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Cataract surgery usually the best choice for elderly patients
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Earlier this week I had the pleasure of seeing one of my long-term patients. She is an 85-year-old family matriarch whose husband, children and grandchildren have all become patients through the years. While she is as pleasant as she was 25 years ago, time has undoubtedly taken its toll. Her husband is recently deceased, she has moved to an assisted living residence and her physical frailty is evidenced by the numerous medications she takes for a variety of ailments. While she continues to do fairly well from an ocular standpoint, she does manifest maturing nuclear sclerotic cataract. This, of course, was the focus of our discussion, which led inevitably to the big question – are my cataracts ready for surgery?
It is a perfectly reasonable question and one that we answer daily. Unfortunately, it is also a question for which there is not always an easy answer. On one hand, it is completely understandable that we defer surgery for this individual. She is no longer driving and she resides in a community in which basic living needs (cooking, cleaning and laundry) are provided for her. Furthermore, given her long list of ailments and medications, why give her one more “condition” to deal with? Additionally, there is good likelihood that she will incur some cost depending on her insurance and IOL selection. However, perhaps most importantly, there is the time-honored dictum: primum non nocere or first, do no harm. Simply put, why subject her to cataract surgery – and any attending risks – if it is not absolutely necessary?
Michael D. DePaolis
While we all consider – first and foremost – primum non nocere when making each and every patient care decision, it might well be the very reason we suggest cataract surgery. It is a given that all seniors experience some degree of physical and cognitive decline as the years advance, but many remain physically active and intellectually engaged. For these individuals, their vision is every bit as important as it was in earlier years. For these folks, cataracts are especially problematic, as suboptimal vision can negatively impact them physically and cognitively.
While the interplay between cataract-induced visual impairment and the role cognitive decline plays in visual processing is not fully understood, we know patients with mild dementia who undergo cataract surgery seem to fare better than their peers who do not have the surgery (Girard et al.). Similarly, while both visual impairment and mobility limitations put seniors at risk for falls, those who undergo cataract surgery are statistically less likely to fall after surgery than those who do not undergo cataract extraction (Brannan et al.).
So, if we truly aspire to primum non nocere, what is the best “medicine”? While this question can only be answered after weighing all considerations for each patient, the evidence increasingly tips in favor of cataract surgery in the majority of cases. Given the exceptional safety profile and impressive visual outcomes of cataract surgery today, it is hard to argue against its risk:benefit ratio, especially, if our goal is to do no harm.
References:
Girard B, et al. Paper presented at: Annual Meeting of the American Academy of Ophthalmology; October 2011; Orlando, FL.