Does a 78-year-old require blood work prior to cataract surgery?

Blood Work for 78-Year-Old Before Cataract Surgery

No, a 78-year-old patient in their usual state of health does not need routine blood work before cataract surgery. This recommendation is based on high-quality evidence showing that preoperative testing does not reduce complications or improve outcomes in cataract surgery patients 1, 2.

Evidence-Based Rationale

The landmark randomized controlled trial of over 19,000 cataract surgeries demonstrated no difference in medical adverse events between patients who underwent routine preoperative testing versus no testing 1. This finding was reinforced by a 2019 Cochrane review of 21,531 cataract surgeries, which confirmed that routine preoperative medical testing does not increase the safety of cataract surgery 3.

Key Findings from the Evidence:

• No reduction in complications: The overall rate of medical adverse events was identical (31.3 events per 1000 operations) whether or not preoperative testing was performed 4
• No benefit across all age groups: Stratified analyses by age, sex, race, and medical history revealed no benefit of routine testing, even in elderly patients 4
• Cost implications: Preoperative testing costs 2.55 times more than selective or no testing, with an estimated $4.8 million in unnecessary testing expenditures and $12.4 million in unnecessary office visits 3, 5

When Testing IS Indicated

Directed testing should only be obtained for specific clinical conditions, not based on age alone 2, 6:

• Hemoglobin/CBC: Only if the patient has known anemia, symptoms suggesting anemia (fatigue, pallor, dyspnea), history of recent blood loss, or anticipated significant perioperative blood loss 1, 6
• Renal function (eGFR): Only if the patient has known kidney disease or takes medications requiring renal dose adjustment 6
• Glucose/A1C: Only if the patient has poorly controlled diabetes requiring perioperative management adjustment, or is at very high risk of undiagnosed diabetes 1, 2, 6
• Coagulation studies: Only if the patient takes anticoagulants, has a history of spontaneous bruising or excessive surgical bleeding, or has medical conditions predisposing to coagulopathy (liver disease, hematologic disorders) 1

High-Risk Patients Requiring Medical Evaluation

Preoperative medical evaluation by the primary care physician should be considered only for patients with specific unstable conditions 2:

• Poorly controlled arterial hypertension
• Recent myocardial infarction or unstable angina
• Poorly controlled congestive heart failure
• Poorly controlled diabetes
• Chronic obstructive pulmonary disease requiring optimization

Important Clinical Context

Cataract surgery is performed with topical anesthesia in most cases, which minimizes systemic medical risk 7. The procedure poses minimal systemic stress compared to surgeries requiring general anesthesia 8.

Common Pitfall to Avoid:

Despite clear evidence against routine testing, 53% of Medicare patients still undergo preoperative testing before cataract surgery, driven primarily by provider practice patterns rather than patient characteristics 5. This represents low-value care that should be avoided 8, 5.

Bottom Line Algorithm

For a 78-year-old scheduled for cataract surgery:

1. Perform ophthalmologic assessment (ocular history, biometry, surgical planning) 2
2. Review medical history for unstable conditions listed above 2
3. Order blood work ONLY if:
   • Specific symptoms or known conditions warrant directed testing 6
   • Patient has unstable medical conditions requiring optimization 2
4. Do NOT order routine CBC, metabolic panel, ECG, or other tests in patients in their usual state of health 1, 2

The operating ophthalmologist should perform the preoperative assessment, and anesthesia staff screening on the day of surgery is sufficient for most patients 2, 8.