Back to Basics

Cataract surgery in patients older than 90 years

Three areas need special consideration in nonagenarian patients.

Average life expectancy is at an all-time high in the U.S. at 79 years, with even better news for people who are already seniors, who are expected to live to 85 years. This means that we will see more patients age 90 years and older having cataract surgery. In my practice, I see multiple patients every month who have reached the age of 90 and now require cataract surgery. But cataract surgery in these patients is not the same as in younger patients. I recommend three important considerations when performing cataract surgery in nonagenarian patients.

1. Be aware of systemic medical conditions

Nonagenarians have more systemic medical conditions than younger cataract patients who are in their 60s, 70s and 80s. The incidence of pathologies such as coronary artery disease, hypertension, metabolic disease and more is higher in older patients. In addition, these patients can be more sensitive to anesthetic agents with only a narrow therapeutic window. The anesthesiologist will pay close attention to the vital signs of your elderly patient during cataract surgery to monitor the patient’s systemic health, but will be conservative in the administration of sedating agents.

You should be aware that arthritis and orthopedic conditions such as kyphosis could mean that positioning the patient for surgery in the standard supine position may be a challenge. The more fragile overall health means that the patient will likely receive less systemic sedation. There may be orthopnea due to congestive heart failure, which would require the patient to be at least partially upright and not completely flat and supine.

This elderly patient had a prior trabeculectomy for management of glaucoma. During cataract surgery, there is an alteration in the normal fluidic balance due to the additional outflow path. This means a higher risk of chamber instability, surge and complications such as posterior capsule rupture.

Source: Uday Devgan, MD

The incidence of neurologic conditions such as Alzheimer’s disease is higher with advanced age. This may mean issues with obtaining an informed consent for surgery or with patient cooperation during the procedure. Even the ability to use postoperative eye drops should be taken into consideration. As ophthalmologists, we have to take a step back and be sure to evaluate the whole patient and not merely the eyes.

2. Be gentle with delicate ocular tissues

The tissues that you will be working with during cataract surgery are older than 90 years, and I suspect that the aging effects that occur from 80 to 90 years are more than from 70 to 80 years. As such, you can expect the zonular structures to be weaker while age has made the lens nucleus denser, and both of these factors increase the risk of surgery and the potential for complications.

The cornea goes through age-related changes as well. Elasticity decreases, and the physical corneal strength may be less. Certainly, with age corneal endothelial cell count and function decrease, which means that the trauma from cataract surgery may induce iatrogenic decompensation. The view through the cornea for cataract surgery can be impaired, and these patients also tend to have arcus senilis, which can obscure a retained lens fragment in the angle. The cornea may not seal as well as in a younger patient, and there is a higher chance that a suture will be needed.

Other ocular comorbidities such as macular disease or glaucoma are more likely to be present because they are age-related. Doing cataract surgery in an eye with macular degeneration may mean a more limited postoperative visual recovery. In an eye with a glaucoma surgery such as trabeculectomy, the fluidics of cataract surgery will be altered with increased outflow, which could mean more risk of surge and complications such as ruptured posterior capsule.

3. Allow more time for postop healing

With a dense cataract, more ultrasonic energy is expected to be used during cataract surgery, and this can lead to corneal edema in the postop period. With a lower corneal endothelial pump function, this corneal edema may take longer to resolve and in rare cases may lead to pseudophakic bullous keratopathy and vision loss requiring more surgery. Elderly patients may also need more time for the cornea to stabilize in terms of refraction.

The incidence of macular edema after cataract surgery is higher due to an increased prevalence of epiretinal membrane and lower retinal function. Keeping the patients on topical anti-inflammatory medications for at least a few weeks after surgery can help them achieve better vision and healing.

Anterior chamber inflammation tends to be moderate in older patients and is typically easily controlled with topical steroids. Corneal healing can be slower with less security in wound closure, particularly if the incision is totally avascular. For this reason, I recommended barely nicking the limbal vessels during creation of the phaco incision. If there is any evidence of leakage at the end of the procedure, placing a 10-0 nylon suture gives the best security.

According to official CDC numbers, the average person who is 65 years old still has, on average, 20 years remaining in life. And with this increased longevity comes more nonagenarian patients. Doing cataract surgery in these patients is rewarding, and it restores the gift of sight to patients who may even reach 100.

Full video of surgical techniques in nonagenarian patients can be seen at www.CataractCoach.com.

Disclosure: Devgan reports he runs www.CataractCoach.com, which is a free cataract teaching site.

Average life expectancy is at an all-time high in the U.S. at 79 years, with even better news for people who are already seniors, who are expected to live to 85 years. This means that we will see more patients age 90 years and older having cataract surgery. In my practice, I see multiple patients every month who have reached the age of 90 and now require cataract surgery. But cataract surgery in these patients is not the same as in younger patients. I recommend three important considerations when performing cataract surgery in nonagenarian patients.

1. Be aware of systemic medical conditions

Nonagenarians have more systemic medical conditions than younger cataract patients who are in their 60s, 70s and 80s. The incidence of pathologies such as coronary artery disease, hypertension, metabolic disease and more is higher in older patients. In addition, these patients can be more sensitive to anesthetic agents with only a narrow therapeutic window. The anesthesiologist will pay close attention to the vital signs of your elderly patient during cataract surgery to monitor the patient’s systemic health, but will be conservative in the administration of sedating agents.

You should be aware that arthritis and orthopedic conditions such as kyphosis could mean that positioning the patient for surgery in the standard supine position may be a challenge. The more fragile overall health means that the patient will likely receive less systemic sedation. There may be orthopnea due to congestive heart failure, which would require the patient to be at least partially upright and not completely flat and supine.

This elderly patient had a prior trabeculectomy for management of glaucoma. During cataract surgery, there is an alteration in the normal fluidic balance due to the additional outflow path. This means a higher risk of chamber instability, surge and complications such as posterior capsule rupture.

Source: Uday Devgan, MD

The incidence of neurologic conditions such as Alzheimer’s disease is higher with advanced age. This may mean issues with obtaining an informed consent for surgery or with patient cooperation during the procedure. Even the ability to use postoperative eye drops should be taken into consideration. As ophthalmologists, we have to take a step back and be sure to evaluate the whole patient and not merely the eyes.

2. Be gentle with delicate ocular tissues

The tissues that you will be working with during cataract surgery are older than 90 years, and I suspect that the aging effects that occur from 80 to 90 years are more than from 70 to 80 years. As such, you can expect the zonular structures to be weaker while age has made the lens nucleus denser, and both of these factors increase the risk of surgery and the potential for complications.

The cornea goes through age-related changes as well. Elasticity decreases, and the physical corneal strength may be less. Certainly, with age corneal endothelial cell count and function decrease, which means that the trauma from cataract surgery may induce iatrogenic decompensation. The view through the cornea for cataract surgery can be impaired, and these patients also tend to have arcus senilis, which can obscure a retained lens fragment in the angle. The cornea may not seal as well as in a younger patient, and there is a higher chance that a suture will be needed.

PAGE BREAK

Other ocular comorbidities such as macular disease or glaucoma are more likely to be present because they are age-related. Doing cataract surgery in an eye with macular degeneration may mean a more limited postoperative visual recovery. In an eye with a glaucoma surgery such as trabeculectomy, the fluidics of cataract surgery will be altered with increased outflow, which could mean more risk of surge and complications such as ruptured posterior capsule.

3. Allow more time for postop healing

With a dense cataract, more ultrasonic energy is expected to be used during cataract surgery, and this can lead to corneal edema in the postop period. With a lower corneal endothelial pump function, this corneal edema may take longer to resolve and in rare cases may lead to pseudophakic bullous keratopathy and vision loss requiring more surgery. Elderly patients may also need more time for the cornea to stabilize in terms of refraction.

The incidence of macular edema after cataract surgery is higher due to an increased prevalence of epiretinal membrane and lower retinal function. Keeping the patients on topical anti-inflammatory medications for at least a few weeks after surgery can help them achieve better vision and healing.

Anterior chamber inflammation tends to be moderate in older patients and is typically easily controlled with topical steroids. Corneal healing can be slower with less security in wound closure, particularly if the incision is totally avascular. For this reason, I recommended barely nicking the limbal vessels during creation of the phaco incision. If there is any evidence of leakage at the end of the procedure, placing a 10-0 nylon suture gives the best security.

According to official CDC numbers, the average person who is 65 years old still has, on average, 20 years remaining in life. And with this increased longevity comes more nonagenarian patients. Doing cataract surgery in these patients is rewarding, and it restores the gift of sight to patients who may even reach 100.

Full video of surgical techniques in nonagenarian patients can be seen at www.CataractCoach.com.

Disclosure: Devgan reports he runs www.CataractCoach.com, which is a free cataract teaching site.