Outcomes of cataract surgeries performed in 8 eyes of centenarians

Abstract

Cataract surgery outcomes in centenarian patients have not previously been explored. This study aimed to examine characteristics and report clinical results of people aged ≥100 years undergoing cataract surgery. This was a retrospective observational study, including patients aged ≥100 years who underwent cataract surgery between 2003 and 2021 at Miyata Eye Hospital in Japan. Medical charts were reviewed for information on cataract severity, surgery type, anesthesia, as well as ocular and medical comorbidities. Using Mann–Whitney test, visual acuity, intraocular pressure, and corneal endothelial cell density were compared before and after surgery. Eight eyes of 5 patients were included in the study (mean age, 101.5 ± 1.2 years). Seven of these eyes (87.5%) belonged to women. All surgeries were performed under topical anesthesia using phacoemulsification and insertion of the intraocular lens fixed in the bag. All patients had multiple preoperative medical comorbidities; however, there were no intraoperative, postoperative ocular, or general complications. The postoperative best-corrected visual acuity was significantly improved compared to that before surgery (1.18 ± 0.74 and 0.29 ± 0.52, respectively, P = .004). Neither intraocular pressure nor corneal endothelial cell density demonstrated a significant difference postoperatively. Cataract surgery can be safely performed under topical anesthesia in centenarians without complications using proper perioperative medical control and preparation.

1. Introduction

Cataracts are a cause of blindness and require surgical lens removal.^[1–3] The age range of patients requiring cataract surgery is expanding based on disease progression.^[4] Japan has one of the fastest aging societies,^[5] and there are many opportunities to perform cataract surgeries globally for older patients over the age of 90 years.^[6–9] Compared with younger patients, older patients generally have higher risks associated with ophthalmologic operations, including pseudoexfoliation syndrome, ciliary zonule weakening, progressive nuclear sclerosis, insufficient cooperation, and poor mydriasis.^[10] Additionally, these patients often have concomitant systemic comorbidities, making cataract surgery difficult for non-ocular reasons.

Although cataract surgery results have been reported for patients over 90 years of age,^[6–9,11] there have been no studies on cataract surgery results for patients aged over 100 years as few people live to this age, even in the current aging society. We hypothesized that cataract surgery could be performed on centenarians. Therefore, we focused on and examined the clinical course and characteristics of cataract surgery performed in patients aged ≥100 years.

2. Methods

2.1. Patient consent

This observational study was conducted in accordance with the tenets of the Declaration of Helsinki. The study was approved by the Institutional Review Board of Miyata Eye Hospital (Miyazaki, Japan) (Identifier: CS-370). The need for written informed consent was waived as participants were allowed to opt out of the study. Additionally, patients signed informed consent regarding publishing their clinical data.

2.2. Examination items

We retrospectively reviewed patients aged ≥100 years who underwent cataract surgery at Miyata Eye Hospital between 2003 and 2021. Patients were excluded if sufficient medical information could not be obtained from their medical records. From these records, we retrospectively examined the preoperative cataract status, presence of nasolacrimal duct obstruction, axial length, anterior chamber depth, central corneal thickness, as well as medical and ophthalmological history. The 3-month preoperative visual acuity, intraocular pressure (IOP), and corneal endothelial cell density were compared to their 3-month postoperative results. Visual acuity was converted to the logarithmic minimum angle of resolution for analysis. The cataract surgery technique, complications, intraocular lens (IOL) fixation method, and postoperative follow-up period were also examined. The presence of nasolacrimal duct obstruction was evaluated by performing a saline flow examination at 1 to 2 months preoperatively.

2.3. Cataract surgery procedure

Cataract surgery was performed by experienced surgeons using 4% xylocaine topical, 2% xylocaine sub-tenon, or 0.75% ropivacaine retrobulbar anesthesia. Before surgery, povidone-iodine was used for disinfection. The surgeons performed a corneal or scleral incision creating the wound, and continuous curvilinear capsulotomy was followed by phacoemulsification and aspiration (PEA) and IOL insertion. The anterior chamber was washed, and the wound was closed. The procedure was terminated with a 0.3-ml subconjunctival dexamethasone injection and antibacterial drops (gatifloxacin or levofloxacin). Finally, 0.3% ofloxacin ointment was used. Postoperatively, antimicrobial (levofloxacin) and steroid eye drops (0.1% betamethasone) were administered 4 times daily, and 0.1% bromfenac eye drops were administered twice daily as needed.

2.4. Statistical analysis

After confirming normality and equal variance of the data, Mann–Whitney tests were performed to examine the visual acuity, IOP, and corneal endothelial cell density before and after surgery. GraphPad Prism (GraphPad Software, San Diego, CA) was used for statistical analyses. P-values of <0.05 were considered statistically significant. All values are expressed as mean ± standard deviation.

3. Results

Eight eyes of 5 patients were included in the study. The mean patient age was 101.5 ± 1.2 years, and 7 eyes (87.5%) were of women. The patient demographic data are summarized in Table 1. According to the Emery–Little classification, the mean cataract severity was 3.0 ± 1.2. None of the patients demonstrated nasolacrimal duct occlusion. The mean anterior chamber depth was 2.52 ± 0.48 mm. Three patients underwent electroretinography and ocular echography because the cataract obscured their fundus; additionally, none exhibited any abnormalities in either examination. All patients had multiple medical comorbidities and were treated by internal medicine doctors (Table 2).

Table 1.

Demographic data of the patients.

N (eyes)	8
Age (years), mean ± standard deviation	101.5 ± 1.2
Side (right: left)	3: 5
Sex (male: female)	1: 7
Emery–Little classification of cataract, mean ± standard deviation	3.0 ± 1.2
Occlusion of the nasolacrimal duct (%)	0.0
Axial length (mm), mean ± standard deviation	22.68 ± 0.33
Anterior chamber depth (mm), mean ± standard deviation	2.52 ± 0.48
Central corneal thickness (μm), mean ± standard deviation	497.5 ± 27.4

Table 2.

Medical and ocular comorbidities of the patients.

Cases	Medical comorbidities	Ocular comorbidities
# 1-R	Chronic pancreatitis, psoriasis, pacemaker implantation.	None.
# 1-L	Chronic pancreatitis, psoriasis, pacemaker implantation.	Retinal vein occlusion.
# 2	Hypertension, femoral neck fracture.	Exotropia.
# 3-R	Hypertension, angina pectoris, aortic regurgitation, mitral regurgitation.	Dry eye, macular degeneration.
# 3-L	Hypertension, angina pectoris, aortic regurgitation, mitral regurgitation.	Dry eye, macular degeneration.
# 4-R	Hypertension, diabetes mellitus, angina pectoris, aortic regurgitation.	Macular degeneration.
# 4-L	Hypertension, diabetes mellitus, angina pectoris, aortic regurgitation.	Epiretinal membrane.
# 5	Hypertension, atrial fibrillation.	Primary-angle closure glaucoma.

All patients were administered topical anesthesia and did not require general anesthesia (Table 3). Five eyes underwent a sclerocorneal incision, and 3 underwent a corneal incision. IOL fixation in the bag was achieved in all cases. None of the patients demonstrated postoperative ocular or general complications. The mean best-corrected visual acuity was 1.18 ± 0.74. Compared with preoperative logarithmic minimum angle of resolution, the postoperative result (0.29 ± 0.52) demonstrated a significant improvement (P = .004, Table 4). IOP and corneal endothelial cell density exhibited no significant change postoperatively.

Table 3.

Clinical data of cataract surgeries in patients aged 100 years and older.

Operation time (s), mean ± standard deviation	738.1 ± 296.2
Pupil diameter after mydriasis (mm), mean ± standard deviation	5.79 ± 1.11
Incision types (sclerocorneal incision: corneal incision)	5: 3
Intraocular lens fixation (in the bag: out of the bag)	8: 0
Follow-up period after surgery (months), mean ± standard deviation	8.00 ± 5.21

Table 4.

Comparison of visual acuity, intraocular pressure, and corneal endothelial cell density before and after surgery.

	Before surgery mean ± standard deviation	After surgery mean ± standard deviation	P-value
Best-corrected visual acuity (logarithm of the minimum angle of resolution)	1.18 ± 0.74	0.29 ± 0.52	.004
Intraocular pressure (mm Hg)	8.50 ± 2.78	8.38 ± 1.06	.966
Corneal endothelial cell density (cells/mm2)	2702.25 ± 349.70	2535.17 ± 626.22	.852

4. Discussion

This study examined cataract surgery characteristics and outcomes in patients aged ≥100 years. Cataract surgery is necessary for many older people. These patients often visit an ophthalmologist for cataract surgery in their 70s or 80s, when cataracts begin to appear and worsen. However, some patients have few subjective symptoms until their vision deteriorates, leading to hospital visits at an advanced age. These patients have a high ophthalmological surgical risk because of their hardened lens nucleus, pseudoexfoliation syndrome, decreased anterior chamber depth, and reduced corneal endothelial cell density.^[7] In the present study, the cataract nucleus was progressively deteriorating, and this finding was reflected in the decreased preoperative visual acuity and shallow anterior chamber depth (2.52 ± 0.48 mm). Previous reports describe cataract surgery significantly improving visual acuity, with a good postoperative course in all cases. However, some patients had ocular comorbidities causing insufficient recovery, including macular degeneration, retinal vein occlusion, or glaucoma.^[10–12] Cataract surgery in older patients can be performed with careful preoperative preparation and attention to anticipated complications. These measures could significantly improve visual acuity, quality of life, and vision.^[13]

All patients in the current study had multiple systemic comorbidities. Many older patients have various medical conditions that complicate cataract surgery. Previous reports have demonstrated the safety and possible visual recovery after cataract surgery in people aged ≥90 years.^[13,14] However, cataract surgery could be performed in patients aged ≥100 years by adequately controlling comorbidities through consulting medical doctors, providing medical care, and postoperative management. All patients underwent surgery under topical anesthesia, as general anesthesia for nonagenarians and centenarians would have adverse outcomes.^[15] Physicians were consulted in all cases, and all patients underwent a medical checkup before surgery. Physicians compared the risk and benefits of general anesthesia and topical anesthesia, and judged topical anesthesia to be appropriate considering the risk of aspiration pneumonia because of decreased swallowing function and risk of high blood pressure fluctuations. Resultantly, all cataract surgeries were performed under topical anesthesia. Most patients in this study were women (87.5%), similar to that in a previous report on ophthalmic plastic surgery performed in older patients.^[16]

In most cases, PEA and IOL insertion into the bag were performed. Only 1 patient required surgery with large incisions, necessitating additional wound suturing. However, in most cases, surgical procedures were performed with small incisions. This procedure is generally widespread and useful due to surgical equipment and technique improvements, even in patients with progressed hard cataracts.^[17] Additionally, the accumulation of such techniques and knowledge is believed to have made cataract surgery possible for older patients in many countries globally. In the current study, because the preoperative anterior chamber depth was shallow and mydriasis severity during surgery was insufficient (5.79 ± 1.11 mm), the surgical procedure required an advanced technique, reflected by the relatively long operation time. Furthermore, the IOL calculation accuracy is reportedly less precise in older patients^[18]; however, it was not evaluated in this study due to the limited number of patients and variation in the IOL calculation formula.

It was assumed that the corneal endothelial cell damage would be greater in older patients due to the harder nucleus during cataract surgery, greater surgical time, and ultrasound power required when performing PEA. However, our results demonstrated that the decrease in corneal endothelial cell density was not significant, and cell density was maintained at more than 2000 cells/mm² at 3 months postoperatively. Additionally, careful follow-up is required to avoid bullous keratopathy after cataract surgery.^[19] If bullous keratopathy develops in older patients postoperatively, corneal transplantation is necessary using Descemet stripping automated endothelial keratoplasty, Descemet membrane endothelial keratoplasty, or penetrating keratoplasty.^[20] As these surgeries require hospitalization, postoperative steroid administration, and long-term follow-up, corneal transplantation should be avoided in older patients. The postoperative observation period was 8.0 ± 5.2 months as most patients had difficulty walking alone, and it was difficult to continue routine postoperative checkups.

One limitation of this study is that there was a small number of patients over 100 years old. Therefore, a comparative study was impossible to perform resulting in the current study being an observational one. This causes selection bias and insufficient generalisability. To investigate cataract surgery safety, the risks associated with it should be compared with other procedures. Additionally, it is necessary to accumulate cases from multiple institutions. Furthermore, owing to the retrospective nature of the study, some medical and surgical information was not available. Further detailed evaluation of changes in the patients’ ability to perform daily life activities before and after surgery using tools such as the National Eye Institute Visual Functioning Questionnaire 25^[21] should be performed. Further, patients with cataracts who could not or did not wish to undergo surgery were not identified; this may be because our institution is a tertiary eye-specialized hospital, and aged patients who do not want to undergo surgery are not referred to us. Aging is an ongoing social problem, and future prospective study analysis is desirable.

5. Conclusions

We demonstrated the clinical course and characteristics of cataract surgery in centenarians. Additionally, we concluded that cataract surgery can be safely performed in patients ≥ 100 years. With careful attention to complications and adequate preoperative control through internal medicine, ophthalmologists can greatly improve the vision of highly aged patients.

Author contributions

Conceptualization: Takashi Ono, Tatsuya Fukuda, Takuya Iwasaki, Kazunori Miyata.

Data curation: Takashi Ono, Tatsuya Fukuda, Takuya Iwasaki, Toshihiro Sakisaka, Yosai Mori, Ryohei Nejima.

Formal analysis: Takashi Ono, Toshihiro Sakisaka, Yosai Mori, Ryohei Nejima.

Funding acquisition: Takashi Miyai, Kazunori Miyata.

Investigation: Tatsuya Fukuda, Toshihiro Sakisaka.

Methodology: Takashi Ono, Takuya Iwasaki, Yosai Mori.

Project administration: Takuya Iwasaki, Ryohei Nejima, Takashi Miyai, Kazunori Miyata.

Resources: Takashi Ono, Tatsuya Fukuda, Takuya Iwasaki, Toshihiro Sakisaka, Takashi Miyai, Kazunori Miyata.

Software: Takashi Ono, Tatsuya Fukuda, Takuya Iwasaki, Toshihiro Sakisaka.

Supervision: Takuya Iwasaki, Ryohei Nejima, Takashi Miyai, Kazunori Miyata.

Validation: Takashi Ono, Tatsuya Fukuda, Takuya Iwasaki, Ryohei Nejima, Takashi Miyai, Kazunori Miyata.

Visualization: Takashi Ono, Takuya Iwasaki, Takashi Miyai.

Writing – original draft: Takashi Ono, Tatsuya Fukuda, Takuya Iwasaki, Toshihiro Sakisaka, Yosai Mori.

Writing – review & editing: Takashi Ono, Tatsuya Fukuda, Takuya Iwasaki, Ryohei Nejima, Takashi Miyai, Kazunori Miyata.