Progressive opacification of the crystalline lens — leading global cause of reversible blindness; surgery is curative.
Also known as: age-related cataract, senile cataract, nuclear sclerotic cataract, cortical cataract, posterior subcapsular cataract
Overview
Opacification of the crystalline lens that scatters light and reduces visual acuity. Age-related (senile) cataracts are the most common form and are classified morphologically as nuclear sclerotic, cortical, or posterior subcapsular (PSC); many patients have mixed types.
Epidemiology
Leading cause of reversible blindness worldwide and the most common cause of preventable blindness. By age 80, more than half of US adults have significant cataract or have undergone cataract surgery. Cataract surgery is the most commonly performed operation in the US.
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Chronic corticosteroid use (topical, inhaled, or systemic) — PSC
Chronic UV-B light exposure
Trauma (traumatic cataract — often rosette pattern)
Intraocular inflammation (uveitis), prior intraocular surgery
Ionizing radiation
Hypocalcemia, Wilson disease, myotonic dystrophy, atopic dermatitis
Genetic / congenital (rubella, galactosemia in pediatric)
Pathophysiology
Oxidative stress, protein cross-linking, and altered lens fiber organization disrupt the transparency of the crystalline lens. Nuclear sclerosis causes hardening and yellow/brown discoloration of the central lens (myopic shift). Cortical opacities are wedge-shaped (spoke-like) in the periphery and cause glare. Posterior subcapsular cataracts develop just anterior to the posterior capsule and disproportionately impair near vision and vision in bright light.
Clinical presentation
Symptoms
Gradual painless decrease in vision over months to years
Glare and halos around lights, especially at night
Difficulty with night driving (oncoming headlights)
Decreased contrast sensitivity, faded colors
Frequent prescription changes; 'second sight' (near vision temporarily improves with myopic shift from nuclear sclerosis)
PSC: prominent glare and poor near vision in bright light
Signs / physical exam
Decreased visual acuity not improved with refraction beyond a point
Diminished red reflex on direct ophthalmoscopy
Lens opacity on slit-lamp examination (graded as 1-4+ by LOCS system)
Brunescence of nucleus in advanced nuclear sclerosis
Cortical spokes peripherally
Posterior subcapsular plaque just anterior to posterior capsule
Classic findings
Painless gradual vision loss, glare, and diminished red reflex in an older patient.
Differential diagnosis
Refractive error — Improves with refraction; clear lens
Age-related macular degeneration — Central distortion (metamorphopsia), drusen on exam; cataract surgery may not restore central acuity
Open-angle glaucoma — Painless peripheral field loss; cupped disc; IOP may be elevated
Diabetic retinopathy — Macular edema, hemorrhages on exam; A1c known
Smoking cessation; control diabetes; minimize unnecessary systemic/inhaled corticosteroids
UV protection with sunglasses to slow progression
Second-line / adjunct
Cataract surgery — phacoemulsification with intraocular lens (IOL) implantation — indicated when cataract causes visual impairment that interferes with daily activities or driving, regardless of Snellen acuity; outpatient under topical/local anesthesia
IOL options: monofocal (most common), toric (corrects astigmatism), multifocal/EDOF (presbyopia correction at cost of nighttime glare/halos)
Femtosecond laser-assisted cataract surgery — alternative technique; no clear superiority for visual outcomes
Combined surgery with MIGS in patients with coexisting glaucoma
Posterior capsular opacification ('after-cataract') in 20-40% — treated with YAG laser capsulotomy
Endophthalmitis 0.05-0.2% — vision-threatening; managed per EVS
PANCE pearls
Visual impact, not Snellen acuity alone, drives the decision for cataract surgery — glare disability and reading difficulty matter.
Nuclear sclerosis classically produces a myopic shift ('second sight'); cortical cataracts cause prominent glare; posterior subcapsular cataracts disproportionately worsen near vision and bright-light vision and are associated with steroids and diabetes.
A diminished red reflex in any age is abnormal — in children, leukocoria warrants urgent evaluation for retinoblastoma.
Coexisting macular disease (AMD, diabetic macular edema) limits the visual gain from cataract surgery — counsel patients about realistic expectations.
Endophthalmitis after cataract surgery is rare but vision-threatening; the Endophthalmitis Vitrectomy Study (EVS) guides vitreous tap + intravitreal antibiotics ± vitrectomy.
References
AAO 2021 — American Academy of Ophthalmology. Cataract in the Adult Eye Preferred Practice Pattern. Ophthalmology 2022;129(1):P1-P126
EVS — Endophthalmitis Vitrectomy Study Group. Results of the Endophthalmitis Vitrectomy Study. Arch Ophthalmol 1995;113(12):1479-1496
AREDS Report 9 — Age-Related Eye Disease Study Research Group. Risk factors associated with age-related nuclear and cortical cataract. Ophthalmology 2001;108(8):1400-1408
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