Preop Tests That Delay Cataract Surgery Tied to Falls in Older People

By David Douglas

September 28, 2020

NEW YORK (Reuters Health) - Postponing cataract surgery because of standard preoperative testing may increase the risk of falls in older people, according to a new study.

"We've known for a while that routine preoperative testing before cataract surgery doesn't improve outcomes. However, the finding that there can be actual harm from delaying surgery for the sake of undergoing these unnecessary laboratory or cardiac tests is a game-changer," Dr. Catherine L. Chen of the University of California, San Francisco, told Reuters Health by email,

Cataract surgery is usually indicated when the disease impacts vision enough to compromise activities of daily living, Dr. Chen and her colleagues note in Ophthalmology. Delays in surgical scheduling prolong the period during which patients with poor vision are at an increased risk of falls.

Routine preoperative medical testing is not necessary in advance of this low-risk procedure, they say, and current guidelines reflect that. Nevertheless, about half of Medicare patients undergo at least one routine preoperative test within 30 days before their first cataract surgery - a proportion unchanged from the 1980s.

Some ophthalmologists rarely order further testing once a decision has been made to operate whereas others always do. To examine the possible impact of a high rate of testing and subsequent delay, the researchers studied data on more than 248,000 Medicare beneficiaries.

They measured the time between ocular biometry (a procedure performed when the ophthalmologist has made the decision to operate) and cataract surgery.

The ophthalmologists involved were stratified into two groups: Those who carried out routine preoperative testing in 75% or more of their patients in the 30 days before surgery were categorized as high-testing physicians, all others as low-testing physicians.

Overall, more than 40,000 patients (16.4%) had high-testing physicians. Significantly more patients of high-testing versus low-testing physicians waited more than 30 days for the procedure (31.4% vs. 25.0%); 8.2% waited more than 90 days, compared to 5.5% of patients with low-testing doctors.

Falls before cataract surgery in patients of high- versus low-testing physicians were 43% higher within the 90 days following ocular biometry (1.0% vs. 0.7%, P<0.0001). The adjusted odds ratio of falling was 1.10 (P=0.008).

The delay associated with having a high-testing physician was close to eight days. After adjustment for surgical wait time, the odds ratio of experiencing a fall was 1.07 (P=0.06).

Dr. Chen concluded, "We are hoping that any patient who needs cataract surgery can get it done with minimal delay, because we found that the risk of falling increases the longer a patient has to wait for cataract surgery once it has been recommended as the appropriate treatment by the ophthalmologist."

Commenting on the findings by email, Dr. Andrew Rabinowitz, chief medical officer at American Vision Partners in Phoenix, Arizona, told Reuters Health, "Historically, ophthalmic surgeons have required pre-operative medical testing and clearance prior to cataract surgery. In light of the advent of advanced surgical techniques and improved surgical skills and technologies, the surgical time, which ranges from 5-20 minutes, does not warrant patients obtaining pre-operative testing and surgical clearance in the majority of cases."

This study, he added, "supports the fact that there is a clear risk to the patients' surgery being delayed even by a few weeks in order for the patient to undergo pre-operative testing. In fact, the risk of hip fracture and bodily harm is significantly increased in patients whose surgery is delayed by the surgeons' insistence on pre-operative testing."

"The results of this testing rarely impacts the surgical treatment plan nor the outcome of the surgery," he said. "Thus, it is apparent that avoiding any delay in cataract surgery dramatically improves the patients' overall health status by reducing the risk of hip fracture once the decision to operate is made."

"Once a visually significant cataract is identified, and biometry is performed," Dr. Rabinowitz concluded, "there is a definite overall health advantage to getting the patient to surgery in as timely a fashion as possible. A delay as short as days to weeks can increase the patient's risk of grave injury due to hip fracture due to a fall."

SOURCE: Ophthalmology, online September 10, 2020.