Cataract Surgery

Italicized font represents CMS national language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national language/wording.

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Code of Federal Regulations:

42 CFR, § 410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements.

CMS Publications:

CMS Publication 100-02, Medicare Benefit Policy Manual,

• Chapter 15, § 30.4 Optometrist’s Services and § 120 Prosthetic Devices
• Chapter 16, § 10 General Exclusions from Coverage and § 90 Routine Services and Appliances

CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1:

• 10.1 Use of Visual Tests Prior to and General Anesthesia during Cataract Surgery
• 80.10 Phaco-Emulsification Procedure - Cataract Extraction
• 80.12 Intraocular Lenses
• 80.8 Endothelial Cell Photography

A cataract is a degradation of the optical quality of the crystalline lens that affects vision. Cataracts cause an opacity or cloudiness in the lens of the eye(s) which blocks the passage of light through the lens.⁶

Cataracts occur frequently as a progressive age-related disease and is the leading cause of blindness worldwide of all ethnic and racial backgrouds.⁶ More than half of all Americans age 80 or older either have cataracts or have had surgical treatment of cataracts.² Cataract is the leading cause of visual impairment among Americans of all studied ethnic and racial backgrounds.³ The number of people in the United States with cataracts is expected to double from 24.4 million to approximately 50 million in the next 30 years.^2,6 Most cataract development is related to aging, and it can occur in one or both eyes. As part of the aging process, the lens increases in thickness and weight causing hardening and compression on the nucleus eventually developing a yellow-brown color that changes the transparency of the lens. Cataracts have several different types that have their own anatomical location, pathology, and risk factors which increases with each decade of life starting around age 40.⁶ Risk factors that can increase cataract development may include smoking, ultraviolet β radiation exposure, complications of diabetes, and drug and/or alcohol use.²

Medicare coverage for cataract extraction, and cataract extraction with intraocular lens implant, is based on services that are reasonable and medically necessary for the treatment of beneficiaries with cataract(s). This policy defines coverage and describes criteria necessary to justify the performance of cataract surgery.

Coverage Indications

In the clinical presence of cataract(s), cataract surgery is considered medically necessary when the following conditions or circumstances exists, and are clearly documented in the medical record:

• After comprehensive medical eye evaluation⁶ AND
• Consideration of the risk factors for undergoing the planned anesthesia,⁶ AND
• Informed consent from the patient or the patient’s health care power of attorney after discussing the risks, benefits, and expected outcomes of surgery, including the anticipated refractive outcome,⁶ AND
• Outcome measures of cataract surgery such as visual acuity, accuracy of refractive correction, occurrence of significant operative and postoperative complications shall be recorded post-operatively,^4,6 AND
• The cataract is causing visual impairment that is not correctable with a tolerable change in glasses or contact lenses, resulting in the inability to perform Activities of Daily Living such as, but not limited to, driving, reading, watching television, and/or meeting vocational or recreational needs,⁴ OR
• The lens opacity interferes with optimal diagnosis or management of posterior segment conditions (e.g., diabetic retinopathy or macular degeneration),⁶ OR
• As a treatment of vision threatening cataract induced complications (e.g, the lens induces or risks angle closure , uveitis, dislocation of the lens),⁶ OR
• During vitrectomy procedures, the lens interferes with the performance of vitreoretinal surgery, as in the case of proliferative vitreoretinopathy, complicated retinal detachments, and severe proliferative diabetic retinopathy,⁶ OR
• There is a high probability of accelerating cataract development because of a concomitant or subsequent procedure (e.g., pars plana vitrectomy, iridocyclectomy, procedure for ocular trauma) and treatments such as external beam irradiation,⁶ OR
• There is clinically significant anisometropia or aniseikonia that exists because of lens extraction in the first eye (despite satisfactorily corrected monocular visual acuity),⁶ OR
• There is lens injury with potential lens swelling (traumatic cataract)⁶

Please refer to NCD 10.1-Use of Visual Tests Prior to and General Anesthesia During Cataract Surgery for information on pre surgery evaluations.

Coverage Limitations

• Cataract surgery is not reasonable and necessary when all the above criteria are not fulfilled. AND
• Cataract surgery can only be performed once for the same eye.⁶

Complex cataract surgery

Coverage Indications:
Complex cataract surgery will be considered medically reasonable and necessary when there is one of the following:

1. A miotic pupil that will not dilate sufficiently requiring the use of a mechanical iris expansion device (Iris retractors through four additional incisions, Beehler expansion device, or Malyugin ring) to adequately visualize the lens in the posterior chamber of the eye,¹⁴ OR
2. Pre-existing zonular weakness requiring use of capsular tension rings or segments or intraocular suturing of the intraocular lens,¹⁵ OR
3. Pediatric cataract surgery, intraoperatively difficult because of an anterior capsule that is more difficult to tear, cortex that is more difficult to remove needing a primary posterior capsulotomy or capsulorrhexis,⁶ OR
4. Mature cataract requiring dye for visualization of capsulorrhexis.⁶

Refer to CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 32, Section 120, for CMS guidelines on IOL insertion benefit following cataract surgery.

According to the American Academy of Ophthalmology (AAO) 2021 et al,⁶ cataract surgery is primarily recommended for visual function that no longer meets the patient’s needs and should be considered based on visual acuity, visual impairment, and potential for functional benefits. The preoperative evaluation should not be solely based on a visual Snellen exam, but to include an ophthalmic evaluation, patient-centered visual function exams and questionnaires, and patient education about treatment options prior to consent. The AAO has set characterizations to ensure that improved visual function, physical function, and mental health is restored after cataract surgery. Cataract surgery is also known to decrease intraocular pressure (IOP) after phacoemulsification cataract surgery in patients with or without glaucoma. Alternatives to cataract surgery and management of cataract are very few. Miller, et al⁶ display outcomes from studies that prove cataract surgery to be effective when considered in the AAO’s practice patterns for cataract surgery guidelines. Across the studies mentioned, patients have improved corrected distance visual acuity (CDVA) scores, increased visual acuity, and were overall satisfied with the results of their surgery and improvement in quality of life. The only major potentially eye-threatening complications of cataract surgery are infectious endophthalmitis, toxic anterior segment syndrome (TASS), toxic posterior segment syndrome (TPSS), suprachoroidal hemorrhage, cystoid macular edema (CME), persistent corneal edema, IOL dislocation, secondary glaucoma, diplopia, and blindness those these complications are rare. Comparing studies have shown that patients who receive cataract surgery in both eyes have greater functional improvement than those that had surgery in one eye.

According to the AAO 2021 et al,⁶ symptomatic cataract is a surgical disease and the standard of care in cataract surgery in the U.S. is a small-incision phacoemulsification with foldable IOL implantation. Cataracts are the leading cause of treatable blindness among all races worldwide. The risk of developing cataracts increases beginning at age 40. As part of the aging process, the lens increases in thickness and weight causing hardening and compression on the nucleus. The lens eventually develops a yellow-brown color that changes the transparency. To confirm that a cataract is causing the visual impairment rather than another ocular or systemic condition, a comprehensive evaluation should be conducted. Cataract surgery is the primary management of significant visual impairment. The complexity of cataract surgery requires special training, clinical experience, and judgment that are necessary to evaluate the medical, ocular, and psychosocial factors used to determine the appropriateness and timing of surgery. There are no pharmacologic treatments to eliminate cataracts. Visual function plays a major role in physical performance, mental and emotional well-being, and mobility for the elderly. Visual impairment increases the risk for falls and hip fractures in the elderly. Improved vision can reduce the fear of falling, which is one of the listed outcomes for characterized improvement in mental health and emotional well-being in the elderly. The indications, contraindications, and complications for cataract surgery are the same. Multiple studies that were used for the AAO’s preferred practice pattern show that CDVA scores improved, over 90% of patients, postoperatively, had improved visual acuity and improvement in VF-14 scores, and that the strongest preoperative indicator for visual function improvement is the glare disability test at low and medium spatial frequencies. Overall, cataract surgery is safe and effective for young adults and the elderly population. It reaches its goal of improving visual function and enhancing quality of life. The preferred practice patterns set by AAO, have clear guidelines that are suited to promote optimal health and a clear path of treating adult cataract patients.

In patients with bilateral cataracts, determining the appropriate time interval between the first eye surgery and the second eye surgery is complex and influenced by several factors. In recent years, studies in Canada, Europe and other countries have concluded immediate sequential bilateral cataract surgery (ISBCS) is safe, effective, and of economic benefit.⁶ Benefits of ISBCS include decreased costs to the patient in travel and office visits, quicker improvement in patients self-reported visual function, and have similar results to performing the first eye surgery and delayed second eye surgery. There are prospective and retrospective studies showing similar results in CDVA, uncorrected distance visual acuity (UDVA) and refractive outcomes with ISBSC compared with delayed bilateral surgery.

The reported drawbacks of performing ISCBS include the inability to adjust the IOL power in the second eye based on the results of the first eye, and bilateral dysphotopsia. While cases are rare, the most serious potential complication is bilateral blindness due to endophthalmitis or toxic anterior segment syndrome (TASS). This most often occurs when recommended guidelines of separate surgical setups is not followed. When recommended guidelines are followed which include an intracameral antibiotic, there have been no reports of bilateral endophthalmitis or TASS.⁶ The American Academy of Ophthalmology IRIS ® Registry database showed in one prospective study that the rate of endophthalmitis after ISBCS and delayed sequential bilateral cataract surgery postoperatively, was not “statistically significant”.⁶

The decision to perform ISBCS is based on multiple factors including physician comfort with the procedure, the use of antibiotics into the anterior chamber if the eyeball, the sterility of the surgical center, appropriate IOL selection, and the patients’ comorbidities that could impact the safety of the procedure. While there are potential benefits and risks for patients who undergo ISBCS, patient safety, comfort, preference, visual health, and refractive status should remain the main element in determining whether to perform same-day bilateral cataract surgery.⁶

Vazquez-Ferreiro⁵ and colleagues conducted a systematic review and meta-analysis to evaluate the association pseudoexfoliation syndrome has on IOL after having phacoemulsification cataract surgery. The aim was to identify pseudoexfoliation as a risk factor for IOL dislocation and explore other related factors from the surgery. Two reviewers performed a systematic search of several cohort studies, case–control studies and clinical trials. Included in this analysis were PubMed MEDLINE, Embase, Web of Science, Cochrane, and Lilacs database. All resources were used for searches specific to IOL dislocation in patients with and without pseudoexfoliation syndrome who had undergone phacoemulsification. The meta-analysis of this review included 2 questions of interest: 1.) Do patients with pseudoexfoliation syndrome have a clinically relevant increased risk of late IOL dislocation compared with patients without this syndrome? and 2.) Can the risk of late lens IOL dislocation in patients with pseudoexfoliation be reduced using hooks, retractors, rings, or other devices to reduce incision size? Inclusion criteria focused on articles that provided enough data with which to calculate odds ratios (ORs) and corresponding confidence intervals (CIs) for IOL dislocation. A few specific data that were extracted for this analysis to mention are sample size, study setting, study population, use of hooks or retractors, type of cataract, study design, etc. A total of 859 articles were retrieved and only 14 articles met the inclusion criteria. All were cohort studies, excluding one that was a case-control study. Only 2 studies were from the United States. The overall OR for IOL dislocation was 6.02 (95% CI: 3.70; 9.79), with a p < 0.0001 suggest that patients with pseudoexfoliation are very prone to IOL dislocation. A reduction in IOL dislocation in patients with pseudoexfoliation syndrome was not noticeable, however there was no significant increase in the ORs throughout the different quarters. The odds of IOL dislocation in patients with pseudoexfoliation was slightly increased using hooks or retractors. It was also suggested that a mild effect for time on overall risk, improvements in techniques, and reduction of incision sizes have reduced the risk of IOL dislocation. The findings suggest that there is a high risk for late IOL dislocation in patients with pseudoexfoliation syndrome after phacoemulsification cataract surgery. Suggestions point to larger incision sizes and the use of hooks and retractors during surgery as a contributing factor to the increased high risk of IOL dislocation. More studies are suggested to assess the long-term effects and if improvements to techniques will change the variables.

Flaxman, et al¹ conducted a systematic review and meta-analysis of published and unpublished population-based data from 1980 to 2014 to determine causes of vision impairment and blindness. They searched online data bases (MEDLINE from Jan 1, 1946, and Embase from Jan 1, 1974, and the WHO Library Database) identifying population-based distance vision impairment data studies published prior to July 8, 2014. Using the 21 Global Burden of Disease regions they estimated causes of visual impairment over time by age and geographical area. Using a Bayesian hierarchical modelling approach, and the Stan Modelling approach, they fitted 6 separate mixed-effects models for cataract, glaucoma, age-related macular degeneration, diabetic retinopathy, corneal opacity, and other. A total of 288 studies of nearly 4 million participants were identified contributing data from 98 countries. The authors determined in 2015 the leading causes of moderate to severe vision impairment was uncorrected refractive error and cataract and among the global population the leading cause of blindness was cataract. They noted that by 2020 the number of people affected by cataract causing vision impairment would increase from 52.6 million to 57.1 million and blindness caused by cataract would increase from 12.6 million to 13.4 million. The findings of the study support that cataract and uncorrected refractive error combined contributed to more than half of blindness and over 75% of vision impairment in adults 50 years or older with women being affected more than men. While there are several limitations to this study and determining causation, they reported that a large scale-up of eye care provision to cope with the increasing numbers of people affected by vision loss and blindness is needed to address avoidable vision loss.

Michalska-Malecka, et al⁴ conducted a study at University Hospital No. 5 of the Medical University of Silesia between 2008-2009. In this retrospective study, the authors set out to investigate the effectiveness and safety of cataract surgery and IOL implantation for patients aged 90 years or older (43 men and 79 women). Patients considered for the study had significant bilateral cataracts causing visual impairment not correctable by glasses, best corrected visual acuity (BCVA) score worse than 0.7, an unacceptable glare, polyopia, or overall reduced vision quality due to cataracts. As this study focuses on the very elderly population, Michalska-Malecka noted that coexisting systemic disorders, patient cooperation during surgery, higher incidence of hard nucleus, smaller pupil size and high rate of pseudoexfoliation syndrome make it difficult to perform cataract surgery. Individuals that were excluded from the study were those that were under the age of 90, had a BCVA score of 0.7 or greater, a baseline endothelial cell density of less than 1,500 cells/mm, uncontrolled glaucoma, and physical or mental disability that would make it difficult to perform the surgery. According to the authors, cataracts are one of the most frequent reasons for visual impairment around the world. As cataracts and its visual impairment reduces quality of life, phacoemulsification surgery and extracapsular cataract extraction have proven to be effective with increasing visual acuity. In this study, phacoemulsification was performed on 113 of 122 eyes and extracapsular cataract extraction (ECCE) was performed on 9 of 122 eyes. Visual acuity was increased after the first postoperative day, 3 months, and 6 months after surgery. The BCVA scores improved in 100 out of the 122 patients (82%) with senile cataracts from this study. Visual acuity results remained the same in 20 of the patients and decreased in 2 of the patients because of co-existing age-related macular degeneration (AMD). The IOP in patients with or without glaucoma were shown to have little to no postoperative differences than preoperatively. Patients with glaucoma had a significant difference in IOP, postoperatively, while the patients without glaucoma had no difference. These results show that cataract surgery is safe and effective in the treatment of senile cataracts in the very elderly population.

Bargoud et al¹⁴ and colleagues conducted a retrospective, observational cohort study with the aim to see whether complex cataract surgery using the phacoemulsification technique and a mechanical iris expansion device (iris hooks, Kuglen hooks, and Malyugin rings) will lower IOP for patients with glaucoma. Bargoud14 mentions the importance of this study in glaucoma patients with the modifiable risk factor of increased IOP. However, a significantly higher proportion of patients with glaucoma have been found to have smaller pupils compared with similar control groups, and on patients who underwent cataract surgery, they require iris manipulation and pupil expansion more frequently. This study was conducted at the University Hospital in Newark, New Jersey of surgeries from 2008-2016. The study was comprised of 2 groups: the primary open angle closure group and the control group that included patients without primary open-angle glaucoma (POAG) who underwent phacoemulsification with intraoperative mechanical pupillary expansion. Thirty-seven eyes from the 31 glaucoma patients (5 with mature cataracts) and 29 eyes from the 28 control patients (3 with mature cataracts) were included in the study and met the inclusion criteria. The other eyes in both groups had non-mature cataracts. Inclusion criteria focused on eyes that were diagnosed with POAG and had no prior incisional surgery for 1 year or 1 year after. Exclusion criteria included 1. eyes that had no confirmed glaucoma diagnosis, 2. had non-POAG types of glaucoma such as neovascular, uveitic, or chronic angle closure, 3. prior incisional glaucoma surgery, 4. eyes that had a phacoemulsification that was combined with another surgery and pupillary expansion devices was not confirmed from the operative report, and 5. had a vitrectomy, anterior chamber intraocular lens, and/or sulcus placement or conversion to large incisional surgery. The POAG group was significantly older than the control group at the time of surgery (72.5 ±10.2 versus 65.3 ±11.5 years old; p = 0.01). However, there were no significant differences in the proportions of hypertension, diabetes, or hyperlipidemia between the control and the POAG group. The study shows an increase 15.0 ± 4.6 to 15.9 ± 3.5 in IOP in the POAG group while the control group shows a decrease 14.1 ± 3.6 to 11.9 ± 3.9 at 12 months postoperative. Throughout the follow up period the control group showed significant decrease in IOP while the POAG group showed a significant decrease in mean antiglaucoma medication burden with improvement in visual acuity in both groups, more specifically the control group. More complications were noted in the POAG group than the control group. Complex cataract surgery did not decrease the IOP in patients with primary open angle glaucoma. However, it did improve visual acuity and reduced medication burden in the POAG group. Complex cataract surgery did, however, decrease IOP in patients without POAG and improve visual acuity. This study shows that complex cataract surgery, such as phacoemulsification with intraoperative mechanical pupillary expansion is useful in improvements of cataracts and glaucoma.

Miyoshi¹⁵ and colleagues conducted a retrospective study to assess the effects of using the capsular tension ring (CTR) on the surgical outcomes of toric and multifocal IOLs in eyes with zonular instability. A total of 55 eyes from 43 patients (70.7 ± 10.3 years old) were included who were high risk for zonular instability that included pseudoexfoliation, shallow anterior chamber, high myopia, phacodonesis, or unstable zonules. A total of 55 eyes from 43 patients (70.7 ± 10.3 years old) were included in this retrospective study undergoing phacoemulsification and IOL implantation using CTR on toric and multifocal IOLs. These eyes were at high risk for zonular instability that included pseudoexfoliation, shallow anterior chamber, high myopia, phacodonesis, or unstable zonules. The Toric IOL group had 9 eyes with CTR and 22 eyes without CTR while the multifocal IOL had 9 eyes with CTR and 15 eyes without CTR. No history of ocular surgery other than cataract removal was reported. The exclusion criteria included any eyes that experienced intraoperative complications affecting the IOL stability, except for zonular instability. One surgeon performed all cases using a standard technique of phacoemulsification through a 2.4-mm temporal clear corneal incision. Patients were followed up for 3 months. Manifest refraction, refractive astigmatism, visual acuity, and degree of IOL decentration and tilt were measured using swept-source anterior segment optical coherence tomography. Axis misalignment of Toric IOLs was also evaluated. Results show that the decentration and axis misalignment of the Toric group was smaller with the CTR than without (p = 0.037), better visual acuity with CTR than without, and a smaller axis misalignment with CTR (p = 0.037). Although the multifocal group prevented IOL tilt, manifested better visual acuity with CTR than without (p = 0.021), and had a smaller degree of tilt in CTR than without (p = 0.025), the follow up period was longer with CTR. There were a few limitations in this study to include a random assignment of eyes to CTR or non-CTR by the judgement of the surgeon, the follow-up period was significantly longer in the multifocal IOL without CTR group than the multifocal IOL with CTR group, measurements of wave-front aberration were not conducted in this study, and no evaluation was done on the multifocal Toric IOLs. Overall, the end results show that the outcome of Toric IOLs co-implantation of CTR significantly reduce decentration and toxic axis misalignment that improves uncorrected and corrected visual acuity postoperatively. In multifocal IOLs, the combined use of CTR significantly prevented IOL tilt and resulted in better uncorrected visual acuity. This study shows that CTR is a useful device to improve surgical outcomes of premium IOL in eyes at high risk of compromised zonular integrity.

Primary angle-closure glaucoma is a leading cause of irreversible blindness around the world.⁹ In the early stages of disease, the intraocular pressure (IOP) is raised without visual loss. In patients with glaucoma, cataract is also common due to changes that occur as the eye ages. A cataract that is growing in the anterior-posterior dimension narrows the anatomical gap between the iris and the cornea. Cataract extraction opens this angle and can alleviate intraocular pressure.

Cheng et al⁹ conducted a retrospective review on 26 eyes of 19 patients over a 17-year period with angle closure glaucoma (AGC) who received regular visual field (VF) examination and uncomplicated phacoemulsification with intraocular lens (IOL) implantation. VF tests using the Humphrey Field Analyzer were completed every 6 months. The mean follow up period was 5.14 ± 3.31 years and 5.97 ± 2.35 years, respectively. The VF rate of progression, visual acuity (VA), IOP, and number of patients needing glaucoma medication before and after cataract surgery were compared. While this retrospective study and small sample size are a limitation, they concluded that after cataract surgery, there was significant improvement in IOP, VA, and a decrease in the number of glaucoma medications used.

Sakai et al¹⁰ set out to investigate the long-term outcomes of cataract surgery in patients with primary angle closure disease (PACD). This retrospective case series reviewed the medical records of 87 patients with PACD. They included only patients with a minimum follow up period of 10 years. They were broken into 3 categories, patient with primary angle closure glaucoma (PACG), primary angle closure (PAC), and primary angle closure suspect (PACS). All eyes included in the study had experienced standard phacoemulsification and IOL implantation. They compared IOP, number of glaucoma eye drops being used, additional need for glaucoma treatment, VF progression, and progression to glaucoma. Among the 87 patients, 39 had PACG, 26 had PAC, and 22 had PACS. Almost half of the PACG group required additional glaucoma treatment, and 6 required surgery. Only 3 patients in the PAC group required additional glaucoma medication. There was no difference in mean IOP at 10 years among the 3 groups and all had significantly decreased from baseline. They concluded that cataract surgery has a long-term effect on reducing IOP in patients with PACD.

Senthil et al conducted a randomized controlled trial of a total of 70 patients with PACG.¹¹ Out of those 70 patients, 33 patients had phacoemulsification (Phaco) and 37 patients had phacotrabeculectomy (PT). They defined PACG as non-visible posterior trabecular meshwork in at least 180 degrees of the angle on an indentation gonioscopy, raised IOP of >21 mm Hg, or requiring eye drops or systemic medication that lowers the IOP <21 mm Hg with glaucomatous optic disk damage, and corresponding defect in the VF. They excluded patients with previous trabeculectomy surgery or documented progression in the last year, and those where glaucoma was not a primary diagnosis. Primary outcome measure was achieving an IOP of >/= 6 mmHg and </= 21 mmHg without antiglaucoma medications in both the groups after 1 year and at last follow up. Secondary outcome measure was the speed of regaining VA, number of antiglaucoma medications, mean IOP and obstacles in the 2 groups.

The overall success probability of the primary outcome measure between the 2 groups was 67.5% in the PT group and 66.6% in the Phaco group. This improved even more to 78% at 1 year in the PT group, and 80% in the Phaco group with the numbers decreasing slightly in both groups over 2 to 5 years. Postoperative VA greatly improved in both groups but were significantly better in the Phaco group initially, however similar in both groups at final follow up. The authors concluded that there was faster visual recovery, with comparable IOP control and VF stability in patients with phacoemulsification vs. trabeculectomy in medically controlled PACG eyes with cataract.

The evidence of literature supports that cataract surgery is a safe and effective procedure in adults and the elderly population. Cataract surgery improved visual acuity, improves driving safety, and quality of life in the elderly population with few intraoperative and postoperative complications.⁶ The most frequent complication following cataract surgery in the very elderly population is posterior capsule tear without vitreous loss and corneal decompression.⁴

Across the studies, patients have shown postoperative improvements in visual acuity, intraocular pressure, and function abilities. In a small prospective study conducted by Dunman et al⁷ Berg Balance Scale scores, Tinetti Gait test scores, and Tinetti Balance test scores, for functional balance all increased postoperatively after 1 month. In a retrospective study conducted by Michalska-Malecka,⁴ the BCVA scores improved in 100 out of the 122 patients (82%) with senile cataracts postoperative and at follow up.

Societies such as the AAO, Ophthalmology Variation Analysis Committee: Optimum Physician Alliance, the American Society of Cataract and Refractive Surgery, and the European Society of Cataract & Refractive Surgeons are all in support of cataract surgery, including complex cataract surgery for its safe and effective methods of treatment for cataract and other ocular diseases.

While more studies are needed in the U.S. to determine the safety between simultaneous or sequential bilateral cataract surgery, other studies have shown it to be safe when recommended guidelines are followed.^6,8 Same-day, bilateral cataract surgery can be of benefit when performed on appropriate patients who understand the risks and benefits and is to be made jointly by the patient and physician.

While phacoemulsification is not a first line treatment for PACD, literature supports that cataract extraction can offer moderate, although temporary improvement in IOP and VA. We received additional documentation from a provider for clear lens extraction for treatment of PACD, but that literature was not included as it was out of the scope of this LCD.

Other Contractor’s Policies

1. Flaxman SR, Bourne RRA, Resnikoff S, et al. Global causes of blindness and distance vision impairment 1990-2020: A systematic review and meta-analysis. Lancet Glob Health. 2017; Volume 5, Issue 12: e1221-e1234. doi:10.1016/S2214-109X(17)30393-5
2. National Eye Institute. Cataract Data and Statistics. www.nei.nih.gov 2020.
3. Congdon N, Vingerling JR, Klein BE, et al. Prevalence of cataract and pseudophakia/aphakia among adults in the United States. Arch Ophthalmol. 2004;122(4):487-494. doi:10.1001/archopht.122.4.487
4. Michalska-Malecka K, Nowak M, Gosciniewicz P, et al. Results of cataract surgery in the very elderly population. Clin Interv Aging. 2013;8:1041-1046. doi:10.2147/CIA.S44834
5. Vazquez-Ferreiro P, Carrera-Hueso F, Fikri-Benbrahim N, Barreiro-Rodriguez L, Diaz-Rey M, Barrios M. Intraocular lens dislocation in pseudoexfoliation: a systematic review and meta-analysis. Acta Ophthalmologica. 2017;95(3):e164-e169. doi:10.1111/aos.13234
6. Miller KM, Oetting TA, Tweeten JP, et al. Cataract in the adult eye preferred practice pattern. Ophthalmology. 2022;129(1):P1-P126. doi:10.1016/j.ophtha.2021.10.006
7. Duman F, Kiliç Z, Özcan-Eksi EE. Impact of Cataract Surgery on Functional Balance Skills of Adults. Turk J Ophthalmol. 2019;49(5):243-249. doi:10.4274/tjo.galenos.2019.70104
8. Zuo L, Zou H, Fei X, Xu W, Zhang J. The impact of unilateral or bilateral cataract surgery on visual acuity and life quality of elderly patients. J Ophthalmol. 2015;509049. doi:10.1155/2015/509049
9. Cheng YC, Sun MH, Wu WC, Su WW. Cataract extraction slowed the visual field progression rate in patients with angle-closure glaucoma. Taiwan J Ophthalmol. 2020;11(4):386-388. Published 2020 Oct 7. doi:10.4103/tjo.tjo_42_20Sakai.
10. Sakai D, Yamamoto S, Yoshimizu S, et al. Ten-year outcomes of cataract surgery for glaucoma management in patients with primary angle-closure disease. Jpn J Ophthalmol. 2023;67(2):129-137. doi:10.1007/s10384-022-00971-8
11. Senthil S, Rao HL, Choudhari N, Garudadri C. Phacoemulsification versus Phacotrabeculectomy in Medically Controlled Primary Angle Closure Glaucoma with Cataract in an Indian Cohort: A randomized controlled trial. Int Ophthalmol. 2022;42(1):35-45. doi:10.1007/s10792-021-01997-6.
12. Helmy H. Long-Term Effect of Early Phacoemulsification in Primary Angle Closure Glaucoma Patients with Cataract: A 10-Year Follow-Up Study. Clin Ophthalmol. 2021;15:3969-3981. Published 2021 Sep 29. doi:10.2147/OPTH.S333202
13. Tham CC, Kwong YY, Leung DY, et al. Phacoemulsification versus combined phacotrabeculectomy in medically controlled chronic angle closure glaucoma with cataract. Ophthalmology. 2008;115(12):2167-2173.e2. doi:10.1016/j.ophtha.2008.06.016
14. Bargoud AR, Parikh H, Kalbag N, Greenberg P, Khouri AS. Outcomes of Complex Cataract Surgery in Patients with Primary Open-angle Glaucoma. J Curr Glaucoma Pract. 2019;13(2):62-67. doi:10.5005/jp-journals-10078-1250
15. Miyoshi T, Fujie S, Yoshida H, Iwamoto H, Tsukamoto H, Oshika T. Effects of capsular tension ring on surgical outcomes of premium intraocular lens in patients with suspected zonular weakness. PLoS One. 2020;15(2):e0228999. Published 2020 Feb 24. doi:10.1371/journal.pone.0228999