Question of the Week

A 67-year-old woman presents with progressive difficulty driving at night and increasing glare from headlights over the past 8 months. She also reports difficulty reading in bright sunlight. Best corrected visual acuity is 20/25 OU. Slit lamp examination of the right eye is shown below.

Which of the following is the most appropriate next step in management?

A. Reassure the patient and repeat examination in 1 year
B. Prescribe updated corrective lenses
C. Recommend cataract extraction with intraocular lens implantation
D. Start topical prednisolone acetate
E. Perform Nd:YAG laser capsulotomy

Answer

Answer:

C. Recommend cataract extraction with intraocular lens implantation

Explanation: Posterior subcapsular cataracts often cause disproportionate visual symptoms relative to Snellen acuity, glare, difficulty with bright light, and trouble with near vision. Cataract surgery is indicated when the cataract becomes visually significant or interferes with activities of daily living, even if the measured visual acuity remains relatively preserved.

A/B: Observation or updated glasses may be appropriate for mild, non-symptomatic cataracts but are inadequate here given significant functional impairment.

D: Topical steroids do not treat cataracts and can worsen them.

E: Nd:YAG capsulotomy is used for posterior capsule opacification after cataract surgery, not for native cataracts.

Cataract surgery is based on functional visual impairment, not visual acuity alone.
Posterior subcapsular cataracts frequently become symptomatic earlier than nuclear or cortical cataracts.