Preoperative Cardiopulmonary Clearance for Cataract Surgery
Routine preoperative cardiopulmonary testing is not required for cataract surgery, even in older adults with hypertension, diabetes, and cardiovascular disease who are in their usual state of health. 1, 2
Evidence-Based Approach
No Routine Testing Required
The American Academy of Ophthalmology and American Family Physician guidelines explicitly state that patients in their usual state of health undergoing cataract surgery do not require preoperative testing. 1
Three randomized controlled trials involving over 21,000 cataract surgeries demonstrated that routine preoperative medical testing does not reduce intraoperative or postoperative medical adverse events (OR 1.02,95% CI 0.85-1.22 for intraoperative events; OR 0.96,95% CI 0.74-1.24 for postoperative events). 3, 4
The largest trial randomized 19,557 cataract operations and found identical complication rates (31.3 events per 1000 operations) whether or not routine testing (ECG, CBC, electrolytes, renal function, glucose) was performed. 4
Routine preoperative evaluation costs 2.55 times more than selective or no testing without improving safety. 3
When to Consider Directed Testing
Obtain specific tests only when clinical conditions warrant them:
Check hemoglobin if the patient is over 75 years old as part of surgical safety protocols, or if there are symptoms or known anemia. 1
Check renal function (eGFR) only if the patient has known kidney disease or takes medications requiring renal dose adjustment. 1
Check glucose only if the patient has known diabetes requiring perioperative insulin adjustment or is at very high risk of undiagnosed diabetes. 1
Obtain ECG only if the patient has new or unstable cardiac symptoms, not for stable chronic conditions. 2
Exceptions Requiring Medical Evaluation
The American Academy of Ophthalmology recommends preoperative medical evaluation only for patients with acute, unstable, or poorly controlled conditions: 2
- Poorly controlled COPD with recent exacerbation
- Recent myocardial infarction (within 30 days)
- Unstable angina
- Poorly controlled heart failure with decompensation
- Poorly controlled diabetes with severe hyperglycemia or recent DKA
Stable, well-controlled chronic conditions (including hypertension, diabetes, and cardiovascular disease) do not require preoperative clearance or testing. 1, 2, 3
Clinical Context
Safety Profile
The 90-day mortality rate after cataract surgery is extremely low at 7.1 per 1000 patients, even in high-risk populations. 5
Of 707 medical adverse events reported across three trials, most were minor cardiovascular events (primarily hypertension and bradycardia) occurring intraoperatively, with no difference between tested and non-tested groups. 3
Even patients with systolic blood pressure ≥180 mmHg on the day of surgery had no increased risk of posterior capsule rupture or postoperative adverse events. 6
Common Pitfalls to Avoid
Do not reflexively order preoperative clearance based solely on age or chronic disease diagnoses. This wastes resources, delays surgery (median 6 months vs. 2 months for non-evaluated patients), and frustrates primary care providers without improving outcomes. 6, 7
Do not cancel or delay surgery for asymptomatic hypertension or glucose elevations on the day of surgery. These findings are not associated with adverse surgical outcomes in cataract surgery. 6
The 2019 CMS regulation change eliminated the requirement for routine history and physical within 30 days of ambulatory surgery, yet many providers remain unaware and continue unnecessary referrals. 7
Medication Management
Continue chronic medications through the morning of surgery including ACE inhibitors, statins, and beta-blockers for patients with established cardiovascular disease. 2
For diabetes medications: Hold metformin on the day of surgery, discontinue SGLT2 inhibitors 3-4 days before surgery, and hold other oral agents the morning of surgery. 2