Cataract surgery is the most  commonly performed surgery by ophthalmologists is cataract extraction with intraocular lens implantation, and the vast majority of the patients undergoing this procedure are firmly in the senior citizen category. We are accustomed to dealing with elderly patients and many of us have even performed surgery on patients who are 100 years old or more. But could there be a cut-off when the patient is just too old for an elective surgery, or is age really just a number?

People are living longer than ever and the average life expectancy is about 80 years old, with females traditionally outliving their male counterparts. This is a big change from just a generation  ago when the life expectancy was a decade less. One of the reasons that our Medicare and Social Security systems are so heavily burdened is that people live much longer; paying for 5 years of benefits vs 15 years for them is a huge difference. But back to the topic: can a patient be too old for surgery?

While I agree that chronologic age is just one factor in determining a patient’s health, it is among the most important and no one can escape its effects. When looking at a person we can use the condition of their face and skin to estimate their age quite accurately. Even among the Hollywood crowd, extensive plastic surgery cannot transform a  senior actress into an ingénue.

The same applies to the eyes: there is no 50-year-old who has been lucky enough to avoid presbyopia and there is no 70-year-old with perfectly clear crystalline lenses. In looking at critical structures for cataract surgery, both the corneal endothelial cells and the zonular attachments have been shown to decline with age. With age the crystalline lens becomes opaquer and denser, requiring more ultrasonic energy and creating a longer procedure with a higher rate of complications. Surgery in a patient aged 90 years or more is challenging and care must be taken to balance the potential benefits with the higher risks involved to make a sound decision.

The presence of dense nuclear sclerosis, a small pupil, low corneal endothelial cell count, shallow anterior chamber, weak zonular structures, poor exposure, and other concurrent ocular disease are all factors that can pose issues during surgery and limit the postoperative visual recovery. We should also take into account the patient’s history. If cataract surgery was suggested multiple times in the past and then refused every year, this patient may have waited too long. Cataract surgery is purely elective more than 99% of the time and the patient should take some responsibility for waiting too long. The surgeon can, and often should, decline to perform the procedure.

When I first started practice many years ago, I was more adventurous, to put it kindly. I would have seen just about any tough case as a challenge that I just had to accept. Needless to say, after many years and tens of thousands of surgeries, surgical judgment tends to improve dramatically and sometimes the best decision  is no surgery at all.

I understand patients’ fears about cataract surgery. The idea of an ophthalmologist entering your eye and swapping out your cataract for a synthetic lens seems terrifying. And this is the most likely reason that some patients refuse cataract surgery year after year and wait until the odds are stacked against them. It’s our job to educate these patients at the early stages to help them overcome their fears and enjoy the immense benefits of successful cataract surgery.

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