity and glare tests in selective patients.
The Lens Opacities Classification System III is a widely
used subjective grading to assess the cataract severity.56
Decision making for cataract surgery also includes
assessment of the visual functional status, especially
limitations in the ability to do daily activities. These
aspects can be measured with clinical history or with
formal instruments or questionnaires, such as the
Catquest-9SF questionnaire, or the Visual Functioning
Index-14, which was designed to assess patient-reported
visual functioning.57
Biometry and intraocular lens power determination
An intraocular lens is implanted following cataract
removal (appendix). A benefit of cataract surgery is the
ability, with the right intraocular lens power, to correct
refractive errors. Accurate calculation of intraocular lens
power (ie, biometry) and identification of possible factors
that might affect the accurate calculation are crucial to
ensure the desired postoperative refractive results
(panel 3).5861
Anaesthesia for cataract surgery
Anaesthesia for cataract surgery has progressed from
general to local (retrobulbar, peribulbar, subconjunctival,
or sub-Tenon anaesthesia) to topical anaesthesia. In
local anaesthesia, peribulbar anaesthesia is a safer
alternative to retrobulbar anaesthesia because the
needle is shorter and the tip is outside the retrobulbar
space. Possible complications of retrobulbar anaesthesia
include retro bulbar haemorrhage, globe penetration,
and optic nerve injury, but the prevalence is low (0032
0066%).62 Although topical anaesthesia has shown an
increase in use to avoid needle-related complications, a
meta-analysis of randomised controlled trials has shown
that there was no significant difference in surgery-
related complications between local (peribulbar or
retrobulbar) and topical anaesthesia. Additionally,
intraoperative and post operative pain perception
(standardised mean pain score difference 067, 95% CI
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Panel 2: Risk factors and protective factors for cataract formation
Risk factors
Individual factors
Increasing age
Low educational or socioeconomic status
Female sex
Racial or ethnic groups:
People of Asian ethnic origins have higher prevalence than do European people
White people have higher prevalence than do Afro-Caribbean people
Genetic factors:
Two genome-wide significant loci for nuclear cataracts: chromosome 3 in
KCNAB1 and chromosome 21 in CRYAA
Gene polymorphisms, including rs3754334, KLC1, APOE, XRCC1 Arg399Gln,
GSTT1, and XPD Lys751Gln, might have roles in susceptibility to age-related
cataract
Lifestyle factors
Ultraviolet-B exposure
Cigarette smoking
Alcohol consumption*
Diet
Consumption of carbohydrates with high-glycaemic index
Malnutrition
Systemic medical problems
Type 2 diabetes mellitus (cortical cataract and posterior subcapsular cataract)
High systemic blood pressure (posterior subcapsular cataract and mixed lens opacities)
Metabolic syndrome (mixed lens opacities)
Moderate or severe renal impairment
Hypocalcaemia
Ocular disorders
Myopic refractive error (nuclear opacity)
Large retinal drusen (mixed lens opacities)
Protective factors
Maintaining a protein intake of 100150 g/day and a vitamin C intake of
approximately 135 g/day (in patients with nutritional deficiency)
Increased consumption of vegetables
Vitamin E, carotenoids, vitamin A or B, or antioxidant supplements*
*Inconclusive evidence. Inadequate evidence.
020113) and need for supplementary anaesthesia
(rate difference 388, 95% CI 1181275) were greater
in topical anaesthesia than in local anaesthesia.63 The
type of anaesthesia suitable for an individual patient
should be considered and discussed before the surgery.
General anaesthesia should be considered for paediatric
patients and for patients who might not be cooperative
during surgery. Most patients are able to have their
procedure with local or topical anaesthesia, but topical
anaesthesia might not be appropriate for patients with
lower pain thresholds. In developing countries, most
surgical procedures are done with larger incision; local
anaesthesia is hence the most common form of
anaesthesia used.64
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Panel 3: Intraocular lens
Intraocular lens (IOL)
Comprises a central optic responsible for refractive function, and haptics to support
the IOL.
Commonly made of polymethylmethacrylate (not foldable), silicone (foldable),
or acrylic (foldable).
The standard IOL implanted is monofocal and it corrects the spherical power.
Astigmatism-correcting IOLs (toric IOLs) correct astigmatism and reduce the need for
glasses after surgery.
Presbyopia-correcting IOLs (bifocal, trifocal, or multifocal IOLs) offer reduced spectacle
dependence after cataract surgery.
Approximately 86% of patients with cataracts still receive standard monofocal IOL
implantation, largely because of the cost of astigmatism-correcting or
presbyopia-correcting IOLs.
For those who have inadequate posterior and anterior capsule support, an anterior
chamber IOL, trans-scleral sutured and externalised posterior chamber IOL (PCIOL), or
iris-sutured PCIOL might be considered. Long-term clinical trials are needed to
determine the optimal technique.
Special-design IOLs: aspheric intraocular lenses to reduce ocular spherical aberration,
and blue-light-blocking IOLs to attenuate blue-wavelength light (studies did not
conclusively show the advantage of blue-light-blocking IOLs in age-related macular
degeneration).
IOL power determination
Various formulas are available to determine the IOL power. These formulas take into
account the constant specific to the IOL, patients axial length, and keratometry
reading. Newer generations of formulas incorporate more ocular measurements than
do older generationseg, anterior chamber depth, to improve the accuracy.
Choosing the appropriate formulas with correct modification is important when
calculating the IOL power for eyes under special circumstances. For example, Barrett
Universal II formula for eyes with long axial length, and Haigis-L method for eyes that
have previously undergone refractive surgery.
Surgery for age-related cataracts
Cataract surgery has evolved from intracapsular cataract
extraction to extracapsular cataract extraction to
phacoemulsification. The comparisons of these three
surgical procedures and the detailed surgical techniques
are summarised in the appendix. Although intracapsular
cataract extraction has been largely superseded by
modern cataract surgery, it is still occasionally used in
some less-developed countries.1,65 In extracapsular
cataract extraction, a limbal incision and an anterior
capsulotomy are made, and the lens nucleus and cortex
are delivered by manual expression. This procedure
leaves the posterior capsule intact, allowing the
intraocular lens to be implanted in the capsular bag and
providing more anatomical stability. Compared with
intracapsular cataract extraction, extracapsular cataract
extraction lowers the prevalence of intraoperative and
postoperative complications, such as vitreous loss,
cystoid macular oedema, and trauma to the corneal
endothelium. Manual small-incision cataract surgery is
a variant of extracapsular cataract extraction. It involves
a smaller incision, and the lens is then removed in
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whole or in fragments. Compared with extracapsular
cataract extraction, manual small-incision cataract
surgery is associated with less surgically induced
astigmatism, and therefore better visual and refractive
outcomes can be achieved.66 Because both these
procedures do not require costly equipment or
consumables, they are still widely used, especially in
developing countries.11 Extracapsular cataract extraction
substantially addresses the problems of cataract
blindness in developing countries.67 Manual small-
incision cataract surgery has comparable safety and
efficacy to phacoemulsification although it is associated
with greater postoperative astigmatism,68 hence it is the
technique of choice in surgical camps in low-income
countries or in high-volume eye-care hospitals where
phacoemulsification is not available.69
Phacoemulsification is the procedure of choice for
cataract surgery. An anterior opening in the lens capsule
or capsulorhexis is made; the lens is emulsified by an
ultrasonic hand piece and is then aspirated through a
2232 mm incision, before an intraocular lens is
implanted into the capsular bag (figure 2). Compared
with extracapsular cataract extraction, the smaller
incision expedites visual rehabilitation and reduces
occurrence of surgical complications such as intra
operative shallow anterior chamber, iris prolapse, or
postoperative astigmatism.
During the surgery, an ophthalmic viscoelastic device
is injected into the anterior chamber to replace the
aqueous humour. The properties of viscosity and
elasticity enable these devices to maintain the anterior
chamber or intraocular spaces, and to allow instruments
to be passed safely into the eye. The surface tension of
viscoelastics also enables them to coat and protect the
corneal endothelium from damage. Their use is manda
tory in modern cataract surgery to protect the corneal
endothelium and other intraocular structures from
manipulations during surgery. Ophthalmic viscoelastic
devices are non-toxic and optically clear, and are removed
by aspiration following intraocular lens implantation at
the end of surgery (figure 2).1
Following cataract removal, an intraocular lens is
implanted. In order to be implanted through a small
incision, foldable intraocular lenses have been developed.
Foldable intraocular lenses can be inserted into the
capsular bag using a special forceps, or can be rolled and
loaded into a cartridge and then be implanted by an
intraocular lens injector (figure 2).
Special situations
In situations for which the red reflex is compromised
(eg, white or mature cataracts, corneal opacity, or
paediatric cataracts), anterior capsular staining with
trypan blue or patent blue enhances visualisation during
capsulorhexis (appendix).70 In patients with zonular
dehiscence or weakness, or subluxated lens (eg, patients
with traumatic cataract, pseudoexfoliation syndrome, or
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A B C

D E F

Figure 2: Surgical steps in phacoemulsification cataract surgery

(A) OVDs are optically clear (arrows). They are used to maintain the anterior chamber and to protect the corneal endothelium when instruments move inside the eye.
(B) Continuous curvilinear capsulorhexis (arrows) is done to open the capsule, (C) and the step of hydrodissection used between the capsule and the lens cortex allows
the cataractous lens to be freed from the capsular bag (fluid wave; arrow). (D) A phacoemulsification device (arrow) is then inserted to emulsify and aspirate the lens
materials. (E) After removal of the lens materials and injection of OVDs (arrows), (F) an intraocular lens (foldable intraocular lens in this case; arrow) is implanted into
the capsular bag. OVDs=ophthalmic viscoelastic devices.

Marfan syndrome), iris hooks or a capsular tension
ringdesigned to maintain the circular contour of the
capsular bag and stabilise the capsulehave been shown
to be useful (appendix).71 Patients who are unable to have
their pupils dilated sufficiently before surgery have more
intraoperative complications than those with sufficient
dilation.72 In such cases, the use of iris retractor hooks or
pupil expansion rings are helpful to mechanically expand
a pupil.73
Femtosecond laser-assisted cataract surgery was first
described in 2010. This technology offers the ability to
precisely automate some of the steps of cataract surgery
by the use of a laser. All laser platforms are composed of
an interface, docking and imaging systems to do the
clear corneal incisions, anterior capsulotomy, and lens
fragmentation (appendix).74 Immediately after the laser
treatment, the surgeon can proceed with phacoe mulsi
fication of the lens and intraocular lens insertion. The actual
clinical benefits of femtosecond laser-assisted cataract
surgery have yet to be convincingly proven against its
negative cost-effectiveness.
Surgery for paediatric cataracts
The timing of surgery for congenital cataract is important.
A key period for visual development is the first 6 weeks of
life, and extraction of cataracts within the first 610 weeks
of life can prevent the risk of development of stimulus
deprivation amblyopia, strabismus, and nystagmus.75 The
anterior capsulorhexis in paediatric cataract surgery is
more difficult than in age-related cataract surgery because
the lens capsule is more elastic. The paediatric cataract is
soft and can be easily aspirated by phacoaspiration.76
Moreover, posterior capsule opacification is more
common after paediatric cataract surgery than after age-
related cataract surgery. Hence additional procedures,
such as polishing of the lens capsule, posterior laser
capsulotomy, primary posterior capsulotomy, or anterior
vitrectomy are widely practised to prevent posterior
capsule opacification.77
Postoperative management and follow-up
Topical antibiotics, corticosteroids, or non-steroidal anti-
inflammatory drugs (NSAIDs) are used for 14 weeks
after surgery. The frequency of use, the choice of drugs,
and the frequency of postoperative follow-up visits vary
between surgeons and countries, and depend on the
postoperative clinical course. Corticosteroids or NSAID
drops, or both, are used more frequently and for longer in
eyes with complications or in those at risk of postoperative
inflammation. A typical postoperative follow-up schedule,
following age-related cataract or paediatric cataract
surgery, consists of examining the patient at 1 day, 1 week,
1 month, and 3 months after surgery,1 but this follow-up
schedule does vary internationally. For patients who have
had uncomplicated small incision surgery, the refraction
usually stabilises 1 month following surgery, and a
spectacle prescription, if necessary, can be considered.78
Infants and children might have more severe
postoperative inflammation, and therefore treatment
with postoperative topical corticosteroids or NSAIDs, or

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Intraoperative complications
Posterior capsule rupture with or without vitreous loss
Intraoperative iris floppy syndrome or iris prolapse
Iris or ciliary body injury
Lens materials dropped into vitreous
Suprachoroidal effusion with or without haemorrhage
Early postoperative complications
Transient elevated intraocular pressure
Corneal oedema
Toxic anterior segment syndrome
Intraocular lens decentration or dislocation
Retained lens materials
Wound leak or rupture
Hyphaema
Endophthalmitis
Late postoperative complications
Posterior capsule opacification
Clinical cystoid macular oedema
Pseudophakic bullous keratopathy
Anterior capsule fibrosis and phimosis
Chronic uveitis
Retinal tear or detachment
Endophthalmitis
Table: Prevalence of complications of cataract surgery
both, should be more aggressive. In children with
aphakia, pupil-dilating drops should be used.79
Complications
Complications of cataract surgery can occur intra
operatively or in the early or late postoperative period, as
summarised in the table (appendix).1,54,80104 The most
common intraoperative complication is posterior capsule
rupture, with a prevalence of 0552%.80,81 Consequences
of posterior capsule rupture include retained lens
fragments in the anterior chamber or vitreous, cystoid
macular oedema, vitreous prolapse or traction, retinal
detachment, endophthalmitis, elevated intraocular
pressure, intraocular inflammation or haemorrhage,
corneal oedema, and intraocular lens dislocation.81,82 An
occurrence of posterior capsule rupture increases the risk
of endophthalmitis by six times (pooled OR 633, 95% CI
422949),105 and the likelihood of retinal detachment
surgery by 1518 times.80,106 Old age (>65 years), dropped
lens fragment into the vitreous, and postoperative retinal,
corneal, and intraocular lens complications are poor
prognostic factors for visual outcomes after posterior
capsule rupture.82
Postoperative corneal oedema usually occurs imme
diately after surgery and generally resolves within
24 weeks. Surgical endothelial trauma resulting from
protracted surgical manipulations, persistent post
operative inflammation or elevated intraocular pressure,
or intraoperative or postoperative complications (eg,
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posterior capsule rupture, toxic anterior segment
Prevalence
syndrome, or detachment of Descemets membrane)
could damage the corneal endothelial cells irreversibly
0552% and lead to bullous keratopathy, a common indication for
0520% corneal transplantation. Pre-existing endothelial disease,
0612% such as Fuchs endothelial dystrophy, is a known risk
000202% factor associated with persistent corneal oedema after
004% surgery.107
Endophthalmitis is the most serious sight-threatening
03181% postoperative complication, and the prevalence is
0154% 0006004%.8791 Intraoperative complications, such as
0121% posterior capsule rupture or vitreous loss, are risk factors
0117% for the development of postoperative endophthalmitis.
0517% Other reported risk factors include patients with
00211% immunosuppressive diseases (eg, type 2 diabetes),
00201% silicone intraocular lenses, a clear cornea incision, and
0006004% male sex.87,88,105,108 Reported predictors of poor final visual
acuity after endophthalmitis include poor initial visual
03284% acuity at presentation, old age, severe initial presentation
12110% with corneal oedema or a hypopyon greater than
0354% 15 mm, detection of bacterial species other than
04733% coagulase-negative Staphylococcus species, and absence
1118% of fundus visibility. Overall, 4957% of patients do not
0113% recover vision better than 20/40 (6/12).109111 Preoperative
0017005% use of povidone-iodine into the conjunctival sac, and a
watertight incision closure, are important for the
prevention of postoperative endophthalmitis. The
European Society of Cataract and Refractive Surgeons
multicentre study showed that an intraoperative
intracameral injection of cefuroxime (1 mg per 01 mL)
effectively reduced the occurrence of postoperative
endophthalmitis.109 However, formulated preservative-
free antibiotics in doses appropriate for intracameral
injection are not commercially available in most
countries, hence prophylactic use of intracameral
antibiotics is not yet universally adopted. Treatment of
endophthalmitis involves rapid assessment and the use
of intensive fortified topical board-spectrum antibiotics
and intravitreal antibiotic injections. The Endophthal
mitis Vitrectomy Study suggested that immediate pars
plana vitrectomy is indicated when patients initial visual
acuity reduces to light perception. Intravenous antibiotics
are of no benefit.112
Clinical cystoid macular oedema can occur after cataract
surgery with peak prevalence at approximately 46 weeks.
The reported prevalence is 12110%, even in the absence
of other complications and risk factors.1,99 However, this
prevalence might be as high as 514% after uncomplicated
phacoemulsification when using optical coherence
tomography, a modern imaging technique for the retina,
to assess the macula.113,114 Risk factors associated with
cystoid macular oedema include posterior capsule rupture,
type 2 diabetes, history of cystoid macular oedema, and
pre-existing epiretinal membrane.99,115 Spontaneous
resolution within 6 months occurs in the majority of
patients, hence it is difficult to assess the effect of
therapeutic agents for cystoid macular oedema.1,115 Topical

corticosteroids, topical NSAIDs, and periocular cortico
steroid injections are commonly used treatments.116
Posterior capsule opacification is the most common
postoperative complication. It is the consequence of
proliferation of remnants of lens epithelial cells. This
proliferative opaque membrane causes decreased visual
acuity, blurred vision, or glare. There is substantial
heterogeneity among published rates of posterior capsule
opacification because it is age-dependent and related to
the intraocular lens material, intraocular lens design,
amount of residual lens cortex, history of ocular
inflammation, and size of capsulorhexis.1 Findings from
a meta-analysis revealed that silicone and square-edged
intraocular lenses have lower posterior capsule
opacification than hydrogel and round-edged intraocular
lens.117 Pooled estimates of the incidence of posterior
capsule opacification are 118% at 1 year (95% CI
93143), 207% at 3 years (93143), and 284% at analysis including 126 studies concluded that multifocal
5 years (93143).100 Neodymium-doped yttrium
aluminium garnet laser capsulotomy is the most
frequently used treatment of posterior capsule
opacification. Although this treatment has been shown
to be safe and effective, it might be associated with minor
complications, such as temporary rise of intraocular
pressure (1530%), intraocular lens movement,
intraocular lens pitting (920%), transient iritis or vitritis
(0407%), cystoid macular oedema (12%), and retinal requiring intraocular exchange.129,133 Motivation to achieve
tear or detachment (2%).101 The incidence of posterior
capsule opacification in infants and children is noticeably
higher than in adults because of the higher proliferative
ability of lens epithelial cells, and posterior capsule
opacification is the most common complication after
paediatric cataract surgery. Jensen and colleagues118
reported that posterior capsule opacification occurred
in 40% of eyes at 22 months after surgery, and therefore
primary posterior capsulotomy is advisable for children
younger than 6 years.
Outcomes
Cataract surgery is safe and effective. 8494% of eyes
achieve best-corrected visual acuity of 20/30 (6/9) or better
at 6 months after surgery.119,120 Comparisons of the visual
outcomes among different surgical procedures are shown
in the appendix.65,68,121123 Studies reporting the 10-year and
15-year outcomes of cataract surgery have also documented
good long-term visual rehabilitation for most patients.124,125
Cataract surgery substantially improves patients quality of
life with gains in social and emotional life.126 Recent studies
have shown that it also decreases all-cause mortality
and extends long-term survival for older people.127,128
Dysphotopsias are the most common subjective complaints
after surgery with a reported prevalence of 3378%,129 and
they are strongly correlated with postoperative visual
function and are the main source of patient dissatisfaction
despite uncomplicated surgical procedures.130 With
improvement in technology of intraocular lenses and
surgical techniques, cataract surgery is able to provide
www.thelancet.com Vol 390 August 5, 2017 607
Seminar
patients with visual outcomes that are tailored to their
lifestyle needseg, options for monovision or specially
designed intraocular lenses with advanced performance
capabilitieswhereas in developing countries the main
purpose of surgery is still for visual restoration.
For astigmatism correction using toric intraocular lenses,
a meta-analysis including 13 randomised controlled trials
found that toric intraocular lenses successfully provided
better postoperative uncorrected distance visual acuity
(logarithm of the minimum angle of resolution mean
difference 007, 95% CI 010 to 004), greater spectacle
independence (risk ratio [RR] 051, 95% CI 036071), and
lower amounts of residual astigmatism (diopter mean
difference 037, 95% CI 055 to 019) than non-toric
intraocular lenses, without increasing the number of
perioperative complications (RR 173, 95% CI 060504).131
With regard to multifocal intraocular lenses, a recent meta-
intraocular lens implantation provided high proportions of
uncorrected vision for both distance and near visual tasks,
81% spectacle independence, and 618100% overall
patient satisfaction.132 However, adverse subjective visual
phenomena (eg, haloes or rings around lights especially at
night, and decreased contrast sensitivity) are commonly
reported.132,133 Although these symptoms usually improve
with time because of neuroadaption, they can be permanent
spectacle independence is a major factor for patients
satisfaction, and the cost of the intraocular lens is an issue
for widespread use. Accommodating intraocular lenses are
still limited by their low and varied amplitude of
accommodation,134 and there is a need for long-term
longitudinal studies to understand how accommodative
intraocular lenses perform on near vision and whether they
have lasting effects.
Paediatric cataract surgery is different from age-related
cataract surgery. After successful surgery, the visual
outcome still depends on the cause of cataracts, timing of
surgical intervention, amblyopia treatment, postoperative
posterior capsule opacification management, and
refractive correction after surgery.
Controversies
Immediately sequential bilateral cataract surgery is a
highly debatable issue. The current standard of care
worldwide is delayed sequential bilateral cataract
surgeryin which patients have two separate operations
scheduled some time apart for each eyeto avoid the
risk of bilateral endophthalmitis from a simultaneous
procedure. This schedule allows complications occurring
in the first procedure to be managed before operating on
the second eye. In delayed sequential surgery, surgeons
also have opportunities to tailor the surgical technique or
intraocular lens of choice for the second eye based on the
outcomes of the first eye. Although immediately
sequential bilateral cataract surgery provides faster visual
rehabilitation, absence of anisometropia, and cost and
 Seminar
time savings, greater evidence is needed to support its
benefits, safety, and efficacy.135
In infantile cataract surgery, a primary intraocular lens
can be implanted or the eye is left aphakic, but visual
correction is with a contact lens. Unlike age-related cataract
surgery, implantation of an intraocular lens in infantile
cataract surgery has some important concerns: the choice
of intraocular lens power is not straightforward because the
infantile eye will continue to grow after the surgery, and the
presence of an intraocular lens prevents fusion of the
anterior and posterior capsule, thereby facilitating the
migration of reproliferating lens epithelial cells into the
visual axis causing opacification.136 The infant Aphakia
Treatment Study is a multicentre, randomised controlled
trial comparing intraocular lens implantation with
spectacle correction, and aphakia with contact lens
correction in congenital cataract infants. There was no
significant difference in the median visual acuity at age
1 year and 45 years between the two treatment groups, but
there were significantly higher rates of adverse events
(eg, lens reproliferation, pupillary membrane, and
corectopia) and additional intraocular surgery in the
intraocular lens group at 1 year and 5 years after surgery
than in the aphakia group. However, 18% of patients in the
aphakia with contact lens group also developed contact
lens-related complications, such as corneal ulcers and
abrasions.136 As of early 2017, there are no established
guidelines concerning intraocular lens implantation in
infants. For children older than 2 years, clinical studies
have supported the safety and efficacy of intraocular lens
implantation.137
With regards to femtosecond laser-assisted cataract
surgery, data from published randomised controlled
trials showed that it is associated with less effective
phacoemulsification time (weighted mean difference
213, 95% CI 260 to 166) and power (657, challenge in paediatric cataracts. A study in 2016
708 to 605) compared with conventional cataract introduced a new method for a 1015 mm anterior
surgery.138 It also yielded faster visual rehabilitation and
better refractive outcomes than conventional cataract
surgery.138 However, there was no difference in the best-
corrected distance visual acuity from 1 month after
surgery onwards, and therefore it appears that the added
clinical benefit was limited.138 Moreover, femtosecond
laser-assisted cataract surgery is much more expensive
than conventional cataract surgery, which will also limit
its use worldwide as the standard of care from the aspect
of cost-effectiveness.
Outstanding research questions
Prevention of cataract formation by pharmacological
treatment to reverse cataract is an area of future research.
Zhao and colleagues reported that treatment by
lanosterol, an amphipathic molecule synthesised in the
lens cyclisation reaction, significantly decreased pre
formed lens protein aggregation in animal models with
cataracts.139 Because an implanted intraocular lens
remains in the eye after surgery, there has been growing
608 www.thelancet.com Vol 390 August 5, 2017
interest in the use of intraocular lenses as drug reservoirs
or as treatment methods for ophthalmic diseases.
Intraocular lenses have been successfully loaded with
antibiotics, corticosteroids, and NSAIDs, potentially
allowing cataract surgery and postoperative treatments in
a single procedure.140 The idea of postoperative dropless
cataract surgery also includes the use of transzonular
drug depots, drug-loaded punctum plugs, intracameral
biodegradable pellets, or nanoparticles to deliver sus
tained antibiotics or corticosteroids for postoperative
treatments, but further optimisation is required before
they reach routine clinical practice.141143
There is growing research on the use of intraoperative
wavefront aberrometry to do real-time biometry measure
ment during surgery. However, improvements in the
measurements in terms of its precision, reproducibility,
and quality are required.144
Intraocular lenses have also been successfully
incorporated with telescopic lens to magnify images for
patients with end-stage age-related macular degeneration.
5-year results showed that the best-corrected distance visual
acuity and quality of life were considerably improved after
the miniature telescope implantation.145 Novel designs of
presbyopia-correcting intraocular lenses have been
introduced, including small aperture intraocular lenses,
accommodative polyfocal bioanalogical intraocular lenses,
thermodynamic accommodative intraocular lenses, and
rotationally asymmetrical multifocal intraocular lenses.
Refinement of the postoperative outcome can be achieved
with a light-adjustable intraocular lens that contains
photoinitiators that can alter the lens power after surgery to
fine tune clinical results.146 Although early results of all
these intraocular lenses are promising,147149 more clinical
studies are required to ascertain their effectiveness.
Prevention of posterior capsule opacification is a
capsulorhexis at the periphery of the lens with removal
of the cataract. This method allowed preservation of
endogenous lens epithelial stem cells, located on the
anterior capsule, to regenerate refractive and
accommodative abilities. The visual outcomes were good
and postoperative posterior capsule opacification was
reduced.77
Conclusion
Age-related cataracts still remain the leading cause of
blindness in middle-income and low-income countries,
and paediatric cataracts account for 520% of global
childhood blindness. With advancements in technology,
surgical techniques, instrumentation, design of intra
ocular lenses, and medications, cataract surgery has been
shown to be a safe and effective intervention to improve
vision and quality of life. Paediatric cataract surgery is also
safe, but the postoperative optical rehabilitation is crucial
for long-term visual outcomes. New developments perti
nent to the surgical technology, techniques, and

proceduressuch as refinement of intraocular lens power
calculation, improvements in intraocular lens design, and
intraoperative aberrometrywill continue to improve the
visual, anatomical, and patient-reported outcomes of
cataract surgery. Future work needs to focus on efforts on
promoting the accessibility and delivery of low-cost and
high-quality cataract surgery in developing countries
through initiatives, programmes, or mass campaigns to
develop infrastructure, personnel, and economic
strategies to provide sustainable high-quality training,
counselling, and facility.
Contributors
All authors contributed to the writing of the manuscript and designing of
tables and figures. Y-CL prepared the final manuscript and JSM critically
appraised the manuscript.
Declaration of interests
TK is on advisory boards for Alcon, Ocular Therapeutix, and Presbyopia
Therapies. BM has received personal fees from Microsurgical Technology,
NovaMedica, Minosys, ValeantBausch & Lomb, and Morcher; has received
grants from Santen, Bayer Alcon, Carl Zeiss Meditec, ValeantBausch &
Lomb, and Novartis; and has a patent Expansion Ring. Y-CL, MW, and
JSM declare no competing interests.
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