APPROPRIATENESS OF CATARACT SURGERY

  • 10/06/2021
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Cataracts are prevalent among older adults, and the incidence of cataract- related vision loss increases with age.1 When performed appropriately, cata- ract extraction usually improves quality of life, reduces injury, and attenuates functional declines. Cataract extraction has proven to be generally safe and highly successful; however, it is important to ensure that surgery is performed for the appropriate indications because vision-threatening complications can occur.

I. GUIDELINES

The American Academy of Ophthalmology Preferred Practice Pattern for Cataract in the Adult Eye offers general parameters for ethical decision- making in cataract surgery:

The primary indication for surgery is visual function that no longer meets the patient’s needs and for which cataract surgery provides a reasonable likelihood of improvement, or when the lens opacity inhibits optimal management of posterior segment disease or the lens causes (inflammation, angle closure, etc) medically unmanageable open-angle glaucoma.2

II. ACADEMIC STUDIES OF APPROPRIATENESS

In 1996, an expert panel of both ophthalmologists and nonophthalmolo- gists first applied well-established standardized criteria for evaluating the appropriateness of medical interventions to assess 1139 cataract surgeries performed in 10 US academic centers during 1990.3 Based on expert review of available medical records, researchers deemed the overwhelming majority of surgeries to be “appropriate” (52%) or “appropriate and crucial” (39%). A small minority of surgeries was considered to be either “uncertain” (7%) or “inappropriate” (2%). Subsequent to this study, a White Paper jointly pub- lished by the American Academy of Ophthalmology, the American Society of Cataract and Refractive Surgery, and the European Society of Cataract and Refractive Surgeons highlighted evidence that cataract surgery as performed in the United States is generally appropriate and beneficial to the patient.4 These findings are in general agreement with subsequent studies showing cataract surgery is generally appropriate.5

III. VISUAL DISABILITY FROM CATARACTS REDUCES OVERALL FUNCTION AND QUALITY OF LIFE

Visual disability from any cause can profoundly affect quality of life and can reduce a person’s ability to function safely and independently. Studies show that visual disability reduces global quality of life (based on the SF-36) more than chronic headache, type 2 diabetes, or a history of myocardial in- farction.6

The visual acuity threshold for functional difficulties varies from patient to patient, but some population-based studies suggest that even mild reductions in vision can be symptomatic. Klein et al demonstrated in a large population- based study that early lens opacities associated with mildly reduced visual acuity are often associated with difficulty reading, driving, and recogniz- ing faces.7 Cataract surgeons can advise patients regarding the impact of decreased distance vision as summarized in Table 1-1.7-10

IV. APPROPRIATE CATARACT SURGERY IMPROVES SAFETY AND QUALITY OF LIFE

Removing visually significant cataracts usually reduces the risk of injury and improves a patient’s quality of life.11-20 Even when surgery is successful in the first eye, second-eye cataract surgery offers additional benefits.15 In one study, patients aged 65 and older who had significant functional limitations due to cataracts had an 85% likelihood of substantial subjective functional improvement after cataract surgery.13

In addition to subjective benefits, research shows that appropriate cataract surgery impacts numerous objective measures of quality of life. Specific im- provements include better night vision, enhanced ability to drive, fewer falls and fractures, fewer motor vehicle accidents, better cognitive functioning on standardized tests, greater ability to live independently, and attenuated de- clines in overall functioning and well-being.13-20

V. ASSESSING THE IMPACT OF CATARACTS ON PATIENTS’ QUALITY OF LIFE

Deciding to proceed with cataract surgery represents a collaborative pro- cess between the patient and the surgeon as well as other family members and caregivers as indicated. This process should include a careful assessment of the patient’s subjective visual function. Preoperative vision-specific qual- ity of life and glare disability remain the most reliable predictors of patient satisfaction with cataract surgery, whereas preoperative visual acuity is only weakly predictive of patient satisfaction.14,21 Patients with the poorest preop- erative subjective visual function are generally the most satisfied after cataract surgery.

To appropriately advise patients regarding the risks and benefits of cataract surgery, ophthalmologists must clearly understand their patients’ needs, de- sires, and priorities. During this process, surgeons should take into account possibly inaccurate expectations regarding functional decline with age (too high/too low) and some patients’ inability to recognize and acknowledge gradual decreases in vision and visual function. Finally, surgeons have a re- sponsibility to educate patients regarding the ways in which decreased vision can limit abilities, safety, and quality of life and to help them balance these risks with the potential risks of surgery.

VI. OTHER PREDICTORS OF GOOD OUTCOME FROM CATARACT SURGERY

In addition to worse vision-associated quality of life, other predictors of good outcome after cataract surgery include age <75 years, posterior subcapsular cataract and glare disability, and the absence of age-related macu- lar degeneration or diabetes.21

VII. DOMAINS OF SUBJECTIVE VISUAL FUNCTION

In order to understand a patient’s subjective visual function, surgeons should ask specific questions about vision as it relates to activities of daily living. Quality-of-life studies have identified several important domains of vision-targeted quality of life and include the following22,23:

Difficulty with near vision activities, such as:

  • Reading small print such as newspaper, telephone book
  • Reading letters from friends and family
  • Identifying medicines
  • Reading legal forms
  • Managing bills
  • Sewing, cooking, using tools such as scissors
  • Finding things on a shelf
  • Performing make-up, hairstyling, shaving Difficulty with distance vision tasks, such as:
    • Going up and down stairs or curbs
    • Playing games, exercising, bowling, etc
    • Recognizing signs across a hall
    • Recognizing people across a room
    • Going to see movies, plays
    • Watching TV
      Vision needs for social functioning, such as:
      • Entertaining friends or family in home/room
      • Visiting people in their rooms, homes, or restaurants
      • Seeing faces and how people react to things Role limitations from visual impairment, such as:
    • Limitations in how long activities can be done
    • Accomplishing less than desired
    • Needing more help than desired
    • Limitations in kinds of activities possible Dependency from visual impairment, such as:
      • Needing lots of help
      • Needing to rely on what others say
      • Not being able to go out alone
      • Staying in a room because of eyesight

Feelings of reduced well-being/distress, such as:

  • Worrying about vision
  • Feeling frustrated with vision
  • Experiencing loss of control
  • Fearing embarrassing self or others
  • Feeling irritable because of poor vision

Peripheral and color vision tasks, such as:

  • Seeing objects off to the side
  • Picking out and matching clothes

*Dikutip dari Buku Essentials of Cataract Surgery 2nd Ed, halaman 1-5

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