What systemic comorbidities are concerning during cataract surgery?
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Dementia
Dementia has been reported to affect nearly 55 million people worldwide, a number that is expected to rise to 78 million in 2030 and 139 million in 2050.
This patient population has unique challenges due to social isolation, fall risk and common comorbid conditions such as hearing loss. Sensory deprivation in the form of visual impairment can lead to further decline.
There are limited treatments for dementia to date, but recent reports have revealed that cognitive decline can be improved after enhancing visual function with cataract surgery. Anecdotally, many ophthalmologists have witnessed this firsthand, with a trend toward encouraging early intervention. In a prospective study by Lee and colleagues, patients who underwent cataract surgery showed a 30% lower risk of developing dementia over 10 years compared with those who did not have cataract surgery.
Special considerations when planning cataract surgery in a patient with dementia include choice of anesthesia, power of attorney conversations and documentation, consideration of same-day bilateral simultaneous surgery, choice of refractive aim and fewer drop protocols.
Regarding the refractive aim, the ophthalmologist should take time to speak with the caregivers and family about how the patient spends most of the day. There will be different preferred aims depending on their daily activities.
The choice of anesthesia should be a well-thought-out plan, as not all levels of dementia are the same. Working with a neurologist to understand the Global Deterioration Scale (GDS), a systematic approach can be implemented. Some patients in the earlier stages of dementia may tolerate a regional sub-Tenon’s or retrobulbar block, while more advanced cases may require general anesthesia. In fact, 64% percent of patients with dementia with GDS of 5 or less were amenable to regional anesthesia, according to Kumar and colleagues. There is a misconception that general anesthesia should be avoided in all patients with dementia due to the possibility of cognitive decline. However, researchers found no association between the type of anesthesia and dementia risk, as confirmed by Velkers and colleagues in a study published in the Journal of the American Geriatrics Society. The goal is to perform the surgery safely with total control and proper anesthesia. Attempts to avoid general anesthesia could result in complications due to patient movements, leading to a difficult postoperative course and a worse prognosis.
There is compelling evidence that cataract surgery may decrease the risk of developing dementia, and ideally patients with signs of dementia should be operated on as early as possible while they can still cooperate. Proper planning and assessment of cognitive decline can help achieve the best possible outcomes.
- References:
- Global action plan on the public health response to dementia 2017-2025. https://iris.who.int/bitstream/handle/10665/259615/9789241513487-eng.pdf?sequence=1. Published 2017. Accessed Sept. 13, 2024.
- Kumar CM, et al. J Anaesthesiol Clin Pharmacol. 2019;doi:10.4103/joacp.JOACP_22_18.
- Lee CS, et al. JAMA Intern Med. 2022;doi:10.1001/jamainternmed.2021.6990.
- Livingston G, et al. Lancet. 2020;doi:10.1016/S0140-6736(20)30367-6.
- Reisberg B, et al. Am J Psychiatry. 1982;doi:10.1176/ajp.139.9.1136.
- Velkers C, et al. J Am Geriatr Soc. 2021;doi:10.1111/jgs.16834.
- Yeo BSY, et al. Ophthalmology. 2024;doi:10.1016/j.ophtha.2024.02.003.
Nicole R. Fram, MD, is Healio | OSN Cataract Surgery Section Editor and managing partner at Advanced Vision Care in Los Angeles.
Heart disease
Because the anesthesia is so light and the procedure is so quick, heart disease is not usually a problem with cataract surgery.
In fact, many of our patients have some form of cardiovascular disease, high blood pressure or atherosclerosis that they are managed and treated for. The American Academy of Ophthalmology does not recommend routine preoperative medical testing for these patients if they are overall stable with their heart condition, and we do not make every patient see their primary care doctor or cardiologist. However, an acute change in blood pressure, with a diastolic above 100 mm Hg or a systolic in the high 170s or 180s mm Hg, as well as new arrhythmias and anything new on an EKG would be a red flag. These signs would obviously warrant us to pause and make sure it is safe to proceed because cataract surgery is an elective procedure, and we would not want to do anything that could harm the patient. Some anesthesiologists may require a diagnostic workup in these cases to rule out the risk for stroke or myocardial infarction.
With appropriate preoperative planning, additional precautions and monitoring, patients with left ventricular assist devices (LVADs) can also safely undergo cataract surgery. I work at a tertiary academic center, and we take care to coordinate with the LVAD team and the patient’s cardiologist so that they could be promptly managed and monitored in place if there were an event with their LVAD. We routinely plan ahead to have the LVAD team come to the operating room with us and with the anesthesiologist. We have had no cardiac events, no side effects and no issue with these patients in our setting. We tend to do bilateral surgery because we have all the team in one place, and it is easier and safer for us and the patient to do everything in one session rather than wait and repeat the whole process because, at that point, the anesthesia becomes a bigger risk than the cataract itself.
From an overall standpoint, 99% of the time we do not need to change our surgical routine or anesthesia in patients with heart conditions, and they can be safely managed also in ASC settings. However, more severe cases should be referred to a hospital that is equipped for cardiac monitoring with an LVAD team.
- References:
- Brooks CC, et al. J Cataract Refract Surg. 2020;doi:10.1097/j.jcrs.0000000000000216.
- Routine preoperative laboratory testing for patients scheduled for cataract surgery – 2014. https://www.aao.org/education/clinical-statement/routine-preoperative-laboratory-testing-patients-s. Published January 2014. Accessed Sept 13, 2024.
Melissa B. Daluvoy, MD, is an associate professor of ophthalmology at Duke University Eye Center in Durham, North Carolina.
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