Is it safe to proceed with cataract surgery with a preoperative blood pressure (BP) reading of severe hypertension?

Proceed with Cataract Surgery for BP 236/78

You should proceed with cataract surgery despite the preoperative blood pressure of 236/78 mmHg, as blood pressures less than 180 mmHg systolic and 110 mmHg diastolic should not preclude elective surgery, and cataract surgery under topical anesthesia carries minimal hemodynamic risk. 1

Guideline-Based Threshold for Proceeding

The AAGBI/British Hypertension Society joint guidelines establish clear thresholds for proceeding with elective surgery 2:

• Blood pressures below 180 mmHg systolic AND 110 mmHg diastolic should not delay elective surgery 2, 1
• Your patient's diastolic pressure of 78 mmHg is well below the 110 mmHg threshold that would warrant postponement
• The systolic pressure, while elevated, does not meet criteria for mandatory delay

Why This Case is Lower Risk

Cataract surgery with topical anesthesia represents a uniquely low-risk scenario for several reasons:

• Topical anesthesia for cataract surgery produces less hemodynamic instability compared to retrobulbar block 3
• The procedure is brief, minimally invasive, and does not involve significant physiological stress 4
• Blood pressure typically decreases postoperatively in cataract surgery patients 3
• Early monitoring and control during the perioperative period effectively manages blood pressure fluctuations without additional medications 4

Risk Stratification Context

The key consideration is target organ damage, not the blood pressure number alone 2, 1, 5:

• Stage 1 and 2 hypertension without target organ damage does not clearly increase perioperative cardiovascular risk 2
• The isolated systolic hypertension pattern (236/78) suggests arterial stiffness rather than acute hypertensive crisis
• No evidence supports that delaying surgery to lower blood pressure in this range improves outcomes 2, 6

Perioperative Management Strategy

Implement these specific measures to optimize safety 1, 4:

• Continue all current antihypertensive medications on the day of surgery, with possible exception of ACE inhibitors/ARBs if the patient is on them 2, 1
• Start early blood pressure monitoring upon arrival to the surgical facility 4
• Have short-acting IV antihypertensives available (e.g., clevidipine, labetalol) if intraoperative control is needed 7
• Monitor for hypotension during and after the procedure, as this may pose greater risk than the elevated preoperative pressure 2

Evidence Supporting Proceeding

The Weksler study specifically addressed this clinical scenario 2, 6:

• 989 treated hypertensive patients with diastolic BP 110-130 mmHg (higher than your patient) were randomized to either proceed with surgery after intranasal nifedipine or postpone for blood pressure control
• No statistically significant differences in postoperative cardiovascular or neurological complications were observed 6
• Surgery postponement provided no benefit while causing unnecessary delay and cost 2, 6

Critical Caveats

Do NOT proceed if any of these apply 2:

• Evidence of acute target organ damage (acute coronary syndrome, acute heart failure, acute stroke, hypertensive encephalopathy)
• Symptomatic hypertension (chest pain, dyspnea, neurological symptoms)
• Diastolic pressure ≥110 mmHg (not present in this case)
• Systolic pressure ≥180 mmHg in the context of other high-risk features requiring optimization

Common Pitfall to Avoid

The most common error is unnecessary surgery cancellation based on an isolated blood pressure reading 2:

• Canceling surgery causes significant psychological, social, and financial harm to patients 2
• Approximately 1-3% of elective patients have surgery postponed for blood pressure, often unnecessarily 2
• Perioperative blood pressure lability (not the preoperative reading) is what correlates with complications 2

Inform the patient and anesthesia team of the elevated reading, ensure monitoring is in place, and proceed with surgery. 1, 4