Abstract
Background:
Although cataract surgery has been proposed as a potentially modifiable protective factor for enhancing emotional well-being in cataract patients, studies examining the relationship between anxiety or depression and cataract surgery have yielded inconsistent findings. This review summarizes existing evidence to establish whether cataract surgery is associated with depression and anxiety in older adults.
Methods:
A literature search was conducted across PubMed, Medline, Web of Science, and Embase databases. An initial screening by abstracts and titles was performed, followed by a review and assessment of the methodological quality of the relevant full papers, and final inclusion of 44 studies were deemed eligible for inclusion in this review.
Results:
Among 44 included studies, 36 studies (81.8%) were observational studies concerning the association of cataract surgery or cataracts with anxiety or depression, four studies (9.1%) were interventional studies, and four studies (9.1%) were reviews. Cataract surgery notably enhances the mental health of individuals with impaired vision. However, the multifaceted nature of psychological well-being, influenced by various factors, suggests that cataract surgery may not address all aspects comprehensively. Additionally, preoperative anxiety and depression significantly impact cataract surgery outcomes.
Conclusion:
Vision impairment in older adults is closely associated with increased symptoms of depression and anxiety. While surgical intervention for cataracts improves these symptoms, it might be less effective for mental disorders with multifactorial causes. Notably, anxiety or depression poses challenges to successful preoperative and intraoperative cataract surgeries.
Keywords: anxiety, cataract surgery, depression, older adults
Introduction
Highlights
Cataract surgery has a strong potential to enhance mental well-being, especially concerning issues related to visual impairment.
The effectiveness of cataract surgery in addressing mental disorders with multifaceted causative factors may vary.
Anxiety and depression symptoms adversely impact cataract surgery.
Cataracts, a most prevalent ocular condition among older adults1, are associated not only with deteriorating visual acuity but also with broader psychosocial ramifications. Beyond impairing vision, cataracts have been linked to decreased physical activity, reduced social engagement, and an increased risk of mental health challenges, including depression and anxiety2–4. As a result, understanding the intricate relationship between cataracts and mental health becomes imperative for comprehensive patient care strategies tailored to older individuals.
The widespread utilization of cataract surgeries, considered a highly effective intervention, underscores the significance of investigating their impact on mental health5. While these surgeries demonstrably improve visual function and quality of life for many6–8, a consensus regarding their definitive positive effect on mental health remains elusive in the scientific literature. Furthermore, limitations in existing studies, such as small sample sizes and short-term assessments, have contributed to the ongoing debate regarding the influence of cataract surgeries on psychological well-being.
In addition, the relationship between cataract surgery and psychological disorders may be bidirectional. Beyond the impact of cataract surgery on mental health, emerging evidence suggests a reciprocal relationship where preoperative mental health can significantly affect surgical outcomes. Research has shown that individuals with higher levels of preoperative emotional tension are more likely to experience increased pain during and after the surgery9. Preoperative mental health concerns may potentially pose risks to cataract surgery, such as the possibility of elevating intraocular or blood pressure during the procedure and increasing the likelihood of intraoperative bleeding9. Despite these findings, preoperative mental health issues lack adequate attention, standardized diagnostic methods, and awareness among surgeons regarding preventive or corrective measures.
Therefore, this systematic review analyzed published literature to establish the relationship between cataract surgery and the mental health of older adults, providing valuable insights that can inform clinical practices, guide interventions, and prompt further research in this critical area of ocular health and psychosocial well-being.
Methods
We conducted a comprehensive search for relevant papers on cataract surgery and mental health from 1989 to 20 December 2022, using databases including PubMed, Medline, Web of Science, and Embase, with language restriction to English. The following keywords were used in various combinations: cataract, cataract surgery, anxiety, anxiety symptoms, depression, depressive symptoms, psychology, mood, mental health, and mental state.
Prospective or retrospective studies, randomized controlled trials, case–control studies, cross-sectional studies, and systematic reviews that provided data on the inter-relationship between cataract surgery and mental health were included. Conference abstracts, comments, and letters to the editor were excluded.
The initial removal of duplicate articles was followed by a meticulous review of the remaining studies based on their titles and abstracts. Subsequently, the selected literature was thoroughly examined in adherence to the aforementioned inclusion and exclusion criteria, which is in accordance with the PRISMA 2020 statement10 and AMSTAR 211 (rated high quality). This review aims to delineate the nuanced interaction between cataract surgery and mental health, delving into the underlying mechanisms. The registration unique identifying number is reviewregistry1764.
Results
Epidemiology and risk factors of mental disorder in cataract patients
Several studies have assessed anxiety or depression in cataract patients2,4,12–23 (Table 1). These studies consistently indicate that cataract patients experience more severe anxiety and depression compared to healthy individuals. Studies conducted in China revealed anxiety and depression rates of 18% among cataract patients, contrasting with 7.0 and 5.2% in healthy individuals14. In Russia, anxiety rates of 20% and depression rates ranging from 26 to 33.7% were reported among cataract patients24–26.
Table 1.
Characteristics of the included studies about cataract and mental health.
Study | Author (Year) | Region | Study design | Number of patients | Age | Anxiety and depression measurement | Key findings |
---|---|---|---|---|---|---|---|
18Comorbidity of depression and anxiety in common age-related eye diseases: a population-based study of 662 adults | Eramudugolla et al.18 (2013) | Australia | Cross-sectional | 662 individuals | >70 years | Goldberg Anxiety and Depression Scales (GADS) | Depressive symptoms were associated with cataract, AMD, comorbid eye diseases and reduced low-contrast visual acuity. Anxiety was significantly associated with self-reported cataract, reduced low-contrast visual acuity, motion sensitivity and contrast sensitivity |
36Depression and disability associated with impaired vision: the MoVies Project | Rovner and Ganguly36 (1998) | USA | Cross-sectional | 872 individuals | ≥68 years (76.3±5.1 year) | Modified Center for Epidemiologic Studies-Depression scale (mCES-D) | Impaired vision and depression were both associated strongly with functional impairment in older adults. Depression increased the odds of functional impairment independent of vision impairment. |
19Depression in ophthalmological patients | Pop-Jordanova et al.19 (2014) | Macedonia | Cross-sectional | 100 patients | 41.6±15.9 years | Beck Depression Inventory (BDI) | Most depressed patients got age-related macular degeneration, proliferative diabetic retinopathy, glaucoma and cataract. The level of depression was related to the severity of eyes diagnoses. A positive correlation between depression and age and educational level was confirmed |
26Depressive symptoms in older adults awaiting cataract surgery | Palagyi et al.26 (2016) | Australia | Cross-sectional | 329 cataract patients | ≥65 years (75.7±5.3 years) | 5-item Geriatric Depression Scale (GDS-5) | Visual impairment in older adults was associated with susceptibility to depression. |
38Longitudinal Associations of Self-reported Vision Impairment With Symptoms of Anxiety and Depression Among Older Adults in the United States | Frank et al.38 (2019) | USA | Cohort | 7584 participants | ≥65 years | Patient Health Questionnaire for Depression and Anxiety (PHQ-4) | There was a significant bidirectional and longitudinal association between self-reported vision impairment (VI) and mental health symptoms |
20Prevalence and correlates of depressive symptoms among Chinese patients with cataracts treated in tertiary general hospitals | Liu et al.20 (2020) | China | Cross-sectional | Three thirty-nine cataract patients | ≥18 years | Chinese Hospital Anxiety and Depression Scale | Depressive symptoms were common among Chinese patients with cataract. Among patients with cataract, depressive symptoms were associated with education, marital status, economic status, and subtype of cataract |
12The associations and mediators between visual disabilities and anxiety disorders in middle-aged and older adults: A population-based study | Zhang et al.12 (2023) | China | Cohort | 117 252 participants | 38–73 years | International Classification of Diseases (ICD-10), Composite International Diagnostic Interview (CIDI) short-form questionnaire, seven-item Generalized Anxiety Disorder Questionnaire (GAD- 7) | An overall association between visual disabilities and anxiety in middle-aged and older adults. The association between poorer visual acuity and anxiety disorders was partially mediated by subsequent onsets of eye diseases, especially cataracts, and socioeconomic status |
21The prevalence of anxiety symptoms and disorders among ophthalmic disease patients | Ulhaq et al.21 (2022) | Indonesia | Systematic Review | 23 415 subjects | / | / | The prevalence of anxiety symptoms and disorders among patients with ophthalmic disease were relatively higher than that reported in the general population |
22The Prevalence of Depression and Depressive Symptoms among Eye Disease Patients: A Systematic Review and Meta-analysis | Zheng et al.22 (2017) | China | Systematic Review | Six thousand five hundred eighty-nine individuals | / | / | The overall prevalence of depression among eye disease patients was 25%, varying with disease categories. The prevalence of depression among eye disease patients was higher than that in healthy people |
23Visual Impairment, Eye Disease, and the 3-year Incidence of Depressive Symptoms: The Canadian Longitudinal Study on Aging | Grant et al.23 (2021) | Canada | Prospective cohort | 22 558 individuals | 45–85 years (59.2±9.6 years) | Center for Epidemiologic Studies-Depression scale (CESD10) | The risk of depressive symptoms was higher in those who report ever having a cataract |
Various factors contribute to anxiety and depression among cataract patients. Concerns about potential blindness, financial strain, declining quality of life due to restricted physical activity, communication barriers, and limited education leading to difficulty understanding medical terms are significant contributors14. Upon cataract diagnosis, inadequate information and communication can fuel uncertainty, encompassing ambiguity, unfamiliarity, unpredictability, and suspicion27. Illness uncertainty, common in chronic conditions, correlates with patients’ mental state due to factors like incomplete information, prolonged disease duration, complex treatments, and compromised physical function14,28,29.
Moreover, it was indicated that ~83% of individuals face challenges in daily activities (e.g. walking, reading, watching TV, or performing needlework) due to worsening vision from cataract development. For 26% of these individuals, cataract progression and subsequent limitations in daily activities triggered anxiety30. Studies also establish an association between depression and cataracts, attributed to reduced daily activities leading to loss of self-esteem, difficulties in social interactions, and compromised autonomy31,32. Sex and age further influence anxiety and depression risk. Females and younger age are independent risk factors for anxiety33, while older age is associated with depression34. This association could relate to younger patients being more concerned about their long-term vision preservation, unlike older patients who may have heightened concerns about vision loss given their life stage.
The precise mechanism underlying the link between cataracts and depression remains elusive. However, a 16-year longitudinal study revealed that individuals with cataracts faced a higher likelihood of experiencing depression (HR=1.78, 95% CI=1.70–1.87, P<0.001), this increased risk might be attributed to challenges in daily activities, particularly instrumental and leisure activities, due to visual impairment35. Depressive symptoms were found to be significantly associated with a higher degree of visual disability, more comorbidity, and lower levels of quality of life26,36,37. Longitudinally, vision impairment was associated with a 1.33 times higher risk of future depression in a national cohort study compared to individuals without visual impairment38. Furthermore, a study involving 662 participants established a direct correlation between reduced edge contrast sensitivity, poorer low-contrast visual acuity, and higher depression and anxiety scores. Impairments in these domains significantly hampered daily functional activities18,39. Decreased visual motion sensitivity may also increase anxiety concerning falls and mobility18. It was highlighted in prospective cohort study that improvements in depressive symptoms were associated with contrast sensitivity or stereopsis following the initial cataract surgery40. Collectively, existing literature largely confirms the association between cataracts and an elevated risk of anxiety and depression. Despite the intricacies in the cause-and-effect relationship, these findings underscore the significant impact of visual impairment on mental health.
Impact of cataract surgery on mental health
Numerous epidemiological evidence reports a robust association of cataract surgery with mental health in Table 2. Anxiety and fear are the most common negative emotions in cataract patients before and during cataract surgery. Prior studies revealed that 32% of patients experienced emotional stress preceding their initial eye cataract surgery41. Throughout the preoperative phase, patient anxiety tends to escalate gradually, peaking on the day of the surgery42. Factors such as withdrawal and visual perception during cataract surgery contribute to heightened preoperative anxiety9. Differences in surgical techniques among different surgeons may contribute to great variation in outcomes43. Crucially, a surgeon’s recommendation, especially from peers, and their expertise notably reduce preoperative anxiety levels44. The surgical process itself serves as a potent stressor, triggering various physiological reactions like sweating, hypertension, tachycardia, hyperventilation, and muscle tension4,9. The conclusion that surgery was significantly associated with anxiety or depression was underscored in a prospective cohort study45. However, postsurgery, a notable reduction in anxiety levels was observed42.
Table 2.
Characteristics of the included studies about cataract surgery and mental health.
Study | Author (Years) | Region | Study design | Number of patients | Age | Anxiety and Depression measurement | Key findings |
---|---|---|---|---|---|---|---|
4Anxiety and depression in cataract surgery: a pilot study in the elderly | Mitsonis et al.4 (2006) | Greece | Case–control | 251 cataract patients 115 controls | >65 years | Hamilton Rating Scales for Anxiety and Depression (HAM-Anxiety, HAM-Depression) | Anxiety and depression scores were higher in cataract patients than in healthy individuals; higher for women than for men. Patients with improved visual acuity after surgery had lower mean levels of anxiety and depression than those with neither improvement before surgery |
80Anxiety in patients undergoing cataract surgery: a preoperative and postoperative comparison | Ramirez et al. 80 (2017) | USA | Prospective cohort | Sixty one cataract patients | >18 years (63.9±13.0 years) | Likert scale | The patient’s preoperative anxiety included the surgery itself and becoming blind, and postoperative anxiety is the surgery itself. The anxiety of patients decreased after operation. Preoperative discussion may improve anxiety and satisfaction |
47Beyond monetary benefits of restoring sight in Vietnam: Evaluating well-being gains from cataract surgery | Feeny et al.47 (2018) | Vietnam | Cohort | Eighty-two cataract patients and 83 caregivers | About 50 years | Rand Corporation’s Rand 36-item Health Survey, 3-point Likert scale | Cataract surgery considerably improved the well-being of patients and their caregivers |
49Blue light-filtering intraocular lenses and postoperative mood: a pilot clinical study | Leruez et al.49 (2014) | France | Prospective cohort | Thirty-four cataract patients | 76.5±7.2 years | 30-item geriatric depression scale (GDS) | The GDS score was improved 3 months after the implantation of IOLs, and that the studied blue-filtering IOLs did not affect the postoperative mood differently than untinted IOLs |
16Cataract and Depressive Symptoms among Older Chinese Adults | Wang et al.16 (2016) | China | Cross-sectional | 4611 elderly adults | ≥60 years | 9-item Patient Health Questionnaire (PHQ-9) depression scale | There was a significant association between age-related cataract and depressive symptoms among older Chinese adults, particularly in poorly educated ones. Cataract surgery may play a role in improving mental health in the elderly |
35Cataract and the increased risk of depression in general population: a 16-year nationwide population-based longitudinal study | Chen et al.35 (2020) | China | Cohort | 280 970 participants (116 629 cataract patients, 116 629 noncataract cohorts) | 62.6 years (20–101 years) | ICD-9-CM codes from 2000 to 2015 (ICD-9-CM codes 296.2, 296.3, 300.4 and 311) and ICD-10-CM codes in 2016 (ICD-10-CM F32, F33, and F34.1) | The risk of depression in cataract patients was higher than that in noncataract patients. Patients with cataract who did not undergo surgery had a higher risk of depression than those who underwent surgery |
50Cataract surgery and changes in quality of life measures | Pesudovs et al.50 (2003) | Australia | Cohort | Thirteen cataract patients | 74.92±9.5 years | Cantril Ladder and the Profile of Mood States (POMS) | Quality of life including anxiety and depression can be measurably improved by cataract surgery |
25Cataract-related vision loss and depression in a cohort of patients awaiting cataract surgery | Freeman et al.25 (2009) | Canada | Cohort | Six hundred seventy-two cataract patients | >45 years | 30-item Geriatric Depression Scale | Patients with worse visual acuity were more likely to be depressed while waiting for cataract surgery. Shortening the wait time for cataract surgery, especially for those with worse vision, could potentially reduce the risk or shorten the duration of depression |
51Change in vision, visual disability, and health after cataract surgery | Helbostad et al.51 (2013) | Norway | Prospective cohort | One hundred forty-eight cataract patients | >70 years (78.9±5.0 years) | Short-Formular 36 mental health index (SF-36 Mental Health) | Vision improved and visual disability decreased in the year after surgery, whereas changes in general health (physical and mental health) and visual functioning were short-term effects |
52Changes in patient subjective happiness and satisfaction with cataract surgery | Yotsukura et al.52 (2020) | Japan | Cohort | Two hundred forty-seven cataract patients | 32–92 y (67.9±11.4 y) | Subjective Happiness Scale (SHS) | Cataract surgery may improve visual function and happiness |
53Correlation between depression and vision in aged patients before and after cataract operations | Fagerström53 (1994) | Finland | Cohort | Hundred cataract patients | 71–76 years | Beck Depression Inventory consisting of 13 items | Depression was significantly correlated with vision after the cataract operation. Depression increased with lowered visual acuity and diminished with improved visual acuity |
42Determinants of surgery-related anxiety in cataract patients | Nijkamp et al.42 (2004) | Netherlands | Cross-sectional | One hundred twenty-eight cataract patients | 50–89 years (73.2±8.6 years) | State-Trait Anxiety Inventory (STAI) | Women and patients with higher trait anxiety were more likely to experience higher levels of state anxiety. Positive outcome expectancies and social support may decrease anxiety. The level of anxiety was the highest before surgery, decreased immediately after surgery, and increased again after the postoperative visit |
7Effect of cataract surgery on cognition, mood, and visual hallucinations in older adults | Jefferis et al.7 (2015) | England | Prospective cohort | One hundred twelve cataract patients | ≥75 years (80.7±3.9 years) | 15-item Geriatric Depression Scale (GDS15) | Cataract surgery did not improve mood, but improved visual acuity, visual quality of life, cognitive performance and neuropsychiatric symptoms |
54Effect of the time interval between cataract surgery for both eyes on mental health outcome: a cohort study of 585,422 patients | Hou et al.54 (2021) | China | Retrospective cohort | 585 422 cataract patients | 69.3±9.5 years | International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) and ICD-10 codes as follows: ICD-9-CM: 296.2*, 296.3*, 311.*, 300.0*, 307.4*, and 780.5*; and ICD-10: F32.*, F33.*, F41.*, F51.*, and G47.*. | It is expected that within 1 y, performing two operations within a short-time interval may be beneficial to maximize the effect of cataract surgery and thus reduce the number of mental health consultations |
44Emotional aspects of cataract surgery | O’Malley et al.44 (1989) | UK | Retrospective cohort | Fourteen cataract patients | 85 years | / | Little effect of surgery was found on mood changes, general cognition on health, or activity. Confidence in the surgeon and reassurance from friends who had undergone surgery were found to be the most anxiety relieving |
65Falls and health status in elderly women following second eye cataract surgery: a randomised controlled trial | A. J. E. Foss et al.65 (2006) | UK | Randomised controlled trial | Twi thirty-nine female cataract patients | >70 years | Hospital Anxiety and Depression Scale | Second eye cataract surgery improved visual disability and general health status, including handicap and confidence about falling, but excluding anxiety and depression |
9Fear and Anxiety Associated with Cataract Surgery Under Local Anesthesia in Adults: A Systematic Review | Obuchowska et al. (2021) | Poland | Systematic Review | / | / | / | Cataract surgery under local anaesthesia was often accompanied by fear and anxiety. These emotions result from fear of surgery, such as pain and loss of vision |
14Illness uncertainty, anxiety and depression in Chinese patients with glaucoma or cataract | Zhang et al.14 (2018) | China | Cross-sectional | Two sixty-three primary glaucoma patients; 100 age-related cataract patients | 57.20±13.94 years (glaucoma group) 70.23±9.78 years (cataract group) |
Hospital Anxiety and Depression Scale (HADS) | Patients with glaucoma or cataract had a high risk of illness uncertainty, anxiety and depression. The scores of HADS of cataract patients decreased after surgery |
55Impact of cataract surgery on depression and cognitive function: Systematic review and meta-analysis | Pellegrini et al.55 (2020) | Italy | Systematic Review | / | / | Geriatric Depression Scale (GDS), Center for Epidemiological Studies-Depression Scale (CES-D), Self-Reporting Questionnaire-20 (SRQ-20), Beck Depression Inventory (BDI), Hamilton Rating Scale for Depression (HAM-D), Self-rating Depression Scale (SDS), Depression Anxiety Stress Scale (DASS) | Cataract surgery had a positive effect on depression and cognitive function in the elderly |
64Impact of cataract surgery on health‐related quality of life in nursing home residents | Owsley et al.67 (2007) | USA | Prospective cohort | Forty-five cataract patients | ≥60 years | 15-item Geriatric Depression Scale (GDS), | Nursing home residents who underwent cataract surgery experienced short-term significant improvements in their vision, vision-targeted health-related quality of life, except for depression |
56Impact of cataract surgery on vision-related life performances: the usefulness of Real-Life Vision Test for cataract surgery outcomes evaluation | Ni et al.56 (2015) | China | Case–control | Fifty-six cataract patients, 44 age-matched controls | 60–82 years | Self-rating depression scale scores | Cataract surgery was associated with improved visual function, self-report surveys, and real-life visual ability. Cataract patients experienced decreased depressive symptoms and significant improvements in the vision-targeted quality of life after surgery |
57Impact of First Eye versus Second Eye Cataract Surgery on Visual Function and Quality of Life | Shekhawat et al.57 (2017) | USA | Cohort | Three twenty-eight cataract patients | 70.4 ±9.6 years | 25-item National Eye Institute Visual Functioning Questionnaire (NEI-VFQ) | Second eye cataract surgery significantly improved visual function and quality of life well beyond levels achieved after first eye cataract surgery alone. Cataract surgery improved certain socioemotional aspects of quality of life |
58Improvement in Cognitive Status and Depressive Symptoms Three Months after Cataract Surgery | Kheirkhah et al.58 (2018) | Iran | Cohort | Two hundred fifty cataract patients | 71.77±8.08 years | Geriatric Depression Scale (GDS) | Cataract surgery was effective for relieving depressive symptoms in the elderly |
68Preoperative Anxiety Levels and Pain during Cataract Surgery | Socea et al.68 (2020) | Israel | Prospective cohort | One hundred three cataract patients | 68.9±8.9 years | Visual Analog Scale for Anxiety (VASA) | A significant association was found between preoperative anxiety and level of pain experienced during routine cataract surgery |
66Randomised trial of effectiveness of second eye cataract surgery | Laidlaw et al.66 (1998) | UK | Randomised controlled trial | Two hundred eight cataract patients | 41–97 years | Short-Form (SF)-36 | There was a clear benefit from second eye cataract surgery, including mental health |
37Sleep and mood changes in advanced age after blue-blocking (yellow) intraocular lens (IOLs) implantation during cataract surgical treatment: a randomized controlled trial | Zambrowski et al.37 (2018) | French | Randomized superiority trial | Two hundred four cataract patients | 60–90 years | Beck Depression Inventory (BDI) | Using yellow IOLs for cataract surgery did not significantly impact sleep but may induce mood changes in aging |
46Successful Cataract Surgery Leads to an Improvement in Depressive Symptomatology | Mylona et al.46 (2021) | Greece | Prospective cohort | One hundred fifty cataract patients | Male: 73.83±8.55 years Female: 73.45±7.055 years |
Beck’s Depression Inventory-II (BDI-II) | The success of phacoemulsification surgery for cataract as evaluated with the change in BCVA was related to the rate of improvement in depressive symptomatology |
8The impact of cataract surgery on cognitive impairment and depressive mental status in elderly patients | Ishii et al.8 (2008) | Japan | Prospective cohort | One hundred two cataract patients | 55–93 years (75.3±8.2 years) | Beck Depression Inventory (BDI) | Cataract surgery significantly improved vision-related quality of life in elderly patients, and cognitive impairment and depressive mental status also improved in parallel with improvement in vision-related quality of life |
63The impact of cataract surgery on depression among older adults | McGwin et al.63 (2003) | USA | Cohort | Three hundred forty-two participants: the cataract surgery group (146), the cataract no surgery group (104), and the no cataract group (92) | The cataract surgery group (70.82±6.75 years) The cataract no surgery group (71.11±5.53 years) The no cataract group (66.82±5.76 years) |
Epidemiological Studies-Depression Scale (CES-D) | Cataract surgery did not appear to have an effect on reducing depressive symptoms in elderly people |
48The impact of cataract surgery on depressive symptoms for bilateral cataract patients in Ho Chi Minh City, Vietnam | To et al.48 (2014) | Vietnam | Prospective cohort | Four hundred thirteen cataract patients | ≥50 years (66.5±7.8 years) | Center for Epidemiological Studies-Depression Scale (CES-D) | There was a small but significant improvement in depressive symptoms score after cataract surgery for an older population in Vietnam |
61The Impact of Cataract Surgery on Vision-Related Quality of Life and Psychological Distress in Monocular Patients | Li et al.61 (2021) | China | Prospective cohort | Eighty cataract patients | Monocular patients group: 63.73±11.56 years Binocular patients group: 67.08±8.45 years |
Self-rating Anxiety Scale (SAS), Self-rating Depression Scale (SDS) | Monocular patients gained more improvements in visual acuity, quality of life, and psychological distress by cataract surgery than binocular patients do |
62The impact of cataract surgery on visual functioning, vision-related disability and psychological distress: a randomized controlled trial | Walker et al. (2006) | Australia | Randomised controlled trial | Forty-five cataract patients | 74.73±7.20 years | Depression Anxiety Stress Scale (DASS) | First eye cataract surgery was effective in improving outcomes in visual functioning and disability. Improved mood after surgery was related to less vision-related disability compared with unchanged or worse depression |
13The impact of first eye cataract surgery on mental health contacts for depression and/or anxiety: a population-based study using linked data | Meuleners et al.13 (2013) | Australia | Retrospective cohort | 21 110 cataract patients | 75.20±7.83 years | International Classification for Diseases (ICD) 10-AM codes: F32, F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.6, F32.7, F32.8, F32.9, F33, F33.0, F33.1, F33.2, F33.3, F33.4, F33.5, F33.6, F33.7, F33.8, F33.9, F38.1, F41.2, F41.3, F43, F43.2, F44.7. |
A significant 18.80% decreased in the number of mental health contacts for anxiety and/or depression in the year after cataract surgery compared with the year before surgery |
40Vision, quality of life and depressive symptoms after first eye cataract surgery | Fraser et al.40 (2013) | Australia | Prospective cohort | Ninety-nine cataract patients | 72.0±7.9 years | Center for Epidemiological Studies-Depression Scale | Contrast sensitivity and stereopsis, but not visual acuity, were significant factors affecting improvement in vision-related quality of life or depressive symptoms after first eye cataract surgery. There was a small, non-clinically significant improvement in depressive symptoms after surgery |
Depressive symptoms disproportionately affect the elderly population. Studies demonstrate an increased incidence of depressive symptoms among patients undergoing surgery4. Moreover, individuals awaiting cataract surgery with impaired vision exhibit a higher likelihood of experiencing depressive symptoms46. The waiting time for cataract surgery is not consistent in different countries or regions, and the longer the waiting time, the greater the negative impact on the emotional state of the patient, including anxiety9. Actually, the potential surgical failure and the risk of vision loss may contribute to depressive symptoms in older adults4.
Cataract surgery, its impact on alleviating anxiety and depression associated with visual impairments is still a subject of debate. While several studies have demonstrated the favorable effects of cataract surgery on anxiety or depression4,6,8,13,14,16,25,35,46–62, others have found no significant effect7,37,40,63–65. Kotaro et al.8 found that many conditions assessed with the mini-mental state examination and the beck depression inventory improved after cataract surgery. These improvements included color vision difficulties, general vision, myopic activity difficulties, hyperopic activity difficulties, peripheral vision difficulties, role limitations, social functioning limitations due to vision, and mental health problems8. In addition, Mitsonis et al. reported elevated anxiety and depression scores in patients whose visual acuity did not improve postsurgery, indicating a potential correlation between lack of visual improvement and heightened postoperative anxiety and depression4,62.
The mechanism of cataract surgery to improve patients’ anxiety or depression mainly includes several aspects (Fig. 1). On the one hand, after successful cataract surgery and vision recovery, vision-related quality of life improves significantly in a broad range of social and visual functions, which leads to an improvement in the psychological state of anxiety and depression in patients. On the other hand, timely cataract surgery plays a crucial role; studies have shown that patients awaiting surgery with severe visual impairment face a higher risk of depression, and a more pronounced improvement in depressive symptoms is observed postsurgery among these individuals25,26,55. Moreover, randomized controlled trials have shown that those who undergo cataract surgery as early as possible have reduced anxiety, increased confidence, and higher activity levels65,66. Beyond visual improvements, cataract surgery appears to impact broader aspects. A functional MRI study has shown that cataract surgery can reverse cataract-induced brain structural and functional changes by improving the fractional amplitude of low-frequency fluctuations and gray matter volume in cognitive-related and visual areas67. Notably, evidence suggests that cataract surgery may not only enhance cognitive performance but also alleviate neuropsychiatric symptoms like visual hallucinations7.
Figure 1.
Schematic diagram of the mechanism of cataract surgery to improve anxiety or depression.
Impact of mental health on cataract surgery
The impact of preoperative anxiety on the cataract surgery experience is notable, particularly concerning pain management. It was shown in a prospective observational study that preoperative anxiety was significantly associated with the level of pain experienced by patients during cataract surgery, and the level of preoperative anxiety was identified as the only significant predictor of painful feeling during cataract surgery68. Besides, heightened pain levels among patients have been linked to decreased co-operation during cataract surgery under topical anesthesia69. Patients who are painful, uncooperative, and possibly agitated are more likely to result in a more difficult procedure, even in eyes without potential risk factors for complications68. Moreover, anxiety-related physiological responses, including increased blood pressure and intraocular pressure, pose potential risks during surgery9.
The primary cause of anxiety during cataract surgery is the fear of the surgery as well. Patients often exhibit involuntary reactions like eye or head movements, coughing, or difficulty co-operating during cataract surgery when experiencing fear or anxiety70. Following cataract surgery, patients commonly report reduced but persisting anxiety levels compared to presurgical stages. When postoperative vision remains unchanged, concerns about surgical failure and potential vision loss may heighten anxiety levels9. However, when the patient’s vision improved, the associated anxiety decreased significantly.
Preoperative depression is frequently observed among patients undergoing major surgeries71. Depressive disorders can lead to a suppressed immune system, which may predispose patients to increased cancer mortality and postoperative infection rates, such as insertion of ventricular assist devices72, craniotomies73, and coronary artery bypass surgery74. It has been demonstrated that depression before surgery is significantly related to postoperative pain measurement and analgesic needs71,75. Patients with preoperative anxiety and depression tend to experience heightened postoperative pain intensity and consume more analgesics76. Moreover, preoperative depressive symptoms often correlate with prolonged postoperative delirium and hindered recovery to independent function71,77. Therefore, depression has been established as an independent risk factor for postoperative delirium. Perioperative depression is mainly related to the degree of diseases and the patient’s psychological state and other factors, including tumor size, type, location, duration of diseases, and their own psychological quality, which may cause extremely adverse effects on the prognosis of surgery, leading to poor clinical treatment effect.
In summary, there is a high incidence of perioperative anxiety and depression, which significantly impacts the surgical outcome. Recognizing and effectively managing these psychological factors are imperative in optimizing clinical interventions and patient care.
Discussion
As medical advancements enhance and life expectancy rises, the incidence of cataracts has surged, leading to an increased need for cataract surgeries as an effective treatment option. Concurrently, there is a growing prevalence of anxiety and depression, particularly in the elderly, necessitating its recognition as a significant public health concern. Our comprehensive review reveals a notable correlation between cataract surgery and anxiety or depression, suggesting its potential in alleviating these mental health concerns. However, while some studies support this correlation, others indicate conflicting outcomes, emphasizing the complexity of this relationship. It is crucial to recognize the broader impact of psychological disorders on surgical outcomes for a more nuanced understanding.
The potential impact of cataract surgery on mental health manifests across various dimensions. Initially, cataract surgery offers promise in bolstering mental well-being by enhancing the vision-related quality of life for older adults. Anxiety and depression, prevalent among the elderly, often go undetected or are mistakenly attributed to aging or other comorbidities, exacerbating disability and compromising their overall quality of life4. Cataract-induced visual impairment significantly limits independence, self-esteem, and daily activities in older individuals, underscoring its role in potentially triggering anxiety or depression58. Deficits in marginal contrast sensitivity and low-contrast vision due to cataracts may also severely impair daily functional activities, thus potentially increasing the risk of anxiety or depression18,39. Also, decreased visual motion sensitivity may also increase the likelihood of falls and mobility, which may contribute to anxiety or depression18. Although senile cataract is the most common type, there are also rare cataracts, such as congenital cataracts. A cross-sectional study involving 11 832 850 subjects reported that congenital cataract (n=17 214) had a 1.45-fold and 1.27-fold increased risk of anxiety and depressive disorders, respectively78. Another national cohort study in Denmark reported that children with cataracts were 4.1 times more likely to develop anxiety disorders than healthy control79. In addition, cataract surgery, by improving visual impairment, presents a positive ripple effect on mental health. Robust evidence from prospective studies consistently shows a notable reduction in anxiety and depression postcataract surgery, particularly among patients experiencing improved visual acuity4,8,58. The restoration of vision through successful cataract surgery significantly enhances the quality of life in terms of various visual and social functions, thereby positively influencing patients’ anxiety or depressive symptoms. However, attributing anxiety or depression solely to visual impairment in cataract patients is a complex assertion, requiring a more comprehensive evaluation.
The notion that cataract surgery may not comprehensively address mental health concerns can be nuanced by considering a broader spectrum of influencing factors beyond visual impairment alone. Anxiety or depression in the elderly is often multifaceted, and influenced by various underlying elements. It is crucial to acknowledge that these mental disorders are not solely attributed to impaired vision but are a culmination of multiple contributors. Physical illnesses prevalent in older adults, such as cardiovascular diseases, cerebrovascular disorders, and respiratory conditions like asthma, can significantly contribute to anxiety and depression53. The intensity of mental disorders may be related to the extent to which various illnesses limit daily life and their lethality4. Furthermore, genetic susceptibility plays a role, alongside life events like social isolation, bereavement, and feelings of loneliness, all of which are significant contributors to mental health challenges63.
An additional aspect warranting consideration revolves around the objectivity of psychiatric diagnosis and the variability in methodologies adopted across studies and regions. This variance in diagnostic criteria and the application of distinct rating scales for anxiety and depression assessment could contribute to disparate conclusions regarding the effect of cataract surgery on these mental health conditions. At present, there are many anxiety and depression screening tools, each of which has diverse measurement scales, items, and degrees of attention to symptomatology. The use of different scales within and across studies introduces a potential source of inconsistency. Studies relying on distinct mental health scales may yield contradictory outcomes, emphasizing the pivotal role of the selected assessment tool in influencing study findings. In brief, the challenge lies in substantially alleviating late-life depression by addressing a single risk factor, such as recovering from visual impairment through cataract surgery. This multifactorial nature of mental health issues contributes to the varying conclusions evident in current studies.
Managing anxiety and depression is crucial for optimizing cataract surgery outcomes in elderly patients, irrespective of the surgery’s direct impact on these conditions. Discussions detailing visual sensations during consultations have been shown to mitigate surgery-related anxiety9,80, emphasizing the importance of surgeon-patient communication. Preoperative education serves as a pivotal tool in providing patients with comprehensive and accessible knowledge about cataracts and their treatment, dispelling doubts, and instilling confidence, all crucial factors in reducing surgery-related fear and anxiety81. Collaborative efforts involving diverse healthcare professionals, including ophthalmologists, nurses, psychologists, social workers, educators, and occupational therapists, can significantly enhance preoperative communication strategies with patients30. Notably, studies have indicated that a majority of surgical patients prefer oral consultations or multimedia aids, such as concise videos, over written information. These visual aids have proven effective in alleviating fear, with ~54% of subjects preferring verbal information, 47% opting for video content, while only 36% favored printed materials82. Additionally, noninvasive interventions like back massage therapy have demonstrated significant reductions in patient anxiety levels before surgery83,84. Other methods, including music therapy, handholding, pharmacological, and psychological options, have shown promise in stress reduction and anxiety management during surgical procedures68,85–87. More than that, early screening for anxiety and depression from the point of cataract diagnosis, coupled with accurate information provision about cataract surgery, remain critical interventions aimed at enhancing patients’ overall quality of life4.
Limitations
The limitation of this review is that most of the studies included did not explore other factors related to cataract surgery, such as surgical pressure, duration of surgery, and rehabilitation expectations to determine the true effect of cataract surgery. These factors may affect the answers to the questionnaire. Besides, inconsistencies in the questionnaires utilized across studies contributed to varied study focuses and outcomes. In addition, the assessment time of the questionnaires of the included studies was inconsistent, such as a fixed preoperative or postoperative half-hour assessment, which may lead to large differences in the assessment results. At present, there are few relevant randomized controlled trials, meta-analyses, and prospective studies, most of which are cross-sectional. Thus, the presence of publication bias within the reviewed research cannot be entirely dismissed, emphasizing the need for methodologically rigorous investigations in this domain.
Conclusion
In conclusion, cataract surgery is highly likely to improve mental health, primarily in relation to visual impairment. However, the scope of improvement may not fully encompass the broader spectrum of psychological well-being, which is influenced by multifaceted factors beyond visual concerns. Importantly, anxiety and depression exert a significant adverse impact on the outcomes of cataract surgery. Recognizing these implications among elderly patients with visual impairment is crucial, necessitating tailored psychosocial and pharmacological interventions. To deepen our understanding of the intricate relationship between cataract surgery and mental health in the elderly, future research is essential, calling for more comprehensive studies in this area.
Ethics approval
Not applicable (review article).
Consent
Not applicable.
Sources of funding
This study was funded by the National Natural Science Foundation of China (82171075, 82301260), the China Postdoctoral Science Foundation (2021M700899), the Medical Scientific Research Foundation of Guangdong Province, China (A2021378), the Science and Technology Program of Guangzhou, China (20220610092, 202103000045), the Outstanding Young Talent Trainee Program of Guangdong Provincial People’s Hospital (KJ012019087), the launch fund of Guangdong Provincial People’s Hospital for NSFC (8217040546, 8220040257), the Project of Special Research on Cardiovascular Diseases (2020XXG007), the National Medical Simulation Education Research Project (2021MNYB01). The funders had no role in the study design, data collection, data analysis, data interpretation, or report writing.
Author contribution
W.S., D.Z.J., Y.H.H., and Z.X.Y.: study concept and design; W.S., D.Z.J., L.C.R., I.S., W.Y.X., H.Y., S.X.W., F.Y., Z.Z.T., and H.Y.J.: acquisition, analysis, or interpretation; W.S., D.Z.J., and Z.X.Y.: drafting of the manuscript; D.Z.J., Z.X.Y., I.S., H.Y.J., and Y.H.H.: critical revision of the manuscript for important intellectual content; W.S., D.Z.J., Z.X.Y., and S.X.W.: statistical analysis; Y.H.H. and Z.X.Y: obtained funding; H.Y.J., Y.H.H., and Z.X.Y.: administrative, technical, or material support; Y.H.H. and Z.X.Y.: study supervision.
Conflicts of interest disclosure
The authors declare no conflict of interest.
Research registration unique identifying number (UIN)
Name of the registry: Research Registry.
Unique Identifying number or registration ID: reviewregistry1764.
Hyperlink to your specific registration (must be publicly accessible and will be checked): https://www.researchregistry.com/register-now/register-your-systematic-review#registryofsystematicreviewsmeta-analyses/registryofsystematicreviewsmeta-analysesdetails/658c3ecb37124d00262600c7/.
Guarantor
Zhang XY, and Yu HH.
Data availability statement
Data from all studies included in this review are available in online databases.
Provenance and peer review
Not commissioned, externally peer-reviewed.
Footnotes
Shan Wang and Zijing Du contributed equally to this manuscript.
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Published online 17 January 2024
Contributor Information
Shan Wang, Email: wangshan@gdph.org.cn.
Zijing Du, Email: duzijing0701@163.com.
Chunran Lai, Email: laichunran@gdph.org.cn.
Ishith Seth, Email: ishithseth1@gmail.com.
Yaxin Wang, Email: drwongmc@163.com.
Yu Huang, Email: huangyu1316@gmail.com.
Ying Fang, Email: 364063460@qq.com.
Huiyi Liao, Email: 473007112@qq.com.
Yijun Hu, Email: huyijun2014@163.com.
Honghua Yu, Email: yuhonghua@gdph.org.cn.
Xiayin Zhang, Email: zhangxiayin@gdph.org.cn.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data from all studies included in this review are available in online databases.