The evolving role of the optometrist in nonsurgical cataract management
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The evolving role of the optometrist in nonsurgical cataract management

Optometry 360

By Carol Aune, OD, and Nevin W. El-Nimri, OD, PhD

The contents of this article are informational only and are not intended to be a substitute for professional medical advice, diagnosis, or treatment recommendations. This editorial presents the views and experiences of the author and does not reflect the opinions or recommendations of the publisher of Optometry 360.

This article is editorially independent content supported by Lexitas.

Understanding Cataract Formation

Cataracts are one of the leading causes of preventable vision impairment and blindness globally.1-3 Cataract formation is fundamentally a biochemical process characterized by progressive loss of lens transparency. The crystalline lens relies on structurally stable proteins—primarily α-, β-, and γ-crystallins—to maintain optical clarity. Over time, these proteins undergo oxidative damage, glycation, deamidation, and truncation, leading to misfolding and aggregation. The resulting protein clumping disrupts the ordered architecture of the lens, increasing light scatter and reducing visual performance. This is a natural consequence of aging due to the lack of protein turnover in the crystalline lens, and the cumulative effects result in modifications to crystallin structure and function.4

However, the onset and rate of progression vary across individuals. Importantly, clinical management is driven by functional visual impairment rather than the presence of lens opacity alone. As a result, cataract development represents a natural consequence of aging, especially after 60 years. In the United States, approximately two-thirds of people ≥80 years are affected.5,6

Causes and Risk Factors

Although aging remains the primary driver of cataract formation, several additional risk factors contribute to disease onset and progression:7

  • Medical conditions and treatments: Diabetes and corticosteroid use are strongly associated with cataract development.
  • Lifestyle factors: Smoking, alcohol use, and chronic ultraviolet exposure contribute to oxidative stress within the lens.
  • Ocular history: Trauma and prior intraocular surgery can accelerate opacification.
  • Environmental exposure: Radiation exposure has also been associated with increased cataract risk.

Understanding these risk factors allows optometrists to identify at-risk patients earlier and tailor monitoring strategies accordingly.

Ethnic Variations in Cataract Presentation

Cataract prevalence and subtype distribution vary across populations, emphasizing the importance of personalized care and inclusive clinical research. Observational data suggest that White populations more commonly present with nuclear cataracts, African Americans have a higher prevalence of cortical cataracts, Asian populations show increased incidence of cortical cataracts, often with earlier onset and higher overall prevalence, and Hispanics show a greater association between cataract and diabetes.8 These findings are based on observational data and may reflect differences in underlying risk factors, comorbidities, and access to care.

Cataract Surgery: Effective But Not Without Limitations

Currently, cataract surgery remains the only proven and effective treatment. It is also among the most commonly performed surgical procedures worldwide and is widely regarded as safe and effective.

However, surgery does not fully address all patient needs. Barriers include:9

  • Limited access to surgical care in rural or underserved regions
  • Financial constraints for uninsured or underinsured patients
  • Medical contraindications to surgery
  • Patient hesitation or fear of complications
  • A desire to preserve the natural lens for as long as possible

While complication rates are relatively low, risks such as infection, intraocular pressure spikes, posterior capsular opacification, and retinal detachment persist.10

Importantly, untreated cataracts can significantly impair quality of life. Even mild visual dysfunction is associated with reduced independence, increased fall risk, decreased productivity, and worsening mental health.11 Emerging evidence also suggests a link between visual impairment and cognitive decline in older adults, particularly in settings such as nursing homes.12

The Current Role of the Optometrist

Optometrists are central to cataract care but have historically been limited to monitoring and referral to ophthalmologists for treatment. Currently, key responsibilities include monitoring progression, optimizing refractive correction, evaluating functional vision (including glare and contrast sensitivity), and determining referral timing based on quality-of-life impacts.

While visual acuity thresholds (eg, 20/40) were once commonly used to guide referral decisions, modern practice emphasizes functional impairment. Patients are often referred when symptoms—such as difficulty driving at night or intolerance to glare—interfere with daily activities.

Importantly, cataracts affect more than acuity alone. Decreased contrast sensitivity and altered color perception contribute significantly to patient-reported visual disability.13

In addition to diagnosis and referral, optometrists play a vital role in perioperative care, including postoperative management and, in some settings, providing clinical input on intraocular lens technologies and selection considerations.

Emerging Topical Therapies: A Paradigm Shift

For decades, the lack of nonsurgical treatment options has defined cataract care. This may evolve with ongoing research, though. Several pharmacologic therapies are in development, with a limited number having progressed to human clinical trials:

  • C-KAD (Livionex)
  • ZOC2017217 (Ocusun)

These investigational agents aim to address the underlying pathophysiology of cataracts by reducing protein aggregation and restoring lens transparency. Experimental work with chelation agents like C-KAD or lanosterol and related compounds (like ZOC2017217) has demonstrated the ability to partially reverse crystallin aggregation in preclinical models.14,15

If successful, these therapies could:

  • Slow or potentially reverse early cataract formation
  • Improve functional vision prior to advanced disease
  • Provide alternatives for patients who cannot undergo surgery
  • Reduce barriers related to cost and access

Expanding the Role of the OD

The introduction of effective topical therapies would represent a major shift in optometric practice. Once these therapies are approved and clinically validated, optometrists could become active therapeutic managers rather than primarily monitoring disease progression.

This expanded role would include:

  • Identifying candidates for early treatment
  • Prescribing and managing pharmacologic therapies (where permitted)
  • Monitoring treatment response using functional vision metrics
  • Integrating medical and surgical care pathways

Importantly, these therapies would not replace cataract surgery but rather complement it—extending the continuum of care and enabling earlier intervention.

Conclusions

Cataract management is on the verge of transformation. While surgery will remain the standard for advanced disease, emerging nonsurgical therapies offer the potential to intervene earlier and more effectively.

For optometrists, this evolution represents a significant opportunity. By combining early detection, functional assessment, and potential pharmacologic intervention, ODs could play a more proactive role in preserving vision and improving patient quality of life.

Carol Aune, OD, is President and Principal Investigator at Oculus Research, with over 15 years of clinical optometry experience and leadership of more than 60 clinical trials in ocular disease. A published author, frequent presenter, and Lexitas Advisory Board Member, she can be reached at carol.aune@oculusresearch.com.

Nevin W. El‑Nimri, OD, PhD, FAAO, is the Senior Director of Clinical and Medical Affairs at Lexitas and an accomplished clinician-scientist with expertise in ocular disease, advanced imaging technologies, and leading ophthalmology clinical trials. She can be reached at nevin.nimri@lexitas.com.

References

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  2. Keel S, Cieza A. Rising to the challenge: estimates of the magnitude and causes of vision impairment and blindness. Lancet Glob Health. 2021;9(2):e100-e101. doi:10.1016/S2214-109X(21)00008-5
  3. Flaxman SR, Bourne RRA, Resnikoff S, et al; Vision Loss Expert Group of the Global Burden of Disease Study. Global causes of blindness and distance vision impairment 1990-2020: a systematic review and meta-analysis. Lancet Glob Health. 2017;5(12):e1221-e1234. doi:10.1016/S2214-109X(17)30393-5
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  7. National Eye Institute. Last updated November 26, 2025. July 6, 2026. https://www.nei.nih.gov/eye-health-information/eye-conditions-and-diseases/cataracts
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  14. Kuboi T, Chuck RS, Pineda R 2nd, Bhushan R, Goswamy A, Olson RJ. Subgroup analysis from a phase 1/2 randomized clinical trial of 2.6% EDTA ophthalmic solution in patients with age-related cataract. Am J Ophthalmol. 2024;268:155-164. doi:10.1016/j.ajo.2024.07.038
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