Proceeding with Cataract Surgery at Elevated Systolic Blood Pressure
Yes, you can proceed with cataract surgery even with systolic blood pressure below 180 mmHg, as this threshold is specifically supported by current perioperative guidelines for elective surgery. 1
Blood Pressure Thresholds for Cataract Surgery
Primary Guideline Recommendations
Elective surgery, including cataract surgery, should proceed if blood pressure is less than 180 mmHg systolic and 110 mmHg diastolic when measured in the preoperative setting. 1 This represents the consensus threshold from the Association of Anaesthetists of Great Britain and Ireland and British Hypertension Society joint guidelines.
The 2024 AHA/ACC perioperative guidelines provide a more nuanced approach:
- Deferring surgery may be considered (Class 2b recommendation) only for patients with recent history of poorly controlled hypertension (SBP ≥180 mmHg or DBP ≥110 mmHg) who are undergoing elevated-risk surgery with cardiovascular risk factors. 1
- Cataract surgery is considered low-risk, making this deferral threshold less applicable 1
Evidence-Specific to Cataract Surgery
Research demonstrates that initial systolic pressure ≥180 mmHg in cataract surgery patients was not associated with higher risk of posterior capsule rupture or postoperative adverse events. 2 This cohort study of 968 consecutive cataract patients found no major cardiovascular events occurred perioperatively, and hypertensive episodes (which occurred in 33% of patients) were not associated with any medical or surgical outcomes.
Key Distinctions for Low-Risk Surgery
The blood pressure thresholds differ between primary care referral and day-of-surgery assessment for important reasons 1:
- Primary care threshold: <160/100 mmHg for referral to surgery
- Day-of-surgery threshold: <180/110 mmHg to proceed
This disparity exists because blood pressure measurements in the surgical setting may be elevated due to situational anxiety ("white coat hypertension"), and there is no evidence that perioperative blood pressure reduction affects cardiovascular event rates in the short timeframe of surgery. 1
Historical Context and Evolving Standards
Older guidelines (JNC 7 from 2003) recommended that blood pressure levels of 180/110 mmHg or greater should be controlled prior to surgery 1. However, this recommendation has been superseded by more recent evidence showing that for low-risk procedures like cataract surgery, these strict thresholds are unnecessary and lead to inappropriate surgical delays. 1
The 2018 ACC/AHA guidelines note that patients with diastolic blood pressure ≥110 mmHg have increased complications including dysrhythmias, myocardial ischemia, neurological complications, and renal failure, but patients with DBP <110 mmHg do not appear at significantly increased risk. 1 The relationship of isolated systolic hypertension to surgical risk is less certain. 1
Practical Management Approach
Preoperative Assessment
- Refer to the patient's baseline ambulatory blood pressure rather than relying solely on day-of-surgery readings, as situational hypertension is common. 1
- Routine preoperative medical evaluation and laboratory testing are not indicated for cataract surgery, as three randomized trials failed to show reduction in systemic or ocular complications. 1
Intraoperative Management
- Early monitoring and control of blood pressure during cataract surgery effectively controls perioperative hypertension without additional drug use. 3
- Maintain intraoperative mean arterial pressure ≥60-65 mmHg or systolic blood pressure ≥90 mmHg to reduce risk of myocardial injury (Class 1 recommendation). 1
- Continue chronic antihypertensive medications throughout the perioperative period in most patients. 1
Risk Factors Requiring Attention
Independent risk factors for intraoperative hypertension during cataract surgery include:
Notably, history of hypertension itself was not a significant predictor of intraoperative hypertensive events. 4
Common Pitfalls to Avoid
Do not delay cataract surgery solely based on elevated blood pressure readings <180/110 mmHg on the day of surgery. 1 This leads to unnecessary patient inconvenience, increased healthcare costs, and no demonstrated improvement in outcomes. 1
Do not abruptly discontinue beta blockers or clonidine perioperatively, as withdrawal syndromes with sympathetic discharge and acute hypertension can occur. 1
Do not assume that preoperative evaluation reduces adverse events in cataract surgery—the evidence shows it does not, despite reducing hypertensive episodes. 2