Evidence‑Based Recommendations for Cataract Grading and Clinical Management

1. Standard Clinical Grading (LOCS III)

The Lens Opacities Classification System III (LOCS III) is the gold‑standard clinical classification, providing standardized photographic references and a decimal‑scale grading for nuclear color (NC), nuclear opalescence (NO), cortical (C), and posterior subcapsular (P) cataracts. 1, 2, 3
For surgical planning and documentation, clinicians should perform LOCS III grading with slit‑lamp biomicroscopy on dilated pupils for all three cataract types (NO, NC, C, P) using the decimal scoring system. 1, 2, 5

Nuclear cataracts may present as brunescent (brown discoloration), opalescent (white opacity), or a combination of both. 1, 2, 3
They progress slowly and primarily impair distance vision more than near vision. 1, 2

Cortical opacities appear as opaque spokes or oil‑droplet‑like lesions and can be located centrally or peripherally. 1, 2, 3
When the entire cortex becomes white and opaque, the condition is termed a mature cortical cataract. 1, 2
Patients with cortical cataract commonly report glare symptoms. 1, 2

PSC is situated just inside the posterior lens capsule. 1, 2, 3
Involvement of the axial region produces substantial visual impairment. 1, 2
Affected individuals experience glare and poor vision in bright light. 1, 2
Near vision is typically more compromised than distance vision because PSC induces miosis during accommodation. 1, 2
PSC progresses more rapidly than nuclear or cortical cataracts. 1, 2, 4

PSC cataracts are the cataract type most frequently associated with the need for surgical intervention in population‑based studies, even though nuclear cataracts are the most common among elderly patients undergoing surgery. 1, 2, 3
Multiple cataract types often coexist in various combinations; therefore, a comprehensive assessment of all three anatomical locations (nuclear, cortical, posterior subcapsular) is required. 1, 2, 3
Because grading system variations hinder prevalence comparisons across studies, standardized use of LOCS III methodology is essential for reliable epidemiologic and outcome reporting. 1, 2

After grading, clinicians should correlate the findings with functional visual measures—best‑corrected visual acuity, contrast sensitivity, and glare testing—to determine the real‑world impact of the cataract and to guide timing of surgery. 5