Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Comment
  • Published:

How old is too old for routine cataract surgery?

Eye volume 37, pages 3304–3305 (2023)Cite this article

Subjects

The safety and cost-effectiveness of cataract surgery are well established [1]. But as with most surgical procedures, there are concerns about whether the risk of complications is higher and whether overall outcomes are negatively correlated with the patient’s age [2]. A recent report from the Royal College of Ophthalmologists National Ophthalmology Database Audit of cataract surgery revealed a higher risk of complications and slightly poorer cataract surgery outcomes in patients 90 years or older, more so in patients with ocular co-morbidities, which were highly prevalent in this cohort [3]. Moreover, it is already known that patients presenting for cataract surgery at advanced age also have higher rates of systemic co-morbidities [4].

The safety and efficacy of cataract surgery in the elderly population is a complex issue. Firstly, ocular factors such as age-related morphological changes in the lens, such as dense nuclear sclerosis, and weak zonules, can increase the complexity of cataract surgery in the elderly [3, 5]. This is supported by a higher risk of intra-operative complications as reported in many studies, including the recent results from the National cataract audit published in 2019; the latter reported a posterior capsular rupture rate of 2.7% in patients 90 years or older with significant risk indicators including pseudoexfoliation/phacodonesis, mature cataracts, smaller pupils and worse preoperative VA [3, 5,6,7]. Secondly, surgeons may be cautious in offering an elective procedure to elderly patients, often because of concurrent systemic co-morbidities [5]. Surgery may further be made complicated by positioning challenges, as a result of neck or back problems, compounded by patient discomfort during a procedure under local anaesthesia. Thirdly, increasing age has been independently linked to worse visual outcomes after cataract surgery and a higher prevalence of ocular co-morbidities such as age-related macular degeneration [1, 6, 8]. Though most studies report good visual outcomes of cataract surgery in the elderly, the benefits are not unequivocal. There are concerns that the outcomes are not as good as younger patients, even whilst adjusting for ocular co-morbidities [2, 5, 6, 9,10,11]. However, it may be pointed out that an improvement in visual acuity and/or vision-related quality of life may be a better indicator of a benefit than those achieving vision better than a cut-off of 6/12, as many elderly patients may have poorer preoperative visual acuity, to begin with. Therefore, offering cataract surgery at the earliest sign of any ocular or systemic co-morbidity is likely to risk fewer complications than continuing to postpone the surgery due to the fear of intra-operative complications.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

References

  1. Sparrow JM, Taylor H, Qureshi K, Smith R, Birnie K, Johnston RL. et al. The Cataract National Dataset electronic multi-centre audit of 55,567 operations: risk indicators for monocular visual acuity outcomes. Eye (Lond). 2012;26:821–6.

    Article  CAS  PubMed  Google Scholar 

  2. Bernth-Petersen P, Ehlers N. Cataract extraction in the ‘nineties’. Acta Ophthalmol (Copenh). 1983;61:392–6.

    Article  CAS  PubMed  Google Scholar 

  3. Theodoropoulou S, Grzeda MT, Donachie PHJ, Johnston RL, Sparrow JM, Tole DM. The Royal College of Ophthalmologists’ National Ophthalmology Database Study of cataract surgery. Report 5: clinical outcome and risk factors for posterior capsule rupture and visual acuity loss following cataract surgery in patients aged 90 years and older. Eye (Lond). 2019;33:1161–70.

    Article  CAS  Google Scholar 

  4. Pham TQ, Wang JJ, Rochtchina E, Maloof A, Mitchell P. Systemic and ocular comorbidity of cataract surgical patients in a western Sydney public hospital. Clin Exp Ophthalmol. 2004;32:383–7.

    Article  PubMed  Google Scholar 

  5. Syam PP, Eleftheriadis H, Casswell AG, Brittain GP, McLeod BK, Liu CS. Clinical outcome following cataract surgery in very elderly patients. Eye (Lond). 2004;18:59–62.

    Article  CAS  PubMed  Google Scholar 

  6. Norregaard JC, Hindsberger C, Alonso J, Bellan L, Bernth-Petersen P, Black C, et al. Visual outcomes of cataract surgery in the United States, Canada, Denmark, and Spain. Report from the International Cataract Surgery Outcomes Study. Arch Ophthalmol. 1998;116:1095–100.

    Article  CAS  PubMed  Google Scholar 

  7. Wong TY. Effect of increasing age on cataract surgery outcomes in very elderly patients. BMJ. 2001;322:1104–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Wong TY. Cataract surgery in patients with cataract and age related macular degeneration: do the benefits outweigh the risks? Br J Ophthalmol. 2000;84:1337–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Applegate WB, Miller ST, Elam JT, Freeman JM, Wood TO, Gettlefinger TC. Impact of cataract surgery with lens implantation on vision and physical function in elderly patients. JAMA. 1987;257:1064–6.

    Article  CAS  PubMed  Google Scholar 

  10. Lundstrom M, Stenevi U, Thorburn W. Cataract surgery in the very elderly. J Cataract Refract Surg. 2000;26:408–14.

    Article  CAS  PubMed  Google Scholar 

  11. Westcott MC, Tuft SJ, Minassian DC. Effect of age on visual outcome following cataract extraction. Br J Ophthalmol. 2000;84:1380–2.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Maharani A, Dawes P, Nazroo J, Tampubolon G, Pendleton N, SENSE-Cog WP1 group. Cataract surgery and age-related cognitive decline: a 13-year follow-up of the English Longitudinal Study of Ageing. PLoS One. 2018;13:e0204833.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Stagg BC, Choi H, Woodward MA, Ehrlich JR. Association of social support network size with receipt of cataract surgery in older adults. JAMA Ophthalmol. 2018;136:423–7.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Chandra S, Sivaprasad S, Ursell PG, Naderi K, O’Brart D, Alwitry A, et al. Recurring themes during cataract assessment and surgery. Eye (Lond). 2021;35:2482–98.

    Article  PubMed  Google Scholar 

  15. Jefferis JM, Clarke MP, Taylor JP, Brittain KR. Challenges for the cataract surgeon treating people with dementia: a qualitative study exploring anesthetic choices. Clin Ophthalmol. 2014;8:1993–9.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Mansour A, Stewart MW, Charbaji AR, El Jawhari KM, El Zein L, Mansour MA, et al. Perceived surgeon stress during no-sedation topical phacoemulsification. Clin Ophthalmol. 2020;14:2373–81.

    Article  PubMed  PubMed Central  Google Scholar 

  17. McLean K, Ferrara M, Kaye R, Romano V, Kaye S. Establishing the influence of case complexity on the order of cataract lists: a cross-sectional survey. BMJ Open Ophthalmol. 2021;6:e000809.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Iacobucci G. Cataract surgery is cost effective and should not be rationed, says NICE. BMJ. 2017;358:j3588.

    Article  PubMed  Google Scholar 

  19. Petrash JM. Aging and age-related diseases of the ocular lens and vitreous body. Invest Ophthalmol Vis Sci. 2013;54:ORSF54–9.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Briszi A, Prahs P, Hillenkamp J, Helbig H, Herrmann W. Complication rate and risk factors for intraoperative complications in resident-performed phacoemulsification surgery. Graefes Arch Clin Exp Ophthalmol. 2012;250:1315–20.

    Article  PubMed  Google Scholar 

  21. Lam D, Zhang H, Jain NS, Agar A, Francis IC. Low-grade versus medium-grade nuclear sclerotic cataract density produces identical surgical and visual outcomes: a prospective single-surgeon study. Cureus. 2020;12:e11997.

    PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Sussex Eye Hospital, University Hospitals Sussex NHS Foundation Trust, Eastern Road, Brighton, BN2 5BF, UK

    Ritika Mukhija & Mayank A. Nanavaty

  2. Brighton & Sussex Medical School, University of Sussex, Falmer, Brighton, BN1 9PX, UK

    Mayank A. Nanavaty

Authors
  1. Ritika Mukhija
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mayank A. Nanavaty
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

RM manuscript drafting, final approval. MAN Conceptualisation, manuscript editing and final approval.

Corresponding author

Correspondence to Mayank A. Nanavaty.

Ethics declarations

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Mukhija, R., Nanavaty, M.A. How old is too old for routine cataract surgery?. Eye 37, 3304–3305 (2023). https://doi.org/10.1038/s41433-023-02521-z

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41433-023-02521-z

Search

Advanced search

Quick links