October 2016




ASA classifications correlate with cataract surgery outcomes

by Vanessa Caceres EyeWorld Contributing Writer


Patients with a higher American Society of Anesthesiologists (ASA) classification before cataract surgery had worse visual outcomes and increased risk of clinically significant macular edema and readmission to the hospital within 30 days after surgery compared with healthier patients, according to a study published in the Journal of Cataract & Refractive Surgery.1 The study’s findings shed light on the relationship between preop assessments and ophthalmic outcomes after cataract surgery, said study author Mary Daly, MD, ophthalmology department, Veterans Affairs Boston HealthCare System, Boston.

Data review

The ASA system evaluates physical status with regard to systemic disease and is a predictor of mortality and morbidity after major non-cardiac and cardiac operations, the study reported. “Less is known, however, for cataract surgery specifically regarding the relationship between ASA class with ophthalmic outcomes,” Dr. Daly said.

Authors of the retrospective observational cohort study included 4,923 cases from five Veterans Affairs Medical Centers across the U.S. Patients in ASA classes I and II (875 patients)—considered healthier patients—were designated as Group A. Patients in ASA classes III and IV (4,032 patients)—generally not as healthy—were designated as Group B. Although the ASA system has two other classes, I through IV are the only ones relevant to ophthalmic surgery, the authors wrote.

Researchers analyzed corrected distance visual acuity (CDVA), unanticipated events, and vision-related quality of life using the National Eye Institute Visual Function Questionnaire (NEI-VFQ). The data reviewed were from the Veterans Health Administration’s Ophthalmic Surgery Outcomes Database Pilot Project, a quality-improvement program.

The mean patient age in Group A was 66 years old versus 71 years old in Group B. Most patients were men. “As ASA class increased, so did the proportion of those with diabetes mellitus, hypertension, peripheral vascular disease, chronic pulmonary disease (COPD), and congestive heart failure,” the authors wrote. The only comorbidity without a major difference among the groups was a history of hearing impairment.

Although the mean CDVA and NEI-VFQ scores improved in both groups after surgery, Group A had a better mean postop CDVA and better postop VFQ composite scores. The proportion of patients with postop CDVA of 20/40 or better decreased with increasing ASA class, and this trend was significant (p=.0017). Patients in higher ASA classes with more systemic disease had lower vision-related quality of life compared to healthier patients with less systemic disease (P<.001).

Group B patients were also more likely to be at risk for two unanticipated events: clinically significant edema (Group A, 0.47% versus Group B, 1.28%) and readmission to the hospital within 30 days (Group A, 0.23% versus Group B, 1.41%). There were eight deaths within 30 days of surgery, all of which occurred in Group B. Researchers found that patients with a history of COPD were at significantly higher risk of all-cause death after cataract surgery. The authors concluded that ASA classification was useful in estimating visual acuity outcomes, perioperative events, and vision-related quality of life after surgery.

Practical implications

This kind of research could help surgeons better estimate the risks of surgery and set reasonable visual outcome expectations for the patients. “It might also provide an opportunity for improved informed consent processes and decision making and better optimization of patients with comorbidities before elective surgery, and it could potentially decrease the risk for poor surgical outcomes,” the authors wrote.

“Though cataract surgery is often referred to as a low-risk procedure, it appears there is an important relationship between ASA class and outcomes of this surgery,” Dr. Daly said. Based on the study, Anita Shukla, MD, assistant in ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, said she will broaden her informed consent discussion to include the importance of optimizing systemic illness prior to routine cataract surgery. “The study demonstrates that best corrected visual acuity and vision-related quality of life results are lower in higher ASA classes. Patients should be aware of these facts so that their postop expectations are clear,” she said.

The significant association of ASA class and clinically significant macular edema with 30-day readmission to the hospital should be addressed with patients, and surgeons should take steps to lower this risk, such as by offering a longer course of nonsteroidal and steroidal drops postop, Dr. Shukla said.

One finding that raised a red flag was the significant association found between a history of COPD and 30-day postop mortality—even if the mortality did not have a direct relationship to cataract surgery. “Patients, anesthetists, and ophthalmic surgeons should consider this additional factor when weighing the risks and benefits of elective surgery in patients with COPD,” Dr. Daly said. “Preoperative consultation with medical, pulmonary, and/or cardiac physicians, more rigorous optimization before surgery, and closer follow-up after surgery could help decrease this risk.” David Mannino, MD, professor of medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky, Lexington, was not surprised that COPD patients had a greater number of deaths within 30 days after surgery. However, he pointed out that the total number of deaths was low. Still, he thinks this research sheds some light on COPD. “It highlights the reality that it’s a chronic condition. There’s a perception that it’s not taken as seriously as other diseases,” Dr. Mannino said. In fact, there are some studies that show a greater number of deaths 90 days after hospital admission in COPD patients versus those with heart disease. Dr. Mannino supports the idea that COPD patients be cleared for any kind of surgery by a pulmonary specialist, if they have one.

“It also appears that patients undergoing cataract surgery in the VA are generally sicker, and such patients would benefit from a higher level of care and team approach with their primary care and medical care teams,” Dr. Shukla added.


1. Payal AR, et al. American Society of Anesthesiologists classification in cataract surgery: Results from the Ophthalmic Surgery Outcomes Data Project. J Cataract Refract Surg. 2016;42:972–982.

Editors’ note: The physicians have no financial interests related to their comments. The views expressed by Dr. Daly do not necessarily reflect the position or policy of the United States Department of Veterans Affairs or the U.S. Government.

Contact information

: mary.daly2@va.gov
Mannino: dmmann2@email.uky.edu
Shukla: anitanathanshukla@gmail.com

Related articles:

Management of capsule rupture at cataract surgery by Steve Charles, MD

Cataract surgery on what could be “the most myopic eye ever operated on” by Liz Hillman EyeWorld Staff Writer

Considerations for cataract surgery in short eyes by Liz Hillman EyeWorld Staff Writer

How are we performing nucleus division during cataract surgery? by Mitchell Gossman, MD

Double trouble: Diplopia following cataract or refractive surgery by Maxine Lipner Senior EyeWorld Contributing Editor

ASA classifications and cataract surgery ASA classifications and cataract surgery
Ophthalmology News - EyeWorld Magazine
283 110
283 110
True, 10