Cataract surgeons must stay alert for systemic, ocular comorbidities
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Systemic and ocular comorbidities are common in the patient who presents for cataract surgery.
Looking at several sources, just more than 50% of cataract surgery patients have at least one systemic comorbidity. It is the cataract surgeon’s duty and responsibility to recognize and manage these comorbidities. According to the American Academy of Ophthalmology IRIS Registry, the mean age of a patient undergoing cataract surgery in the U.S. is 73 ± 11 years. So, the age of most cataract surgery patients is 62 to 84 years. At this age, systemic comorbidities are common.
The most common systemic comorbidities include diabetes, hypertension, heart disease, pulmonary disease including bronchial asthma and chronic obstructive pulmonary disease, renal insufficiency/benign prostatic hyperplasia and endocrine abnormalities such as thyroid disease. It is incumbent on the surgeon to screen for these and any other systemic disease as they can affect intraoperative cataract surgery safety and postoperative visual outcomes. Having each of them diagnosed and properly treated enhances the safety of the surgical procedure. In particular, the patient with diabetes has a much higher incidence of postoperative cystoid macular edema. This visually significant complication can be mitigated using increased topical and/or subconjunctival steroids, topical NSAIDs and, in some cases, properly timed intravitreal injection therapy. Many studies confirm that while cataract surgery does not make dry age-related macular degeneration worse, it does increase the risk for retinal tears or detachment in the axial myope and can affect the timing of wet AMD anti-VEGF injections. Many surgeons include a retinal colleague in the management of these more complex patients. Recognition of the patient on alpha-1 adrenergic receptor antagonists that may result in intraoperative floppy iris syndrome is also critical, as proper preoperative and intraoperative management can significantly reduce complications.
Ocular comorbidities are also extremely common and include every other ophthalmic diagnosis. If we include preoperative refractive error including presbyopia and ocular surface disease, and I think we should, every cataract surgery patient has at least one ocular comorbidity. The recognition and discussion with the patient and family of all ocular comorbidities are critically important. It has been popularized by my friend Eric Donnenfeld, MD, that if these ocular comorbidities are recognized, discussed and treated before surgery, they are the patient’s problem. If they are recognized, discussed and treated only after surgery, they become the surgeon’s problem. Other common ocular comorbidities include glaucoma and the often associated pseudoexfoliation, many corneal dystrophies, degenerations and diseases, uveitis and a host of retinal pathologies. Especially important is the recognition of the glaucoma/ocular hypertension patient as many safe and effective microinvasive glaucoma surgery procedures are available that can be offered to the patient, making lifelong management of their disease easier, a win-win-win for the patient, surgeon and payer.
There are many useful pearls in the accompanying Healio | OSN cover story. I recommend that every eye care professional and ophthalmic surgeon presume every cataract surgery patient has at least one systemic and more than one ocular comorbidity. It is our duty to discover them, record them in the medical record, discuss them with the patient and their family, and manage them before, during and after their procedure.
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