Average life expectancy is at an all-time high in the US at 79, with even better news for people who are already seniors who are expected to live to 85. This means that we will see more patients age 90 and above 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 play 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.
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 the post-operative eye drops should be taken into consideration. As ophthalmologists, we have to take a step back and be sure to evaluate the who patient and not merely the eyes.
(2) Be gentle with delicate ocular tissues
The tissues that you’ll be working with during the cataract surgery are greater than 90 years old. And I suspect that the aging effects that occur from 80 to 90 are more than from 70 to 80. 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 the corneal endothelial cell count and function decreases 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 co-morbidities such as macular disease or glaucoma are more likely to be present since they are age-related. Doing cataract surgery in an eye with macular degeneration may mean a more limited post-operative 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 post-op 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 post-op 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 also higher due to an increased prevalence of epi-retinal 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 it 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 the official CDC (Centers for Disease Control) 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.