Cataract Surgery with Macular Degeneration: What to Expect and How Decisions Are Made

Age-related macular degeneration and cataract frequently coexist in older patients. Both conditions cause progressive vision loss and both are common after the age of 65. When a patient has both conditions, the decision to proceed with cataract surgery requires a careful discussion of what improvement can be realistically expected, which intraocular lens is most appropriate given the macular disease, and what effects the surgery itself may have on the macula. This post addresses each of these questions with reference to the published evidence.

Does cataract surgery benefit patients with macular degeneration?

The answer depends on the severity of the macular degeneration and which part of the retina is affected. Published evidence consistently shows that cataract surgery improves visual acuity in the majority of patients with coexisting AMD, but the magnitude of improvement varies by AMD subtype and severity.

A large retrospective cohort study published in Ophthalmology analysing outcomes in 435 eyes with AMD undergoing cataract surgery found that at 12 months postoperatively, visual acuity improved significantly in patients with intermediate AMD (mean improvement of 10.1 letters) and neovascular AMD (mean improvement of 9.7 letters), but not in patients with fovea-involving geographic atrophy where improvement was not statistically significant. The authors concluded that cataract surgery provides meaningful visual benefit in early and neovascular AMD but that realistic expectations must be set for patients with central GA (Seredyka-Burduk et al., J Clin Med. 2024;13(13):3832. doi: 10.3390/jcm13133832).

A randomised controlled trial published in PubMed evaluating cataract surgery in eyes with high-risk AMD fundi found a 2.8-line improvement in logMAR visual acuity and a 2.1-fold average gain in quality of life at six months in the operated group. The study found no increased short-term risk of progression to choroidal neovascularisation following uncomplicated phacoemulsification and concluded that there are distinct benefits of cataract surgery in people with early AMD (Baatz et al., PubMed 19702706).

A 2024 study published in a peer-reviewed journal analysing cataract surgery outcomes by AMD severity across 333 eyes found that 80 percent of patients showed improvement in best-corrected visual acuity after surgery, 14 percent remained stable, and 6 percent experienced a decline. The improvement was most consistent in early and intermediate AMD and less predictable in advanced disease.

Setting realistic expectations by AMD severity

The most important part of the pre-operative consultation for a patient with coexisting cataract and AMD is setting accurate expectations about the likely visual outcome. The visual result after cataract surgery is limited by the integrity of the macula. Removing the cataract improves the optical quality of the image reaching the retina, but the retina's ability to process that image depends on the health of the photoreceptors and retinal pigment epithelium.

Early AMD (drusen, early pigmentary changes): patients with early AMD and a visually significant cataract can expect meaningful improvement in vision after surgery. The cataract is likely contributing significantly to the vision loss. Postoperative vision may approach the pre-AMD baseline.

Intermediate AMD (larger drusen, pigmentary abnormalities): improvement is expected but is less predictable. The macular disease itself is contributing to vision loss alongside the cataract. Postoperative vision will be limited by the degree of macular dysfunction.

Neovascular AMD (wet AMD) on anti-VEGF treatment: patients with treated stable neovascular AMD can benefit from cataract surgery. Published evidence shows meaningful visual improvement in this group. The macular disease must be stable and well-controlled before cataract surgery is appropriate. Active neovascular AMD should be treated and stabilised before proceeding.

Geographic atrophy involving the fovea: this is the group in which cataract surgery provides the least benefit and expectations must be most conservative. If the fovea is already destroyed by atrophy, removing the cataract cannot restore central vision because the photoreceptors responsible for central vision are no longer functional. Surgery may still improve peripheral vision and contrast, and should be discussed individually.

New complement-inhibitor treatments for geographic atrophy are now available in Australia. See our clinical guide to new treatments for geographic atrophy, and the geographic atrophy treatment at Northern Eye Consultants page for information on pegcetacoplan and avacincaptad pegol.

IOL selection in patients with macular degeneration

The choice of intraocular lens in patients with AMD is one of the most important and frequently misunderstood aspects of surgical planning.

Diffractive trifocal and multifocal lenses are not appropriate for patients with significant macular degeneration. The fundamental reason is that diffractive lenses reduce contrast sensitivity by splitting incoming light across multiple focal points. Contrast sensitivity is already reduced in AMD, even in early disease before Snellen visual acuity is affected. Adding a diffractive lens to a macula with already impaired contrast processing compounds the problem. The result is that the patient may achieve adequate measured visual acuity but experience poor subjective visual quality, difficulty with low-contrast tasks, and significant halos and glare that the compromised macula cannot neuroadapt away.

The American Academy of Ophthalmology and published consensus guidelines are clear that diffractive multifocal and EDOF lenses are not recommended for patients with macular degeneration or other conditions affecting contrast sensitivity. This applies even to patients with early AMD where Snellen acuity appears relatively preserved. For a complete guide to IOL types and patient selection criteria, see our premium IOL guide Australia.

Monofocal lenses are the standard recommendation for patients with moderate to advanced AMD. A monofocal lens maximises optical efficiency by directing all light to a single focal point, producing the highest contrast image possible at that focal distance. For patients whose central vision is already compromised, optimising image quality at the available focal distance is more important than providing multiple focal distances at the cost of contrast. Most patients are targeted for distance correction with reading glasses for near tasks.

Toric monofocal lenses are appropriate in patients with AMD who also have significant astigmatism. Correcting astigmatism with a toric lens improves uncorrected distance vision without the contrast penalty of a diffractive design.

Non-diffractive EDOF lenses occupy an intermediate position. For patients with early mild AMD where macular function is relatively preserved, a non-diffractive EDOF lens such as the Clareon Vivity or TECNIS PureSee may be considered in carefully selected patients. These lenses extend the focal range without splitting light across discrete focal zones, preserving contrast sensitivity more effectively than diffractive designs. A 2023 study evaluating EDOF lenses in patients not suitable for multifocal lenses, which included those with mild nonprogressive maculopathy, found satisfactory outcomes in this group (Alvarez-Garcia et al., PMC10289873). However this remains a nuanced decision requiring individual assessment of macular function, patient expectations, and disease stability. For a detailed clinical analysis of EDOF lens platforms available in Australia, see our full range of vision IOL analysis.

The light-adjustable lens (LAL) is an emerging option that may be of particular relevance in AMD patients. The LAL allows the refractive power to be adjusted postoperatively using UV light treatments, enabling fine-tuning of the final refraction after the corneal wound has healed. Because refractive accuracy is particularly important in patients whose vision is already compromised by macular disease, the ability to optimise the refraction postoperatively may be advantageous. Experience with LAL in AMD patients is limited but the rationale is sound.

Does cataract surgery cause or accelerate AMD progression?

This is one of the most common questions from patients with AMD who are considering cataract surgery and one where the evidence has evolved considerably.

Earlier observational studies raised concerns that cataract surgery might accelerate AMD progression, particularly to neovascular disease, by removing the natural UV-filtering effect of the crystalline lens and exposing the macula to new wavelengths of light. These concerns were based partly on theoretical mechanisms and partly on epidemiological data that was difficult to interpret because AMD and cataract share the same risk factors and often progress together.

The current evidence does not support the conclusion that uncomplicated phacoemulsification accelerates AMD progression in a clinically meaningful way. A 2022 meta-analysis by Chen et al. examining eight studies found that while there was a relative risk signal for AMD progression after cataract surgery, the absolute risk was small and the relationship was confounded by the fact that patients with more severe AMD are more likely to progress regardless of surgery. A randomised controlled trial specifically designed to address this question found no increased short-term risk of progression to choroidal neovascularisation following uncomplicated phacoemulsification in high-risk AMD fundi.

A 2023 review published in Current Opinion in Ophthalmology by Bhandari and Chew concluded that the risk of AMD progression after cataract surgery is low, that surgery can be recommended for patients with visually significant cataract and AMD, and that the visual benefits of surgery generally outweigh the theoretical risks of progression in appropriately selected patients (Bhandari S, Chew EY. Curr Opin Ophthalmol. 2023;34(1):27-31. doi:10.1097/ICU.0000000000000909).

The phototoxicity question: operating microscope light and the AMD macula

A separate concern from AMD progression is the potential for operating microscope light to cause phototoxic damage to the macula during cataract surgery. This is a distinct issue from AMD progression caused by postoperative light exposure.

Retinal phototoxicity from the operating microscope is a recognised though rare complication of cataract surgery in general. It is caused by the high-intensity light from the operating microscope, particularly short-wavelength blue light, being focused on the fovea during the aphakic phase of the procedure when the natural crystalline lens and its UV-filtering properties are absent. The macula in AMD is already compromised and may be more vulnerable to phototoxic damage from the surgical microscope than a healthy macula.

Published management recommendations for reducing phototoxicity risk in AMD patients include using the minimum microscope light intensity necessary for safe surgery, reducing the light coaxiality during the aphakic phase of the procedure, using a UV-blocking occluder or the optic of the intraocular lens to protect the macula as soon as the lens is implanted, and minimising the duration of the aphakic period (Teh et al., Surv Ophthalmol. 2016;62:346-356, and management of cataract in AMD, PMC8228734).

Modern surgical microscopes increasingly incorporate blue-light filtering systems and lower-intensity illumination options specifically to address this concern. Shorter surgical times and efficient technique reduce the cumulative light exposure.

Timing of surgery in relation to anti-VEGF treatment

Patients with neovascular AMD on intravitreal anti-VEGF injections require specific consideration around the timing of cataract surgery relative to their injection schedule.

The published evidence and clinical consensus support the principle that cataract surgery should be performed when the neovascular AMD is well-controlled and stable, ideally during a period when anti-VEGF injections have recently been given and macular disease is quiescent. Surgery itself can occasionally trigger a transient inflammatory response that may affect macular stability in neovascular AMD.

A study published in the European Journal of Ophthalmology evaluating phacoemulsification in eyes with neovascular AMD treated with intravitreal anti-VEGF injections found that cataract surgery was safe and produced visual improvement without inducing a significant increase in anti-VEGF injection frequency or central macular thickness in most patients.

The practical implication is that cataract surgery can be coordinated with the patient's retinal specialist to time the procedure appropriately within the injection cycle. Post-operative monitoring of the macular status is important in the weeks following surgery in neovascular AMD patients.

Pre-operative assessment in patients with AMD

The pre-operative assessment for cataract surgery in AMD patients requires additional steps beyond the standard cataract workup.

Optical coherence tomography (OCT) of the macula should be performed before cataract surgery in all patients with known or suspected AMD. OCT identifies the presence and location of geographic atrophy, drusen burden, subretinal fluid, and choroidal neovascularisation. This information is essential for predicting the likely visual outcome, counselling the patient accurately, and identifying any active neovascular disease that should be treated before surgery.

In patients with neovascular AMD receiving anti-VEGF injections, recent OCT imaging should be available confirming stable disease before proceeding. Any evidence of active exudation should prompt a discussion with the retinal specialist before cataract surgery is scheduled.

Electrophysiological testing such as multifocal electroretinography can provide objective assessment of macular function in patients where the expected visual improvement from cataract surgery is uncertain. A macula that shows severely reduced function on mfERG is unlikely to recover significant vision after cataract surgery regardless of how well the cataract is removed.

Potential acuity testing using a laser interferometer can estimate the visual acuity that would be achievable if the cataract were removed. While not perfectly predictive, a poor potential acuity result in the context of severe macular disease suggests that the visual benefit of surgery will be limited.

Recommendations for optimising outcomes

Based on the published evidence and clinical principles, the following recommendations apply to cataract surgery in patients with AMD:

Stabilise active neovascular AMD before proceeding with cataract surgery. Active exudation increases the risk of postoperative macular destabilisation.

Use a monofocal lens in all patients with moderate to advanced AMD. Do not implant diffractive trifocal or multifocal lenses in eyes with significant macular disease. Non-diffractive EDOF lenses may be considered in carefully selected patients with early stable mild maculopathy.

Correct astigmatism with a toric lens where significant astigmatism is present. Maximising the optical quality of the image delivered to the compromised macula is important.

Target the final refraction carefully. In patients whose central vision is limited by AMD, achieving accurate refraction is particularly important because glasses correction and low vision aids are more likely to be needed postoperatively. Consider a light-adjustable lens where precise postoperative refraction optimisation is a priority.

Minimise operating microscope light exposure during the aphakic phase of the procedure. Use minimum necessary illumination intensity. Insert the intraocular lens promptly to restore UV protection to the macula.

Ensure pre-operative OCT confirms no active neovascular disease before surgery. A low threshold for pre-operative imaging is appropriate in patients with AMD, including those without a known neovascular history, as occult CNV is not uncommon.

Counsel patients specifically about the distinction between cataract-related vision loss and macular disease-related vision loss. Patients should understand that surgery will improve the optical quality of the image reaching the macula but cannot repair the macula itself.

Continue AREDS2 supplementation before and after surgery. There is no evidence that cataract surgery alters the benefit of AREDS2 supplementation for AMD.

GPs and optometrists referring patients with coexisting AMD and cataract can find referral information for optometrists on this site. For a general patient guide to cataract surgery in Melbourne including what to expect from the assessment and how to evaluate a surgeon, our companion overview may also be helpful.

Arranging an assessment

If you have been diagnosed with macular degeneration and have been told you also have a cataract, or if your vision has deteriorated and you are unsure how much is due to cataract versus macular disease, a combined assessment can clarify the contribution of each condition and guide the decision about timing and approach to surgery.

I consult at Northern Eye Consultants, Northpark Private Hospital, Bundoora, and at Bass Coast Eye Centre, Wonthaggi. A referral from your GP or optometrist is required. Referrals can be addressed to Dr Ross MacIntyre at either location.

Contact Northern Eye Consultants to arrange an appointment. For referral information for GPs and optometrists, visit the Northern Eye Consultants for-referrers page. Further information on cataract surgery Melbourne including a published five-year surgical outcomes audit is available at drmacintyre.com.

References

1. Seredyka-Burduk M, et al. Visual outcomes following cataract surgery in age-related macular degeneration patients. J Clin Med. 2024;13(13):3832. https://pubmed.ncbi.nlm.nih.gov/38999398/
2. Bhandari S, Chew EY. Cataract surgery and the risk of progression of macular degeneration. Curr Opin Ophthalmol. 2023;34(1):27-31. https://pubmed.ncbi.nlm.nih.gov/36165022/
3. Baatz H, et al. Cataract surgery in high-risk age-related macular degeneration: a randomized controlled trial. PubMed 19702706. https://pubmed.ncbi.nlm.nih.gov/19702706/
4. Teh BL, Megaw R, Borooah S, Dhillon B. Optimizing cataract surgery in patients with age-related macular degeneration. Surv Ophthalmol. 2016;62:346-356. https://pubmed.ncbi.nlm.nih.gov/27845093/
5. Management of Cataract in Patients with Age-Related Macular Degeneration. PMC8228734. https://pmc.ncbi.nlm.nih.gov/articles/PMC8228734/
6. Alvarez-Garcia M, et al. Clinical Outcomes with Extended Depth of Focus Intraocular Lenses in Cases in Which Multifocal Lenses Are Not Primarily Recommended. PMC10289873. https://pmc.ncbi.nlm.nih.gov/articles/PMC10289873/
7. American Academy of Ophthalmology. Factors to Consider in Choosing an IOL for Cataract Surgery. Updated March 2025. https://www.aao.org/eye-health/tips-prevention/best-artificial-lens-implant-iol-cataract-surgery
8. Cataract Surgery Implications for AMD. Retina Today. May-June 2024. https://retinatoday.com/articles/2024-may-june/cataract-surgery-implications-for-amd