December 2018

CATARACT

Research highlight
Cataract removal in the ultra-golden years


by Maxine Lipner EyeWorld Senior Contributing Writer


Slit lamp photograph of a mature, white cataract that is visually significant
Source: Curtis Margo, MD

 

What to keep in mind

Even if a patient is very old, he or she should not necessarily be precluded from undergoing cataract surgery, according to Emily Li, MD, post-graduate fourth-year resident physician, Yale University, New Haven, Connecticut. Despite battling higher rates of ocular comorbidity, investigators in a recent study, published in the Journal of Cataract and Refractive Surgery,1 found that cataract surgery in this group significantly improved visual acuity.
It’s important not to underestimate this group, Dr. Li said. She cited a prior cataract study that compared patients in the 80- to 89-year-old age range to those ages 90 to 99. “They found that patients in the older group tended to be healthier,” she said, adding that since this is an elective procedure, if older patients are opting for cataract surgery, they would be less likely to have other more serious health issues.

Taking a new look

Dr. Li noted that she and the other authors were spurred to take on the current study by the fact that they were all actively involved in the care of very elderly patients. “Given the trend of the aging population in the U.S. and other countries around the world, we see a lot more of these patients,” Dr. Li said. “For our patients, if we want to know what the risks are, we turn to evidence-based medicine.” When investigators did a literature review on the success of cataract surgery in the very elderly, they found that there were no recent publications on the topic. “The one that was most recent was more than a decade ago,” she said. “Given the new advances in cataract surgery over the past decade, this warranted another look.”
Investigators used the World Health Organization and National Institute of Aging definition of 85 years and older to determine who was included in this group. “The studies we included were from various populations around the world, so there was no ethnic exclusion,” Dr. Li said, adding that they prioritized trials that had quality of study evidence and that were well designed.
While there were limited studies to draw conclusions from, investigators found that the very elderly cohort fared well. “It did not seem that age significantly reduced the risk of ocular or systemic complications from cataract surgery,” Dr. Li said. “We found that across studies that looked at effect on quality of life, cataract surgery improved very elderly patients’ quality of life.” This included factors such as ability to read or watch TV, walk, or perform activities of daily living; for cognitive orientation, they had better function, Dr. Li reported. “When patients self-reported their satisfaction, there was also a significant improvement,” she said. “Lastly, when we looked at survival time after cataract surgery, we found that the majority of patients were able to enjoy the benefits of cataract surgery at least 1 year out, if not longer.”

In the clinic

From a clinical perspective, Dr. Li views the results as important, pointing to the fact that this segment of the population continues to grow. “There may be a very elderly population some day because people are living longer,” she said. Clinicians may want to share with those whose quality of life has diminished due to cataracts that these study results show that age alone does not preclude someone from being considered for cataract surgery.
Still, this population tends to be different from their younger compatriots. “From the ophthalmologist’s perspective, a collaboration with the primary care physician is key because no one knows a patient more intimately than his or her primary care doctor,” Dr. Li said. “These patients should undergo medical clearance for the surgery, and physicians should assess whether it will make an impact on the patient’s life.” The ophthalmologist alone may not fully understand what the patient’s needs are.
Also, it’s important to be cognizant of other factors such as whether or not the patient has the support needed to get to an anesthesia or cardiologist appointment or some other assistance if they need that kind of clearance, Dr. Li noted. It is important to ensure the patient has the support he or she needs. There was one case recorded where the patient had dementia and restlessness, and family members were able to be in the operating room with the patient and reassure them so that they could undergo the cataract surgery.
It’s also important to be realistic with the patient, Dr. Li stressed. “If a patient has a visually significant comorbidity such as advanced glaucoma or macular degeneration, which are more prevalent as patients age, ophthalmologists should counsel the patient on the visual potential from the surgery,” she said.
Overall, Dr. Li hopes that practitioners come away with the realization that age alone should not be a deterrent to very elderly patients who have significant cataracts who would be interested in undergoing the procedure.
Since there aren’t a lot of large quality studies examining this, further research is needed, especially given the expanding aging population, Dr. Li concluded.

Reference

1. Li E, et al. Cataract surgery outcomes in the very elderly. J Cataract Refract Surg. 2018; 44:1144–1149.

Editors’ note: Dr. Li has no financial interests related to her comments.

Contact information

Li
: emily.li@yale.edu

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