Best Practices

A Primary Care Provider’s Guide to Cataract Surgery in the Very Elderly

Planning for cataract surgery and perioperative care in the very elderly requires the teamwork of the patient’s primary care provider and the ophthalmologist.

Fed Pract. 2019 April;36(4):176-180

Author(s):

Emily Li, MD

Curtis E. Margo, MD, MPH

Paul B. Greenberg, MD, MPH

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References

1. US Census Bureau. An aging nation: the older population in the United States. https://www.census.gov/library/publications/2014/demo/p25-1140.html Published May 2014. Accessed March 18, 2019.

2. VA Office of Inspector General. Healthcare inspection: evaluation of cataract surgeries and outcomes in veterans health administration facilities. Report No. 11-02487-158. https://www.va.gov/oig/pubs/vaoig-11-02487-158.pdf. Published March 28, 2013. Accessed March 11, 2019.

3. Lee CM, Afshari NA. The global state of cataract blindness. Curr Opin Ophthalmol. 2017;28(1):98-103.

4. American Academy of Ophthalmology. Cataract in the adult eye preferred practice pattern—2016. https://www.aao.org/preferred-practice-pattern/cataract-in-adult-eye-ppp-2016. Published October 2016. Accessed March 19, 2019.

5. Mutoh T, Isome S, Matsumoto Y, Chikuda M. Cataract surgery in patients older than 90 years of age. Can J Ophthalmol. 2012;47(2):140-144.

6. Monestam E, Wachmeister L. Impact of cataract surgery on the visual ability of the very old. Am J Ophthalmol. 2004;137(1):145-155.

7. Lai FH, Lok JY, Chow PP, Young AL. Clinical outcomes of cataract surgery in very elderly adults. J Am Geriatr Soc. 2014;62(1):165-170.

8. Michalska-Malecka K, Nowak M, Gos´ciniewicz P, et al. Results of cataract surgery in the very elderly population. Clin Interv Aging. 2013;8:1041-1046.

9. Syam PP, Eleftheriadis H, Casswell AG, Brittain GP, McLeod BK, Liu CS. Clinical outcome following cataract surgery in very elderly patients. Eye (Lond). 2004;18(1):59-62.

10. Rosen E, Rubowitz A, Assia EI. Visual outcome following cataract extraction in patients aged 90 years and older. Eye (Lond). 2009;23(5):1120-1124.

11. Mehmet B, Abuzer G. Results of cataract surgery in the very elderly population. J Optom. 2009;2(3):138-141.

12. To KG, Meuleners L, Bulsara M, et al. A longitudinal cohort study of the impact of first- and both-eye cataract surgery on falls and other injuries in Vietnam. Clin Interv Aging. 2014;9:743-751.

13. Song E, Sun H, Xu Y, Ma Y, Zhu H, Pan CW. Age-related cataract, cataract surgery and subsequent mortality: a systematic review and meta-analysis. PLoS One. 2014;9(11):e112054.

14. Brannan S, Dewar C, Sen J, Clarke D, Marshall T, Murray PI. A prospective study of the rate of falls before and after cataract surgery. Br J Ophthalmol. 2003;87(5):560-562.

15. Jefferis JM, Mosimann UP, Clarke MP. Cataract and cognitive impairment: a review of the literature. Br J Ophthalmol. 2011;95(1):17-23.

16. Yu WK, Chen YT, Wang SJ, Kuo SC, Shia BC, Liu CJ. Cataract surgery is associated with a reduced risk of dementia: a nationwide population-based cohort study. Eur J Neurol. 2015;22(10):1370-1377, e1379-1380.

17. Tseng VL, Greenberg PB, Wu WC, et al. Cataract surgery complications in nonagenarians. Ophthalmology. 2011;118(7):1229-1235.

18. Jefferis JM, Clarke MP, Taylor JP. Effect of cataract surgery on cognition, mood, and visual hallucinations in older adults. J Cataract Refract Surg. 2015;41(6):1241-1247.

19. Celebi AR. The relationship between age and the intraoperative complication rate during phacoemulsification surgery. Aging Clin Exp Res. 2014;26(2):177-181.

20. Berler DK. Intraoperative complications during cataract surgery in the very old. Trans Am Ophthalmol Soc. 2000;98:127-130; discussion 130-132.

21. Lai FHP, Lok JYC, Chow PPC, Young AL. Clinical outcomes of cataract surgery in very elderly adults. J Am Geriatr Soc. 2014;62(1):165-170.

22. Li E, Margo CE, Greenberg PB. Cataract surgery outcomes in the very elderly. J Cataract Refract Surg. 2018;44(9):1144-1149.

23. Young JS. Age-related eye diseases and recommendations for low-vision AIDS. Home Healthc Now. 2015;33(1):10-17; quiz 18-19.

24. Virgili G, Acosta R, Grover LL, Bentley SA, Giacomelli G. Reading aids for adults with low vision. Cochrane Database Syst Rev. 2013;(10):CD003303.

25. Young JS. Age-related eye diseases: a review of current treatment and recommendations for low-vision aids. Home Healthc Nurse. 2008;26(8):464-471; quiz 472-473.

26. Thomas MM, Harpaz-Rotem I, Tsai J, Southwick SM, Pietrzak RH. Mental and physical health conditions in US combat veterans: results from the National Health and Resilience in Veterans study. Prim Care Companion CNS Disord. 2017;19(3):17m02118.

27. Havnaer AG, Greenberg PB, Cockerham GC, Clark MA, Chomsky A. Cataract surgery practices in the United States Veterans Health Administration. J Cataract Refract Surg. 2017;43(4):543-551.

28. Rapoport Y, Wayman LL, Chomsky AS. The effect of post-traumatic-stress-disorder on intra-operative analgesia in a veteran population during cataract procedures carried out using retrobulbar or topical anesthesia: a retrospective study. BMC Ophthalmol. 2017;17(1):85.

29. Payal AR, Gonzalez-Gonzalez LA, Chen X, et al. Outcomes of cataract surgery with residents as primary surgeons in the Veterans Affairs Healthcare System. J Cataract Refract Surg. 2016;42(3):370-384.

30. US Department of Veterans Affairs. Mission of the office of academic affiliations. https://www.va.gov/oaa/oaa_mission.asp. Updated November 30, 2018. Accessed March 18, 2019.

31. American Academy of Ophthalmology. Choosing wisely: five things ophthalmologists and patients should question. https://www.aao.org/choosing-wisely. Published February 2013. Accessed March 18, 2019.

32. Martin SK, Cifu AS. Routine preoperative laboratory tests for elective surgery. JAMA. 2017;318(6):567-568.

33. Schein OD, Katz J, Bass EB, et al; Study of Medical Testing for Cataract Surgery. The value of routine preoperative medical testing before cataract surgery. N Engl J Med. 2000;342(3):168-175.

34. Margo CE. Asymptomatic bacteriuria and acute-onset endophthalmitis after cataract surgery. Can J Ophthalmol. 2015;50(4):e51-52.

35. Fukui K, Fujioka M, Yamasaki K, Yamakawa S, Matsuo H, Noguchi M. Risk factors for postoperative complications among the elderly after plastic surgery procedures performed under general anesthesia. Plast Surg Int. 2018:7053839.

Cataract surgery is the most commonly performed surgical procedure in the US, including within the Veterans Health Administration (VHA).^1,2 As the risk of surgical complications has decreased with improved techniques and instrumentation, the threshold for performing surgery has lowered.³ A substantial number of patients do not develop clinically significant cataracts until they are “very elderly,” defined as aged ≥ 85 years by the World Health Organization and National Institute of Aging.⁴

Should the general approach to cataract evaluation and surgery differ in this subset of patients? Advanced age is associated with a variety of systemic and ocular comorbidities that theoretically increase the risk of cataract surgery and reduce the potential visual benefit it might yield. However, the impact of age on the outcomes of cataract surgery differs even among the very elderly. There are no universally acknowledged guidelines that address the perioperative evaluation and management of cataracts in the very elderly, whose systemic and ocular health have greater variability than those of their younger counterparts. For very elderly patients who are found to have visually significant cataracts by their ophthalmologists, input from the primary care provider (PCP), who has insight into a patient’s health and well-being, is vital for formulating a management plan. Herein, we provide a framework for PCPs to assist very elderly patients and their ophthalmologists in making an informed decision regarding cataract surgery and in planning for perioperative care.

Cataract Surgery

Cataract surgeons recommend surgical extraction when there is a clinically significant lens opacity that imposes functional impairment, such as inability to read, perform near work, watch television, or drive.⁴The standard of care for a clinically significant cataract is surgical removal of the crystalline lens and replacement with an artificial intraocular lens (IOL). At times, the onset of vision loss from a cataract is insidious such that patients may not be aware of their declining vision or the deterioration in quality of life (QOL) that it causes.

Despite the higher burden of ocular comorbidity (eg, age-related macular degeneration, glaucoma) relative to their younger counterparts, most very elderly patients obtain functionally important improvement in their vision, QOL, and cognitive function after surgery.^5-16 Cataract surgery can also reduce the risk of dementia and the risk of falls and hip fractures.^{6,9,12-14,16-18} Ophthalmic complications of cataract surgery in the very elderly include posterior capsule tear (< 1%-9%), vitreous loss (< 1%-8%), zonular rupture (2%-5%), and retained lens fragments (≤ 1%).^{5,8-11,17,19-21} There is no evidence from well-controlled studies that suggests that very elderly cataract surgery patients are at higher risk of ocular complications relative to that of their younger counterparts.²²

Surgery Alternatives

In some very elderly patients, cataract surgery may not be the best option, and PCPs can aid in establishing an alternative plan. Such patients include those with a limited life expectancy, incapacitating anxiety over surgery, or those in whom the potential for visual improvement is marginal because of ocular or systemic comorbidities—eg, vision-limiting glaucoma or age-related macular degeneration, history of stroke to the visual pathway, or restriction to bed. Alternatives to cataract surgery in these instances include changing environmental conditions to improve visual function, such as enhanced lighting and contrast, and/or use of low-vision aids (referring patients to low-vision professionals often improves QOL).²³ Low-vision specialists also have a variety of nonvisual aids that can expand functional capabilities: large-print and talking versions of reading materials, telephones, remote controls, clocks, scales, calculators, and glucose monitors; glare-free lights for stairs, floors, and counters; and specialty glasses that use light-emitting diode screens and live video streams to magnify sight.^23-25