LONG CASE RESOURCE

Approach to Cataract

MRCP (UK) PACES Learning Library

Learn a structured PACES approach to the patient presenting with cataract, including focused history taking, examination, differential diagnosis, investigations, management, patient explanation and common examiner questions.

8 min read Presenting Complaint High Yield

At a Glance

Presentation Gradually progressive painless visual loss
Most Likely Diagnosis Age-related (Senile) Cataract
Key Examination Finding Lens opacity with reduced red reflex
Must Not Miss Giant Cell Arteritis
Definitive Treatment Phacoemulsification
PACES Tip Always assess visual acuity before fundoscopy

Overview

Cataract is one of the commonest causes of gradually progressive painless visual impairment and is frequently encountered in the MRCP (UK) PACES examination. Candidates should demonstrate a structured approach to history taking, focused eye examination, patient counselling and appropriate referral for definitive management.

Structured History

  • Gradual or sudden onset
  • Progression of visual loss
  • One eye or both eyes
  • Difficulty reading or watching television
  • Night vision problems
  • Driving difficulties
  • Use of spectacles / previous eye assessment
  • Eye pain or redness
  • Jaw pain, temporal headache (GCA)
  • Past history of diabetes, trauma or steroid use

Examination

  • Visual acuity
  • Visual fields
  • Pupillary reflexes
  • Inspect the lens
  • Fundoscopy
  • Assess the red reflex
  • General examination for diabetes and Cushing syndrome
  • Look for previous eye surgery

Differential Diagnosis

Age-related Traumatic Diabetes Steroids Radiation Congenital Uveitis Infection

Investigations

  • Formal visual acuity assessment
  • Slit-lamp examination
  • Dilated fundoscopy (if possible)
  • Blood glucose / HbA1c if indicated
  • ESR & CRP if Giant Cell Arteritis suspected
  • Pre-operative assessment before surgery

Diagnosis

Age-related (Senile) Cataract

Suggested by gradually progressive painless visual impairment, lens opacity on examination and a diminished red reflex.

Management

Referral Ophthalmology review
Definitive Treatment Phacoemulsification with intraocular lens implantation
Safety Advice Driving advice and optimisation of co-morbidities

Explaining to the Patient

"A cataract is a clouding of the natural lens inside the eye. As the lens becomes cloudy, vision gradually becomes blurred. The condition is common with ageing and can usually be treated successfully with a small operation that replaces the cloudy lens with an artificial one."

Examiner's Corner

Common Causes of Cataract
Age-related Congenital Trauma Diabetes Uveitis Steroids Radiation Hypoparathyroidism
Drugs Causing Cataract
Corticosteroids Chlorpromazine Chloroquine Busulphan Chlorambucil Tamoxifen Amiodarone
Treatment Options
  • Phacoemulsification (preferred)
  • Extracapsular Cataract Extraction (ECCE)
  • Intraocular lens implantation
  • Occasionally Intracapsular Cataract Extraction (ICCE)
High-Yield Viva Questions
  • What are the causes of cataract?
  • Which drugs cause cataract?
  • How do you examine the red reflex?
  • What operations are available?
  • How would you counsel the patient?

Pathfinder Pearls

Visual acuity first Always assess the red reflex Think diabetes in younger patients Review steroid exposure Exclude Giant Cell Arteritis Inspect the lens carefully Explain in simple language Refer early for ophthalmology review

Common Pitfalls

  • Starting fundoscopy before checking visual acuity.
  • Forgetting to examine the red reflex.
  • Missing diabetes or long-term steroid use.
  • Not asking about jaw pain or temporal headache.
  • Using excessive medical jargon when explaining the diagnosis.

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