October 2017

COVER FEATURE

Challenging cataract cases
Special considerations for cataract surgery in patients with dementia


by Liz Hillman EyeWorld Staff Writer





“At the end of the day, the days of doctors telling patients what
to do are long gone. We’re in a partnership with our patients and their families, and we try to help them make good decisions and
explain to them the options.”
—John Hart, MD

From extra preop prep to anesthesia to target refraction, surgeons explain how they modify their care to best suit these patients

While there are various ocular factors that can drive the course of cataract surgery, non-ophthalmic factors, such as the patient’s mental state, can impact all aspects of the surgery as well as preoperative and postoperative care.
Take dementia, the most common form of which is Alzheimer’s disease. According to the latest data from the Alzheimer’s Association, there are more than 5 million Americans with Alzheimer’s. The association estimates that this number could reach 16 million by 2050.
“With our aging population, the increased prevalence of dementia and cataracts, I am seeing a larger number of patients who have the diagnosis of both dementia and cataract,” said Cynthia Matossian, MD, Matossian Eye Associates, Doylestown, Pennsylvania, and adjunct clinical assistant professor of ophthalmology, Temple University School of Medicine, Philadelphia.
But, Dr. Matossian continued, there is a spectrum of dementia diagnosis, ranging from those mildly forgetful to those who are extremely confused and unable to follow commands. Treatment and the surgeon’s approach should vary based on the level of dementia.
While a physician might be informed that a patient has dementia before they even enter the exam room, the physician needs to make their own observations and ask the right questions of the patient and caregiver to make appropriate surgical decisions, including type of anesthesia, refractive aim, and more.
Susan MacDonald, MD, associate professor, Tufts University School of Medicine, Boston, said early dementia can be hard to detect in patients, especially if they or their family members are being protective and private. Dr. MacDonald said she’ll direct her staff to alert her to anything in the patient’s history or behavior that might cause them to question the patient’s mental status, but she’ll also be watching for red flags herself.
“When you’re talking with patients about lens choices, risks, and benefits … ask some open-ended questions and make sure they understand what you’re talking about. There are some patients who, when they have early dementia, will be clever by changing the subject or joking about things,” Dr. MacDonald said. “If a patient is redirecting the discussion or if they’re unable to remember something, it’s critical to probe a little bit more. It is important to be gentle with these patients and their families, but it’s also important not to miss this diagnosis. Another sign to look for is if the patient’s family members are answering questions for the patient, being overprotective, or helping the patient save face.”

Decision making in the preoperative stage

Because cataract surgery can improve these patients’ quality of life quite a bit, John Hart, MD, Associates in Ophthalmology, Farmington Hills, Michigan, and clinical assistant professor of biomedical sciences, Oakland University, Rochester, Michigan, said his threshold for offering cataract surgery to patients with dementia is low. Dr. MacDonald also stressed the importance of early cataract surgery for dementia patients. Not only are mature cataracts more difficult to operate on, but dementia patients have a greater fall risk; having a more confused mental state might make it more difficult for them to feel physically oriented.
“Confusion and decreased vision are a dangerous combination, so we want to make sure we are equipping them with all the tools we can for them to stay oriented and safe,” Dr. MacDonald said.
A study published in the American Journal of Ophthalmology found vision-related quality of life, cognitive impairment, and depression were strongly related and that cataract surgery could improve all three.1 Dr. Matossian said sometimes children or caregivers might think a patient’s cognitive ability has declined—for example, because they’re no longer reading magazines or showing interest in other hobbies—when in fact, it is the cataract that’s inhibiting the activity.
“In those circumstances, when I have done cataract surgery and helped them see again, their level of interest … is back up because now we’ve eliminated the visual hindrance,” Dr. Matossian said.
First and foremost, it’s “critical” for dementia patients to have someone present who is legally allowed to make decisions for them, when needed, at appointments, Dr. Matossian said. Having that second set of ears to absorb all the information about the options, the surgery, and postop care is important and is something she recommends for all her patients.
Dr. Hart pointed out that some parts of the exam might not be possible with a dementia patient, such as subjective refraction testing. As such, asking questions of the caregiver, at times, can help identify what the patient is and is not seeing and what his or her visual needs might be postop.
“They’re likely not driving a car. They need to be able to watch television, see the food on their plate and the people who are across from them, and typically you’re gearing the surgical result to reflect that. Usually a low amount of myopia is an appropriate end point to be looking for,” Dr. Hart said.
The risks that need to be explained as much as possible to the patient and the caregiver are those that go hand-in-hand with the possibility of general anesthesia, the possible neurologic risk of anesthesia making dementia worse, and sight-threatening risks if the patient, not under general anesthesia, is unable to control himself or herself, Dr. Hart said.

Considering anesthesia

Dr. Matossian said she is generally able to judge in the preoperative visits whether patients will be suitable for topical anesthesia, if they will need a block, or if they’ll require general anesthesia. Dr. Matossian uses laryngeal mask airway general anesthesia, finding it to be less invasive.
In patients who are marginal when it comes to their level of dementia, Dr. Matossian plans for the possibility of having to switch from topical to general anesthesia.
“Sometimes patients are marginal, meaning they appear OK, but under an unfamiliar setting of an operating room, they may become confused, especially once the drape is placed over them,” she said.
“Anesthesia works very differently with these folks,” Dr. Matossian continued later. “Often less medication is better than more. The more anesthesia we give them, the more confused they become.”
Dr. Hart expressed a similar sentiment. “As much as possible, less is more, but ultimately, you’re doing anesthesia so that you can have a safe surgery,” he said. On the vein of keeping the patient calm, Dr. Hart provided a couple of other simple tips for the OR.
“Have a running commentary, calm demeanor, talk with the patient,” he said. “I also tend to like the CRNA to hold the patient’s hand. Before we drape the patient, she will explain that she’s going to be there holding their hand and if there is an issue, they should squeeze her hand and that will be our clue to respond right away. It’s something we try to do with everyone because it is very calming.”
Both Drs. Matossian and MacDonald said they will tape the head of dementia patients who they fear might get confused during the surgery and try to move.

Reflecting on refraction

Target refraction is of particular importance in this group. As Dr. Hart previously stated, he thinks these patients are less likely to need clear distance vision, making intermediate vision important. As such, Dr. Hart targets patients for slightly myopic, rather than plano.
Dr. Matossian pointed out that these patients, if wanting to read or do near tasks, might have trouble remembering where they put their reading glasses. For this reason, she said she has used multifocals in some dementia patients.
“They’re not driving so halos and starbursts are not a big problem for them, and this way they don’t have to rely on glasses,” she said.
Dr. Hart said multifocal IOLs for these patients would be the preference “in a perfect world,” but the expense and the likelihood of other ocular comorbidities usually preclude them from being multifocal candidates.
Dr. MacDonald said she thinks maintaining good distance vision is important for these patients. While monovision or a multifocal could be useful if the patient is likely to lose reading glasses, Dr. MacDonald stressed the importance of good depth perception.

Postop care and other considerations

With dementia patients, Dr. Matossian said she’ll often do a “double prep,” expanding the area where she applies betadine and also using SteriLid (TheraTears, Ann Arbor, Michigan) because sometimes their hygiene might not be as well accounted for.
She used to put in one suture just in case patients forgot they were not to rub their eye. For the last few years, however, she’s been using ReSure Sealant (Ocular Therapeutix, Bedford, Massachusetts) instead.
“I also place a plastic shield over their eye when they leave the OR; I don’t do that for my typical cataract patients. They wear it home while the eye is still numb since I don’t want them to touch their eye. I recommend the shield be used during naps and every night for a minimum of 7 days,” Dr. Matossian said.
Dr. MacDonald has all of her cataract patients where a shield for a week.
Both Drs. Hart and Matossian said they make sure the patient has someone who will help them remember their drops or instill the drops for them. However, because some patients might fight instillation of these drops, Dr. Matossian said in her more confused patients she will use an intracameral antibiotic and steroid combination requiring only a topical NSAID, the latter of which she noted is branded and only requires one drop a day.
“I decrease the drop burden to the patient postoperatively,” Dr. Matossian said.
Dr. MacDonald said she’ll consider subconjunctival delivery of antibiotics and steroids as well if she fears noncompliance.
“I try to keep it as simple as possible,” she said. “I’ll work with the family to try and figure out how we can taper them off any drops as quickly as possible.”
What about other considerations such as immediately sequential bilateral cataract surgery (ISBCS)? Dr. Hart thinks there are several very real barriers to its implementation in any patient, whether or not the patient has dementia. These include the risk for TASS or endophthalmitis occurring in both eyes, less reimbursement, and, he noted, medical malpractice doesn’t cover it.
Dr. Matossian said she doesn’t do ISBCS, but added that sometimes she’ll do just one of the cataracts. “Most of the time, just doing the one eye is all they need because then they can see well enough to navigate, see their food,” she said.
There may be patients who are not good candidates for cataract surgery at all, such as patients with serious medical conditions or who cannot follow commands, Dr. Matossian said. Dr. Hart said it might not be worth going through surgery for a patient who is near the end of life.
“At the end of the day, the days of doctors telling patients what to do are long gone. We’re in a partnership with our patients and their families, and we try to help them make good decisions and explain to them the options. These are not easy answers,” Dr. Hart said.
As a final piece of advice, Dr. Hart said it’s important to talk to, not over, the patient, regardless of the level of dementia.
“It’s easy, because they don’t talk back, to cut them out of the informed consent, but I think it’s important to keep them involved and let the family see that you’re keeping them involved because it’s the right thing to do,” Dr. Hart said. “Because they can’t express themselves, we don’t know exactly what’s going on inside their mind. We have to treat them like we would any other human being.”

Reference

1. Ishii K, et al. The impact of cataract surgery on cognitive impairment and depressive mental status in elderly patients. Am J Ophthalmol. 2008;146:404–9.

Editors’ note: Drs. Matossian, MacDonald, and Hart have no financial interests related to their comments.

Contact information

Hart
: j.c.hartjr@sbcglobal.net
MacDonald: Susan.M.MacDonald@lahey.org
Matossian: cmatossian@matossianeye.com

Special considerations for cataract surgery in patients with dementia Special considerations for cataract surgery in patients with dementia
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