Cataract

CLINICAL PROTOCOL FOR DIAGNOSIS AND TREATMENT

Classification [5-14]: By time of occurrence: congenital; acquired: - senile (age-related) cataract; - complicated (caused by certain eye diseases (uveal, in glaucoma, myopia, etc.), as well as systemic diseases (diabetes mellitus, rheumatoid arthritis, etc.), as a result of side effects of long-term use of certain medications or exposure to certain physical or chemical factors); - traumatic (as a result of blunt or penetrating eye trauma); - secondary cataract (posterior capsule opacification that may occur after cataract surgery). By localization of opacification: nuclear; cortical; subcapsular; diffuse. By degree of opacification: incipient; immature; mature; hypermature (morgagnian). Separately distinguished: Intumescent cataract - an acute condition accompanied by hyperhydration of lens tissues, occurrence of secondary phacomorphic glaucoma. Classification of lens nucleus density grade [15-17]. Various classifications exist for assessing the degree of cataract density. Cataract density can be assessed according to the LOCS III classification (Lens Opacities Classification System), consisting of assessment by six grades of nuclear color (NC) and nuclear opalescence (NO) on slit lamp, assessment by five grades of retroillumination images for cortical cataract (C), and assessment by five grades of retroillumination images for posterior subcapsular (P) cataract. Cataract severity is assessed on a decimal scale. The classification of cataract density grade by L. Buratto has gained wide clinical recognition:

First grade (1) - soft nucleus, transparent or light gray shade, with cortical or subcapsular opacities; Second grade (2) - low-density nucleus, nuclear cataract gray with yellow or light gray shade; Third grade (3) - medium-density nucleus. Gray color of the nucleus is characteristic of cataracts with predominantly cortico-capsular component, yellow color - for nuclear cataracts; Fourth grade (4) - dense nucleus of amber-yellow color; Fifth grade (5) - very dense nucleus having dark color, shades of which may vary from amber to black.

Classification of lens subluxations/dislocations (Pashtaev N.P.) [104,105,106] • lens subluxation grade I - the lens has no lateral displacement relative to the optical axis of the eye, but minor displacements along the optical axis are possible; iridodonesis is observed, decrease or increase in anterior chamber depth; zonular fibers are partially ruptured; • lens subluxation grade II - the lens has lateral displacement, shifts toward the preserved zonular fibers, with significant rupture of the zonule the lens equator can be seen even with a narrow pupil, uneven deepening of the anterior chamber is observed, pronounced phacodonesis, iridodonesis, light rays pass through the peripheral parts of the lens, myopic refraction is observed; • lens subluxation grade III - the zonule is ruptured more than half of its circumference, the lens edge is displaced beyond the optical axis of the eye, may significantly deviate into the vitreous body, aphakic refraction is observed; • lens dislocation into the anterior chamber - changes in the cornea, iris, anterior chamber angle are observed, sharp rise in intraocular pressure, rapid loss of visual functions; • lens dislocation into the vitreous body - the author distinguishes: -lens fixed by adhesions to the retina, to the optic disc, ciliary body, and in the center of the vitreal cavity; -mobile lens, freely moving in the vitreous body; -migrating lens, moving from the vitreous cavity into the anterior chamber and back.

Indications for planned hospitalization: Clinically significant, established cataract with decreased visual functions: which no longer satisfies the patient's needs and surgical intervention implies a reasonable probability of vision improvement; with clinically significant anisometropia; hindering optimal diagnosis and treatment of posterior segment pathology; contributing to anterior chamber angle closure (phacomorphic); with signs of zonular apparatus pathology of varying severity (lens subluxation). 4.2 Indications for emergency hospitalization: secondary phacogenic glaucoma resulting from intumescent cataract.

Aldasheva Neilya Akhmetovna - Doctor of Medical Sciences, General Director of "Kazakh Scientific Research Institute of Eye Diseases" LLP. 2. Bulgakova Almira Abdulkhakovna - Candidate of Medical Sciences, Senior Lecturer of the Postgraduate Education Department of "Kazakh Scientific Research Institute of Eye Diseases" LLP, Head of the "Cataract" Research Group. 3. Esenzhan Galiya Anuarbekovna - ophthalmic surgeon at "Kazakh Scientific Research Institute of Eye Diseases" LLP. 4. Kim Vladimir Ukhenovich - Candidate of Medical Sciences, General Director of "Astana Vision" clinic network. 5. Panchenko Snezhana Konstantinovna - Candidate of Medical Sciences, Medical Director of "Astana Vision" clinic, Astana. 6. Akhmedyanova Zeinet Ugubaevna - Professor, Head of the Department of Eye Diseases, "Astana Medical University" NAO. 7. Akhmadyar Nurzhamal Sadyrovna - Doctor of Medical Sciences, Head of the Department of Clinical Pharmacology, "Astana Medical University" NAO. 8. Kadralieva Elvira Ibragimovna - Candidate of Medical Sciences, Associate Professor of the Department of Eye Diseases, "Astana Medical University" NAO. 9. Dautbaeva Zhibek Seithanovna - PhD, Associate Professor of the Department of Eye Diseases, "Astana Medical University" NAO.

1. Indication of conflict of interest: none
2. Reviewers: Kurmangalieva Madina Maratovna – Doctor of Medical Sciences, highest category physician, Chief Ophthalmologist of the Hospital of the Medical Center of the Administration of the President of the Republic of Kazakhstan.
3. Indication of conditions for protocol revision: revision of the protocol 5 years after its development or in the presence of new methods with evidence level.
4. List of references used: 1. Cataracts in adults: management. London: National Institute for Health and Care Excellence (NICE); 2017 Oct. PMID: 29106797. 2. Miller KM, Oetting TA, Tweeten JP, Carter K, Lee BS, Lin S, Nanji AA, Shorstein NH, Musch DC; American Academy of Ophthalmology Preferred Practice Pattern Cataract/Anterior Segment Panel. Cataract in the Adult Eye Preferred Practice Pattern. Ophthalmology. 2022 Jan;129(1):P1-P126. doi: 10.1016/j.ophtha.2021.10.006. Epub 2021 Nov 12. PMID: 34780842. 3. Ong-Tone L. Practice patterns of Canadian Ophthalmological Society members in cataract surgery: 2018 survey. Can J Ophthalmol. 2019 Aug;54(4):411-412. doi: 10.1016/j.jcjo.2018.11.010. Epub 2019 Jan 14. PMID: 31358135. 4. Koli PG, Kshirsagar NA, Shetty YC, Mehta D, Mittal Y, Parmar U. A systematic review of standard treatment guidelines in India. Indian J Med Res. 2019 Jun;149(6):715729. doi: 10.4103/ijmr.IJMR_902_17. PMID: 31496524; PMCID: PMC6755779. 5. Zhang JH, Ramke J, Lee CN, Gordon I, Safi S, Lingham G, Evans JR, Keel S. A

Systematic Review of Clinical Practice Guidelines for Cataract: Evidence to Support the Development of the WHO Package of Eye Care Interventions. Vision (Basel). 2022 Jun 20;6(2):36. doi: 10.3390/vision6020036. PMID: 35737423; PMCID: PMC9227019. 6. Clinical recommendations "Senile cataract", approved by the Scientific-Practical Council of the Ministry of Health of the Russian Federation, 2022. 7. Nizami AA, Gulani AC. Cataract. 2022 Jul 5. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 30969521. 8. Chuck RS, Dunn SP, Flaxel CJ, Gedde SJ, Mah FS, Miller KM, Wallace DK, Musch DC; American Academy of Ophthalmology Preferred Practice Pattern Committee. Comprehensive Adult Medical Eye Evaluation Preferred Practice Pattern®. Ophthalmology. 2021 Jan;128(1):P1-P29. doi: 10.1016/j.ophtha.2020.10.024. Epub 2020 Nov 12. PMID: 34933742. 9. Liu Y-C, Wilkins M, Kim T, Malyugin B, Mehta J.S Cataracts The Lancet. 2017;390(10094): 600-612. doi:10.1016/S0140-6736(17)30544-5. 10. Kessel L, Andresen J, Erngaard D, Flesner P, Tendal B, Hjortdal J. Indication for cataract surgery. Do we have evidence of who will benefit from surgery? A systematic review and meta-analysis. Acta Ophthalmol. 2016 Feb;94(1):10-20. doi: 10.1111/aos.12758. Epub 2015 Jun 3. PMID: 26036605; PMCID: PMC4744664. 11. Lundström M, Stenevi U. Indications for cataract surgery in a changing world. Acta Ophthalmol. 2016 Feb;94(1):9. doi: 10.1111/aos.12820. PMID: 26790636. 12. Date RC, Al-Mohtaseb ZN. Advances in Preoperative Testing for Cataract Surgery. Int Ophthalmol Clin. 2017 Summer;57(3):99-114. doi: 10.1097/IIO.0000000000000171. PMID: 28590284. 13. See CW, Iftikhar M, Woreta FA. Preoperative evaluation for cataract surgery. Curr Opin Ophthalmol. 2019 Jan;30(1):3-8. doi: 10.1097/ICU.0000000000000535. PMID: 30489358. 14. Núñez MX. et al. Consensus on the management of astigmatism in cataract surgery. Clin Ophthalmol. 2019;13:311-324. 15. Gali HE, Sella R, Afshari NA. Cataract grading systems: a review of past and present. Curr Opin Ophthalmol. 2019 Jan;30(1):13-18. doi: 10.1097/ICU.0000000000000542. PMID: 30489359. 16. Wan, Y., Wang, Y., Zhao, L. et al. Correlation among Lens Opacities Classification System III grading, the 25-item National Eye Institute Visual Functioning Questionnaire, and Visual Function Index-14 for age-related cataract assessment. Int Ophthalmol 40, 1831–1839 (2020). https://doi.org/10.1007/s10792-020-01353-0. 17. Lu W, Hou Y, Yang H, Sun X. A systemic review and network meta-analysis of accuracy of intraocular lens power calculation formulas in primary angle-closure conditions. PLoS One. 2022 Oct 14;17(10):e0276286. doi: 10.1371/journal.pone.0276286. PMID: 36240196; PMCID: PMC9565378. 18. Hou M, Ding Y, Liu L, Li J, Liu X, Wu M. Accuracy of intraocular lens power calculation in primary angle-closure disease: comparison of 7 formulas. Graefes Arch Clin Exp Ophthalmol. 2021 Dec;259(12):3739-3747. doi: 10.1007/s00417-021-05295-w. Epub 2021 Jul 14. PMID: 34258655. 19. Belov D.F., Nikolaenko V.P. Alternative method for calculating the optical power of intraocular lenses in short anteroposterior axis of the eye. Vestnik

I notice that the source text provided appears to be a bibliography/references section rather than a "symptoms" field describing clinical symptoms of cataracts. The text contains numbered references (items 20-31) citing various academic papers about intraocular lens (IOL) power calculation formulas and cataract surgery.

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of ophthalmology. 2022;138(3):24-28. https://doi.org/10.17116/oftalma202213803124. 20. Arzamastsev A.A., Fabrikantov O.L., Zenkova N.A., Belousov N.K. Optimization of formulas for IOL calculation. Bulletin of Tambov University. Series: Natural and Technical Sciences. 2016;21(1): 208–213. 21. Darcy K, Gunn D, Tavassoli S, Sparrow J, Kane JX. Assessment of the accuracy of new and updated intraocular lens power calculation formulas in 10 930 eyes from the UK National Health Service. J Cataract Refract Surg. 2020 Jan;46(1):2-7. doi: 10.1016/j.jcrs.2019.08.014. PMID: 32050225. 22. Carmona-González D, Castillo-Gómez A, Palomino-Bautista C, Romero-Domínguez M, Gutiérrez-Moreno MÁ. Comparison of the accuracy of 11 intraocular lens power calculation formulas. Eur J Ophthalmol. 2021 Sep;31(5):2370-2376. doi: 10.1177/1120672120962030. Epub 2020 Oct 15. PMID: 33054421. 23. Pereira A, Popovic MM, Ahmed Y, Lloyd JC, El-Defrawy S, Gorfinkel J, Schlenker MB. A comparative analysis of 12 intraocular lens power formulas. Int Ophthalmol. 2021 Dec;41(12):4137-4150. doi: 10.1007/s10792-021-01966-z. Epub 2021 Jul 27. PMID: 34318369. 24. Zhang C, Dai G, Pazo EE, Xu L, Wu X, Zhang H, Lin T, He W. Accuracy of intraocular lens calculation formulas in cataract patients with steep corneal curvature. PLoS One. 2020 Nov 20;15(11):e0241630. doi: 10.1371/journal.pone.0241630. PMID: 33216749; PMCID: PMC7678954. 25. Zhou D, Sun Z, Deng G. Accuracy of the refractive prediction determined by intraocular lens power calculation formulas in high myopia. Indian J Ophthalmol. 2019 Apr;67(4):484-489. doi: 10.4103/ijo.IJO_937_18. PMID: 30900579; PMCID: PMC6446621. 26. Wang Q, Jiang W, Lin T, Wu X, Lin H, Chen W. Meta-analysis of accuracy of intraocular lens power calculation formulas in short eyes. Clin Exp Ophthalmol. 2018 May;46(4):356-363. doi: 10.1111/ceo.13058. Epub 2017 Oct 10. PMID: 28887901. 27. Ryu S, Jun I, Kim TI, Kim EK, Seo KY. Accuracy of the Kane Formula for Intraocular Lens Power Calculation in Comparison with Existing Formulas: A Retrospective Review. Yonsei Med J. 2021 Dec;62(12):1117-1124. doi: 10.3349/ymj.2021.62.12.1117. PMID: 34816642; PMCID: PMC8612861. 28. Cheng H, Wang L, Kane JX, Li J, Liu L, Wu M. Accuracy of Artificial Intelligence Formulas and Axial Length Adjustments for Highly Myopic Eyes. Am J Ophthalmol. 2021 Mar;223:100-107. doi: 10.1016/j.ajo.2020.09.019. Epub 2020 Sep 18. PMID: 32950507. 29. Savini G, Naeser K. An analysis of the factors influencing the residual refractive astigmatism after cataract surgery with toric intraocular lenses. Invest Ophthalmol Vis Sci. 2015;56:827-835. 30. Rocha-de-Lossada C, Colmenero-Reina E, Flikier D, Castro-Alonso FJ, Rodriguez-Raton A, García-Madrona JL, Peraza-Nieves J, Sánchez-González JM. Intraocular lens power calculation formula accuracy: Comparison of 12 formulas for a trifocal hydrophilic intraocular lens. Eur J Ophthalmol. 2021 Nov;31(6):2981-2988. doi: 10.1177/1120672120980690. Epub 2020 Dec 18. PMID: 33339479. 31. Kane JX, Melles RB. Intraocular lens formula comparison in axial hyperopia with a high-power intraocular lens of 30 or more diopters. J Cataract Refract Surg. 2020

Sep;46(9):1236-1239. doi: 10.1097/j.jcrs.0000000000000235. PMID: 32384418.

Cao K. et al. Multifocal versus monofocal intraocular lenses for age-related cataract patients: a system review and meta-analysis based on randomized controlled trials. Surv Ophthalmol. 2019 Sep-Oct;64(5):647-658. doi: 10.1016/j.survophthal.2019.02.012. 46. Rosen E, Alió JL, Dick HB, Dell S, Slade S. Efficacy and safety of multifocal intraocular lenses following cataract and refractive lens exchange: Metaanalysis of peerreviewed publications. J Cataract Refract Surg. 2016 Feb;42(2):310-28. doi: 10.1016/j.jcrs.2016.01.014. PMID: 27026457. 47. Khandelwal S.S. et al. Effectiveness of multifocal and monofocal intraocular lenses for cataract surgery and lens replacement: a systematic review and meta-analysis. Graefes Arch Clin Exp Ophthalmol 257, 863–875 (2019). doi.org/10.1007/s00417-018-04218-6. 48. Zhong, Y. et al. Comparison of trifocal or hybrid multifocal-extended depth of focus intraocular lenses: a systematic review and meta-analysis. Sci Rep 11, 6699 (2021). https://doi.org/10.1038/s41598-021-86222-1. 49. McNeely, R.N., Moutari, S., Stewart, S. et al. Visual outcomes and patient satisfaction 1 and 12 months after combined implantation of extended depth of focus and trifocal intraocular lenses. Int Ophthalmol 41, 3985–3998 (2021). https://doi.org/10.1007/s10792-021-01970-3. 50. Mehta H. Management of Cataract in Patients with Age-Related Macular Degeneration. J Clin Med. 2021 Jun 8;10(12):2538. doi: 10.3390/jcm10122538. PMID: 34201114; PMCID: PMC8228734. 51. Casparis H, Lindsley K, Kuo IC, Sikder S, Bressler NM. Surgery for cataracts in people with age-related macular degeneration. Cochrane Database Syst Rev. 2017 Feb 16;2(2):CD006757. doi: 10.1002/14651858.CD006757.pub4. PMID: 28206671; PMCID: PMC5419431. 52. Karahan E, Er D, Kaynak S. An Overview of Nd:YAG Laser Capsulotomy. Med Hypothesis Discov Innov Ophthalmol. 2014 Summer;3(2):45-50. PMID: 25738159; PMCID: PMC4346677. 53. Grzybowski A, Kanclerz P. Does Nd:YAG Capsulotomy Increase the Risk of Retinal Detachment? Asia Pac J Ophthalmol (Phila). 2018 Sep-Oct;7(5):339-344. doi: 10.22608/APO.2018275. Epub 2018 Jul 24. PMID: 30043556. 54. McKinney S K Responding to Premium IOL Setbacks. Review of Ophthalmology 10 Oct 2021 https://www.reviewofophthalmology.com/article/responding-to-premiumiol-setbacks. 55. Hillman L An algorithm for 'Getting to Happy' after cataract surgery ASCRS EYEWORLD, Cataract, April, 2022. https://www.eyeworld.org/2022/an-algorithm-forgetting-to-happy-after-cataract-surgery/ 56. Kozhukhov A.A., Kapranov D.O. Modern methods of fixation of posterior chamber intraocular lenses after phacoemulsification of cataract complicated by impaired capsular support of the lens // Clinical Practice. 2018. No. 1. 57. Fayzrakhmanov, R. R., Shishkin, M. M., Konovalova, K. I., Karpov, G. O. Transscleral fixation of IOL. From complex to simple. – Ufa: Bashk. encycl., 2020. – 104 p. ISBN 978-5-88185-472-0. 58. Lacy M, Kung TH, Owen JP, Yanagihara RT, Blazes M, Pershing S, Hyman LG, Van Gelder RN, Lee AY, Lee CS; IRIS® Registry Analytic Center Consortium. Endophthalmitis Rate in Immediately Sequential versus Delayed Sequential Bilateral

Cataract Surgery within the Intelligent Research in Sight (IRIS®) Registry Data.

Ophthalmology. 2022 Feb;129(2):129-138. doi: 10.1016/j.ophtha.2021.07.008. Epub

Approved by the Joint Commission on Quality of Medical Services

of the Ministry of Health of the Republic of Kazakhstan dated September 19, 2024, Protocol No. 214

INTRODUCTORY PART: 1.1 ICD-10 Code(s):

ICD-10

CATARACT

Code Name H25 Age-related (senile) cataract H25.0 Incipient senile cataract H25.1 Senile nuclear cataract H25.2 Senile Morgagnian cataract H25.8 Other senile cataracts H25.9 Senile cataract, unspecified H26 Other cataracts H26.0 Infantile, juvenile and presenile cataract H26.1 Traumatic cataract

H26.2 Complicated cataract

H26.3 Drug-induced cataract H26.4 Secondary cataract H26.8 Other specified cataract H26.9 Cataract, unspecified H27 Other disorders of lens H27.0 Aphakia H27.1 Dislocation of lens Z96.1 Presence of intraocular lens (pseudophakia)

Date of protocol development: 2017 (revised 2023). 1.3 Abbreviations used in the protocol:

AGO

antiglaucoma operation

IOP

intraocular pressure

CTR

capsular tension ring

AMD

age-related macular degeneration

GCS

glucocorticosteroids

ONH

optic nerve head YAG laser yttrium-aluminum garnet laser

IOL ICCE CME CRS LDSC LVC BCVA-N BCVA-D INN

intraocular lens intracapsular cataract extraction cystoid macular edema keratorefractive surgery laser discission of secondary cataract laser vision correction best corrected visual acuity for near best corrected visual acuity for distance international nonproprietary name of drug

NPDS UCVA-N UCVA-D NPA NSAIDs OCT AL

non-penetrating deep sclerectomy uncorrected visual acuity for near uncorrected visual acuity for distance normative-legal acts nonsteroidal anti-inflammatory drugs optical coherence tomography anterior-posterior segment/size of the eyeball

PES

pseudoexfoliation syndrome

IH

inpatient care

STE

sinustrabeculectomy

tIOL

toric intraocular lens

TSF

transscleral fixation

UBM

ultrasound biomicroscopy Femto-PHACO femtosecond-assisted phacoemulsification of cataract

PHACO

CCD

ciliochoroidal detachment

EPI

electrophysiological investigation

ECCE

extracapsular cataract extraction EDOF IOL Extended Depth of Focus IOL – IOL with extended depth of focus OVD Ophthalmic Viscosurgical Devices - ophthalmic viscoelastic solutions

Protocol users: ophthalmologists, general practitioners, internists, feldshers. 1.5 Patient category: adults. 1.6 Level of evidence scale:

A High-quality meta-analysis, systematic review of RCTs or large RCT with very low probability (++) of systematic error.

B High-quality (++) systematic review of cohort or case-control studies or high-quality (++) cohort or case-control study with very low risk of systematic error or RCT with low (+) risk of systematic error.

C Cohort or case-control study or controlled study without randomization with low risk of systematic error (+).

D Case series description or uncontrolled study, or expert opinion.

METHODS, APPROACHES AND DIAGNOSTIC PROCEDURES [1-17]: 2.1 Diagnostic criteria:

Complaints and history [1-17]: painless progressive decrease in UCVA-D, BCVA-D, BCVA-N; blurred vision; distortion of object shape; change in refraction; deterioration of color perception;

impairment of depth perception, binocular vision; in intumescent cataract, presence of acute severe pain in the eye, with

radiation to the corresponding half of the head; change in pupil color from black to grayish-white in cases with

hypermature forms of cataracts. Physical examination [1-17]:

General somatic examination reveals no specific features for diagnosis. Laboratory investigations: none. Instrumental investigations [1-17]: Basic: Visometry: decrease in UCVA-D and/or BCVA-D, deterioration of BCVA-N, in

some cases temporary improvement of UCVA-N due to progression of myopic lenticular sclerosis, in later stages absence of object vision up to light projection; Autorefractometry: measurement of eye refraction with narrow pupil, possible myopization (discrepancy in degree of ametropia with AL and keratometry data), increase in cylindrical component due to appearance of lenticular astigmatism, in some cases inability to perform the study due to density of cataract; Biomicroscopy: presence of dystrophic changes in the anterior segment of the eye, lens opacities of varying intensity, unevenness of the anterior chamber, possible iridodonesis, phacodonesis, presence of PES, sluggish pupillary reaction to light and mydriatics. In intumescent cataract there may be injection of the eyeball, corneal edema, shallow anterior chamber; Ophthalmoscopy and/or fundus examination with Goldmann lens or non-contact lens: depending on the intensity of opacity, the fundus may not be accessible to examination, fundus reflex is weakened or absent, when examination is accessible, visual assessment of the posterior segment of the eye (retina, optic nerve) is performed to exclude the influence of changes in these eye structures on visual functions; Keratometry – performed to assess the radius of corneal curvature, necessary for calculation and selection of IOL type. Optical biometry - measurement of biometric parameters of the eye: anteroposterior axis, anterior chamber depth, lens and corneal thickness, corneal diameter and keratometry, based on laser interferometry, - with subsequent calculation of the appropriate IOL. Pneumotonometry or tonometry by Maklakov method with 10 g weight: within normal limits in the absence of concomitant pathology (glaucoma). In intumescent cataract - elevation of intraocular pressure;

Additional:

Gonioscopy: varying degrees of anterior chamber angle opening depending on anterior chamber characteristics and lens thickness;

A-B scan: echographic measurements are taken when optical biometry cannot be performed in cases with denser forms of cataract, and also when visualization of the posterior segment is not possible to exclude the influence of changes in these eye structures on visual function. If there is no concomitant pathology, no pathological echo signals are detected on B-scanning;

EFI (electrophysiological investigation): results allow assessment of the functional state of the retina and optic nerve;

Spectral endothelial microscopy: evaluation of the number of hexagonal endothelial cells per 1 sq. mm of corneal area;

OCT of macula and optic disc: measurement of morphometric parameters of fundus structures to exclude the influence of changes in these eye structures on visual function and to establish prognosis for postoperative results;

UBM (ultrasound biomicroscopy): study of anatomical and topographical features of the anterior segment (thick lens, lens position, anterior chamber angle characteristics, posterior chamber condition, zonular ligament status, etc.);

Keratotopography/keratotomography, including with Scheimpflug cameras – examination of the structure of the anterior and posterior corneal surfaces, anterior chamber structure to exclude corneal pathology;

Corneal examination on diagnostic modules of navigational surgery systems – examination of corneal parameters (radius and curvature), position of steep and flat meridian axes, position of limbal vessels and pupil diameter, as well as automatic IOL calculation for the purpose of creating a surgical plan for toric IOL (tIOL) implantation;

Perimetry – examination of the patient's visual field by quantitative computerized automated static perimetry, consisting of determining light sensitivity in various areas of the visual field using stationary objects of variable brightness, to assess the state of the visual system.

Indications for specialist consultations. Consultations with narrow specialists in the presence of concomitant diseases as indicated.

Diagnostic algorithm:

Complaints of decreased vision History taking Visometry

(UCVA, BCVA)

Biomicroscopy Lens transparent Cataract present Exclusion of diseases affecting vision (consultation with specialists of other profiles) Exclusion of fundus pathology

OCT

EFI

Immature cataract Mature cataract Cataract with zonular apparatus pathology Optical biometry Echobiometry (A-B-scan) Pachymetry Keratotopography

SEC UBM

IOL calculation Surgical treatment

Differential diagnosis and justification for additional investigations [1-17]:

Diagnosis: Hemophthalmos

Retinal detachment

Justification for differential diagnosis

Examinations Diagnostic criteria for exclusion Hemorrhage into the vitreous cavity from surrounding space, which may be caused by rupture of retinal vessels.

Depending on the volume of blood extravasated, it may either only interfere with normal vision with opaque blood elements floating in the vitreous body, or may significantly reduce it, down to light perception.

Most often occurs against the background of peripheral vitreoretinal degeneration (PVRD) on the retina, in diabetes, against the background of increased blood pressure, in vasculitis, in trauma.

Separation of neurosensory layers of the retina from the pigment epithelium.

Occurs in the presence of PVRD and formation of breaks with subsequent leakage of subretinal fluid into the space formed behind the break (rhegmatogenous detachment), or with pronounced tractions Visometry

Biomicroscopy

Ophthalmoscopy

Fundus

examination with

Goldmann lens

B-scanning Visometry

Tonometry

Biomicroscopy

Ophthalmoscopy

Fundus

examination with

Goldmann lens

B-scanning Unlike cataract, hemophthalmos develops rapidly, suddenly; patients complain of rapid (possibly within an hour) decrease in visual acuity, which may occur against the background of hypertension or diabetes mellitus.

Biomicroscopy reveals a transparent lens against the background of absent or reduced fundus reflex.

On ophthalmoscanning, diffuse vitreous opacity is noted.

On fundus examination with Goldmann lens in partial hemophthalmos, the site of rupture with the vessel that became the source of hemorrhage may be detected.

The disease develops rapidly; patients complain of sudden vision loss, appearance of a "veil" or "curtain" before the eyes.

Fundus reflex may be grayish; on biomicroscopy the lens is transparent; on ophthalmoscopy retinal detachment is detected.

Tonometry may show decreased IOP.

On fundus examination with Goldmann lens, it is possible to detect the projection of the break that served as the source of detachment.

B-scan: echo signs of retinal detachment.

Late stages of glaucoma

Age-related macular degeneration from vitreoretinal adhesions, or with fluid accumulation under the retina in the absence of breaks (exudative detachment) Gradual progressive vision loss due to glaucomatous optic neuropathy (GON), visual field constriction.

Gradually progressive vision loss due to formation of pathological changes in the central area of the retina (macula) Visometry

Tonometry

Biomicroscopy

Ophthalmoscopy

Perimetry

OCT of the optic

nerve disc Visometry

Biomicroscopy

Ophthalmoscopy

Perimetry

OCT Decreased UCVA and BCVA;

Visual field constriction or inability to perform them due to extremely low visual acuity;

Biomicroscopy reveals a transparent lens;

ophthalmoscopy shows characteristic glaucomatous optic nerve atrophy;

tonometry shows elevated intraocular pressure.

On OCT - grade 3 neuroretinal rim deflection.

Gradual decrease in UCVA, BCVA, BCNVA, sensation of distortion, deformation objects, sensation of a "spot" before the eye;

on biomicroscopy the lens may be transparent;

on ophthalmoscopy dystrophic changes of the retina in the macular area are detected;

on perimetry there may be loss of central visual field.

On OCT signs of RPE dystrophy, neurosensory epithelium, drusen of Bruch's membrane, presence of CNV.

1. TREATMENT TACTICS AT THE OUTPATIENT LEVEL [33-76]:

1. Non-pharmacological treatment (regimen, diet):

Regimen – IV.

Diet – table No. 15 (in the absence of concomitant diseases)

1. Pharmacological treatment [81-103]:

List of essential medicines (with 100% probability of use):

Pharmacotherapeutic group | INN of the drug | Method of administration | LE

GCS for injections | Dexamethasone | Subconjunctival, parabulbar injections 0.5 ml, 1-3-5 times according to | B

Antibacterial drug of the fluoroquinolone group for topical use in ophthalmology | Levofloxacin | Instillations into the conjunctival cavity 1 drop 4 times a day, 7–14 days. | C

Antibacterial drug of the fluoroquinolone group | Moxifloxacin | Instillations into the conjunctival cavity 1 drop 4 times a day, 7–14 days. | C

Antibacterial drug of the fluoroquinolone group for topical use in ophthalmology | Ofloxacin | Instillations into the conjunctival cavity 1 drop 4 times a day, 7–14 days. | C

Antibacterial drug of the aminoglycoside group for topical use in ophthalmology | Tobramycin | Instillations into the conjunctival cavity 1 drop 4 times a day, 7–14 days. | C

Antibacterial drug of the fluoroquinolone group for topical use in ophthalmology | Ciprofloxacin | Instillations into the conjunctival cavity 1 drop 4 times a day, 7–14 days. | C

Local anesthetic for use in ophthalmology | Proxymetacaine | Instillations into the conjunctival cavity 1 drop 3 times once. | C

Local anesthetic for use in ophthalmology | Oxybuprocaine | Instillations into the conjunctival cavity 1 drop 3 times once. | C

Regeneration stimulators, keratoprotectors | Dexpanthenol | Instillations into the conjunctival sac 1 drop 6–8 times, frequency and duration of use | C

Antimicrobial bacteriostatic agent, sulfonamide | Sulfacetamide | are established individually, according to |

dehydration and local hypotensive therapy.

After discharge, observation at the place of residence is recommended:

● Outpatient observation by an ophthalmologist at 10 days, 1 month from the day of surgery, in the presence of complications up to 3 months;

● Instillations of antibacterial and anti-inflammatory drugs for 2 weeks to 1 month after surgery;

● If necessary, selection of spectacle correction from 3 months after surgery;

● In the presence of concomitant disease, regular monitoring of the latter.

5) Indicator of treatment effectiveness [33-76]:

Restoration of transparency of the optical media of the eye as a result of cataract removal;

Absence of inflammatory reaction in the late postoperative period;

Location of the IOL after its implantation in the capsular bag, in the ciliary sulcus or in the anterior/posterior chamber depending on the selected IOL model and type of fixation;

Improvement of UCVA and BCVA in the absence of fundus pathology;

Increased ability to perform daily activities;

Increased ability to maintain or resume work activity;

Improvement of mental health and emotional well-being.

Indicator of YAG capsulotomy effectiveness:

• Presence of a discission opening in the posterior lens capsule of sufficient size in the center of the pupillary area;
• Absence of inflammatory reaction of the eye;
• Improvement of UCVA and BCVA in the absence of fundus pathology.

1. INDICATIONS FOR HOSPITALIZATION WITH INDICATION OF TYPE OF HOSPITALIZATION [129]:

5. TREATMENT TACTICS AT THE INPATIENT LEVEL [33-76]:

1) Patient observation card, patient routing (schemes, algorithms):

Complaints, anamnesis, objective examination data

Surgical treatment in day surgery conditions.

Surgical treatment in round-the-clock inpatient conditions taking into account indications:

• impossibility of performing surgical intervention in outpatient conditions; - cataract surgery on the only functionally viable eye; - presence of concomitant pathology requiring round-the-clock inpatient observation.

2) Non-pharmacological treatment (regimen, diet):

Regimen – III B.

Diet – table No. 15 (in the absence of concomitant diseases).

3) Pharmacological treatment: see section 3.2.

4) Surgical intervention: see section 3.3.

5) Further management: see section 3.4.

6) Indicators of treatment effectiveness and safety: see section 3.5.

Organizational aspects of the protocol:

1. List of developers:

Moshirfar M, Milner D, Patel BC. Cataract Surgery. 2022 Jun 21. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 32644679.

Malyugin B.E., Shpak A.A., Morozova T.A. Cataract Surgery: Clinical and Pharmacological Approaches. M.: Publishing House "Ophthalmology"; 2015: 82.

Essentials of cataract surgery / edited by Bonnie An Henderson Second edition. SLACK Inc., 2014. ISBN 978-1-61711-067-2.

Day AC, Gore DM, Bunce C, Evans JR. Laser-assisted cataract surgery versus standard ultrasound phacoemulsification cataract surgery. Cochrane Database Syst Rev. 2016 Jul 8;7(7):CD010735. doi: 10.1002/14651858.CD010735.pub2. PMID: 27387849; PMCID: PMC6458014.

Manning S, Barry P, Ype H, Rosen P, Stenevi U, Young D, Lundstrom M, Femtosecond laser-assisted cataract surgery versus standard phacoemulsification cataract surgery: Study from the European Registry of Quality Outcomes for Cataract and Refractive Surgery. J Cataract Refract Surg. 2016;42: 1779–1790.

Chi Q, Yang T, Chen Y. A systematic review and meta-analysis on intraocular lens implantation with different performances for the treatment of cataract. Ann Palliat Med.

Jan;11(1):260-271. doi: 10.21037/apm-21-3767. PMID: 35144417.

Zamora-de La Cruz D, Zúñiga-Posselt K, Bartlett J, Gutierrez M, Abariga SA.

Trifocal intraocular lenses versus bifocal intraocular lenses after cataract extraction among participants with presbyopia. Cochrane Database Syst Rev. 2020 Jun 18;6(6):CD012648. doi: 10.1002/14651858.CD012648.pub2. PMID: 32584432;

PMCID: PMC7388867.

Anisimova N.S., Malyugin B.E., Sobolev N.P. Femtolaser support

in surgery of intumescent cataract. Modern Technologies in Ophthalmology.

2016;5: 11–13.

Pershin K.B., Pashinova N.F., Tsygankov A.Yu., Solovyeva G.M., Batalina L.V.

15-year experience of combined cataract and glaucoma surgery. National Journal "Glaucoma". 2017;16(2): 38–46.

C. Xu, "Successful Premium Multifocal IOL Surgery: Key Issues and Pearls", in

Current Cataract Surgical Techniques. London, United Kingdom: IntechOpen, 2021 [Online].

Available: https://www.intechopen.com/chapters/75474 doi: 10.5772/intechopen.96182.

Gogate P, Optom JJ, Deshpande S, Naidoo K. Meta-analysis to Compare the Safety

and Efficacy of Manual Small Incision Cataract Surgery and Phacoemulsification. Middle East Afr J Ophthalmol. 2015 Jul-Sep;22(3):362-9. doi: 10.4103/0974-9233.159763.

PMID: 26180478; PMCID: PMC4502183.

Wang L, Xiao X, Zhao L, Zhang Y, Wang J, Zhou A, Wang J, Wu Q. Comparison

of efficacy between coaxial microincision and standard-incision phacoemulsification in patients with age-related cataracts: a meta-analysis. BMC Ophthalmol. 2017 Dec 29;17(1):267. doi: 10.1186/s12886-017-0661-6. PMID: 29284444; PMCID:

PMC5747124.

Kadatskaya N.V., Fokin V.P., Marukhnenko A.M. Comparative analysis of

results of implantation of various IOL models in correction of aphakia in

complicated cases. Bulletin of VolgSMU, 2014;2(50): 54–57.

Jul 13. PMID: 34265315; PMCID: PMC8755857.

Ye Z, Li Z, He S. A Meta-Analysis Comparing Postoperative Complications and

Outcomes of Femtosecond Laser-Assisted Cataract Surgery versus Conventional Phacoemulsification for Cataract. J Ophthalmol. 2017;2017:3849152. doi:

10.1155/2017/3849152. Epub 2017 Apr 30. PMID: 28540082; PMCID: PMC5429954.

Chen L, Hu C, Lin X, Li HY, Du Y, Yao YH, Chen J. Clinical outcomes and

complications between FLACS and conventional phacoemulsification cataract surgery: a PRISMA-compliant Meta-analysis of 25 randomized controlled trials. Int J Ophthalmol.

Jul 18;14(7):1081-1091. doi: 10.18240/ijo.2021.07.18. PMID: 34282395; PMCID:

PMC8243176.

Day AC, Burr JM, Bennett K, Hunter R, Bunce C, Doré CJ, Nanavaty MA, Balaggan

KS, Wilkins MR. Femtosecond laser-assisted cataract surgery compared with phacoemulsification: the FACT non-inferiority RCT. Health Technol Assess. 2021 Jan;25(6):1-68. doi: 10.3310/hta25060. PMID: 33511963; PMCID: PMC7883211.

Wang J, Su F, Wang Y, Chen Y, Chen Q, Li F. Intra and post-operative

complications observed with femtosecond laser-assisted cataract surgery versus conventional phacoemulsification surgery: a systematic review and meta-analysis. BMC Ophthalmol. 2019 Aug 9;19(1):177. doi: 10.1186/s12886-019-1190-2. PMID: 31399070;

PMCID: PMC6688351.

Farahvash A, Popovic MM, Eshtiaghi A, Kertes PJ, Muni RH. Combined versus

Sequential Phacoemulsification and Pars Plana Vitrectomy: A Meta-Analysis.

Ophthalmol Retina. 2021 Nov;5(11):1125-1138. doi: 10.1016/j.oret.2021.01.004. Epub

Jan 20. PMID: 33482399.

Erikitola OO, Siempis T, Foot B, Lockington D. The incidence and management of

persistent cystoid macular oedema following uncomplicated cataract surgery-a Scottish Ophthalmological Surveillance Unit study. Eye (Lond). 2021 Feb;35(2):584-591. doi: 10.1038/s41433-020-0908-y. Epub 2020 May 6. PMID: 32376978; PMCID:

PMC7202460.

Han JV, Patel DV, Squirrell D, McGhee CN. Cystoid macular oedema following

cataract surgery: A review. Clin Exp Ophthalmol. 2019 Apr;47(3):346-356. doi: 10.1111/ceo.13513. PMID: 30953417.

Park CY, Lee JK, Chuck RS. Toxic anterior segment syndrome-an updated review.

BMC Ophthalmol. 2018 Oct 25;18(1):276. doi: 10.1186/s12886-018-0939-3. PMID:

30359246; PMCID: PMC6203205.

Gurnani B, Kaur K. Pseudophakic Bullous Keratopathy. 2022 Aug 29. In: StatPearls

[Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 34662019.

Pricopie S, Istrate S, Voinea L, Leasu C, Paun V, Radu C. Pseudophakic bullous

keratopathy. Rom J Ophthalmol. 2017 Apr-Jun;61(2):90-94. doi: 10.22336/rjo.2017.17.

PMID: 29450379; PMCID: PMC5710027.

Konstantinos T. Tsaousis, Dimitrios Z. Panagiotou, Eirini Kostopoulou, Vasileios

Vlatsios, Despoina Stampouli, Corneal oedema after phacoemulsification in the early postoperative period: A qualitative comparative case-control study between diabetics and non-diabetics. Annals of Medicine and Surgery, Vol 5, 2016, Pp 67-71, ISSN 2049- 0801, https://doi.org/10.1016/j.amsu.2015.12.047.

Sharma N, Singhal D, Nair SP, Sahay P, Sreeshankar SS, Maharana PK. Corneal

edema after phacoemulsification. Indian J Ophthalmol. 2017 Dec;65(12):1381-1389. doi:

10.4103/ijo.IJO_871_17. PMID: 29208818; PMCID: PMC5742966.

Chang VS, Gibbons A, Osigian C. Phacoemulsification in the Setting of Corneal

Endotheliopathies: A Review. Int Ophthalmol Clin. 2020 Summer;60(3):71-89. doi:

10.1097/IIO.0000000000000315. PMID: 32576725; PMCID: PMC7360340.

Riks I.A., Papanyan S.S., Astakhov S.Yu., Novikov S.A. New clinical and

morphological classification of endothelial-epithelial corneal dystrophy // Ophthalmological Statements. - 2017. - Vol. 10. - No. 3. - P. 46-52. doi:

10.17816/OV10346-52.

Astakhov S.Yu., Riks I.A., Papanyan S.S., Kasparov A.A., Kasparova E.A.,

Pavlyuk A.S., Fedotova K. Experience of clinical application of personalized cell therapy for treatment of patients with primary endothelial dystrophy after phacoemulsification // Ophthalmological Statements. - 2017. - Vol. 10. - No. 4.

• pp. 6-12. doi: 10.17816/OV1046-12.

Salari F, Beikmarzehei A, Liu G, Zarei-Ghanavati M, Liu C. Superficial

Keratectomy: A Review of Literature. Front Med (Lausanne). 2022 Jul 6;9:915284. doi:

10.3389/fmed.2022.915284. PMID: 35872789; PMCID: PMC9299356.

Stuart AJ, Romano V, Virgili G, Shortt AJ. Descemet's membrane endothelial

keratoplasty (DMEK) versus Descemet's stripping automated endothelial keratoplasty (DSAEK) for corneal endothelial failure. Cochrane Database Syst Rev. 2018 Jun 25;6(6):CD012097. doi: 10.1002/14651858.CD012097.pub2. PMID: 29940078;

PMCID: PMC6513431.

Pavlovic I, Shajari M, Herrmann E, Schmack I, Lencova A, Kohnen T. Meta-

Analysis of Postoperative Outcome Parameters Comparing Descemet Membrane Endothelial Keratoplasty Versus Descemet Stripping Automated Endothelial Keratoplasty.

Cornea.

2017 Dec;36(12):1445-1451.

10.1097/ICO.0000000000001384. PMID: 28957976.

Li S, Liu L, Wang W, Huang T, Zhong X, Yuan J, Liang L. Efficacy and safety of

Descemet's membrane endothelial keratoplasty versus Descemet's stripping endothelial keratoplasty: A systematic review and meta-analysis. PLoS One. 2017 Dec 18;12(12):e0182275. doi: 10.1371/journal.pone.0182275. PMID: 29252983; PMCID:

PMC5734733.

FROLYCHEV I.P., POZDEEVA N.A. Postoperative endophthalmitis.

Literature review. PRACTICAL MEDICINE 09 (17) OPHTHALMOLOGY.

VOLUME 1 | AUGUST 23, 2017 UDC 617.747-002.3-089.168.1-06.

Juthani VV, Clearfield E, Chuck RS. Non-steroidal anti-inflammatory drugs versus

corticosteroids for controlling inflammation after uncomplicated cataract surgery.

Cochrane Database Syst Rev. 2017 Jul 3;7(7):CD010516. doi:

10.1002/14651858.CD010516.pub2. PMID: 28670710; PMCID: PMC5580934.

Ma X, Xie L, Huang Y. Intraoperative Cefuroxime Irrigation Prophylaxis for Acute-

Onset Endophthalmitis After Phacoemulsification Surgery. Infect Drug Resist. 2020 May

18;13:1455-1463. doi: 10.2147/IDR.S252674. PMID: 32547114; PMCID:

PMC7244738. 81. Gower EW, Lindsley K, Tulenko SE, Nanji AA, Leyngold I, McDonnell PJ. Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery. Cochrane Database Syst Rev. 2017 Feb 13;2(2):CD006364. doi: 10.1002/14651858.CD006364.pub3. 82. Grzybowski A, Brona P, Zeman L, Stewart MW. Commonly used intracameral antibiotics for endophthalmitis prophylaxis: A literature review. Surv Ophthalmol. 2021 Jan-Feb;66(1):98-108. doi: 10.1016/j.survophthal.2020.04.006. 83. Barry, P., Cordovés, L. & Gardner, S. European Society of Cataract and Refractive Surgeons. ESCRS Guidelines for Prevention and Treatment of Endophthalmitis Following Cataract Surgery: Data, Dilemmas and Conclusions 2013. Available at: http://www.escrs.org/downloads/Endophthalmitis-Guidelines.pdf. (Data of access: March 12, 2014). 84. Carlo Cagini, Giovanni Di Pasquale, Tito Fiore.Timolol 0.1% Gel versus Timolol 0.5% Eyedrops in the Prophylaxis of Ocular Hypertension after Phacoemulsification Surgery. Volume 24, Issue 6 https://doi.org/10.5301/ejo.5000472 85. Stanislao Rizzo, Gloria Gambini , Umberto De Vico, Clara Rizzo , Raphael Kilian. A One-Week Course of Levofloxacin/Dexamethasone Eye Drops: A Review on a New Approach in Managing Patients After Cataract Surgery 2022 ;11(1):101-111. doi: 10.1007/s40123-021-00435-1. Epub 2021 Dec 22. DOI: 10.1007/s40123-021-00435-1 86. Zhenyu Wang, Pei Zhang, Chen Huang, Yining Guo, Xuhe Dong & Xuemin Li Conjunctival sac bacterial culture of patients using levofloxacin eye drops before cataract surgery: a real-world, retrospective study BMC Ophthalmology volume 22, Article number: 328 (2022) 87. Joanne g Bolinao.Prophylactic intracameral levofloxacin in cataract surgery – an evaluation of safetyClinical Ophthalmology 2017:11 2199–2204 88. Nelise de Paiva Lucena, Indira Maria de Sousa Pereira, Maria Isabel Lynch Gaete,Kaline Sandrelli Alves Ferreira, Mathias Violante Mélega, Rodrigo Pessoa Cavalcanti Lira.Intracameral moxifloxacin after cataract surgery: a prospective study. Arq Bras Oftalmol. 2018 Apr;81(2):92-94. doi: 10.5935/0004-2749.20180022 89. Arshinoff S. J Cataract Refract Surg. 2016;doi:10.1016/j.jcrs.2016.10.017. 90. Chang DF. Routine IC antibiotic prophylaxis for cataract surgery. Presented at: Hawaiian Eye 2018; Jan. 13-19, 2018; Wailea, Hawaii. 91. Bowen RC, et al. Br J Ophthalmol. 2018; doi:10.1136/bjophthalmol-2017-311051. 92. Lynne S. Sandmeyer , Bianca S. Bauer, MSc, Seyed Mohammad Mohaghegh Poor, Cindy Xin Feng, and Manuel Chirino-Trejo. Alterations in conjunctival bacteria and antimicrobial susceptibility during topical administration of ofloxacin after cataract surgery in dogs DOI: https://doi.org/10.2460/ajvr.78.2.207 Volume/Issue: Volume 78: Issue 2 93. Ai Kato, Nobuyuki Horita, Ho Namkoong, Eiichi Nomura, Nami Masuhara, Takeshi Kaneko, Nobuhisa Mizuki & Masaki Takeuchi .Prophylactic antibiotics for postcataract surgery endophthalmitis: a systematic review and network meta-analysis of 6.8 million eyes. Scientific Reports volume 12, Article number: 17416 (2022) 94. W Zhang, H Han, K Feng, X Wang, M Du, X Meng, Y Liu, B Huang, R Brant, H

Yan Is It Necessary to Use Tobramycin-Dexamethasone Eye Ointment Prophylactically in Eyes at the End of Intraocular Surgery?.BMC Ophthalmol 2020 May 27;20(1)208 95. Josep Tuñí-Picado, Ana Martínez-Palmer,corresponding author Xènia FernándezSala, Jaime Barceló-Vidal, Miguel Castilla-Martí, Yasmin CartagenaGuardado.Infectious postoperative endophthalmitis after cataract surgery performed over 7 years. The role of azithromycin versus ciprofloxacin eye drops. Rev Esp Quimioter. 2018 Dec; 31(6): 499–505. 96. Swati Vijay Zawar, Sanjay Mahadik Corneal deposit after topical ciprofloxacin as postoperative medication after cataract surgery. Canadian Journal of Ophthalmology. Volume 49, Issue 4, August 2014, Pages 392-394 97. Kemal Örnek, Nesrin Büyüktortop, Nurgül Örnek, Reyhan Oğurel, İnci Elif Erbahçeci, and Zafer Onaran Effect of 1% brinzolamide and 0.5% timolol fixed combination on intraocular pressure after cataract surgery with phacoemulsification. Int J Ophthalmol. 2013; 6(6): 851–854.. doi: 10.3980/j.issn.2222-3959.2013.06.19 98. Constantine D Georgakopoulos, Konstantinos Kagkelaris,Brinzolamide– brimonidine fixed combination for the prevention of intraocular pressure elevation after phacoemulsification. European Journal of Ophthalmology.Volume 30, Issue 2.https://doi.org/10.1177/1120672118817997 99. Hayashi K, et al. Brinzolamide may be most effective for IOP reduction after cataract surgeryAm J Ophthalmol. 2019;doi:10.1016/j.ajo.2019.03.012. 100. Perera ME, Ramos LM, García FL, Jing SJ, Hernández RH, Hernández SJR. Dorzolamide for the treatment of cystoid macular edema after cataract surgery. Revista Cubana de Oftalmología 2018; 31 (1) .ISSN 1561-3070 101. Matusow, Rachel Brodman. Perioperative Administration of Topical Dorzolamide Hydrochloride/Timolol Maleate Reduces Postoperative Ocular Hypertension in Dogs Undergoing Cataract Surgery. http://hdl.handle.net/10919/73382 102. Makki, A. A. ., Joma, A. K. ., Alnuaimy, A. I. ., & Alwan, E. H. . (2023). Dorzolamide Hydrochloride %2 and Timolol Maleate %0.5 Fixed Combination in Lowering Intraocular Pressure after Phacoemulsification cataract Surgery. AMJ (Advanced Medical Journal) Is the Scientific Journal of Kurdistan Higher Council of Medical Specialties, 3(1), 1-5. https://doi.org/10.56056/amj.2017.16 103. Yan Wen, Xiaocheng Zhang, Maosheng Chen, Dengmei Han Sodium hyaluronate in the treatment of dry eye after cataract surgery: a meta-analysis. Vol 9, No 3 (May 29, 2020): Annals of Palliative Medicine 104. Batkov E.N., Pashtaev N.P. Tactical approaches to surgical treatment of lens subluxation. Ophthalmosurgery 2018; (3): 80-7. 105. Potemkin V.V., Ageeva E.V. Zonular instability in patients with pseudoexfoliation syndrome: analysis of 1000 consecutive phacoemulsifications. Issue: Volume 11, No. 1 (2018), pp.41-46 DOI: https://doi.org/10.17816/OV11141-46 . 106. Pirogova E.S., Fabrikantov O.L., Nikolashin S.I., Kurbatova V.A. Determination of the correct size of capsulorhexis in lens subluxation for optimal fixation of the capsular bag: 2020, volume 16 Number: No.1 Pages: 253-258

de Silva SR, Riaz Y, Evans JR. Phacoemulsification with posterior chamber intraocular lens versus extracapsular cataract extraction (ECCE) with posterior chamber intraocular lens for age-related cataract. Cochrane Database Syst Rev. 2014:CD008812. 108. Riaz Y, Mehta JS, Wormald R, et al. Surgical interventions for age-related cataract. Cochrane Database Syst Rev 2006, Issue 4. Art. No.: CD001323. DOI: 10.1002/14651858.CD001323.pub2. 109. To KG, Meuleners L, Bulsara M, et al. A longitudinal cohort study of the impact of first- and both-eye cataract surgery on falls and other injuries in Vietnam. Clin Interv Aging. 2014;9:743-751. 110. Hill W, Li W, Koch DD. IOL power calculation in eyes that have undergone LASIK/PRK/RK. Version 4.7. American Society of Cataract and Refractive Surgery. Available at: http://iolcalc.ascrs.org/. 111. Harris JK, Mizuiri D, Ambrus A, Lum FC., Garratt S. Cataract in the Adult Eye Preferred Practice Pattern 2016. https://www.aao.org/preferred-practice-pattern/cataractin-adult-eye-ppp-2016 112. Zetterström C, Behndig A, Kugelberg M, et al. Changes in intraocular pressure after cataract surgery: Analysis of the Swedish National Cataract Register Data. J Cataract Refract Surg. 2015;41:1725-1729. 113. Budenz DL, Gedde SJ. New options for combined cataract and glaucoma surgery. Curr Opin Ophthalmol. 2014;25:141-147. 114. Turalba A, Payal AR, Gonzalez-Gonzalez LA, et al. Cataract surgery outcomes in glaucomatous eyes: Results from the Veterans Affairs Ophthalmic Surgery Outcomes Data Project. Am J Ophthalmol. 2015;160:693-701. 115. Zhang ML, Hirunyachote P, Jampel H. Combined surgery versus cataract surgery alone for eyes with cataract and glaucoma. Cochrane Database of Sys Rev 2015, Issue 7. Art. No.: CD008671. DOI: 10.1002/14651858.CD008671.pub3. 116. Lavia C, Dallorto L, Maule M, et al. Minimally-invasive glaucoma surgeries (MIGS) for open angle glaucoma: A systematic review and meta-analysis. PLoS One. 2017;12:e0183142. 117. Toth M, Shah A, Hu K, et al. Endoscopic cyclophotocoagulation (ECP) for open angle glaucoma and primary angle closure. Cochrane Database Syst Rev. 2019;2:CD012741. 118. Pfeiffer N, Garcia-Feijoo J, Martinez-de-la-Casa JM, et al. A randomized trial of a Schlemm's canal microstent with phacoemulsification for reducing intraocular pressure in open-angle glaucoma. Ophthalmology. 2015;122:1283-1293. 119. Clement CI, Howes F, Ioannidis AS, et al. One-year outcomes following implantation of second-generation trabecular micro-bypass stents in conjunction with cataract surgery for various types of glaucoma or ocular hypertension: multicenter, multisurgeon study. Clin Ophthalmol. 2019;13:491-499. 120. Le JT, Bicket AK, Wang L, Li T. Ab interno trabecular bypass surgery with iStent for open-angle glaucoma. Cochrane Database Syst Rev. 2019;3:CD012743. 121. Gedde SJ, Vinod K, Wright MM, et al. Primary open-angle glaucoma Preferred Practice Pattern. Ophthalmology. 2020;128:71-150.

Yusef Yu.N., Yusef S.N., Vvedensky A.S., Ivanov M.N., Alkharki L.

Phacosurgery in disorders of the ligamentous-capsular apparatus of the lens. Vestnik Oftalmologii. 2023;139(3-2):21-27.

Shekhawat NS, Stock MV, Baze EF, et al. Impact of first eye versus second eye cataract surgery on visual function and quality of life. Ophthalmology. 2017;124:14961503. 124. Schlenker MB, Thiruchelvam D, Redelmeier DA. Association of cataract surgery with traffic crashes. JAMA Ophthalmol. 2018;136:998-1007. 125. Essue BM, Li Q, Hackett ML, et al. A multicenter prospective cohort study of quality of life and economic outcomes after cataract surgery in Vietnam: The VISIONARY study. Ophthalmology. 2014;121:2138-2146. 126. Javed U, McVeigh K, Scott NW, Azuara-Blanco A. Cataract extraction and patient vision-related quality of life: A cohort study. Eye (Lond). 2015;29:921-925. 127. Ao M, Li X, Qiu W, et al. The impact of age-related cataracts on colour perception, postoperative recovery and related spectra derived from test of hue perception. BMC Ophthalmol. 2019;19:56. 128. Order of the Minister of Health of the Republic of Kazakhstan dated March 24, 2022 No. QR-DSM-27. Registered with the Ministry of Justice of the Republic of Kazakhstan on March 25, 2022 No. 27218. On approval of the Standard for the provision of medical care in inpatient settings in the Republic of Kazakhstan. 129. Borkar DS, Lains I, Eton EA, et al. Incidence of management changes at the postoperative week 1 visit after cataract surgery: Results from the perioperative care for IntraOcular Lens Study. Am J Ophthalmol. 2019;199:94-100. 130. Perez-Vives C. Biomaterial influence on intraocular lens performance: An overview. J Ophthalmol. 2018;2018:2687385. 131. Li Y, Wang J, Chen Z, Tang X. Effect of hydrophobic acrylic versus hydrophilic acrylic intraocular lens on posterior capsule opacification: Meta-analysis. PLoS One. 2013;8:e77864. 132. Ursell PG, Dhariwal M, O'Boyle D, et al. 5 year incidence of YAG capsulotomy and PCO after cataract surgery with single-piece monofocal intraocular lenses: a realworld evidence study of 20,763 eyes. Eye (Lond). 2020;34:960-968. 133. Kossack N, Schindler C, Weinhold I, et al. German claims data analysis to assess impact of different intraocular lenses on posterior capsule opacification and related healthcare costs. Z Gesundh Wiss. 2018;26:81-90. 134. Cullin F, Busch T, Lundstrom M. Economic considerations related to choice of intraocular lens (IOL) and posterior capsule opacification frequency - a comparison of three different IOLs. Acta Ophthalmol. 2014;92:179-183. 135. Thom H, Ender F, Samavedam S, et al. Effect of AcrySof versus other intraocular lens properties on the risk of Nd:YAG capsulotomy after cataract surgery: A systematic literature review and network meta-analysis. PLoS One. 2019;14:e0220498. 136. Rønbeck M, Kugelberg M. Posterior capsule opacification with 3 intraocular lenses: 12-year prospective study. J Cataract Refract Surg. 2014;40:70-76.

Praveen MR, Shah GD, Vasavada AR, Dave KH. The effect of single-piece hydrophobic acrylic intraocular lenses on the development of posterior capsule opacification. Am J Ophthalmol. 2015;160:470-478. 138. 1268. Elzarrug H, Miller KM, Farzad S, Grusha YO. Effect of anterior capsule polishing on the need for laser capsulotomy. Open Journal of Ophthalmology. 2017;7:319-331. 139. Kanclerz P, Wang X. Postoperative capsular bag distension syndrome - Risk factors and treatment. Semin Ophthalmol. 2019;34:409-419. 140. Wesolosky JD, Tennant M, Rudnisky CJ. Rate of retinal tear and detachment after neodymium:YAG capsulotomy. J Cataract Refract Surg. 2017;43:923-928. 141. Vinod K, Gedde SJ, Feuer WJ, et al. Practice preferences for glaucoma surgery: A survey of the American Glaucoma Society. J Glaucoma. 2017;26:687-693.

Appendix 1 Main types of IOLs:

Monofocal - designed to provide the best vision at one focal distance (either distance or near);

Monofocal toric - designed to provide the best vision at one focal distance (either distance or near) with the additional function of maximum astigmatism correction;

Multifocal - diffractive-refractive lenses having multiple nodal focal points for optimal vision at various distances;

Multifocal toric - diffractive-refractive lenses having multiple nodal focal points for optimal vision at various distances with the additional function of maximum astigmatism correction;

With EDOF technology - lenses with extended (prolonged) depth of focus, providing continuous perception and smooth transition from near to far focus;

With EDOF toric technology - lenses with extended (prolonged) depth of focus, providing continuous perception and smooth transition from near to far focus with the additional function of maximum astigmatism correction.

All modern methods for calculating IOL power are based on formulas that include a number of parameters and constants. The main formulas for lens calculation are: Barrett Universal II, Haigis, Hoffer, Holladay 1, Holladay 2, SRK/T, Olsen, which, in most cases, are already built into optical biometers, A-scans, as well as diagnostic modules designed for planning navigational surgery. The choice of formula is determined by the treating physician, depending on biometric parameters (axial length of the eye, anterior chamber depth), on the structural features of the cornea (keratometry, presence or absence of scarring, dystrophic changes, as well as previously performed keratorefractive surgeries). For other types of cataracts in adults, consideration of existing clinical features is possible. [18-32,110,111]

Appendix 2 Diagnostic algorithm for selecting the type of IOL and calculating IOL optical power in senile cataract. Algorithm for selecting an IOL for implantation taking into account all examination parameters, lifestyle, requirements and preferences of the patient.

Additional information necessary for selecting an IOL in cataract:

Surgeons should consider the lifestyle and expectations of each individual patient so that the most appropriate IOL can be selected. Patient selection and preoperative discussion are especially important when recommending multifocal/EDOF and toric IOLs.

For the most accurate calculation of IOL optical power in patients after previously performed keratorefractive surgery for myopia or hypermetropia, it is necessary to use special formulas (for example, Shammas-PL formula, Barrett True K), as well as the ASCRS-developed online calculator for IOL optical power.

It is mandatory to warn the patient after previously performed KRS that refractive results after cataract removal surgery are more difficult to predict, and that additional surgery may be required, including LVC, if the patient does not plan to use glasses for distance vision correction.

The surgeon may make adjustments to the IOL calculation in the fellow eye, guided by data obtained from analysis of the achieved refractive result of surgery on the first eye.

All modern methods for calculating IOL power are based on formulas that include a number of parameters and constants. The main formulas for lens calculation are: Barrett Universal II, Haigis, Hoffer, Holladay 1, Holladay 2, SRK/T, Olsen, which, in most cases, are already built into optical biometers, A-scans, as well as diagnostic modules designed for planning navigational surgery. The choice of formula is determined by the treating physician, depending on biometric parameters (axial length of the eye, anterior chamber depth), on the structural features of the cornea (presence of scarring, dystrophic, degenerative changes), as well as in the presence of a history of previously performed keratorefractive surgeries.

Modern formulas for calculating intraocular lenses Formula Variables in addition to Notes

keratometry and axial

length

Barrett Anterior chamber Uses theoretical ray tracing

Universal II depth formula with data-based

Lens thickness improvement.

White-to-white Eye model correlates axial length and keratometry with anterior chamber depth

Includes location of the principal refractive plane of the IOL

Haigis Anterior chamber Uses dual regression analysis

depth to optimize three variables

Hill-RBF Anterior chamber Uses artificial intelligence for

depth pattern recognition and data

Lens thickness interpolation.

White-to-white

Hoffer Q None Optimization of equation constant (individual anterior chamber depth) Holladay 1 None Optimizes surgeon factor to determine anterior chamber depth Holladay 2 Anterior chamber depth

Lens thickness

Age

White-to-white

Postoperative refraction Kane Anterior chamber depth

Gender

Lens thickness

Central corneal thickness Olsen Anterior chamber depth

Lens thickness SRK/T None

Adds additional variables to Holladay 1. Updated using a nonlinear regression model.

Based on theoretical optics, incorporating regression components and artificial intelligence.

Uses ray tracing and thick lens calculations to obtain constant C. Combines theoretical optics with regression analysis. Formula T2 uses regression analysis to update SRK/T.

Appendix 3 Additional information affecting the course and outcome of both the disease itself and surgical intervention. It is recommended to postpone operations in patients in the post-infarction state for at least 3 months after acute cardiac event, with a cardiologist's clearance for surgery. Medications used to alter blood rheological properties in cataract surgery are applied according to the cardiologist's instructions. - Cataract surgery after acute cerebrovascular accident is recommended no earlier than 3 months after obtaining permission from a neurologist. In some cases, a reduction in postoperative functional outcome is possible due to damage to the central part of the visual analyzer. - In patients after cardiac pacemaker implantation, it is recommended to exclude all types of diathermy and radiofrequency coagulation, including Klöti radiofrequency capsulorhexis, to prevent complications from the cardiovascular system. Opening of the anterior lens capsule should be performed manually using forceps technique. If necessary to stop capillary bleeding, a non-contact YAG laser method, medication, or thermal exposure with a metal instrument heated on an alcohol lamp flame is possible.

Recommendations for organizing the treatment process for cataract: When planning cataract surgery, it is mandatory to provide patients with cataract and their family members or guardians with both oral and written information in an accessible format about:

• what the entire process involves and how long it takes;
• possible risks and complications;
• what support may be needed after surgery;
• probable rehabilitation time;
• probable long-term outcomes, including the possibility that glasses may be needed to perform some tasks;
• how vision impairment from cataract without surgical intervention may affect quality of life, how a person's quality of life may be affected if they decide not to have cataract removal surgery;
• significantly increased risk of complications with delayed cataract surgery when it becomes denser;
• whether one or both eyes are affected;
• what types of IOLs exist;
• types of anesthesia;
• individual risk of complications during or after surgery (for example, risk of postoperative retinal detachment in people with high myopia);
• what to do and what to expect on the day of cataract removal surgery;
• what to do and what to expect after cataract removal surgery;
• postoperative medications (eye drops) and other drugs and their regimen;
• refractive consequences after previous refractive surgery;
• about the possibility and indications for bilateral simultaneous cataract removal surgery, if necessary.

Appendix 4 Tactics for prescribing anti-inflammatory therapy in the pre- and postoperative periods after cataract removal: NSAIDs in the preoperative period should be prescribed to the following patients: Diabetes mellitus; History of systemic or autoimmune diseases; History of macular edema (wet AMD, CSC, or CME in the fellow eye); Previously experienced uveitis. Prescription of NSAIDs is recommended in the postoperative period for the following group of patients with complicated cataract course: - High myopia, hyperopia (in the presence of shallow AC – less than 2.5 mm); - Mature, hypermature, intumescent, post-traumatic cataract - Zonular weakness and lens subluxation - Retinal detachment - Silicone in the vitreous cavity, aphakia, operated retinal detachment.

Prescription of NSAIDs is necessary in the postoperative period: - Diabetes mellitus; - TASS syndrome; - Postoperative uveitis; - CME; - Reactive ocular hypertension (discontinuation of dexamethasone, switch to NSAIDs). Duration of NSAID use is from 14 to 30–45 days, depending on the degree of clinical manifestations.

Prescription of systemic corticosteroids: As indicated, systemic corticosteroids may be prescribed both in the pre- and postoperative periods for patients at increased risk (history of uveitis, certain comorbidities, for example, rheumatoid arthritis, Bechterew's disease, and similar). Duration and doses of systemic corticosteroid use are determined individually.

Appendix 5 Combination of Cataract and Glaucoma: In cases of combination of cataract with glaucoma [112-122]: 1) In POAG and PACG of initial or developed stages with compensated IOP on the background of hypotensive drugs, cataract surgery with IOL implantation without combination with AGS is recommended. In these clinical situations, cataract surgery with IOL implantation may contribute to moderate reduction of IOP after surgery. 2) In cases of POAG and PACG in developed and advanced stages and uncompensated IOP on the background of hypotensive therapy, simultaneous combined cataract and glaucoma surgery (phaco + IOL + AGS) is recommended. 3) In cases of POAG and PACG in developed and advanced stages and compensated IOP on the background of hypotensive therapy, but ophthalmotonus remains above target pressure, simultaneous combined cataract and glaucoma surgery (phaco + IOL + AGS) is recommended. 4) In complicated forms of cataract in combination with secondary glaucoma with compensated IOP on the background of hypotensive drugs, cataract surgery with IOL implantation without combination with AGS is recommended. In the absence of ophthalmotonus compensation, simultaneous combined cataract and glaucoma surgery (phaco + IOL + AGS) is recommended. The algorithm for choosing surgical tactics for cataract in combination with glaucoma is presented in the figure. However, it should be noted that in each case of combined pathology, it is necessary to approach the choice of treatment tactics individually.

Cataract in combination with glaucoma Primary glaucoma Secondary glaucoma

ACG OAG

IOP compensated

to target pressure on

background of hypotensive therapy

IOP on max. regimen

not compensated

I-II

III stage stage

AGS+ phaco

phaco

IOP not compensated

IOP reduction (hypotensive, dehydration

therapy)

IOP decreased IOP not decreased

AGS+phaco

Appendix 6 Recommendations for performing standard phacoemulsification through microaccess with posterior chamber IOL implantation [123-128]: Creation of an incision of appropriate size, which is sufficient for IOL implantation and achieving a stable anterior chamber. The location, size and shape of the incision may depend on several factors, including the patient's orbital anatomy, the type of IOL being implanted, the role of the incision in treating astigmatism, as well as the surgeon's preferences and experience. Use of OVD to protect the corneal endothelium, manipulate tissues and maintain adequate working space during surgery. Creation of capsulorhexis, which can be performed manually, with a femtosecond laser or radiofrequency device. Hydrodissection to separate the cortex-nucleus complex of the lens. Nuclear phacofragmentation using standard techniques such as "divide and conquer," "phaco-chop," "stop-chop," etc., and/or femtosecond laser fragmentation. Thorough removal of remaining epinucleus, cortical layers, polishing of anterior and posterior capsule when necessary. Intracapsular implantation of posterior chamber IOL. Removal of OVD to minimize postoperative IOP elevation. Wound sealing by various methods (stromal hydration or sutures). There is high-level evidence of substantial effectiveness in reducing the frequency of postoperative endophthalmitis development (by 57 times) through intraoperative intracameral administration of antibacterial drug solution immediately upon completion of phacoemulsification or through perioperative use of antibacterial drug solution in irrigation solution during phacoemulsification surgery. IOL implantation during removal of opacified lens is the most physiological method of cataract treatment with simultaneous restoration of visual functions, in the absence of contraindications. However, in some clinical situations, cataract removal without IOL implantation or with the possibility of delayed IOL implantation as a second stage is indicated according to indications and in the absence of contraindications.

Appendix 7 Recommendations for performing phacoemulsification in eyes with cataract complicated by zonular weakness, lens dislocation, narrow rigid pupil [116, 123, 129]:

• In cases of lens subluxation grade I-III, implantation of polymeric capsular tension rings is recommended; intracapsular rings are widely used for defects of the lens zonular apparatus. However, it should be noted that with modern technologies, in patients with minor lens subluxation, phacoemulsification can be successfully performed without insertion of an intracapsular ring. Use of an intracapsular ring in combination with retractors stabilizes the position of the capsular bag, ensures smoothing of posterior capsule folds, restores the circular contour of the capsular bag, to some extent prevents vitreous prolapse, and helps prevent decentration of the capsular bag with the IOL implanted in it during the postoperative period. Intracapsular ring implantation is performed either immediately after capsulorhexis or at subsequent stages of surgical intervention when the need arises for stabilization, centration, and smoothing of the capsular bag.

• For phacoemulsification with inadequate mydriasis, narrow and rigid pupil, the use of polymeric iris retractors or pupil dilators is recommended for mechanical pupil expansion;

• In the absence of capsular support for IOL in zonular pathology and/or disruption of the integrity of the anterior and/or posterior lens capsule, including during surgery, extracapsular IOL implantation with different fixation methods is recommended. The surgeon should have reserve IOLs available for such situations. Options include anterior chamber IOLs or posterior chamber IOLs that can be positioned with or without active fixation in the ciliary sulcus. Suturing of the haptic of a posterior chamber IOL to the iris or sclera may be necessary in the absence of capsular support. Each type of fixation has its specific risks.

• For IOL fixation in the ciliary sulcus: Optimal characteristics of a posterior chamber IOL should have sufficient overall optical diameter and haptic length, posterior haptic angulation, and absence of sharp anterior optical or haptic edges. IOL power should be reduced by 0.5–1.0 D compared to calculated. Since extracapsular fixation increases the likelihood of IOL tilt and decentration, the surgeon should reconsider whether to implant multifocal or toric IOLs. Additionally, monobloc acrylic IOLs are not recommended for fixation in the ciliary sulcus due to associated risks such as IOL decentration and dislocation and friction of the iris pigment epithelium, which can cause refractive failure, transillumination defects, pigment dispersion, elevated IOP, recurrent hyphema, and inflammation.

• Suture fixation of one or both haptic elements of the IOL to the iris is possible in the absence of adequate capsular support, in conditions of posterior capsule rupture, insufficient fixation in the ciliary sulcus, for secondary implantation in an aphakic eye, for repositioning of a dislocated IOL. Possible risks and complications: incorrect anatomical positioning, suture breakage or knot failure, recurrent IOL dislocation, dyscoria, ocular hypertension, cystoid macular edema, development of epiretinal membrane, and postoperative inflammation.

• Scleral IOL fixation methods - intrascleral and transscleral - include: scleral access ab externo or ab interno fixation of the posterior chamber IOL haptic into scleral pockets, or transsclerally externalized haptic ends can be fixed using a formed flange, as well as fixed to the sclera with non-absorbable sutures. Possible complications include: haptic deformation and breakage, IOL decentration and dislocation, intraocular hemorrhage, glaucoma, cystoid macular edema, conjunctival erosions over the haptic attachment site, endophthalmitis, and retinal detachment.

• Use of anterior chamber IOL depends on appropriate design, size, and positioning of the IOL. Iris and pupil deformation, corneal endothelial cell loss, and visual discomfort may result from an IOL that is too long, whereas rotation and mobility in the anterior chamber of an IOL that is too short can cause chronic inflammation, cystoid macular edema, and also corneal endothelial damage. Measurement of corneal diameter white-to-white in the horizontal meridian is recommended for using an anterior chamber IOL of appropriate length if anterior chamber OCT is unavailable. The anterior chamber IOL should be oriented so that its haptic is directed away from the incision. Peripheral iridectomy should be performed to prevent pupillary block.

according to indications.

GCS for topical application Dexamethasone Instillations into the conjunctival cavity 1 drop 2-4 times for 2–4 weeks, duration is determined individually.

NSAIDs for topical application in ophthalmology Bromfenac Instillations into the conjunctival cavity 1 drop 2 times a day for 2-4 weeks, duration is determined individually.

M-cholinergic receptor blocker for topical application in ophthalmology (mydriatic) Tropicamide Instillations into the conjunctival cavity 1 drop 3-4 times, duration is determined individually.

Preparation for moisturizing and Sodium corneal protection hyaluronate Instillations into the conjunctival cavity 1 drop 6–8 times a day, frequency and duration of use are established individually.

List of additional medications (less than 100% probability of use): Instillations into the conjunctival sac 1 drop 6–8 times a day, 7 days.

In case of increased intraocular pressure, treatment is carried out according to the clinical protocol "Glaucoma".

2) Surgical intervention [27-80, 107–109]: Removal of the opacified lens with IOL implantation: • phacoemulsification of cataract with IOL implantation in standard cases; • femtolaser cataract extraction with IOL implantation in standard cases; • phacoemulsification of cataract with CTR and IOL implantation in grade I lens subluxation. • phacoemulsification of cataract with IOL implantation with extracapsular fixation in grade II–III lens subluxation; • extracapsular cataract extraction with IOL implantation in grade IV–V lens nucleus density; • intracapsular cataract extraction with anterior vitrectomy and IOL implantation with extracapsular fixation in grade III lens subluxation; • phacoemulsification of cataract/ECCE with IOL implantation and antiglaucoma surgery (trabeculectomy/non-penetrating deep sclerectomy) in the presence of cataract and glaucoma with uncompensated IOP. Indications: - decreased visual acuity; - clinically significant anisometropia associated with cataract; - lens opacities hindering diagnosis and/or treatment of posterior segment diseases; - angle-closure glaucoma with impairment or risk of impairment of ophthalmotonus (increased IOP), other conditions associated with cataract development (phacomorphic, phacolytic, phacoanaphylactic, phacotopic glaucoma); Contraindications: - level of corrected visual acuity in the affected eye corresponding to the patient's needs; - presence of concomitant psychosomatic pathology in the patient that does not guarantee safe performance of surgical intervention;

• absence of conditions for adequate postoperative patient care and provision of appropriate postoperative treatment. Intra- and postoperative complications of cataract surgery: ● endophthalmitis; ● iris sphincter damage at the pupil margin; ● posterior capsule rupture; ● iridodialysis; ● hemorrhagic suprachoroidal effusion; ● expulsive hemorrhage; ● lens fragment prolapse; ● Descemet's membrane rupture or detachment; ● corneal edema (bullous keratopathy); ● iritis. Secondary cataract. An effective surgical method for eliminating posterior capsule opacification, contributing to restoration of visual functions and improvement of contrast sensitivity, is YAG-laser capsulotomy (LDVK). YAG-laser capsulotomy (LDVK). The indication for this operation is the presence of posterior capsule opacification contributing to decreased visual acuity to a level not satisfying the patient's functional needs and/or worsening fundus visualization. Complications after LDVK: ● increased IOP; ● corneal erosion; ● iritis; ● IOL damage; ● vitreous destruction; ● IOL dislocation; ● vitreous prolapse into the anterior chamber; ● retinal detachment; ● cystoid macular edema. The main types of IOLs are presented in Appendix 1. The diagnostic algorithm for selecting the type [18-32,110,111] and calculating the optical power of IOL in cataract is described in Appendix 2. [18-32,110,111] Additional information affecting the course and outcome of both the disease itself and surgical intervention is set forth in Appendix 3. Tactics for prescribing anti-inflammatory therapy in the pre- and postoperative periods after senile cataract removal are provided in Appendix 4. The algorithm for choosing surgical tactics in senile cataract combined with glaucoma is considered in Appendix 5 [112-122]. Recommendations for performing standard phacoemulsification through microaccess with posterior chamber IOL implantation are displayed in Appendix 6 [123-128].

Recommendations for performing phacoemulsification on eyes with cataract complicated by

zonular weakness, lens dislocation, narrow rigid pupil are described in Appendix 7 [116, 123,129].

4) Further management [130]: In the early postoperative period, the established regimen of conservative treatment for each type of surgical procedure is performed. In the postoperative period are prescribed: antibacterial, anti-inflammatory, as well as other medications in volumes and with duration corresponding to the type of operation and features of the clinical picture in the postoperative period. In case of increased IOP, are prescribed