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Customized treatment plan needed for cataract patients with comorbidities
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 Richard L. Lindstrom |
The population in advanced countries worldwide is aging. Those older than age 65 are growing in number at twice the rate of those younger than age 65. Patients older than 65 in America consume 10 times the eye care of those younger than 65. In combination, these facts make age-related eye disease critically important to the ophthalmologist.
The most common age-related eye disease is presbyopia, occurring in 100% of those older than 65. Presbyopia can be considered a natural aging change rather than a disease, but in either case its presence definitely has a negative impact on visual performance and quality of life. In my opinion, presbyopia represents the first evidence of a dysfunctional lens that is on the pathway toward visually significant cataract, the second most common age-related eye disease, affecting approximately 44% of patients older than 65 in America, according to Market Scope.
The definition of cataract in the surgical sense continues to evolve, and visual acuity standards as an indication for cataract surgery are becoming a historical footnote. Today, a functional disability for some patients with high visual demands is defined by loss of contrast sensitivity and glare disability, and these symptoms in combination can indicate cataract surgery in a patient with 20/20 visual acuity on a high-contrast Snellen visual acuity chart. In the future, the word cataract may well be replaced with a more accurate descriptor such as “dysfunctional lens syndrome,” which might better represent the combined disability arising from presbyopia, loss of contrast sensitivity and dysphotopsia. These symptoms together can be quite disabling for many patients with high visual needs and are definitely a detriment to quality of life.
After presbyopia and cataract, the third most common age-related eye disease is the triad of ocular surface disease, including dry eye syndrome, blepharitis/meibomian gland dysfunction and ocular allergy. Studies by the RAND Corporation suggest that 35% or more of office visits to an eye doctor are related to ocular surface disease. Newer studies suggest that ocular surface disease, if aggressively diagnosed, may be present in more than 50% of senior patients, so perhaps it really belongs ahead of cataract surgery if even mild cases are considered.
In fourth place is age-related macular degeneration at approximately 20% of patients older than 65, followed by diabetic retinopathy in fifth place at 11%. Number six is glaucoma. Of course, there are other comorbidities to cataract that occur in smaller numbers, but these are the most frequently encountered. Thus, the five most common comorbidities facing the cataract surgeon are presbyopia, ocular surface disease, AMD, diabetic retinopathy and glaucoma.
It is not unusual in my practice to encounter individual patients with all these maladies. A comprehensive discussion of each of these diseases and their management in the cataract patient is beyond the scope of this short commentary, but a few thoughts are appropriate.
A major problem with ocular surface disease is that it is both underdiagnosed and undertreated by the cataract surgeon. Proper diagnosis leading to ocular surface preparation before surgery, ocular surface protection during surgery, and appropriate ocular surface rehabilitation and long-term maintenance of health can significantly enhance outcomes and patient quality of life, especially when utilizing premium IOLs if patients are motivated to reduce their dependence on glasses.
The earliest findings of AMD, including some loss of foveal reflex, a few drusen and retinal epithelial pigment dispersion, are usually visible with ophthalmoscopy. The more subtle findings, such as an early epiretinal membrane, may require optical coherence tomography for recognition. Both are important to recognize, as patient counseling and IOL elected may change in their presence, and postoperative complications such as cystoid macular edema may indicate a more aggressive prophylactic medical regimen when retinal disease is detected before surgery.
A medical history of diabetes mellitus, especially if type 1 and of long-standing duration, is a critical finding. In those with significant disease, I include a retinal specialist in the treatment plan and aggressive medical therapy to reduce the incidence of macular edema. Prompt treatment with intravitreal steroids, anti-VEGF therapy or laser, when appropriate, is important to prevent permanent loss of vision.
In regard to glaucoma, a high index of suspicion is needed, as many patients present to the cataract surgeon with this disease undiagnosed. Once the diagnosis is made, appropriate treatment can be tailored to the individual patient, but the risk factors of even mildly elevated IOP in the face of advanced age, positive family history, race, thin corneal pachymetry and myopia should all alert the surgeon to look even more carefully at the optic nerve and consider imaging and visual fields when appropriate.
The challenge of treating the senior patient with cataract includes looking carefully for all of the age-related eye diseases that so frequently present to the clinician in combination, allowing a customized treatment plan for each individual patient.