Identifying, Referring Cataracts in Primary Care

Medscape

3 days ago

Cataract surgery is the most common surgery in medicine, and the first signs that a patient needs it may come in primary care.
Everyone — '100% of people' — will get a cataract if they live long enough, David Rivera, MD, a cataract surgeon in private practice in Westerly, Rhode Island, told Medscape Medical News. The risk increases with age, certain conditions, such as diabetes and obesity, and for those who smoke or take steroids.
Nearly 1 in 5 people aged 65-74 years in the US report that cataracts affect their vision. 'Most of the patients I do surgery on are in their 70s and 80s,' Rivera said.
Commonly Reported Symptoms
Patient reports that should trigger a primary care provider's (PCP's) referral to a specialist 'are blurriness, cloudiness, glare, halos around lights at night, and dull colors,' Rivera said. And though surgery is the only way to eliminate cataracts, surgery is not always immediately necessary, he said, unless patients report that their diminished vision affects everyday activities, such as driving, reading, or watching TV.
One key question to ask a patient reporting symptoms, Rivera said, is whether vision fluctuates. If the patient has clear vision when they start reading, then blurriness as they continue, 'that's almost always dry eye,' he said, which can be treated with artificial tears and other lubricants. 'Whatever cataracts blur is going to be constant.'
PCPs May Be First to Spot Cataract Signs
Philip Eskew, DO, JD, MBA, a family physician in Mauldin, South Carolina, and vice president of Clinical Development at Proactive MD, told Medscape Medical News he often is the first to see signs of cataracts in his patients.
He said he routinely checks for cataracts and other eye conditions in well visits, particularly for patients with diabetes or hypertension, using a panoptic ophthalmoscope. Though panoptic varieties are less common in primary care offices, most PCPs use ophthalmoscopes, he said.
Ophthalmoscopes aim a light into the eye onto the retina, which reflects a typically reddish-orange light (though the color can vary with skin pigment) if the eyes are healthy. 'If you've got a severe cataract, you're going to see that red reflex, and instead of being nice and red, it might be more white and cloudy,' he said.
'Because ultraviolet [UV] light can contribute to cataract development. Eskew said, 'If you've got a patient who does a lot of outdoor work, especially in the sunshine,' that person may be at higher risk for cataracts, he said. Similarly, if patients have a long driving commute and are squinting into the sun, they may be at higher risk without UV-blocking sunglasses.
'We refer patients for [cataract] surgery when they have impaired vision, glare sensitivity, or trouble driving at night,' Eskew said. He added that insurance requirements are important to consider.
'Some insurance companies use a visual acuity of 20/40 or worse as a benchmark,' he said. 'Some might require documented best-corrected visual acuity of 20/60 or worse in both eyes.'
Annual Vision Screening for Patients With Diabetes
The most common vision-related referral from primary care is for patients with diabetes, Rivera said, and PCPs typically refer them for annual screening. People with diabetes are at higher risk for both developing cataracts and developing them at an earlier age, according to the American Diabetes Association.
With any suspicion of an eye condition, a PCP can refer to either an optometrist or an ophthalmologist, Rivera said. 'If you're suspicious of a more complex condition, you may want to go directly to an ophthalmologist.' Sudden loss of vision should trigger an ophthalmologist referral, he said. 'That's almost never routine.'
Children May Have Cataracts
Though cataracts are more typically seen in older adults, 'finding them and treating them is crucial in kids,' M. Edward Wilson, MD, distinguished professor and chair of the Department of Ophthalmology at Storm Eye Institute in Charleston, South Carolina, told Medscape Medical News.
'Deprivation by a cataract blocking the light path can cause permanent amblyopia [lazy eye],' he explained.
In kids, one of the checkpoints that all babies go through is a check of the red reflexes, he noted. 'Eyes are checked at birth, and they really should be checked at every well visit,' he said.
Photo Screeners Popular
Cataracts can appear at any time — congenitally, through trauma, or at any development point, Wilson pointed out. Now 'almost every pediatrician's office has a photo screener. It looks like a point-and-shoot camera, and it gives a pass/fail reading. It will pick up anything that blocks light, like a cataract, and they also look for a white pupil that might mean a retinoblastoma, which is the most common eye tumor in childhood.' If pediatricians don't have a photo screener, they can use an ophthalmoscope, he added.
He also notes that vision screening now has a billing code, which addresses some complaints in the past that physicians had to buy the screener and they weren't getting reimbursed by payers.
Supplements Can't Treat Cataracts
Eskew says one misconception about cataracts is that they can be treated with the vitamin supplement AREDS. While supplements do not decrease the risk for cataract formation, 'they do slow the progression of age-related macular degeneration, he explained, which is a condition different from cataracts.'
Rivera, Eskew, and Wilson reported having no relevant financial relationships.