What is the recommended preoperative evaluation for an elderly patient with potential comorbidities undergoing cataract surgery?

Preoperative Evaluation for Cataract Surgery

Routine preoperative medical testing (laboratory tests, ECG, chest X-ray) is not indicated for cataract surgery, as three randomized trials have demonstrated no reduction in perioperative complications. 1, 2

Medical Evaluation Requirements

Standard Approach

• The operating ophthalmologist should perform the preoperative assessment to establish rapport and formulate the surgical plan 1, 3
• Routine laboratory testing, ECG, and chest X-ray provide no safety benefit and increase costs by 2.55 times without reducing adverse events 2
• A self-administered health questionnaire is highly specific (91-100%) for identifying relevant comorbidities and can substitute for formal medical evaluation in most patients 4

When Medical Clearance IS Needed

Preoperative medical evaluation by the patient's primary care physician should be obtained only for patients with severe, poorly controlled systemic diseases including: 1, 3

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

Critical caveat: Even elevated systolic blood pressure ≥180 mmHg on the day of surgery does not increase risk of posterior capsule rupture or postoperative complications, though preoperative evaluation modestly reduces intraoperative hypertensive episodes (which have no clinical consequences) 5

Essential Ophthalmic Evaluation

Mandatory Assessments

• Complete ophthalmic examination by the operating surgeon documenting symptoms, findings, and surgical indications 1
• Optical biometry (preferred over ultrasound) for IOL power calculation 6, 3
• Assessment of patient's ability to cooperate and position for surgery, as this directly impacts surgical safety 1, 3
• Evaluation of upper-eyelid blepharoptosis, which induces corneal astigmatism and can worsen postoperatively 1, 3
• Tear function assessment including tear meniscus, tear breakup time (<10 seconds indicates dysfunction), and evaluation for punctate erosions that compromise keratometry accuracy 1

Selective Advanced Testing

• Macular OCT when visual acuity is disproportionate to cataract density, to identify epiretinal membranes (which increase CME risk) or other macular pathology 1
• Corneal topography/tomography for astigmatism management planning, toric IOL selection, or when considering advanced technology IOLs 1, 6
• B-scan ultrasonography when dense cataract prevents posterior segment visualization 1
• Specular microscopy and pachymetry only when corneal endothelial dysfunction is suspected from prior surgery, trauma, or dystrophies (though these have low accuracy predicting postoperative corneal clarity) 1
• Gonioscopy or anterior segment OCT for complex anterior pathology like narrow angles or subluxated lenses 1

Patient Counseling and Consent

Required Discussions

• Risks, benefits, and expected outcomes including timeline for vision improvement (93.5% of patients want to know risks as rare as 1 in 50; 62.4% want to know risks of 1 in 1000) 1, 7
• Refractive options (bilateral emmetropia, myopia, or monovision) and specialty IOL choices 1
• Postoperative care arrangements including setting, provider, and ensuring patient/caregiver commitment to follow-up visits 1
• Barriers to communication such as language or hearing impairment 1, 3
• Transportation and medication administration logistics 1
• Written information should be provided as requested by 85.7% of patients to reinforce verbal counseling 7

Common Pitfalls to Avoid

• Do not order routine preoperative testing as it wastes resources (costs 2.55× more) without improving safety—three RCTs with 21,531 surgeries found identical adverse event rates (OR 1.00,95% CI 0.86-1.16) 2
• Do not delay surgery for medical clearance in patients without severe, poorly controlled disease—median wait time increases from 2 to 6 months with unnecessary evaluation 5
• Do not cancel surgery for isolated hypertension on the day of surgery, as systolic BP ≥180 mmHg is not associated with increased surgical or medical complications 5
• Do not skip dry eye evaluation, as tear dysfunction compromises keratometry accuracy and postoperative outcomes 1, 3