Cataracts: when to operate and when you can wait

‘Wait for it to ripen’: many people have heard this said about cataracts. The idea was to operate only when the lens of the eye had become completely opaque. Today, anyone wondering when to have cataract surgery will find a different answer in the guidelines: what counts is not so much the stage of the cataract as the weight it has on the life of the person who has it.

The British guidelines from NICE, the National Institute for Health and Care Excellence, ask that the decision be based on a conversation with the person, and that access to surgery not be restricted on the basis of visual acuity, that is, the ‘tenths’ read on the letter chart¹. The European recommendations of the European Society of Cataract and Refractive Surgeons (ESCRS), published in 2024, go in the same direction: the decision is shared between patient and ophthalmologist².

In this article

1. There is no magic number: what the guidelines say
2. When you can wait
3. When waiting has a cost
4. And the second eye?
5. The questions to bring to the appointment
6. Frequently asked questions
7. Sources

There is no magic number: what the guidelines say

According to NICE, the decision to offer surgery arises from a discussion that covers five points: how the cataract affects vision and quality of life, whether it affects one eye or both, what the operation involves with its risks and benefits, how life would change if the person chose not to be operated on and, finally, whether the person really wants to have the operation¹.

The ESCRS recommendations list similar aspects: the presence and appearance of the cataract, visual acuity but also the quality of vision, the discomfort reported by the patient and the benefits that can be expected². A review published in 2025 in the journal JAMA sums up the criterion in one sentence: surgery is indicated when the loss of vision gets in the way of the activities of daily life³.

Why are the ‘tenths’ not enough? The letter chart measures sharpness in ideal conditions; it does not measure glare or contrast sensitivity, that is, the ability to distinguish a grey object against a grey background. Yet this matters too: in a 2023 meta-analysis on the effects of vision on driving, reduced contrast sensitivity was associated with a higher risk of accidents⁶.

When you can wait

If the cataract is mild and does not get in the way of what matters to you, putting surgery off is a legitimate choice. Among the information that the surgeon has to give before consent, the ESCRS puts first of all the option of not having the operation²; NICE asks that how quality of life might change without surgery also be discussed¹.

There are also situations in which it is worth choosing the moment with care. For people with other active eye diseases, such as wet macular degeneration, proliferative diabetic retinopathy or uveitis, the ESCRS recommendations suggest operating when the disease is in a quiet phase².

When waiting has a cost

NICE asks that people at risk of developing a very dense cataract be told that, if surgery is put off and the cataract becomes denser, the risk of complications rises¹.

A 2007 systematic review pooled 27 studies on waiting times. The data could not be combined in a meta-analysis, but the picture was consistent: people who waited more than six months had more loss of vision, a worse quality of life and more falls than those operated on within six weeks. For intermediate waits, between six weeks and six months, the conclusions were not clear⁵. The review in JAMA adds that surgery is associated with lower rates of falls and of dementia³: these are associations, which on their own do not show a cause-and-effect relationship.

Then there is driving. A 2008 review of seven studies found that, after surgery, the likelihood of having difficulty driving fell by 88%⁷. The much larger 2023 meta-analysis found that surgery halved the risk of road accidents, but that figure came from only three studies with very different results⁶. On this subject you can also read our article on vision and the driving licence.

And the second eye?

In older people, cataracts usually affect both eyes⁸. For the second eye, NICE recommends using the same criteria as for the first¹. What is gained? A British systematic review from 2014, with three randomised trials, found small and probably not very relevant improvements in acuity and contrast with both eyes open, but a clear improvement in stereopsis, the depth perception that allows you to judge distances⁹.

The same group behind the study on falls then repeated the experiment for the second eye, with 239 women over 70. Falls fell by 32% in the group operated on, but the difference was not statistically significant; self-confidence and visual disability, on the other hand, improved⁸. Whether both eyes can be operated on in the same session is another question, which we answer in our article on cataract surgery.

The questions to bring to the appointment

The guidelines list the information that a person should receive before deciding^1,2. Turned into questions, they become an outline for the conversation:

• How much does the cataract affect my vision, and how much worse could it get?
• What does the operation involve, how long does it take and how long does recovery take?
• What are the risks in my case, given the other diseases of my eyes?
• After the operation, will I still need glasses, and for which activities?
• Which artificial lens is right for me? We discuss this in our article on artificial lenses.

Frequently asked questions

Do you have to wait until a cataract is ‘ripe’ before operating?

No. The guidelines tie surgery to the effect of the cataract on vision and daily life, not to a particular stage^1,2. NICE, in fact, asks that people at risk of a very dense cataract be told that putting it off can increase the risk of complications¹.

Is there a maximum age for cataract surgery?

The guidelines we consulted give no age limits: what counts is vision, other eye diseases and the person’s risk profile^1,2. In the randomised trials on falls, all the participants were over 70^4,8.

Can you keep driving with a cataract?

It depends on how much the cataract reduces vision and on the legal requirements of the country where you live. The studies indicate that after surgery driving difficulties decrease⁷ and, in the few studies available, so does the risk of accidents⁶. If you have doubts, ask your ophthalmologist for an assessment.

How long can you wait after the diagnosis?

There is no time that is right for everyone. A systematic review found worse outcomes for people who waited more than six months than for those operated on within six weeks, while for intermediate waits the data are not clear⁵.

There is no right date for everyone, nor a number on the letter chart that decides in your place. The guidelines ask for something that is both simpler and more demanding: to look at how you live, at what you are missing and at which risks you are prepared to accept, and to decide with your ophthalmologist. If you want to go over the signs with which the disease presents, you will find them in our article on the symptoms of cataracts.