What are the criteria for a patient to be considered medically fit for cataract surgery?

Medical Fitness Criteria for Cataract Surgery

Medical fitness for cataract surgery should be determined through a systematic evaluation of patient factors that could affect surgical outcomes, with the primary contraindication being when a patient cannot safely undergo surgery due to coexisting medical or ocular conditions. 1

Primary Indications for Surgery

• Decline in visual function that no longer meets patient's needs with reasonable likelihood of improvement 1
• Clinically significant anisometropia in the presence of a cataract 1
• Lens opacity interfering with diagnosis or management of posterior segment pathology 1
• Lens-induced inflammation and related secondary glaucoma 1
• Lens-induced primary angle closure or other forms of lens-related glaucoma 1

Contraindications to Surgery

• Tolerable refractive correction provides vision that meets the patient's needs 1
• Surgery not expected to improve visual function with no other indication for lens removal 1
• Patient cannot safely undergo surgery due to coexisting medical or ocular conditions 1
• Appropriate postoperative care cannot be arranged 1
• Patient or surrogate decision maker unable to give informed consent 1

Preoperative Medical Assessment

• Routine preoperative laboratory testing has been shown in multiple randomized clinical trials to provide no benefit for cataract surgery patients 1, 2, 3
• Preoperative medical history and physical examination has not been proven to reduce systemic or ocular complications 1, 4
• For patients with severe systemic diseases (e.g., poorly controlled COPD, hypertension, recent MI, unstable angina, poorly controlled heart failure or diabetes), a targeted preoperative medical evaluation may be considered 1
• Directed testing should be recommended only as appropriate for particular surgical candidates with specific medical problems 1

Essential Ophthalmic Evaluation Components

• Patient history, including assessment of functional status, pertinent medical conditions, medications (particularly alpha-1 antagonists), and risk factors affecting surgical plan 1, 5
• Visual acuity with correction at distance and near 1
• Refraction and measurement of corrected distance visual acuity in both eyes 1
• Glare testing when indicated (especially important as visual acuity alone may underestimate functional impact) 1, 5
• Assessment of pupil size and function 1
• Visual field assessment 1
• Examination of ocular alignment and motility 1
• External examination (eyelids, lashes, lacrimal apparatus, orbit) 1
• Measurement of intraocular pressure 1
• Slit-lamp biomicroscopy of anterior and posterior segments through dilated pupil 1
• Indirect ophthalmoscopy 1

Supplemental Testing When Indicated

• Optical biometry for IOL power calculation (more accurate than applanation A-scan) 1
• Corneal topography/tomography to assess for corneal irregularities affecting surgical planning 5
• Optical coherence tomography of macula to rule out concurrent retinal pathology 5
• Endothelial cell counts and corneal pachymetry in cases of corneal disease 6
• B-scan ultrasonography when posterior segment cannot be visualized 6

Mental and Physical Status Assessment

• Ability to cooperate and position for surgery 1
• Assessment of barriers to communication (language or hearing impairment) 1
• Commitment and ability of patient and caregiver to attend postoperative visits 1
• Ability to manage transportation, medication administration, and other postoperative needs 1

Common Pitfalls to Avoid

• Relying solely on Snellen visual acuity to determine surgical need (may underestimate functional disability) 1, 5
• Failing to rule out other causes of vision loss before attributing symptoms solely to cataracts 5
• Ordering unnecessary routine preoperative tests that add cost without improving outcomes 4, 2, 3
• Not identifying patients on alpha-1 antagonists (e.g., tamsulosin) who are at risk for intraoperative floppy iris syndrome 5
• Overlooking the patient's ability to manage postoperative care requirements 1

By systematically evaluating these criteria, ophthalmologists can determine medical fitness for cataract surgery while prioritizing patient safety and optimizing visual outcomes.