Customized Clinical Practice Guidelines for Management of Adult Cataract in Iran
Identifieur interne : 000448 ( Pmc/Curation ); précédent : 000447; suivant : 000449Customized Clinical Practice Guidelines for Management of Adult Cataract in Iran
Auteurs : Zhaleh Rajavi ; Mohammad Ali Javadi ; Narsis Daftarian ; Sare Safi ; Farhad Nejat ; Armin Shirvani ; Hamid Ahmadieh ; Saeid Shahraz ; Hossein Ziaei ; Hamidreza Moein ; Behzad Fallahi Motlagh ; Sepehr Feizi ; Alireza Foroutan ; Hassan Hashemi ; Seyed Javad Hashemian ; Mahmoud Jabbarvand ; Mohammad Reza Jafarinasab ; Farid Karimian ; Hossein Mohammad-Rabei ; Mehrdad Mohammadpour ; Nader Nassiri ; Mahmoodreza Panahi-Bazaz ; Mohammad Reza Rohani ; Mohammad Reza Sedaghat ; Kourosh SheibaniSource :
- Journal of Ophthalmic & Vision Research [ 2008-2010 ] ; 2015.
Abstract
To customize clinical practice guidelines (CPGs) for cataract management in the Iranian population.
First, four CPGs (American Academy of
The agreed recommendations were accepted as conclusive while those with no agreement were discussed at the consensus session. Finally, all customized recommendations were codified as 80 recommendations along with their sources and levels of evidence for the Iranian population.
Customization of CPGs for management of adult cataract for the Iranian population seems to be useful for standardization of referral, diagnosis and treatment of patients.
Url:
DOI: 10.4103/2008-322X.176913
PubMed: 27051491
PubMed Central: 4795396
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Customized Clinical Practice Guidelines for Management of Adult Cataract in Iran</title>
<author><name sortKey="Rajavi, Zhaleh" sort="Rajavi, Zhaleh" uniqKey="Rajavi Z" first="Zhaleh" last="Rajavi">Zhaleh Rajavi</name>
<affiliation><nlm:aff id="aff1"><italic>Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Javadi, Mohammad Ali" sort="Javadi, Mohammad Ali" uniqKey="Javadi M" first="Mohammad Ali" last="Javadi">Mohammad Ali Javadi</name>
<affiliation><nlm:aff id="aff1"><italic>Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Daftarian, Narsis" sort="Daftarian, Narsis" uniqKey="Daftarian N" first="Narsis" last="Daftarian">Narsis Daftarian</name>
<affiliation><nlm:aff id="aff1"><italic>Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Safi, Sare" sort="Safi, Sare" uniqKey="Safi S" first="Sare" last="Safi">Sare Safi</name>
<affiliation><nlm:aff id="aff1"><italic>Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Nejat, Farhad" sort="Nejat, Farhad" uniqKey="Nejat F" first="Farhad" last="Nejat">Farhad Nejat</name>
<affiliation><nlm:aff id="aff1"><italic>Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Shirvani, Armin" sort="Shirvani, Armin" uniqKey="Shirvani A" first="Armin" last="Shirvani">Armin Shirvani</name>
<affiliation><nlm:aff id="aff2"><italic>Office for Healthcare Standards, Deputy of Curative Affairs, Ministry of Health and Medical Education, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
<affiliation><nlm:aff id="aff3"><italic>Department of Medical Education, Faculty of Medical Education, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Ahmadieh, Hamid" sort="Ahmadieh, Hamid" uniqKey="Ahmadieh H" first="Hamid" last="Ahmadieh">Hamid Ahmadieh</name>
<affiliation><nlm:aff id="aff1"><italic>Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Shahraz, Saeid" sort="Shahraz, Saeid" uniqKey="Shahraz S" first="Saeid" last="Shahraz">Saeid Shahraz</name>
<affiliation><nlm:aff id="aff4"><italic>Tufts Medical Center, Boston, Massachusetts, USA</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Ziaei, Hossein" sort="Ziaei, Hossein" uniqKey="Ziaei H" first="Hossein" last="Ziaei">Hossein Ziaei</name>
<affiliation><nlm:aff id="aff1"><italic>Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Moein, Hamidreza" sort="Moein, Hamidreza" uniqKey="Moein H" first="Hamidreza" last="Moein">Hamidreza Moein</name>
<affiliation><nlm:aff id="aff1"><italic>Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Motlagh, Behzad Fallahi" sort="Motlagh, Behzad Fallahi" uniqKey="Motlagh B" first="Behzad Fallahi" last="Motlagh">Behzad Fallahi Motlagh</name>
<affiliation><nlm:aff id="aff5"><italic>Department of Ophthalmology, Tabriz University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Feizi, Sepehr" sort="Feizi, Sepehr" uniqKey="Feizi S" first="Sepehr" last="Feizi">Sepehr Feizi</name>
<affiliation><nlm:aff id="aff6"><italic>Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Foroutan, Alireza" sort="Foroutan, Alireza" uniqKey="Foroutan A" first="Alireza" last="Foroutan">Alireza Foroutan</name>
<affiliation><nlm:aff id="aff7"><italic>Department of Ophthalmology, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Hashemi, Hassan" sort="Hashemi, Hassan" uniqKey="Hashemi H" first="Hassan" last="Hashemi">Hassan Hashemi</name>
<affiliation><nlm:aff id="aff8"><italic>Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Hashemian, Seyed Javad" sort="Hashemian, Seyed Javad" uniqKey="Hashemian S" first="Seyed Javad" last="Hashemian">Seyed Javad Hashemian</name>
<affiliation><nlm:aff id="aff7"><italic>Department of Ophthalmology, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Jabbarvand, Mahmoud" sort="Jabbarvand, Mahmoud" uniqKey="Jabbarvand M" first="Mahmoud" last="Jabbarvand">Mahmoud Jabbarvand</name>
<affiliation><nlm:aff id="aff8"><italic>Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Jafarinasab, Mohammad Reza" sort="Jafarinasab, Mohammad Reza" uniqKey="Jafarinasab M" first="Mohammad Reza" last="Jafarinasab">Mohammad Reza Jafarinasab</name>
<affiliation><nlm:aff id="aff6"><italic>Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Karimian, Farid" sort="Karimian, Farid" uniqKey="Karimian F" first="Farid" last="Karimian">Farid Karimian</name>
<affiliation><nlm:aff id="aff6"><italic>Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Mohammad Rabei, Hossein" sort="Mohammad Rabei, Hossein" uniqKey="Mohammad Rabei H" first="Hossein" last="Mohammad-Rabei">Hossein Mohammad-Rabei</name>
<affiliation><nlm:aff id="aff9"><italic>Department of Ophthalmology, Imam Hussein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Mohammadpour, Mehrdad" sort="Mohammadpour, Mehrdad" uniqKey="Mohammadpour M" first="Mehrdad" last="Mohammadpour">Mehrdad Mohammadpour</name>
<affiliation><nlm:aff id="aff8"><italic>Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Nassiri, Nader" sort="Nassiri, Nader" uniqKey="Nassiri N" first="Nader" last="Nassiri">Nader Nassiri</name>
<affiliation><nlm:aff id="aff9"><italic>Department of Ophthalmology, Imam Hussein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Panahi Bazaz, Mahmoodreza" sort="Panahi Bazaz, Mahmoodreza" uniqKey="Panahi Bazaz M" first="Mahmoodreza" last="Panahi-Bazaz">Mahmoodreza Panahi-Bazaz</name>
<affiliation><nlm:aff id="aff10"><italic>Department of Ophthalmology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Rohani, Mohammad Reza" sort="Rohani, Mohammad Reza" uniqKey="Rohani M" first="Mohammad Reza" last="Rohani">Mohammad Reza Rohani</name>
<affiliation><nlm:aff id="aff11"><italic>Department of Ophthalmology, Al-Zahra Eye Center, Zahedan University of Medical Sciences, Zahedan, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Sedaghat, Mohammad Reza" sort="Sedaghat, Mohammad Reza" uniqKey="Sedaghat M" first="Mohammad Reza" last="Sedaghat">Mohammad Reza Sedaghat</name>
<affiliation><nlm:aff id="aff12"><italic>Department of Ophthalmology, Mashhad University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Sheibani, Kourosh" sort="Sheibani, Kourosh" uniqKey="Sheibani K" first="Kourosh" last="Sheibani">Kourosh Sheibani</name>
<affiliation><nlm:aff id="aff13"><italic>Basir Eye Safety Research Center, Basir Eye Clinic, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
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<sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Customized Clinical Practice Guidelines for Management of Adult Cataract in Iran</title>
<author><name sortKey="Rajavi, Zhaleh" sort="Rajavi, Zhaleh" uniqKey="Rajavi Z" first="Zhaleh" last="Rajavi">Zhaleh Rajavi</name>
<affiliation><nlm:aff id="aff1"><italic>Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Javadi, Mohammad Ali" sort="Javadi, Mohammad Ali" uniqKey="Javadi M" first="Mohammad Ali" last="Javadi">Mohammad Ali Javadi</name>
<affiliation><nlm:aff id="aff1"><italic>Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Daftarian, Narsis" sort="Daftarian, Narsis" uniqKey="Daftarian N" first="Narsis" last="Daftarian">Narsis Daftarian</name>
<affiliation><nlm:aff id="aff1"><italic>Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Safi, Sare" sort="Safi, Sare" uniqKey="Safi S" first="Sare" last="Safi">Sare Safi</name>
<affiliation><nlm:aff id="aff1"><italic>Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Nejat, Farhad" sort="Nejat, Farhad" uniqKey="Nejat F" first="Farhad" last="Nejat">Farhad Nejat</name>
<affiliation><nlm:aff id="aff1"><italic>Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Shirvani, Armin" sort="Shirvani, Armin" uniqKey="Shirvani A" first="Armin" last="Shirvani">Armin Shirvani</name>
<affiliation><nlm:aff id="aff2"><italic>Office for Healthcare Standards, Deputy of Curative Affairs, Ministry of Health and Medical Education, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
<affiliation><nlm:aff id="aff3"><italic>Department of Medical Education, Faculty of Medical Education, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Ahmadieh, Hamid" sort="Ahmadieh, Hamid" uniqKey="Ahmadieh H" first="Hamid" last="Ahmadieh">Hamid Ahmadieh</name>
<affiliation><nlm:aff id="aff1"><italic>Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Shahraz, Saeid" sort="Shahraz, Saeid" uniqKey="Shahraz S" first="Saeid" last="Shahraz">Saeid Shahraz</name>
<affiliation><nlm:aff id="aff4"><italic>Tufts Medical Center, Boston, Massachusetts, USA</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Ziaei, Hossein" sort="Ziaei, Hossein" uniqKey="Ziaei H" first="Hossein" last="Ziaei">Hossein Ziaei</name>
<affiliation><nlm:aff id="aff1"><italic>Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Moein, Hamidreza" sort="Moein, Hamidreza" uniqKey="Moein H" first="Hamidreza" last="Moein">Hamidreza Moein</name>
<affiliation><nlm:aff id="aff1"><italic>Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Motlagh, Behzad Fallahi" sort="Motlagh, Behzad Fallahi" uniqKey="Motlagh B" first="Behzad Fallahi" last="Motlagh">Behzad Fallahi Motlagh</name>
<affiliation><nlm:aff id="aff5"><italic>Department of Ophthalmology, Tabriz University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Feizi, Sepehr" sort="Feizi, Sepehr" uniqKey="Feizi S" first="Sepehr" last="Feizi">Sepehr Feizi</name>
<affiliation><nlm:aff id="aff6"><italic>Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Foroutan, Alireza" sort="Foroutan, Alireza" uniqKey="Foroutan A" first="Alireza" last="Foroutan">Alireza Foroutan</name>
<affiliation><nlm:aff id="aff7"><italic>Department of Ophthalmology, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Hashemi, Hassan" sort="Hashemi, Hassan" uniqKey="Hashemi H" first="Hassan" last="Hashemi">Hassan Hashemi</name>
<affiliation><nlm:aff id="aff8"><italic>Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Hashemian, Seyed Javad" sort="Hashemian, Seyed Javad" uniqKey="Hashemian S" first="Seyed Javad" last="Hashemian">Seyed Javad Hashemian</name>
<affiliation><nlm:aff id="aff7"><italic>Department of Ophthalmology, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Jabbarvand, Mahmoud" sort="Jabbarvand, Mahmoud" uniqKey="Jabbarvand M" first="Mahmoud" last="Jabbarvand">Mahmoud Jabbarvand</name>
<affiliation><nlm:aff id="aff8"><italic>Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Jafarinasab, Mohammad Reza" sort="Jafarinasab, Mohammad Reza" uniqKey="Jafarinasab M" first="Mohammad Reza" last="Jafarinasab">Mohammad Reza Jafarinasab</name>
<affiliation><nlm:aff id="aff6"><italic>Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Karimian, Farid" sort="Karimian, Farid" uniqKey="Karimian F" first="Farid" last="Karimian">Farid Karimian</name>
<affiliation><nlm:aff id="aff6"><italic>Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Mohammad Rabei, Hossein" sort="Mohammad Rabei, Hossein" uniqKey="Mohammad Rabei H" first="Hossein" last="Mohammad-Rabei">Hossein Mohammad-Rabei</name>
<affiliation><nlm:aff id="aff9"><italic>Department of Ophthalmology, Imam Hussein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Mohammadpour, Mehrdad" sort="Mohammadpour, Mehrdad" uniqKey="Mohammadpour M" first="Mehrdad" last="Mohammadpour">Mehrdad Mohammadpour</name>
<affiliation><nlm:aff id="aff8"><italic>Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Nassiri, Nader" sort="Nassiri, Nader" uniqKey="Nassiri N" first="Nader" last="Nassiri">Nader Nassiri</name>
<affiliation><nlm:aff id="aff9"><italic>Department of Ophthalmology, Imam Hussein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Panahi Bazaz, Mahmoodreza" sort="Panahi Bazaz, Mahmoodreza" uniqKey="Panahi Bazaz M" first="Mahmoodreza" last="Panahi-Bazaz">Mahmoodreza Panahi-Bazaz</name>
<affiliation><nlm:aff id="aff10"><italic>Department of Ophthalmology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Rohani, Mohammad Reza" sort="Rohani, Mohammad Reza" uniqKey="Rohani M" first="Mohammad Reza" last="Rohani">Mohammad Reza Rohani</name>
<affiliation><nlm:aff id="aff11"><italic>Department of Ophthalmology, Al-Zahra Eye Center, Zahedan University of Medical Sciences, Zahedan, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Sedaghat, Mohammad Reza" sort="Sedaghat, Mohammad Reza" uniqKey="Sedaghat M" first="Mohammad Reza" last="Sedaghat">Mohammad Reza Sedaghat</name>
<affiliation><nlm:aff id="aff12"><italic>Department of Ophthalmology, Mashhad University of Medical Sciences, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Sheibani, Kourosh" sort="Sheibani, Kourosh" uniqKey="Sheibani K" first="Kourosh" last="Sheibani">Kourosh Sheibani</name>
<affiliation><nlm:aff id="aff13"><italic>Basir Eye Safety Research Center, Basir Eye Clinic, Tehran, Iran</italic>
</nlm:aff>
</affiliation>
</author>
</analytic>
<series><title level="j">Journal of Ophthalmic & Vision Research</title>
<idno type="ISSN">2008-2010</idno>
<idno type="eISSN">2008-322X</idno>
<imprint><date when="2015">2015</date>
</imprint>
</series>
</biblStruct>
</sourceDesc>
</fileDesc>
<profileDesc><textClass></textClass>
</profileDesc>
</teiHeader>
<front><div type="abstract" xml:lang="en"><sec id="st1"><title>Purpose:</title>
<p>To customize clinical practice guidelines (CPGs) for cataract management in the Iranian population.</p>
</sec>
<sec id="st2"><title>Methods:</title>
<p>First, four CPGs (American Academy of <italic>Ophthalmology</italic>
2006 and 2011, Royal College of Ophthalmologists 2010, and Canadian Ophthalmological Society 2008) were selected from a number of available CPGs in the literature for cataract management. All recommendations of these guidelines, together with their references, were studied. Each recommendation was summarized in 4 tables. The first table showed the recommendation itself in clinical question components format along with its level of evidence. The second table contained structured abstracts of supporting articles related to the clinical question with their levels of evidence. The third table included the customized recommendation of the internal group respecting its clinical advantage, cost, and complications. In the fourth table, the internal group their recommendations from 1 to 9 based on the customizing capability of the recommendation (applicability, acceptability, external validity). Finally, customized recommendations were sent one month prior to a consensus session to faculty members of all universities across the country asking for their comments on recommendations.</p>
</sec>
<sec id="st3"><title>Results:</title>
<p>The agreed recommendations were accepted as conclusive while those with no agreement were discussed at the consensus session. Finally, all customized recommendations were codified as 80 recommendations along with their sources and levels of evidence for the Iranian population.</p>
</sec>
<sec id="st4"><title>Conclusion:</title>
<p>Customization of CPGs for management of adult cataract for the Iranian population seems to be useful for standardization of referral, diagnosis and treatment of patients.</p>
</sec>
</div>
</front>
<back><div1 type="bibliography"><listBibl><biblStruct></biblStruct>
<biblStruct></biblStruct>
<biblStruct><analytic><author><name sortKey="Resnikoff, S" uniqKey="Resnikoff S">S Resnikoff</name>
</author>
<author><name sortKey="Pascolini, D" uniqKey="Pascolini D">D Pascolini</name>
</author>
<author><name sortKey="Etya Ale, D" uniqKey="Etya Ale D">D Etya'ale</name>
</author>
<author><name sortKey="Kocur, I" uniqKey="Kocur I">I Kocur</name>
</author>
<author><name sortKey="Pararajasegaram, R" uniqKey="Pararajasegaram R">R Pararajasegaram</name>
</author>
<author><name sortKey="Pokharel, Gp" uniqKey="Pokharel G">GP Pokharel</name>
</author>
</analytic>
</biblStruct>
<biblStruct><analytic><author><name sortKey="Hashemi, H" uniqKey="Hashemi H">H Hashemi</name>
</author>
<author><name sortKey="Hatef, E" uniqKey="Hatef E">E Hatef</name>
</author>
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<biblStruct><analytic><author><name sortKey="Javadi, Ma" uniqKey="Javadi M">MA Javadi</name>
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<author><name sortKey="Rezaie, A" uniqKey="Rezaie A">A Rezaie</name>
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<journal-id journal-id-type="iso-abbrev">J Ophthalmic Vis Res</journal-id>
<journal-id journal-id-type="publisher-id">JOVR</journal-id>
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<issn pub-type="ppub">2008-2010</issn>
<issn pub-type="epub">2008-322X</issn>
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<article-id pub-id-type="pmc">4795396</article-id>
<article-id pub-id-type="publisher-id">JOVR-10-445</article-id>
<article-id pub-id-type="doi">10.4103/2008-322X.176913</article-id>
<article-categories><subj-group subj-group-type="heading"><subject>Clinical Practice Guidelines</subject>
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<given-names>Hamidreza</given-names>
</name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="aff1">1</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Motlagh</surname>
<given-names>Behzad Fallahi</given-names>
</name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="aff5">5</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Feizi</surname>
<given-names>Sepehr</given-names>
</name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="aff6">6</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Foroutan</surname>
<given-names>Alireza</given-names>
</name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="aff7">7</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Hashemi</surname>
<given-names>Hassan</given-names>
</name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="aff8">8</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Hashemian</surname>
<given-names>Seyed Javad</given-names>
</name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="aff7">7</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Jabbarvand</surname>
<given-names>Mahmoud</given-names>
</name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="aff8">8</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Jafarinasab</surname>
<given-names>Mohammad Reza</given-names>
</name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="aff6">6</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Karimian</surname>
<given-names>Farid</given-names>
</name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="aff6">6</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Mohammad-Rabei</surname>
<given-names>Hossein</given-names>
</name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="aff9">9</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Mohammadpour</surname>
<given-names>Mehrdad</given-names>
</name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="aff8">8</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Nassiri</surname>
<given-names>Nader</given-names>
</name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="aff9">9</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Panahi-Bazaz</surname>
<given-names>Mahmoodreza</given-names>
</name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="aff10">10</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Rohani</surname>
<given-names>Mohammad Reza</given-names>
</name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="aff11">11</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Sedaghat</surname>
<given-names>Mohammad Reza</given-names>
</name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="aff12">12</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Sheibani</surname>
<given-names>Kourosh</given-names>
</name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="aff13">13</xref>
</contrib>
</contrib-group>
<aff id="aff1"><label>1</label>
<italic>Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</aff>
<aff id="aff2"><label>2</label>
<italic>Office for Healthcare Standards, Deputy of Curative Affairs, Ministry of Health and Medical Education, Tehran, Iran</italic>
</aff>
<aff id="aff3"><label>3</label>
<italic>Department of Medical Education, Faculty of Medical Education, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</aff>
<aff id="aff4"><label>4</label>
<italic>Tufts Medical Center, Boston, Massachusetts, USA</italic>
</aff>
<aff id="aff5"><label>5</label>
<italic>Department of Ophthalmology, Tabriz University of Medical Sciences, Tehran, Iran</italic>
</aff>
<aff id="aff6"><label>6</label>
<italic>Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</aff>
<aff id="aff7"><label>7</label>
<italic>Department of Ophthalmology, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran</italic>
</aff>
<aff id="aff8"><label>8</label>
<italic>Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran</italic>
</aff>
<aff id="aff9"><label>9</label>
<italic>Department of Ophthalmology, Imam Hussein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran</italic>
</aff>
<aff id="aff10"><label>10</label>
<italic>Department of Ophthalmology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran</italic>
</aff>
<aff id="aff11"><label>11</label>
<italic>Department of Ophthalmology, Al-Zahra Eye Center, Zahedan University of Medical Sciences, Zahedan, Iran</italic>
</aff>
<aff id="aff12"><label>12</label>
<italic>Department of Ophthalmology, Mashhad University of Medical Sciences, Tehran, Iran</italic>
</aff>
<aff id="aff13"><label>13</label>
<italic>Basir Eye Safety Research Center, Basir Eye Clinic, Tehran, Iran</italic>
</aff>
<author-notes><corresp id="cor1"><bold>Correspondence to:</bold>
Mohammad Ali Javadi, MD. Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, No. 23, Paidarfard St., Boostan 9 St., Pasdaran Ave., Tehran 16666, Iran. E-mail: <email xlink:href="ma_javadi@yahoo.com">ma_javadi@yahoo.com</email>
</corresp>
<corresp id="cor2">Sare Safi, MS. Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, No. 23, Paidarfard St., Boostan 9 St., Pasdaran Ave., Tehran 16666, Iran. E-mail: <email xlink:href="sare.safi@yahoo.com">sare.safi@yahoo.com</email>
</corresp>
</author-notes>
<pub-date pub-type="ppub"><season>Oct-Dec</season>
<year>2015</year>
</pub-date>
<volume>10</volume>
<issue>4</issue>
<fpage>445</fpage>
<lpage>460</lpage>
<history><date date-type="received"><day>10</day>
<month>8</month>
<year>2015</year>
</date>
<date date-type="accepted"><day>12</day>
<month>9</month>
<year>2015</year>
</date>
</history>
<permissions><copyright-statement>Copyright: © Journal of Ophthalmic and Vision Research</copyright-statement>
<copyright-year>2015</copyright-year>
<license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-sa/3.0"><license-p>This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.</license-p>
</license>
</permissions>
<abstract><sec id="st1"><title>Purpose:</title>
<p>To customize clinical practice guidelines (CPGs) for cataract management in the Iranian population.</p>
</sec>
<sec id="st2"><title>Methods:</title>
<p>First, four CPGs (American Academy of <italic>Ophthalmology</italic>
2006 and 2011, Royal College of Ophthalmologists 2010, and Canadian Ophthalmological Society 2008) were selected from a number of available CPGs in the literature for cataract management. All recommendations of these guidelines, together with their references, were studied. Each recommendation was summarized in 4 tables. The first table showed the recommendation itself in clinical question components format along with its level of evidence. The second table contained structured abstracts of supporting articles related to the clinical question with their levels of evidence. The third table included the customized recommendation of the internal group respecting its clinical advantage, cost, and complications. In the fourth table, the internal group their recommendations from 1 to 9 based on the customizing capability of the recommendation (applicability, acceptability, external validity). Finally, customized recommendations were sent one month prior to a consensus session to faculty members of all universities across the country asking for their comments on recommendations.</p>
</sec>
<sec id="st3"><title>Results:</title>
<p>The agreed recommendations were accepted as conclusive while those with no agreement were discussed at the consensus session. Finally, all customized recommendations were codified as 80 recommendations along with their sources and levels of evidence for the Iranian population.</p>
</sec>
<sec id="st4"><title>Conclusion:</title>
<p>Customization of CPGs for management of adult cataract for the Iranian population seems to be useful for standardization of referral, diagnosis and treatment of patients.</p>
</sec>
</abstract>
<kwd-group><kwd>Adult</kwd>
<kwd>Cataract</kwd>
<kwd>Iran</kwd>
<kwd>Practice Guideline</kwd>
</kwd-group>
</article-meta>
</front>
<body><sec sec-type="intro" id="sec1-1"><title>INTRODUCTION</title>
<p>Cataract is the progressive deterioration of optical qualities of the crystalline lens.[<xref rid="ref1" ref-type="bibr">1</xref>
<xref rid="ref2" ref-type="bibr">2</xref>
] The most common form is age-related cataract which affects a high percentage of people over the age of 50 years.[<xref rid="ref2" ref-type="bibr">2</xref>
] Cataract has been reported to be the cause of 47.8% of all cases of blindness worldwide and are a serious health issue particularly in developing countries.[<xref rid="ref3" ref-type="bibr">3</xref>
] In Iran, cataract is are highly prevalent, and based on two studies performed on Tehran citizens over 40 years, a prevalence of 12% to 19.1% has been reported.[<xref rid="ref4" ref-type="bibr">4</xref>
<xref rid="ref5" ref-type="bibr">5</xref>
] Another study from Varamin district has reported cataract as the cause of blindness in 31.7% of cases and severe visual acuity impairment in 47.5% of cases.[<xref rid="ref6" ref-type="bibr">6</xref>
] Currently, the only option for visual rehabilitation in human subjects with cataract is surgical removal of the lens,[<xref rid="ref7" ref-type="bibr">7</xref>
] which is one of the most successful surgical treatments.[<xref rid="ref2" ref-type="bibr">2</xref>
] This surgery has vastly changed during the past 20 years,[<xref rid="ref8" ref-type="bibr">8</xref>
] and with advances in microscopic surgery and intraocular lens (IOL) manufacturing, the quality of vision after surgery has dramatically improved, leading to more cases of surgical treatment being performed.[<xref rid="ref9" ref-type="bibr">9</xref>
]</p>
<p>National clinical practice guidelines (CPGs) include clinical recommendations based on systematically verified evidence. These guidelines are developed to evaluate the effectiveness, safety, and efficiency of inventions considering domestic factors and justly distributed health care. These guidelines have an impact on decision-making by both clinicians and health care authorities.[<xref rid="ref10" ref-type="bibr">10</xref>
<xref rid="ref11" ref-type="bibr">11</xref>
]</p>
<p>The present guideline for management of cataract in adult patients has been customized in order to comply with guidelines of the Fifth National Development Program of the Islamic Republic of Iran, particularly section D of the 32<sup>nd</sup>
amendment calling for customizing national CPGs for the healthcare system and providing fair access to continuous and qualified health care as one of the main goals of the health care system. We also stressed adhering to the 75<sup>th</sup>
strategic goal of the Iranian Ministry of Health and Medical Education regarding use of national medical guidelines and establishment of evidence-based practices. This guideline was customized in the Ophthalmic Knowledge Management Unit (KMU) at Shahid Beheshti University of Medical Sciences in 2011 to fulfill requirements by the Iranian Ministry of Health and Medical Education.[<xref rid="ref12" ref-type="bibr">12</xref>
<xref rid="ref13" ref-type="bibr">13</xref>
]</p>
<p>Iranian cataract management guidelines contain 80 clinical recommendations with the aim of standardizing and customizing different aspects of cataract management in adults including etiology, progression, indication for intervention, diagnosis, treatment, and pre-and post-surgical care.</p>
</sec>
<sec sec-type="methods" id="sec1-2"><title>METHODS</title>
<p>A group including general ophthalmologists as well as cornea, vitreoretinal and strabismus subspecialists, masters of optometry and biostatistics, expert searcher, head of the Office for healthcare standards, Deputy of Curative Affairs, Iran Ministry of Health and Medical Education representative participated in this effort.</p>
<sec id="sec2-1"><title>Search for Related Guidelines and Screen Extracted Guidelines</title>
<p>First, medical data resources including National Guideline Clearinghouse, Guidelines International Network, National Institute for Clinical Excellence, Scottish Intercollegiate Guidelines Network, National Health and Medical Research Council, and New Zealand Guidelines Group were searched to find national guidelines related to our subject. All guidelines were evaluated based on their quality characteristics such as structural soundness, availability of the full guideline, and being up-to-date. In the next step, guidelines which fulfilled all of the above-mentioned requirements were scored by using AGREE instrument. This evaluation instrument included 23 questions covering different aspects of the guideline, and the guidelines were given a score of 0 to 100. Finally, based on their scores, the guidelines from the American Academy of Ophthalmology (2006 and 2011),[<xref rid="ref2" ref-type="bibr">2</xref>
<xref rid="ref14" ref-type="bibr">14</xref>
] the Royal College of Ophthalmologists,[<xref rid="ref9" ref-type="bibr">9</xref>
] and the Canadian Ophthalmological Society[<xref rid="ref1" ref-type="bibr">1</xref>
] with total scores of 85, 81, 80, and 75, respectively, were selected as reference guidelines.</p>
</sec>
<sec id="sec2-2"><title>The Process of Evaluating the Selected Clinical Guidelines</title>
<p>We first designed the questions based on the selected CPGs, then categorized them according to their precedence in the treatment process of cataract [<xref ref-type="table" rid="T1">Table 1</xref>
].</p>
<table-wrap id="T1" position="float"><label>Table 1</label>
<caption><p>Algorithm of the clinical practice guidelines</p>
</caption>
<graphic xlink:href="JOVR-10-445-g001"></graphic>
</table-wrap>
<sec id="sec3-1"><title>Evaluating the content of referenced guidelines</title>
<p>The recommendations of the selected guidelines which have addressed each question were included in <xref ref-type="table" rid="T2">Table 2</xref>
. Those recommendations which had similar populations or interventions were placed in the same table. To fill this table, we first recorded four parts of questions which included the patient population or the disease (P), intervention or exposure (I), comparison (C), and finally, outcome (O), and then entered the main related recommendation. We also entered technical breakthroughs if suggested by reliable scientific organizations or countries as new recommendations.</p>
<table-wrap id="T2" position="float"><label>Table 2</label>
<caption><p>Analysis of recommendation</p>
</caption>
<graphic xlink:href="JOVR-10-445-g002"></graphic>
</table-wrap>
<p>Organizing the recommendations in tables helped us recognize different aspects of the final guideline. This method also optimized the search for related evidence.</p>
</sec>
<sec id="sec3-2"><title>Analysis of the evidence supporting each recommendation</title>
<p>Abstracts of all supporting evidence for each recommendation were extracted. We also searched the Coherence Library, Trip Database (Evidence-based synopses), Bandolier, and PubMed (Clinical queries section) databases from 2007 to 2012 for the clinical questions related to each suggested recommendation. These databases are known as reliable sources for information with highest levels of evidence based on systematic review, meta-analysis, and clinical trial studies. All these abstracts were criticised by our team, and their related details were entered in <xref ref-type="table" rid="T3">Table 3</xref>
. If there was any ambiguity in the abstract, the full text was studied.</p>
<table-wrap id="T3" position="float"><label>Table 3</label>
<caption><p>Analysis of evidences</p>
</caption>
<graphic xlink:href="JOVR-10-445-g003"></graphic>
</table-wrap>
<p>The level of evidences have been determined based on Tables <xref ref-type="table" rid="T4">4</xref>
and <xref ref-type="table" rid="T5">5</xref>
. If there was more than one recommendation for a clinical question and those recommendations did not have the same level of evidence, the recommendation with a higher level of evidence was selected.</p>
<table-wrap id="T4" position="float"><label>Table 4</label>
<caption><p>Level of evidence</p>
</caption>
<graphic xlink:href="JOVR-10-445-g004"></graphic>
</table-wrap>
<table-wrap id="T5" position="float"><label>Table 5</label>
<caption><p>Level of evidence according to the type of study</p>
</caption>
<graphic xlink:href="JOVR-10-445-g005"></graphic>
</table-wrap>
</sec>
<sec id="sec3-3"><title>Analysis of the clinical advantage of recommendations</title>
<p>After completing the supporting evidence and choosing the recommendation with the highest level of evidence, the related recommendation was entered in <xref ref-type="table" rid="T6">Table 6</xref>
. Next, the internal group evaluated the recommendation in terms of its benefits, side effects, and treatment cost.</p>
<table-wrap id="T6" position="float"><label>Table 6</label>
<caption><p>Clinical advantages of recommendations</p>
</caption>
<graphic xlink:href="JOVR-10-445-g006"></graphic>
</table-wrap>
<p>The benefit of an intervention is different from its outcome. It includes the ability to manage the treatment at lower levels of the health care system, at specialty and subspecialty levels, decrease admission rate and duration, decreased the need for surgical treatment, increase patient satisfaction, allow faster recovery, reduce the need for post-treatment visits, and minimize patient pain and suffering.</p>
<p>We also categorized side effects based on their nature and severity as well as the effectiveness based on the supporting evidences.</p>
<p>Finally, our team, as an internal reviewer, gave low, moderate, or high scores to the clinical advantages of each recommendation.</p>
</sec>
<sec id="sec3-4"><title>Customizing the recommendations</title>
<p>Customization of each recommendation was evaluated in <xref ref-type="table" rid="T7">Table 7</xref>
. In this table, the applicability, external validity, and acceptability of each recommendation was determined, and each recommendation was given a score of low,[<xref rid="ref1" ref-type="bibr">1</xref>
<xref rid="ref2" ref-type="bibr">2</xref>
<xref rid="ref3" ref-type="bibr">3</xref>
] moderate,[<xref rid="ref4" ref-type="bibr">4</xref>
<xref rid="ref5" ref-type="bibr">5</xref>
<xref rid="ref6" ref-type="bibr">6</xref>
] or high.[<xref rid="ref7" ref-type="bibr">7</xref>
<xref rid="ref8" ref-type="bibr">8</xref>
<xref rid="ref9" ref-type="bibr">9</xref>
]</p>
<table-wrap id="T7" position="float"><label>Table 7</label>
<caption><p>Adaptability of the recommendation</p>
</caption>
<graphic xlink:href="JOVR-10-445-g007"></graphic>
</table-wrap>
</sec>
</sec>
<sec id="sec2-3"><title>Consensus Process</title>
<sec id="sec3-5"><title>First consensus (External peer review)</title>
<p>All customized recommendations and related data [Tables <xref ref-type="table" rid="T2">2</xref>
, <xref ref-type="table" rid="T3">3</xref>
, <xref ref-type="table" rid="T6">6</xref>
and <xref ref-type="table" rid="T7">7</xref>
] were sent to expert in the field of cataract surgery at different public hospitals supervised by medical universities (Tabriz University of Medical Sciences, Shahid Beheshti University of Medical Sciences, Iran University of Medical Sciences, Tehran University of Medical Sciences, Ahvaz Jundishapur University of Medical Sciences, Zahedan University of Medical Sciences, and Mashhad University of Medical Sciences) after removing the internal scores.</p>
<p>Participants were asked to:</p>
<p><list list-type="bullet"><list-item><p>Evaluate the recommendations and determine the clinical advantage score, customized potential score, and total score for each recommendation</p>
</list-item>
<list-item><p>Add any evidence related to recommendations that were not included in our search, which could change the final decision, if possible.</p>
</list-item>
</list>
</p>
</sec>
<sec id="sec3-6"><title>Evaluation of total scores</title>
<p>After collecting the external peer review scores, agreement among the external peer review was assessed by our team, and the agreed recommendations were considered as final customized recommendations.</p>
</sec>
<sec id="sec3-7"><title>Second consensus</title>
<p>The external and internal reviewers gathered again and discussed non-agreed recommendations, some of which were modified and rescored to achieve agreement from both groups.</p>
</sec>
</sec>
<sec id="sec2-4"><title>Final Assessment of Recommendations</title>
<p>All recommendation were re-evaluated by our team, and the final recommendations were recorded in a file with special codes in abbreviations, which included the name of the adopted CPG [<xref ref-type="table" rid="T8">Table 8</xref>
], its level of evidence, and the number for its reference. For example (C4), (I), indicates that the recommendation has stemmed from recommendation number 4 from the Canadian Ophthalmological Society clinical practice guidelines for adult cataract surgery, a Clinical Practice Guideline with level of evidence of I.</p>
<table-wrap id="T8" position="float"><label>Table 8</label>
<caption><p>Abbreviations of the reference guidelines</p>
</caption>
<graphic xlink:href="JOVR-10-445-g008"></graphic>
</table-wrap>
</sec>
</sec>
<sec sec-type="results" id="sec1-3"><title>RESULTS</title>
<p>The result of customizing 4 prior guidelines for the Iranian population may be summarized into the 80 recommendations classified below.</p>
<sec id="sec2-5"><title>Non-surgical Treatments/Risk Factors for Cataract Progression</title>
<p><list list-type="order"><list-item><p>It is recommended that ophthalmologists suggest that patients use sunglasses and hats with visors to reduce sun ray (UV-B) damage and progression of cortical cataracts.[<xref rid="ref15" ref-type="bibr">15</xref>
<xref rid="ref16" ref-type="bibr">16</xref>
<xref rid="ref17" ref-type="bibr">17</xref>
] (I), (A<sub>1,2</sub>
)</p>
</list-item>
<list-item><p>Based on a high level of evidence, supplements such as antioxidants, Vit C, Vit E, Vit A and beta-carotene do not prevent or reduce the rate of progression of cataracts.[<xref rid="ref18" ref-type="bibr">18</xref>
<xref rid="ref19" ref-type="bibr">19</xref>
<xref rid="ref20" ref-type="bibr">20</xref>
] (I), (A<sub>1,2</sub>
)</p>
</list-item>
<list-item><p>Considering the proven effect of quitting cigarette smoking in limiting the progression of cataracts, it is recommended that ophthalmologists ask all patients with lens opacity to quit smoking.[<xref rid="ref21" ref-type="bibr">21</xref>
<xref rid="ref22" ref-type="bibr">22</xref>
<xref rid="ref23" ref-type="bibr">23</xref>
<xref rid="ref24" ref-type="bibr">24</xref>
<xref rid="ref25" ref-type="bibr">25</xref>
] (I), (A<sub>1,2</sub>
R3-3)</p>
</list-item>
<list-item><p>It is recommended to inform patients about the increased risk of cataracts after long-term use of oral or inhaled steroids, and alternative medications should be used, if possible.[<xref rid="ref26" ref-type="bibr">26</xref>
<xref rid="ref27" ref-type="bibr">27</xref>
] (II), (A<sub>1</sub>
)></p>
</list-item>
<list-item><p>The use of steroids, amitriptyline, statins, anti-diabetes pills, insulin, and potassium-sparing diuretics increase the risk of cataracts and cause faster progression of the condition, but aspirin and thiazides do not have a role in this respect. Discontinuation of cataract-causing drugs may be recommended by physicians, if possible.[<xref rid="ref28" ref-type="bibr">28</xref>
<xref rid="ref29" ref-type="bibr">29</xref>
] (I), (A<sub>1</sub>
)</p>
</list-item>
<list-item><p>It is recommended that the increased risk of cataract be discussed with diabetic patients[<xref rid="ref30" ref-type="bibr">30</xref>
<xref rid="ref31" ref-type="bibr">31</xref>
<xref rid="ref32" ref-type="bibr">32</xref>
] (II), (A<sub>1</sub>
)</p>
</list-item>
<list-item><p>It is recommended that the increased risk of accidents and bone fractures be discussed with patients who have cataracts but do not wish to be operated on.[<xref rid="ref33" ref-type="bibr">33</xref>
<xref rid="ref34" ref-type="bibr">34</xref>
<xref rid="ref35" ref-type="bibr">35</xref>
<xref rid="ref36" ref-type="bibr">36</xref>
<xref rid="ref37" ref-type="bibr">37</xref>
] (I), (C4).</p>
</list-item>
</list>
</p>
</sec>
<sec id="sec2-6"><title>Surgical Treatments/Preoperative/Indication of Cataract Surgery Based on Visual Acuity</title>
<p><list list-type="simple"><list-item><label>8.</label>
<p>If cataract is the main and primary cause of visual loss, surgery is indicated. (IV), (consensus C19)</p>
</list-item>
<list-item><label>9.</label>
<p>Cataract surgery is recommended when vision loss is not corrected with non-surgical methods meet patients' needs.[<xref rid="ref38" ref-type="bibr">38</xref>
<xref rid="ref39" ref-type="bibr">39</xref>
] (IV), (A<sub>2</sub>
2, C2)</p>
</list-item>
<list-item><label>10.</label>
<p>It is recommended that in evaluating cataracts and determining the time of surgery, with the exception of visual acuity, other factors such as need for far sight, near sight, and sight under different lighting conditions be considered.[<xref rid="ref40" ref-type="bibr">40</xref>
<xref rid="ref41" ref-type="bibr">41</xref>
<xref rid="ref42" ref-type="bibr">42</xref>
<xref rid="ref43" ref-type="bibr">43</xref>
<xref rid="ref44" ref-type="bibr">44</xref>
<xref rid="ref45" ref-type="bibr">45</xref>
] (I), (A<sub>1</sub>
)</p>
</list-item>
<list-item><label>11.</label>
<p>In patients who have less than standard visual acuity according to their occupation (like drivers, soldiers, and pilots) and wish to continue their occupation, cataract surgery is indicated even when there are not many functional deficits under normal life circumstances. (IV), (consensus C3).</p>
</list-item>
</list>
</p>
</sec>
<sec id="sec2-7"><title>Surgical Treatments/Preoperative/Indication for Fellow Eye Cataract Surgery</title>
<p><list list-type="simple"><list-item><label>12.</label>
<p>Indication for surgery on the second eye is the same as the first eye, but in some cases of anisometropia, earlier operation is recommended. The time between surgeries should be long enough for detecting possible complications of the first procedure such as endophthalmitis or residual refractive errors. (IV), (consensus, C11)</p>
</list-item>
<list-item><label>13.</label>
<p>In bilateral cataract cases, it is recommended to perform surgery in separate sessions in order to achieve better binocular vision.[<xref rid="ref46" ref-type="bibr">46</xref>
<xref rid="ref47" ref-type="bibr">47</xref>
<xref rid="ref48" ref-type="bibr">48</xref>
<xref rid="ref49" ref-type="bibr">49</xref>
<xref rid="ref50" ref-type="bibr">50</xref>
] (I), (R5.2)</p>
</list-item>
<list-item><label>14.</label>
<p>Because of the chance of endophthalmitis and bilateral toxic anterior segment syndrome (TASS), simultaneous surgery on both eyes is not recommended.[<xref rid="ref51" ref-type="bibr">51</xref>
<xref rid="ref52" ref-type="bibr">52</xref>
<xref rid="ref53" ref-type="bibr">53</xref>
] (III), (C12)</p>
</list-item>
<list-item><label>15.</label>
<p>In one-eyed cataract patients, surgery is recommended if the advantages of performing the surgery are higher than its side effects.[<xref rid="ref54" ref-type="bibr">54</xref>
<xref rid="ref55" ref-type="bibr">55</xref>
] (III), (C10)</p>
</list-item>
<list-item><label>16.</label>
<p>Based on scientific evidence, performing cataract surgery might reduce intraocular pressure in patients who also have closed angle glaucoma.[<xref rid="ref56" ref-type="bibr">56</xref>
<xref rid="ref57" ref-type="bibr">57</xref>
<xref rid="ref58" ref-type="bibr">58</xref>
<xref rid="ref59" ref-type="bibr">59</xref>
<xref rid="ref60" ref-type="bibr">60</xref>
<xref rid="ref61" ref-type="bibr">61</xref>
<xref rid="ref62" ref-type="bibr">62</xref>
<xref rid="ref63" ref-type="bibr">63</xref>
] (II), (A<sub>2</sub>
6)</p>
</list-item>
<list-item><label>17.</label>
<p>If there is a chance of blindness due to increased intraocular pressure after cataract surgery and glaucoma surgery, simultaneous surgery is recommended. (IV), (consensus, C18)</p>
</list-item>
<list-item><label>18.</label>
<p>Cataract surgery is indicated in patients with phacomorphic glaucoma, lens-induced uveitis, and posterior segment diseases, if lens opacity limits fundus examination or treatment. (IV), (consensus, C5).</p>
</list-item>
</list>
</p>
</sec>
<sec id="sec2-8"><title>Surgical Treatments/Preoperative/Assessment/Eye Assessment</title>
<p><list list-type="simple"><list-item><label>19.</label>
<p>It is recommended for all cataract surgeons to answer the following questions prior to surgery in order to prevent or reduce some risk factors:[<xref rid="ref64" ref-type="bibr">64</xref>
]</p>
<p>Is the cataract the main cause of vision loss?</p>
<p>Is there any other eye disease like glaucoma that might worsen because of cataract surgery?</p>
<p>Is there any eye disease that might complicate the surgical process? (I), (C7)</p>
</list-item>
<list-item><label>20.</label>
<p>The surgeon should refer the patients to facilities with more expertise if the surgery seems to be very complicated, has a high risk of complications, or the surgeon does not have enough experience.[<xref rid="ref65" ref-type="bibr">65</xref>
] (II), (C8)</p>
</list-item>
<list-item><label>21.</label>
<p>α-blockers (tamsulosin) should be discontinued before surgery because of the high risk of floppy iris syndrome (FIS) and other serious complications.[<xref rid="ref66" ref-type="bibr">66</xref>
<xref rid="ref67" ref-type="bibr">67</xref>
<xref rid="ref68" ref-type="bibr">68</xref>
<xref rid="ref69" ref-type="bibr">69</xref>
<xref rid="ref70" ref-type="bibr">70</xref>
<xref rid="ref71" ref-type="bibr">71</xref>
] (I), (A2, 5)</p>
</list-item>
<list-item><label>22.</label>
<p>Due to the absence of serious vision related side effects, discontinuation of anti-coagulant medications (except for Warfarin and Clopidogrel) is not recommended.[<xref rid="ref72" ref-type="bibr">72</xref>
<xref rid="ref73" ref-type="bibr">73</xref>
<xref rid="ref74" ref-type="bibr">74</xref>
<xref rid="ref75" ref-type="bibr">75</xref>
] (I), (C26, R7-5-1)</p>
</list-item>
<list-item><label>23.</label>
<p>If a surgeon encounters a higher incidence of endophthalmitis compared to what has been reported in the literature, it is recommended to search for the source of this complication by taking serial microbial cultures from personnel, surgery room, and devices as well as controlling the sterilization process. Also preps of eyelashes with 10% betadine and preps of the cul-de-sac and conjunctiva with 5% betadine are recommended. (IV), (consensus, C57 and external consensus)</p>
</list-item>
<list-item><label>24.</label>
<p>It is recommended that a form, including the eye undergoing surgery, IOL power, medications used by the patients, previous diseases, etc., be prepared at all eye surgical centers and filled out immediately before surgery by the surgeon or the operating room staff. It is also recommended that patient education brochures be given to all patients or their accompanying person after surgery (including information about post-surgical pain, introduction of drugs, time for post-operative visits, etc.).[<xref rid="ref76" ref-type="bibr">76</xref>
<xref rid="ref77" ref-type="bibr">77</xref>
<xref rid="ref78" ref-type="bibr">78</xref>
<xref rid="ref79" ref-type="bibr">79</xref>
<xref rid="ref80" ref-type="bibr">80</xref>
<xref rid="ref81" ref-type="bibr">81</xref>
] (II), (A<sub>2</sub>
11).</p>
</list-item>
</list>
</p>
</sec>
<sec id="sec2-9"><title>Surgical Treatments/Preoperative/Assessment/Lab Assessment</title>
<p><list list-type="simple"><list-item><label>25.</label>
<p>Performing general medical preoperative examinations, even when using local anesthesia, is recommended.[<xref rid="ref82" ref-type="bibr">82</xref>
<xref rid="ref83" ref-type="bibr">83</xref>
] (I), (R4) and (IV), (external peer review).</p>
</list-item>
</list>
</p>
</sec>
<sec id="sec2-10"><title>Surgical Treatments/Preoperative/Assessment/IOL Assessment</title>
<p><list list-type="simple"><list-item><label>26.</label>
<p>It is recommended to repeat A-scan biometry in the following circumstances:[<xref rid="ref84" ref-type="bibr">84</xref>
<xref rid="ref85" ref-type="bibr">85</xref>
]</p>
<p><list list-type="bullet"><list-item><p>Axial length more than 26mm or less than 21mm</p>
</list-item>
<list-item><p>Keratometry more than 47 diopters or less than 41 diopters</p>
</list-item>
<list-item><p>Astigmatism more than 2.5D</p>
</list-item>
<list-item><p>Axial length difference more than 0.7 between the two eyes</p>
</list-item>
<list-item><p>Keratometry difference of more than 0.9 between the two eyes (III), (R 8-7-4)</p>
</list-item>
</list>
</p>
</list-item>
<list-item><label>27.</label>
<p>It is recommended that optical (laser interferometry) biometry or utrasonography with immersion technique be used to find the exact axial length. Both methods are superior to contact method.[<xref rid="ref86" ref-type="bibr">86</xref>
<xref rid="ref87" ref-type="bibr">87</xref>
] (I), (C31)</p>
</list-item>
<list-item><label>28.</label>
<p>In eyes with abnormal size, the surgeon should use Holladay 2 or Haigis formulas to achieve the best post-operative refractive outcomes. (IV) (consensus, C33)</p>
</list-item>
<list-item><label>29.</label>
<p>To achieve the best postoperative refractive results, it is recommended to calculate the lens power using the new generation formulas (Hoffer Q, SRK/T, Holladay).[<xref rid="ref88" ref-type="bibr">88</xref>
] (III), (C32)</p>
</list-item>
<list-item><label>30.</label>
<p>Surgeons should optimize their IOL A-constant based on their postoperative refractive results and consider it in IOL power calculation. (IV), (consensus, C34)</p>
</list-item>
<list-item><label>31.</label>
<p>The effect of A-constant optimization on IOL power prediction is more pronounced when using the modern IOL power calculation formulas. In some cases, the percentage of eyes with acceptable refractive range after surgery (Target refraction ± 1D) can be increased by 20% when A-constant optimization is applied. (IV), (consensus, R 8-7-5)</p>
</list-item>
<list-item><label>32.</label>
<p>The A-constant provided by the manufacturer which is calculated by contact sonography is different from optical optimized A-constant. To improve the A-constant of newer intraocular lenses in optical biometry, ULIB online website should be utilized. (IV) (consensus, R8-7-1)</p>
</list-item>
<list-item><label>33.</label>
<p>Patients with a history of refractive surgery should be informed about the possibility of errors in IOL power calculation and postoperative refraction even when utilizing adjustments. (IV), (consensus, C38)</p>
</list-item>
<list-item><label>34.</label>
<p>In patients who have a history of keratorefractive surgery, surgeons should be aware of the possibility of unusual postoperative refractive results and should calculate the real corneal refractive power using adjusted formulas, utilizing patient preoperative findings, or direct calculation of the central corneal power using SimKs or Scheimpflug methods. It is ideal to apply several methods for calculating the IOL power. (IV), (consensus, C36)</p>
</list-item>
<list-item><label>35.</label>
<p>It is recommended that the past medical and ocular history, including keratometry and biometry results, of all patients undergoing keratorefractive surgery be kept by the treatment center.[<xref rid="ref89" ref-type="bibr">89</xref>
] (II), C37)</p>
</list-item>
<list-item><label>36.</label>
<p>It is recommended to use IOLs with sharp angles to lessen the chance of posterior capsule opacity.[<xref rid="ref90" ref-type="bibr">90</xref>
<xref rid="ref91" ref-type="bibr">91</xref>
<xref rid="ref92" ref-type="bibr">92</xref>
<xref rid="ref93" ref-type="bibr">93</xref>
<xref rid="ref94" ref-type="bibr">94</xref>
<xref rid="ref95" ref-type="bibr">95</xref>
<xref rid="ref96" ref-type="bibr">96</xref>
<xref rid="ref97" ref-type="bibr">97</xref>
<xref rid="ref98" ref-type="bibr">98</xref>
<xref rid="ref99" ref-type="bibr">99</xref>
<xref rid="ref100" ref-type="bibr">100</xref>
<xref rid="ref101" ref-type="bibr">101</xref>
<xref rid="ref102" ref-type="bibr">102</xref>
<xref rid="ref103" ref-type="bibr">103</xref>
<xref rid="ref104" ref-type="bibr">104</xref>
<xref rid="ref105" ref-type="bibr">105</xref>
<xref rid="ref106" ref-type="bibr">106</xref>
<xref rid="ref107" ref-type="bibr">107</xref>
<xref rid="ref108" ref-type="bibr">108</xref>
<xref rid="ref109" ref-type="bibr">109</xref>
] (I), (R10, C62)</p>
</list-item>
<list-item><label>37.</label>
<p>The use of anterior aspheric IOLs is recommended to achieve better contrast sensitivity and visual performance particularly during the night. It should be noted that in conditions like zonular rupture and astigmatism, which increase the chance of IOL decentration, or after hyperopic corneal refractive surgery, spherical IOLs should be implanted.[<xref rid="ref110" ref-type="bibr">110</xref>
<xref rid="ref111" ref-type="bibr">111</xref>
<xref rid="ref112" ref-type="bibr">112</xref>
] (I), (C42, R 9-7-4)</p>
</list-item>
<list-item><label>38.</label>
<p>In the process of using multifocal or accommodative IOLs which correct different degrees of presbyopia, careful patient selection and consultation, informing the patient about the results, and utilizing necessary preoperative examinations are vital. (IV), (consensus, C44)</p>
</list-item>
<list-item><label>39.</label>
<p>It is recommended that multifocal and adjustable lenses be used based on patient needs and desires, and after giving the patient complete information about the advantages and disadvantages of such lenses, including glare/haloes, posterior capsular opacity and reduction of contrast sensitivity.[<xref rid="ref113" ref-type="bibr">113</xref>
<xref rid="ref114" ref-type="bibr">114</xref>
<xref rid="ref115" ref-type="bibr">115</xref>
] (I), R 9-7-1)</p>
</list-item>
<list-item><label>40.</label>
<p>To use toric IOLs in patients with regular preoperative corneal astigmatism, accurate preoperative calculations, correct marking of the steep axis, and implanting the IOL in correct axis should be considered to eliminate undesirable surgical induced astigmatism. (IV), (consensus, C43)</p>
</list-item>
<list-item><label>41.</label>
<p>Visual outcomes after cataract surgery and implantation of UV filter IOLs and blue filter IOLs are comparable.[<xref rid="ref116" ref-type="bibr">116</xref>
<xref rid="ref117" ref-type="bibr">117</xref>
] (I), (New) - (IV), (Internal and external consensus)</p>
</list-item>
<list-item><label>42.</label>
<p>When the PCIOL is placed in the ciliary sulcus, decreasing the power by 0 to 1.5 diopters should be considered. (IV), (consensus, C35).</p>
</list-item>
</list>
</p>
</sec>
<sec id="sec2-11"><title>Surgical Treatments/Preoperative/Risk Factors of Cataract Surgery</title>
<p><list list-type="simple"><list-item><label>43.</label>
<p>It is preferable that the waiting time for cataract surgery be less than 2 to 3 months to avoid the chance of visual deterioration and possible accidents.[<xref rid="ref118" ref-type="bibr">118</xref>
<xref rid="ref119" ref-type="bibr">119</xref>
] (I), (R 4)</p>
</list-item>
<list-item><label>44.</label>
<p>Patients with cataracts and at danger of the consequences of reduced vision, namely falls, fractures or accidents, should undergo surgical correction as soon as possible.[<xref rid="ref120" ref-type="bibr">120</xref>
<xref rid="ref121" ref-type="bibr">121</xref>
<xref rid="ref122" ref-type="bibr">122</xref>
<xref rid="ref123" ref-type="bibr">123</xref>
<xref rid="ref124" ref-type="bibr">124</xref>
<xref rid="ref125" ref-type="bibr">125</xref>
] (I), (C6)</p>
</list-item>
<list-item><label>45.</label>
<p>It is recommended that all patients with cataracts be informed about the chance of PCO before surgery.[<xref rid="ref90" ref-type="bibr">90</xref>
<xref rid="ref91" ref-type="bibr">91</xref>
<xref rid="ref92" ref-type="bibr">92</xref>
<xref rid="ref93" ref-type="bibr">93</xref>
<xref rid="ref94" ref-type="bibr">94</xref>
<xref rid="ref95" ref-type="bibr">95</xref>
<xref rid="ref96" ref-type="bibr">96</xref>
<xref rid="ref97" ref-type="bibr">97</xref>
<xref rid="ref98" ref-type="bibr">98</xref>
<xref rid="ref99" ref-type="bibr">99</xref>
<xref rid="ref100" ref-type="bibr">100</xref>
<xref rid="ref101" ref-type="bibr">101</xref>
<xref rid="ref102" ref-type="bibr">102</xref>
<xref rid="ref103" ref-type="bibr">103</xref>
<xref rid="ref104" ref-type="bibr">104</xref>
<xref rid="ref105" ref-type="bibr">105</xref>
<xref rid="ref106" ref-type="bibr">106</xref>
<xref rid="ref107" ref-type="bibr">107</xref>
<xref rid="ref108" ref-type="bibr">108</xref>
<xref rid="ref109" ref-type="bibr">109</xref>
] (III), (R10)</p>
</list-item>
<list-item><label>46.</label>
<p>It is recommended that the chance of aggravation of diabetic retinopathy be discussed with patients with diabetes and lens opacity who are undergoing cataract surgery.[<xref rid="ref126" ref-type="bibr">126</xref>
<xref rid="ref127" ref-type="bibr">127</xref>
] (III), (C21)</p>
</list-item>
<list-item><label>47.</label>
<p>If the surgeon finds a serious condition in the pre-surgical examinations like tractional retinal detachment, it is recommended that consultation for performing combined vitrectomy and cataract surgery be considered.[<xref rid="ref128" ref-type="bibr">128</xref>
] (III), (C20)</p>
</list-item>
<list-item><label>48.</label>
<p>Treatment of proliferative diabetic retinopathy (PDR) and clinically significant macular edema (CSME) should be performed before cataract surgery, if possible. (IV), (consensus, C20)</p>
</list-item>
<list-item><label>49.</label>
<p>It is recommended that the risk of retinal detachment be discussed with high-risk patients (patients with posterior capsule tear and consequent anterior vitrectomy, age less than 60 years, male sex, and high myopia). They should also be informed of the warning signs and symptoms of retinal detachment to facilitate early diagnosis and treatment.[<xref rid="ref129" ref-type="bibr">129</xref>
<xref rid="ref130" ref-type="bibr">130</xref>
<xref rid="ref131" ref-type="bibr">131</xref>
] (I), (C64)</p>
</list-item>
<list-item><label>50.</label>
<p>In patients with Fuchs' dystrophy and cataract, if the chance of corneal decompensation is considerable, combined cataract and corneal transplantation could be considered. (IV), (consensus, C17)</p>
</list-item>
<list-item><label>51.</label>
<p>Anterior chamber depth less than 2.5mm in patients with pseudoexfoliation (PEX) increases the chance of complications during the cataract surgery.</p>
<p>Accompanying recommendation: It is recommended that cataract surgery in these patients be performed by a more experienced surgeon in order to decrease the risk of complications.[<xref rid="ref132" ref-type="bibr">132</xref>
] (II), (C23)</p>
</list-item>
<list-item><label>52.</label>
<p>Cataract surgery after trabeculectomy (TX) increases the chances of TX failure. A shorter time interval between the two surgeries increases the risk of this failure[<xref rid="ref133" ref-type="bibr">133</xref>
] (I), (New) - (IV), (Internal and external consensus)</p>
</list-item>
<list-item><label>53.</label>
<p>It is recommended that patients with age-related macular degeneration (ARMD) undergo cataract surgery only if there is a chance for improved vision. Informing the patient about the chance of worsening of macular degeneration following cataract surgery is necessary.[<xref rid="ref134" ref-type="bibr">134</xref>
<xref rid="ref135" ref-type="bibr">135</xref>
<xref rid="ref136" ref-type="bibr">136</xref>
<xref rid="ref137" ref-type="bibr">137</xref>
] (I) (C 15).</p>
</list-item>
</list>
</p>
</sec>
<sec id="sec2-12"><title>Surgical Treatments/Intraoperative</title>
<p><list list-type="simple"><list-item><label>54.</label>
<p>Treatment of blepharitis before surgery and also prep of the eyelashes with 10% betadine and prep of the cul-de-sac and conjunctiva with 5% betadine immediately before surgery is recommended to decrease the chance of endophthalmitis.[<xref rid="ref138" ref-type="bibr">138</xref>
<xref rid="ref139" ref-type="bibr">139</xref>
<xref rid="ref140" ref-type="bibr">140</xref>
<xref rid="ref141" ref-type="bibr">141</xref>
<xref rid="ref142" ref-type="bibr">142</xref>
<xref rid="ref143" ref-type="bibr">143</xref>
] (II), (C55)</p>
</list-item>
<list-item><label>55.</label>
<p>The choice of local anesthesia for cataract surgery is made based on the patient and surgeon's preference.[<xref rid="ref144" ref-type="bibr">144</xref>
<xref rid="ref145" ref-type="bibr">145</xref>
<xref rid="ref146" ref-type="bibr">146</xref>
<xref rid="ref147" ref-type="bibr">147</xref>
<xref rid="ref148" ref-type="bibr">148</xref>
<xref rid="ref149" ref-type="bibr">149</xref>
] (I) (R 7-2-2)</p>
</list-item>
<list-item><label>56.</label>
<p>Phacoemulsification using a small incision is the preferred method of cataract surgery compared to extracapsular cataract extraction since it causes less astigmatism, achieves fast and better visual outcomes, and has fewer complications.[<xref rid="ref150" ref-type="bibr">150</xref>
<xref rid="ref151" ref-type="bibr">151</xref>
<xref rid="ref152" ref-type="bibr">152</xref>
] (I) (C45)</p>
</list-item>
<list-item><label>57.</label>
<p>Smaller incisions (3.2 mm) during cataract surgery are recommended due to less astigmatism and less short-term changes in the cornea.[<xref rid="ref153" ref-type="bibr">153</xref>
<xref rid="ref154" ref-type="bibr">154</xref>
] (I), (C46)</p>
</list-item>
<list-item><label>58.</label>
<p>Implantation of foldable IOLs is preferable to rigid IOLs since they require smaller incisions, cause less astigmatism, provide better visual acuity, and cause less postoperative inflammation.[<xref rid="ref155" ref-type="bibr">155</xref>
] (I) (C40)</p>
</list-item>
<list-item><label>59.</label>
<p>Staining of the anterior capsule is recommended in mature cataracts, white cataracts, complicated cataracts and in children.[<xref rid="ref156" ref-type="bibr">156</xref>
] (I) (C50)</p>
</list-item>
<list-item><label>60.</label>
<p>Smaller capsulorhexis (4.5mm to 5mm) which can completely cover the margin of the IOL optic are preferable to larger ones since they decrease the chance of PCO.[<xref rid="ref157" ref-type="bibr">157</xref>
] (I), (C47)</p>
</list-item>
<list-item><label>61.</label>
<p>It is recommended that hydrodissection and hydrodelineation be performed routinely to reduce tension on the zonulae, facilitate cortical removal, and reduce the chance of PCO.[<xref rid="ref158" ref-type="bibr">158</xref>
] (I) (C48)</p>
</list-item>
<list-item><label>62.</label>
<p>The surgeon should ask patients about the history of using alpha adrenergic blocker medications (e.g. Tamsulosin), which cause intraoperative floppy iris syndrome. If there is a positive history, atropine drops and intraocular epinephrine should be used both before and during surgery. The surgeon should also use less fluid circulation and more viscoelastic materials as well as iris retractors and pupil rings to reduce the chance of floppy iris syndrome. Due to chance of bleeding, iris sphincterotomy should be avoided.[<xref rid="ref159" ref-type="bibr">159</xref>
<xref rid="ref160" ref-type="bibr">160</xref>
<xref rid="ref161" ref-type="bibr">161</xref>
<xref rid="ref162" ref-type="bibr">162</xref>
<xref rid="ref163" ref-type="bibr">163</xref>
<xref rid="ref164" ref-type="bibr">164</xref>
] (I), (A<sub>2</sub>
5), (IV), (consensus C53)</p>
</list-item>
<list-item><label>63.</label>
<p>To reduce surgical complications, a small pupil should be enlarged appropriately. To achieve this goal, different methods can be used based on surgeon's experience and methods with less trauma. Usual methods include stretching hooks, rings, and pupil retractors, and using ophthalmic visco-surgical devices (OVDs).[<xref rid="ref165" ref-type="bibr">165</xref>
] (IV) (consensus, C52)</p>
</list-item>
<list-item><label>64.</label>
<p>Performing phacoemulsification with a torsional probe is preferred to conventional longitudinal probes since there is less chance of corneal trauma.[<xref rid="ref166" ref-type="bibr">166</xref>
<xref rid="ref167" ref-type="bibr">167</xref>
<xref rid="ref168" ref-type="bibr">168</xref>
<xref rid="ref169" ref-type="bibr">169</xref>
<xref rid="ref170" ref-type="bibr">170</xref>
<xref rid="ref171" ref-type="bibr">171</xref>
] (I), (New) - (IV), (Internal and external consensus)</p>
</list-item>
<list-item><label>65.</label>
<p>In patients with local or general zonular weakness, applying capsular tension rings is recommended to achieve better control during surgery, reduce complications, and provide better IOL centration.[<xref rid="ref172" ref-type="bibr">172</xref>
] (I), (51)</p>
</list-item>
<list-item><label>66.</label>
<p>Considering the reduced incidence of side effects of using injectors (as compared to forceps) for implanting IOLs such as less wound damage, less IOLs damage, and a lower chance of endophthalmitis, it is recommended to implant the IOL using its special injector.[<xref rid="ref173" ref-type="bibr">173</xref>
] (III), (C41)</p>
</list-item>
<list-item><label>67.</label>
<p>In the absence of inadequate capsular bag support, the surgeon should determine a suitable IOL (considering lens power and material) to be implanted in the ciliary sulcus.[<xref rid="ref174" ref-type="bibr">174</xref>
<xref rid="ref175" ref-type="bibr">175</xref>
<xref rid="ref176" ref-type="bibr">176</xref>
<xref rid="ref177" ref-type="bibr">177</xref>
<xref rid="ref178" ref-type="bibr">178</xref>
] (III), (A<sub>2</sub>
, 10)</p>
<p><list list-type="simple"><list-item><p>67-1: IOLs designed for in-the-bag implantation should not be implanted in the ciliary sulcus.[<xref rid="ref174" ref-type="bibr">174</xref>
<xref rid="ref175" ref-type="bibr">175</xref>
<xref rid="ref176" ref-type="bibr">176</xref>
<xref rid="ref177" ref-type="bibr">177</xref>
<xref rid="ref178" ref-type="bibr">178</xref>
] (III) (A<sub>2</sub>
, 10-1)</p>
</list-item>
<list-item><p>67-2: When placing an IOL in the ciliary sulcus, the power should be reduced as compared to in-the-bag implanted IOLs.[<xref rid="ref174" ref-type="bibr">174</xref>
<xref rid="ref175" ref-type="bibr">175</xref>
<xref rid="ref176" ref-type="bibr">176</xref>
<xref rid="ref177" ref-type="bibr">177</xref>
<xref rid="ref178" ref-type="bibr">178</xref>
] (A<sub>2</sub>
, 10-2)</p>
</list-item>
<list-item><p>67-3- Implantation of multifocal and aspheric IOLs in the ciliary sulcus are not recommended.[<xref rid="ref174" ref-type="bibr">174</xref>
<xref rid="ref175" ref-type="bibr">175</xref>
<xref rid="ref176" ref-type="bibr">176</xref>
<xref rid="ref177" ref-type="bibr">177</xref>
<xref rid="ref178" ref-type="bibr">178</xref>
] (III), (A<sub>2</sub>
10-3)</p>
</list-item>
</list>
</p>
</list-item>
<list-item><label>68.</label>
<p>In case of posterior capsular rupture and inadequate capsular support for in- the-bag IOL implantation, ACIOLs, scleral fixation PCIOLs, or iris fixation IOLs may be used.[<xref rid="ref179" ref-type="bibr">179</xref>
] (III), (C39)</p>
<p>69- 1- Intracameral antibiotic injections are not recommended to reduce the chance of endophthalmitis due to the toxic effects and likelihood of reduction in corneal endothelial cells.[<xref rid="ref180" ref-type="bibr">180</xref>
<xref rid="ref181" ref-type="bibr">181</xref>
<xref rid="ref182" ref-type="bibr">182</xref>
<xref rid="ref183" ref-type="bibr">183</xref>
<xref rid="ref184" ref-type="bibr">184</xref>
<xref rid="ref185" ref-type="bibr">185</xref>
<xref rid="ref186" ref-type="bibr">186</xref>
<xref rid="ref187" ref-type="bibr">187</xref>
] (III), (A<sub>2</sub>
8) - (IV), (Internal and external consensus)</p>
<p>69-2- Subconjunctival antibiotic injection may be recommended to reduce the chance of postoperative endophthalmitis with weak level of evidence.[<xref rid="ref180" ref-type="bibr">180</xref>
<xref rid="ref181" ref-type="bibr">181</xref>
<xref rid="ref182" ref-type="bibr">182</xref>
<xref rid="ref183" ref-type="bibr">183</xref>
<xref rid="ref184" ref-type="bibr">184</xref>
<xref rid="ref185" ref-type="bibr">185</xref>
<xref rid="ref186" ref-type="bibr">186</xref>
<xref rid="ref187" ref-type="bibr">187</xref>
] (III), (A<sub>2</sub>
8).</p>
</list-item>
</list>
</p>
</sec>
<sec id="sec2-13"><title>Surgical Treatments/Postoperative/Complications</title>
<p><list list-type="simple"><list-item><label>70.</label>
<p>Use of high frequency postoperative antibiotics is recommended to reduce the chance of endophthalmitis.[<xref rid="ref180" ref-type="bibr">180</xref>
<xref rid="ref181" ref-type="bibr">181</xref>
<xref rid="ref182" ref-type="bibr">182</xref>
<xref rid="ref183" ref-type="bibr">183</xref>
<xref rid="ref184" ref-type="bibr">184</xref>
<xref rid="ref185" ref-type="bibr">185</xref>
<xref rid="ref186" ref-type="bibr">186</xref>
<xref rid="ref187" ref-type="bibr">187</xref>
] (III), (A<sub>2</sub>
8) - (IV), (Internal and external consensus)</p>
</list-item>
<list-item><label>71.</label>
<p>To treat postoperative cystoid macular edema (CME), topical non-steroidal anti-inflammatory drugs (NSAIDs) such as ketoralac 0.5 percent are recommended as the first step of therapy.[<xref rid="ref188" ref-type="bibr">188</xref>
<xref rid="ref189" ref-type="bibr">189</xref>
] (I), (R4) - (IV), (Internal and external consensus)</p>
</list-item>
<list-item><label>72.</label>
<p>Before performing Nd: YAG laser capsulotomy for treatment of PCO, patients at high risk of retinal detachment (RD) such as posterior capsule rupture in the other eye, axial length more than 23 mm, and male sex, should be informed of the possibility of RD following laser capsulotomy.[<xref rid="ref190" ref-type="bibr">190</xref>
] (II), (C63)</p>
</list-item>
<list-item><label>73.</label>
<p>Postoperative intraocular inflammation is considered as a risk factor for corneal, trabecular and retinal complications, therefore the use of steroids or NSAIDs immediately after surgery to reduce inflammation is recommended. (IV), (consensus, C54)</p>
</list-item>
<list-item><label>74.</label>
<p>Because of the common use of antibiotics, resistance to several antibacterial agents such as penicillin and fluoroquinolones for treatment of postoperative staphylococcal endophthalmitis is observed. Ophthalmologists should be aware of this problem and consider it when prescribing post-operative antibiotics (resistance to ciprofloxacin has also been reported in several reports).[<xref rid="ref191" ref-type="bibr">191</xref>
<xref rid="ref192" ref-type="bibr">192</xref>
<xref rid="ref193" ref-type="bibr">193</xref>
<xref rid="ref194" ref-type="bibr">194</xref>
<xref rid="ref195" ref-type="bibr">195</xref>
<xref rid="ref196" ref-type="bibr">196</xref>
<xref rid="ref197" ref-type="bibr">197</xref>
] (III), (A<sub>2</sub>
7)</p>
</list-item>
<list-item><label>75.</label>
<p>Although toxic anterior segment syndrome (TASS) is rare, ophthalmologists should be aware of its predisposing factors such as posterior capsule rupture, vitreous loss, and potential complications.[<xref rid="ref198" ref-type="bibr">198</xref>
<xref rid="ref199" ref-type="bibr">199</xref>
] (III), (A<sub>2</sub>
9)</p>
</list-item>
<list-item><label>76.</label>
<p>It is recommended to consider complications like dysphotopsia and lens capsule opacity when choosing the IOLs.[<xref rid="ref200" ref-type="bibr">200</xref>
] (I), (C65).</p>
</list-item>
</list>
</p>
</sec>
<sec id="sec2-14"><title>Surgical Treatments/Postoperative/Follow-up</title>
<p><list list-type="simple"><list-item><label>77.</label>
<p>All patients undergoing phacoemulsification surgery should be aware of the postoperative examination schedule and possible side effects of the surgery. It is recommended to perform the first postoperative examination up to 24 hours after the surgery. The exact timing of other postoperative visits depends on the circumstances of the operation and the method used, complications, and surgeon and patient preference. (IV) (consensus, C59-60) - (IV), (Internal and external consensus)</p>
</list-item>
<list-item><label>78.</label>
<p>In high risk conditions like monocular patients, glaucomatous eyes or glaucoma suspects and surgical complications, the first visit should be performed by 24 hours after surgery and more frequent follow-up examinations are needed. Patients should be instructed to inform their ophthalmologists as soon as possible in case of severe reduction of vision, increased pain, redness, or inflammation around the eye as these might be signs of endophthalmitis. (IV) (consensus, C61)</p>
</list-item>
<list-item><label>79.</label>
<p>Final evaluation of refractive power should be performed 2 weeks postoperatively in patients with small corneal incisions (under 3.5mm) and after 6 weeks in patients with larger incisions or extracapsular operations. More postoperative examinations during this period, or even after it, are recommended based on special circumstances of the surgery, postoperative complications, the need for removing corneal sutures, and also evaluating intraocular pressure (IV), (consensus, C61).</p>
</list-item>
<list-item><label>80.</label>
<p>To evaluate patient satisfaction, visual assessment using a high contrast Snellen chart is not enough. Standard questionnaires like the VF14 will provide greater insight into patient satisfaction. (IV), (consensus, R12-6) - (IV), (Internal and external consensus).</p>
</list-item>
</list>
</p>
</sec>
</sec>
<sec sec-type="discussion" id="sec1-4"><title>DISCUSSION</title>
<p>The current CPG for treatment of cataracts in adult Iranian patients was customized based on the standard method suggested by the Iranian Ministry of Health and Medical Education at the knowledge management unit (KMU) of Shahid Beheshti University of Medical Sciences. This guideline includes 80 recommendations covering preoperative, intraoperative, and postoperative aspects related to adult cataract management. In the process of preparing the guidelines, preliminary consensus was not achieved in 15 out of 80 recommendations. These 15 recommendations were further discussed in internal panels, and 6 primary recommendations were reapproved, 8 recommendations were modified, and one recommendation was omitted. The changes were applied to 8 recommendations as follows: Recommendation number 5, which initially recommended that “the use of steroid drugs, amitriptyline, statins, and potassium-sparing diuretics increase the risk of cataract or its progression, and the use of aspirin and thiazides do not increase this chance”, was modified to “The use of steroids, amitriptyline, statins, anti-diabetes pills, insulin, and potassium-sparing diuretics increase the risk of cataracts and cause faster progression of the condition, but aspirin and thiazides do not have a role in this respect. Discontinuation of cataract-causing drugs may be recommended by physicians, if possible.”</p>
<p>Recommendation number 23, which stated, “If a surgeon encounters a higher incidence of endophthalmitis compared to what has been reported in the literature or in instances that the risk of postoperative endophthalmitis is higher due to complicated surgery, the postoperative injection of intracameral or subconjunctival antibiotics should be considered.” was changed to “If a surgeon encounters a higher incidence of endophthalmitis compared to what has been reported in the literature, it is recommended to search for the source of this complication by taking serial microbial cultures from personnel, surgery room, and its devices as well as controlling the sterilization process. Also, preparation of eyelashes with 10% betadine and preparation of the cul-de-sac and conjunctiva with 5% Betadine is recommended.”</p>
<p>Recommendation number 25 initially stated, “Considering the available data, preoperative examination does not increase the safety of cataract surgery. If the patient does not suffer from any special condition or diseases, performing routine preoperative exams are not recommended.” Considering the condition among Iranian patients and the fact that they might not have any previous systemic evaluation, after panel discussion this was changed to: “Performing general medical preoperative examinations, even when using local anesthesia, is recommended.”</p>
<p>Recommendation number 39 which stated that “The use of multifocal or adjustable lenses should be based on the necessity and the desire of the patient and after giving the patient a good understanding of advantages and disadvantages (glare/haloes, PCO)”, was changed to “It is recommended that multifocal and adjustable lenses be used based on patient needs and desires, and after giving the patient complete information about the advantages and disadvantages of such lenses, including glare/haloes, posterior capsular opacity and reduction of contrast sensitivity).”</p>
<p>The first version of recommendation number 50 stated: “In cataract patients with Fuchs' dystrophy, if the surgeon gives a chance of corneal decompression, the cataract and corneal surgeries are better to be combined.” After panel discussion, the term “is better” was changed to term “could”, and the final recommendation was:” In patients with Fuchs' dystrophy and cataract, if the chance of corneal decompensation is considerable, combined cataract and corneal transplantation can be considered.”</p>
<p>The initial statement for recommendation number 64 was “Performing phacoemulsification using a torsional probe is recommended compared to the use of conventional longitudinal probes since there is less chance of corneal trauma.” This recommendation was finalized in the discussion panel with a minor change as follows: “Performing phacoemulsification with a torsional probe is preferred to conventional longitudinal probes since there is less chance of corneal trauma.”</p>
<p>Two recommendations which were about antibiotic usage during surgery and postoperatively were discussed in the panel and the primary recommendation of “inject proper antibiotic in the anterior chamber to reduce the chance of endophthalmitis” was rejected by panel members, and intracameral prophylaxis antibiotic was not recommended as mentioned in recommendation 69-1.</p>
<p>Finally, before the panel discussion, recommendation number 71 suggested the use of NSAIDS for treatment of postoperative acute cystoid macular edema was not recommended, but it was changed to, “To treat postoperative cystoid macular edema (CME), topical non-steroidal anti-inflammatory drugs (NSAIDs) such as ketoralac 0.5 percent are recommended as the first step of therapy.”</p>
<p>At the end of the discussion panel, all final recommendations were edited and finalized as final recommendations.</p>
<p>This guideline, as compared to the cited CPGs which were used, has more detailed recommendations considering different aspects of cataract surgery, including important pre-, intra-, and postoperative aspects of the surgery. For example, the Canadian Ophthalmological Society evidence-based clinical practice guidelines for cataract surgery in the adult eye (2008) contains 65 recommendations, but the present guideline consists of 80 recommendations. On the other hand, this customized guideline has the benefit of considering clinical advantages and practicality among Iranian patients, so its use among the Iranian population should be more effective.</p>
<p>In conclusion, the current clinical practice guideline for adult cataract management was customized for an Iranian adult population at KMU at the Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences as suggested by the Standardization and CPG Development Office, Deputy of Curative Affairs, and the Iranian Ministry of Health and Medical Education. Therefore, its recommendations can be used to standardize different aspects in the management of adult patients with cataracts.</p>
</sec>
</body>
<back><ack><title>Acknowledgments</title>
<p>We are immensely grateful to the external faculty members of all universities for scoring the recommendations of the clinical practice guidelines and their valuable comments.</p>
<p>We would like to show our gratitude to Ms. Bahar Kheiri for checking the evidences in terms of statistic criteria and all her efforts. We also would like to thanks Ms. Shirin Mohebikho for assistant with the literature review and coordination. Moreover, we really appreciate Ms. Soheila Khoshneshin for their kind attempts for typing the CPGs and tables.</p>
</ack>
<sec id="sec2-15"><title>Financial Support and Sponsorship</title>
<p>Nil.</p>
</sec>
<sec id="sec2-16"><title>Conflicts of Interest</title>
<p>There are no conflicts of interest.</p>
</sec>
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